THE HSC EXPERIENCE

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NARCOTIC DIVERSION

• THE HSC EXPERIENCE
• Jan Beales, Pharmacy
  
• Linda Carroll, Pharmacy
• Roberta Lowry, Nursing
• Monique Yakiwchuk, Pharmacy

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OVERVIEW

• Who are we?
• What were our challenges?
• What were our solutions?
• What are the current barriers?
• What are our future plans?
• What is our wish list?

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Who are we?

• 850 bed tertiary bed teaching hospital
• Catchment area- Province of MB and northwestern
  Ontario
• Hospital footprint 32 acres
• HSC Staff Total 7,000
• 3,800 nursing staff
• 150 pharmacy staff
• 90 anesthesiologists

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Who are we?

• Unit Dose Distribution- includes both cart fill
  and Pyxis/CIVA
• Pyxis Operations Pharmacy/Nursing Operations
  Committee
• Pyxis Equipment (46 wards)
• 62 Pyxis Medstations
• 41 Pyxis Auxiliary cabinets
• 1 tower
• CII Safe

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OVERVIEW

• Who are we?
• What were our challenges?

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NARCOTIC DIVERSION

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What were our challenges?

• 2001 completely manual narcotic system
• 2002 Pyxis on 20 Adult patient care wards
• many areas still a manual narcotic system a
  manual narcotic vault
• High volumes of narcotics
• 167,000 T3 tablets/year
• 103,000 morphine 10mg/ml amps/year
• 20,000 fentanyl 100mcg/2mL/year
• Security over 4,000 staff in database difficult
  to maintain
• Reporting tool deficiencies
• Limited resources for proactive surveillance

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OVERVIEW

• Who are we?
• What were our challenges?
• What were our solutions?

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What were our solutions ?

• Proactive Audit

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THE PROACTIVE AUDIT

• Roberta Lowry , Nursing

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THE PROACTIVE AUDIT

• Mandate (March 2005)
• Develop a business plan for a Proactive Narcotic
  Diversion Monitoring Program
• Plan to include software, PP, education staff

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THE PROACTIVE AUDIT

• Deficiencies of Existing System
• Pyxis insufficient data reporting (1 mo.)
• Pandora reports dont combine mirrored MS
• No dedicated EFT positions
• No data to project workload requirements

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THE PROACTIVE AUDIT

• Starting point
• Anomalous Use Report HospitalWide All Stations
  Report (for 9 mo)
• Findings
• 547 potential highly likely diversions
• 819 potential highly suspect diversions

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THE PROACTIVE AUDIT

• Where do we start???????

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THE PROACTIVE AUDIT

• Narrowing the choices..
• Select a drug likely to be used in many areas
• Select an area with a single MS
• ..and the winner is

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THE PROACTIVE AUDIT

• Diazepam 10 mg tablets

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THE PROACTIVE AUDIT

• Next step
• Pandora Anomalous Use Report for selected MS
• nurse
• patient
• time frame
• Findings..
• Mean removals for all MS 77
• Selected MS Max 660 (2nd 431)
• Next step.
• Audit 1 health record with diazepam use

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THE PROACTIVE AUDIT

• Findings
• All diazepam accounted for on MAR, but
• Dose not always indicated (ROD order)
• Initials missing from MAR Signature Record
• Initials signature of nurse who removed from MS
  nowhere in the health record
• Nurse who signed MAR had no MS activity

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THE PROACTIVE AUDIT

• Now what ???
• 1. Meet with Manager
• Mystery nurse identified
• 2. Select other nurses with same EFT, similar
  rotations and run activity reports (Pyxis OPS)
• 3. Health record audits (Manager)

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THE PROACTIVE AUDIT

• Findings
• 1. Nurse removes
• approx amt month/month
• amt similar to cohort for the specialty area
• (5 mo 325 vs 301 tab)
• 2. Doses removed from MS signed for on MAR but
  gt4 instances drug admin documented on MAR or PN
  with no corresponding removal from MS
• 3. No personality or behaviour changes

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THE PROACTIVE AUDIT

• Conclusion
• We could not find evidence of diversion

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THE PROACTIVE AUDIT

• Some Measurable Costs of the Audit
• Report generation analysis 8h
• Report review (MOPC/DOPC) 2h
• Chart/MAR review 5h
• Meetings 5h
• 20 hours!

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THE PROACTIVE AUDIT

• Or,
• gt 800.00!!

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THE PROACTIVE AUDIT - Summary

• Did our solution work?
• Pro
• Some data on how long an audit would take
• Cons
• Lots of resources required
• Not always productive use of resources
• Software reporting tools not adequate

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What were our solutions ?

• Proactive Audit
• CII Safe

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CII SAFE

• Jan Beales, Senior Pharmacist

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CII SAFE

• Automated Checks Balances
• Purchasing/Receiving
• Inventory
• Compounding
• Restocking/Returns
• Expire, Waste, Recall
• Outpatient Rx/Resale
• Non- Pyxis Restocking Returns

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CII SAFE

• Purchasing/Receiving Meds
• Suggested PO prints weekly
• Purchasing done by Purchasing Tech
• Med received and scanned into C2 Safe by Narcotic
  Tech
• Invoice reconciled with Acquisition Record by
  Manager/Pharmacist

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CII SAFE

• Inventory/NarcVault Access
• CII Safe controls both accessible and remote
  stock
• All accessible inventory is counted once a week
  by two narcotic technicians
• All remote inventory is counted once a month
• All CII Safe Events report prints daily and is
  reviewed for unusual activity

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CII SAFE

• Compounding
• CII Safe automatically reduces bulk inventory and
  increases unit dose quantity for compounded item
• If item not returned to CII Safe a variance is
  created on the Pyxis vs. CII Safe Report

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CII SAFE

• Medstation Restocking/Returns
• Restocking
• Communication link between MedStn CII safe
• Meds removed from CII safe must be loaded into
  MedStn or a variance is created
• Returns
• Removals from a MedStn must be returned to the
  CII Safe or a variance is created
• Overall
• Open Discrepancy Pyxis vs CII Safe reports are
  printed daily.
• Pyxis vs CII Safe report picks up loads, returns,
  loads to wrong machines, return bin variances,
  unload variances
• Variances resolved daily by narcotic tech

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CII SAFE

• Expire, Waste, Recall
• Meds returned first, then expired, wasted, or
  recalled
• Meds pending destruction report reconciled with
  return bin contents
• Requires witness to empty return bin

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CII SAFE

• Fill a RX /Sell to Another Pharmacy
• The All CII Safe Events report shows fill a
  prescription rx sales. These are reconciled
  with signature delivery sheets and RX or sales
  report
• Only Pharmacists Narc Techs have access to Sell
  to Another Pharmacy

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CII SAFE

• Non- Pyxis Restocking/Returns
• Narcotic Control Record (NCR) generated for
  non-Pyxis areas
• Barcoded for tracking of outstanding forms
• Restocking Locked Drawer
• Signature delivery sheets returned to pharmacy
• Returns
• NCR scanned upon return to pharmacy
• Labels Returns on NCRs reconciled with
  signature delivery sheets return reports
• 10 of NCRs audited for complete information

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CII SAFE - Summary

• Was it a solution?
• Pros
• Automated areas increased tracking and
  reconciliation of narcotic transactions to 100
• Gained efficiencies in staffing
• Expanded services and track more medications (all
  control drugs)
• Cons
• Generates lots of paper
• Only 10 monitoring in non-pyxis areas
• Still too many non- pyxis high use narcotic areas

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What were our solutions ?

• Proactive Audit
• CII Safe
• Expansion of Pyxis
• Psychiatric Hospital
• Cart fill wards (ICU, Peds) added Pyxis for
  narcotics only
• Anesthesia use in OR

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PYXIS FOR ANESTHESIA

• Working with the Physicians
• Monique Yakiwchuk, Pharmacy

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DEVICE SET UP

• No OR Admitting feed
• Set up as Non-Rx, Drs as patients
• Pharmacy sets user templates

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CLINICAL DATA

• Add to clinical data category ENTER NCDUR
• Narcotic Control Drug Utilization Record (NCDUR)
  manual record for the shift.
• Pharmacy reconciles removals, returns and wastes
  associated to that NCDUR Drs activity compared
  to the Pyxis All Station Events Report

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RETURN BIN

• A double sized drawer reserved for an internal
  return bin
• Accommodates a large quantity of returns
• Unloaded daily reconciled with manual NCDUR /
  All Station Events Reports

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PENDING MEDS

• Single dose pockets no beginning count is
  required
• 12 pocket mini drawers
• Anaesthesia Med Station set on OVERRIDE

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USER SET UP

• USER ACCESS
• Approval for access from Head of Anaesthesia
• Pharmacy Create user ID ANES licence number
• Create Users as Patients will enable Drs to
  remove under their own name

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EDUCATION TRAINING

• Pharmacy Education Support
• key to success of TEAM culture
• Highlights
• Removals
• Setting up Kits
• NCDURs
• Returns
• Waste
• Demanding Recounts
• Document Discrepancies

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INVENTORY MANAGEMENT

• Maintaining accurate Inventory according to usage
  reports
• Pharmacy manages all Attention Notices
• Loads / Refills and Unloads are accurate

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DISCREPANCY MANAGEMENT

• Monitor / Reconcile Discrepancies for ALL End
  Users
• Reports Currently Being Used by Pharmacy
• DAILY
• Manual NCDURs compared to Pyxis All Station
  Events Report done every morning to reconcile
  anything not matching
• Pyxis vs. CII Safe Compare - reviewed daily
  detects pocket refills, unloads, loading errors
  and potential diversion
• All CII Safe Events reviewed daily provides an
  account for all activities

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OUTSTANDING DISCREPANCIES

• Narc Tech to follow up with the end user
• Pull patient MAR for review /compare to NCDURs
  OR record
• Un-resolvable occurrence report completed
  documentation given to Senior Pharmacist
• Follow-up with Head of Anesthesia

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PYXIS ANESTHESIA - Summary

• Was it a solution?
• Pros
• Anesthesia took ownership of their narcotic usage
  (no more nursing involvement)
• Anesthesia workflow has changed with 24 hour
  access
• Ability to track electronically, an area with
  high narcotic volumes
• Significant decreases in outstanding
  discrepancies
• Anesthesia Pharmacy work as team
• Cons
• Return of manual NCDUR still not 100

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What were our solutions ?

• Proactive Audit
• CII Safe
• Expansion of Pyxis
• Psychiatric Hospital
• cart fill wards added Pyxis for narcotics only
• anesthesia use in OR
• Security Centre- Wide Process

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SECURITY

• Centre- Wide Process
• Standard Employee Application Form for all
  computer access
• Pyxis User Database maintained by Nursing
  Pharmacy
• BIOid registration handled by Nurse Educators or
  Pharmacy
• Monthly HR Turnover Report used to process
  terminations transfers to non-Pyxis areas
• Annual purge of users inactive for gt 1 yr
• Expiry dates for students are grad dates

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OVERVIEW

• Who are we?
• What were our challenges?
• What were our solutions?
• What are the current barriers?

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What are the current barriers?

• Still have non-pyxis areas ( 10)
• Proactive Diversion Surveillance
• Staff resource
• Reporting Tools
• Formalized process

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OVERVIEW

• Who are we?
• What were our challenges?
• What were our solutions?
• What are the current barriers?
• What are our future plans?

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What are our future plans?

• Pandora SQL Software
• Narcotic Diversion Education Support for
  Managers
• Quarterly Diversion Reports for Managers to
  review and monitor potential problems
• Formal Investigation Template
• Intervention
• Checklist
• Formal Intervention Team
• Hospital Pharmacy 2007 Vol.42 No.3 pp244-248

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OVERVIEW

• Who are we?
• What were our challenges?
• What were our solutions?
• What are the current barriers?
• What are our future plans?
• What is our wish list?

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What is on our wish list?

• Extra staff resources
• Pyxis Reporting capabilities- more dynamic
  Medstation, console, and CII Safe reports (eg gt1
  month at Medstation, large capacity for large
  data)
• Fix Anesthesia set-up discrepancy causes drawer
  failure
• Interface Pyxis with electronic staffing program
  medical records to reconcile staffing, patients
  removal times

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NARCOTIC DIVERSION

• Questions?

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NARCOTIC DIVERSION

• BREAK OUT SESSION
• What has worked well in your institution?
• What are your barriers?
• What is your wish list?