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The Safety of Multi-Dose Vials

November 7, 2014 Leave a comment

It has long been embraced in the healthcare industry that using multi-dose vials is cost-effective and saves the organization lots of money. Some healthcare providers will argue that they are safe. ..that safeguards in place in the organization deem the possibility of an infection contacted from the use of multi-dose vials to be remote. The argument is presented over and over and over in many institutions. However, evidence refuses to support these arguments.\

It is true that multi-dose vials do, in fact, contain common preservatives that are effective against most bacteria. However, these same preservatives are NOT ant-viral. Furthermore, the true hazard lies in the potential for contamination with multiple penetrations of the protective seal/lid/stopper. According to a paper published by Barbara DeBaun, RN, MSN, CIC contaminating pathogens can live for longer than two hours in the container before the preservative “kicks in”. It is possible, according to Ms. DeBaun, that endotoxins survive even after the preservative inactivates the organism.

Faulty aseptic technique is the leading cause for contamination in MDVs. It has been reported that 25% of practitioners reentered a vial with a needle that had been introduced into a patient. At the least, it is common to see the provider use a needle to administer the medication into an IV line, then stick the needle and syring back into the vial awaiting the next dose. Nursing staff report numerous incidents of contamination of MVDs especially by the anesthesia providers in the OR or Procedure Room. Some studies show the incident of contaminated vials to be as high as 27%. In the face of this totally unacceptable statistics, anesthesia providers, especially,continue to refuse to follow protocal It is the responsibility of the nurse circulator in the room to monitor the use of the MVDs and to report on an incident report breaks in technique in using these containers.

When discussing infections and the use of MVDs, HCWs tend to look only at stopper penetration. Stopper penetration is, of course, crucial to maintaining the sterility of the contents of the container. No MVDs should be used without a transfer device to minimize the number of stopper penetrations. Everytime the stopper is penetrated there is an increased risk of contamination. Surveyors have reported seeing stoppers with so many penetrations as to look like the stopper is mesh. Again, a transfer device MUST be used for MVDs.

Other considerations for the safe use of MVDs has to do with storage. This author noted in one center that in the medication room, half of the inventory of a specifice MVD medication was stored in a cupboard while the remainder was divided between the drug refrigerator and the anesthesia cart. Care must be taken to identify the correct storage requirements for all medication and to follow those carefully.

Labeling MVDs becomes crucial, and yet, surveyors continue to find containers where there is no label, or where the outdated medication is still in circulation. Arguments may be that it is just the preservative and not the medication. Say what?????

Some of the pathogens identified in contaminated MVDs include:

  • HIV, hepatitis B and C, staph aureus, klebsiella pneumonia, streptococcus A, serratia marcescens, pseudomonas aeruginosa and candida albicans.

Lipoid medications such as propofal are more likely to be associated with outbreaks than others followed by preservative free medications. One contaminated vial can lead to widespread outbreaks. Protection of our patients is the primary responsibility of the staff in any healthcare setting. This is not the place to note that the anesthesia provider stuck the syring and needle back into the MVD and left it there after administering the drug into the IV line. This “one little time” could be deadly—and we all know there is no such thing as “this one little time”

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Categories: Uncategorized

IMPORTING EBOLA

October 8, 2014 Leave a comment

In 2005 CDC and WHO put us on alert for the Avian Flu. We were told we were at threat for a widespread pandemic imported from Asia and other countries. Indeed, we read about the spread of this disease. The TV news stations stirred the “fear” pot daily reporting the number of cases abroad and the danger we were all in. Discussions regarding the use of rebreathing masks, especially fitted, were all over the news. Some people went to army surplus stores and stockpiled these. When news of the vaccine broke, those same people spent hours searching for a source, and, once found, stocked enough for their entire family.

Fortunately, this disease did not spread, as forcasted, in this country, and we lazy, complacent Americans leaned back and put our feet upon our desks scoffing at dire predictions regarding various diseases and potential epidemics. Regardless of CDC’s efforts to get everyone vaccinated against the flu, the % of Americans paying attention to these efforts and complying with the CDC’s recommendations remains low…perhaps, to some, alarmingly so.

We have become “non-believers” when it comes to protective vaccines. Perhaps if we had experienced the epidemics in other countries, we would be less so.

Recently, in exploring and researching information regarding childhood immunizations, I found a statement coming out of a healthcare committee studying the influenza vaccine and childhood immunization vaccinations of healthcare workers. In this article, the committee members asserted that the United States, for the most part, imports its diseases from other countries. Our immunization rates for these diseases are significantly higher than other nations, however, there are “pockets” of Americans, such as the Amish communities and reservations, where immunization is not practiced, thus putting these populations “at risk” should they be exposed to someone with the disease. Indeed, the measles epidemic in the Amish community in Ohio was traced to a person who had come in from Europe where he had contacted the disease.

Having just researched the above, it was with alarming recognition that I viewed the television reports of the gentleman from Liberia coming into this country sick with Ebola. Other admissions across the country are patients who have been flown here after becoming ill. One hospital in DC reports a possible case. It appears that we are importing this deadly disease.

What can surgery centers do to protect their patients and staff?

  • Screen the patient during the preop call. Ask them, “Have you or a member of your immediate family traveled outside the US in the last 30 days”? If yes, inquire as to where the travel occurred.
  • Query the patient about a fever or flu-like symptoms. Ask them if they have been around someone who is sick with flu-like symptoms in the last 30 days?

Ask who and the extent/type of contact.

  • Query the patient, specifically, about his having a fever, or someone with whom he has contact having a fever.
  • If your center doesn’t make those preop calls, meet with your admitting office and set up a process by which these become questions that are asked at the time of admission.
  • Teach the people performing the admitting process how to take a temperature with your skin or ear probe. If un-educated persons in Liberia can learn to do this, surely your admitting staff can learn how to perform this task.
  • Where the answers to the above questions, are a “yes”, develop a protocal for safely dispensing of the patient. If the person is febrile, or is experiencing other symptoms, remove him, to the extent possible from other patients and staff. Alert his physician advising him of the questions and responses. Follow his orders to either discharge the patient with instructions to go to the hospital for follow-up or call an ambulance for immediate transfer.

Recently, while working with a particular surgery center, I was advised the admitting office was not qualified, nor were they staffed to perform the above task. This particular center wanted to bypass those questions, and especially, never take a temperature citing lack of training, experience and time. Ergatz! In the face of a potential exposure to Ebola, I assert we cannot afford NOT to train the staff and NOT to take the time! This group suggested that the preop nurses should be managing this process. So….risk the exposure of the admitting staff and add the potential exposure of the preop nurse(s)??? Really? Again, as a group, meet. Discuss the risks. Review the disease, symptoms and risks. Discuss the logistics. Take on that this is something that has to be done, and is best done on the initial patient contact, which is at the admitting desk. Taking that on, then explore methods and avenues to make it happen. Perhaps, posting a nurse at admitting, or having a nurse assigned on a daily basis, to go to admitting when a patient is being admitted to ask the questions and take the temperature. For many centers this would mean bringing on additional preop staff. Is there a CMA or LPN who could perform these duties and who would call for the RN only if a positive result or answer is found?

In the face of the Ebola pandemic it is crucial that the ASC staff and leaders stay alert to the seriousness of this crises. We cannot afford to keep our heads buried in the sand thinking “it doesn’t apply to us”. IT APPLIES TO ALL OF US! We need to do our part to prevent the spread of and to control this disease.

Begin a QA/PI study identifying the number of your patients who HAVE traveled outside the US in the last 30 days. This will illustrate to you the degree of mobility present among your patient population and will emphasize the importance of tracking such travel. Some surgery centers ask this question as a matter of course during their initial preoperative contact.

In closing, you cannot be too vigilant—-always!

Categories: Uncategorized

NO SUCH THING!

September 12, 2014 Leave a comment

As we wait to hear more news as to how the comedienne, Joan Rivers, is doing following her “minor” throat surgery and subsequent respiratory/cardiac arrest, I am reminded of the phrase I used to preach to my staff early on in this ambulatory movement.

I remember working in the hospital recovery room managing 13 recovering outpatients a day mixed in with the inpatients. On this particular day one of the outpatients scrunched into the preop “holding” room was an 18 year old female coming in for a local D & C. I recall hearing the OR staff refer to her as “just a local”. At that time the hairs on the back of my neck stood straight up, as subconsciously I registered that there couldn’t possibly be “no such thing” as “just a local”. Sure enough a few hours later, the doors from the OR corridor burst open and anesthesia propelled a bed on which lay this same young woman being bagged with an ambu bag. During the hand-off communication, the anesthesia resident advised me that she had experienced an apparent allergy to the local—lidocaine. It was touch and go for a while, but ultimately the allergic reaction abated. When interviewing this patient in preparation for her discharge, I queried her regarding any previous such reactions. She confided in me that she had undergone some recent dental work during which she had experienced problems with her mouth swelling, etc. She allowed as how she had not told the physician or the anesthesia provider because she didn’t think it was important—–BUT, neither had they ASKED!!! We clearly could have lost this patient just from the lack of a detailed preoperative history.

The collecting of a thorough preoperative history as part of the preop assessment is a challenge always, whether the patient is an inpatient OR an outpatient. However, it becomes even more crucial in the outpatient setting where the amount of time allocated for the collection of data can be minimal in the face of busy, busy schedules, short staff, and the effort, and time, required to reach patients over the phone vs. visiting them in their hospital room. Nevertheless, such information is crucial in assuring patient safety and a safe outcome.

We do not know what the issue was with Joan Rivers. Was it a drug reaction?…a drug overdose?…some underlying, previously undetected condition? I recall the incident of a few years ago regarding an 8 year old patient in one of the surgery centers. The child came in for pe tubes and an adenoidectomy.The patient had a history of Transposition of the Great Vessels which had been repaired during infancy. He was under the care of a cardiology, was active in school playing flag football, was symptom free of any lingering health problems. A medical clearance was obtained from his cardiologist. The decision was made to do the tubes first followed by the adenoids using an LMA device to protect the airway. Bottom line, once the surgeon inserted the electrosurgery pencil ( he made no incision),the patient bled out in a bit over 1 and ½ minutes. Even the post did not reveal what happened. The point is that we, who work in ambulatory surgery, must NEVER be complacent. We must NEVER assume that the procedure being performed is “just another pe tube, etc.” We must NEVER assume that anything is routine. We must NEVER assume nothing will ever happen. We must, rather be ever vigilant through all established processes. We must never assume that a detailed patient history/assessment isn’t required. I hear so often that certain practices reserved for general anesthesia patients are not implemented for “just a local”. At one time in the ambulatory industry, local patients did not have a comprehensive H&P performed. Rather, a “procedure specific H&P” was considered adequate. CMS put the kebash on that practice with the new regulations of 2009. Too often “just a local” can turn into a major disaster!

What can be done to decrease the possibility of a catastrophe occurring in the surgery center? I would suggest:

  • Perform a comprehensive preoperative assessment on ALL patients. Demand that the patient’s H&P have been performed within the last 30 days and that it adequately documents the patients health status. I recently had an EGD performed at a corporate/physician owned “chain” center. No member of the ASC staff contacted me preoperatively to conduct a preop assessment, and during my preop visit with my physician (whom I adore and respect immensely.), he spent most of the time at the desk across the room with his back to me filling out forms on the EMR. As a knowledgeable HCP I KNOW my health status, but I should have screamed, “Hey, LOOK AT ME! This visit was followed by my annual healthy patient visit. The same thing happened. This physician, who has been my FP for many years, listened to my heart in one spot on my chest, did not auscultate my lungs any further than what he might have heard while listening to my heart, did not palpate my ankles, my glands, my belly, didn’t look in my ears,…but he sure did get that EMR filled out, and the lab requisitions! Is this happening to your patients?

As nurses, it is our responsibility to make sure that our patients are safe. It is our job to read that H&P. It is our job to collect a thorough patient assessment and to alert the physician/anesthesia provider to special conditions, or conditions not heretofore disclosed. Talk to the patient about previous medication issues from anesthesia to pain medications, to locals….all of it.

CMS says that the physician must update the H&P on the day of the procedure. Initiate a policy whereby the patient is not taken back to the OR unless the physician has been at the patient’s bedside as required by CMS.

  • Be alert regarding the drugs patients are being given. The nurse in the operating room is ultimately responsible for patient safety.       Confirm with the anesthesia provider the drug and dosage. Observe the patient. Watch the monitors. We are getting reports that not only is the anesthesia provider playing on the Notepad, but the circulating nurses are also joining in this fun Who is watching the patient?

Nurses complain about anesthesia not being vigilant during procedures. They complain about those games, the stockbroker calls, but what do they do about it?

Complete an incident report and forward it to your manager EVERYTIME you see inattention being given to the patient.

  • Use those alarms! The Joint Commission and CMS continue to beat us over the head for failure to use the alarms in the centers. Use an alarm log. Walk through with your staff and identify every alarm in the center.       Activate it such that all persons working in the center will recognize what the alarm sounding is …and where it is. Check those alarms to make sure they work. In the ORs, and PACU, make sure they are never turned down or off….and they continue to be turned off throughout the country. Perhaps the status of the alarms needs to be added to the Surgery Flow Sheet? Perhaps it is going to take a requirement for such documentation for it to be taken seriously.
  • Check the equipment.

Are you familiar with the equipment, its state of readiness for patient procedures, and its maintenance history? ADA receives numerous incident reports on an ongoing basis regarding malfunctioning equipment during a surgical procedure. Who in your organization is responsible for determining the equipment is in good working order PRIOR to its being used on a patient—-PRIOR to the start of the case? Does your organization demand that an Equipment Assessment be performed on any and all pieces of equipment that either could cause injury to a patient during a procedure, or whose absence due to a breakdown, could cause harm to a patient? If so, how often is this information updated? Who reviews it?

Is it shared with staff members? Too often, we see it done just to meet a standard prior to a survey.

Finally, beware of ROTE! Beware of performing while on auto-pilot. ThisCondition occurs where staff perform the same type of procedure over and over  and over. The advantage is that they become experts in that procedure. The danger is that they can do the procedure “in their sleep”….kinda like driving home, pulling into your driveway and wondering how you got there ‘cause you ave no recollection of the drive home. This goes with being alert, but even more so.

In conclusion, remember nothing more than this: The patient is someone’s child, mother, father, husband, wife, brother, sister, etc. His life is in your hands. You  are his advocate, his Patient Safety Officer.

Categories: Uncategorized

WHAT? MORE SHOTS?

September 12, 2014 Leave a comment

Measle cases have hit a 20-year high in the United States. CDC believes that the number of reported cases may be more elevated due to unvaccinated international travelers.

Between Jan1, 2014 and May 23 of this year, 288 measles cases were reported to CDC, the highest since 1994.

According to CDC homegrown measles was, essentially, eliminated in 2000,.but cases imported from those unvaccinated travelers and patients traveling abroad continue to infect unvaccinated Americans.

A large outbreak in the Phillipines was connected to 138 cases this year involving the Ohio Amish community, as well as that in Pennsylvania.

Unvaccinated residents of the US provide a “welcome wagon” for measles imported from abroad. Measles is still common in Europe, Asia and Africa. The Phillipines has reported more than 32,000 measles cases and 41 deaths from January to April 20, 2014.

CDC recommends not only children receive the vaccination, but adults who were not previously immunized or are unsure of their immunity status.

The Advisory Committee on Immunization Practices and the Healthcare Infection Control Practices Advisory Committee (HICPAC) for vaccinating healthcare personnel in the United States has made recommendations for vaccination of HCP to include HCP in long-term care centers, nursing homes, skilled nursing facilities, physician’s offices, hospitals, rehabilitation centers, urgent care centers, outpatient clinics, home health care and emergency medical services. Ambulatory Surgery Centers fall under outpatient clinics.

According to this report (discussed in this article), many HCP are at risk for exposure to, and possible transmission of, vaccine-preventable diseases because of their contact with patients or infective material from patients. Employers and HCP have a shared responsibility to initiate reasonable precautions to prevent transmission of vaccine-preventable diseases. Vaccinations are an integral part of the organization’s Infection Prevention Program. .Inclusion of this process into the active IPP could substantially reduce the number of susceptible HCP as well as the potential risks of transmitting vaccine-preventable diseases to their patients and other persons with whom they come in contact.

In so far as the Hepatitis-B vaccination is so widely acceptable among HCP, we will not be discussing this vaccination in this article. Rather, we shall be discussing the efficacy of the influenza and rubeola vaccines, specifically..Additional information regarding other childhood diseases will also be included.

Influenza:

According to the Advisory Committee report influenza causes an estimated average of >200,000 hospitalizations and 3,000-4,900 deaths annually in the United States. The majority of influenza-related severe illnesses and deaths occur among persons with chronic medical conditions, infants, young children, seniors and pregnant women. Reducing the risk for influenza among higher risk patients is a focus of influenza prevention strategies.

HCP are especially susceptible to exposure in their workplace, and are, thus, at risk for transmission of influenza to their patients and other HCP. A study conducted among hospital staff reported 37% were experiencing flu-like symptoms during the active “flu” season. The average staff member lost 7 days of work. Of concern, however, are those HCPs who continue to work while experiencing flu symptoms, thus infecting all in their environment. While few expansive studies have been conducted, one study did report that HCP receiving the vaccination had fewer respiratory infections associated with influenza.

Influenza outbreaks of severe respiratory illness among HCPs have been associated with low HCP vaccination rates. Vaccination of HCPs can provide additional protection for those patients who are at risk for influenza, but who cannot receive the vaccination;e.g., infants, the elderly, pregnant women, those with sever allergic reactions, and the immuno-suppressed, among others.

Barriers to HCP acceptance of the influenza vaccination include:

  • Fear of vaccine side-effects (especially influenza-like symptoms0
  • Insufficient time or inconvenience
  • Perceived ineffectiveness of the vaccine,
  • Perceived low likelihood of contracting the flu
  • Avoidance of medication
  • Fear of needles

CMS has mandated that the flu vaccine be offered to all staff to include physicians and allied health staff. In addition, the organization is to calculate its percentage of staff compliance annually and develop strategies for improving compliance. Such strategies might include:

  • Encouraging the staff person’s desire for self-protection,
  • Identifying previous acceptance of the vaccine,
  • Capitalizing on the desire to protect patients and their family
  • Stressing the effectiveness of the vaccine
  • Developing a campaign to include posters and educational material identifying the benefits of vaccination
  • Vaccination of leaders
  • Making the vaccination process easy and stress-free
  • Providing intranasal vaccine for those staff who dislike needles

Those staff who refuse the vaccine should sign the Declination Form themselves stating the reason for the declination. The Employee Health Nurse/Infection Preventionist should calculate total compliance and shall identify annual compliance goals to reach the CMS goal of 90% by 2020.

Effectiveness of the vaccine varies from year to year and is specific to the individual and to the strain in circulation.Vaccine strains are selected for inclusion based on international studies identifying those in circulation.

Measles

Measles is a highly contagious illness that is transmitted by droplets and is airborne spread. Prior to the national immunization program being implemented in 1963 an estimated 3-4 million persons in the US acquired measles annually. Approximately 500 persons a year died, and 1000 had permanent brain damage from encephalitis. Measles remains widespread in countries outside the Western Hemisphere with an estimated 20 million cases reported each year. The United States continues to experience international importation leading to transmission to unvaccinated residents with resultant outbreaks.

Of reported cases, over half of the patients had never been vaccinated.

Vaccine coverage in the US is high with 90.5% of adolescents having received the vaccination.

Medical settings played a prominent role in perpetuating outbreaks of measles. Because of the severity of the disease, infected persons are most likely to seek medical care in primary-care settings. Because of the greater risk of exposure, HCPs are at a higher risk for contracting the illness. Some studies show this risk as high as 19% greater than the general population. Studies show that immunity among those having received the vaccination in infancy remain at 93-95% through the ages of 6-49 years.

The recommendation from the Advisory panel is that all HCP should have demonstrated evidence of immunity to measles. This information should be documented and readily available in the employee’s health file.

New York, Oklahoma, Rhode Island and New Jersey have laws regarding the proof of measles immunity and do not allow for religious or philosophic exemptions.

The measles vaccine is given in conjunction with rubella and mumps thus protecting the patient from all three infections.

Mumps

Adults experiencing either measles or mumps may react severely requiring intensive care in the hospital setting.

There is a concern that the reporting of mumps infections may be under-reported, as in some patients, the symptoms are minimal. The highest rates occur among dentists and Health Care Persons. Mumps outbreaks have occurred in the US as late as 2010 in the northeastern region of the U.S.with 3,400 cases reported. Of these only 7 were healthcare workers. Most likely, the HCPs were infected by the patients.

It is estimated that as high as 13-14% of healthcare workers lack antibodies to the mumps virus This author knows, personally, of two HCPs who contacted the disease at work and ended up in the intensive care unit fighting for their lives.

The Advisory Committee recommends all persons who work in health-care facilities should have presumptive evidence of immunity to mumps.

Rubella

Rubella (German measles) is a viral disease characterized by a rash, low-grade fever and malaise. Prior to the vaccine being licensed in the US, reported rubella diseases were at 57,686 annually. This disease could lead to encephalitis, fetal deaths, miscarriages, stillbirths, various other birth defects to include blindness, deafness, mental retardation and congenital heart defects. From 2005-2009 54 cases were reported. 23 of these were import-related. Rubella importation is expected to continue.

Only three states (as of 2011) have laws mandating proof of rubella vaccination among HCPs with no exceptions. The Advisory Committee recommends vaccination, or proof of immunity among all HCPs.

Whooping Cough

Pertussis is a highly contagious bacterial infection that was once prevalent in the US. Like the other infections discussed above contact is through respiratory secretions. Symptoms in the early stage are indistinguishable from other upper respiratory infections.

Vaccinated adolescents and adults whose immunity wanes (5-10 years from the most recent dose of the vaccine, are an important source of pertussis. Outbreaks across the US occur frequently. Some are misdiagnosed and result in continued transmission in the population. One report included a young mother who unknowingly had pertussis and passed it to her infant who had not, as of yet, been vaccinated, and who subsequently died.

In healthcare settings transmission can occur from patients, visitors or HCPs. Exposure

is difficult to define in the healthcare environment. The exposure is highest in those facilities catering to pediatric patients; however, even in ambulatory settings not catering to pediatric patients, children may abound in the waiting room.

Summary:

Care of the patient exhibiting any of the above infectious processes, must include the masking of the patient. Part of the patient’s preoperative assessment should include the status of his childhood immunizations and the presence of any symptoms that might be indicative of the infections discussed above.

The Employee Health Program should include the status of the employee’s childhood immunizations, and, if the employee has no knowledge of his status, titers should be drawn with results placed in his employee health file. If no antibodies are present, re-immunization or a booster shot should be indicated.

It is time for Ambulatory Surgery Centers managers to fully embrace the hazards that failure to become knowledgeable about their staff’s health status regarding childhood immunizations and to incorporate this information into their basic employee health program.

Categories: Uncategorized

Language Barriers

October 4, 2012 Leave a comment

Staff

The question arises over and over as to whether people who are doing the housekeeping and who are cleaning instruments and scopes have to be able to read and speak English in order to be able to read instruction manuals for the use of equipment and for cleaning equipment and scopes, and for mixing solutions, reading instrument cleaning agent labels, and reading MSDS no say nothing of emergency instructions and signs.

According to OSHA, it is not necessary for those persons to be able to read English if the information is also available to them in their language, or if there is a translator who has trained them and/or is available to translate.  

Hmm..so….you best get your applicable MSDS also in that language and you had best get the instructions on the labels on bottles for mixing, etc. in that language, too.  

Can you GUARANTEE that there will always be a translator available when needed?  

What about during the night when housekeeping is there?  Think about it.

 

 

 

 

Patients

How are you all handling your patients’ health literacy?  Health literacy includes much more than reading proficiency.  It is a person’s ability to obtain, use and understand the information given to them.  It includes English proficiency and cultural beliefs.  We, as health care professionals, need to include these in our teaching even though we are feeling rushed in our busy ambulatory surgery/endoscopy centers.  Incorporating these learning styles, cultural beliefs and language abilities will result in the patient having a more positive surgical experience as well as outcomes.

It may be that many of us complete our cultural competencies as a chore, and not incorporate the distinctions we learn into practice in taking care of our patients.  What cultural competency means is that you are open to recognizing that people’s beliefs may be different from our own and some of these beliefs may influence how patients understand their health.

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

July 27, 2012 Leave a comment

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.

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