Discontinuing the Use of PRN Intramuscular Medication for Agitation in an Acute Psychiatric Hospital

Use of a Novel Standardized Administration Protocol Reduces Agitation Pro Re Nata (PRN) Medication Requirements: The Birmingham Agitation Management (BAM) Initiative

BACKGROUND

Agitation management is a principal challenge on inpatient psychiatric units. Overreliance on common prescribing strategies of pro re nata (PRN) medication administration is problematic, given the tendencies to have overlapping or unclear indications.

OBJECTIVE

Piloted project to determine whether a standardized protocol for agitation intervention may reduce PRN medication administration.

METHODS

The Birmingham Agitation Management (BAM) interdisciplinary team uniquely connected the Brøset Violence Checklist (BVC) for assessment of agitation severity to a standardized PRN medication order set. Nurses on the piloted unit were trained on how to score the BVC and administer medications. Patients were assessed by the BVC every 4 hours and, based on their score, would receive no medication, low-dose benzodiazepine, high-dose benzodiazepine, or high-dose benzodiazepine plus antipsychotic. The primary end point compared the number of PRNs administered after novel protocol implementation with a retrospective cohort. Secondary measures included analysis of medication-related effects, seclusion, and physical restraint rates.

RESULTS

377 patients were included in the final analyses (184 pre-BAM, 193 BAM intervention group). No significant differences were seen in patient characteristics between groups. The total number of PRNs administered decreased by 42.5%, with both the mean and median number of administrations decreasing significantly (95% confidence interval [CI] = [1.68-5.75]; P < 0.001). A trend was noted between the number of PRNs administered and seclusion rates, but did not reach statistical significance (95% CI = [-7.28 to 60.31]; P = 0.124).

CONCLUSIONS

In seemingly the first initiative of its kind, we found that a standardized agitation management protocol can help decrease the total number of PRN administrations for agitation without worsening of restraint rates and may possibly reduce the risk of adverse effects. These results require validation in specific, larger populations.

Characterization of Psychotropic PRN Medications in a Canadian Psychiatric Intensive Care Unit

BACKGROUND

Pro re nata (PRN) antipsychotics and benzodiazepines are routinely used for the rapid stabilization of acutely agitated patients. Despite the popular use of PRN medications in mental health units, primary literature supporting efficacy and safety is poor, and there is no single universally accepted practice guideline. PRN psychotropic medications have the potential to cause adverse effects when used inappropriately.

AIMS

Our objective was to characterize the prescribing, administration, and documentation practices of PRN psychotropic medications in a psychiatric intensive care unit.

METHODS

We conducted a retrospective chart review of patients admitted to a 12-bed psychiatric intensive care unit between June and September 2018. All PRN antipsychotic and benzodiazepine orders, administrations, documentation practices, and attempted nonpharmacological strategies were assessed for each order and patient. Descriptive statistics were used to analyze data.

RESULTS

Thirty-two patients with a total of 123 physicians' orders and 1,179 PRN administrations of antipsychotics and benzodiazepines were reviewed. Of the total administrations, 720 (61%) were combinations with at least two psychotropic agents. Forty-one (33%) physicians' orders had a prescribed indication, and 559 (47%) administrations had an attempted nonpharmacological method prior to PRN administration. Eight patients (25%) had antipsychotic PRN orders, which exceeded the total daily maximum dose. Three adverse drug effects were attributed to PRN administration.

CONCLUSIONS

Areas of improvement that we identified included documentation practices of effectiveness of administered PRNs, prescriptions to include clear indications and dosage within the 24-hour maximum limits, and documentation of nonpharmacological methods utilized.

Non-pharmacological interventions to reduce restrictive practices in adult mental health inpatient settings: the COMPARE systematic mapping review

Objectives

The study aimed to provide a mapping review of non-pharmacological interventions to reduce restrictive practices in adult mental health inpatient settings; classify intervention components using the behaviour change technique taxonomy; explore evidence of behaviour change techniques and interventions; and identify the behaviour change techniques that show most effectiveness and those that require further testing.

Background

Incidents involving violence and aggression occur frequently in adult mental health inpatient settings. They often result in restrictive practices such as restraint and seclusion. These practices carry significant risks, including physical and psychological harm to service users and staff, and costs to the NHS. A number of interventions aim to reduce the use of restrictive practices by using behaviour change techniques to modify practice. Some interventions have been evaluated, but effectiveness research is hampered by limited attention to the specific components. The behaviour change technique taxonomy provides a common language with which to specify intervention content.

Design

Systematic mapping study and analysis.

Data sources

English-language health and social care research databases, and grey literature, including social media. The databases searched included British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CCRCT), Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effects (DARE), EMBASE, Health Technology Assessment (HTA) Database, HTA Canadian and International, Ovid MEDLINE®, NHS Economic Evaluation Database (NHS EED), PsycInfo®and PubMed. Databases were searched from 1999 to 2019.

Review methods

Broad literature search; identification, description and classification of interventions using the behaviour change technique taxonomy; and quality appraisal of reports. Records of interventions to reduce any form of restrictive practice used with adults in mental health services were retrieved and subject to scrutiny of content, to identify interventions; quality appraisal, using the Mixed Methods Appraisal Tool; and data extraction, regarding whether participants were staff or service users, number of participants, study setting, intervention type, procedures and fidelity. The resulting data set for extraction was guided by the Workgroup for Intervention Development and Evaluation Research, Cochrane and theory coding scheme recommendations. The behaviour change technique taxonomy was applied systematically to each identified intervention. Intervention data were examined for overarching patterns, range and frequency. Overall percentages of behaviour change techniques by behaviour change technique cluster were reported. Procedures used within interventions, for example staff training, were described using the behaviour change technique taxonomy.

Results

The final data set comprised 221 records reporting 150 interventions, 109 of which had been evaluated. The most common evaluation approach was a non-randomised design. There were six randomised controlled trials. Behaviour change techniques from 14 out of a possible 16 clusters were detected. Behaviour change techniques found in the interventions were most likely to be those that demonstrated statistically significant effects. The most common intervention target was seclusion and restraint reduction. The most common strategy was staff training. Over two-thirds of the behaviour change techniques mapped onto four clusters, that is ‘goals and planning’, ‘antecedents’, ‘shaping knowledge’ and ‘feedback and monitoring’. The number of behaviour change techniques identified per intervention ranged from 1 to 33 (mean 8 techniques).

Limitations

Many interventions were poorly described and might have contained additional behaviour change techniques that were not detected. The finding that the evidence was weak restricted the study’s scope for examining behaviour change technique effectiveness. The literature search was restricted to English-language records.

Conclusions

Studies on interventions to reduce restrictive practices appear to be diverse and poor. Interventions tend to contain multiple procedures delivered in multiple ways.

Future work

Prior to future commissioning decisions, further research to enhance the evidence base could help address the urgent need for effective strategies. Testing individual procedures, for example, audit and feedback, could ascertain which are the most effective intervention components. Separate testing of individual components could improve understanding of content and delivery.

Study registration

The study is registered as PROSPERO CRD42018086985.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

Seclusion: A Patient Perspective

The appropriate treatment of mentally unwell, aggressive patients has challenged psychiatry for centuries. Seclusion is practiced worldwide, but concerns remain regarding its appropriateness and lack of alternatives. Patients generally report seclusion as a negative experience, though there is a paucity of literature exploring this in detail. This investigation was a service evaluation appraising inpatients' perspective of processes occurring before (information, communication), during (review, care), and after (debrief, reflection) seclusion in a psychiatric intensive care unit (PICU). In this phenomenological study, qualitative data were gathered using a questionnaire in a structured interview. All patients had been nursed in seclusion during admission to a male PICU at South London and the Maudsley NHS Foundation Trust. Ten patients were interviewed over 4 months. The central theme was perceived lack of communication in the patient-professional relationship, which manifested itself as (i) violence against patients, (ii) lack of psychological support, and (iii) the need for alternatives. Such feedback from patients queries whether national guidelines are appropriate and/or being adhered to. Healthcare practitioners have a responsibility to challenge accepted practice to continually improve the standard of patient-centred care. Utilising patient perspectives can be a powerful driver of change towards more humane treatment of vulnerable patients.

PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review

Many medications are prescribed and administered PRN (pro re nata, as needed). However, there are few integrative reviews to inform PRN psychotropic medication use in long-term care facilities and nursing or care homes. Accordingly, this integrative systematic review aimed to improve our understanding of PRN medicines management with a focus on psychotropic medications (antipsychotics, sedatives, anxiolytics, and hypnotics) in long-term care settings. Keywords relating to PRN in English, Norwegian, and Spanish were used, and articles published between 2009 and 2019 were retrieved. Based on the inclusion criteria, eight articles were used for data analysis and synthesis. This review offers a description of PRN prescription and administration of psychotropic medications in long-term care. Variations were observed in the management of PRN psychotropic medications based on residents’ underlying health conditions and needs, duration of use, and changes between medications and doses. Neither the reasons for PRN prescription and administration nor the steps taken to identify and manage any associated adverse reactions or adverse drug events were reported. Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities.

Determination of combination therapy prescribing patterns for the treatment of acute agitation in psychiatric patients: A regression model of patient diagnoses and demographics

Introduction

Guidelines for the treatment of acute agitation typically recommend monotherapy with an antipsychotic or a benzodiazepine, but combination therapy is frequently used in practice. We created a regression model to identify which factors lead to the prescribing of combination therapy for acute agitation on a psychiatry unit.

Methods

We collected retrospective data from hospitalized patients in the psychiatry unit. An a priori alpha of 0.05 was used for binary logistic regression models to determine if and how the number of prescribed medications for acute agitation was influenced by: age, sex, race, cardiovascular comorbidities, and psychiatric diagnoses.

Results

We identified 1998 encounters from 1200 patients. Patients are significantly more likely to be prescribed combination therapy if they are young, male, and of non-white race or have a diagnosis of central nervous system stimulant use, hallucinogen use, depression, bipolar, cluster B personality, or psychosis. Patients are significantly more likely to be prescribed monotherapy if they have cardiovascular comorbidity or have neurocognitive disorder.

Discussion

Several demographic or diagnostic factors predict combination therapy prescribing. Acute agitation guidelines should be reviewed to include more clear instructions on combination therapy use.

PRN Medication Administration in a Geriatric Psychiatric Hospital: Chart Review and Nursing Perspective

OBJECTIVE

To improve patient care/outcome, an evaluation was conducted of nursing procedures and protocols for pro re nata (PRN) medications.

METHODS

A 14-day chart review was conducted for 27 patients with mood and thought disorders (MTD) and for 24 patients with organic disorders (OD) at a geriatric psychiatric hospital, and a questionnaire was completed by 20 nurses.

RESULTS

377 PRNs were administered to patients in the MTD and OD units (240 and 137, respectively). The majority of PRNs were administered during the evening shifts on the MTD unit and during the day shifts on the OD unit. Chart notes indicated the behavior requiring PRN administration was not always specifically described and therapeutic interventions were not often attempted before PRN administration. Inconsistency between chart notes and medication record books was noted in the majority of cases. It was often not known whether the PRN was initiated by the staff, patient, or family. PRNs were reported to be not effective in the majority of cases.

CONCLUSIONS

Documentation was suboptimal and effectiveness was poor.

CLINICAL IMPLICATIONS

It would be worthwhile to train all staff in a patient-centered or ecopsychosocial (i.e., non-pharmacological) model of care, which would provide staff alternatives to PRNs. In that context, it would be important to implement standards of practice into geriatric psychiatry inpatient settings for PRN administration and documentation.

Involuntary Medication, Seclusion, and Restraint in German Psychiatric Hospitals after the Adoption of Legislation in 2013

BACKGROUND

Involuntary medication in psychiatric treatment of inpatients is highly controversial. While laws regulating involuntary medication have been changed in Germany, no data have been available to date on how often involuntary medication is actually applied. Recently, our hospital group introduced specific routine documentation of legal status and application of involuntary medication in the patients' electronic records, which allows the assessment of the frequency of involuntary medication.

METHOD

For the year 2014, we extracted aggregated data from the electronic database on age, sex, psychiatric diagnosis, legal status during admission, kind of coercive measure (mechanical restraint, seclusion, and involuntary medication) applied, and the number and duration of seclusion and restraint episodes for seven study sites.

RESULTS

A total of 1,514 (9.6%) of 15,832 admissions were involuntary. At least one coercive measure was applied in 976 (6.2%) admissions. Seclusion was applied in 579 (3.7%) admissions, mechanical restraint was applied in 529 (3.3%) admissions, and involuntary medication was applied in 78 (0.5%) admissions. Two-thirds of involuntary medications were applied in cases of emergency; the remainder was applied after a formal decision by a judge. In 55 (70.5%) of the admissions with involuntary medication, at least one other coercive measure (seclusion, restraint, or both) was applied as well.

CONCLUSION

Involuntary medication is rarely applied and less frequent than seclusion or mechanical restraint, possibly as a consequence of recent legal restrictions.