* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Guidelines for the prescribing and administration of `when required
Survey
Document related concepts
National Institute for Health and Care Excellence wikipedia , lookup
Pharmacokinetics wikipedia , lookup
Atypical antipsychotic wikipedia , lookup
Prescription costs wikipedia , lookup
Pharmaceutical marketing wikipedia , lookup
Prescription drug prices in the United States wikipedia , lookup
Intravenous therapy wikipedia , lookup
Theralizumab wikipedia , lookup
Antipsychotic wikipedia , lookup
Pharmacogenomics wikipedia , lookup
Medical prescription wikipedia , lookup
Transcript
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 Once printed, this document could become out of date.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 Page 5 of 6 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