Identifying Prescription Drug Misuse and Abuse

piatto di farmaci e drogaOne of my first mentors in correctional health care described prisons and jails as functioning like a city or town with many of the same characteristics as the surrounding community. I still think that is a good description. So we can expect trends identified in the larger community to eventually transcend the walls of the correctional facility in some way. One of these trends is the growing problem of prescription drug misuse and abuse.

According to a 2010 survey done by the Substance Abuse and Mental Health Services Administration more Americans over age 12 are taking prescription medications for non-medical purposes. These medications include pain relievers, tranquilizers, stimulants, sedatives and psychotherapeutic drugs. More than half of those said that they obtained the drug from a friend or relative for no cost. More than half the teens surveyed in another study obtained prescription drugs for non-medical purposes from the family medicine cabinet (Kirchner et. al., 2014).

The Centers for Disease Control and Prevention (CDC) reports that visits to Emergency Rooms (ER) increased 114% from 2004 to 2011. The majority of this increase is due to misuse or abuse of pharmaceuticals. In 2011 half of the admissions to the ER were related to prescription drug misuse or abuse. Of these admissions, one third involved medications used to treat anxiety or insomnia and another third were opioid analgesics (2014).

Deaths by poisoning or drug overdose have been the leading cause of injury in the United States since 2008. Overdose deaths have increased five-fold since 1980 (Kirchner et. al., 2014). In 2010 among deaths related to overdose with prescription drugs 75 % involved opioid analgesics and 35 % involved benzodiazepines. The number of overdose deaths from opioid analgesics is now greater than those of deaths from heroin and cocaine combined (CDC 2014).

All of this is to say that detainees arriving at our jails and prisons are likely to have recently misused or abused prescription drugs. Thorough, routine and non-judgmental inquiry about recent drug use during reception health screening is essential to identify individuals who will need to be managed medically during withdrawal. These questions should solicit the name of the drug, the usual dose; the route used, frequency, date and time of the last dose. Other questions include previous withdrawal symptoms and whether hospitalization was necessary (Laffan 2013).

The characteristics of people who overdosed with prescription drugs include:

  • Middle age
  • Male
  • White, Native American or Alaska Native
  • Rural community
  • History of chronic pain
  • History of mental health disorder
  • History of substance abuse
  • Have multiple health care providers or inconsistent providers
  • Taking multiple prescriptions (DHHS, 2013).

These are not listed as a definitive means to diagnose prescription drug abuse but instead to point out how many of our inmates have these same characteristics and are at risk of adverse consequences from this behavior.

When inmates are identified who will need assistance with detoxification the nurse’s next step is to contact a provider. Monitoring and management of withdrawal from prescription drug abuse should be initiated by a provider according to protocols established by the facility medical director. Nurses should not be expected to use standing orders to initiate detoxification (NCCHC 2014). For more about drug withdrawal in the correctional setting read Chapter 5 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Resources:

Centers for Disease Control and Prevention. (2014) Prescription Drug Overdose in the United States: Fact Sheet. Accessed at http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html.

Kirschner, N., Ginsburg, J., Sulmasy, L. S., (2014) Prescription Drug Abuse: Executive Summary of a Policy Position from the American College of Physicians. Annals of Internal Medicine 160 (3).

Laffan, S. (2013) Alcohol and Drug Withdrawal in Schoenly, L. & Knox, C.M. (ed.) Essentials of Correctional Nursing, pp. 81- 96, (New York: Springer Publishing Company LLC).

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

U.S. Department of Health and Human Services (DHHS), Behavioral Health Coordinating Committee, Prescription Drug Abuse Subcommittee, (2013) Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. Accessed at http://www.cdc.gov/HomeandRecreationalSafety/overdose/hhs_rx_abuse.html.

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Factors effecting adherence and more evidenced based strategies

young african nurse explaining medical test resultWe were introduced to your patient, Jessie, in the post last week on medication adherence. She had come to sick call because she was feeling depressed and anxious.  She was only taking about half of her prescribed medications and she didn’t know what the medications are or why they had been prescribed. You have been thinking about how to help Jessie take her medication more regularly.

One of the recommendations from a study by Megan Ehret and her colleagues (2013) is to identify those inmates at risk for non-adherence and intervene early.  This study builds on a literature review by Shelton et al. (2010) which found these variables associated with medication adherence among inmates:

  • Older age
  • Male gender
  • Personal motivation
  • Inmate involvement in care
  • Therapeutic relationship with healthcare providers
  • Positive outcomes of treatment
  • Prior experience with treatment

In Jessie’s case many of these variables are absent so she is at greater risk for non-adherence.  The next step is to explore her reasons for non-adherence. Motivational interviewing (MI) is an evidenced based technique that has been found to improve medication adherence by prompting the patient to consider and adopt behavior that is consistent with their goals (Julius et al. 2009, Velligan et al. 2010, Shelton et al. 2010). Using this technique you help Jessie articulate that she wants relief from feelings of depression and anxiety and yet does not link taking the medication to feeling better.  How can you help Jessie to adopt behavior consistent with her goal?

Your first inclination is to educate Jessie about the medications and why each has been prescribed but recall that education alone is ineffective in improving adherence (Brown & Bussell 2011, Velligan et al. 2010, Julius et al. 2009, Haynes et al. 2008). Instead you look again at her prescriptions and decide to talk with her providers to see if the number of medications and number of doses can be simplified. It is likely that when Jessie was seen by her providers she reported still not feeling well. The MAR is not routinely available to the provider when the patient is seen so the provider asked Jessie if she was taking her meds. She said yes. Patients in general, not just our patients, overestimate their adherence (Velligan et al. 2009, Julius et al. 2009). So over time higher doses have been prescribed and more medication added.  If the number of medications and doses per day are reduced you are sure her adherence will improve (Ehret et al. 2013, Haynes et al. 2008, Brown & Bussell 2011).

Your next step is to find out Jessie’s past experience and preferences when taking medications to determine what kind of schedule or routine works best. She has some cognitive deficits (not knowing her schedule, missed medications and appointments, and disheveled appearance) so you want to embed taking medication into a regular part of her day (Shelton et al. 2010, Velligan et al. 2010). She says that she used stickers on a calendar to remember her children’s appointments and it worked pretty well for her. She thinks that something like a reminder on a calendar or daily diary would help her remember. She also thinks that morning would be the best time to take her meds because she is an early riser and by the end of the day she is too preoccupied with her anxiety to remember.

You schedule her for a return visit in three days. By then you will have talked to the providers and know whether her medication regime can be simplified. She has a calendar so you ask her to bring it to the appointment and you will develop a medication reminder with her. You are also planning to provide some education about the most important medication she is taking but need some time to think about how to link the information to her short term goals and low health literacy. See a prior post on this subject.

Lastly you ask her what has worked in the past to manage feeling anxious. She says that she has had some success with breathing exercises and thinks that she can use this technique to help her now. You suggest adding some visual imagery to the breathing. She agrees with the plan and you are on to your next patient.

Summary: Supporting medication adherence among inmates
  •   Identify patients at risk for non-adherence to intervene early.
  •   Explore the patient’s reasons for non-adherence and motivation for treatment.
  •   Develop multifaceted plan that links medication taking behavior to the patient’s strengths and  motivation (education alone is not enough).
  •   Increase frequency of visits to monitor treatment efficacy and support behavior change.

For more about patient adherence and monitoring treatment efficacy read Chapters 6 and 12 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.  

Brown, M. T. & Bussell, J.K. (2011) Medication adherence: WHO cares? Mayo Clinic Proceedings 86 (4) 304-314.

Ehret, M.J., Barta, W., Maruca, A., et al. (2013) Medication adherence among female inmates with bipolar disorder: results from a randomized controlled trail. Psychological Services, 10 (1), 106-114

Haynes, R.B., Ackloo, E., Sahota, N. McDonald, H.P. & Yao, X. (2008) Interventions for enhancing medication adherence (Review). Cochrane Database of Systematic Reviews, Issue 2. Art.

Julius, R. J, Novitsky, M.A. & Dubin, W.R. (2009) Medication adherence: a review of the literature and implications for clinical practice. Journal of Psychiatric Practice, 15 (1) 34-44.

Shelton, D., Ehret, M.J., Wakai, S., Kapetanovic, T. & Moran, M. (2010) Psychotropic medication adherence in correctional facilities: a review of the literature. Journal of Psychiatric and Mental Health Nursing, 17, 603-613.

Velligan, D.I., Weiden, P.J. & Sajatovic, M., et al. (2010) Strategies for addressing adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice 16 (5) 306-324

Velligan, D.I., Weiden, P.J., Sajatovic, M. et al. (2009) The expert consensus guideline series: adherence problems in patients with serious and persistent mental illness. Journal of Clinical Psychiatry, 70 (suppl 4) 1-48.

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Medication Adherence

Знак вопроса из медицинских таблетJessie has put in a sick call request because she is depressed and anxious.  You see her later in the day; she is worried about her children, who are under the care of their aunt while Jessie is incarcerated. She is unable to sleep, tearful and was sanctioned recently for not following orders. She is having difficulty getting along with her cellmate and prefers to stay in the corner of the dayroom.  You note in her record that Jessie has diagnoses of schizoaffective disorder, asthma and hypertension.  She takes several different medications and misses taking them about half of the time.  Jessie uses sick call frequently and has declared several medical emergencies for chest pain and shortness of breath; later diagnosed as anxiety. Jesse missed a recent mental health appointment and claimed she was not notified. She unsure about her work and program assignments and her appearance at the sick call is disheveled.

This is a classic example of a patient seen in the correctional setting; one who has a chronic mental health condition, comorbid chronic health problems and a likely history of substance abuse, who is only partially compliant with treatment. How many times have you wondered what else you might do to better support her and other patients like this to adhere to the plan of treatment?

The first step is to congratulate yourself that you identified non-adherence to treatment as a primary reason for the symptoms she is experiencing. What would Jessie’s clinical condition be like today if she were taking medication as prescribed, keeping her appointments with mental health providers and engaged in work and other program assignments? When you ask Jesse why she is not taking her medication her answer is vague. She professes to have a good relationship with the psychiatric nurse practitioner but cannot tell you what medications she is prescribed or why.

According to the World Health Organization (Sabaté 2003) approximately 50% of patients with chronic illnesses do not take medications as prescribed. Failure to take medications as prescribed is associated with poor patient outcomes, relapse, increased mortality and increased hospitalization (O’Malley 2013). Adherence is defined as the extent to which a person’s behavior corresponds with the recommendations for treatment to which the patient agreed. Adherence is complex, involving the patient’s knowledge, beliefs and attitudes, and their relationship with health care providers. Adherence also changes over time and may vary from day to day. The nature of the treatment itself, health care provider behavior and the system that provides the patient care impact adherence.

One of the most important factors affecting adherence among inmates is the patient’s experience of symptom relief (Mills et al. 2011, Ehret et al. 2013). In Jessie’s case, the anxiety and depression she is experiencing probably is because she is missing half of her medications. Several studies report good adherence rates among prisoners because of directly observed therapy (Gray et al. 2008, Westergaard et al. 2013, Saberi et al. 2012). However, even with directly observed therapy, inmates miss taking their medication because the request for refill was not made timely, the inmate was asleep or not present at the time medication was administered, the inmate forgot or was experiencing unwanted side effects (Mills et al. 2011, Ehret et al. 2013).

Viewing the patient as solely accountable for adherence is considered an uninformed and destructive model. Experts suggest instead that helping patients’ increase adherence would have a greater effect on health outcomes than any other specific medical treatment (Brown & Russell 2011, Sabaté 2003).  In an expert guideline series on adherence two first-line interventions were recommended:

1. Symptom and side effect monitoring

2. Medication monitoring and environmental supports

Listed below are specific actions that can be taken which are consistent with these two interventions. They provide guidance about how to assist our patient, Jessie.  Monitoring and support of patients to improve adherence are independent functions and within the scope of practice for registered nurses.

Symptom and side effect monitoring

Medication monitoring and environmental supports

  • Monitor closely for symptom response using a daily checklist or chart
  • Institute directly observed therapy
  • Increase frequency of contact
  • Provide reminders to take medication
  • Address side effects promptly
  • Provide reminders to get medication refills
  • Consider how distressing the side effect is for the patient
  • Target support to address barriers
  • Provide information about how to manage side effects
  • Increase visit frequency to monitor for relapse
  • Simplify the medication regime
  • Involve family or other social support
  • Consider the patient’s preference for dosing regime

(Velligan et al. 2010)

Poor adherence is due to multiple factors and requires several concurrent strategies to effect change. The goal of our interventions is not adherence, per se, but to achieve the best possible outcome for the patient. Involving the patient in the identification of the outcome she wants to achieve will provide clarity and motivation for the patient. Tailoring the medication experience, as much as possible, to the patient’s goals will improve their adherence.

The next post will describe the various factors affecting adherence among our patients and provide more strategies which have evidence to support their use to improve adherence. Until then, we invite you to tell us about the most challenging aspects of supporting patient adherence to prescribed medication in your setting?  Please share your opinions by responding in the comments section of this post.

Read more about monitoring and supporting patient compliance with prescribed medication in Chapters 6 and 12 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

References: 

Brown, M. T. & Bussell, J.K. (2011) Medication adherence: WHO cares? Mayo Clinic Proceedings 86 (4) 304-314.

Ehret, M.J., Barta, W., Maruca, A., et al. (2013) Medication adherence among female inmates with bipolar disorder: results from a randomized controlled trail. Psychological Services, 10 (1), 106-114

Gray, R., Bressington, D., Lathlean, J. & Mills, A. (2008) Relationship between adherence, symptoms, treatment attitudes, satisfaction, and side effects in prisoners taking antipsychotic medication. The Journal of Forensic Psychiatry & Psychology, 19 (3), 335-351

Mills, A., Lathlean, J., Forrester, A., Van Veenhuyzen, W., & Gray, R. (2011) Prisoners’ experiences of antipsychotic medication: influences on adherence. The Journal of Forensic Psychiatry & Psychology, 22 (1) 110-125

O’Malley, P. A. (2013) Medication adherence and patient outcomes. Part 1: Why patients fail to take prescribed medications. Clinical Nurse Specialist, 227-228

Sabaté, E., ed. (2003) Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization. Accessed 11/20/2013 at http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf

Saberi, P., Caswell, N.H., Jamison, R., Estes, M. & Tulsky, J.P. (2012) Directly observed versus self-administered antiretroviral therapies: preference of HIV-positive jailed inmates in San Francisco. Journal of Urban Health 89 (5) 794-801

Velligan, D.I., Weiden, P.J. & Sajatovic, M., et al. (2010) Strategies for addressing adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice 16 (5) 306-324

Westergaard, R.P.; Spaulding, A. C., Flanigan, T.P. (2013) HIV among persons incarcerated in the USA: a review of evolving concepts in testing, treatment and linkage to community care. Current Opinion in Infectious Disease 26 (1) 10-16

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Drug Diversion or Bad Habits?

Packs of pillsYou have been asked by the CQI (continuous quality improvement) committee to initiate a weekly review of accountability for administration of controlled substances.  Your facility recently installed an automatic dispensing cabinet (ADC) in the clinic to store controlled substances. Nurses withdraw medication from the cabinet that corresponds to a specific patient order.  A feature of the ADC is that every transaction involving the administration of narcotics is recorded electronically and counts are verified at the time of each transaction.

Your first step is to review a report of all transactions that took place last week. The report lists each medication and whether it was removed, returned or wasted.  The information included with each of these transactions is the date and time, the order number, the quantity, the patient identifier, and the identity of the nurse responsible for the transaction.  You randomly select eight medication administration events to review.  The results are surprising.

Problems with accountability for controlled substances are identified in four of the eight instances reviewed. These problems are:

1. The nurse removed two tablets of tramadol HCL when the patient’s order was only for one tablet. On the medication administration record (MAR) only one tablet was documented as given. The second tablet was not accounted for.

2. The nurse removed a dose of clonazepam for a patient at 5 pm when the order was only for a morning dose. There was no documentation that the dose removed from the cabinet at 5 pm was ever given to the patient or returned to the cabinet later.

3. One nurse removed a dose of clonazepam at 5:30 AM but it was recorded as given by another nurse at 9:00AM.

4.  A nurse records wasting 50 tablets of tramadol HCL at 10:20 PM. There is no record that another nurse witnessed the event and the number of tablets wasted is not consistent with the count of tramadol HCL kept in the cabinet.

You report these findings to the CQI committee and after some discussion an action plan is developed which will continue monitoring and follow up of discrepancies. The plan also includes informing nursing staff about the methods that are used to monitor accountability for administration of controlled substances, the definition of drug diversion and associated risk behaviors, and recommended best practices to improve accountability for controlled substances.

Nurses who fail to account for controlled substances violate the state nurse practice act, the Controlled Substances Act and may be at risk of criminal sanctions as well. Drug diversion is defined by the U.S. Department of Justice simply as diverting drugs from their original purpose (2013). A discrepancy between the patient’s MAR and the controlled substance log can be sufficient evidence to prove drug diversion (Mooney, 2013).  A discrepancy is lack of documentation to account for each step in the administration of a controlled substance after its removal from the narcotic cabinet. Instances 1, 2 and 4 described above are discrepancies because there is insufficient documentation to verify the disposition of each dose removed from the ADC.

Other practices that are associated with increased potential for drug diversion include:

  • Excessive amounts of controlled substances signed out
  • More sign outs by a particular nurse
  • Lack of waste or excessive wasting
  • Documentation of medication administered for pain that does not correspond to the patient’s rating of pain.
  • Lengthy periods of time between sign out and administration to the patient (Mooney, 2013; LaFerney, 2010; Vrabel, R. 2010).

Instance 3 described above involved a controlled substance that was signed out four hours before it was administered. It also was given by a nurse other than the one who signed it out. Instance 4 involved excessive wasting and was not verified by a second nurse.

After further follow up of each of these instances no additional evidence is found to support a conclusion that any of these nurses were diverting controlled substances. Instead each involved poor work place practices, time and staffing constraints. The nursing staff was surprised at how many problems were brought to light by simply monitoring the controlled substance log against the MAR and discussed the steps they would take to better account for the disposition of each medication dose. Your subsequent audits provide feedback and evidence of improvement in accountability for controlled substances.

Additional resources on accountability for controlled substances and recommendations to prevent and detect diversion can be obtained at the Institute for Safe Medication Practices and from a series of articles that appeared in Volume 42 of the journal, Hospital Pharmacy, published in 2007 (McClure et.al. 2011). For more on best practices for medication administration in the correctional setting see Chapter 4 of the Essentials of Correctional Nursing which can be ordered directly from the publisher. If you use Promo Code AF1209 the price is discounted by $15 off and shipping is free.

Have you had success solving problems with accountability for controlled substances that you would like to share with others? If so please tell us about it by writing in the comments section of this post.

References:

LaFerney, M.C. (2010) Dealing with drug diversion. Reflections on Nursing Leadership. 36 (2).

McClure, S.R.; O’Neal, B.C.; Grauer, D.; Couldry, R.J. (2011) Compliance with recommendations for prevention and detection of controlled-substance diversion in hospitals. American Journal of Health-System Pharmacy. 68: 689-694

Mooney, D. H. (2013). Investigating and Make a Case for Drug Diversion. Journal of Nursing Regulation. 4 (1): 9-13.

U.S. Department of Justice, Office of Diversion Control. (2013). Code of Federal Regulations 21 Part 1300. Retrieved 5/30/2013 from  http://www.deadiversion.usdoj.gov/21cfr/cfr/2100cfrt.htm.

Vrabel, R. (2010) Identifying and dealing with drug diversion. Health Management Technology. 31 (12):1-5

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Nursing practice and use of non-pharmacologic measures to address chronic pain

Recently I attended a meeting of the local chapter of the American Correctional Health Services Association and heard a presentation about a program to manage chronic pain in the correctional setting.  Even though nurses deliver the majority of care in the correctional setting no nurses were involved in this program; it was a completely physician- driven model of care. It made me wonder why nurses are not collaboratively managing clinical care of patients with chronic pain. What role do correctional nurses have in addressing patient’s chronic pain?

 

The Institute of Medicine (IOM) identified pain management as an essential responsibility for nurses (Relieving Pain in America, 2011).  This responsibility is more than simply carrying out the provider’s treatment orders; it includes implementation of nursing interventions to manage and reduce a patient’s experience of pain. Interventions that are within the independent scope of nursing practice include non-pharmacologic measures to manage symptoms and assist the patient with coping.

 

The National Commission on Correctional Health Care (NCCHC) adopted a position statement October 2011 recognizing that chronic pain requires more than just determining which medications are appropriate.  The position statement emphasizes a multifaceted approach to chronic pain using a biopsychosocial model that includes evidenced based therapeutic options. The NCCHC’s position statement can be obtained at http://ncchc.org/resources/statements/chronic_pain.html. The Institute for Clinical Systems Improvement (ICSI) recommends that treatment plans for chronic pain include:

  • The patient’s personal goals regarding quality of life
  • Sleep improvement
  • Increased physical activity
  • Stress management
  • Decreased levels but not elimination of pain (2011).

 

There are a number of non-pharmacologic approaches to improve sleep, increase activity and manage stress but which ones have the best evidence to support their use?  The ICSI and the Registered Nurse Association of Canada (RNAO) are two organizations that evaluate the research and publish recommendations regarding chronic pain on a periodic basis. There is strong evidence to incorporate the following interventions into the plan of care for patients who have chronic pain. Each is within the nursing professions’ scope of practice.

 

Exercise: Exercise provides physical reconditioning, elevates mood, increases functionality and helps maintain mobility. No one type of exercise is more effective than another. Nurses can recommend, teach, coach and supervise patient exercise. No referral to a physical therapist or recreation specialist is needed. No special equipment or facility is needed.

 

Relaxation: Helpingpatients incorporate relaxation techniques into their daily life has been found to improve treatment adherence, reduce anxiety, and enhance pain tolerance. Relaxation techniques include massage, use of heat or cold, meditation, imagery, diaphragmatic breathing, autogenic training, progressive muscle relaxation and music. Relaxation decreases physical tension, increases oxygenation and circulation, lengthens and relaxes muscle fibers.

 

Cognitive behavioral change: This intervention is considered by the ICSI to be the most effective non-pharmacologic tool in managing chronic pain. Cognitive change involves restructuring the patient’s view of pain and increases the patient’s coping strategies. It involves finding ways to change habits or beliefs by experimenting with different ways to solve problems. The nurse assists the patient to develop goals for change, a plan to accomplish the goal incrementally and periodic coaching and follow up on progress.

 

The recommendations and evidence for these interventions can be found at these sites:

 

 

  • Registered Nurses Association of Ontario. (2002, Supplement 2007). Assessment and Management of Pain. International Affairs and Nursing Best Practice Guidelines Program. Toronto: Registered Nurses Association of Ontario. Retrieved 4/14/2012 at http://rnao.ca/bpg/guidelines/assessment-and-management-pain

 

Here are some great resources about non-pharmacologic approaches to pain:

 

http://www.youtube.com/watch?v=aUaInS6HIGo&noredirect=1

 

http://im4us.org/Chronic+Pain+Patient+Resources

 

http://healingchronicdisease.org/en/chronic_pain/self_care/index.html

 

http://www.mayoclinic.com/health/yoga/MM00650

 

http://www.fammed.wisc.edu/sites/default/files//webfm-uploads/documents/outreach/im/module_meditation_patient.pdf

 

Chapter 13 of the Essentials of Correctional Nursing has more discussion about the nurses’ role in managing pain and the challenges of doing so in the correctional setting.  If you would like to share your successes incorporating non-pharmacologic approaches into the treatment of patients with chronic pain please use the comments section of this post?  You may also want to attend the session on this subject at the National Conference on Correctional Health Care in Las Vegas on October 22, 2012 (registration information is at http://ncchc.org/education/national.html). If so, see you there!

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Timeliness of Medication Administration in the Correctional Setting

Timely administration of medication is one of the challenges identified by nurses discussing the ANA Corrections Nursing Scope and Standards of Practice at the Updates in Correctional Health Care Conference held in May 2012.  Medication administration is one of the aspects of practice that distinguish the specialty of correctional nursing.

Many correctional facilities have established a one hour window before or after the designated time for medication to be administered. For example, if 9 am is the time for the morning dose, administration is timely if given anytime between 8 am and 10 am.  Medication not given within the designated window is considered a medication error and requires contact with the prescriber to adjust the plan of care.

The Institute for Safe Medication Practices (IMSP) published guidelines in January 2011 for timely administration of scheduled medications in acute care settings.  These can be accessed at http://ismp.org/Tools/guidelines/acutecare/tasm.pdf.  The IMSP recognized that not all medications require exact timing of doses and suggested a more reasonable approach to timeframes than the “30 minute rule” proposed by the Centers for Medicare and Medicaid Services (CMS).

If you struggle with timeliness of medication administration you may want to consider using the approach recommended by the IMSP summarized here.

Time Critical Medications 

  • Identify the medications used at your facility that are time critical or should be administered within 30 minutes of the scheduled time. This might include all QID medications, insulin and antidiabetic agents, and medications that must be administered apart from other medications. These might also include medications that are time critical only for certain patients or certain conditions.
  • Develop a method to administer time critical medications within the window. It may be that patients are admitted to an inpatient unit or are co-housed so that these medications are administered before other medications. Another option is to establish a time critical medication line that differs from the time for administration of medications that are not time critical.

Discussion: the number of patients on time critical medications should be small given that these are correctional settings and not acute care facilities. If there are a lot of QID orders or other medications that are identified as time critical, nursing
must collaborate with the facility medical director to develop alternatives for appropriate treatment of these patients.

Medications which are not Time-Critical

  • Daily, weekly or monthly doses do not have a timeliness window if given on the day it is due. It has long been recommended that the dose be timed to some other event (e.g. after breakfast or the morning med line) to help the patient remember.   These patients could be scheduled on a separate med line so that they do not slow down med line for other patients or scheduled among all the med lines. Weekly or monthly doses could be scheduled as clinic appointments rather than on med line.
  • Medications administered more frequently than daily but not more frequent than every 4 hours (e.g. BID, TID, q 4 h) should be given within the window of an hour before or after the scheduled time.

Discussion: The majority of patients on medication in a correctional setting should be on daily dosing schedules.  It is worth looking at patients on multiple daily schedules and asking prescribers to consider less frequent dosing. Often prescribers are unaware of the challenges nurses have with timely medication administration and are willing to alter orders.  Patients also complain about long waits in med line and may be more willing to adhere to less frequent dosages.

Still having problems meeting timeframes for timeliness?  More information about medication administration can be found in Chapter 4: Safety for the Nurse and the Patient in the Essentials of Correctional Nursing. Another resource is a newsletter Lorry wrote about managing the risks of medication administration which can be downloaded at http://www.omnisure.com/newsletters/Medication_Newsletter.pdf

We will continue this discussion in a future post. Please let us know by writing in the comments section of this post the challenges you have experienced with timely medication administration?

 

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