Monthly Archives: February 2013

Nursing Clinics and Scope of Practice. What Do You Think?

20130123-1At the last Essentials of Correctional Medicine conference, Dr. Marc Stern gave a thought-provoking lecture about the proper use of nurses in the correctional setting. I have to admit that his talk was a bit controversial; some of the nurses in attendance were uncomfortable and even a little offended.  But whether you like Dr. Stern’s talk or not, his thoughts deserve some consideration.

The main thrust of his talk was to compare how nurses are used outside of corrections—the community standard as it were–as opposed to how nurses are used inside jails and prisons.  There are quite a few differences.  Why is this so?  And if nurses are used inside of correctional facilities differently than the community standard, is this proper?

Dr. Stern brought up two distinct differences between how nurses are used in the community and how they tend to be used in corrections:  Acute Care and Chronic Care.  I am going to discuss the Acute Care issue today and the Chronic Care issue in my next post.

The Nursing Role in Acute Care Clinics–Community vs. Corrections

The single major difference between how nurses are used in the community and how they are used inside correctional facilities is this: in the community, nurses do not run acute care clinics–ever.  Nurses in the community do not diagnose or prescribe treatment.  It does not matter whether you go to your doctor’s office or a hospital emergency department or a “Doc-in-the-Box” urgent care clinic or even one of those mini-clinics you find in grocery stores nowadays.  In each case, you will be seen by a medical practitioner of some sort; whether a doctor, a physician assistant or a nurse practitioner.  Nurses will be there, but in the role of assisting the practitioner.  It just will not happen in the community that a patient will be seen only by a nurse—no practitioner in sight—who does an examination, makes a diagnosis like, “You have bronchitis,” and hands out a prescription.

On the other hand, acute “sick call” clinics in correctional facilities are commonly run only by nurses.  These nursing clinics tend to be of three main types:

  1.  Triage clinics.   In this type of clinic, a nurse sees every patient who puts in a medical request and schedules them to see a practitioner depending on the urgency of the complaint.  For example, a patient complaining of abdominal pain might be scheduled for the very next medical clinic whereas a patient complaining of dandruff might be scheduled a week out.  The Triage nurse could also have the on-call practitioner come in urgently to evaluate a patient with, say, chest pain or decide to send that patient to the ER.  However, in this model, nurses never diagnose or prescribe treatment.
  2. OTC clinics.  “OTC” stands for “Over-the-Counter” medications that do not require a doctor’s prescription.  In this type of nurse clinic, a nurse again sees every patient with a medical request and schedules medical clinic appointments, but also is authorized to dispense over-the-counter medications for common minor complaints.  For example, a patient with abdominal pain still would be scheduled in to medical clinic, but a patient with athlete’s foot might be given OTC clotrimazole cream by the nurse without the patient ever seeing a practitioner.  Some facilities have quite detailed protocols to guide nurses in this endeavor, but not all.
  3. Full Service Nurse Clinics.  In some correctional facilities, nurses take care of almost all sick call patients.  The nurse will still schedule complicated patients to see the practitioner, but will take care of other, simpler, problems even if these require a prescription medication.  If a nurse thinks that a patient needs a medication requiring a doctor’s prescription, he/she usually will call the on-call practitioner for authorization.  An example would be a female inmate thought to have a Urinary Tract Infection.  The nurse would call the practitioner for orders, say an antibiotic, and then administer it.    Sometimes, this patient will be seen by the practitioner in a subsequent clinic, but not always.

As Dr. Stern pointed out in his talk, it is clear that this system of using nurses in jails and prisons is very different from the “community standard.”  Dr. Stern also pointed out that in many correctional facilities, the nurse performing these tasks is not an RN, but an LPN or even a “Correctional Medical Technician” with even less formal medical training than an LPN.  The concern is that by running acute care clinics, which involves making diagnoses and prescribing treatment, nurses may be exceeding their scope of practice.

Why Are the Two Systems Different?

Personally, I can easily see how this system of nursing duties evolved within corrections.  Community urgent care clinics have a practitioner in attendance at all times.  These clinics are never staffed with nurses only.  But jails and prisons are not that way.  Consider very small jails, for example, where the doctor’s sick call clinic may only be held once a week.  Someone, then, has to evaluate inmate medical requests to decide if the inmate can safely wait until the next scheduled clinic, which may be days away.  You certainly don’t want the inmate with appendicitis to wait a week to see the doctor!  And the jail nurse is certainly a better choice to do this evaluation than a detention deputy!

But what if the inmate complaint is so simple that it only requires an Over-the-Counter medication?  Say heartburn?  The inmate can certainly wait until clinic but why can’t the nurse just give out some OTC ranitidine?  Or foot fungus cream for athlete’s foot?  Is it even ethical to make the inmate suffer until clinic for such a simple problem?  On the outside, the inmate would not even have to go to medical.  They could just go to the store and buy ranitidine.  Can’t a nurse just give the patient some OTC ranitidine?

Other simple inmate complaints can be just as easily resolved with prescription medications.  Take the young healthy woman who has the classic symptoms of a urinary tract infection: dysuria, urgency and frequency.  Can’t we get the antibiotics started before the doctor’s clinic?  Do we make her wait?  And what about other, more serious, medical problems like alcohol withdrawal that absolutely should not wait until the next sick call.  Librium must be started now, whether there is a doctor on site or not.

But then, it is but a short, dangerous step to the next level:  By the time the doctor comes in for clinic, the woman with the UTI is cured!  The alcohol withdrawal patient is doing well!  The patient with heartburn has no complaint!  Isn’t it just a waste of the doctor’s valuable time to see these asymptomatic patients?

In the end, you have the scenario where a nurse has made a diagnosis and perhaps prescribed treatment without a practitioner ever having seen the patient and maybe even without ever having been contacted!  Somewhere along that continuum is a fine line that, when crossed, means that nurses are diagnosing and treating beyond their scope of practice.

In prisons, where a practitioner may be present in the facility every single day, it may be possible to run acute care clinics as they are done on the community.  However, it also may not be feasible.  Since I don’t practice in a prison setting, I will leave the discussion of the proper role of nursing clinics in prison to my prison based colleagues!  Please comment below!

However, in jails, it is simply not possible to run acute care clinics like the community standard.  No 50-bed jail can afford to have a doctor show up for clinic every day.  Even large jails don’t typically have practitioners on site every day.  There has to be some sort of partnership with nurses to triage medical requests and to take care of simple problems.  However, jails should take care not to cross the line where nurses exceed their scope of practice!

The following reflects my personal opinions on the subject:

  1. Nurses should have a protocol or guideline to follow when they evaluate simple complaints that can be treated with OTC medications.  Patients with complaints like “I have athlete’s foot and need cream for it” or “I have heartburn–can I have some Zantac?” do not necessarily need to be seen by a doctor since they do not need to see a doctor on the outside to obtain these items.  But even these simple complaints can be fraught with some danger—like when the guy with “heartburn” is really having a heart attack.  Nurses should have written guidelines that indicate when OTC remedies are appropriate and what “Red Flags” indicate a referral to clinic.  If nurses have such guidelines, they are not diagnosing and treating independently; they are instead assisting patient to obtain appropriate OTC medications.
  2. Why make inmates see a nurse to get OTC medications in the first place?  People outside of jail don’t have to go to a clinic to get Zantac or foot fungus cream or whatever.  They just go to the store and buy them!  So why do we make them do it in jails?  It is a waste of both the nurse’s time and the inmate’s time.  Put appropriate OTC medications on the commissary (see You Need a Medical Commissary in Your Facility! and Obstacles to a Medical Commissary Program.
  3. If a nurse thinks a patient needs an urgent prescription drug before the next medical clinic, the on-call practitioner must be called for an order! Nurses should not start prescription medications based on protocols alone.  That is not done in the community; it should not be done in correctional facilities.  For example, if a nurse sees a MRSA lesion and wants to start antibiotics before the next clinic, he must call for an order.  Does an alcoholic need to begin therapy for withdrawal tremors?  Call.  If these calls are not made, then the nurse has diagnosed and prescribed treatment independently, outside of the scope of practice.  The only exception to this rule is emergency treatment, like epinephrine for anaphylaxis.
  4. Every patient who receives a prescription medication should be seen by a practitioner!  I don’t mind authorizing antibiotics over the weekend for a woman with a UTI.  But I then am obligated to see her, however briefly, in my next medical clinic.  It doesn’t matter if she is better—that just means that the clinic visit will be brief.  But if I prescribed the medication, I need to document a history and an examination in her chart.  If I don’t, the nurse again diagnosed and prescribed beyond her scope of practice, albeit with my “rubber stamp.”  Interestingly, here in Idaho, the Board of Medicine recently condemned the practice of prescribing medication without examining the patient.  The Board was specifically addressing situations like when a family member or friend calls and says, “I have a sore throat.  Will you call something in?”  But the principle applies to this situation in corrections, as well.  If I prescribe something, I need to see the patient and document a history and physical.

As always, I have expressed my own opinion here.  Feel free to disagree.  I might be wrong!  But if you do disagree, please comment and explain why!

Next Post:  Chronic Care Clinics in Corrections vs. the Community!

In the Essentials of Correctional Medicine Conference, Dr. Stern’s lecture on nursing roles raised some eyebrows.  What is your opinion on nursing roles in corrections?

What Makes a Good Medical Scoring System?

20050629My good friend Al Cichon wrote the following comments to me about my article on the 10 Point Pain Scale.

Use of a ‘scale’ to measure subjective factors is a true oxymoron (heavy on the moron part). The ‘fifth vital sign’ is a misdirected effort to solve a true quality care problem – in my opinion. Vital Signs are objective (as in measurable) indicators that have been demonstrated to provide consistently valid data for patient care.

JCAHO has imposed the ‘Pain Scale’ in an effort to assure that the assessment of pain will be factored into patient care. Unfortunately, it is a bureaucratic response to a clinical situation – if it can be made to be measurable (regardless of practical validity) it can be enforced. My apologies to proponents and defenders – but no matter how well intended; it is still dysfunctional.

Yet, we are obliged to employ some process of assessment to determine the impact of subjective symptoms in an efficient / effective manner. The many schemes (Pain 1-10; Cardiac pain 1-5; etc.) developed have achieved relative success / adoption / adaptation. It does seem that these processes have provided some benefit – yet they all suffer from the same susceptibility – subjectivity. Whether you are working in corrections (where any subjective report must be verified) or the community (where verification is not always considered) any of these schemes has the same risk – because there is no objective validation.

One possible option to stabilize the use of any such scale is some method of anchoring the initial or end point of the scale. That would then provide a somewhat stable reference for guiding care and transmitting information (about the patient) to other providers. Also, this mechanism can be employed in other subjective areas.

Begin with asking the patient – ‘What is the worst pain you have ever experienced?’ (the response is usually associated with fractures, renal calculi, child-birth, etc.) Now, lets’ label that as a 10 (or 5) and now –‘What is the discomfort you have now in comparison to that prior event?’ Then document the exchange in the record: Worst Pain: fractured wrist – 10); Current Pain: pulled muscle – 7. Now, no matter the number system you have an ‘anchor’ to both the scale and the present condition that can be related to the care process and others. It is important to document the ‘source’ of pain too – as this may be quite useful if you are explaining the case later (DOC, court, etc.)

One variant of this is: If you had a ‘bucket labeled depression and a stick marked off from 0 to 10 what is the worst you’ve ever felt and when”? The response will then provide an anchor (9 when I was admitted to the hospital after trying to kill myself). Additional questions are: How deep is that bucket now? Has it ever been at 0? If I could make it happen (wave magic wand) and get you released and home now – what would it be? (interestingly it can go up with release for many reasons)

When you ‘anchor’ the ‘pain scale’ it establishes the assessment in a relatable setting and can be quite helpful in guiding patient care. The ‘anchor’ can also be quite useful in discerning the ‘historical validity’ of the case as well – ‘Doc when I had that car accident with multiple fractures it was a 10; now my sprained (non-swollen, non-bruised) ankle is a 10 too!’

Clinical judgment is always the most important skill in any patient care situation. The data subjective & objective is helpful but must be understood / applied in the clinical context.

Also confounding the assessment is the different types of acute / chronic discomfort (myofascial, neuropathic, visceral). As important as assessing the level of pain is the type – physiologic source – since it is critical in guiding treatment.

As noted – ‘chronic pain’ is better measures by an assessment of the patients ADL (what daily activities are disrupted and is that new). If a patient can function (nutrition, hygiene, elimination) and participate in some activities then treatment of the physiologic cause is the most important clinical consideration.

Thanks, Al!  Excellent comments.  Let’s summarize:

  1. The 10-Point Pain Scale is not the only scoring system in medicine for subjective complaints. There is the Hamilton Rating Scale for Depression, for example.  Also, the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) for alcohol withdrawal.   There are scoring systems to rate abdominal pain and chest pain and the likelihood of pulmonary embolism.  I could go on and on.  All of these systems have the same limitations and liabilities, though some do a better job than others.
  2. Just because you assign a number to a complaint, that does not make it objective.  Because each of these scoring systems assigns a number to the complaint, there is a tendency to think of them as objective rather than subjective.  But as Al points out, this is not the case.  There is no real difference between someone who says his pain is “a six” and someone who says that he has “moderate pain.”
  3. In order for a subjective scoring system to work, it needs to be “anchored” in some way.  Al anchors the 10-Point Pain scale on the patient’s own worst experience.  Another commonly used clinical pain scale, the Visual Analogue Pain Scale, anchors the scale onto facial expressions.  The more “anchored” a system is, the better it is.  The less anchored it is, the less useful it will be.Unknown
  4. The more numbers in the scoring system, the less reliable it becomes.  Let’s say instead of a 10-Point Pain Score, we used a 1000-point pain score and were asking patients “would you say your pain is a 671 or a 672?”  Of course, a pain score of “672” gives us no more useful information than a “6.”  In fact, it gives us less useful information because it is more confusing.  In a scientific sense, the more numbers a subjective rating system has, the less “inter-rater reliability” that system has. The simplest subjective scale has only two scores, “None (zero)” and “Some (one),” as in “Do you have pain or not?”  The subjective scale perhaps used most often in daily life (Like when you go to a Thai restaurant and are asked how hot you want your food to be) is a four score scale:  None, Mild, Medium, Severe.  The Visual Analogue score is a 6 point scale.  CIWA-Ar uses 8 points.  And the 10-Point JCAHO Pain Scale uses 11 points (zero plus one through ten). Is the 10-Point JCAHO scale more accurate than a simple “mild-moderate-severe” system?  Probably not. In fact, no “probably” about it.  No.
  5. Subjective scoring systems work better at evaluating changes over time than the initial severity of a symptom.  If a patient says his pain is a “6,” I may not know exactly how that is different from a “7” or even a “4.”  But later, when the same patient now rates his pain as a “5,” I am pretty confident that his pain has decreased, at least by a little.
  6. Subjective scoring systems only work if the patient understands and is cooperative with the process.  Al helps the patient to understand the process with his excellent “anchoring” technique (which I will be adopting, by the way).  But the system still will not work if the patient always, no matter what, says “my pain is a 10.”   That is the main problem I run into in my jails; deciding when patients are exaggerating their symptoms.  For example, if a patient complains of “severe” constipation, what weight do I give to their use of the word “severe?”
  7. There are two types of subjectivity in scoring, the patient’s and ours.  The patient is subjective when rating her own pain or depression or whatever.  Then we clinicians make our own subjective assessments.  How sick does the patient look?  Often, the two assessments do not coincide, as when the patient rates his abdominal pain as a ten while munching on Cheetos and looking bored.  If I do not trust the patient’s own subjective assessment, sometimes I must substitute my own clinical judgment.
  8. Scoring systems for pain perform worse for chronic pain than for acute pain.  For chronic pain, a more useful assessment tool is to evaluate how the chronic pain affects Activities of Daily Living (ADLs).  Is the pain too debilitating to hold a job?  Play golf?  Go to the store?  Walk?  ADLs are usually much easier to assess in a correctional facility than in the outside world.  You can go down to housing and watch the patient.  How easily does the patient sit, stand, walk?  Does the patient go to recreation?  Sit for long periods of time playing cards or watching TV?  This sort of assessment is very useful for gauging the impact of chronic pain.

Any thoughts?  Please comment!

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Understanding Pharmacy Prices. Can It Be Done?

20130206There are several good reasons to know what your pharmacy is charging you for each of the drugs you order. You need to know actual prices in order to assess the value of similar drugs, like two different first generation cephalosporins. In fact, you will have to know this in order to be able to set up a Pre-Approved Drug List. You need to know when a particular drug has a sudden price decrease or increase so you can switch to the most cost effective drug. Finally, you want to know that you are being charged fairly. If a pharmacy sells you a drug for 5% more than the price they paid to the wholesaler to obtain it; that seems fair. But if they jack up the price literally by 46 times, well, that does not go down so well. (See story below)!

Unfortunately, pharmaceutical prices are among the most convoluted and hard to understand of all drug prices. They are kind of like airline ticket prices. Have you ever heard of the game in which passengers on a commercial airline flight compare what each of them paid for their ticket with the lowest price being crowned the winner? (Their reward is the deep satisfaction that comes from knowing that everyone else is jealous of them). Airline tickets are kind of a unique item in the economy in that the price varies depending on many factors like when you book, how you book, how often you fly, how many bags you check and on and on.

Who Can Understand Pharmacy Industry Jargon?

Pharmacy prices are similar to this. What you pay per pill for drug X at your facility may be far different than what the facility down the street pays. The system is so convoluted, in fact, that it sometimes can be hard to even find out what your pharmacy is charging you and how they derive this price.

Pharmacies have their own professional jargon that can be hard for outsiders to understand—just like us! We say, for example, that a patient has an “erythematous urticaria” when we mean “itchy red rash.” Pharmacists say “I’m charging you the Average Wholesale Price minus 12%.” What the heck does that mean?

It turns out that there are many pricing systems in the pharmaceutical industry. You only really have to know about two of them, but it is worthwhile to peruse a list of the others:

Average Wholesale Price (AWP)
Actual Average Acquisition Cost (AAC)
Wholesale Acquisition Cost (WAC)
Average Manufacturer’s Price (AMP)
Maximum Allowable Cost (MAC)
Federal Supply Schedule (FSS)
Federal Upper Limit (FUL)
Estimated Acquisition Cost (EAC)
Average Sale Price (ASP)
Usual and Customary Charge (UCC)

And that is not all of them! The problem is that each of these pricing systems can give amazingly different prices for the exact same medication.

Fortunately, you only have to know about two of these pricing schemes; one that you don’t want to use and one that you do want to use. Forget about all of the others.

Average Wholesale Price (AWP)

The one that you don’t want to use is the Average Wholesale Price (AWP). Historically, this is the most common price system used by pharmacies. The problem is that it is a misleading term. You would think that the “Average Wholesale Price” would be the average price that the wholesalers charge for a drug. Well, you would be wrong. AWP is not a wholesale price and it is not an average. It is just a price set by the pharmaceutical industry. It is debatable exactly where that price comes from. However, AWP is, on average, 20% higher than the true wholesale price. But can be as much as 120% higher!  That means if a pharmacy says to you “I’m going to charge you AWP less 12%,” that means that they will be making somewhere between 8% and120% profit on these sales.  (They were probably smiling when they said it).  And that is in addition to their “Fill fee,” which I will discuss in a future post.

In addition to being an inaccurate representation of wholesale costs, AWP is quite hard for the typical consumer, like you and me, to find. You can’t just look up AWP online. AWP are listed in certain pharmacy trade publications like The Red Book, but access to the Red Book is quite expensive. And even if you get one, you will find that a certain medication, say ranitidine 150mg, has not just one AWP like you would expect, but a bewildering array of AWPs that range in price from one cent a tablet to well over one dollar a tablet. Some AWPs apply only to hospitals, some to huge bulk purchases like Wal-mart would make. It is often almost impossible to decipher what would apply to your situation. I know. I have tried.
Some pharmacies really like to use AWP and I can see why. It has many advantages for them. AWP overestimates wholesale costs to the advantage of the pharmacy. The pharmacy understands it, but you don’t. In essence, AWP is what the pharmacy says it is! How are you going to know differently? If possible, do not deal with the AWP!

Average Actual Acquisition Cost (AAC)

The price that you want to use instead is the Average Actual Acquisition Cost (AAC). AAC is an estimate of the actual wholesale cost your pharmacy pays for medications. Instead of being head-scratchingly hard to understand, AAC is easy to understand. It is the true wholesale price. And instead of being almost impossible to find out, you can find out the AAC in one of two easy ways. First, you can ask your pharmacy for the AAC of medications you commonly order. Some pharmacies will give this information to you, no problem. If you have a pharmacy like this, consider yourself blessed. Other pharmacies can be quite loathe parting with this information.

Fortunately, there is a second way to find AAC prices: You can look them up online. Most state’s Medicaid programs utilize AAC to set Medicaid drug prices and publish the AAC on their website. If your state does not offer online access to AAC, feel free to use Idaho Medicaid’s AAC website, found here.

How Much Difference Does It Really Make?

Is the difference between AAC and AWP really that important? Here is a true story that illustrates the difference.

Like many doctors, I have a little black bag with some doctor tools and medications that I can use in urgent situations. One such “stat” medication that I keep in my black bag is ondansetron (Zofran), which is, of course, used to treat nausea. A couple of weeks ago, I went to a local chain pharmacy to get some new ondansetron for my black bag. I had looked up the AAC online before I went to the pharmacy and found that the AAC of generic ondansetron 8mg tabs was 15 cents apiece. For 30 of them, the total AAC would be approximately $4.50. Figure in a percentage markup and a fill fee and I thought I would be charged approximately $10.00-$15.00 for this prescription.
Instead, the pharm tech looked me in the eye and said “That’ll be $235.43.” The pharmacy had calculated the price using AWP!

$10.00 vs. $235.43. Now that is the difference between AWP and AAC in a nutshell. What would your facility have done had it been charged $235.43 for this prescription? Paid it without question, I suspect.

So getting back to the original question: Is it possible to understand pharmacy prices? The answer is Yes! As long as you use the Actual Average Acquisition Price. You can understand the numerous other pharmacy pricing schemes only if you understand their relationship to AAC.

Do you have a good relationship with your pharmacy? What do you pay for your pharmaceuticals?  Please Comment!

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