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

Measuring Patient Satisfaction, Part 2

September 16, 2011 1 comment

The first step is to review and revise your existing questionnaire.  Turn it into a tri-fold brochure and place a stack of them in your waiting room with a sign that says, “Please tell us how we are doing!”

The goal now becomes to transform the measurement of patient satisfaction/perception of care into focus questions.  These are questions that are identified by the QI Committee and the members of the Medical Advisory/Executive Committee and may be asked of the patient over a designated period of time by the staff during the postoperative phone calls.

Meet with the QIC members and the medical staff on the MAC/MEC.  Advise these persons of the intent to ask the patient questions the outcome of which will make a difference in how you practice.  A topic is selected with 2-4 questions regarding that topic.  These are put into a questionnaire or QI study format and are asked during the post-op phone call.  The callers gather the questionnaires and forward these to the QI Coordinator for analysis.  The QI Committee and/or the MAC/MEC determine if the identified topic will be queried for one, two or three months.  Results are submitted to the various committees when completed for further input.  Some of the questions asked include:

  • Did you observe the staff washing their hands during your stay at the center? How? When?
  • Was your recovery experience what you expected and how could we have improved upon that?
  • Was you pain management adequate?  Did the pain medication you were prescribed work, or did you have to contact your physician for another/different prescription?
  • Did your caretakers ask your name, the type and site of the procedure you were to undergo in pre-op, prior to starting a treatment such as an IV or prior to giving a medication, and in the OR?
  • Did you feel the staff provided you a safe environment?
  • Did you experience any infections postoperatively even if not related directly to the procedure you had done?  Were you on postoperative antibiotics?  How long did you take them?  Did you finish your course of medications?

Periodically, physicians may come forth with a comment like, “You know, I have always wondered if patients (fill in the blank) post-operatively.”  You can use these questions for your focus studies.

From questions like those identified above the committee members can identify two or three additional questions on each subject.

Results of these focus studies can be dramatic; e.g., the question about the recovery experience produced several major issues:

  • One patient had undergone a knee arthroscopy with a inguinal block. He was a professional football player whose caretaker was his 5’4”, 112 lb wife.  It seems he had to climb a series of steps from his driveway to get into his house.  The TV was in a basement media center and the bedroom was on the second floor.  He fell several times while trying to navigate to reach these various areas.
  • Patient # 2 underwent surgery for her bilateral carpal tunnels.   During the postoperative phone call she expressed her upset in that both hands were splinted.  Her husband was the helpless type who couldn’t even” fill the teakettle for a cup of tea”, but she couldn’t help…neither could she perform her own personal, intimate care.  She reported being extremely frustrated and embarrassed.
  • Patient #3 had experienced bilateral bunionectomies to include excision of her Taylor bunionettes with no understanding whatsoever of the amount of pain she would experience.  In this instance, she, too, had to climb stairs to her front door and to her second floor  media room  and bedroom.

In all of the above cases, which occurred at different surgery centers, there was inadequate teaching for the postoperative experience. Obviously the level of satisfaction regarding their experience was very low.

Part 3

Categories: Quality Improvement

Measuring Patient Satisfaction, Part 1 of 3

August 17, 2011 Leave a comment

“There must be a mechanism in place to measure a patient’s satisfaction.  The patient has  the right to express his satisfaction or otherwise.”  

These are the regulations and the standards imposed upon surgery centers by regulatory agencies such as CMS and the different state licensing agencies as well as by the various accreditation organizations.

In the early days of ambulatory surgery we took that to mean that every patient was to be given a copy of our standardized patient satisfaction questionnaire upon his discharge from the center with a request to mail it back at his earliest convenience.  This form was frequently a list of questions put together by the Medical Director, the Administrative Director and the OR Supervisor/QI Coordinator.  We dutifully distributed these forms to our patients and implemented numerous tactics trying to get back more than the usual 20-30%.  We tried giving them a self-addressed, stamped envelope at no small expense.  That helped, and sometimes got us up to a 40% return.  We tried telling our Medicare patients that the form was required to be given to them by Medicare in the hopes they would think that they had to send it in if they wanted Medicare to pay the ASC fees.

These tactics worked to the extent that they worked.  There were centers who reported returns as high as 80-90%.

Research into these reports, however, sometimes uncovered some interesting processes in place to reach those percentages.

In one center that reported nearly a 100% return rate, we found the surgeon was bringing the form into the exam room during the patient’s post-operative visit.  He would ask the patients the questions and duly complete the questionnaire with their responses.  After that, he would have the patients sign and date the form.  He was very proud of his response rate, but one wonders whether his patients felt free to respond openly with any criticisms.

In another center the staff went over the questionnaire with the patients during the post-operative phone call and completed the form.  Again, concerns are raised regarding how free the patients felt in giving their response. Nevertheless the organization was reporting exceptionally high percentage of returns on their surveys.

The passing out of the questionnaires, or the completion of them by the staff, met the absolute requirement that the patient be queried, or be given the opportunity to express his satisfaction or otherwise; however, within three-four months of a center’s opening, it became blaringly obvious that certain questions were problematic.  These questions always resulted in poor ratings; e.g.,

  • Waited too long.
  • Surgery didn’t start on time.
  • The room was too cold.
  • The fees weren’t discussed adequately.

The QI Committee reviewed the comments and implemented everything they could to try to increase satisfaction in these areas.  We did time studies and tried to work with the patients to ensure they didn’t arrive too early at the center on the morning of their procedure.  We met with the medical staff, especially those who were chronically late.  We altered our schedules, but still those complaints persisted.  We let patients wear their street clothes where possible.  We got them socks to wear on their feet.  We bought blanket warmers and wrapped them in toasty blankets.  We bought warming units of various kinds.  We met with surgeons and, where possible, increased the OR temperature as much as allowable.  We developed proposed fee schedules to give to the patients identifying the various fees for which they would be billed along with those of the ASC.  But…in spite of all these efforts these areas continued to be the ones with the ongoing complaints. So….we set up critical thresholds and declared that we would not address those issues unless we got a percentage of complaints greater than our threshold.  We continued, though, to get the complaints even though we had done everything we could think of to remedy those issues.  We even altered the survey forms taking off the offending questions, but what we, again, found was that we were not learning anything new from the questionnaires.  They truly were just an exercise to meet the regulations and standards, as we struggled to get an acceptable return rate.

But wait!  What if there was a better way the results of which could impact the way we deliver our care in our surgery center? This would take the entire process out of being a painful exercise and turn it, instead, into a valuable tool.

In part 2, I’ll share how to make this process  simple, impactful and painless…

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