wasting of narcs in pacu

inchii · Mar 22, 2014

I don't work in the PACU, but in our hospital, all nurses need to waste excess doses every time. Every med pulled out is only single use.

darwinsbluefish · Mar 22, 2014

I have worked PACU for the majority of my career and at multiple facilities. Every facility I have worked allowed the nurse to hold narcs. In a busy environment were each patient is being treated for pain frequently (most q5 min) this is common practice. I have never left a syringe of pain medication at the bedside as that is too risky. I am also very cautious to label all medications appropriately and waste once the patient is released from my care. I have never had any issues with this practice but I am also very mindful of which medications I have on me at all times. Ideally, in a perfect world, I would waste initially but it is not always feasible in a busy PACU with high acuity patients.

Ginger's Mom, MSN, RN · Mar 23, 2014

Joint Commission and CMS have issues with narcotics not being properly disposed of, narcotics should never be left at the bedside or worse in a nurse's pocket. I would warn any nurse carrying extra narcotics without wasting them they are risking their nursing licensed.

MunoRN, RN · Mar 24, 2014

Joint Commission and CMS have issues with narcotics not being properly disposed of narcotics should never be left at the bedside or worse in a nurse's pocket. I would warn any nurse carrying extra narcotics without wasting them they are risking their nursing licensed.[/quote']
Considering the JC and CMS and specific guidelines on how medications should be labelled when drawn up if the full dose is not intended to be given immediately, as well as guidelines for storing the meds securely between doses it certainly wouldn't appear that they simply don't allow it.

LLLovely, BSN, RN · May 19, 2014

Our PACU has no spot to secure medications between doses. I suppose we could waste after each dose, but there is a lot of discussion at our facility about unnecessary waste. For example, Fentanyl comes in a 100mcg vial, but our order set only allows doses up to 50mcg at a time. If we kept wasting, we'd go through vials like crazy, as if we don't go through them quickly already. We, as a group, do tend to leave them at bedside on the computer carts. Those are generally out of reach of patients and still in full view of all nursing staff due to the configuration of our bays and nurse's station. I never put meds in my pocket if I can help it because I don't want to forget something in there. Forgetting it in my pocket would be a much bigger deal than having it at the bedside, at least at our facility.

Jaesim · May 24, 2014

Thank you all for your answers. LLLovely had the answer that best explains how my pacu used to do it, until we were told we could not leave them at the bedside and HAD to carry or waste them. (I have dropped syringes on the floor when bending over, and also leaked into my pocket!) As of next month we are going on a computer system which will dictate that we waste for each dose. I can only imagine how many vials we will be going through each day to accommodate this new system, not to mention all the time we are going to be spending at the Pyxis med machine instead of at our patient's bedside.

azhiker96, BSN, RN · Jun 28, 2014

I don't see a problem as long as the med is under control of the RN and out of reach of the patient/family. There is space by my computer where I can place drawn/labeled meds. I am right next to it and the patients cannot reach it.

Wasting meds when there are such chronic shortages is not a good plan. I typically will have an order for dilaudid .5 mg q5min prn pain. One vial contains 2 mg. It does not make sense to use four vials to get four doses. As someone else mentioned fentanyl comes in 100 mcg and also 250 mcg glass vials. I'll typically pick a 100 mcg vial and give two doses of 50 but on a couple of occasions I've pulled the larger vial because I knew I'd need all five doses.

Pacu.teletriagern · Jun 29, 2014

Hello :) First of all, although I understand careful monitoring and guidelines about narcs, you have to understand that the PACU is a different bird than the rest of the units folks often work. The environment, med orders and administration, and everything is just really different. Having worked all over I understand how this conversation sounds to someone who has never worked in the PACU, and I agree that having rules regarding these drugs is important. That said....

If you haven't worked PACU you have a hard time understanding why this is an issue, but it is. Rules are only as good as the nurses ability to, within her care and workflow, reasonably follow them. Special guidelines are, I think, needed in certain units. I have worked in 5 different PACUS, and one if them in one of the foremost teaching institutions in the US. PACUs all handle this differently, but NONE of them handle it like an ICU or floor. One PACU has little locking acrylic boxes at each bedside that meds are locked in after being labeled, and the nurses have the keys. You draw up, medicate, and lock right there by the patient. Seemed to work pretty well Then when they patient meets criteria and leaves you waste. Some places simply leave the meds at the bedside, a disaster waiting to happen quite frankly. I wear a scrub jacket. I stand between my two patients. I leave one pocket for one patient, and one for the other. I tape the vial with clear tape to the med syringe so I can scan my med as many times as needed, and then Label the cap with the patient label. I then check the label and scan the med for each administration.

What is helpful is a REAL look at the environment. The best place I worked had a meeting about the issue, and that's how they came up with their box system. The manager and nurses discussed the real situation and needs of the PACU environment and came up with REAL solutions. Simply saying, that's not what you should do doesn't help. Clear guidelines prevent problems and help us to work more efficiently as well!!

(When you are medicating every 5 minutes with 50 mcg of fentanyl per dose it is just not going to work out to waste50 mcg every 5 minutes and get out a new vial)