Strategies for improving medication management in LTC, Part 2
In my last blog, we identified room for improvement in reducing the number of preventable adverse drug events in the LTC setting. This time, I'll address strategies for two of the most vulnerable areas in medication management: inappropriate prescribing/dosing and inadequate monitoring of medications.
For the prescribing and dosing of medications, prescribers can get help by employing an EHR with computerized prescriber order entry and clinical decision support tools. Drugs that meet Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, for example, can be flagged in a CPOE system. Recommendations for therapeutic alternatives or monitoring criteria, as well as any appropriate dosage adjustment if the medications must be used, can be employed as prompts for prescribing changes or triggers for monitoring and documentation.
Also, to address an often overlooked situation, incorporating dosing guidelines into the CPOE system for medications prescribed for the elderly who commonly have poor kidney function can help reduce ADEs. Future innovation of clinical decision support tools in CPOE systems could involve integrating lab results or concomitant drug therapies or comorbid conditions with arriving at the proper dose of a medication (dosing decision support).
An EHR can also help address preventable ADEs that result from misreading handwritten orders. The use of the “tall man” lettering convention to differentiate similar drug names within a CPOE system can help providers prescribe, pharmacy staff dispense, and nursing staff administer medications correctly. CPOE systems can also assist the provider with identifying and avoiding potentially dangerous drug interactions that can lead to preventable ADEs.
Other best practice advice to reduce ADEs related to inappropriate prescribing:
Not prescribing unnecessary drugs. For each drug the resident is taking, assess if it is still needed.
Being hyper-vigilant as to whether a new symptom or condition in a resident could actually be a side effect of a drug or drugs they are currently taking. Consider this possibility before adding another drug to the regimen to treat it.
Consider non-drug therapies, safer alternatives, using the lowest effective dose (start low, go slow).
It's critical to have timely access to lab test results and other medical records, as mentioned previously. Getting different systems to “talk” to each other may be a barrier, but there are available products that help facilitate interoperability and communication between systems. If systems cannot be integrated, insist on secure access to outside medical records systems for clinical staff who need it.
Besides transitions from the inpatient hospital back to the LTC community, watch for opportunities to reduce ADEs with other points of care. Consider a resident who goes to another facility to receive periodic cancer chemotherapy or dialysis. Medication reconciliation and monitoring for the effects of drug therapy given in those settings when the resident returns to the nursing facility would be helpful in preventing ADEs. Again, it would help to have access to lab results, medication lists, or medical records from these other care settings.
Other ways to improve medication monitoring are:
Step up monitoring if there are multiple care providers involved (such as a pain specialist or a psychiatric consultant). They may not necessarily be as familiar with geriatric age-related differences in how the body handles drugs or the increased vulnerability to certain adverse effects in the elderly, as they add medications to the drug regimen. Coordinate care and communicate concerns with all specialists.
Enhance surveillance and reporting systems for ADEs. Form a multidisciplinary group to review ADE cases, perform root cause analyses, identify trends, develop best practices, and roll out educational initiatives.
Implement specific clinical practice guidelines, policies, and care-planning for the administration and monitoring of high risk drugs to minimize ADEs (such as warfarin and bleeding risk, diabetes medications and hypoglycemia risk).
Use the EHR to help identify possible ADEs. The consultant pharmacist can monitor the residents receiving certain drug classes (such as antipsychotic drugs), look for certain symptoms in the EHR notes, or look for rescue drug orders to treat ADEs. Dispensing pharmacists can also look for these rescue drug orders and initiate ADE follow-up.
Doris Yee, PharmD, currently serves as a clinical pharmacist in the Consumer Drug Information Group at FDB (First Databank, Inc.) where she is responsible for maintaining the patient education monographs, prioritized label warnings, and counseling messages modules. Her past experience in long-term care includes serving as Director of Pharmacy at Laguna Honda Hospital and Rehabilitation Center in San Francisco, California.