The use of PRN in acute inpatient settings.

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The use of PRN in acute inpatient settings.

• John Baker
• Lecturer
• The University of Manchester

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• 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.
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• 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.

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• 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.

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How do you get a Clinical Protocol?
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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)
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Evidence (data) from many sources.
Interview Service Users
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
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Evidence (data) from many sources.
Explore the Literature
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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
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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
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Evidence (data) from many sources.
Ask Experts (Delphi Project)
Explore the Literature
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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

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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.
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Research project
Delphi Project
Exploring the Literature
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Research project
Delphi Project
Scoping Literature Review
Interviews with Multi-disciplinary team
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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.
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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
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Evidence (data) from many sources.
Interviews with Service Users
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
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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.
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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
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Synthesis into clinical protocol.
Interview Service Users
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
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Similarities Service user focus
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Similarities Process issues
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Similarities Side effects
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Similarities Use of alternatives
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Similarities Information
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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.
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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

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