Administration of PRN medication by mental health nurses

Lorazepam prescription and monitoring in acute adult psychiatric wards

Aims and Method

This study examines prescription and monitoring of lorazepam on three acute adult psychiatric wards at a university teaching hospital. Retrospective data from 102 consecutive in-patients were analysed.

Results

There were 83 patients (81.4%) who were prescribed lorazepam, however 45 of these (46%) were never administered it. Indication for lorazepam prescription was documented by the doctor in 35 patients (42.2%). Administration by nursing staff was documented in the medical notes on 86 occasions (60.0%) and on 32 of these (37.0%) the indication was unclear. On 21 occasions (14.7%) more than 2 mg was given; 13.7% of prescriptions were not reviewed and 64% of those reviewed after more than 4 weeks.

Clinical Implications

Lorazepam was overprescribed and inadequately monitored, which may increase the risk of dependence.

A study of the prescription and administration of sedative PRN medication to older adults at a secure hospital

BACKGROUND

There is a paucity of research into PRN medication use in older psychiatric inpatients. This is an important topic given the risks of polypharmacy, adverse drug reactions, and high dose medication.

METHOD

In 2013, we carried out a cross-sectional survey of the prescription and administration of sedative PRN medication to older adult inpatients on seven wards at a UK tertiary referral centre. We compared them with 242 patients of working age.

RESULTS

Of the 92 patients studied, 56 (60.9%) were prescribed PRN sedation and 25 (27.2%) had received one or more doses in the previous fortnight. In total, 70 doses had been administered; all by mouth and all but one as single doses. Lorazepam was by far the most commonly prescribed and administered PRN drug. Agitation was the main indication, although violence was the most commonly cited reason for administration but documentation of antecedents, non-pharmacological strategies and outcome including side effects was uniformly poor with only 37 (52.9%) doses recorded in the case notes. Those with organic disorders were just as likely to receive PRN as those with functional illnesses. Patients very rarely actually received high dose antipsychotics or antipsychotic polypharmacy as a result of PRN prescriptions. Older patients were less likely than adults of working age to be prescribed PRN and dosages were smaller.

CONCLUSION

Prospective studies of PRN prescription and administration are needed to better understand the reasons underpinning its use and to gain objective data upon its effectiveness or otherwise in this vulnerable patient group.

Limited evidence for the effectiveness of p.r.n. Medications among psychiatric inpatients

The use of medications on a p.r.n. basis on psychiatric inpatient wards is common and widespread but without clear evidence of effectiveness. While individual studies have explored the use of p.r.n. medications in patients receiving scheduled psychotropic medications, no systematic review of the effectiveness of this use of p.r.n. medications has been done. A MEDLINE search was performed of all articles published in English between 1966 and November 2008. Studies were included only if they involved psychiatric patients and if they quantitatively explored the effectiveness of p.r.n. medications. Ten retrospective studies were identified that met inclusion criteria. Among the studies involving adult inpatients, estimates of effectiveness, primarily in the management of agitation, were consistently moderately high, averaging approximately 75%. These studies mainly involved use of antipsychotics and benzodiazepines. Lower estimates of about 30% were obtained in studies involving non-adult inpatients who had few psychotic disorders and among whom there was only minimal use of p.r.n. benzodiazepines. The meaning of effectiveness was often unclear across these retrospective studies. It also appears that important outcome measures, such as duration of hospitalization, may not be affected. Administration of p.r.n. medication was also associated with a greater risk of adverse events. Future studies concerning use of p.r.n. medications in psychiatric patients should examine objective ratings of agitation, medication effects, and adverse events.

A best-evidence synthesis review of the administration of psychotropic pro re nata (PRN) medication in in-patient mental health settings

AIMS AND OBJECTIVES

This paper aims to synthesise published literature of drug use/administration studies of pro re nata psychotropic medications in mental health wards.

DESIGN

The study employed a best-evidence synthesis review design.

BACKGROUND

The administration of psychotropic pro re nata medications is a frequently used clinical intervention in mental health wards. Pro re nata contributes to exposing patients to high doses of antipsychotic medication. Despite the frequent use of pro re nata, there is limited evidence of their effectiveness.

METHODS

A best-evidence synthesis review.

RESULTS

Six major themes emerged from the literature: (i) frequency of administration; (ii) administration during the 24-hour day; (iii) administration associated with length and stage of admission; (iv) rationales for administration; (v) medicines administered (including route of administration); and (vi) effects and side effects of the medicines administered.

CONCLUSIONS

Overall findings indicate that the administration of psychotropic pro re nata varies radically and appears to be influenced by many variables. Relevance to clinical practice. Patients are most likely to receive a benzodiazepine or typical antipsychotic as pro re nata. Pro re nata is an important and under-researched clinical intervention used in mental health wards.

Pro re nata medication for psychiatric inpatients: time to act

Pro re nata (PRN; 'as needed') medication is an archetypal mainstay for managing acute psychiatric inpatient symptoms and behaviours. Psychiatric and mental health nursing practices have circumnavigated the development of a uniform medical-ethical standard for the administration of PRN psychotropic medication. This paper examines the evidence for administration of PRN psychotropic medications and, in the context of evidence-based best practice, current mental health policy and professional ethics, proposes a standardized Australian PRN administration protocol. The procedures and circumstances leading to a nurse administering psychotropic PRN medication are divided into five simple steps, namely (i) medical prescription; (ii) nurse evaluation of patient indications for an intervention; (iii) nurse consideration of therapeutic options; (iv) obtaining patient informed consent; and (v) documentation of outcomes of PRN administration. The literature associated with each step is reviewed, along with national and international professional ethics, guidelines and patient rights documents pertaining to the care of mental health patients. Recommendations for best-practise care are discussed for each step. There is a lacuna of published evidence supporting the use of PRN medications in psychiatric inpatients. Yet there is published evidence that PRN medications are associated with increased risks of morbidity, inappropriate use, may result in above-recommended dosages or polypharmacy, and complicate the assessment of efficacy of regular scheduled medicines. Alternative non-pharmacological treatment options to PRN medication are effective and associated with fewer side-effects. There are no national explicit standards, operational criteria or quality assurance for the use of PRN medication in inpatient psychiatric units. Contemporary PRN practices are largely unregulated and driven by essentially anecdotal evidence, leaving the clinicians and the service open to claims of poor accountability and misuse (intentional and unintentional) of psychotropic medications. Development of best practice guidelines for the use of PRN administration is essential.

Use of pro re nata medications in acute inpatient care

OBJECTIVES

Available evidence suggests that the use of 'as needed' (PRN; from the Latin pro re nata: for an occasion that has arisen) medications has remained a standard aspect of treatment in acute inpatient mental health units over a number of years despite lack of evidence from controlled clinical trials. The practice is one in which doctors and nurses are interdependent; that is, while doctors prescribe the medications, professional nurses are the ones who make the clinical decisions to administer them. The aim of the present study was to provide a detailed description of the circumstances surrounding the use of PRN medications across four inpatient units in Sydney.

METHODS

The medical records of all patients admitted for >24h during a 2 month period were retrospectively audited for details regarding prescriptions and administrations of PRN medications.

RESULTS

A total of 420 records were reviewed, producing a total of 3868 PRN medication administrations. Ninety-seven per cent of all patients were prescribed PRN medications and 93.8% were prescribed regular medications. The most frequently prescribed medications were second-generation antipsychotics for regular use along with benzodiazepine for PRN use. Nearly 84% of patients received at least one PRN medication during their admission, while patients diagnosed with personality disorder received more PRNs per day. The most common reason for PRN administration was patient agitation. The results indicated poor documentation in the prescription and documentation of PRN administrations. Also, the findings show that a small subset of the patients (5%) received >30% of all PRN medications.

CONCLUSION

PRN medication use has endured as standard practice and the results of the present study are consistent with the reported frequency of use increasing slightly over the years. The combination of second-generation antipsychotics as regular medications and benzodiazepines for PRN medication is consistent with recommended treatment guidelines. The small subset of patients who were overrepresented in the PRN administrations is noteworthy.

Evaluation of the use of the positive and negative syndrome scale-excited component as a criterion for administration of p.r.n. medication

BACKGROUND

This study evaluates the use of the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) to evaluate control of agitation and aggression in inpatients with schizophrenia as a criterion for administration of p.r.n. (as needed) medication.

METHODS

Information was collected retrospectively from clinical records of patients diagnosed with schizophrenia who were admitted to Nakhonsawan Rajanakarindra Psychiatric Hospital, Nakhonsawan, Thailand 1) prior to the adoption of the PANSS-EC, when the decision to administer p.r.n. medication for agitation was based solely on individual judgment, and 2) during the period when the PANSS-EC was used during the first 3 days of admission and its scores were considered as one factor in the decision to administer p.r.n. medication.

RESULTS

The 35 patients in the group who did not receive PANSSEC assessment and the 41 patients in the group who were assessed with the PANSS-EC showed no statistically significant difference in mean number of doses of p.r.n. medication administered for agitation. However, 55.4% of all p.r.n. doses administered in the group assessed with the PANSS-EC were given during the first 3-day period (when the PANSS-EC was used), compared with 37.0% of the p.r.n. doses being administered during the first 3 days in the group not assessed with the PANSS-EC (p = 0.054). The mean number of episodes of aggression during the period of hospitalization was significantly lower in the group assessed with the PANSS-EC (p = 0.021).

CONCLUSIONS

Including the score on the PANSS-EC in the criteria used to decide whether to administer p.r.n. psychotropic medication to agitated patients with schizophrenia had an impact on staff decision-making and resulted in a more favorable clinical outcome. Further investigation is warranted to test these findings.

Exploration of therapeutic interventions that accompany the administration of p.r.n. ('as required') psychotropic medication within acute mental health settings: a retrospective study

Within acute mental health settings, pro re nata (p.r.n.) 'as required' medication is a widely used adjunct to regular treatment plans, and is administered at the discretion of a registered nurse. However, there is concern that some orders may benefit staff more than patients by providing a 'quick fix' to compensate for inadequate therapeutic programmes. Previous authors assert that p.r.n. medication administration should not be the first line of action, but should be used when other less invasive interventions such as de-escalation, talking, or separation from the group are unsuccessful. This project explored the occurrence of p.r.n. medication administration and the type of alternative therapeutic interventions that are documented as accompanying its administration. A retrospective 1-month chart audit was undertaken for a cohort of inpatients in a 20-bed mental health facility attached to a regional hospital in New South Wales, Australia. Forty-seven patients (73.4%) received p.r.n. medication at least once, with a total of 309 doses of p.r.n. medication administered during this time. There were wide variations in the documented rationales, and for nearly three-quarters (73%) of p.r.n. medication administrations, no other therapeutic intervention was documented as occurring prior to administration.

Service users' experiences of 'as needed' psychotropic medications in acute mental healthcare settings

AIMS

This paper reports a study which aimed to explore service users' views and experiences of the processes associated with the prescription and administration of 'as needed' (p.r.n.) psychotropic medications in acute mental health settings.

BACKGROUND

Few studies have explored the use of 'as needed' medication in acute mental healthcare settings. Such medication is frequently requested by service users, but the literature is unclear about the reasons for these requests or service users' experiences of this treatment.

METHOD

A convenience sample of 22 inpatients participated in face-to-face semi-structured interviews exploring their treatment experiences of 'as needed' psychotropic medication in acute mental health settings in a large city in the United Kingdom in 2005. Thematic content analysis was carried out.

RESULTS

Interviewees highlighted the value of 'as needed' medications. However, the process associated with their use was perceived as confusing and stigmatizing. Service users had limited understanding of and felt unsupported in attempts to use alternatives approaches. Additionally, the decision-making and information-giving processes were unclear to them, which raises issues of power and control in acute mental health settings.

CONCLUSIONS

Nurses should take account of the issues of power and control when administering 'as needed' medication. The provision of adequate treatment information should be a priority to enable informed choices to be made about this form of medication.

Administration of 'as needed' psychotropic medication: a retrospective study

Mental health nurses are increasingly encouraged to discuss and document the outcomes of their nursing practice in order to maximize the care that they offer clients. One frequent function performed by mental health nurses working in inpatient units is the administration of 'as required' (PRN) psychotropic medications. However, according to the literature, this important aspect of nursing practice has been poorly explored and studies that have been undertaken demonstrate that nursing documentation of PRN medication administration is often inadequate. This study presents the results of a descriptive study examining the administration of PRN psychotropic medication at a secure acute inpatient mental health unit attached to a regional hospital in Australia. Of major concern is the findings of inadequate or no documentation regarding PRN administration. In 41% of cases the results of the PRN administration was not documented in the nursing progress notes, in 38.6% of entries it was not possible to identify who initiated the request for medication and in 9.1% of cases no reason was given for the administration of PRN medication.

Pro re nata medication for psychoses: an audit of practice in two metropolitan hospitals

OBJECTIVE

To examine the use of pro re nata (PRN) (as needed) medication in hospitalized patients with psychotic disorders.

METHODS

Retrospective chart reviews were conducted at two large public psychiatry units situated in inner city general hospitals. Pro re nata medication prescription, administration and outcomes were examined during inpatient episodes of care for 184 consecutive admissions of patients diagnosed with a psychotic disorder. Patient demographics, diagnoses, and regularly prescribed medication were also recorded. All admissions were drawn from a three-month period from December 1998-February 1999.

RESULTS

The most prevalent diagnoses were schizophrenia related disorders (n = 111) and mania (n = 34). Substance use disorders (n = 49) were the most common comorbid dis-orders. Pro re nata medication was administered during the acute phase of 82% of admissions. Drugs prescribed Pro re nata were mostly typical antipsychotics, benzodiazepines and/or anti-cholinergics. Coprescription of typical antipsychotics PRN with regularly scheduled atypical antipsychotics was common (64%). Pro re nata medications accounted for 31% of the total antipsychotic dose and 28% of the total anxiolytic dose administered during acute treatment. Higher daily doses of PRN medication were given to manic patients, males, younger patients and those with substance use disorders. Pro re nata prescriptions usually specified a maximum daily dose (87%) but rarely gave indications for use (6%). Administration records frequently lacked a specified reason for use (48%) or a notation of outcome (64%). Unit staff noted medication-related morbidity in 37% of patients receiving PRN medication, compared to 3% of patients receiving only regularly scheduled medication. Extrapyramidal symptoms (EPS) were most frequently associated with administration of PRN haloperidol (Relative Risk vs other PRN medications = 5.61, 95% CI = 2.36-13.73).

CONCLUSIONS

Pro re nata medications comprised a significant part of the treatment which psychotic patients received. The common practice of coprescribing PRN typical antipsychotics with scheduled atypical antipsychotics is potentially problematical since administration of PRN medication is associated with significant medication related morbidity. Preferential use of benzodiazepines as PRN agents may minimize this morbidity and foster subsequent compliance with regularly prescribed antipsychotics.

Mental health nurses' PRN psychotropic medication administration practices

PRN psychotropic medications (medications given with the aim of changing the patient's mental state on an 'as needed' basis) are frequently prescribed and administered in mental health facilities. Their administration is largely an autonomous nursing role. However, little research has explored this important area of nursing practice in any detail and therefore the use of this intervention by mental health nurses is not fully understood. A descriptive project was undertaken to explore the factors involved in the administration of PRN psychotropic medications. It utilized a retrospective chart audit, conducted at one regional and one urban setting in Queensland, Australia. The results indicate a lack of clarity surrounding psychotropic PRN medication administration practices, confusion surrounding decision-making processes related to this intervention, and poor documentation practices. The study found a high incidence of PRN psychotropic medication administration when compared to similar studies, and an excessive reliance on the use of typical antipsychotics over benzodiazepines. This practice is not supported by contemporary literature. As a result of our findings, we recommend further studies in areas of related importance, in order to increase our understanding of the complexities surrounding this important nursing intervention, and an investigation into documentation practices in inpatient mental health settings.

Medication management: an exploratory study into the role of community mental health nurses

The recent emphasis on community care for those with mental illness has changed working patterns and modified inter-professional role boundaries within multi-disciplinary teams. Clients with serious mental illness are usually prescribed medications, which have a wide range of side effects. However, it is uncertain who is responsible for monitoring clients for the side effects of their medications, ensuring clients' and carers' understandings of their prescribed medications and optimizing compliance with medication. This paper discusses the findings of the first phase of an ongoing study designed to assess the role of community mental health nurses (CMHNs) in managing clients' medication and the provision of appropriate continuing professional education. Our respondents were 14 CMHNs, seven of whom were preparing to undertake a pharmacology module as part of a higher education diploma, and seven who were to act as comparators. Data from questionnaires, interviews and clinical observations were triangulated. All respondents felt that issues surrounding clients' medication were not accorded a sufficiently high profile and that it was, in part, their responsibility to expand their roles to meet these unmet needs of clients. Administering and managing clients' medications were considered to be the main area of 'occupational territory' which distinguished CMHNs from social workers. However, the nurses felt that their practice was limited by lack of appropriate educational preparation.