Last updated 10.2006

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TITLE: Accountability of Controlled Substances NUMBER: 300.1

SECTION: Medication and Equipment

EFFECTIVE DATE: 9/1 /99 REVISED/REVIEWED: 10/1/06

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PURPOSE: The following procedure for accurate accounting of controlled substances is to be followed by the Resource and all Associate Hospitals in the Loyola Emergency Medical Services System. These procedures are the requirements set forth by the U.S. Department of Justice Drug Enforcement Administration (DEA) for accountability for all controlled substances used in the Advanced Life Support ambulances.

POLICY:

Responsibilities of the Resource Hospital

1. The Resource Hospital will initially stock the IDPH/system approved ALS ambulances with those controlled substances approved by the LEMSS medical director and included in the LEMSS drug inventory.

2. The Resource Hospital will track ALS Ambulance Run reports on which controlled substances were used for later DEA accountability purposes.

3. The Resource Hospital will accept any excess controlled substances from the ambulance personnel and dispose of such substances according to appropriate hospital and DEA policy. The Resource Hospital, upon proof of use, will then replace the controlled substance used by the ALS provider.

Responsibility of Associate Hospitals

1. The Associate Hospital will accept any excess controlled substances from the ambulance personnel and dispose of such substances according to appropriate hospital and DEA policy. Upon proof of use, each Associate Hospital will then replace the controlled substance used by the ALS provider.

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TITLE: Documentation of Controlled Substance Usage NUMBER: 300.2

SECTION: Medication & Equipment

EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06

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PURPOSE: To establish standard documentation for inventory and use of controlled substances on Loyola Emergency Medical Services System ALS vehicles.

POLICY:

1. Controlled substances include those DEA Scheduled drugs approved for use by the LEMSS medical director.

2. Controlled substances will be inventoried daily and documented on a system approved Controlled Substance Inventory Sheet. Administration of Controlled substances will be documented on the administration record located on the Inventory Sheet.

PROCEDURE:

1. Daily inventory of controlled substances requires the signatures of both the paramedic going off duty and the paramedic coming on duty.

2. Administration of controlled substances will be documented on the Controlled Substance Inventory Sheet and a copy of the ambulance report will be attached.

3. Replacement of the used controlled substances at the receiving hospital will be documented in the hospital controlled substance logbook.

4. The completed Loyola Emergency Medical Services System Controlled Substance Inventory Sheet will be submitted to the EMS office monthly. Any discrepancy is to be reported to the EMS office and should be documented on a Quality Control Communication Report form as soon as possible.

5. Missing Doses or Suspected Tampering

A. If a controlled substance is unaccounted for or shows signs of tampering, the EMS System Coordinator must be notified by the ALS Providers EMS Coordinator within 24 hours of the incident. The EMS System Coordinator shall investigate the incident; replacement of the controlled substance will be issued to that vehicle by the Resource Hospital only.

B. The ALS Provider EMSC will forward within 72 hours to the LEMSS office the following:

1. Original incident documented by EMT-P's involved.

2. Summary of events documented on system Quality Control Communication Report form completed by the ALS Providers EMS Coordinator.

3. A copy of the police report, if applicable documenting the missing controlled substances.

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TITLE: Medication Exchange NUMBER: 300.3

SECTION: Medication & Equipment

EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06

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PURPOSE: To provide a mechanism for a means for Loyola Emergency Medical Services System prehospital providers to exchange used, expired or damaged medications.

POLICY:

1:1 Exchange

1. All medications utilized in prehospital patient care will be exchanged on a 1:1 basis.

2. To replace all medications utilized in prehospital patient care the provider should request assistance from an emergency department nurse to access the Omni-cell/Pyxis system. The following information is required:

A. Prehospital provider

B. Patient's name

C. Type and amount of supplies used

Soon-to-be Expired / Damaged Medications

All drugs according to FDA are dated with an expiration date on the outside of the box. If dated with month and year only, the drug will expire on the last day of indicated month. (For example; 10/05 will expire 10/31/05).

A “Drug Exchange Record” form must be completed to exchange soon-to-be-expired or damaged medications thru the Loyola University Medical Center Pharmacy. Drugs must be exchanged at least 60 days prior to the expiration date.

Expired Medications

In order to honor the 1:1 exchange drugs must be received 60 days prior to expiration date without incurring a charge to the provider.

Refusal of Service

When there are medications used for prehospital care of a patient and the patient is a documented refusal of service, the following procedure must be followed.

1. Submit a copy of the ambulance run sheet to the receiving hospital indicating the medications used.

2. Medications will be exchanged on a 1:1 basis at the expense of the prehospital provider.

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TITLE: Prehospital Provider Disposable Supplies Exchange NUMBER: 300.4

SECTION: Medication & Equipment

EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06

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PURPOSE: To provide a mechanism for an expedient and financially equitable means for prehospital providers to exchange supplies through the Loyola EMS System.

POLICY:

Supplies utilized in patient care.

1. All supplies utilized in prehospital patient care will be exchanged on a 1:1 basis.

2. Exchanges for supplies are completed through the Omni-cell/Pyxis system. The following information is required:

a. Prehospital provider

b. Patient's name

c. Type and amount of supplies used

Refusal of Service

When there are supplies used for prehospital care of a patient and the patient is a documented refusal of service, the following procedures must be followed:

1. Submit a copy of the ambulance run sheet to the receiving hospital indicating the supplies used.

2. Supplies will be exchanged on a 1:1 basis at the expense of the prehospital provider.

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TITLE: Non-Disposable Equipment:Hospital Storage/Replacement NUMBER: 300.5

SECTION: Medication & Equipment

EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06

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PURPOSE: It is recognized that equipment is often left at a receiving hospital by prehospital providers. The Loyola Emergency Medical Services System has developed this policy for identification and storage of non-disposable equipment left in emergency departments by prehospital providers.

POLICY:

1. Hospital responsibilities:

a. Equipment will be stored in a designated area for 72 hours.

2. Prehospital Provider's responsibilities:

a. All equipment should be properly marked to facilitate identification.

b. Appropriate identification will be required upon collection of equipment.

c. Every attempt should be made to pick equipment up within 72 hours.

3. If the equipment cannot be located, arrangements may be made with the Emergency Department manager to replace the item.

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TITLE: Supplies for New Ambulances NUMBER: 300.6

SECTION: Medication & Equipment

EFFECTIVE DATE: 9/1/99 REVISED/REVIEWED: 10/1/06

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PURPOSE: To standardize the method for obtaining supplies for new ambulances.

POLICY: Requests for supplies should be submitted to the EMS System Coordinator two weeks in advance of need. Requests for controlled substances must be signed by EMS Medical Director or designee.