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Spotlight on the Standards
Standing
Up to Medication Practice Challenges (Part 1)
In my last
column (Fall 2006), I described 10 problematic
medication practices and promised to follow up with some
solutions. I found that solving problems was much harder than
listing them! Moreover, these issues are so thorny that many
different solutions may apply depending on the setting and
situation. Given the volume of possibilities that emerged, we
are publishing this “Part 2” in two parts.
In keeping with
NCCHC’s approach to correctional health care matters, we look to
the Standards for Health Services for guidance. Essential
standards D-01 Pharmaceutical Operations and D-02 Medication
Services focus on medication issues. These standards intend to
ensure that “the facility’s pharmaceutical services are legally
and properly operated” and that “prescriptive practices are
commensurate with current community practice.” Other standards
provide guidance for specific medication-related issues (*see
list below). Most important in deciding if a practice will
assist you is whether the intent of the standards is met.
For any given
problem, potential solutions will depend, in part, on a access
to a registered clinical pharmacist and the extent to which that
pharmacist will assist the health staff. Large facilities may
have a full-time pharmacist whose role allows for ongoing
consultation with prescribing clinicians, participation in
quality improvement initiatives and patient education. More
often, however, the health staff are working with a contracted
pharmacy’s representative or a pharmacy consultant. (At a
minimum, an accredited facility must have a consulting
registered pharmacist review pharmacy operations quarterly.)
When using a
contracted pharmaceutical services provider, the contract should
stipulate duties beyond supplying medications. When the
contractor or pharmacy is not expert in correctional issues,
health services should provide an orientation to the unique
challenges of the correctional setting and explicit
expectations.
Solutions
for Problematic Practices
1. Eliminating
medication delays on admission or transfer
The facility’s
responsible physician has options to consider to facilitate
continuing prescribed medications for inmates being newly
admitted or transferred from another facility. These protocols
must be in writing and available to staff for reference.
The first
decision is which medications are to be considered priorities
and necessary to continue without interruption. All medications
are not equal when it comes to missing a dose or two. The
pharmacist can assist the responsible physician in writing
guidelines for the screening staff as to which medications’
timely continuation is an urgent concern.
For admissions
from the community, one option is to allow the use of
medications brought by the inmate or family in the original
pharmacy bottle until a facility physician sees the patient.
This requires a system of validating the order by calling the
prescribing physician or pharmacy and checking that the
medication in the bottle is what it says it is.
When inmates
arrive without medication (or if the facility prohibits personal
medications), there must be a way to obtain necessary
medications immediately, either by contract with a 24/7 pharmacy
or by use of stock drugs or starter packs. If authorized
prescribers are not on-site at the time, access to an on-call
physician who will give a verbal order is necessary. Usually the
order is valid until the facility physician can see and evaluate
the inmate.
The issue of
medications for inmates transferred from other correctional
facilities or community hospitals must be addressed in the
letters of agreement that define what is required for the
facility to accept the inmate. Besides advance notice of the
transfer, requirements can include an alert to the need for
specific medications via phone, fax or e-mail, or sending at
least a few days’ supply of the medication along with a health
summary or copy of medical records. When this does not occur,
the sending facility should be notified. The agreement also can
state consequences for noncompliance.
Two important
points are the attitude of the screening staff and the need to
communicate with the inmate. The stress of booking into a
correctional facility is compounded when you have a chronic or
urgent health condition that depends on medication for control
or relief. Unprofessional comments such as “Where do you think
you are?” or “This is not a hospital” can exacerbate a tense
situation. A calm “We will contact the nurse” or “It will take a
day to get that prescription, but your body maintains a level of
this drug for more than a day so you will be OK” will help.
Nonhealth staff should refrain from commenting on these health
issues.
2. Timely
medication renewals
Running out of
prescribed medications can be avoided once you know your system
and how long the various processes take, both external (time
between pharmacy order and delivery) and internal (steps from
physician’s order to administration of the first dose). Using
flowcharts or other graphics and CQI studies may help orient
staff to the need to perform these tasks in a timely manner
based on established time lines.
Here are some
ideas for improving the internal steps to getting the right
medication to the right patient at the right time. Schedule
reminders for the physician to review and renew medications such
that, if not done, there is time to renew before the meds are
stopped. Write prescriptions to coincide with chronic care
visits. Write them for three months vs. one month when the doses
are no longer being titrated. Use a backup system to check that
orders are processed. Write protocols to require an order from
the prescribing clinician to stop a medication. Ask the pharmacy
or a staff member to flag meds that are about to expire in time
for the order to be renewed. If you don’t have an electronic
system that helps address these issues, consider whether one
might be more efficient and cost-effective in the long run.
Finally, clear,
consistent and respectful communication with the pharmacy will
do much to prevent errors and to promote professional resolution
of any that do occur. Since problems can occur at both ends of
the line, focus on immediate resolution and prevention of
reoccurrence, not assignment of blame.
3. Addressing
security concerns
The aim is to
get at the root of the problem and to individualize solutions as
opposed to a knee-jerk reaction. Just because one inmate hoards
pills and needs his stomach pumped does not mean all procedures
need to be changed. Why did this happen? Does it indicate a
trend? How does the nurse check the inmate’s mouth?
There can be no
blanket edicts such as “All medication will be crushed” or “No
narcotics will be used.” The physician and/or pharmacist can
determine which medications may be altered and how so that
their efficacy and safety are not affected. The pharmacist can
review the problematic patient’s medication to determine if the
drug can be crushed, if a cost-effective alternative form is
available, or if an alternative medication can substitute for
the patient’s current therapy.
A facility
guideline to the effect that “Narcotic medications are not
generally used at the facility except where the health of the
individual inmate requires this as determined by the treating
physician” is in keeping with the standards.
4. The inmate
as partner in treatment
Changing
medications or doses without discussion with inmates may be the
single root cause of a significant number of health-related
grievances. Regardless of the extra time and effort it may need,
explaining and helping the inmate to understand the link between
the change and better health, or that the change is merely one
of suppliers and the blue pill is the same as the yellow
capsule, makes cooperation and medication compliance so much
easier.
One of the
pharmacist’s most valuable roles is the ability to provide some
of this one-on-one counseling. Use of patient information sheets
like the ones community pharmacies provide to patients is very
helpful.
5. Clinical
parameters for medication changes
Frequent
medication changes by different prescribers may be linked to
lack of access to the patient health record when the prescriber
is ordering or renewing meds. Always having the record available
for clinical encounters and medication renewals will help avoid
too many changes in too short a time. Documentation should
include the reasons why the change is being made earlier than
usual (e.g., side effects).
Pharmacists can
assist here by establishing a protocol to alert the clinician
when the change does not provide an adequate trial period for
the drug to have an effect. They also can send a reminder of the
need to taper off certain drugs before starting others.
Prescribing
clinicians are well aware of the need to understand a patient’s
history and total health picture when deciding which medications
to use, particularly if the patient has a chronic disease for
which many medications may have been tried in the past. It is
best to validate the patient’s claims (“Please do not give me
haldol, I have bad reactions to it. Just call my wife.”) before
switching medications simply because the practitioner prefers a
specific drug (“Sorry, I always start my patients with haldol.”)
or is not familiar with the current drug.
Pharmacists can
alert prescribers to new drugs or new findings regarding
established drugs, and researching information on a drug the
prescriber is not familiar with.
Finally, using
a primary care model for assigning patients and prescribing
(except in emergencies) is a good practice to prevent “too many
cooks in the kitchen.”
An Ongoing Dialogue
That’s Part 2-A. See the Spring
2007 column for the rest. And
remember, this list is not meant to be exhaustive but rather to
spark new ideas. We’d like to hear from you about these issues.
Also let us know if you are interested in a periodic column to
address pharmacy questions.
__________
*The
standards mentioned in paragraph 2 above are A-01
Access to Care, A-03 Medical Autonomy, A-06 Continuous Quality
Improvement Program, E-02 receiving Screening, E-07 Nonemergency
Health Care Requests and Services, E-12 Continuity of Care
During Incarceration, G-01 Special Needs Treatment Plans, G-02
Management of Chronic Disease, G-04 Mental Health Services, G-06
Intoxication and Withdrawal, I-02 Emergency Psychotropic
Medication, I-05 Informed Consent.
(This article first appeared in the
Winter 2007 issue of CorrectCare.
Thanks to Syd Mulder, PharmD, CCHP, for his contributions to
this article. Mulder is a cofounder of Clinical Solutions
LLC, Nashville, TN.)
Back
to Spotlight on the Standards home page
Do you have a question about the NCCHC standards for health services?
Contact us at:
Standards Q&A
National Commission on Correctional Health Care
1145 W. Diversey Pkwy.,
Chicago, IL 60614
Phone (773) 880-1460 • Fax (773) 880-2424
E-mail accreditation@ncchc.org
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