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The use of PRN in acute inpatient settings.

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Title: The use of PRN in acute inpatient settings.


1
The use of PRN in acute inpatient settings.
  • John Baker
  • Lecturer
  • The University of Manchester

2
  • Project (PhD) Aims and Objectives
  • To identify, devise and test a clinical protocol
    to enhance the use of psychotropic PRN (pro re
    nata) medication within acute mental health
    settings.

Research supported by the Health Foundation.
3
  • Approximately
  • 2.9 million doses of PRN
  • are given out in England
  • per Year
  • in
  • Adult Acute Mental Health Services alone.
  • Assumes 14,000 beds, average 2 week stay, and
  • 80 will receive 10 doses.

4
  • This common current common practice has no
    support from randomised trials. Current
    practiceis therefore difficult to justify.
  • Cochrane review
  • (Whicher et al., 2003).
  • N/B There are a number of interesting Cochrane
    reviews of medication and Psychosis eg.
    Benzodiazepines, doses for acute psychosis.

5
How do you get a Clinical Protocol?
6
Project methodology
Study 1. Narrative literature review
(Informs studies 2, 3 and 4)
Study 4. Interviews service users
Study 3. Interviews MDT
Study 2. Expert opinion (Delphi study)
Triangulation of results lead to good practice
manual development
Study 5. Exploratory and acceptability trial
(pre/post measures)
7
Evidence (data) from many sources.
Interview Service Users
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
8
Evidence (data) from many sources.
Explore the Literature
9
Narrative Literature Review
  • Search for all relevant literature found 51
    papers (from 7,601).
  • Poor quality research,
  • Mainly retrospective case note analysis.
  • Few studies of prospective research.

Baker JA, Lovell K, Harris N (2008)
Administration of psychotropic pro re nata (PRN)
medication in adult inpatient mental health
settings A narrative literature review. Journal
of Clinical Nursing, 17, 9, 1122-1131
10
Narrative Literature Review key themes
  • PRN is routinely prescribed on admission.
  • PRN contributes to High doses, these are often
    hidden.
  • PRN contributes to polypharmacy.
  • Typical antipsychotics and benzodiazepines are
    most likely to be prescribed.
  • Agitation, insomnia and patient request most
    cited.
  • PRN is most likely to be given out evening/night
    time, in the first 4 days of admission.

Baker JA, Lovell K, Harris N (2008)
Administration of psychotropic pro re nata (PRN)
medication in adult inpatient mental health
settings A narrative literature review. Journal
of Clinical Nursing, 17, 9, 1122-1131
11
Narrative Literature Review key themes
  • A sub-group continue with PRN and get lots of it.
  • With a dose range the higher one is more likely
    to be chosen.
  • Effectiveness of PRN (32 to 80) - ill defined
    concept.
  • Lack of documentation all aspects and
    disciplines.
  • Limited review of PRN.
  • No systematic recording of side effects/negative
    effects associated with PRN.

Baker JA, Lovell K, Harris N (2008)
Administration of psychotropic pro re nata (PRN)
medication in adult inpatient mental health
settings A narrative literature review. Journal
of Clinical Nursing, 17, 9, 1122-1131
12
Narrative Literature Review key themes
  • In conclusion, our findings indicate that the
    use of PRN orders may expose psychiatric
    inpatients to unnecessary psychotropic
    medications. Given the objective of regulatory
    bodies to minimise the use of chemical
    restraints in the population of vulnerable
    patients, these findings have important policy
    implications
  • Thapa et al (2003) p1286.

Baker JA, Lovell K, Harris N (2008)
Administration of psychotropic pro re nata (PRN)
medication in adult inpatient mental health
settings A narrative literature review. Journal
of Clinical Nursing, 17, 9, 1122-1131
13
Evidence (data) from many sources.
Explore the Literature
14
Evidence (data) from many sources.
Ask Experts (Delphi Project)
Explore the Literature
15
Delphi Panel (experts)
  • 33 experts identified
  • 5 Doctors (4 participated)
  • 13 Nurse Consultants (7 participated)
  • 4 Pharmacists (1 participated)
  • 11 Others including NIMHE/DoH/Sainsbury
    /Academics (6 participated)
  • 18 in total agreed to participate

16
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17
Delphi research 34 items to 7 themes
  • Service user focus.
  • Transparent correct process (from prescription to
    administration).
  • Clear process of review.
  • Correct prescriptions.
  • Side effect monitoring.
  • Use of alternatives.
  • Improvements to knowledge.

Baker JA, Lovell K, Harris N, Campbell M (2007)
Multi-disciplinary consensus of best practice for
Pro Re Nata (PRN) psychotropic medications usage
within acute mental health settings a Delphi
study. Journal of Psychiatric and Mental Health
Nursing, 14, 478-484.
18
Research project
Delphi Project
Exploring the Literature
19
Research project
Delphi Project
Scoping Literature Review
Interviews with Multi-disciplinary team
20
Interviews MDT
  • 59 members of MDT
  • 6th April to 5th July 2005
  • 49 interviews
  • 1690 minutes of data
  • Range 18-74 minutes

Baker JA, Lovell K, Harris N (2007) Mental
health professionals PRN psychotropic medication
practices within acute mental health care A
qualitative study. General Hospital Psychiatry,
26, 163-8.
21
Interviews Main themes
  • Advantages relieving distress, preventing and
    managing violence , removal of doctors from the
    process.
  • Disadvantages misuse by nursing staff or
    patients, quality of prescriptions.
  • PRN has become a first resort option, used when
    alternatives would be preferable.
  • Information about PRN to service users limited.
  • PRN probably reviewed at ward round.
  • Benzodiazepines dichotomous response.
  • A lack of clinical responsibility for PRN
    medications.

Baker JA, Lovell K, Harris N (2007) Mental
health professionals PRN psychotropic medication
practices within acute mental health care A
qualitative study. General Hospital Psychiatry,
26, 163-8.
22
Evidence (data) from many sources.
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
23
Evidence (data) from many sources.
Interviews with Service Users
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
24
Interviews Service Users
  • Total 22 (from 27) service users (9th May 21st
    June).
  • 3 Interviews terminated due to mental state.
  • 406 minutes of data, range 555 to 4152
  • Variations in ages, diagnosis, ethnicity, gender
    and mental health act status.

Baker JA, Lovell K, Easton K, Harris N (2006)
Service Users experiences of 'as needed'
psychotropic medications in acute mental
healthcare settings. Journal of Advanced Nursing
56(4), 354362 Baker JA, Lovell K, Easton K,
Harris N (2006) Poster at National Psychiatric
Nursing Research conference, Oxford University,
UK.
25
Interviews Service Users - Main themes
  • Value of PRN.
  • Preferences of some medications.
  • Enables control.
  • The process is perceived as confusing,
    stigmatising, and embarrassing especially in
    public areas.
  • Dislike for forced medication begrudging
    acceptance.
  • Information provision poor.
  • Despite identifying alternatives, few had tried
    them, perceived lack of support.
  • Link between PRN and low resources.

Baker JA, Lovell K, Easton K, Harris N (2006)
Service Users experiences of 'as needed'
psychotropic medications in acute mental
healthcare settings. Journal of Advanced Nursing
56(4), 354362 Baker JA, Lovell K, Easton K,
Harris N (2006) Poster at National Psychiatric
Nursing Research conference, Oxford University,
UK.
26
Evidence (data) from many sources.
Interview Service Users
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
27
Synthesis into clinical protocol.
Interview Service Users
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
28
Similarities Service user focus
29
Similarities Process issues
30
Similarities Side effects
31
Similarities Use of alternatives
32
Similarities Information
33
9 Principles of good practice
  • 1. Remaining focused on the patient
  • 2. Prescription quality
  • 3. PRN as part of the clinical management plan
  • 4. Evaluating the use and effect of PRN
  • 5. PRN requires frequent review
  • 6. Enhanced documentation by the
    Multi-disciplinary team
  • 7. Preventing distress when using PRN
  • 8. PRN as a last resort
  • 9. Training and education in the use of PRN for
    all clinical staff

Baker JA (2006) Enhancing the use of as
required/extra (PRN) medication within acute
mental health settings. Good practice
guidelines, supporting manual. PelicanPress,
Manchester.
34
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35
The protocol and manual testing
  • Feasibility study
  • (based on MRC framework for complex
    interventions).
  • 2 wards recruited in Greater Manchester.
  • MDT approach
  • (focus prescribing and administration).
  • Sept - Dec 06

Baker JA (2006) Enhancing the use of as
required/extra (PRN) medication within acute
mental health settings. Good practice
guidelines, supporting manual. PelicanPress,
Manchester.
36
The protocol and manual testing
  • Pre post design for 4 weeks either side of a
    two week intervention period, this involves
  • A questionnaire about individual PRN practices at
    the beginning and end of the study.
  • An audit form each time you either prescribe
    (yellow form) or administer (blue form) a PRN
    psychotropic medication.
  • Weekly audit of case notes.
  • The use of the clinical protocol in practice.
  • Evaluating the clinical protocol (interviews and
    questionnaire).

Baker JA (2006) Enhancing the use of as
required/extra (PRN) medication within acute
mental health settings. Good practice
guidelines, supporting manual. PelicanPress,
Manchester.
37
Trial results
  • Twenty-eight (of 35) patients received 484 doses
    (mean 17.3, range 1-64) in the 10 week period.
  • Benzodiazepines accounted for 62.8 (n343) of
    all drugs administered.
  • Lorazapam,
  • accounted for 51.8 of all drugs administered
    (n283 administrations)
  • 78 (n221) of Lorazepam administered was given
    at 2mg (40.4 of all drugs).
  • Combined doses were given on 52 times,
  • Haloperidol and Lorazepam accounted for 76.9 of
    these.

Baker JA, Lovell K and Harris N (2008) The impact
of good practice guidelines on professional
practice associated with psychotropic PRN in
acute mental health wards An exploratory study.
International Journal of Nursing Studies,
doi10.1016/j.ijnurstu.2008.01.004
38
Trial results
  • Patients had on average 3.6 prescriptions for PRN
    psychotropic medications (Quality standard
    established at 3).
  • 14 different psychotropic drugs were prescribed
    in 34 different combinations.
  • 36.5 (n46) of the prescribed maximum doses were
    BNF limits
  • Agitation and its eight variations accounted for
    71.5 of the prescriptions.
  • 76.1 (n35) of prescriptions of antipsychotic
    medication would (if taken) have contributed to
    polypharmacy.

Baker JA, Lovell K and Harris N (2008) The impact
of good practice guidelines on professional
practice associated with psychotropic PRN in
acute mental health wards An exploratory study.
International Journal of Nursing Studies,
doi10.1016/j.ijnurstu.2008.01.004
39
Trial results
  • Administration of PRN was not documented in 39.3
    of occasions (n185).
  • Nursing note quality reduced from 1.5 (pre) to
    0.98 (post) during the study.
  • There was no documented evidence of side effect
    monitoring.
  • 77.4 of rationales for the administration of PRN
    can be accounted by 3 reasons, agitation (n88,
    37.4), distress (n50, 21.3) , and psychotic
    symptoms (n44, 18.7).
  • Eighty-six medication errors were detected in
    prescribing of PRN psychotropic medications, a
    further 26 were associated with the
    administration of PRN.

Baker JA, Lovell K and Harris N (2008) The impact
of good practice guidelines on professional
practice associated with psychotropic PRN in
acute mental health wards An exploratory study.
International Journal of Nursing Studies,
doi10.1016/j.ijnurstu.2008.01.004
40
Conclusions
  • Routine clinical practices are rarely critiqued
    in detail.
  • PRN is one example of many interventions that
    occur without an evidence base

41
  • John Baker
  • Lecturer
  • 0161 306 7837
  • john.a.baker_at_manchester.ac.uk
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