2006 OPEN FORUM Abstracts
Transition to PYxis medication distribution away from department stock when utilizing a therapist-driven protocol
--Tim Frymyer, BS, RRT, David Mussetter, BA, RRT, Michael
Trevino, MS, RRT, Gary Weinstein, MD, FCCP, Presbyterian Hospital of Dallas,
Background: Our 903-bed metropolitan hospital averages approximately 14K metered dose inhaler (MDI) treatments and 18K nebulizer (SVN) treatments/year (excluding neonatal). These medications were delivered to the respiratory therapy department where they were stored, retrieved and administered by the respiratory therapist (RCP). Our department has utilized a therapist-driven protocol (TDP) system for 13 years. All physician written orders on adult patients for respiratory therapy (RT) are viewed as an order for TDP (unless otherwise stated). The RCP evaluates the patient within two hours of receiving an electronic notification, which pharmacy also receives. The RCP then writes or rewrites the appropriate medication and therapy orders. A PYXIS system can create a challenge to workflow with regard to the RCP evaluating the patient, writing an order for treatment and then administering that treatment. Previously, the RCP shouldered the responsibility for first review when administering the initial treatment, with pharmacies initial review being completed within 24 hours. PYXIS, however, requires pharmacy's review and activation before the medication can be dispensed. The questions were, how much of a delay would this step create to our workflow, would RCP productivity be negatively impacted, and would timeliness of care be delayed.
Method: An initial pilot was conducted to familiarize the RT staff with the PYXIS concept. A group from pharmacy and respiratory met to discuss plans for advancing the PYXIS concept to the remainder of the hospital. Medications to be stored in PYXIS were identified and par levels were set. Pharmacists and RT staff were in-serviced on all facets of the conversion. After reviewing our practice model and published commentary on JCAHO and medication management, a list of medications were identified that could be overridden in PYXIS by the therapist for immediate delivery: albuterol, levalbuterol, racemic epinephrine, and ipratropium bromide. This was endorsed by the pharmacy clinical manager, RT leadership and our medical director. Additionally, the following override choices were agreed to: 1) Immediate bronchodilator evaluation needed by Respiratory Therapy and 2) Patient in respiratory distress.
Results: Since the conversion on March 1st, 2006, the RT staff has embraced the PYXIS idea and communication between the staff pharmacists and RCPs have grown exponentially. Pharmacy now pages the RCP if we have not rewritten the initial medication orders within one and a half hours of the electronic notification. During our recent unannounced JCAHO survey, the examiner was very pleased with our medication management solution. The override feature has enabled the continued seamless dispensing and administration of medications. The RCP still operates with the responsibility of first review with the initial treatment. However, the RCP is not allowed to retrieve a second round of medication from PYXIS until pharmacy has reviewed and activated the order, unless it is an urgent need for respiratory distress (for example, back to back treatments). Therapists' productivity did not change in relationship to the assigned workloads and RCP feedback has remained positive, thus providing two leading indicators that no disruption to the TDP workflow was created. Finally, levalbuterol was removed from PYXIS due to its storage/packaging limitations.
Conclusion: Our experience with converting to a comprehensive medication management solution using PYXIS, within the framework of a therapist driven protocol, has been positive. We have been able to process and administer orders in the same seamless manner as before PYXIS with the use of the override choices. We continue to operate with a common canister MDI system, maintain workflow and productivity, and have decreased the likelihood of missed orders by partnering with pharmacy to spot and communicate new orders. Communication and detail planning can provide a positive outcome to your medication management strategy.