GDRs, antipsychotics and PRNs, Oh My!
Randy Beckett, DNP, FNP, PMHNP
With off-label antipsychotic use dangerously high in U.S. nursing homes as reported by Human Rights Watch, a question undoubtedly on the tip of everyone's tongue is “How do we fix this?” We all know the scenarios. We've seen them happen. How do we handle them?
Eighty-year-old long-term care resident Sally was hospitalized over the weekend for pneumonia and returns to the skilled nursing facility with an order written by the hospitalist for Seroquel 25mg to be taken at bedtime for insomnia. Sally does not have schizophrenia, Tourette's or Huntington's Disease.
A stack of Gradual Dose Reduction requests for psychotropic medications from the consulting pharmacist sits on your desk. If you fax them to the very busy primary care provider, two weeks and several phone calls later you will get them back with a “No. Not indicated” scribbled across the response section with no further rationale or documentation to support the denial of the pharmacist's request.
A PCP is chatting with a staff member, who mentions she has noticed sixty-six-year-old long-term care resident Roger is occasionally nervous during cares. She asks what can be done. The PCP writes an order for lorazepam 0.5mg — “take one every six hours as needed for anxiety.” Roger doesn't have an anxiety diagnosis. The PCP doesn't change the chart to reflect an anxiety diagnosis. The PCP did not put a stop date on the as-needed lorazepam and there is no documentation in Roger's chart of any anxious behaviors at any time.
The names have been changed to protect the patients' privacy. However, you may face one or all three of the scenarios this month, or even next Monday morning. How can these situations be handled? Who can you turn to?
If you have a geriatric psychiatric provider, perhaps a MD, but now more commonly a psychiatric mental health nurse practitioner, who sees your residents face-to-face or via telehealth, and if this provider is trained and familiar with the CMS regulations on the use of psychotropic drugs, then you have a resource to call upon before you give up completely.
This is how your day can go.
You would call or fax the PMHNP and ask if the Seroquel 25mg is an appropriate drug for Sally before sending the Seroquel prescription to the pharmacy and entering it into your system. The PMHNP would know Sally does not have an appropriate diagnosis or indication for Seroquel and would tell you that Sally will not be started on the drug. The PMHNP would then arrange for you to call back if Sally has insomnia now that she is home.
You would send the GDRs to the PMHNP, who knows the patients and will refer back to their last visit and see if the GDR is reasonable. If unsure, the PMHNP will ask to see the patient sooner than scheduled. And if the PMHNP is really on the ball, he or she anticipated the upcoming GDR based on the drugs' start date and either has already done a dose reduction or documents why tapering the medication will not achieve the desired therapeutic effects.
In the last scenario, your PCP knows the PMHNP who sees this patient and would refer the staff member to consult the PMHNP before prescribing a psychotropic drug. Alternatively, your staff member, having been educated to the role of the PMHNP, knows to request that Roger be seen for the anxiety during cares and check to see if it has been documented as a behavior.
Adding a psychiatric provider to your team can reduce stressors ranging from helping residents with behaviors and mood disorders to staying in compliance with CMS regulations for psychotropic medicines. A psychiatrist or psychiatric mental health nurse practitioner who has been trained in treating residents of nursing homes and is well acquainted with the nuances of the psychotropic regulations will make a difference in the lives of your residents and the morale of your staff.
Randy Beckett, DNP, FNP, PMHNP is Encounter Telehealth's Vice President of Geriatric Psychiatric Services. Dr. Beckett provides telehealth psychiatric services to the residents of 27 rural long-term care facilities in Iowa and Nebraska.