[Medication safety in nursing homes]

[Estimation of the risk of drug-related problems in nursing home residents : A retrospective analysis of routine data]

BACKGROUND

Polypharmacy and drug-related problems are major challenges in the care and treatment of nursing home residents. Many interventional studies showed disappointing results, which lead to the question if this could also be due to the selection of the target parameters of these studies.

MATERIAL AND METHODS

A routine data set from six long-term care facilities was retrospectively analyzed. The question is if the recently validated medication risk score (MERIS) is suitable for carrying out a risk assessment in a population of nursing home residents. Associations between MERIS and the dependent variables hospital admissions and falls over 12 months and a weight loss of ≥ 5% over 3 months were examined.

RESULTS

Out of 495 residents 38.6% (n = 191) have a high risk of drug-related problems according to MERIS. A univariate regression analysis showed a significantly increased risk of hospital admissions (OR 2.2; p < 0.001) and weight loss of ≥ 5% (OR 1.95; p = 0.041) with high MERIS, but no significant association with falls. In the multivariate regression the risk of hospitalization was increased by diabetes mellitus (OR 1.88; p = 0.004), falls in the same period (OR 1.91; p = 0.001), positive MERIS (OR 1.75; p = 0.006) and decreased with stable weight (OR 0.88; p = 0.004).

CONCLUSION

The results indicate the potential of the score for future research projects and individual risk assessment; however, due to the limitations of retrospective secondary analyses further studies are required.

The role of qualification and quality management in the prescription of antipsychotics and potentially inappropriate medication (PIM) in nursing home residents in Germany: results of the HIOPP-3-iTBX study

BACKGROUND

Nursing home residents (NHR) show high rates of polypharmacy. The HIOPP-3-iTBX study is the first cRCT on medication optimization in nursing homes (NH) in Germany. The intervention did not result in a reduction of PIM and/or antipsychotics. This analysis looks at structure quality in the HIOPP-3-iTBX study participants.

AIMS

Evaluation of structure quality as part of a cluster-randomized controlled intervention study.

METHODS

Structure quality in multiprofessional teams from n = 44 NH (n = 44 NH directors, n = 91 family doctors (FD), and n = 52 pharmacies with n = 62 pharmacists) was assessed using self-designed questionnaires at baseline. Main aspects of the questionnaires related to the qualification of participants, quality management, the medication process and size of the facilities. All completed questionnaires were included. number of PIM/antipsychotics was drawn from the baseline medication analysis in 692 NHR. Data were analyzed by descriptive statistics and mixed model logistic regression.

RESULTS

The presence of a nurse with one of the additional qualifications pain nurse or Zertifiziertes Curriculum (Zercur) Geriatrie in the participating NH was associated with a lower risk for the prescription of PIM/antipsychotics. No association between any characteristic in the other participants at baseline was observed.

CONCLUSIONS AND DISCUSSION

The results support the known role of nursing qualification in the quality and safety of care. Further studies need to look more closely at how use is made of the additional qualifications within the multiprofessional teams. Perspectively, the results can contribute to the development of quality standards in NH in Germany.

[Polypharmacy in nursing homes: options to improve drug therapy safety]

Patients in need of care usually suffer from multiple chronic conditions and therefore receive a high number of drugs. Polypharmacy involves multiple risks, for example, drug-drug and drug-disease interactions, adverse effects and potentially inappropriate medication (PIM), more hospital admissions, and increased mortality.Residents in long-term care facilities are particularly sensitive to adverse drug reactions because of age-related changes, frailty, and the high prevalence of dementia. Numerous drugs have side effects that lead to sedation, particularly in old age, and increase the risk of falls. In addition, anticholinergic effects negatively modify cognition. These PIMs are frequently prescribed to nursing home residents.The medication process in long-term care facilities is complex and requires numerous coordinated processes. In addition to the correct administration, the nursing staff have other important tasks such as monitoring the effects and potential adverse drug reactions and communicating their observations to the prescribing physicians and home-supplying pharmacists. The nursing staff therefore play a crucial role in the prescription of psychotropic drugs and contribute to the medication quality for nursing home residents. National and international studies indicate that improvements of polypharmacy and drug therapy safety in nursing homes can only be achieved by interprofessional collaboration.

Drug Safety for Nursing-Home Residents - Findings of a Pragmatic, Cluster-Randomized, Controlled Intervention Trial in 44 Nursing Homes

BACKGROUND

The safety of drug use by nursing-home residents can be impaired by polypharmacy, potentially inappropriate medications (PIM), and neuroleptics, as well as by a lack of adequate interprofessional coordination in the nursing home. The goal of the HIOPP-3- iTBX Trial was to improve drug safety in nursing-home residents, including a reduction of PIM and/or neuroleptic use, by means of a complex interprofessional intervention.

METHODS

This cluster-randomized, controlled trial was performed in nursing homes in Germany. Residents over age 65 were included in the trial. The intervention was carried out over six months and consisted of four elements: a drug review by trained pharmacists, educational sessions for general practitioners and nurses, a drug safety toolbox, and change management seminars for members of the three participating professions. The nursing homes in the control group continued to provide usual care. The primary endpoint was the prescription of at least one PIM and/or at least two neuroleptic drugs simultaneously. The secondary endpoints were the incidence of falls and hospitalizations, quality of life, and health-care costs. This trial is registered in the German Clinical Trials Registry (DRKS00013588).

RESULTS

44 nursing homes with 862 residents were randomized, 23 of them (with 452 residents) to the intervention group and 21 (with 410 residents) to the control group. 41% of all nursinghome residents initially took at least one PIM and/or at least two neuroleptic drugs simultaneously. Follow-up data (including, among other things, the current drug regimen) were obtained for 773 residents. The intention-to-treat analysis continued to show no difference between the intervention group and the control group with respect to the primary endpoint.

CONCLUSION

This trial of an intervention to improve drug safety in nursing homes led neither to reduced prescribing of PIM and/or neuroleptic drugs, nor to any improvement in the overall health status of the nursing-home residents.

[Selected safety-relevant medication processes in Swiss nursing homes: Current state of affairs and optimization potentials]

BACKGROUND

Reducing adverse drug events in nursing homes is a central patient safety concern. The aim of this study was to assess how often selected medication processes to increase medication safety are already implemented in Swiss nursing homes and to examine how nursing homes that have not yet implemented these processes can be characterized based on their organizational features.

METHODS

Cross-sectional survey study among directors of nursing in Swiss nursing homes.

RESULTS

420 of 1,525 invited individuals participated in the survey (response rate: 27.5 %). Of these, 65.0 % stated that regular systematic medication reviews have been provided in their institution. 9.5 % of the nursing homes use a list to identify potentially inappropriate medication, and 6.7 % of the nursing homes have a standardized process to monitor side effects of medications. 66.0 % of the participating nursing homes have implemented at least one of these three processes, 34.0 % of the participating nursing homes have not implemented any of the three processes. Statistically significant differences in process implementation were found according to the geographical location of the nursing home, the type of documentation used for medications, the physician model, the number of external general practitioners, as well as the medication supply channel and the legal obligation to cooperate with pharmacists. No differences were found with regard to the nursing home size.

CONCLUSION

In Swiss nursing homes, central safety-relevant medication processes have not yet been implemented nationwide. In particular, implementation is not widespread in nursing homes where medical care for their residents is provided by many different external general practitioners. The organizational features need to be taken into account to successfully implement quality improvement measures.

[Medication safety for nursing home residents]

Due to demographic change, the number of elderly patients in need of long-term care is continuously increasing. Residents in nursing homes often suffer from various chronic diseases leading to the prescription of a plethora of drugs and a high risk for adverse drug reactions (ADR). Particularly, CNS-active drugs are critical in this context. Moreover, the medication process in nursing homes is complex with numerous interfaces and error sources. Therefore, medication safety for long-term care residents is regarded as a multiprofessional challenge.In Germany, several model projects have been conducted and initiated that aim at enhancing medication safety in nursing homes. The AMTS-AMPEL project is the largest intervention study so far dealing with medication safety in German long-term care facilities. After implementation of a complex multiprofessional intervention consisting of educative and structural measures, prevalence and incidence of preventable ADR could be significantly reduced. This and other projects suggest that medication safety in long-term care residents can be improved by targeted multiprofessional interventions.Although there is already evidence that interventions enhancing medication safety can improve medication appropriateness and solve drug-related problems, they still lack evidence of affecting clinical endpoints like hospitalization rate and mortality. Nevertheless, the model projects already enhance patient safety by increasing the awareness for risks in the medication process in long-term care facilities.

Multidisciplinary intervention to improve medication safety in nursing home residents: protocol of a cluster randomised controlled trial (HIOPP-3-iTBX study)

Background

Medication safety is an important health issue for nursing home residents (NHR). They usually experience polypharmacy and often take potentially inappropriate medications (PIM) and antipsychotics. This, coupled with a frail health state, makes NHR particularly vulnerable to adverse drug events (ADE). The value of systematic medication reviews and interprofessional co-operation for improving medication quality in NHR has been recognized. Yet the evidence of a positive effect on NHR’ health and wellbeing is inconclusive at this stage. This study investigates the effects of pharmacists’ medication reviews linked with measures to strengthen interprofessional co-operation on NHR’ medication quality, health status and health care use.

Methods

Pragmatic cluster randomised controlled trial in nursing homes in four regions of Germany. A total of 760 NHR will be recruited. Inclusion: NHR aged 65 years and over with an estimated life expectancy of at least six months. Intervention with four elements: i) introduction of a pharmacist’s medication review combined with a communication pathway to the prescribing general practitioners (GPs) and nursing home staff, ii) facilitation of change in the interprofessional cooperation, iii) educational training and iv) a “toolbox” to facilitate implementation in daily practice. Analysis: primary outcome - proportion of residents receiving PIM and ≥ 2 antipsychotics at six months follow-up. Secondary outcomes - cognitive function, falls, quality of life, medical emergency contacts, hospital admissions, and health care costs.

Discussion

The trial assesses the effects of a structured interprofessional medication management for NHR in Germany. It follows the participatory action research approach and closely involves the three professional groups (nursing staff, GPs, pharmacists) engaged in the medication management. A handbook based on the experiences of the trial in nursing homes will be produced for a rollout into routine practice in Germany.

Trial registration

Registered in the German register of clinical studies (DRKS, study ID DRKS00013588, primary register) and in the WHO International Clinical Trials Registry Platform (secondary register), both on 25th January 2018.

[Medication safety in nursing home residents with renal insufficiency - Results of a qualitative study]

BACKGROUND

Nursing home residents often suffer from multimorbidity and polypharmacy. Impaired renal function and the lack of dose adjustments further increase the risk of adverse drug reactions (ADR). The aims of this qualitative study were to analyze the reasons for inadequate drug treatment and to identify possible intervention options to improve safety of drug treatment in nursing home residents with renal insufficiency.

METHODS

Using a mixed-method approach a cross-sectional study and focus group discussions were performed in the project. Focus groups with general practitioners, nursing staff, nephrologists and pharmacists were held. Audiotapes were transcribed verbatim, qualitative content analysis of the transcripts according to Mayring was conducted using MAXQDA.

RESULTS AND CONCLUSIONS

Focus groups discussed different aspects and possible interventions related to inadequate drug treatment in nursing home residents with renal insufficiency. The main topics identified were "health service situation", "reasons for ADR" and "interventions". Regarding the current health service situation "infrastructure", "role of polypharmacy", "assessment of renal function" and the "different role models" were identified as relevant aspects for improving the safety of drug treatment in nursing homes. According to the participants, there is a lack of evidence-based standards regarding laboratory monitoring and estimation of kidney function.

Effect of training and structured medication review on medication appropriateness in nursing home residents and on cooperation between health care professionals: the InTherAKT study protocol

BACKGROUND

Pharmacotherapy in residents of nursing homes is critical due to the special vulnerability of this population. Medical care and interprofessional communication in nursing homes are often uncoordinated. As a consequence, polypharmacy and inappropriate medication use are common and may lead to hospitalizations and health hazards. The aim of this study is to optimize communication between the involved professional groups by specific training and by establishing a structured medication review process, and to improve medication appropriateness and patient-relevant health outcomes for residents of nursing homes.

METHODS/DESIGN

The trial is designed as single-arm study. It involves 300 nursing home residents aged ≥ 65 years and the members of the different professional groups practising in nursing home care (15-20 general practitioners, nurses, pharmacists). The intervention consists of interprofessional education on safe medication use in geriatric patients, and a systematic interprofessional therapy check (recording, reviewing and adapting the medication of the participating residents by means of a specific online platform). The intervention period is divided into two phases; total project period is 3 years. Primary outcome measure is the change in medication appropriateness according to the Medication Appropriateness Index. Secondary outcomes are cognitive performance, occurrence of delirium, agitation, tendency of falls, total number of drugs, number of potentially dangerous drug-drug interactions and appropriateness of recorded analgesic therapy regimens according to the Medication Appropriateness Index. Data are collected at t0 (before the start of the intervention), t1 (after the first intervention period) and t2 (after the second intervention period). Cooperation and communication between the professional groups are investigated twice by qualitative interviews.

DISCUSSION

The project aims to establish a structured system for monitoring of drug therapy in nursing home residents. The newly developed online platform is designed to systematize and to improve the communication between the professional groups and, thus, to enhance quality and safety of drug therapy. Limitations of the study are the lack of a control group and the non-randomly recruited study sample.

TRIAL REGISTRATION

DRKS Data Management, DRKS-ID: DRKS00007900.

Renal Insufficiency and Medication in Nursing Home Residents. A Cross-Sectional Study (IMREN)

BACKGROUND

Nursing home residents often suffer from a multiplicity of medical conditions and take many different drugs. Many drugs are eliminated via the kidneys and thus require dose adjustment in patients with renal insufficiency. This is the first study to address the prevalence of renal insufficiency among nursing home residents in Germany, and the extent to which such persons take drugs that are contraindicated or incorrectly dosed because of renal insufficiency.

METHODS

We carried out a cross-sectional study in nursing homes in the German regions of Bremen and Lower Saxony. Data were collected by nursing staff and given to us anonymously. Whenever the nursing home data did not include a current creatinine value, the patient's general practitioner was asked to supply this value. The estimated creatinine clearance (eCCr) was calculated with the Cockcroft-Gault formula.

RESULTS

852 residents of 21 nursing homes were included in the study; eCCr values were obtainable for 685 (80.4%) of them (average age, 83.3 years; 75.2% female). 48.2% of these patients (95% confidence interval [CI] 41.8-54.5) had moderate renal insufficiency (eCCr 59-30 mL/min), and 15.5% (95% CI 12.4-18.6) had severe renal insufficiency (eCCr <30 mL/min). 19.7% were regularly taking at least one medication that was contraindicated or incorrectly dosed in the light of renal insufficiency. Predictors for such inappropriate drug use were advanced age, female sex, arterial hypertension, and polypharmacy. The drugs that were most often inappropriately used were metformin, ramipril, and potassium chloride.

CONCLUSION

Nursing home residents often suffer from renal insufficiency and should therefore have their creatinine levels measured regularly. A knowledge of the creatinine level is a prerequisite for the proper adjustment of drug doses (if necessary). A practical and compact summary of dose-adjustment recommendations for patients with renal insufficiency would be desirable but is not yet available.

[Medication safety in nursing homes]

Multimorbidity, polymedication and functional impairment together with diminished everyday competence and communication ability predispose nursing home residents to adverse drug events (ADE). The high number of psychiatric drug prescriptions is a characteristic feature. The project "Medication Safety in Nursing Homes", funded by the Federal Ministry of Health, found an incidence of approximately 8 ADEs per 100 nursing home resident-months. About one third of the ADEs had clinical consequences, notably hospital admissions and additional visits of general practitioners. Many ADEs are due to errors in the medication process, coupled with the effects of poor communication among health care professionals. Thus, structured interventions are intended to not only sensitize to these problems, but also to support and foster a multidisciplinary way of thinking and acting.