Quality improvement in remote prescribing

Abstract

Aims To evaluate attitudes in prescribing and utilising As Required (referred to as PRN/Pro Re Nata) sedating medications (Benzodiazepines, Z-Drugs, Anti-psychotics, and Promethazine) To evaulate current remote prescribing processes and improve safety and transparency Method Plan: Review of remote prescribing policy. It was highlighted that current practice was not in line with NMC guidance of the time as no follow-up written instruction by a doctor was received. Concerns were also raised about the general safety of verbal communication of prescriptions out of hours. A survey was conducted to assess attitudes towards the prescription of ‘PRN medication’ and the role of psychological therapies as an alternative to both doctors and nurses working in ABUHB s Mental Health and Learning Disabilities division. Do: Survey results showed a nuanced response from both doctors and nurses but an agreement that there is a role for as required medication, especially in the context of acute mental distress, indicating safety around the process rather than elimination/reduction of PRN medication prescribing would be desired. This lead to an overhaul of the out of hours prescribing process between junior doctors and those receiving the ‘verbal order’ as detailed below: Phone conversation between a junior doctor and ward nurse receiving the verbal order. A digital form is then completed by the ward nurse including current regular medication, PRN medication (including times of use), physical health history, and any additional requested information such as QTc on 12 lead electrocardiogram (ECG) or current vital signs. The junior doctor may assist with obtaining the relevant information but there are clear prompts on the form, to ensure the pertinent questions regarding safe prescribing are considered by both parties. The dose and route of the medication are clearly documented by the junior doctor as well as time of prescription and the form is emailed back to the ward nurse. This process is far more transparent and much less prone to errors due to miscommunication. a. The prompts also save time ensuring the relevant information is on hand prior to discussion as opposed to searching for medication charts, ECGs, etc. b. Highlighting the importance of QTc monitoring to encourage safe prescription of anti-psychotics and Promethazine c. The prompts also highlight the importance of physical health and current vital signs with regards to safe prescribing d. The prompts are stored on a network drive alongside other verbal orders allowing for easier future auditing off remotely off and on site These changes were highlighted via email, junior doctor forums, and induction of new doctors. Study A Round 2 survey was drafted to evaluate the new process and forms with an aim to ensure uptake and to identify any issues. Despite using the same channels to identify survey participants, the response rate was much lower than the Round 1 survey. See Round 2 results. Act With the limited feedback obtained the main issue identified was with regards to rapid tranquilisation of an aggressive patient who poses a risk to self and others. In this scenario it was deemed a risk to wait for an email form to be completed. Clarification emails were sent to relevant professionals to clarify that the rapid tranquilisation policy does allow for verbal orders with a subsequent digital order form to be completed at a later time when it is safe to do so. Result Round 1 Nurses n = 26 Doctors n = 27 Nursing 92% routinely request Z-Drugs and Benzodiazepines for treatment of insomnia 88% routinely request Benzodiazepines for treatment of agitation 73% routinely request Promethazine for for treatment of agitation 69% routinely request PRN Anti-Psychotics for treatment of agitation 35% would routinely request Promethazine for treatment of insomnia 19% would routinely request Haloperidol without a recent ECG (>3 months) 15% would request Benzodiazepines for treatment of psychotic symptoms 12% would request Lorazepam above British National Formulary maximum doses As required medications dispensed per shift 54% report 0 to 3 times 23% report 4 to 6 times 23% report 6 to 10 times Agitation was most commonly defined as 96% hostile behaviour/physical aggression 92% hostile/threatening/derogatory speech 81% visible anxiety 69% disturbed behaviour that is not threatening/derogatory towards others 31% patient reported anxiety without objective evidence PRN medication use reviewed by doctors Daily (8%) Weekly (85%) Monthly (8%) 5 most commmonly cited reasons contributing to PRN medication use 77% Ward atmosphere (ie. volatile ward environment) 69% Patient depdence (psychological/physiological) 54% Patient expectation 42% Limitted expectation of benefit from psychological skill utilisation 42% Usual habit/culture of prescribing by doctors What are your thoughts on the use of psychological interventions in an acute setting? [Open Ended, n = 22] Reviewing the themes from the open ended responses: Nursing staff feel positively about psychological interventions in the right setting at the right time but find challenges to delivering them. Some staff cite the fact that a patient is admitted indicates their level of acuity requiring PRN utilization. Some responses indicate that patients may be medicating the normal human experience. Ward atmosphere, how ill the patient currently is, patient willingness, staff shortages, paperwork taking priority, lack of training in psychological therapies were all cited as challenges. Doctors 96% routinely prescribe Benzodiazepines for treatment of agitation 92% routinely prescribe Z-drugs and Benzodiazepines for treatment of insomnia 63% routinely prescribe PRN Anti-psychotics for treatment of agitation 38% routinely prescribe Promethazine for treatment of agitation 29% routinely prescribe Promethazine for treatment of insomnia 25% routinely prescribe Benzodiazepines for treatment of psychosis 12.5% routinely prescribe Lorazepam above British National Formulary maximum doses 8% routinely prescribe Haloperidol without a recent ECG (>3 months) Rapid Tranquilisation Policy 70% of doctors were familiar with the up to date Rapid Tranquilistion Policy 5 most commmonly cited reasons contributing to PRN medication use 19% nursing staff shortages 15% ward atmosphere (ie. volatile ward environment) 15% nursing staff expectations 11% usual habit of prescribing 11% patient expectations What are your thoughts on the use of psychological interventions in an acute setting (n = 26)? Reviewing the themes from the open ended responses: Doctors are somewhat divided in their approach to psychological approaches, the majority stating or alluding to it being a first line management option but some citing staffing levels to be a deterrent. Others had a more nuanced view of it rather than a general first line treatment, requiring risk/benefit analyses before use. The minority did not know enough about psychological interventions or thought it often doesn t work. Round 2 Nurses n = 8 Doctors n = 8 Nursing Total responded n = 8 Acute psychiatric ward nurses n = 4 Psychiatric intensive care unit nurses n = 4 50% were unaware that physical health emergencies and rapiq tranquilisation can allow for the older process of verbal orders followed by the form due to the imminent risks associated with delaying treatment to complete the form 100% (n = 8) were familiar with the digital order forms 87.5% (n = 7) were familiar with the digital order policy With regards to form locations 87.5% (n = 7) had access to blank forms and would store them alongside paper medication charts 12.5% (n = 1) were not aware that the ‘verbal order’ policy was not digitised With regards to digitised order requests: 75% (n = 6) did not report any change the frequency of requesting out of hours prescriptions 12.5% (n = 1) reported a reduction in requests 12.5% (n = 1) reported an increase in requests 75% (n = 6) reported that the digital order form puts up barriers to requesting medication out of hours With regards to the form: 12.5% (n = 1) report that the form helps them formulate their requests 50% (n = 4) report that the form requires the appropriate amount of information 12.5% (n = 1) report that the form requires too much information 37.5% (n = 3) did not comment on the amount of information the form requires With regards to safety: 25% (n = 2) report that the digitised system is safer 75% (n = 6) did not comment on safety With regards to time to fill out the form: 87.5% (n = 7) report that the form is more time consuming 12.5% (n = 1) did not comment on time consumption If given the option to revert to verbal orders: 37.5% (n = 3) would like to revert back to the old system 25% (n = 2) would like to remain on current system 37.5% (n = 3) did not comment on which system they d prefer Doctors Total responded n = 8. Consultants n = 2 Staff Grade doctors n = 1 Core Trainees in Psychiatry n = 3 Fixed term appointees n = 2 100% (n = 8) were familiar with the up to date rapid tranquilisation policy With regards to the digital order forms 62.5% regularly see them in patient files (n = 5) 37.5% occasionally become aware of them (n = 3) 0% were unaware of the new digital order forms (n = 0) With regards to inappropriate out of hours prescriptions 37.5% report that there was a reduction (n = 3) 50% report there being no significant change (n = 4) 12.5% report there being an increase (n = 1) With regards to safety: n = 6 reported the new system to be safer n = 2 did not comment on safety With regards to time: n = 2 report it being more time consuming to use the digital orders n = 6 did not comment on time consumption With regards to returning to verbal order forms n = 3 would like to remain on digital orders n = 5 did not comment on returning to verbal order forms Other: n = 2 commented in the comment box that this change was overdue n = 1 commented that the forms give insight into patient presentations and manage