rescue meds...or not.

[johnys]

So, this is one part question, one part unloading, and 4 parts heartache. It is long, and I apologize for that. I am an admissions hospice rn. What I experienced with two patients on back-to-back days is making me question what I am doing. Both cases are similar, involve patients in SNF's (two different facilities) and in both situations the patient's were in the active process of dying. Both patients were clearly in distress. The 1st one had a HR in the 130's, temp 104.5, resp rate in the low 50's, PaO2 on 3L of 81%, lungs filled to the brim from aspiration PNA. I evaluated her in les than 5 minutes, got confirmation for admission from our doc, and got orders for roxanol, ativan, atropine and tylenol suppositories faxed to the pharmacy. The order was for a stat delivery. The SNF had a locked e-kit with everything I needed. The delivery from the pharm never came, the SNF refused to open the e-kit (their rational was why bother, the pharm meds would be here anytime...) This pharmacy is notorious for being 4 to 6 hours on a stat delivery. The poor woman died with nothing on board - 4 hours after I arrived, and 3 1/2 hours after I started begging and pleading for the e-kit to be opened. 2nd pt, next day... no e-kit in the facility; pt 63 yr old male actively dying, (DKA and stroke), agitated, clearly in pain, resp 40, HR 115. Facility had a pyxis med admin system...but not a drop of morphine or ativan in the joint. Once again, 4 hours after my arrival and faxed orders received by the pharmacy (same pharm in both cases, but I will leave them nameless) no meds arrived. The family was very upset and so was I. I got called down to the administators office to be chewed out for being "unprofessional" with the staff. (What I said to a staff RN was I thought it was "rediculous" that the facility did not have any rescue meds, that was reported back, and hence the chewing out by the admin. MY bad, sorry, I should have been more attentive to the feelings of the staff and less concerned about "our" patient who was trying to throw himself out of his bed, he was so agitated with pain.) I recommended to the tearful and angry family (reluctantly) that they send the patient out to a nearby hospital for symptom relief, which the did end up doing. I prayed to god the transfer didn't kill him. The pharm delivery of my stat meds came after he left, 6 hours after they were ordered and CONFIRMED. He died the next morning. My question to you all now is this; do any of you have state laws or regulations requiring SNF's to have rescue meds in the facility, and are there any time frames within which they must open them once orders are verified? I am thinking legislative changes need to take place in my state; I am looking for a place to start. What I do know is something has got to change. I know you may be thinking get a different pharm, but the rest of them in this state are worse, believe it or not. I didn't get into hospice to sit by and watch dying people suffer. I am not leaving. I am going to effect change, so God help me. I am angry, hurt, and feeling utterly useless.

[OCNRN63, RN]

Can you contact your hospice administration about these situations and ask for some problem-solving help? Like having some sort of agreement in place with the SNFs for having the meds available or carrying your own E-kit. I would also contact whomever oversees SNFs in your state and ask if there are any regulations regarding the care provided to hospice patients. I might even contact the pharmacy board to check if there are any state statutes about what constitutes a STAT order.

Sometimes you just have to rattle enough cages to finally get a ball rolling. You may in future want to drop a quiet word to the distraught families about who they can complain to. It may take awhile to achieve critical mass. God bless you for stepping up.

Does your hospice have a medical director who could get involved, either by suggesting to the pt's primary phys that rescue meds be in place on adm.? Can you have the emergency kits delivered on admission? That won't help in situations where staff refuse to use them.

Sounds like those nurses need education...and FAST!

[grayduck]

johnys,

We were not permitted to carry ekits or keep them at our office. Our admissions coordinator did get comfort med orders upon admission. In cases where we had the order, but couldn't seem to get the med quickly enough, we enlisted the help of our absolutely fabulous medical director. I, as well as every other nurse on our staff have called him, asked for his help, shown up at his door at all hours to get "blue scripts," taken them to a 24 hour pharmacy that we knew kept the meds we needed in stock, and delivered the meds to a home or a SNF. As our LMD was so accommodating to us and our patients' needs, we were able to avoid this problem.

[NC29mom, ASN, LPN, RN]

i just use a local pharmacy to get the meds. This allows the pt to have immediate medication and saves the snf the step. We are paying for the meds anyway, so it's never been a problem just to run the scripts down the road.

[TammyG]

This is an awful situation. Many states require or at least permit emergency medication kits to be on-site at SNFs and often even specify the contents. These kits are allowed under DEA and CMS rules, although I believe that the nurse must verify with the pharmacy that a valid order has been received before providing the drug. All of the SNFs locally here have emergency kits with morphine. I have had a few nurses be resistant to providing emergency meds because of all the paperwork, but I always ask for the supervisory RN and have never had a problem. If I did, boy I would scream holy murder. For the facility you were at that refused to use their med box, they should lose their license. As a nurse, I think we have the obligation to correct this situation by any means necessary, and that would include using all the resources in your hospice. If they did not pursue it, I would go to the state myself. But really, this is a job your medical director and clinical supervisors should handle.

We also have assisted living facilities in the area that do not carry E-kits. In those situations I have the family go to the pharmacy. Luckily we have pharmacies in the area that carry morphine, liquid lorazepam, etc. Sometimes the ALFs will push back, but that does not deter me. Unfortunately sometimes there is no family present, and my hospice forbids us to pick up controlled substances from the pharmacy. I always call the supervisor on duty and just tell her "I am doing this." I have never had a problem.

The most outrageous situation is that you were given crap by the facility for being "rude."

For patients coming from the hospital, we make sure our discharge nurse sends them home with comfort meds, although that doesn't always happen either.

I had a situation a while back where a patient died in pain in an assisted living facility because the pharmacy took 6+ hours to get the comfort meds. No more.

[areensee]

Wow! Your heart was in the right place and clearly the facility's heart wasn't. I doubt there are any state laws requiring e-kits in facilities. The facility did leave themselves (as well as your hospice organization) open to a law suit from the family and scrutiny from Medicare (could deny billing to your hospice agency and the facility). The failure to treat pain is a big source of malpractice suits these days. Was the family present during this fiasco? Also, you should have completed an incident report for your employer. This is a service failure as well as a travesty for the patient. I can understand why you said what you did, however it is important to remember that we are guests in a facility. Now that doesn't mean you do nothing! My first suggestion would have been to call your physician and ask him/her to intervene for you. If a physician gives an order that the e-kit be accessed STAT then by law they are required to do just that or come up with a darn good reason for not following the physician order. Second, vent to the right people, not the facility staff. Often they are just as frustrated as you are, but are bound by the rules of their employer. Even if it was a decision made exclusively by a staff member, the way to approach it is to go through the chain of command, talk to your PCM and let them approach the facility. Please don't let this change your passion for hospice care. We need nurses who are willing to speak out and advocate and change the system to reflect what we know to be the best interests of all of our patients.