Archive for October, 2011

Disposing of Drugs

October 19, 2011 1 comment

More and more surgery centers (and other healthcare institutions) are faced with the challenge of disposing of their unwanted or expired drugs.  The Controlled Substance Act and DEA regulations dictate the handling of controlled substances to include the disposal of unused drugs.  Pharmacies are mandated NOT to take back unused or expired drugs.  In the past, organizations were advised to return these to reverse drug distribution centers or to the DEA, but now, neither of these will accept unused or expired drugs.  We were, also in the past, advised to flush them down the drain.  This included not only unused drugs or expired drugs, but medication left in syringes and IV solutions and/or other medications in solution.  While expired pharmaceuticals do not represent a serious threat to public health or to the environment, improper disposal may be hazardous if it leads to contamination of water supplies or local sources used by nearby communities or to wildlife.  States such as California and Washington prohibit disposal of virtually any drugs down the sewage system.

In general, wastes that are acceptable for flushing down the sewage system include IV solutions such as saline or glucose, lactated ringers, or solutions containing nutrients or electrolyte salts.  Not acceptable would be IV solutions containing antibiotics, actineoplastic/chemotherapeutic agents, controlled substances or narcotic pain medication.

Drugs Suitable for Flushing per the FDA include:

  • Fentanyl citrate
  • Daytrana Transdermal Patch
  • Duragesic Transdermal System (fentanyl)
  • OxyContin Tablets
  • Avinza Capsules (morphine sulfate)
  • Baraclude Tablets (entecavir)
  • Reyataz Capsules (atazanavir sulfate)
  • Tequin Tablets (gativloxacin)
  • Zerit for Oral Solution (stavudine)
  • Meperidine HCL Tablets
  • Percocet (oxycodone and acetaminophen)
  • Xyrem (sodium Oxybate)
  • Fentora (fentanyl buccal tablet)
  • Meperedine tablets (demoral)

Understand that this author and other environmental experts disagree with the FDA and these disposal recommendations. Instead it is recommend to crush all solid medication or dissolve medications (solid or liquid) in water and mixing that solution with kitty litter (already in the center as part of the spill kit for hazardous substances) or other unpalatable substance such as coffee grounds for disposal.

The White House Office of National Drug Control Policy (ONDCP) and the EPA, as well as the American Pharmacists Association (APhA) have all published similar recommendations.

Institutions producing large amounts of unused pharmaceuticals such as hospitals or pharmaceutical distribution centers may utilize encapsulation to destroy unused or expired drugs.  Encapsulation involves immobilizing the pharmaceutical in a solid block with a plastic or steel drum.  The container is then filled with cement, a cement-like mixture, plastic foam or sand.  Such disposal methods are not practical for a surgery center; rather, surgery centers should use either the above “crushing and dissolution” method or inertization/immobilization.

Inertization is a variant of encapsulation and involves removing the packaging materials, paper, cardboard and plastic, from the pharmaceuticals.  Pills are removed from the blister packs, ground, mixed with water and some mixture—could be litter or coffee grounds—placed in a bottle such as an empty saline bottle, top taped and then hidden in the trash to go to landfill.

Ampoules can be crushed using protective hand and eye wear and placed in mixtures such as above or diluted with water and disposed of as above.  Sweep up the crushed glass and dispose of in sharps containers practicing safety precautions.

The disposal of controlled substances must always be in the presence of two licensed persons, one of whom should be your pharmacy consultant.  Substances have to be rendered unusable as discussed above, and then can be dispersed among the landfill (or follow the above FDA list for sewage disposal).

Aerosol containers to include inhalers should go to the landfill.

Non-controlled substances may be disposed of by:

  • Keep the medication in the original container, but mark out any identifying information.
  • If pills, add water to dissolve.  For liquids, add litter or coffee grounds or even dirt/sand.
  • Close the lid and secure with duct or packing tape.
  • Place the bottles inside an opaque container such as a saline or water/irrigating solution bottle, detergent bottle, etc.
  • Capeand tape the container closed.
  • Hide the container in the trash.  DO NOT place in your recycling bin

SmarXt Disposal poster

There is HUGE emphasis being placed on controlling the unlawful distribution of drugs today.  We, in the ambulatory surgery industry, can do much to curtail this activity by properly controlling how WE dispose of the unused or expired drugs in our centers.

Please follow our blog for more information to come as this remains a hot topic especially in the realm of controlled substances.

Measuring Patient Satisfaction, Part 3

October 3, 2011 Leave a comment

Conversations with the QI Coordinator in these incidences (in part 2) resulted in significant changes in the entire education of the patients. In all of the centers the decision was made to conduct the postoperative teaching during the preoperative phone call or visit.   The QI Committee met to discuss what additional steps could be taken to enhance patient teaching and in all cases came to the realization that their teaching really had been only to cover the usual basics all patients experience during the first 48 hours postoperatively, but did not include effective discharge planning; i.e., care beyond the basic physical care of the wound, etc.  The next step was to identify the types of procedures where additional education and planning would be warranted.  The groups identified additional information that would be needed.  All of the groups admitted that they always asked if there was a caregiver and stressed that that person, or someone, had to be there to drive the patient home.  However, they never inquired regarding the health of the caretaker or much more beyond the driving the patient home conversation.  “Can your caretaker adequately care for you at home?  Can this person provide your meals?  Change your dressing?  Help you ambulate?”  These questions were added to the preoperative teaching.  Additional questions developed included the home environment; e.g., are there stairs to navigate to the TV?…to the bedroom?  Who will prepare your meals?  Help you bathe?  These questions became very helpful when in the course of interviewing one patient, it was discovered that his “caretaker” would be his wife.  He had planned to take a cab in for his cataract surgery and to return home where his wife would assume his care.  However, it was discovered that his wife was a cardiac patient and was bedridden!

The next step many of the groups made was to contact the various patient care coordinators in some of the physicians’ offices soliciting their help in getting this information from the patient at the time he was scheduled for his surgical appointment.

The pre-op staff in the centers revised their preoperative phone call process to make the call on the average two weeks prior to the scheduled appointment in order to allow adequate time for the patient to make his plans.  One center developed a service of adult care persons to serve as caregivers for their patients.  These persons were all known to the center staff.  Background checks were done on them. CPR certification was a requirement to be placed on the list.  The patients who had no caregivers were given the list and had the option to contract with one of these persons.  The patient paid the caretaker.  These persons were bonded and screened by the center leaders.  This alleviated cancellations at the last minute due to the unavailability of a caretaker, or the confrontation of the patient postoperatively when no caretaker arrived to take him home.  The caretaker brought the patient to the center for his procedure, stayed and participated in the postoperative instructions, drove the patient home, prepared him a meal, stayed the first night and brought him back for his first postoperative visit.  This program has been in place several years at this particular center resulting in high patient satisfaction rates.

Additional centers have begun asking their focus questions through postoperative e-mails to the patients and are reporting very positive results from this process.

Measuring patient satisfaction need not be a hair pulling, frustrating process, but, rather, can result in tremendous satisfaction on the part not only of the patient but of the center leaders and staff.

Categories: Quality Improvement
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