And now, I would like to introduce our speaker to get us started today. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPIC, she served as the Director of Western Region Patient Safety and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. We thank you so much for being here with us today, Laura, and we invite you to go ahead and get us started. Okay. Thank you very much, Lindsay, and welcome, everyone. Our topic today is on medication administration and blood. Now, these are typically nursing-focused processes that occur within a hospital, and so what you're going to hear a great majority of today is revolving around nursing, and it talks about nursing, but still there's some pharmacy components in there and some of the requirements that are just basically needed for these events to occur. And CMS and Joint Commission, they're very, very interested in this because, as you probably know, that this is an area where patient injury can occur, and it doesn't have to be with just the wrong medication. It can be in how is it prepared? Are we maintaining a sterile environment? So that's why CMS and Joint Commission, why they are so concerned and so really involved in this entire process. Well, I do want to include this disclaimer in that the information I'm presenting today is informational only. It is not intended to serve as any legal advice or establish an attorney-client relationship, so you will have to reach out to your own counsel, professional legal representative for advice, and specifically if there's any particular state law as it relates to medication administration, such as who can do that? Can an LPN administer certain IV medications? So items like that. I'm going to do a brief introduction, and for those of you who had the opportunity to listen in on these programs, this is going to sound very familiar. So why are we here? That's so we don't get one of these statement of deficiencies and plan a correction that you have to develop if CMS or one of the other accredited organizations comes in and finds a deficiency that we do need to address and hopefully rectify. No facility or provider wants to get the notice of an involuntary termination of their Medicare Medicaid agreement. That means that you would still have to take care of that patient. You just wouldn't get paid to do so. So again, no one ever wants to get this. Overall, how does it work? The regulations we're touching upon today start in the federal register. CMS, which is a division of Health and Human Services, they have the responsibility to do a couple things. First of all, they have to publish that regulation out to their surveyors in what's called a transmittal. They also have to develop interpretive guidelines and survey procedures so their surveyors know what to do once they are on site. And of course, they have to update the manual that you are required to know and to follow. Three types of survey, the certification when you're getting started, validation, they're coming back or if they want to follow up on one of the accrediting organizations, and then the complaint survey. None of you have had to go through. And keeping up with changes, there's a couple ways to do it. One is to subscribe to the federal register. This is free. You just get notice of when something new is coming out. Make sure the most recent manual, acute hospitals, your manual has changed almost four times since 2020. And in fact, the last edition came out in 2024, just this year and April. And by the way, for critical access, yours has not been updated since 2020. If there is a new manual, look at the transmittal page and check that survey and certification website at least monthly. That will keep you up to date on when those new transmittals come out. I have the links here on this slide, slide number seven, to where you can copy paste that into your surf engine to get to those. So the manual itself, the conditions of participation manual, and what we're covering today is appendix A, that's for your acute hospitals, and then appendix W for critical access hospitals. But keep an eye also on appendix Q, that is the immediate jeopardy manual, where if there has been an injury to a patient or they get a complaint, or someone's come out and done a survey and they find something that threatens immediate threat to the health and safety well-being of patients, they'll be out in two days. And that's why you want to keep an eye on that manual also. So for appendix A, again, you can see your last revision was in April 24, and those transmittals I mentioned, once you open up the manual online, you will get that blue lettering. That's where you want to click it for those transmittals. W for critical access, yours has the same manual. But this is what that will look like when you open it up. Go to the top of the page, and it will take you to those revisions. It's a much quicker way to find out what has changed as opposed to going through 560 pages for an acute or 340 plus for your critical access hospitals. And again, criticals, yours hasn't been updated for several years. On your survey memos, this is just what one would look like when you open it up. That's the link there for you. And again, that's what it looks like. That's what they talk about, who it addresses, and then they will add into there those areas within the manual that have been changed. Now, I did mention deficiencies at the beginning, so I just want to let you know you can access those reports. This is what CMS has gone out, done their survey, they come back, they upload that information of the deficiencies into their database. And of course, it has the name of the hospital, the address, date of the survey, tag numbers, and a brief description of what was found. And so you can access that now. It doesn't have a plan of correction, but you'll know what they're looking at and where are they honing in on some of these surveys. So when you get to the deficiency report page, you want to scroll to the bottom, and it says full text statements. Now this one, when you open it, it gives you two Excel documents. One is from 2010 to 16, and the other is 2017 to current. And by the way, it's updated quarterly. And so when you open up one of those, this is what you will see, an address, what was the tag number, and a very brief description. So for the topic I'm covering today, here's just some examples of those deficiencies. One is we didn't compare the name and number on the wristband with the blood bank label prior to admission. This was nursing 101. For anything, I don't care if it's blood or medication. So why that wasn't happening, that's a good question. They didn't make sure controlled substances were stored in a double lock system. Staff didn't check vital signs according to what their policy said on blood administration. And they didn't make sure all expired medications were removed and not available for patient use. Whoever does this, that's up to you, whoever you assign that task. For deficiencies, they didn't make sure medications were correctly labeled according to policy. They didn't make sure medications were stored according to what their policy and procedures are. I just want to point out a common theme here is those policies and procedures. If you're not following them, that will really cause a citation, because those are there as directions and the expectations for what they want the hospital and the staff to do. And again, they didn't make sure not following hand hygiene policy and procedures or making sure refrigerator temperatures were checked daily and documented. Now, these are daily tasks and sometimes patient-to-patient tasks that we must do. Again, CMS, Joint Commission are very concerned with the safety that we provide for the care that we give to our patients. All right, let's go ahead and start in the conditions of participation. Again, there's three main components that we'll be touching on, nursing, medication administration, and safe opioid use. These are all together within these conditions. And Lindsey did mention we have a few polling questions, so I'm going to turn it back to Lindsey to go ahead and start the polling question. Yep, absolutely. Okay, this first one is now on your screen that says our nursing policy and procedures. The first option here is describe what level nurse are in LPN and may administer IV medications, require training and education prior to the nurse administering those IV medications, both one and two, or no specific training as long as they are licensed. And for those of you who have joined us in just the last few moments, and if you do have questions for Laura as we go throughout today's presentation during these polling questions, we'll also pause to address those questions. So at the bottom of your Zoom window, you should see that option that says Q&A, and you can go ahead and be typing in your questions there as you think of them throughout the presentation, and then we'll pull those up and address those in the order that they were received during the time of these polling questions. So go ahead and be typing those in as you have them as well. And if for some reason you don't see that Q&A option, you can, of course, utilize the chat to send in your questions. I did go ahead and provide the link to the slides and some additional information there for you in the chat, but I'll go ahead and post that again there so everybody can see that who may have just joined in the last few moments. I'm kind of going to get some good responses here. Good. This question really resolved around, I think a lot of, some of the states are now starting to see that we can utilize other levels of nursing rather than just RNs in order to administer medications, and especially IV medication. My state, Colorado, is going through that right now. They're evaluating, are we going to allow this? If so, what has to be in place? And so a lot of you are now not only describing the level in your policies, but the required training. So that's great that you are starting to do this. All right, so moving on. Pharmacy standards, which we'll cover, will impact nursing, and they are 490 through 511. Now that is a separate section, but I am going to touch on those as we go through here. Administration, the actual giving the medicine to the patient, that is under nursing. And only some of those regulations really impact the overall medication process. I already mentioned acute hospitals, you're in Appendix A. I did include in here one for PACU because you administer medicines, and especially pain medication. And critical access, yours is a little bit shorter session, you're only in TAG 1049. But again, we will touch on these as we go through. So overall, CMS calls them drugs and biologicals. Joint Commission goes old school and calls them medications. And of course, medical staff, you can determine who can order them. Is it going to be just physicians? Are you going to allow your advanced practice non-physician providers to do that? Each state law differs on what their scope of practice is. What can a PA do? What can a PharmD do? They order medications. When I worked in coronary care, we were fortunate to have a PharmD on staff. And he worked very closely with us in the coronary care unit on helping regulate the cardiac rhythm using certain medications. And so he was such a huge resource for us. And I really think some of our patients are alive because of his input. But again, medical staff allowed him to come in and do this, consult and write the orders. And of course, we have to administer the medications under the supervision of nursing. Again, that's administration. Now, there are times when your policy and procedures, your bylaws, your rules and regulation may allow others to do it. But the overall key is, does the state law allow those other individuals to supervise the administration of medication, such as a physician assistant? So I'm going to start. This is in the nursing section, tag 405. And this is a very large section. In this one, drugs have to be prepared and administered according to state and federal law. In other words, are there certain medications that have to be only done by RNs? Or what about federal law? Does federal law prohibit certain levels of individuals from administering medication? The key is that you have to have an order, a practitioner orders. That's for all medications. Whether it's going to be those day-to-day orders, or are we using standing orders? It must be in the medical record. It must be documented, whether it starts as a verbal order and then written in the record and co-signed, but nonetheless, it must be there. And again, administered by or under the supervision of nursing or others. As far as other practitioners begin, they have to be allowed by state law to do that. It has to be within their scope of practice, which the state determines, not CMS. And again, hospital policy and procedures, bylaws, rules, and regulations. So everything has to come together to make sure that order is a valid order. As far as preparation and administer, we follow our standards of practice for that. And again, federal and state law. Now, there are certain organizations that CMS has mentioned in the interpretive guidelines. As far as proper administration and preparation, such as the American Society of Health System Pharmacists, maybe the Infusion Nurses Society. They have certain guidelines. U.S. Pharmacia, those are just some that CMS has mentioned. But CMS does allow others to document and sign off on the order. Remember I mentioned that PharmD? Well, that's an example of one. Maybe they're going to actually run the anticoagulant clinic. Maybe they're going to help with the diabetic clinic. The medical staff, they approve the INR chart for patients who are on, whether it's Coumadin, whatever they happen to be on. Maybe the pharmacist then would adjust the dose and signs and writes off the order. But again, the state scope of practice has to permit that. And the hospital bylaws, the medical staff has to grant privileges in order for them to occur. Now, standing orders. You can have standing orders in order to administer medications. And that includes outpatient services. Those who are not privileged, but yet they're allowed by rules and regulation and policy and procedures to write orders. So you can allow that. You're not required. But your medical staff, your governing body can say, yeah, we're going to let that happen. There's two exceptions, flu and pneumovax. And the reason is, is CMS, Joint Commission, CDC, everybody's trying to get a handle on the flu and pneumonia and make sure that we make these readily available. So in order to have that, what you want to do or what you need to do is have a physician-approved protocol so that the patient walks in, let's say they're in ED, they're there for something minor, but they're going to go home. The nurse can go and ask them, have you had your flu and pneumonia? Would you like it here? And they can give it. They don't have to track down a physician to do that. They can do those protocols. Of course, assess the patient, make sure there's no contraindication to receiving either the flu or pneumovax. So again, that's one way that they've allowed this to happen. And also just think about it in your pharmacies when you go in and the pharmacist can also administer those. Otherwise, these are the basic requirements for any order. Name of our patient. The age and weight, and we do that for dose calculation. You definitely want policy and procedures on minors, those children. Medications. Kilograms for children, grams for newborn. But don't forget your elderly patient or those who have some other comorbidities that might impact it, say renal failure. Maybe you have a very cascadic patient who you'd really have to adjust that dose to make sure that, yes, they're very, very skinny, but we're not going to wipe out their kidneys by giving them a certain dose of medication that we would normally give to a 180-pound male. And then the date and time of the order. I just included this one. This is the dosing chart. Again, we use kilos for kids or for newborns, we use grams. That's so we're not overdosing them. But otherwise, order requirements. Of course, we have to know what we're administering or ordering. What is the dose? How often? Is there a route that we're going to give it? And then there's some that are pretty, they may be very specific, like, what are the dose calculation requirements? Strength or concentration? Quantity, duration when applicable. For example, your IV antibiotics. How long are you going to administer those IV antibiotics before we convert to an oral? And then if there's any specific instructions for use. And then finally, who prescribed it? What was the name of that person? Now, in dose calculations, that's like kilograms, milligrams per kilogram per hour. Now, that's why some of these are required. But the medical staff, or if they want to delegate this to their executive committee, which they can, they have to approve those policy and procedures on our medication administration. So it should be part of your QAPI process. Now, we don't have to make great changes over time. We just have to make sure we're monitoring it and keeping it safe. It should be done in consultation with nurses for these medication administration and pharmacists, of course. Pharmacy will know what is the newest generation of certain medication or if there's been any changes. And again, under the supervision of nursing or other personnel. There are many specifics on what CMS has for what should be included in that policy and procedure, and of course, consistent with their scope of practice in any state law. So as far as who can administer, who is authorized, that's what your policies have to spell out. What is the category of your personnel? And what type of medications can they administer? I always put this example in here because, again, we're going through changes here in my state. What can an LPN administer? Now, that's different than what can an LPN prepare, because that could be vastly different. But the policies have to address that education or training requirement. CMS actually has certain recommendations for us. Of course, during orientation and as part of their annual skills lab, if that's how you want to approach it. How about safe handling and preparation? Maybe what are the indications, side effects, interactions, compatibility? That's, we got to keep that in mind. And then do we need any special equipment? If we have that as special equipment, do they know how to run it? Can they troubleshoot when it's one o'clock in the morning and that IMEDD alarm is going off? Can they troubleshoot? Do they know who to contact in order to get a replacement? They also have to address in your policies those required components of any training. What must be included for that person to demonstrate competency and the documentation of such that goes into their personnel folder. We all know the five rights. We're very familiar with that. Those who've gone through nursing or any clinical experience, it's probably been drilled into your head. These are the five rights for medication administration. Of course, the right patient. What are we using for identifiers? Full name, their ID number, date of birth, patient identification card, get the patient to say, what are their names? What goes into your policy? And it could be, what's your name and what's your date of birth? And this is very important when you have like or similar names. We used to have four bed units in one of my old hospitals and we had to make sure we were at the right bed with the right person. So those five rights came in real handy. The right medication, did it match? What is in the order? And there's no allergy documented to that medication. The right dose. And that it doesn't have an unsafe dosage level. Most of your nurses, once they've been on the floor and done this for several years, they're going to be really astute to knowing that doesn't sound right for this patient. And that's okay, then question it. The right route. Is it going to be oral? IM, IV, sub-Q, and of course the right time. And we do this so we adhere to that frequency and time of administration. They really focus on the process of administration, but there's something else, there's another part of it. And this is the overall process. Where we have five, again, five stages. Ordering, transcribing and verifying. Dispensing, in other words, getting it up to the floor. Administering by nurses. And then we monitor and report back on how that patient responded. Now, CMS talks about in their blue boxes, I mentioned those before, they're optional. You're not cited if you don't do what's in the blue box. But they talk about recent literature that talks about nine rights of administration as opposed to five. So it adds in there, right documentation, right action. Why are we giving this? The right form and the right response. So they've added those four additional ones. It's up to you if you want to do that. There's even some who use seven rights, eight rights, whatever the hospital or facility decides to do. But the minimum is those five rights. And then I mentioned that culture where if the nurse senses something's wrong, they need to feel safe speaking up. So they have to feel safe to ask a question, bring it to the attention of the prescriber. It's like, help me understand this. Normally, you know, like with pericarditis, we would give a cellular cortex. Why am I giving cellular medrel in place of it? I don't understand. That's okay. You know, a lot of those physicians are great teachers and they love that. And so that's why it helps. And it also just clarifies, yes, that's what I intended to order. And of course, that culture includes getting my question answered promptly and without the fear of getting my head snapped off or bitten off by that provider. So that's the culture of safety that they're talking about in medication administration. But they also talk in those interpretive guidelines about safe injection practices, that we have to follow the standards of practice so we prevent our healthcare associated infections, not just with administration, but preparation. Because here you're assessed under infection control. So if they're out there observing nurses and preparing the medication in pharmacy, and they find a slip up in some of this sterile preparation, not only will they be cited under medication, but you may also get a citation under infection prevention standards. And they know that these compounded sterile preparations, they can cause infections if not properly followed. Most of you may remember that event, Northeast United States where we had the epidural medications that weren't done under sterile and some patients died as a result of the infections that were passed along. But nurses also can prepare those sterile medications for immediate use. So that's why they will observe pharmacy and nurses. Now ISMP has some IV push medication guidelines. You can download these, they're free. They put it into factors that increase the risk of medication in adults and their response. Like current practices with the IV injectables. There is a guideline, census guideline for the push medication. 90% of your patients are going to have some form of infusion therapy, whether it's an actual IV med or a long infusion. There will be those patients who have, that's just what it looks like. This is the most recent copy that I could find of it. And I believe I have how you get that, the link to that. But ISMP, safe injection practices, you Google that and it comes right up. So here's just some of the other guidelines. Have the meds in ready to administer form so they don't have to worry about diluting, getting it ready. Only use those prepared syringes of solution to flush that lock. If available in single dose, try and buy it. Now I know that's outside the scope of what a nurse can do, but that's what we need to consider. Aseptic technique when preparing and administering, that means washing our hands before and after administration. These are in the ISMP guidelines. Clean off the diaphragm, even if you've just popped off the cap. If you've got a glass ampule, use one with the filter, unless of course the medication prohibits it. Dilute it only when recommended by the manufacturer, using those policies and approved practice guidelines. If it requires dilution, do it in a clean, uncluttered, separate location. By the way, in your med room, if you have a sink, make sure there's a certain amount of space between the sink and where these are being prepared. And the reason is they don't want the splash from the sink contaminating that preparation area. And I've even seen it in some areas where they put up a plastic screen to prevent that splash. Don't take medications from one cartridge and put it into another for administration. You shouldn't draw up using the pre-filled saline flushes because they're used to flush the IV medicine. They're not used to dilute. Putting more than one medication in a syringe, seldom necessary. Label the syringe, we went through this years ago, unless you're drawing it up and immediately administering it. Then to stop and label, that's not what they intended it to be. It's when it was sat down or pre-prepared, that's when they wanted them labeled. Of course, administer at the rate manufacturer recommends. And there's also guidelines for safe preparation. They put this out in 23, they revised it in 16, I have the link. And it talks about those frontline caregivers where they may have to do it. So that's why it's so important that they know or aware of it. Now they did put out some key guidelines and best practices. I do wanna point out CMS will not establish a standard of care. That's up to these type of professional organizations, ISMP, CDC, whichever it happens to be. If you are using an outside pharmacy for compounding medication, if you're doing it also, first of all, outside the pharmacy, try to minimize it. But otherwise, if you are doing it for again, compounding sterile preparations, we have to follow USP standards and standard procedures for labeling, make sure we know so we prevent any variation by staff when it goes time to administration. Staff are trained and they show competency for sterile combinations. And again, that's annually at least. So this is from 2020 U2, guidelines for sterile compounding and use of sterile technology. CDC is weighed in on it also. They have safe injection recommendations, excerpts from the guidelines on isolation precautions. Now the asterisks, I have that reference in the appendix for you. And it really summarizes recommendations for safe injection practices. I'm not going to repeat those because they're very similar to what ISMP has put out. But again, CMS expects you to follow CDC guidelines. Some of us are familiar with the beyond-use date. Those are medications that are outdated either after its expiration date or beyond-use date. So there's two different times we have to look for. The manufacturer sets the expiration date. That's because they've got FDA approval. This is how long it will last. But the beyond-use date takes into account where is that medication now since it was maybe reconstituted or taken out of its original location? What are the conditions and potential for deterioration or bugs growing in it? And this is based on information from the manufacturer. We have to have policies to give clear direction to staff so they know how to determine it if the manufacturer doesn't have it. And some facilities have said pharmacy help us determine this beyond-use date. So the nurses are consistent. So bring me to question number two, Lindsey. Okay, I'm gonna actually read this first part to you and then I'll post the question up there on the screen for you to have the options to choose from. So this says hospital D has floor stock of vaccines and saline or sterile water for dilution as needed. All vials are multi-dose with an expiration date clearly printed. During a state survey, several vials were noted to not have a beyond-use date printed or affixed to the label. Nursing reported this was a duty of pharmacy. Pharmacy said it was nursing's responsibility. Will hospital D be cited? And then let me put these options up here for you on the screen. So yes, no, or possibly you do not know. I don't see any pending questions at this time. So again, if you do have any questions for Laura up to this point in the presentation, go ahead and be typing those into the Q&A option or into the chat as well. Okay, we've gotten some pretty strong response here. Let's go ahead and end that and share that result. Yes, they will. Because one of the problems with this one here was no policy. They didn't have policy on who was supposed to be doing this. Now, it's not really, I say fair, to say it's your job, I don't have to do it. No, if it's not there, then someone needs to step up and make that determination. What is the beyond you state on here? Or get back to leadership and say, we've got a little drop here in communication. We need to get this cleared up and make sure that everyone knows it. If there's a policy, everybody's following it. So yeah, they're gonna be cited, unfortunately, on this one. And Laura, one question did just come in maybe before we go on here that says, could you please clarify about reconstitution of a vial used with the same syringe? Can you be more specific, reconstitution of a vial using the same syringe? Okay. Sandy, I see that question came from you. Maybe if you have a little bit more information that might help a little bit. And we can pause and come back to that one if we need to, for sure. Very good. Yeah, because there'll be another question coming up later on. Okay, so we have some timing. This is when we're actually gonna get that patient this medication. Before, if you didn't give it within 30 minutes, you were outside and you had to file an incident report and it was a headache because that just sometimes doesn't happen and sometimes more often than we'd like. Well, this is where I gotta hand it to CMS. They worked with ISMP and ISMP came up with this information saying, well, that doesn't make any sense because some of these medicines, even if a patient's taking it at home, they're not gonna take it at the same time every day. There may be a gap. And so they really did a lot of research on medications to determine what is the life of this medication between doses? And with that, and again, hand it to CMS, say thank you. They came up with three blocks of time based upon the recommendations of ISMP. And so now you wanna maybe look at your policy, make sure it's there. And they also have sections on standing orders. So for timing of medications, you want to address the timing of administration based upon the nature and clinical application for that medication. You want to include in your policies what medications aren't eligible for these scheduled dosing times, and then which ones are. And what happens if it's outside that time of administration? And then go back and look at those policies. Evaluate, is staff adhering to them? If not, why? Is it because there's a gap in when the medication's ordered and it gets up? Is there a gap in time of just simply when it gets to them because of shortages? What is it? That's part of the QAPI process. So here are the three timeframes for administration. Time critical, one hour before, after, two hours. And we're gonna go into this. But just briefly, the medications not eligible. These are ones you have to give it when it's ordered because of the patient's diagnosis or why we're giving it. What are the treatment requirements, the therapeutic goals? Stat doses, PRN medications. We never time those, we just don't. Those where you have a serum drug level, your peaks and troughs. Maybe it's your pre-op antibiotic or loading dose. Now they included investigational drugs in this because investigational drugs have to go through a host of requirements and necessary steps in order for that to occur. So they included investigational drugs, they time them out. Otherwise they are not considered eligible for scheduling. Then pretty much everything else is eligible. Those who may be a repeated cycle, whether it's daily or four times a day. We're trying to achieve that therapeutic blood level. Now, when you give them, that's up to you. Hospital policy or when the patient gets it. But they need to include those standardized times. So pharmacy knows when to send it and the nurses know maybe when to assess the patient. We were given, again, I always refer to coronary because I had a lot of most recent experience in there. Where, what did we have to know about that patient? What were their pressure, their heart rate? What was going on? Were we given a certain medication that we had to watch our DIG level? But then we also have the one hour before and after and two hours. And essentially you have for one hour, you have a total of a two hour window of time to give that medicine. Likewise for your two hours before, after you have four hours window of time, usually that's your daily where you've got a little bit more leeway. But your policies have to address, which first off, which medications and then when is the first dose and when can nursing use their judgment on the next dose? The policy addresses what happens if I miss it? Maybe it was late or I forgot about it. Those that can be given outside their dosing times and no report is necessary. And those who are not, those units that are not going to use your dosing times, which units if you have those? So I'm gonna start with the time critical medications. These are ones where if we give it too early or too late, it's going to impact the effect of it. So that's what the policy must include. Administered within 30 minutes of that dosing time. So you still have that hour. If it's 9 a.m., you have 8.30 to 9.30. Are these always time critical? Because you may change those medications over time as the patient either is on it for a long time or they change how they respond. So I've just got some examples. Your immunopressants agents, non-IV pain medicines, maybe those where anticoagulants, insulin. Those are some of the time critical medications you have to watch out for. And then again, everything else, something that's not so crucial. If you give it sooner or later, not such a significant impact on that effect. Maybe daily or monthly even. Again, I mentioned the two hours. So you have that four hour window of time or one hour for two hours windows of time. Again, the policy addresses what happens if it's late or we just miss it within that time because patient's down an X-ray. Maybe they're nauseating, just I can't take that pill right now, but let's give me a break. And then when the nurses can use their judgment to reschedule late or missed doses. One of probably the most frustrating things is patients who are inpatient and you start their timing of QID or every six hours and it's two in the morning, you gotta wake them up to give them a pill. Can you balance letting them rest and recover to being on schedule? That's one medication that we always had to really balance within the unit on, do I really wanna wake this guy up to give him a pill? And of course, if it is late or it's omitted, reporting to the attending. They may say, I skipped that dose and give them in the next morning or don't worry about it or give it now, wait to the next dose, give it an hour later and then get them back on track. We need to evaluate our policies on timing, but include how is the staff adhering to it? Why aren't they adhering to it? Is it just something, like I said, I don't wanna wake my patient up at 1.30 in the morning. That's not right, they're trying to rest. Make sure of course it's safe and effective administration, look at your QAPI, look at errors on timing. We need to track those and analyze them. And do we need to revise the policies in that case? That's where coordinating with nursing and your pharmacy is very beneficial, gets a lot of that good dialogue going. And there is huge component within this tag number, we're still on 405 by the way, a patient assessment and monitoring because we have to watch to make sure a therapeutic effect is being met. And also, are there any adverse effects? And then taking action, if there is an adverse effect, that could be your toxicity levels, pressure, physical signs and symptoms, are they itching where we're starting to have an allergic reaction? Or are they getting agitated? Which maybe we're not circulating that blood well enough. ISMP again, here's another blue box example where they talk about it, you're not cited if you don't use it, but CMS gives us some benefit here and they have that list of those high alert medications. And there's also a big guide on how to from the Institute of Health and Improvement, IHI, they also have it. Some things you wanna keep in mind that staff are expected to include how the patient responds and what the patient says about that medication and how it affected them. And of course, notify this nurse if they're having something different. I would offer that you also instruct the family if they're staying with them. If your family member, your loved one, isn't responding or starting to act a little different after that medication, please let us know because maybe we need to evaluate that medication. Of course, the policies to address how and how often you monitor the patient and what you communicated, shift change. Document after administration. There is reference in here, pre-documentation is not in line or in compliance with the requirements, but document after administration. Always take into account what are the patient's risk factors, not just with the patient, but what goes along with that medication as far as how often are we going to monitor this patient? Make sure that when you're doing a handoff, whether it's shift change or the patient's being transferred to another unit, what are those factors and monitoring requirements for the patient? And of course, any adverse reaction, not only to the next shift member, but the practitioner. They must know what goes on with that patient. And that includes your opioid-induced respiratory depression, not just anaphylaxis. They list out patient risk factors for us, age of course, sleep apnea, maybe obesity, the weight. Do they have a history of smoking? Is this the first time they've gotten the medication? Any other drug-to-drug interactions? Because they do talk quite a bit about monitoring the patients for high alert medications, post-administration, regular assessment of vital signs, pulse ox, sedation levels, especially on your post-surgical patients. Anything that the patient has an experience with the medication. No, you gave me oxycodone. I'm probably not going to want it because I get severely nauseated with it. Just something like that. Maybe there's something else we could administer. Again, tell the patient and family, if you see something going on different with their loved one, please let us know. It doesn't help if, oh, he'll settle down in just a minute. We need to know that. And the manner and frequency of monitoring, again, taking into account your patient risk factors to include in your policy and procedures. So documentation, that is addressed in the medical records section and it does include the specific content, but it talks about in there everything that we need to document, medication on the patient's condition. And again, document after administration. Advanced documentation, it's inappropriate. And so that's in that tag number 467, after administration. The surveyor is going to look at your policy and procedures. First, have they been approved by your medical staff and governing body? They'll verify approved policies cover who can administer these medications and that we're following them. That it's within the nursing scope of practice. They will know it when they show up. And if anyone else administers it, are they following federal laws? Maybe it's a PA who's allowed to administer it. Are they within their scope of practice? The hospital policy, again, and the bylaws, rules, and regulations. They will also verify you have identified medications that are eligible for the scheduled dosing times. Those who are eligible, are there any time critical or non-time critical? This goes on for quite a bit, as you can see here with the survey procedure. They make sure the established time requirements don't exceed that one hour, two hours, whatever it happens to be. And that it ascribed the requirements for any time critical. By the way, is this for the entire hospital or are you gonna go by unit? Which again, you could have a couple policies out there if you've got several units. And then they're going to look at some medical records. Are they administered according to the orders? Is it the right, is that the five rights? Med, patient, dosed, route, time. And is it still in effect when the medication was administered? Or is it an automatic stop, but yet we're still administering it? They also going to look at your standing orders to make sure they comply with all of those requirements. But they're not done. They're gonna also watch your staff administer the medication, prepare and administer. Did they confirm the patient's identity? And is the nurse following policy when they are administering medications? Are there certain patients that we have to assess before we administer? At-risk patients, those who have those high-risk medicines, are we monitoring them? And does staff know what to do, how to intervene if there is an adverse event? And then they're going to talk to their nursing staff. They wanna make sure they know the policy or at least understand it and the timing. Can they distinguish between time critical and non-time critical medications? What are the requirements for the timing of medicines? And then finally, they'll look at your standing orders again. Do they comply with all of those requirements? So again, it's a very, very in-depth survey in that PAG number. So that's 405. It takes up quite a few pages and it's very in-depth. Next one is our physician orders. And of course they are prepared and administered according to the orders. Now these can be in a couple varieties. The usual, physician writes the order, we're done. But they can be in pre-printed sets. They can be in protocols or standing orders. If they do that, then they have to meet under medical records section 457. But again, the exception of flu and pneumovac where you have your protocol. This one, you don't have to authenticate those orders. So again, these are like standing orders or protocols where they really wanna get ahead of the flu. The drugs, the orders, they can be signed off by those who are allowed to do so. And that's usually those who are authorized by state law, scope of practice, your policy and procedures, your bylaws. And it's not just PAs. This can be other providers, your dentist, your podiatrist, your oral surgeons, whoever the medical staff and governing body says can do this. I have those, those are listed in text 63 through 68, but I'm not going to cover those today just so you know, they can do that. And nurse practitioners, PAs, same thing. They can be allowed to do that. So standing orders, back to nursing. Nurses are those others who are authorized, can administer drugs according to standing orders. Now CMS puts these all into the same bucket. Standing orders, order sets, protocols. They call them standing orders just for ease. But what you do need to do is have those well-defined clinical scenarios when the medication is going to be administered under those conditions. The practitioner still has to sign off on those standing orders. And I'm just going to call them again, standing orders for just ease of understanding. So examples, you've got a patient that comes in with chest pain. What's going to happen? Who's going to be allowed to administer maybe some nitroglycerin so we can give up. In the ambulance, they have those standing orders, give them an aspirin. Code teams, ACLS, that's a standing order. All of these should be, they're okay. Timing shouldn't be, the order shouldn't be a barrier so that we have that emergency response. That's why there's some examples of standing orders. And surprisingly, that was pretty brief because a lot of the bulk of that is in the medical records section. But verbal orders are next. If you use them, please use them infrequently because they know it's a patient safety issue and it's resulted in many errors. You know, the doctor calls in one and then it's get it written down, come back. No, that's not what I ordered, totally wrong. We never use it for the provider's convenience. It's in an emergency when you can't get ahold of the physician, the physician can't be there to sign off or write the order themselves and you have to have it. There are four requirements in your policy and procedure for verbal orders. One is limitation on use, which medications, which situation may they be used and which may not. What are the elements for a complete verbal order? Name, drug, dose, frequency, person taking and who's giving the order. Protocols, so we have clear and effective communication. Readback, so we verify that verbal order. And then in your policy, who can give it? Who can issue that verbal order? There is one separate tag number that talks about who can accept a verbal order, that's 408. And that's authorized by not only hospital policy, but by state law, within their scope of practice and federal law, who can accept them. Maybe you want hospital to accept all verbal drug orders, the pharmacist, maybe they won't accept verbal orders for certain medications, like chemotherapy, or getting that vancomycin IV order from a medical assistant in a physician's office, saying, nah, our policy says we need to have a nurse or the physician do it, or a provider. And of course, documenting that order. On the sign-off, there were two changes that were placed in the medical record chapter, but they're not in the nursing section. And I want to stress them, because again, nursing takes verbal orders. They should be authenticated based upon what your state law says. Some say, you got 24 hours to sign them off. Some say 48 hours to sign them off. If there is no state law, then your policies must stress it as soon as possible. And give a timeframe for that as soon as possible, because you don't want that to go on three days, four days, oops, time for discharge, and that was never signed off, and it was not the right order. So if your policy says the next time the physician sees the patient, that's the policy, or whosoever covering form as authorized by the policy, they can do it too. Otherwise, you write it down and repeat it back. Again, for other practitioners, they can sign off on it, as long as they're within their state scope of practice and policies and rules and regulations, that's fine. Again, this can be standing orders, fluenomo, if you want to do that. It is the same wording that's in tag 406. So again, I won't repeat it, but that's what needs to be done. Another person can sign off. If your state law permits PAs to sign off on physician orders, you might want to check that out, because hospitals can permit it if the state law permits it. And then another major topic we wanted to cover today was blood and administration IV meds. Well, we have to, again, follow state laws. Before, you had to have this very long list of training, and CMS put it in the regulations. Well, they decided, you know what, they eliminated that, because they figured, and this is for non-physicians, where they're directing to. Really, it's part of their training. That should be standard practice, but they still have to be competent and following scope of practice and any policy and procedures. Policy and procedures for blood and IV have to be based upon those. What route are you going to use? Are you going to allow central line or not? Or must it only be a peripheral line? What medications can be given that direct, either, again, through a port or IV? Basic, say, practices for administration. Trace the line and make sure your pumps, your infusion devices, are properly timed. Some of you have probably seen these constantly, where you've got five or six, seven pumps running and seven lines running, okay? What's in it? Do they work and play well together? If I have to give a push medicine, am I going to knock out that IV line because of the interaction with those two medicines? That's why we need to make sure we're tracing the line. With IV administration, blood administration, they also talk about patient monitoring because, of course, we know it's a rapid effect on the patient. And include assessment of risk factors that could include how often do we assess that patient? You know, do we have somebody who's in heart failure and we're giving them Lasex? Okay, great. What about their kidney failure? How's their kidneys responding? What is their potassium level with that? Policies are expected to address fluid and electrolyte balance and monitoring patients for those high alert meds, especially opioids, so that we monitor for over sedation and respiratory depression. They have a good section in the interpretive guidelines on IV opioids. They included their recommendation from the Patient Safety Movement Foundation. They include in there that patient, this is the interpretive guidelines, not a blue box. This is in the guidelines. Those who are on IV opioids need continuous pulse ox and if they're on supplemental oxygen, nasal O2, well, we need to watch their CO2 rate, their entitled CO2 rate, because that reacts much faster. And with that addressed additional oxygen, we're knocking out that drive perhaps a little bit. You also want to include in your monitoring system a way to notify staff if those parameters that we set up are starting to drift and go high or go low. And also, what is your escalation protocol? If one staff member who's responsible for the patient can't respond within a certain amount of time, 60 seconds, or do you want to shorten that to 30 seconds? You have to determine that within your policy and procedures. For the risk factors, very similar to what we saw normally, snoring or sleep apnea. Opioid naive, maybe they have taken it forever and they're used to it. Now we've just given them a little extra IV route. Maybe they've been under long anesthesia. That will increase the potential effects of your IV opioids. What other medications are they given? Benzos? Maybe they have an antihistamine on board. Is there any preexisting cardiac or pulmonary issues that might reduce their ventilation? And then surgeries that into the thoracic area that could impair their breathing. They don't want to take a deep breath when you've got a chest tube in place. It hurts. So maybe those are some of the factors that we need to keep an eye on. Patients on opioids. So here's question three, and perhaps we can go back and address that other question that the attendee had. Lindsey. Absolutely. I'm gonna go ahead and get this one on your screen. Okay, this says, our facility has instituted annual education for all nursing staff on patient care with opioid administration. Yes, no, or not sure. And so she did further clarify just slightly here, Laura, that it was several slides ago now, but when you were discussing reconstituting a vial with the same syringe. And so she was just asking if you could possibly just clarify about reconstitution of a vial used with the same syringe. Same syringe. Not using the same. I'm trying to think back to what that slide happened to mention. What they don't want you to do is, okay, you've drawn up the diluent into the syringe, and then you put it into there and mix it up and do all of that. What they don't want you is to use that syringe again and again and again. So it's one syringe, one medication. That's what they're looking at because some of that medication could be held over from the previous one. And so that's what they wanna make sure of, you're using a sterile syringe for each medication that you're administering. There's no, none of that other old medication is retained in that syringe in order to be used. We did have, there have been some situations where surgeons were a little, well, not surgeons, just the provider was reusing syringes to save money, and it was causing some problems, and especially between patients with that transmission of the infection, they ate hepatitis C. But again, one syringe, one medication. That's what they're looking at. Perfect. I hope that answers her question. If not, I'm happy to give further explanation. Yeah, she said that's perfect. Yeah. Okay. Perfect, perfect. Okay, I'm gonna go ahead and end this one and share those results here. Great, okay. Again, this is just informational only on this question. Okay, all right. Again, going to a lot with IV opioids, and especially post-op patients. We have to have policies we know on our high alert medications. At a minimum, this is what's required. What is the process for assessment? Who is going to do that? Is it going to be an RN? Will it be an aide? Will it be an LPN? What are you gonna check? What are you gonna monitor and how? And when do we, what protocols can the physician have established for administration and monitoring that are different from what the hospital-wide policies happen to be? Again, what circumstances can that physician have different monitoring protocols than what the rest of the policies throughout the hospital say? So that's the minimum. Otherwise, don't forget your frequency and duration of those assessments. What are their risk factors? How often are we going to dose them? And what is the duration of our IV opioid therapy? Is it the first 24 hours and then we convert them to oral? The minimum monitoring, vitals, pulse, respiration, maybe entitled CO2, pain level, respiratory status, sedation level. They talk about the APSF monitoring of opioids, including entitled CO2. Again, this is through the ISMP that they have decided that is the Institute for Safe Medication Practices on the standard sedation. In other words, what unit four is you doing, unit eight is also using that scale because then it's consistent. They know and they're trained on what to look for. So pretty much you'll see in here an ISMP for PCA monitoring. In other words, the PCA, they pretty much checked everything. So also they did mention the anesthesia patient foundation, safety foundation. They talk about IV opioids and post-op and how to monitor the patient. They talk in their supplemental oxygen, continuous monitoring, that's very important because they are so labile once they come out of surgery. I already mentioned that for those who are on IV opioids, continuous pulse ox and those who are in supplemental, including entitled CO2, link with the notification and follow-up. And again, the patient safety foundation, they are really, really monitoring and giving us some really good resources. I just have this one here I did wanna point out. They have some nice videos in here. If you wanna use that for some of your training. Then over to adverse drug reactions, anaphylaxis, respiratory depression, we know we have to act fast on that. They do talk about how we assess the patient, whether we use Richmond scale, Sero. Again, whichever one you use, make sure it's consistent throughout the hospital. They found that that's the best way. I've just got some examples of what they look like. Medscape actually did a comparison of those sedation scales that maybe you just wanna take a look at when you're looking at yours. Is there a better one? One that's more efficient that the staff will do and will complete it fully. So they do have, I was appreciative of Medscape for putting out that comparison for those. And then back to blood administration, right patient, right product. Under CMS, their standard has two qualified individuals that you have to use. One is actually going to administer it. Joint commission, on the other hand, if you're deemed status, the national patient safety goals allow for one person, but you must use barcoding. And CMS is okay with that, that this is the policy and that would be acceptable for them also. So if you are deemed status, you wanna use the joint commission and one person with barcoding, okay. Otherwise you have to have the two people do it. You can still do it if you're deemed status, that's totally your decision, but you document what you did and you're monitoring how frequently you're doing that. And how about treating an adverse reaction? Staff have to be competent in venipuncture and which device are they going to use? They must be trained in detection intervention, not only opioid over sedation, but also with any adverse reaction to the blood. Document their competency. This needs to go into their personnel folders. So nursing education needs to be aware of what they have to know and that they're trained also on the policy and procedure. Otherwise administered by qualified personnel, usually an RN. But again, your state law may be expanding the scope of non-RNs on IV medication administration and blood. That's where you want to check with your council on it. Otherwise you have to have the approved policies for medical staff. If it is a non-RN, they must demonstrate competency, following state laws for scope of practice, their hospital approved medical staff policy and procedures. So there's still quite a few steps that have to be done with allowing non-RNs to administer. The surveyor will interview the staff on different units. Those who do administer, not only blood, but IV medicines, they want to talk to them about their knowledge on the policy. Again, they don't have to know the exact wording, but they have to have an idea. Hey, this is what I have to do. Do they know venipuncture techniques? What size of needle do you have to have? What is the minimum amount? Because we know some of these patients don't have the best veins and trying to get an 18 gauge needle in there can be somewhat of a challenge. Administration practices, such as maybe there's IV tubing or infusion pumps that you can and cannot use for certain medicines. Watching that electrolyte balance. Assessing our patients. And early detection and intervention. So that's what they're gonna talk about with the staff. They'll look to see if there are any blood transfusions going on, and then they will review the files for competency of that person administering the blood and blood products. Now they are encouraged to watch staff hang blood or administer the IV medicines. And essentially they're just making sure they're following all of the safe practices, the safe injection practices. Did they use the appropriate access? Are patients monitored? And do we correctly identify the patient for that blood transfusion? And then finally reporting the reaction. You have to have a way to do that. How soon, who do they report it to? How do they report it and then document it? To whom do they need to make sure pharmacy and not only the provider, but pharmacy again are notified. They will ask, the surveyor is going to ask for how you report these. They wanna see your procedure. They may wanna look at incident reports or something that goes through QAPI program when these events occur. So they will ask to see your incident reports on those. So that means we have to have a procedure to report our adverse drug reactions and error. They're two different things. What are the guidelines do mention? A pharmacy tag again. They talk about reporting into the QAPI. And we normally do this through our incident reports. Those of you who have probably seen a transfusion reaction know it can be life-threatening. Bloody urine, pain, kidney failure, respiratory arrest, shock. I fortunately have never seen one, but for those of you who have seen it, what I've been told it's not a pretty sight and it's really can be very hard to treat at that point. So that's why you need to have that policy on making sure they are reported internally immediately to the practitioner because they need to step in and start giving care. Document the record and report to the program, the QAPI program, because we need to track these. What happened? Why did it happen? And then take it back to that root cause analysis to determine what can we change. I've combined these next two tag numbers because they're pretty much word for word. The survey procedures are the same. They have the same requirements. Your hospital can allow patients or their caregiver to self-administer medication where appropriate. That means of course we have to have specified policy and procedures on this. Now these can be meds the patient has brought in. These can be meds that you have supplied through the hospital pharmacy. This is optional. You don't need to do this. But if you're going to do that, you have to have an order. You have to assess and document this patient's capacity. Are they competent to do this? Or is the caregiver, the person administering it, competent to do it? Do they do it safely and appropriately? Where's that medication going to be kept? Are you going to keep it bedside? Or does it need to be at the nurse's station? And then what are the processes to document that administration of the medication? That includes notifying the nurse, I did this at this time for this reason. It is optional. It can be beneficial for some patients. Usually those can inpatient, but maybe if you're doing outpatient services, you can allow this. So you've got a patient coming in for maybe outpatient infusion therapy, and they're asthmatic. And you want to have them be able to administer their inhaler when they start to feel that symptom. Could be very helpful. Maybe hemorrhoid cream. Or if they're diabetic and they're on insulin, give them their own insulin. We just have to make sure patients are educated. This helps avoid those readmissions, return to the EDs. So what do you want to do? What other items do you want to consider if you're going to do this? Your nursing may need to supervise this. Do a, you know, teach one, see one, do one, teach one sort of option. Include in your policies when supervision for administration is needed. And which medications are you going to not allow for self-medication administration? Medical, nursing, pharmacy, they need to collaborate on these policy and procedures. If the patient brings it in, make sure somebody's looking at that medication for that integrity. So if it's insulin, how often was it refrigerated? How long has it been out of the refrigerator? You know, is there any particulates in that medication that said, probably not a good idea. Check the expiration date. Is it past that? Do we need to, okay, this is old. We need to get rid of it. The surveyor will assess to make sure the policy, all of those requirements are met if you're going to do this. Now, I did mention, I did want to talk about PACU because there's quite a bit on PACU and opioids. This is a separate section. It's in 957, but there must be adequate provisions for post-op care within the standards of care. And they do talk about opioids. They talk about really emphasized monitoring of those who are receiving IV opioids. That means we have to have policy and procedures on frequency of monitoring, staff training, so they know what to observe for and respond appropriately and what equipment. Because in PACU, that's going to include level activity, their pain, their vitals. What color are they, ashen? Do we have a little cyanosis around the mouth, meaning we're not breathing? What's the Aldrete score or whatever score you're using? If they're not sent to PACU, they're coming out of surgery, they're not going to PACU, it must be a close observation by a qualified RN until the patient has regained consciousness. That does say a qualified RN. That's what the standards say. Monitoring in PACU, policies have to spell out what is the minimum scope and frequency, consistent of course with the standard of care, because they are very concerned about those getting IV opioids and over sedation or respiratory arrest, depression. Once out of PACU, we know they're not monitored so closely. They're down the end of the hall maybe, and we don't have that opportunity. So that's why the last dose of IV pain medicine when they're in PACU, then when do they go to the floor? What is the half-life on that medication? So the staff on the floor know, maybe we need to go check on them again so that we prevent those. There's many resources I have in the appendix on PACU and assessment and monitoring of the patient. The surveyor will observe care in PACU. They want to make sure they're monitored and they're assessed, especially before transfer, or if they're going to be discharged from PACU. Do you have a system to monitor those needs transferred from PACU to other areas of the hospital? How are you going to do that? So overdose opioid use, which brings me to my last question, Lindsey. Okay, I'm gonna read this first part and then I'll post the question up here for you. It says, hospital B's emergency department has noted an increase in patients presenting with opioid overdose attributed to one provider. The emergency room treats the patients, but is concerned with prescribing practices by the physician. Should hospital B take additional actions? And then let me post those options up here for you. Okay, you should now see this on your screen. You can select all that you think apply here. Yes, no, up to the physician's professional decision-making. Yes, and bring to QAPI, and or yes, report the provider to the DEA. And just a reminder, as we were approaching kind of the towards the end of the presentation this morning if you have any questions at all for Laura, go ahead and be typing those into the Q&A option or of course they're in the chat so we can make sure we have time to address those questions today as well. Give me another couple of seconds here. I saw some responses still coming in. Okay, perfect, and here are those results. Great, okay, yes, yeah, did it, did it, okay, good enough. You guys are tough, man. You're not letting anybody get away with anything. So I want to just kind of bring this up. Now we're facing criminal charges for patients who overdose. They're getting serious on this. This is murder or manslaughter. They're getting serious on this. This is murder or manslaughter charges. We had one New York physician, six, death of six of his patients. He's looking at life. Oklahoma physician, five patients died as early as February of 22. Johnson & Johnson, they had 26 billion because of the role in the opioid addiction crisis. Now in some of those opioid matters, pharma, for example, some of those cases are still in process and they have been appealed and many things have been going on, but the Johnson & Johnson, that settlement stands. Here we have that physician who was convicted because now they're trying to, but it's not just criminal. Office of Inspector General is also getting into the game. They had a physician who pled guilty, $5.7 million fraud scheme. What they were doing was bringing patients to the clinic with unnecessary, asking for painkillers. This physician then billed Medicare for multiple unnecessary tests and office visits. Again, this is Pharma-Medica. They agreed to pay 35 million where they routinely dispensed without any written prescription. This is different than the one that's now going through all of the appeals. We have a Florida physician, murder, for overprescribing of pain medicine. Again, these are getting to be pretty significant cases. The pill mill, they were, again, the former. Here's 20 years for prescribing of medications and of opioids where a Tennessee physician, 20 years on distribution. This one just came up most recently. This was through Becker's. This was a Pennsylvania physician in a patient's death, 22 years because they were overprescribing of medication. Again, they're getting pretty serious on this prescribing of medication. Some states have instituted state-mandated guidelines on opioid prescribing. Used to be you come in, you have a minor injury in the ER, oh, here's 30 of oxycodone. They don't do that anymore. Now they'll give them maybe five days and that's it. Joint Commission, I did want to mention their pain assessment and management standards because CMS does not have anything like that. Just assess your patient. They put one in the leadership and this includes safe opioid prescribing. This is an organizational priority for the hospital. In fact, they even put out seven elements of performance because leaders, you establish not only this is what we're going to do, but the ethical framework for your entire hospital. They have the resources and services, so we give safe patient care. Solutions to those issues, are there safety or quality on pain management? That does require not only physician leadership but administrative leadership, so that we promote these initiatives and we have enough resources for pain management. Pain management is very real. We have patients who have unfortunately suffer from chronic pain, whether it's from an injury or from what we used to call RSD, a complex pain management system, or we have those who have fibromyalgia. These are very real pain situations. But leaders, they need to make sure there's enough support for pain management and safe prescribing. Give them the education, have them those resources, those tools so that we can monitor the performance and yet properly treat our patients. They are engaged in the oversight of pain management, so it is safe and it's effective. We can sustain these improvements across the disciplines, including pain management, the assessment, and safe practice of prescribing. In leadership, you have a leadership team or a leader for the pain management and safe opioid practicing. Who you describe to do that, that's up to you. You provide non-pharmacological treatment modalities, whether that's therapeutic touch or again, you provide it. That staff and providers, they have those educational resources, so they are aware what pain management and the assessment needs to be along with our prescribing. That they have information on consultative services. Perhaps we have that complex pain management that we need to refer them out to. We've identified programs that they can use. SAMHSA, they do have a treatment locator that you can find in your area that physicians, providers, they have access to what is the state's prescription drug monitoring program, that they can access it so that we can properly administer and order it when it's due. That's that treatment locator that I happened to mention that SAMHSA has. That they work with clinical staff leadership. What equipment do you need to monitor our patients who are at high risk? Especially when you're, again, post-op opioid treatment. Is it going to be entitled CO2? Do we have enough of them so that we can use it? We know how to use it. Are they also working? Whether it's opioid naive patients or those who have the same comorbidities that CMS has mentioned. In the medical staff section, they talk about medical staff's responsibility and their role in QAPI. In their element of performance 18, they're actively involved in the assessment, managing, and opioid prescribing. That they review that performance improvement data. We need to also consider others that might increase the risk of patient adverse reaction. Again, longer time for receiving anesthesia, our underlying cardiac and pulmonary disease. In provision of care, in that section, it requires the hospital to assess and management the patient's pain. They have defined criteria in place to screen, assess, and reassess the patient according to their age, and their condition. We're screening them for pain during that ED visit, and then or if they're direct admission. Their EP3, we treat the pain, maybe non-pharmacological. Maybe there's other resources we can use. A plan is developed based upon evidence-based practices, based on their condition, past medical history, and what are the goals for pain management? No longer is it, we're going to get your pain level down to zero. When my husband had his knee surgery, the nurse was very specific. Says, I can't get rid of your pain total, but I want to get it down to maybe a two or three to where you can function. I really liked that. That was very straightforward and he understood it, that the pain will not entirely go away, but we're going to manage it. But that involved the patient. That's where EP5 came into that call. Excuse me, into call. Realistic expectation for that pain management, that we help the patient understand. These are the objectives. We're going to help decrease it, but we may not take it away, but we're still going to keep you functioning. And that there's education on treatment options for this patient. We monitor the patient. They do reference, again, back to leadership and that there could be more frequent assessment of that patient based upon their condition. Then we reassess and that we respond to their pain. Maybe it's deep breathing, turning them over, that we can walk with improved pain control, that we still have side effects, we're aware of them. And what are the risk factors that we do have from that treatment? And of course we educate our patient and family on pain management and especially at discharge. What are they expected to know? What are the side effects that, okay, watch how many times they're taking that narcotic pain so that they're not forgetting and taking it again. And of course, safe storage. What happens to that medication after discharge when you're no longer taking that opioid? Don't hold onto it for a couple of years. A lot of the police departments now and some of the pharmacies will take back those controlled substances for proper disposal. FDA, they have proper disposal guidelines for any unused medications on what you need to know. But Joint Commission isn't done. They have also in their performance improvement that we collect data on pain assessment and management. What are the effectiveness of those interventions that we compile and analyze that data on assessment and management? Maybe some things we need to change. They put out FAQs back in 2019. There was one on actually using Tylenol for pain or the Dilaudid for pain. When can we convert it? Joint Commission says, yeah, you can use a lesser amount as long as what the nurse is doing is not outside the scope of practice. That's where policies and procedures have to stress it. And they also even put out a report on pain from Joint Commission. So they do try to help us. And then as we start to wrap up, there are some CDC opioid guidelines. So again, this is different from the ISMP. This is the CDC putting it out in 22. They had practice guidelines to hopefully help. Really what they're trying to do is improve our communication with patients. What are the benefits and risk of opioid therapy? And how can we improve our safety and effectiveness of this treatment? So we mitigate it, improve our function if you do have ongoing and continued pain and reduce those risks. Now, this is intended. It was focusing on your family practice physician and internal medicines, 18 and older with chronic pain, anything outside, hospice, palliative care, end of life. That's not where this was geared. But there were 12 recommendations. They put them into four areas of consideration. But overall, keep in mind, this is not a federal regulation. It is not meant to substitute for clinical judgment. And again, certain conditions, this simply doesn't apply. And adherence is totally voluntary. But determining whether or not to initiate opioids for pain, this is one area. How often, how long are you going to have that continued? Which opioids for dosages also? Assessing the patient and the potential for harm. Again, family practice and internal medicine and outside 18 and older. There's the prescribing practices that I did mention, their clinical practice guidelines that they have. And then finally, AHRQ has provided us some treatment. It is an evidence map. These are resources for pain management. They put out a public, excuse me, technical brief back in 2019. It hasn't been updated since then. So it's really good on treatment of acute pain, not chronic, but acute pain. They have that evidence map. And there is also the National Action Plan for Adverse Reaction Prevention. Health and Human Service found three classes of meds common for AERS. Opioids, of course, is one. We also have diabetes and anticoagulants. CMS, they have clinically significant preventable measures such as our targets, our high priority targets in the action plan. Just some numbers for you. Prolonged the length of stay. If there is an adverse reaction, they've gone from 1.7 to almost five days stay. That had to be over and above. 3.5 office visits, 1 million ED visits, and then quarter of a million hospitalizations as a result. So that adverse drug plan for events and the prevention, 190 pages long. Opioids was one of the three targets primarily concerned with accidental overdose. And chapter seven actually has a section on opioids and benzodiazepines. It starts on page 147 once you get in there. So this lift data, chronic pain, 100 million people annually. And opioid use has, we know, increased dramatically over the past 10 years. And that's caused many reactions, whether it's overdose or immunological and hormonal dysfunctions. So section seven, abuse is not directly addressed, but it's mentioned as a target for many of our agencies, CDC, DEA, all of them. And it's challenging to identify when you drift from therapeutic to abuse or misuse. It can be very hard to identify those patients. But there's a list of systems, surveillance systems that you can do and collect data for your adverse reactions. Now there's no outcome or process indicators on this, but nonetheless, they do have it when you can try and address it. Many evidence-based guidelines to address inpatients. That's many errors that can occur. And it does have a list of resources for safer care. Even SAMHSA has some really good overdose prevention toolkits for providers and other community members. There's five essential steps for first responders. 2018, 47,000 plus people died from an overdose. And we know those numbers have been going up ever since. Treatment guidelines came out in 15. There's not much change in the treatment guidelines, but there's sections on medication, the unit, telemedicine, and even human resource management for your treatment guidelines. And of course, AMA got involved in it too, how we have to end this epidemic. Use that PDMP. Maybe there is a potential abuse that we can start touching upon. IHI has resources on that crisis, 30 pages long. And it talks about what current efforts are using. And some of them aren't working, to be blunt. Human Health and Human Services talks about guidelines and tapering opioids. So they're very serious on this, all of this. So in our last half an hour, we do wanna go over discussion and see if there's any final questions. So here we have a 36-year-old, came in for a left below the knee amputation. He had gangrene on his leg. Remote history of IV drug use, remote. Tox screens are negative on admission. He's closely monitored in rehab. For six years, that was part of his probation. Well, now surgery, we've gone through it, and there's no complication. He's admitted to PACU with a PACU of morphine. Maximum amount per dose allowed is within the standard of care and our policy and procedures. Well, six hours after admission, he's reporting a lot of breakthrough pain. That's not uncommon. A lot of phantom pain is going on. Now his vitals are higher. He's requesting a little something for that breakthrough pain. The nurses reach out to the physician. The surgeon asked for medication. He's ordered Valium and Benadryl. Now he does report some relief, but continues to ask for more morphine. He has two visitors during the first night, both friends. 2,200 hours, 10 o'clock. He appears to be sleeping, so they leave him undisturbed. During midnight rounds, he's now abdundant. He's respiratory depression. He's pretty much in shock. No pulse, pressure's very palpable. They do the rapid response. He's resuscitated with some residual effects. They do do a tox screen again at this time, and they find oxycodone, 20 morphine milliequivalents. So they do an RCA. Policy and procedure, they found monitoring wasn't followed. He was left to sleep. Patient, they didn't ask about any other substance use, illicit or otherwise. They just asked him, what else have you taken in the past? The visitors, they had no instruction about bringing anything from the outside to help their buddy, and the PCA. There was nothing on that. They didn't monitor him for that. So what recommendations would you have for our hospital? Do you do staff education, wake him up regardless? Patient education, you're on this PCA. This is pretty good stuff here you've got going. Don't supplement it. Keeping the visitors, watching those visitors, educating them. Maybe we need to go back over a policy. Do we need to change anything as affiliated? Or is there anything else you wanna suggest to our wonderful hospital on this? So I'll turn it back over to you, Lindsay, see if we have any questions, et cetera. Perfect. I did go ahead and post those options there on the screen for you all to select. And if you have other comments you'd like to make regarding this final discussion question, you can, of course, post those in the chat as well. I don't see any pending questions at this time. So as we wrap up, if you would go ahead and, oh, actually I said that, there's one here in the chat. It says, where is the best place to look up state law for verbal orders? I would go to your, for verbal orders, I would try the medical board or the pharmacy board. Because again, the physicians give the verbal orders. And in our state, it's in our nursing also. So it's in our medical and our nursing and our pharmacy. We could do a little overkill, but they wanted to make sure they covered all three sections, who can take it and who can give a verbal order. That's where I would start with that. And then your hospital policy spells it out. If your state law is silent, and again, that's where your in-house counsel or your attorney comes in real handy. They should help you with that. Make sure your hospital policy spells out what is, if your state law is silent. The other one is, you might want to check with some of the nursing organizations because CMS, again, won't establish that. They go to the professional societies to determine who do you want to have under LP and RN license to take a verbal order? Who do you want to have do that? Because again, the nursing will know what questions to ask. Your unit clerk, they won't know what questions to ask of the doc. They can repeat it back, but they may not know. So we always had the unit clerk, got a doc wants to give verbal orders and the phone had to be handed to the charge nurse or another RN that was around. Okay, I don't see any other pending questions. I'll go ahead and end this and share those results for that final discussion. Oh, good, I'll leave up. That's great. Yeah, there was a whole host of things that we really had to do. I understand, yeah, post-op, maybe we want them to sleep, but when the patient's been in four and five days and okay, they're good with that medicine and we're okay, maybe we can let them sleep, but again, we need to work with the patient, the physician on determining that. They should have woken this guy up. Now, granted his tox screen was negative on admission, it didn't mean it wouldn't change. Because yes, he had a few other environmental supplements, so to speak, in his system when they redid do the tox screen. And the only way they could try sit back and he fessed up. He said, yeah, my friends were trying to help and they knew I was in pain and it almost cost him his life. So that was a harsh lesson to learn. So that was a harsh lesson to learn. And they did change the policy after that, that when they have patients, anybody, didn't have to be a former drug user. They did stress to the other family members and visitors, you know, he's having some breakthrough pain here. Don't give him anything, really. He's on some very potent medicines and that could really harm him or her, whoever it happens to be, if we give it to him. So we know you're trying to help him, but please don't. That's our job, we need to take care of him. So yeah, this one, they did have to change a few items. One thing I do want to point out, now you probably saw in the slides that Lindsey is going to make available to you. There's roughly 30 some odd pages of resources in here for you. I don't endorse any one of them. They're here strictly for your information, the guidelines, even a treatment disorder from SAMHSA, they're really good about that on where they can find them and what's involved in them. They have in here the pain history, initial treatment, even countering, stemming the tide, AHA, ASPAN. This is the Association of Perianesthesia Nurses. I didn't know there was one, but there is. And they talk about pain control. And American Society of Anesthesiology is wonderful on providing resources at no charge to you on some of these ASA standards and guidelines. They're very good on that. Otherwise, I always suggest folks look at ISMP for doing even a gap analysis tool for your IV push medicine. So again, I've got roughly 30 pages of resources here. I don't want to go through all 30 of them. If you have the opportunity, great. Otherwise, Lindsey, I'll turn it back to you in a final and give them about 20 minutes of their time back for another cup of coffee. Perfect. I do see one question that came in here that asks, if a doctor provider wants to mix a medicated drip and they choose not to wait for pharmacy, what is the liability there? Oh, that's going to be up to the hospital to determine that. Of course, the physician's going to have their own liability. They will. That's separate and apart from what the hospital is. But if your policies and hospital policies allow that, then they just have to make sure that the physician is following the standards safely, infection prevention and control, you know, that they're doing it right. It's nice that the physicians do it. I've never had a physician do that. It's usually like, I need you to mix this up for me is usually what happened. But if your policies allow it and your guidelines allow it, then the physician has to follow the same prevention, sterility that anybody else would have to follow, pharmacy or nursing. But if it's a medication that absolutely, policy says it must be done under a laminar flow hood, then I wouldn't allow it. I think you're going to be causing trouble. Or why are they not waiting for pharmacy? What's going on? That pharmacy can't get to it ASAP. I don't know. And that could very well be. Right. Okay. I don't see any other pending questions. I did post some information there for you all in the chat. If you have not joined us for webinar before, this is just kind of an overview of the process. So tomorrow morning you will receive an email, but just note that it comes from educationnoreplyatzoom.us. And so because it comes from that Zoom email, it very well may get caught in your spam, quarantine, junk folders. And so if you don't see that email in your inbox in the morning, I would encourage you just to check those additional folders first. If it's still not there and you'd like to access the recording of today's presentation, you can always just use the same Zoom link that you use to join us for today's live presentation to also go back and access that recording. And then just remember that the recording link through Zoom is available for 60 days from today's date. And then we do have an additional security measure in place so that we're protecting Laura's intellectual property here. So when you click on that Zoom link, it'll ask you to put in your information. That will prompt an email to come to us for approval. And once we approve that recording access request, you will receive a confirmation from Zoom that will contain the final link into the recording. And then again, that link is available for 60 days from today's date. And then also included in that email tomorrow morning will be a link to the slides that Laura presented for us today. And of course that includes all of the additional resources that she just covered. I did go ahead and provide that link there for you in the chat. So you have that as a resource now as well. And then also if you're joining us, especially as a member of the Georgia Hospital Association, pay attention to that final link in that email that will come out tomorrow morning. And that will be a link to the survey. And that is how you will obtain further information regarding continuing education credits and receive your certificate of attendance for today's presentation. If you're joining us as a member of a partner state hospital association, please reach out to your contact within your association to obtain any information that they may be able to provide regarding continuing education for your state as well. And then if you do have any additional questions at all, don't hesitate to reach out to us at education at gha.org. And we'll be happy to get those over to Laura. She is wonderful about being very timely and thorough in her response, always going above and beyond. And we so appreciate her for doing that. You do see her contact information here on the screen, but we're happy to facilitate those. So I did post that email address there in the chat. So please don't hesitate to send any questions that you have to email address and we're happy to help. Thank you all so much for joining us today. I see a comment here, Laura saying great presentation. And of course it was, and we always appreciate you for your time and information that you share with us. And we hope to have you all back with us for future presentations and hope you have a wonderful rest of your week. Thank you so much, Laura. Thanks everyone. Thank you, Lindsay. Bye-bye.

Laura Dixon

risk management

patient safety

Kaiser Permanente

COPIC

medication administration

blood administration

nursing

pharmacy

CMS

Joint Commission

five rights

opioid administration

patient safety education