Med pass in LTC

[Cat Truitt RN]

I am more accustomed to working in acute care settings and later as a nurse teaching new nurse students. Is it me or the med pass in the LTC setting for 45 patients time consuming and almost impossible. I worked 7p-7a and found the pass to be almost unreasonable with this many patients. I had 2 CNAs who worked with me that night but yet I felt it was very hard work indeed. I admire those nurses who work this shift without any other help. I was the nurse who answered the call from the facility when another nurse called off. I feel that I didn't get a chance to do a good assessment of the patients because my time was spent passing meds. I had a pass at 9pm, 12am, 4am and 6am. The GLUMS at 6 were tremendous with 15 of the residents getting BS test with coverage. This did not account for the other insulin being given. No only that but the night I work the power in the building was affected by outages so that no call lights worked on that unit and residents were given bells. Also, the refrigerator was out and the meds refrigerated meds were being stored on another unit. I spent my time getting those items refrigerator to give to my patients. I also do not understand the pass set up at the facility I am at. I am used to 8am, 4am, 8p, 4a pass or a 6a 12p 6a 12midnight. The pass is totally illogical with some getting meds any time during the night. I hate to wake up patients, who are confused, just to give 1 or two pills. I know some of the items I gave were antibiotics so I could see this a reason for the time. But others tabs or meds could have be given more on routine and with other meds. Any suggestions, I would appreciate. I handled the cart only 3 times before.

[dblpn]

Med pass in LTC sucks! you're always out of the time parameters which is a huge med error. i'm a cmt and i absolutely hated to pass meds to a bunch of people. i started to work for an agency, and they would send me out to places where i ended up passing meds for two halls. most of the residents were on more than 5 diff meds. i remember where i had a few that were on at least 15 meds. it took me forever to pass without any help from the staff.

[Ms.RN]

i'm pretty comfortable with passing meds in ltc setting becuase i've worked in ltc for several years. at the beginning of the shift, i use flags inside mar. i go through mar's and flag all 9pms with blue color and red for blood sugars and insulins that needs to be given. then i start my 9pm med pass. after i'm done then i sit down and start flagging for the midnight shift. i flag green color for all 12ams and blue color for 4 and 6am's and red color for insulings. we have one hour before and after scheduled time to give medications so i would combine 4 am and 6 am's and start my med pass at 5am .if those 4 and 6 am's are the same medications that needs to be given at that time, then i would use two different colors, yellow for 4am and blue color for 6ams. i would go through all the red tags and write down their room numbers and bed number in a piece of paper. then i would start my 12 ams and when i'm done giving medications, then i would put flags back inside mar so i know the one's that i'm flagged is the ones that i have to give to the patient. then at 5 am i would start my morning med pass. if medication is like tylenor and if patient is sleeping, then i would circle it and write down not given becuase patient is sleeping. when i'm done with all the morning med pass, i would take my paper and insulin supplies and start checking blood sugars and either give coverage or give report to the morning nurse to give insulins. before i start my med pass, i want to make sure i have all the supplies i needed like apple sauce, thick water, spoons, insulin syringles, etc so i dont have to walk back and forth from cart to the med room. most of the morning meds given are pain patches, stomach medications (prilosec etc), antidiabetic, pain meds. all routine meds should be one in the morning and evening like 9a, 9p. if somebody scheduled routine meds like blood pressure meds, you might want to let physician know and change it to 9a and 9pm

[CapeCodMermaid, RN]

Old people take too many meds. That is a given. Old people need uninterrupted sleep so they shouldn't be woken up at 12 midnight or 4 am. Have a discussion with your pharmacy consultant. We had many people getting a med three times a day. I spoke to our consultant...he recommended a long acting version of the same med so it's down to once a day. Have the consultant review the meds with the idea of eliminating the useless ones...vitamins are notoriously prescribed in LTC. Studies show that most older people don't even absorb the vitamins so it's a waste of time and money. Some residents have been admitted on meds they needed 5 or 10 years ago so have the doc take a good look at them and determine if they really need every med they are on.

[sasha2lady]

i work in LTC and I agree that some of the med times are outrageous. I think its crazy to wake someone up at 5 am to give them 1 prilosec! Im not a morning person so when I get old that routine is not going to work in my nurses favor lol. I work 2nd and on my passes not only do I give a ton of narcs, but I also give a bunch of vitamin c's, oscals, eye vites, irons, colaces, diabetic meds, bp meds, coumadins, laxatives, some get bumex which I was always told that its best to give fluid pills in the am so that one isnt up all night having to go to the BR...but hey.....whatever floats their boat I guess. Oh...did I mention the stupid eye drops? i dont see how someone could possibly need artificial tears q 2 hrs??????????? If one of mine is asleep i circle it and put why I didnt give it...thats insane to wake someone up like that for some drops. Plus...another thing I dont get is why 2 different eye doctors prescribe 2 eye drops that do the exact same thing????? makes no sense to me. it took me a year to get used to the meds...I had to get my own routine. before I ever go down the hall...I look over my cart and see if its got everything i need....I dont have to do that when i work behind one particular nurse b/c she always leaves me in good shape as do I when 3rd gets there.

[4treasures]

I just worked my second midnight shift, and it was horrible. 40+ residents, I was behind all night. I couldn't keep up with 2 tube feeders, a dialysis pt, so many treatments, breathing treatments, and the meds. I also think it is ridiculous to wake someone up for things like an eye drop. I feel that this is where there people live, and if they are sleeping, we need to respect that, who knows how long it's been since they slept well for some of them. I didn't sit down all night long, thank God I only had 1 medicare chart to do. Seriously thinking about keeping looking for an hospital job......

[wiley6coyote]

Wow, I was tired just reading your post. I'm just curious as to the kinds of residents you have in LTC. I have been working as a RN manager full time 12 hour nights for 4 years. The only meds I give out ( approx. 85 residents) at night are prn's, narcs ( 2400, 0400/0500) and supps. No CBS checks unless they are sick and need to be monitored more closely- dayshift gives out the insulins and all other meds are 0800, 1200, 1700, 2000 - even antib. are not given through the night if it can be helped. Sometimes 0600 I have had a few but not very often. We don't have IV's or trachs or even tube feedings although that just may be a fluke at the moment because no one needs one.

The RPN's handle the med passes through the evening ( they work 3-11) and I take over @ 2300. Occasionally if the RPN is sick, I handle the evening med pass- it takes me awhile because I don't know everyone's quirks such as who likes juice, needs meds crushed etc. I also help out with treatments, vital signs etc as necessary too.

Perhaps your facility needs to sit down with the front line staff and come up with a working solution taking the resident and staff needs into consideration.

[lisamc1RN, LPN]

We have a pharmacist come in once a month who analyzes the meds that our residents are on. When I became the day shift nurse, I began asking her questions about some of the meds and what I've found out is that we can really make a difference about some of this. For instance, for one lady, we were giving her meds at 6am, 8am, and 12p. We analyzed the meds and combined the 6am, 8am and part of the 12 p med pass so that it is all given at 8 am now, with one pill at 12 p. We've asked doctors to dc meds that are no longer appropriate, as well. It's made a big difference for our unit. The other nurses leave notes for me about meds on their shift as well, so that we can discuss it with the pharmacist when she gets there. Vitamins are a biggy.

[makes needs known]

There is no such thing as perfect in LTC. It is impossible to complete everything that is supposed to be done. Anyone who works in LTC knows this. There's too much paperwork. Too many medications, too many problems that can occur and not enough staff to handle it all. KEEP THEM SAFE, KEEP THEM HAPPY. The patients, not the management.

[VivaLasViejas, ASN, RN]

I've made it a practice to fine-tune the med passes so that we're not giving Lasix at 1700 or disturbing residents 6-8 times in a 24-hour period for meds and treatments. Luckily, I have an RCM who trusts my judgment and listens to my recommendations---she is notorious for giving her charge nurses a hard time, but we've always gotten along because she knows I know my stuff.

I do this on a case-by-case basis as well; some residents honestly don't mind taking meds all through the day and night; but with others who are harder to deal with, e.g. have swallowing problems or frequent med refusals, I try to combine as many passes as possible to save both time and patience.

It's ridiculous sometimes---a resident who needs every one of her 25 pills crushed in applesauce will be admitted with med passes scheduled for 0700, 0800, 1200, 1600, 1700, 2000 and 2100, and that just makes me crazy!! So I'll go over the schedule and combine everything I can, and then we end up with only 3-4 passes (at 0800, 1400, and 2000, for example) instead of six or seven. I also try to schedule suppositories so that no one is going around at 0500 sticking silver bullets in places where, if it were done to ME at that hour, would cause all hell to break loose along with my bowels!

I also try to work with the pharmacy consultant and the PCP to try to minimize the med list where possible. Like CapeCod, I think most elderly people are on far too many drugs, and I've seen a lot of cases of dementia that got dramatically better after the patients were taken off an excess of psychotropics and/or narcotics. I also agree that vitamins, for the most part, don't do much good unless an older person is anemic or has a wound, in which case I like to ask the PCP to order a good MVI, Vitamin C, and zinc for a limited number of weeks to boost healing.

Anyway, the take-home lesson here is that nurses CAN manage LTC med passes if they're willing and able to do the legwork that can help streamline the process, as well as management that's willing to listen to their ideas (a most crucial component!). Good luck!

[Skeetersmom119]

I work 3-11 in LTC/Rehab, where the med pass is not as heavy as day shift, however, I call my hall "Accucheck Alley" because I usually have at least 1/3 of the 30 patients have at least a 4:30pm. Recently I had 14 out of 28. What I started doing is keeping an eye on their readings, and if after a couple of weeks they stayed within normal parameters, I would communicate to our NP or MD to see if the fingersticks could be cut back to BID. Most always, they were changed. If your narcs are PRN, know your "pain people", (those that always hit the light routinely) and take care of them before they hit the light. It is also helpful if the person that worked before you has assessed pain, and took care of those folks. I took the time when I was off and made my own "jot sheet", color coded it with information that was of most importance, and it has been much help when I am "muddling thru the muck"LOL unfortunately I have to update it almost every day, but it is well worth it. Perhaps you can somehow communicate with the consult pharmacist , to have them review some of the folks that are polypharmacy. Hang in there.

[nursenow]

I have passed alot of antibiotics and am sitting here wondering why in the world someone would be passing them in the middle of the night? I have never heard of that. Even TID doesnt mean wake your patient up in the middle of the night.