Should ASC’s Consider Valium A Safe “Take-At-Home” Pre-Operative Drug?

I recently received an inquiry from one of our Clients regarding a practice the physicians wanted to initiate at their ASC.  The physicians believed that patients would be best served if given 0.5mg of Valium taken post-operatively at home the morning of surgery.  This would enable them to be nice and relaxed when they got to the pre-op area.

Consideradtion #1 Patient Age and Side Effects 

There are several issues going on here.  When considering what drugs to use with any patient, one has to consider the age of the patient and all possible side effects inherent to the age.  Obviously, the elderly and the very young have special considerations regarding their age whenever choosing a drug, but what is in consideration here is adult and geriatric patients.

Valium is a benzodiazeprine and is used widely to reduce tension and anxiety and, in surgery or certain medical treatments, to induce amnesia.  It is also used for seizures, restless leg syndrome, as a muscle relaxant, and for its sedative effects.

Adverse effects include anterograde amnesia.  Cognitive deficits can persist for up to 6 months or longer. Produces sedfation.  Paradoxicaol effects include excitement, rage, worsening of seizures in epileptic patients.  In patients suffering from, or prone to depression these symptoms can worsen.

The sedative effect of Valium may last longer in older patients.  There is also an increased incident of falls and accidents following the administration of Valium in the older patients.  It can lead to catastrophic side effects if mixed with alcohol. (Remember Karen Ann Quinlan?).  Valium is very addictive.  One physician discourages it use under any condition due to its degree of impairment in some patients.

Valium is detectable in the blood for up to 3 days.

If patients are given a sedative at home, doesn’t this increase their chances of falling at home?

Consideration #2 Falls Prevention Strategies at Home 

Falls in the elderly are a serious concern.  Within our ASCs, we initiate a “Falls Prevention Program.”  We inservice our staff in this area and measure their competency.  We track and trend falls and make changes in our Centers to decrease the possibility of falls.  We paint parking guards in the  parking lots and curbs.  We escort patients to their car.  We don’t leave patients alone to dress following surgery, but insist on staying with them to assist.  We identify patients at a high risk to fall with colored socks or wristbands.  We hold their arm when ambulating.  We recognize that the patient has received sedation, and are, thus, at a higher risk to fall.

BUT if these same patients are given a sedative at home doesn’t this increase their chances of falling at home?  I think of some of our elderly patients especially with their walkers, canes, and underlying health conditions that pre-dispose them to falling.  I know, too, how many times patients with underlying conditions get their feet “tangled up” and fall, and know that this risk has to increase when sedated.

Consideration #3 Alcohol Use by Patients

Valium can be lethal if taken with alcohol.  While alcohol use in the elderly is far below that of the 20 something age group, it is not uncommon.  Alcohol use in the elderly may, in fact, be under-reported.  Many retirees believe they can now sit back and do whatever they want.  Many believe they have earned the right to drink whenever and whatever they choose.  Many life-long habitual users may have increased their alcohol intake with all the golf games, card games, bingo matches, etc. to the extent that a “little nip” at breakfast is not uncommon.  This under reporting includes admitting to their physicians the extent of their use.  Valium and Alcohol do NOT mix…even that little nip can be dangerous.  It should be a concern that our patients fully understand this, discuss their use honestly with their physicians, and comply with instructions.

Consideration #4 Patient Depression and Dependence

Depression is increasingly common among our older population.  Their lives have changed, and are continuing to change, on an ongoing basis, in almost every aspect.  They retire from careers of 20-30 years that have demanded a large part of their lives and have helped to define them as individuals.  They become “stay at home” residents of the community.  This is where they might discover they have no hobbies, or they find that the hobbies they had before aren’t available to them now due to heath problems.  Their physical condition has changed.  They don’t have the stamina they once had.  They may be experiencing some underlying health conditions such as high blood pressure, cardio-vascular disease, coronary disease, diabetes.  Their mortality may be smacking them square in the face.   Husbands and wives are thrust together all day long, another adjustment.  Valium can increase this depression…but, the sedative properties may also provide an escape from all their problems and lead to dependence.

Consideration #5 Choosing Alternative Drugs 

The advantages of Valium under a controlled situation cannot be argued.  However, I would argue that there are other equally advantageous drugs that may be used to provide sedation and insomnia.  Cost may be a factor, as some of the alternative drugs are certainly more costly than Valium.

Consideration #6 Patient/Care Person’s Education 

Patients being given Valium should be reminded to not drive, make important decisions, or sign legal documents for up to 24 hours after taking the drug.

At the very least, the patient’s care person needs to be thoroughly educated about the drug during the pre-operative phone call, so as to be able to take the necessary precautions.

Consider #7 Risk Management and an Alternative Strategies

I am not pointing fingers at this drug and saying, “No! No! No!”  Valium is a staple in any health clinic’s inventory as recommended by WHO.  I am merely pointing out that it is not to be considered lightly, and we, as ambulatory surgery healthcare specialists, need to look at it seriously when prescribing it as a “take at home” med prior to surgery.

I recommend, as a licensed risk manager, that we not give the patients this drug at home prior to their admission to the center, but that we expedite the admission process such that their dosage could be given as soon as possible once they are admitted to the pre-op area.

We should always take great consideration in selecting any drug we prescribe to the patient to be taken at home with no medical supervision.

The Pre-Operative Patient Assessment in an Ambulatory Surgery Center

According to The ADA Group Center policies “all patients deemed appropriate for procedures performed at the Center are to be interviewed in order to collect a comprehensive patient history, to include medications, and to identify inherently dangerous patient conditions. Patients are to be counseled and assessed paying particular attention to special needs inherent to the patient’s age, prior historical events and underlying health conditions as they impact the proposed surgical and anesthetic event.  Vigilance will occur especially in regards to the recognition of risks inherent to surgical procedures relating to potential adverse drug reactions and interactions, potential or anticipated critical events and to the potential for surgical site infections.

During the pre-operative interview, whether conducted on-site or through a telephone call,  the peri-operative staff assess the patient’s ASA status, anxiety level, food and drug allergies, skin issues and integrity,  any potential airway issues such as those identified due to a history of sleep apnea, previous anesthesia issues/susceptibility to malignant hyperthermia, pending lab/radiographic studies and results, pre-operative disease status and those special needs inherent to the patient’s age.

Patient education during this pre-operative interview is crucial.  The time constraints in the ambulatory surgery setting make the collection of comprehensive information and patient education challenging at best.  These time constraints do not, however, serve to provide an excuse to erase the performance of the pre-operative assessment and education process from the organization’s routine activities.

And yet, this seems to be a growing trend, as more and more surgery centers are reporting that staffing constraints have, in fact, negated this activity.

Patient education is one of the primary roles of the peri-operative nurse working in ambulatory surgery.  Research has proven that patient education plays a huge part in successful and positive patient outcomes and in patient outcomes and satisfaction.

Patient education should start with pre-operative brochures either sent to the patient when scheduled, procured by the patient through the organization’s website, or provided to the patient during their pre-operative physician or ASC interview/visit.  This process would be enhanced through on-site tours, group educational meetings, phone calls and education reinforcement conducted on the day of the procedure.

Recently, a licensed risk manager did a trend analysis of patient cancellations in just one of her surgery centers to determine the number of patients being cancelled in the pre-op area on the morning of their scheduled surgical/endoscopic appointment.  Of these, many had either eaten or drank something.  Several had not taken required medication or followed their plastic surgeons pre-operative antibiotic regime.  At least two to three per month had inadequate preps with the same number presenting with incomplete lab work.  Three to four patients each month presented with atrial fibrillation or pulmonary issues.  Top this with a minimum of two to three patients a month presenting with no care person and you have a large number of cancellations occurring after the patients were admitted, and, frequently, had IVs started.  While this number was excessive in this one center, a review of some other centers uncovered similar problems—though not so extensive.  In virtually all of the instances identified, none of the patient’s had received a pre-operative phone call from the center, though all had been sent written instructions.  In all centers staff were queried regarding the breakdown in the performance of pre-operative phone calls/interviews.  New staff members were appalled. Faced with the tight staffing they experienced in the ASC, they could not believe that such a thing would be required of them.  They had no understanding, moreover, of the impact these cancellations had on the organization.  Older staff members often recalled a time when pre-op phone calls and/or interviews were done, and that, oftentimes, there was even a pre-operative coordinator who performed this duty.  None believed there was adequate time allowed in the schedule for this activity to occur.  And yet, this licensed risk manager saw part-time nurses rushing to get out of the center at the end of the schedule, or sitting at the nurses’ station or in the lounge for 20-30 minutes chatting.  This same licensed risk manager witnessed staff gossiping and chatting with one another in different parts of the center throughout the day.  All of this activity added up to a rejection of the staff’s assertion that “there is no time to make these calls”.

Further investigation of center’s performing as many as 7,000 cases a year found that those centers were being successful in completing 85-90% of their calls/interviews. A 100% goal was rejected due to late “add ons” and failure of patient response/inability to connect with the patient preoperatively.  These patients were educated and assessed the morning of their procedure.

CASE STUDY

Adequate preparation makes a huge difference in the patient’s response to his entire procedure.  A four year old was scheduled for bilateral PE tubes.  The grandmother, an OR trained registered nurse living with the family eagerly awaited the child’s phone call scheduling a time for the child to come in for her tour and to get her sample anesthesia and/or surgical mask and to play with the stuffed animal surgical patient.  No call came, so the grandmother awaited the pre-operative phone call to educate the child on what to expect and to gather information in order to best prepare for the care of the child.  No call came.  The grandmother put all her experience in place and did the teaching for the child.  A trip to the hardware store got a mask and hair cover.  The child was told what to expect on arrival, in the pre-operative area…what the OR would look and sound like…it would be cold…everyone would be dressed the same…the equipment, the noises, the table/bed…the anesthesia mask.  On the day of the procedure, the little girl hopped off the pre-op stretcher taking the OR nurses’ hand and walked right down the OR corridor and into the room.  The ASC staff did make a post operative phone call to the family during which she bragged on how brave the child had been and that they had never had a child do that before “without even a whimper”.

CASE STUDY

In another case, a 69 year old patient was scheduled for a colonoscopy.  During her pre-operative visit her physician provided her the packet of information from the surgery center.  This particular patient happened to be an ASC registered nurse of nearly 30 years experience.  A week prior to the surgical appointment, the nurse opened the packet and discovered that the first piece of literature advised her that the procedure would be performed at one of two centers, but not which one. She waited a day or two for her pre-operative call to clarify the issue.  None came, so she called her physician the Friday before the surgical appointment to find out where she should go.

A comprehensive pre-operative phone call or interview is crucial to patient safety and satisfaction.  Needless to say, neither the grandmother in the first example or the RN in the second will frequent those two centers again…and…rest assured their dissatisfaction has been loudly shared with family and friends who will also, most assuredly, shy away from those two centers.

Conducting a comprehensive pre-operative patient assessment and teaching interview, whether on site or over the phone, need not erode into staff overtime pay.  How is it possible to get this very important activity done in the face of “staffing skinny”?

Pre-operative assessments can be conducted as near the time the patient is scheduled as possible.  Consider setting up a system identifying those patients who are awaiting surgery/awaiting the pre-operative assessment and education interview.  All pre-operative staff should be trained to conduct these interviews and to recognize Red Flags reported during the interview for referral.  The “Awaiting” files are checked daily.  The goal would be to do the assessment as soon as possible—some may be two weeks out from their surgery date.  Staying ahead is a bonus allowing time to get those patients scheduled closer to the date of their procedure interviewed.

Once the history is collected, cultural diversities identified, special learning needs addressed and general educational

information imparted, the pre-operative nurse monitors the receipt of lab, EKG or radiographic reports, the physician’s H&P and consents which are all added to the patient’s file whether paper or electronic.  Anything missing is identified well in advance of the surgery date and collected at that time.  Continual monitoring identifies “missings” well ahead of the surgical date thus decreasing those nasty surprises that happen on that date when the H&P, lab work, consents, etc. are missing resulting in case cancellations and/or delays to say nothing of the irate patient and physician.

ASCs pride themselves on patient satisfaction.  Cancellations and delays impact patient AND physician satisfaction tremendously to say nothing of the cost incurred by the organization for supplies used in pre-op, staff hours and salaries, supplies opened in the OR and those corresponding staff costs.  Add this to the negative experience by both the patient and physician, and the cost is even higher.  It could be argued that the organization cannot afford to NOT do the pre-operative interview and assessment.

The Joint Commission and CMS urge ASCs to embrace a culture of patient safety.  How could this even remotely be possible without a pre-operative assessment and educational interview conducted by the ASC?