Wednesday June 19th 2019

30-minute pressure cooker?

ANA, nurses say multiple factors come into play with passing meds

A staff nurse for 41 years, Paula Anderson, RN-C, would never cut corners to pass meds faster.

“That would endanger patients,” said Anderson, president of the Ohio Nurses Association and a staff nurse IV at the Ross Heart Hospital, Ohio University Medical Center, where she has worked for the past 23 years.

So recently, when she had to administer 30 medications to one patient during her 9 a.m. med pass, Anderson did what she always does: assess the patient’s condition and explain each medication as she gave it to him.

Apryl Brand, BSN, RN, an Arizona Nurses Association member and a staff nurse for nearly 30 years, is equally as methodical.

As all nurses are educated to do, she always follows the “5 Rs”: right patient, right drug, right dose, right route, and right time.

“I always call the patient by name and check his or her ID bracelet,” said Brand, who works the 7 p.m. to 7 a.m. shift on a 52-bed medical unit with many patients who are undergoing chemotherapy or peritoneal dialysis. She also takes the medication administration record (MAR) into each room, checking the accuracy of the meds every step of the way. Her typical patient-load is seven. And the 9 p.m. med pass is generally her busiest, with each patient getting anywhere from two to 10 separate medications, including a potential IV piggyback.

“Administering medications is one of the most important duties a nurse has to do,” Brand said.

Although both nurses say that they generally can give all their patients their medications in about an hour during a typical med pass, they know that there are numerous factors that can prevent them — or their colleagues — from achieving that goal.

A focus on fast?

The American Nurses Association (ANA), other nursing organizations, and individual nurses have provided input to the Institute for Safe Medication Practices (ISMP) about a 2008 Centers for Medicare and Medicaid Services (CMS) rule that requires all medications to be given within 30 minutes of the scheduled time in order for facilities to receive Medicaid and Medicare payments. For example, nurses must give medications scheduled for 9 a.m. to all their patients between 8:30 and 9:30 a.m.

About 70 percent of the more than 17,500 nurses who responded to a 2010 ISMP survey on the 30-minute rule reported that their facility enforces such a policy, and only about 5 percent of those nurses reported that they were “always” able to comply with it. More than half were “infrequently” or only “sometimes” able to comply.

Most respondents called the rule “unsafe, unrealistic, and impractical.” Further, the vast majority stated that it posed risks to patients, including leading some nurses to take shortcuts or make errors.

ANA also has shared its safety concerns with ISMP and CMS.

“Strict compliance with the 30-minute rule poses significant patient safety and workload issues for nurses,” said ANA Senior Policy Fellow Carl Bickford, PhD, RN-BC. And even though barcode-medication administration and documentation is designed to ensure patient safety, nurses can fall behind in passing medications because of technological problems with the system. Additionally, the location of automated dispensing cabinets away from patients’ rooms and paper-based documentation can force nurses to race the clock.

Added Pam Robbins, BSN, RN, president of the Illinois Nurses Association (INA) and a long-time staff nurse, “Do meds need to be delivered in a timely fashion? Yes. Is it always possible when nurses have too many patients requiring so many meds? No. Nurses are working at warp speed to pass meds, and that should be sending up a red flag that staffing may not be sufficient to meet the acuity of the patients.”

Robbins also spoke to the increasing complexity of medication regimens — with nurses having to know far more medications than before, accurately differentiate more medications with similar names, and catch potential drug interactions.

Looking at the big picture, Robbins noted that consumers might not have to take so many medications — or even be hospitalized — if nurses had the time to educate patients on lifestyle choices, other preventive health issues, and ways to effectively manage chronic illness.

Anderson said that passing meds also is not a “black and white” type of task in which “you put the [medication] cup down in front of the patient and go.”

“There are so many situations that can come up with patients and the process,” said Anderson, who generally provides care to three to four patients on her cardiac care unit. “A patient may develop an issue, ask a question, or need to use the bathroom first. There might be a new med that I might have to look up, or the doctor just changed the dosage of a medication.”

Nurses also must educate patients on any new medication, as well as assess and reassess the effectiveness of pain medication given to their patients, according to Brand, who has been employed at Yuma Regional Medical Center in Arizona for 16 years and enjoys taking care of patients.

Nine out of 10 ISMP survey respondents reported that the 30-minute rule should be changed, with most calling for a timeframe of 60 minutes before or after the scheduled time for medications administered every four hours or less often, according to the ISMP. Further, many RNs commented that they should be able to use their clinical judgment and critical thinking skills to make exceptions to any rule.

The guidelines, ongoing efforts

This May, the institute released its finalized ISMP Acute Care Guidelines for Timely Administration of Scheduled Medications, which were developed by an expert panel. The guidelines can be accessed online at www.ismp.org/Tools/guidelines/acutecare/tasm.pdf.

In this guidance document, ISMP cautions that hospitals are still accountable to the CMS 30-minute rule. It hopes, however, that CMS surveyors “will allow hospitals to justify their carefully considered policies and procedures regarding timely medication administration” using the ISMP guidelines as part of the process.

The ISMP guidelines include recommendations on time-critical and non-time–critical scheduled medications and first doses. They suggest that hospitals evaluate their goals for timely medication administration using these guidelines and develop lists of non-critical and non-time–critical scheduled medications specific to their facilities.

The ISMP recommends, for example, that non-time–critical medications that are administered more frequently than daily, but not more often than every four hours, be given within one hour before or after the scheduled time. Examples are meds given twice a day or every six hours. ISMP considers non-time–critical scheduled meds as those that, if given too early or later than a specified range of one or two hours, should not cause harm or lead to a substantially altered therapeutic effect.

Hospital-defined, time-critical medications should be given at exactly when scheduled when necessary, such as rapid-acting insulin. Otherwise, they can be administered within a half hour before or after the scheduled time, the ISMP advises.

The finalized document offers advice on specific operational issues, such as the use of automated dispensing cabinets, MAR documentation, and event reporting.

And it includes issues raised by ANA, including the importance of maintaining adequate staffing levels and ensuring nurses are part of the interdisciplinary team developing policies and procedures around medication administration, according to Bickford.

ANA will continue to monitor and provide input to CMS directly and through its representation on the National Coordinating Council on Medication Error Reporting and Prevention and the Nursing Advisory Committee of the Joint Commission. The CMS 30-minute rule can be found in CMS’ Conditions of Participation Interpretive Guidelines for Hospitals, State Operations (section 482.3 (c)(1), which outlines indicators for assessing drug administration.

— Susan Trossman is the senior report for The American Nurse.

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