Hospital Pharmacy Practices designed to reduce incoming phone calls and medication requests.

[Sparda29]

I'm looking for some policies/workflow adjustments that would help a pharmacy reduce how often nurses call down for missing meds.

Some of my ideas:

- Day shift IV room should produce and send up enough patient specific IV products/IV antibiotics/pressors/sedation meds to last the patient until 24 hours later for meds that are not stored in the pyxis or that have to be compounded. Have the meds stored on the floor in a med room. The nurse should not be calling down every 6-8 hours for the same ****. Part of my job is to do the PO fill list for the whole hospital for meds that are not in the Pyxis. I send up enough stuff to last them until the next cart fill. When I get an order for a medication, I give them enough supply to last them until the next cart fill. Everyone else seems to send one dose.

- Produce IV meds in the highest concentration possible to ensure each bag as long as possible. My per diem hospital makes fentanyl drip in 2000 mcg/100 mL. My full-time does it in 500 mcg/100 mL.

The reasons I've gotten in resistance to what I propose is they don't want a bunch of meds being returned because of patients being moved around constantly, nursing losing/misplacing meds, medications expiring, cost of losing meds to expiration. It is bizarre.

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[PharmDBro2017]

Have nurses send a msg via EMR, rather than calling you. EPIC has that capability and it is so much better than getting calls all night.

We do fentanyl drip 2500mcg/250mL.

Precedex 1000mcg/250mL is good too (maintain 4mcg/mL standard concentration).

 

[ValeRx]

We do 1000mcg/100ml fentanyl drips at my hospital.

As far as missing doses, BCMA has an option for "missing dose" which then prints off in the pharmacy which we then send up to them on the next med run. Nurses still call though, which defeats the purpose.

 

[gwarm01]

Have nurses send a msg via EMR, rather than calling you. EPIC has that capability and it is so much better than getting calls all night.

We do fentanyl drip 2500mcg/250mL.

Precedex 1000mcg/250mL is good too (maintain 4mcg/mL standard concentration).

Yeah, answer enough phone requests with "sure thing, just send me a request in Epic so I have the right patient / med / won't forget" and eventually most of them will stop calling. Most of them.

 

[Sparda29]

Yeah, answer enough phone requests with "sure thing, just send me a request in Epic so I have the right patient / med / won't forget" and eventually most of them will stop calling. Most of them.

We have Meditech. It prints out a request with the info on it, so then i gotta get up and walk to the printer lol. Better than anawering the phone though.

i love epic

 

[confettiflyer]

Yeah, answer enough phone requests with "sure thing, just send me a request in Epic so I have the right patient / med / won't forget" and eventually most of them will stop calling. Most of them.

It took about 3/4 of a year of consistently doing this across all shifts by all techs for it to finally be noticeable in the pharmacy.

The hardest ones to get to commit were our best techs known for going above and beyond...they were so used to asking for patient info right away and not deflecting a bit.

Seriously though, 1000% best practice to institute.

 

[Sparda29]

I like that idea from above. But that still results in a nursing request.

What else can we do to ensure they have everything they need upstairs? One of our problems is there is no room in the pyxis to fit stuff. They have the entire top shelf of the Pyxis tower for patient specific meds when we could be using that to put in pre-made pressor drips.

The patient specific meds should be placed inside the patient's room or at the nursing stations or on the nurses computer on wheels. Ain't no JCAHO inspection happening now.

 

[TheBlaah]

I like that idea from above. But that still results in a nursing request.

What else can we do to ensure they have everything they need upstairs? One of our problems is there is no room in the pyxis to fit stuff. They have the entire top shelf of the Pyxis tower for patient specific meds when we could be using that to put in pre-made pressor drips.

The patient specific meds should be placed inside the patient's room or at the nursing stations or on the nurses computer on wheels. Ain't no JCAHO inspection happening now.

I agree it's kind of dumb to put patient specific meds in the Pyxis. I also disagree vehemently about leaving meds in patient's rooms...


You don't have locked med rooms to place patient specific bins in?

 

[Sparda29]

I agree it's kind of dumb to put patient specific meds in the Pyxis. I also disagree vehemently about leaving meds in patient's rooms...


You don't have locked med rooms to place patient specific bins in?

We do have locked med rooms to put patient specific bins in, but when we got the Pyxis (before I started) they took out the patient specific bins from the med rooms.

Normally, none of this is an issue, but we are in Covid and we need to have the the ICUs fully stocked at all times with Fentanyl, Midazolam, Vecuronium, Norepinephrine, Phenylephrine, Vasopressin drips.

Also, each patient who is on antibiotics should have at least a day's worth of antibiotics upstairs or enough until the next cart-fill if the med is not loaded in pyxis instead of every shift getting a call for it.

 

[WVUPharm2007]

I'm looking for some policies/workflow adjustments that would help a pharmacy reduce how often nurses call down for missing meds.

Some of my ideas:

- Day shift IV room should produce and send up enough patient specific IV products/IV antibiotics/pressors/sedation meds to last the patient until 24 hours later for meds that are not stored in the pyxis or that have to be compounded. Have the meds stored on the floor in a med room. The nurse should not be calling down every 6-8 hours for the same ****. Part of my job is to do the PO fill list for the whole hospital for meds that are not in the Pyxis. I send up enough stuff to last them until the next cart fill. When I get an order for a medication, I give them enough supply to last them until the next cart fill. Everyone else seems to send one dose.

- Produce IV meds in the highest concentration possible to ensure each bag as long as possible. My per diem hospital makes fentanyl drip in 2000 mcg/100 mL. My full-time does it in 500 mcg/100 mL.

The reasons I've gotten in resistance to what I propose is they don't want a bunch of meds being returned because of patients being moved around constantly, nursing losing/misplacing meds, medications expiring, cost of losing meds to expiration. It is bizarre.

There aren't any. Pharmacists have been trying for half a century. There is no going up against the nursing monster. They have an incredibly strong union. They do whatever they want and we just have to take it. You will answer the phone. You will tube them yet ANOTHER med. The lost med WILL go onto the pharmacy budget. You will smile and be nice to your masters in scrubs.

 

[Sparda29]

There aren't any. Pharmacists have been trying for half a century. There is no going up against the nursing monster. They have an incredibly strong union. They do whatever they want and we just have to take it. You will answer the phone. You will tube them yet ANOTHER med. The lost med WILL go onto the pharmacy budget. You will smile and be nice to your masters in scrubs.

If I'm working on something, I don't answer the phone other than saying "pharmacy hold". I wear scrubs too, so that's nice.

 

[rxkrafted]

We have Meditech. It prints out a request with the info on it, so then i gotta get up and walk to the printer lol. Better than anawering the phone though.

i love epic

You can configure it to not print out if its something you already planned on filling before the request.

Also, each patient who is on antibiotics should have at least a day's worth of antibiotics upstairs or enough until the next cart-fill if the med is not loaded in pyxis instead of every shift getting a call for it.

I don't agree with day-shift putting 24 hours worth of antibiotics if its being prepared/mixed ahead of time for specific patients because many of them could end up getting discontinued/switched and it'll take more labor to try to reuse them for other patients. If the nurse is just pulling the antibiotics/diluent from the pyxis to mix themselves, I don't see why they aren't loading them in pyxis.

 

[Rockinacoustic]

We do have locked med rooms to put patient specific bins in, but when we got the Pyxis (before I started) they took out the patient specific bins from the med rooms.

Normally, none of this is an issue, but we are in Covid and we need to have the the ICUs fully stocked at all times with Fentanyl, Midazolam, Vecuronium, Norepinephrine, Phenylephrine, Vasopressin drips.

Also, each patient who is on antibiotics should have at least a day's worth of antibiotics upstairs or enough until the next cart-fill if the med is not loaded in pyxis instead of every shift getting a call for it.

Do you at least have propofol and norepi drips loaded in ED/ICU pyxis?

 

[Sparda29]

Do you at least have propofol and norepi drips loaded in ED/ICU pyxis?

Propofol yes.

Norepinephrine, yes but for some reason we aren't using one single concentration. We have 4 mg/500 ml, 8 mg/500 ml and 16 mg/500 ml in D5W and NS. We should just stick to 16 mg/500 ml or 32 mg/500 ml. Instead they leave the lower concentrations up for the doctors to order and the patients run through it fast.

 

[Sparda29]

You can configure it to not print out if its something you already planned on filling before the request.



I don't agree with day-shift putting 24 hours worth of antibiotics if its being prepared/mixed ahead of time for specific patients because many of them could end up getting discontinued/switched and it'll take more labor to try to reuse them for other patients. If the nurse is just pulling the antibiotics/diluent from the pyxis to mix themselves, I don't see why they aren't loading them in pyxis.

Problem is not all the floors have the same size Pyxis. We usually never had a filled up ICU, now we have 2 make shift ICUs.

 

[Sparda29]

Example of an interaction between me and a nurse from the same floor last night, tell me if I was being too snarky/callous:

Phone call #1 - we need a dopamine drip for X
Me: ok
Phone call #2 3 minutes later - we need a levophed drip for X
Me: ok
Phone call #3 5 minutes later - we need Zosyn for this patient
Me: we aren't gonna play this game all night. Find out what your patients and the other patients will need all night. Write it down and fax it to me.
Nurse: Excuse me? Who is this? What is your name?
Me: My name is Sparda29. We aren't gonna play this game where you just call every time you need something. We are gonna find out what you and everyone else needs so I can make it all and send it all up within the hour so we don't need to be calling each other all night.

 

[Sparda29]

Yeah, answer enough phone requests with "sure thing, just send me a request in Epic so I have the right patient / med / won't forget" and eventually most of them will stop calling. Most of them.

I have a bone to pick with you.

I asked three nurses to do this, then the printer broke and the hospital had no replacement toner cartridges which resulted in the worst night ever.

 

[PharmDBro2017]

Propofol yes.

Norepinephrine, yes but for some reason we aren't using one single concentration. We have 4 mg/500 ml, 8 mg/500 ml and 16 mg/500 ml in D5W and NS. We should just stick to 16 mg/500 ml or 32 mg/500 ml. Instead they leave the lower concentrations up for the doctors to order and the patients run through it fast.

Levophed drips in 500mL? Interesting. We always do single, double, quad strength levophed in 250mL.

 

[Rockinacoustic]

Levophed drips in 500mL? Interesting. We always do single, double, quad strength levophed in 250mL.

Same. Especially in the era of COVID fluid restriction is key.

 

[Seriously Serious]

This is probably automated, but I'd review the data of what is being requested frequently vs what is hardly being pulled each month and optimize pyxis real estate. Also, I think you should bring back patient bins and not use the pyxis for that haha. I worked for a hospital that had locked cabinets/drawers outside each room for patient meds. Perhaps an annual pharmacy training for the nursing staff about what to do when a barcode doesn't scan or they can't pull a med from the pyxis instead of dumping it on pharmacy.

 

[gwarm01]

I have a bone to pick with you.

I asked three nurses to do this, then the printer broke and the hospital had no replacement toner cartridges which resulted in the worst night ever.

Always have a backup printer man

 

[farmadiazepine]

My previous hospital eliminated all missing IVs. We scheduled IVs only for even hours (like 4p, 6p, 8p, etc) and we only made the IV 4 hours ahead of time. The IVs were delivered 2 hours before they were due. This was the most efficient way. It eliminated us from making IVs which were discontinued, and made sure we had the latest floor and room number as well. We used dispense prep and check in Epic. We also used dispense tracking in Epic. Once implemented, our missing IVs went from a ton a day to almost zero every shift. The hospital is an inner city teaching hospital with over 500 beds.

 

[samven582]

Propofol yes.

Norepinephrine, yes but for some reason we aren't using one single concentration. We have 4 mg/500 ml, 8 mg/500 ml and 16 mg/500 ml in D5W and NS. We should just stick to 16 mg/500 ml or 32 mg/500 ml. Instead they leave the lower concentrations up for the doctors to order and the patients run through it fast.

why 500 mL?

 

[RXDOC1986]

Based on 3 decades of experience with IV's and hospital policy, here is my input:
On titratable drips, mostly vasopressors, the volumes and concentrations are determined by P&P guidelines and specific "smart" IV pump guardrails. AND most are Manufacturer Pre-mixed anyway.
You just can't max concentrate all drips and put them all in 500-1000ml bags! Why? Because they are "titratable drips", at the lowest dose, the rate might be too small for the pump to run!
And to make a "jumbo" supersized bag of (let's say) vasopressin, or Isordil, the cost would be huge!
Missing IV's:, mixing for 24hrs is huge mistake, orders change, doses change. patient is D/Cd or moved. NOBODY does that. Having set batch times for IV's every 6-8 hrs or so is the best option.
Messaging: condition the RNs to send a message - Epic and Cerner have excellent messaging functions, even meditech has some form of messaging where the RN can use the drug edit function to message you and you can message RN the same way OR just give up on meditech.
Phone calls, TWO hospitals ago, working for a large teaching hospital, there was no direct calling the inpatient pharmacy. The caller had to go through 3 or 4 levels of voice prompts (options) to get to a live pharmacist. It would discourage most callers.

 

[WVUPharm2007]

Apparently the dude that covered for me while I was on vacation a few months back just muted all the ringers and didn't answer the phone from like 12AM to 7AM.

That seems like a reasonable solution.

 

[Sparda29]

why 500 mL?

As opposed to 250 mL? We want them to leave us alone. So give them a big bag and hope it lasts the whole day or more. I'd make it in 1000 mL if possible, lol.

 

[sunnyandseventytwo]

Based on 3 decades of experience with IV's and hospital policy, here is my input:
On titratable drips, mostly vasopressors, the volumes and concentrations are determined by P&P guidelines and specific "smart" IV pump guardrails. AND most are Manufacturer Pre-mixed anyway.
You just can't max concentrate all drips and put them all in 500-1000ml bags! Why? Because they are "titratable drips", at the lowest dose, the rate might be too small for the pump to run!
And to make a "jumbo" supersized bag of (let's say) vasopressin, or Isordil, the cost would be huge!
Missing IV's:, mixing for 24hrs is huge mistake, orders change, doses change. patient is D/Cd or moved. NOBODY does that. Having set batch times for IV's every 6-8 hrs or so is the best option.
Messaging: condition the RNs to send a message - Epic and Cerner have excellent messaging functions, even meditech has some form of messaging where the RN can use the drug edit function to message you and you can message RN the same way OR just give up on meditech.
Phone calls, TWO hospitals ago, working for a large teaching hospital, there was no direct calling the inpatient pharmacy. The caller had to go through 3 or 4 levels of voice prompts (options) to get to a live pharmacist. It would discourage most callers.

I agree with everything you said, except: "mixing for 24hrs is huge mistake, orders change, doses change. patient is D/Cd or moved. NOBODY does that."

I'm only disagreeing with the "nobody does that" part. As we do a 24 hour batch. We waste a whole lot of drugs, but most of it ends up getting recycled. And it doesn't cut down on phone calls. Patient's transfer and their drugs don't go with them. Nurses pull stuff out of the fridge and then forget they've taken it and get another one. Were I running things, we'd do 3 batches a day. I'd say the main thing is to be proactive and not wait until the nurses are calling for 1800 meds to make/send them.

I'll also add: particularly with pressors, your concentrations are limited by the absence of a central line. We start most patients on minimum concentrations, then increase if/when they have better access.

 

[El Trombopag]

I had success getting a couple older nurses to stop calling and just send a message w/request (Epic). A bit passive aggressive, but eh. I’m not that great of a person.
After getting their call, asking for them to send a message, I’d call them back after it was ready to deliver, letting them know it was on its way. Then I’d call 15 min later to make sure they got it. After a couple times, all I’d start getting is the med message.

 

[storyhill2]

We have Meditech. It prints out a request with the info on it, so then i gotta get up and walk to the printer lol. Better than anawering the phone though.

i love epic

When I used to work in the central pharmacy at our hospital I would tell the tech that their job was to keep me off the phone. My tech did a pretty good job with it. We do have the feature where nurses can now message us in Epic so that is helpful.