A drug hypothetical for nurses

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Surgical nurse Alice Suttie [right] asks: Fellow nurses, I have a hypothetical situation that is gnawing at me. We have now started locking up our propofol at night as do other hospitals, barring the theatres used at night for emergency caesars, neurosurgery or cardiac surgery. My concern is this: if there is a code 1 obstetric emergency – something like a ruptured uterus during normal labour (happened to someone I knew years ago) – during the day when most of the theatres are in use and there is one theatre not usually used for emergencies available, is there really time for nurses to be running to cupboards at the other end of the theatre complex to retrieve propofol and thiopentone when every minute counts for mother and child?

While this scenario is rare, it’s certainly not non-existent and I am deeply concerned we are creating a situation that can put patients’ lives at risk.

How do other hospitals handle this? Just take the risk? Keep thiopentone on hand and just lock away the propofol? Or are we all waiting for a court case to make the decision for us when those precious minutes might have made a difference?

I put the same scenario to one of our senior anaesthetists and he also thought it was a potential issue. As rare as major obstetric crises may be for us in first world private hospitals, the risk is never zero. I just don’t want there to be a preventable maternal death on account of this.

An NSWNMA legal officer responds:

Public hospitals: If you are working in a public hospital in NSW, the facility is required to comply with the NSW Health Policy Directive Medication Handling in NSW Public Health Facilities PD 2013_043 (“policy”). The policy applies to NSW Public Hospitals and the other facilities stated on the front coversheet. The policy also applies to private facilities as listed in the Health Services Act 1997 – Schedule 3 Affiliated health organisations.

The policy requires S4 Appendix D (S4D) and S8 medication to be locked up and stored within the requirements set down in 6.3.1 and 6.3.2.

Thiopentone is an S4D medication and should be stored as prescribed in 6.3.2, “except:

  • When stored in the Schedule 8 medication storage, or
  • when stored in an emergency trolley, or operating theatre trolley. In these cases, S4D medications must be kept at minimal levels and the trolleys kept in a locked room when the patient care area is closed, with access only by authorised persons”.

Propofol is an S4 medication. In accordance with the policy, it is an Unscheduled medication and should be stored in accordance with the requirements set down in 6.3.3.

“Must be stored out of patient and public access, preferably in a  locked cabinet securely attached to the wall or floor of the premises with the following exceptions:-

  1. On a medication trolley used for medication rounds, which should be kept in a locked room when not in use, or
  2. On an anaesthetic trolley or operating theatre trolley, which is kept in a locked room when not in use, or
  3. Minimum quantities of medications on an emergency trolley, or
  4. In a secure cabinet (such as a bedside cabinet), including that used for patient self administration in an approved program, in situations for which it may be impractical to attach the cabinet to the wall or floor of the premises.

However, in order to minimise the risk of misappropriation, the Drug and Therapeutics Committee (“DTC”) at some facilities may impose a local policy and direct the medications be recorded in a drug register or it may add additional controls on storage, for example limiting access at night if it deems it appropriate.

If Alice works in a public hospital and is concerned about access to Propofol and Thiopentone during the day where there is only a non-emergency theatre available and Propofol or Triopentone are not readily available, she should raise her concerns with the facility’s DTC, who will then review the facility’s procedure and provide advice and direction in order that care can be provided in a safe care in a timely manner. A lockable anaesthetic emergency trolley placed in an accessible convenient location within the operating theatre complex may be appropriate.

Private hospitals: In NSW, private hospitals not listed in the Health Services Act 1997 – Schedule 3 Affiliated health organisations are not required to comply with the policy. They are however required to comply with the principles set down in the Poisons and Therapeutic Goods Act 1966 and the Poisons and Therapeutic Goods Regulations.

The Private Health Facilities Regulation 2010 states in Schedule 1, Division1 (5) (3):

“The medical, surgical and nursing equipment, appliances and materials required to be available at a private health facility by this clause must be provided in quantities that are appropriate for the safe and effective provision of the services for which the facility is licensed”.

If Alice works in a private hospital and is concerned about access to Propofol during the day where there is only a non-emergency theatre available and Propofol or Triopentone are not readily available, she should raise her concerns with the facility’s Medical Advisory Committee, who will then review the facility’s procedure and provide advice and direction in order to provide safe care in a timely manner. A lockable anaesthetic emergency trolley placed in an accessible convenient location within the operating theatre complex may also be appropriate in the private hospital setting.

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