Download Guidelines for the prescribing and administration of `when required

Guidelines for the prescribing and administration of ‘when required’
(‘PRN’) psychotropic medication for in-patients (MG04)
Document author
Ben Browning, Locality Lead
Pharmacist Secure Services
Assured by
Review cycle
MOG sub-group (11.05.16)
Review every two years or
sooner if guidance changes.
Next review April 2018
This document is version controlled. The master copy is on
Ourspace.
Once printed, this document could become out of date.
Check Ourspace for the latest version.
This document should be read in conjunction with:
AWP Trust Rapid Tranquillisation Policy for Use in an Adult Mental Health Setting
MG01AWP High-dose Antipsychotic Prescribing guideline
1.
Background
The use of ‘when required’ (or ‘PRN’) psychotropic medication is common practice within the inpatient setting. The ‘PRN’ section of the drug administration and patient record (DPAR) allows
‘PRN’ medication to be prescribed for indications such as rapid tranquilisation, so nursing staff can
administer. However, there have been concerns raised in the Trust that increasing pressure to
assess the appropriateness to administer ‘PRN’ medication is being placed on nursing staff. The
use of ‘PRN’ psychotropic medication can also increase the risk of patients being prescribed Highdose antipsychotics, as demonstrated within AWP by previous POMH UK audit results.
2.
Aim
The aim of these guidelines is to help change the culture of prescribing ‘PRN’ psychotropic
medicines by:
Encouraging the safe, effective and appropriate prescribing for the individual patient
through regular review of ‘PRN’ medication.
Discouraging routine ‘PRN’ prescribing where practically possible.
3.
Potential risks of prescribing ‘PRN’
Although ‘PRN’ prescribing is a valuable and useful intervention, (particularly in those with acute,
fluctuating conditions) it is open to misuse if it is used unnecessarily or inappropriately, increasing
the risk of patients being given above the BNF maximum licensed dose, in addition to a total
cumulative antipsychotic dose that exceeds 100%.
Guidelines for the prescribing and administration of
‘when required’ (‘PRN’) psychotropic medication for inpatients
Review date: April 2018
Page 1 of 6
The use of ‘PRN’ prescriptions over the longer term may increase the likelihood of dependence on
and tolerance to, the effects of the medication. This is more likely to be a problem with
benzodiazepines and hypnotic medications.
4.
Summary of ‘when required’ (‘PRN’) prescribing – key points
Do not prescribe ‘PRN’ medication in advance, or routinely, on admission.
Lorazepam is the first line drug of choice for agitation. Antipsychotic ‘PRN’ should only be
used for agitation due to psychosis.
Consider whether the service user is neuroleptic naïve and potential adverse effects of
‘PRN’ antipsychotics before prescribing.
The ‘single’/one-off’ (‘STAT’) section should be used for verbal orders, but must be
followed up by a new prescription signed by the prescriber within 24 hours.
Staff prescribing or administering ‘PRN’ medication should be aware of any regular
prescription and the potential for ‘PRN’ medication to raise the total daily dose of
antipsychotic above a cumulative total of 100%.
For those patients already prescribed an antipsychotic at maximum BNF dose and who
require rapid tranquilisation, an anxiolytic or promethazine should be considered first line.
Prescribe IM & oral doses separately, as the maximum daily dose for each route may be
different.
Clearly state the route, frequency, maximum dose and indication for PRN medication.
If it is clinically appropriate for the dose to be prescribed as a range, the lowest strength
should be offered first.
The maximum single dose of IM haloperidol permitted within AWP is 5mg.
‘PRN’ procyclidine should always be prescribed when IM haloperidol is prescribed.
All ‘PRN’ prescriptions should be reviewed at least once a week and discontinued if no
longer required. Any ‘PRN’ medication that has not been administered for 2 weeks should
normally be cancelled, as per the Enabling policy.
All ‘PRN’ medication which is administered via the oral or intramuscular route should be
clearly documented by nursing staff in the patient’s RiO record.
Where ‘PRN’ antipsychotics are added the service user must be monitored for response to
treatment, including rating scales, side effects and physical health.
Always check any current consent to treatment paper work to ensure ‘PRN’ medication is
covered.
5.
Prescribing of ‘PRN’ medication
‘PRN’ medicines should only be prescribed on an individual clinical needs basis and not
prescribed in advance, or routinely, on admission.
Staff should be trained in alternative ways of managing acutely disturbed patients.
Prescribers and nursing staff should consider whether the patient is neuroleptic naïve and
the potential adverse effects of ‘PRN’ medication.
Physical health (e.g. cardiovascular, respiratory status etc) and potential interactions with
current medication must also be considered. (Refer to High-Dose Antipsychotic Prescribing
AWP guideline - Appendix 1.3).
Staff prescribing or administering ‘PRN’ medication should be aware of its potential to raise
the total daily antipsychotic dose above 100% BNF maximum. If the prescription becomes a
High-Dose Antipsychotic prescription the consultant needs to assess the need and
Guidelines for the prescribing and administration of
‘when required’ (‘PRN’) psychotropic medication for inpatients
Review date: April 2018
Page 2 of 6
complete the required paperwork. The prescription chart will need to be endorsed with the
respective % of BNF maximum for each antipsychotic.
6.
Choice of drug
Care should be taken to avoid where possible combinations and high doses of antipsychotic
medication, especially where the total cumulative dose exceeds 100% of BNF maximum.
If the patient is already prescribed a regular antipsychotic and needs ‘PRN’ medication, the same
drug could be prescribed as ‘PRN’, providing the total cumulative dose does not exceed the
maximum (100%) BNF dose.
For those patients already prescribed an antipsychotic at maximum BNF dose and who require
rapid tranquilisation (RT), an anxiolytic or promethazine should be considered as first line.
Oral ‘PRN’ promethazine (25mg) may also be considered as an option for those on PRN
haloperidol (and not taking a regular oral or depot antipsychotic) and who require RT
If IM haloperidol is prescribed ‘PRN’, consider adding IM promethazine (refer to the AWP RT policy
for more details/rationale).
The maximum single dose of haloperidol that can be administered by short-acting IM injection is
5mg.
Note that the SPC for haloperidol recommends “avoiding concomitant antipsychotics” and a pretreatment ECG.
‘PRN’ procyclidine should always be prescribed when IM haloperidol is prescribed.
The route of administration must also be considered, as the maximum recommended daily dose for
each route of administration may be different. Parenteral doses generally have greater
bioavailability than oral doses (e.g. maximum dose of oral haloperidol in 24 hours is 20mg, but
12mg when it is given as a short-acting IM injection.
The conversion table below should be used to determine how much oral and/or IM haloperidol the
patient has already received, to establish how much they could still have within the 24hr period:
Route
Approximate equivalent doses (mg)
Oral haloperidol
0.5
1
1.5
2.5
4.2
5
7.5
8.3
10
Short-acting IM
haloperidol
0.3
0.6
0.9
1.5
2.5
3
4.5
5
6
Where an anxiolytic is required, a benzodiazepine such as lorazepam should be considered and
regularly reviewed (i.e. patient response, side effects etc) by the staff involved with the patient’s
care.
Those patients who require night sedation should be prescribed licensed hypnotics, sedative
antihistamines (e.g. promethazine) or melatonin m/r tablets (Circadin® ) (licensed for those ≥ 55
years) as clinically indicated. Antipsychotics must not be prescribed for night sedation.
Guidelines for the prescribing and administration of
‘when required’ (‘PRN’) psychotropic medication for inpatients
Review date: April 2018
Page 3 of 6
7.
Specifics of the Prescription:
All ‘PRN’ prescriptions should specify:
A dose - If the prescriber feels that prescribing the dose as a range is appropriate for the
individual patient, e.g. 1mg to 2mg for lorazepam, the lowest strength should be offered
first.
The minimum interval between doses
A maximum daily dose, or frequency to be given within a 24-hour period.
Precise indication/reason for which the drug is to be given must be clearly stated by the
prescriber to help nursing staff assess the appropriateness for its use (especially if/when
the patient asks for it) e.g. for lorazepam: For severe agitation only.
8.
Review of PRN Medicines
All ‘PRN’ prescriptions should be reviewed at least once a week by the multidisciplinary team and
at CPA meetings, especially if the ‘PRN’ medication contributes to a High-Dose Antipsychotic
prescription.
Any ‘PRN’ medication that has not been administered for 2 weeks should be cancelled, unless
specific conditions apply or continued clinical need is established. Cancellation can be undertaken
by a pharmacist in accordance with the Procedure Enabling Ward Pharmacists and Medicines
Management Technicians. Where cancellations or changes are made, this must be clearly written
and documented in RiO. Significant changes should be discussed with the prescriber first and then
documented on RiO.
If there is a need for the repeated administration of ‘PRN’ medication, the prescriber should
consider reviewing the regular prescription (which may include prescribing the PRN medication
regularly and discontinuing a ‘PRN’ prescription).
If there is any doubt or concern, or the member of staff is unsure of the criteria given for the
administration of ‘PRN’ medication, advice must be sought from the prescriber, a senior colleague
or pharmacist.
9.
Documentation of ‘PRN’ Medication
All episodes of ‘PRN’ medication administered via the oral or intramuscular route should be clearly
documented by nursing staff in the patient’s RiO record, with details of the name and dose of drug,
date and time given, the specific symptoms which resulted in the drug being administered. A
description of the patient’s response to the medication should also be recorded.
Actions and interventions taken to prevent ‘PRN’ psychotropic medication being administered
should also be documented in the service users records on RiO.
After the event the patient should be offered the opportunity to write an account of their experience
of receiving ‘PRN’ medication and this should be kept in their records on RiO. (NICE guidance for
schizophrenia, 2009).
Reason(s) for not administering ‘PRN’ medication when requested by the service user should also
be recorded in the patient’s records.
10.
Monitoring
If a ‘PRN’ antipsychotic is added, registered practitioners should ensure that the patient is
monitored for response to treatment, including rating scales (listed under ‘specialist assessments’
Guidelines for the prescribing and administration of
‘when required’ (‘PRN’) psychotropic medication for inpatients
Review date: April 2018
Page 4 of 6
on RiO), side effects and physical health monitoring e.g. ECG is recorded where appropriate,
especially if a cumulative antipsychotic dose of 100% BNF maximum has been exceeded.
A physical health check, including relevant blood tests and ECG, should be offered before
treatment with high-dose antipsychotic medication commences. Refusal by the patient to engage
with this must be clearly documented on RiO.
Prescribers engaging in high dose prescribing must refer to the AWP guidance on ‘High-dose
antipsychotic prescribing’ for further advice and for key recommendations.
11.
Consent to treatment
The prescriber and nursing team must check if the patient is subject to consent to treatment
requirements under the Mental Health Act, and ensure any pharmacological treatment at the dose
prescribed is covered by forms T2, T3, 62 or 64 where relevant.
Where there is high dose prescribing, informal patients should give their consent to treatment and
be given a copy of the ‘Patient information letter’ to sign (See Appendix 1.2 of the ‘High
dose/combination antipsychotic medication monitoring form’). This must be uploaded to RiO.
12.
Advanced decisions
The Prescriber or senior nursing staff must check if there is an advanced decision in the patient’s
notes on RiO, detailing the patients preferred treatment choices in the event of an acute episode of
illness which may require ‘PRN’ medication.
If an advanced decision is not available, the prescriber / senior nursing staff must ensure that the
patient is given the opportunity (where possible) to make an informed choice about the treatment
they receive.
All details must be recorded in the patient’s records on RiO.
13.
Verbal orders for ‘PRN’ medication
If a verbal order is considered, the registered practitioner should first check that the medication
being requested is covered on any consent to treatment paperwork.
If it is the professional judgement of a registered member of nursing staff that a patient would
benefit from ‘PRN’ psychotropic medication, then in exceptional circumstances, where the
medication has been previously prescribed and the prescriber is unable to issue a new
prescription, but where a change of dose or re-prescribing of the given psychotropic is considered
necessary, a verbal order for a single (‘STAT’) dose, can be accepted from the prescriber (or if it is
out of hours, the duty doctor).
For further details on how to obtain verbal orders for medication please refer to the AWP
Procedure for Prescribing Medicines
http://ourspace/Skills/MedicinesPharmacy/Medicines%20procedures/Med02.doc
14.
References and further reading:
1) The Maudsley Prescribing Guidelines in Psychiatry 12th Edition 2015
2) Psychotropic Drug Directory 2014. S. Bazire.
3) Psychosis and schizophrenia in adults: prevention and management. NICE guidelines
[CG178] Published date: February 2014
4) www.medicines.org.uk
Guidelines for the prescribing and administration of
‘when required’ (‘PRN’) psychotropic medication for inpatients
Review date: April 2018
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Version History
Version Date
Revision description
Editor
Status
1
12/06/2014
Legacy document
B. Browning
Approved
2
15/04/2016
Reviewed and updated
B. Browning
Draft
2
11/05/2016
Approved by MOG subgroup and converted to
standard guideline format
S. Jones
Approved
Guidelines for the prescribing and administration of
‘when required’ (‘PRN’) psychotropic medication for inpatients
Review date: April 2018
Page 6 of 6