Significance Of Admission To Adult Acute Psychiatric Wards - Dissertation Example

Significance Of Admission To Adult Acute Psychiatric Wards Table of Contents Abstract ……………………………………………………………………………………. 2 Table of Contents ………………………………………………………………………….. 3 1. Introduction ………………………………………………………………………… 4 1.1 Purpose of the Study …………………………………………………… 4 1.2 Research Objectives ……………………………………………………. 5 1.3 Research Questions …………………………………………………….. 5 1.4 Rationale for Selecting the Research Topic ……………………………. 5 1.5 Scope and Limitations ………………………………………………….. 6 2. Literature Review ………………………………………………………………….. 8 2.1 Differences when Prescribing B&Zs during Pre and Post Admission …. 8 2.2 Bases for Prescribing B&Zs in line with the Current Best Practice ......... 10 2.3 Differences in Patient Population being Prescribed with B&Zs ............... 14 2.4 Differences between Medication Reconciliation and Treatment Plan ...... 15 2.5 Impact of Lack of Communication in the Misuse or Abuse of B&Zs .... 17 3. Research Methodology …………………………………………………………….. 4. Research Findings and Discussion …………………………..…………………….. 5. Conclusion and Recommendations ……………………….………………………… References ………………………………………………………………………………….. Chapter 1 – Introduction Benzodiazepines and Z-hypnotics or non-benzodiazepine hypnotics are two of the most common types of psychotic medications that are used in acute psychiatric ward (Weich et al., 2014; Gallagher, 2013; Tsimtsiou, Ashworth and Jones, 2009). Often times, these two (2) types of drugs are being prescribed to patients in case there is a need to manage high-levels of anxiety and/or insomnia (NHS, 2012; Wilson and Nutt, 2007). Between January to March 2013, Hurding and MacBride-Stewart (2013, p. 13) reported that a minimum of 0.66 to a maximum of 214.15 defined daily dose (DDD) of hypnotics and anxiolytics are given to 1,000 patients in NHS Greater Glasgow & Clyde each day. In general, the admission of patients within the acute psychiatric ward can strongly influence the prescription of Benzodiazepines and Z-hypnotics; including its long-term use. To protect the health and socio-economic welfare of people from the adverse health consequences of wrong use of both Benzodiazepines and Z-hypnotics, it is necessary to increase the existing knowledge and skills of healthcare professionals when prescribing and/or administrating these two (2) particular psychotic drugs. In relation to the misuse or wrong prescription of Benzodiazepines and Z-hypnotics within the acute psychiatric ward, this study will seek to identify the danger of prescribing both Benzodiazepines and Z-hypnotics during the pre-admission, admission, and post-admission process across the acute Psychiatric Hospitals and among the general practitioners (GPs). 1.1 Purpose of the Study To investigate if Benzodiazepine and Z-hypnotics prescribing (B&Z) is influenced by admission to adult acute psychiatry wards and to assess the accuracy of B&Z medicines reconciliation pre and post admission. 1.2 Research Objectives The research objectives are as follows: 1. To identify differences in B&Z prescribing pre and post admission; 2. To assess if B&Zs are prescribed in line with current best practice advice; prescribed for ≤4 weeks as per license; 3. To identify differences in patient population prescribed B&Zs pre and post admission in comparison to patients not prescribed B&Zs; and 4. To assess B&Z medicines reconciliation pre and post admission. 1.3 Research Questions The main research question is “Is Benzodiazepine and Z-hypnotic prescribing influenced by admission to acute psychiatric wards?” The following sub-research questions will be used as a guide throughout the completion of the literature review: 1. What are the differences in B&Z prescribing pre and post admission? 2. What are the bases for prescribing B&Zs in line with current best practice? 3. Does lack of communication contribute to the misuse or abuse of using either Benzodiazepines or Z-hypnotics? 4. What are the differences in patient population being prescribed with B&Zs during pre and post admission? 1.4 Rationale for Selecting the Research Topic As a general rule, both Benzodiazepine and Z-hypnotics should be used in small quantities for a time period of 5 days to 4 weeks (NHS West Essex, 2012, p. 4). However, there are cases wherein these drugs are being prescribed to the patients for long-term use. Because of the adverse health consequences of misusing both Benzodiazepines and Z-hypnotics, a lot of patients can be admitted or re-admitted to psychiatric wards. In the process of going through this study it is possible to determine whether or not the professional negligence of the GPs can contribute to the misuse or wrong prescription of Benzodiazepines and Z-hypnotics. Likewise, it is possible to identify all human errors or flaws during and after the pre-admission, admission, and post-admission process that can lead to the misuse or wrong prescription of Benzodiazepines and Z-hypnotics. By knowing all factors that can lead to human errors during the pre- and post-admission process, health care practitioners such as the GPs and nurses can become more conscious only how to protect the patients from the adverse side-effects and long-term health consequences of both Benzodiazepines and Z-hypnotics. In the process of doing so, the healthcare professionals can play their role in terms of preventing unnecessary hospital admissions or re-admissions as they improve the patients’ overall health condition. 1.5 Scope and Limitations In relation to the main purpose of this study, the scope of literature review will focus only in addressing the main and sub-research objectives and research questions presented in this study. As such, the literature review was purposely divided into five (5) main headings known as: (1) differences when prescribing B&Zs during the pre and post admission; (2) the bases for prescribing B&Zs in line with the current and best practice; (3) differences in patient population being prescribed with B&Zs; (4) the differences between medication reconciliation and treatment plan; and (5) the impact of lack of communication in the misuse or abuse of B&Zs. As part of discussing factors that can cause wrong prescription of Benzodiazepines and Z-hypnotics during the pre-admission process, the literature review will first discuss the differences when prescribing B&Zs during the pre and post admission followed by discussing the bases for prescribing B&Zs in line with the current and best practice. In line with this, the proper procedure when withdrawing from Benzodiazepines or Z-hypnotics after the long use will be tackled in details. To learn more about the group of patients who are using B&Zs, the literature review will purposely discuss the differences in patient population who were prescribed with B&Zs. Medication errors can cause more adverse impact on the health condition of each patient. For this reason, it is necessary to discuss the importance of medication reconciliation and its differences with a treatment plan. Miscommunication may arise between the hospital staff and GPs during the patients’ admission and prior to the patients’ discharge. Therefore, in relation to the need to prevent the high incidence of medication errors, the last part of the literature review will focus on discussing the negative impact of miscommunication within the psychiatric department and its contribution to the misuse or abuse of B&Zs. Eventually, important ways on how to avoid such internal miscommunication was mentioned in the literature review. With regards to the factors that can cause misuse of Benzodiazepines or Z-hypnotics before and after the post-admission stage, the literature review focuses on discussing the possibility wherein the registered nurses has failed to educate the patients about the long-term health consequences of using either Benzodiazepines or Z-hypnotics. Eventually, the link between the patients’ lack of knowledge with regards to the health consequences of long-term use of Benzodiazepines and Z-hypnotics and their dependency on these drugs was also tackled in details. To assess whether the issue of misuse or abuse of using either Benzodiazepines or Z-hypnotics is caused by some flaws in the process of pre-admission, admission, and post-admission of patients within the acute psychiatry settings, the health records of certain number of patients will be observed particularly with regards to their prescription of either Benzodiazepines or Z-hypnotics before and after their admissions to psychiatry settings. In the process of checking the patients’ required doses of Benzodiazepines or Z-hypnotics before the admission, during the admission, and after discharging the patients from psychiatry settings, it is possible to determine whether or not admission to a psychiatry setting can increase the patients’ daily consumption of either Benzodiazepines or Z-hypnotics. The main purpose of this study is to investigate if Benzodiazepine and Z-hypnotics (B&Z) prescribing is influenced by admission to adult acute psychiatry wards and to assess the accuracy of B&Z medicines reconciliation pre and post admission. Therefore, this study is limited in terms of discussing how Benzodiazepines or Z-hypnotics are being prescribed in other hospital settings outside the psychiatry ward. Chapter 2 – Literature Review 2.1 Differences when Prescribing B&Zs during Pre and Post Admission There are quite a lot of factors that can affect the differences when it comes to prescribing B&Zs during pre and post admissions. Specifically the main action of the drug as well as the risks of developing dependence on these drugs including other related side-effects are some of the few factors that can affect the differences when prescribing B&Zs during the pre and post admissions (AWMSG, 2011; French et al., 2005). For example, the use of shorter-acting high potency Benzodiazepine Hypnotics such as loprazolam and lorazepam can increase the patients’ risk of experiencing drug dependence problems (Hallfors and Saxe, 1993). Therefore, some GPs would consider prescribing Benzodiazepine Hypnotics with intermediate half-life such as temazepam to avoid problems related to drug dependence after short-term use (AWMSG, 2011). Patients’ health complaints can also affect the differences when prescribing B&Zs during pre and post admission (French et al., 2005). For example, among the drug choices when treating patients with high levels of anxiety include: (1) diazepam (2 mg tds); (2) chlordiazepoxie (10 mg tds); (3) lorazepam (1 to 4 mg per day); and (4) oxazepam (15 to 30 mg 3 to 4 times per day) (AWMSG, 2011). On the other hand, drug choices when treating patients with insomnia include: (1) nitrazepam (5 to 10 mg nocte); (2) temazepam (10 to 20 mg nocte); (3) loprazolam (1 to 2 mg nocte); (4) lormetazepam (0.5 to 1.5 mg nocte); (5) zopiclone (7.5 mg nocte); (6) zolpidem (10 mg nocte); and (7) zaleplon (10 mg nocte) (AWMSG, 2011). Another important point of consideration when prescribing B&Z to patients is the socio-economic status or the ability of the patients to pay for their own medications (French et al., 2005). Basically, the GPs need to keep in mind that there are some types of Benzodiazepine or Z-hypnotic medications that are generally affordable while some are quite expensive (French et al., 2005; Guest, Russ and Lenox-Smith, 2005). Therefore, to ensure that the patients are capable of buying the prescribed drugs, GPs should consider the actual costs of B&Zs for 28 days or 4 weeks. For example, the drug choices when treating patients with insomnia include nitrazepam (£1.22 to £2.44), temazepam (£2.85 to £4.21), loprazolam (£18.00 to £36.00), lormetazepam (£52.90 to £103.63), zopiclone (£1.64), Zolpidem (£1.73), and Zaleplon (£5.72) (AWMSG, 2011). In relation to the high cost of lormetazepam, it is unlikely for GPs to prescribe this particular shorter-acting Benzodiazepine Hypnotics to patients who are currently going through financial difficulty because of the higher risks wherein this group of patients will not be able to afford the drug. To avoid non-conformity to the prescribed medication, GPs should consider other cheaper options such as zopiclone (£1.64) or Zolpidem (£1.73). After examining the prevalence rate of using off-label antidepressant drugs on patients with insomnia, Lai, Tan and Lai (2011) found out that paediatricians and neurologists are most likely to prescribe antidepressant drugs (45.1%), z-hypnotics (43.2%) and Benzodiazepines (11.7%) as compared to psychiatrists and that people who are capable of paying for their own medications are most likely to be prescribed with these drugs as compared to those patients who are heavily relying on the use of private insurance. Even though patients would normally approach GPs for health consultancy, one cannot disregard the fact that there are some GPs who have limited knowledge with regards to the main action of the drug, right dosage, right route for the drug administration, and right duration when administering the drug (Gallagher, 2013; Kopp et al., 2006; Alonso et al., 2004). For instance, in countries like Belgium, France, Italy, Germany, Netherlands and Spain, Benzodiazepines are being prescribed as anxiolytics (Gallagher, 2013; Alonso et al., 2004). Likewise, there are also some cases wherein the patients are not adequately treated by their GPs; not because of unavailability of effective treatment(s); but due to the fact that some GPs are not prescribing the right drug (Andrews, 2000). Therefore, it is clear that poor psychiatric literacy on the part of the GPs can be considered as a significant fact that can directly affect the prescribing practices of B&Zs during pre and post admission. A significant part of the universal guidelines with regards to the prescription of B&Zs when treating anxiety and insomnia is to learn more about the underlying factors makes a patient unable to sleep well at night (Information Services Division and NHS, 2013, p. 4; Baxter, 2012). However, there are some GPs who would immediately prescribe either Benzodiazepine or Z-hypnotics without even knowing whether or not the main reason why the patient is unable to sleep is because of severe depression or because of pain, dyspnoea, urinary frequency or other forms of psychiatric disorder (Lyne et al., 2011). 2.2 Bases for Prescribing B&Zs in line with the Current Best Practice Both the National Health Service (NHS) and the British National Formulary (BNF) has published clear guidelines with regards to the purpose and limitations when prescribing B&Zs to patients (Information Services Division and NHS, 2013, p. 4; Baxter, 2012; NHS West Essex, 2012; NHS Cumbria, 2011). In line with this, it was clearly stated under section 4.1.1 to 4.1.3 of the BNF that both Anxiolytics and Hypnotics can be used for treating insomnia and anxiety provided that the following conditions are satisfied: (1) avoid the long-term use of both Benzodiazepines and Z-hypnotics; (2) prescribe Z-hypnotics to patients “only after” identifying and treating the main causes of insomnia; (3) avoid prescribing Anxiolytics as short-term treatment for mild anxiety; (4) prescribe Anxiolytics only for short-term relief of severe anxiety; (5) prescribe Barbiturates only when there is a need to treat patients with severe insomnia who are already using Barbiturates; and (6) avoid prescribing Barbiturates to elderly patients (Information Services Division and NHS, 2013, p. 4). Except for exceptional cases, it was clearly noted by the NHS that there should be no repetition of B&Zs prescription (Baxter, 2012). However, despite the clear guidelines and limitations set on the use of both Benzodiazepines and Z-hypnotics, a lot of evidences show that these guidelines are not being observed in real practice.(See Table I – General Information when Prescribing B&Zs on page 12) Table I – General Information when Prescribing B&Zs Drug Name Minimum Adult Dosage Peak Onset in Minutes Elimination Half-Life in Hours Shorter-Acting Benzodiazepine Hypnotics Temazepam 10 to 20 mg ON 30 to 60 5 to 22 Loprazolam 1 mg ON 30 to 240 6 to 15 Lormetazepam 500 mcg to 1.5 mg ON 30 to 60 10 to 12 Longer-Acting Benzodiazepine hypnotics Nitrazepam 5 to 10 mg ON 20 to 50 15 to 38 Z-Hypnotics Zaleplon 10 mg ON 30 2 Zolpidem 10 mg ON 7 to 27 2 Zopiclone 7.5 mg ON 15 to 30 5 to 6 Benzodiazepine Anxiolytics (Longer-Acting) Diazepam 2 mg TDS 30 to 60 20 to 100 Chlordiazepoxide 10 mg TDS 120 to 240 6 to 30 Lorazepam 1 to 4 mg (divided dosage per day) 60 to 90 10 to 18 Oxazepam 15 to 30 mg (3 to 4 times per day) 20 to 50 5 to 15 Source: Baxter, 2012, p. 3 For example, it is okay to prescribe Hypnotics when treating patients with insomnia provided the main cause of sleeping problem has been “established and treated” (Information Services Division and NHS, 2013, p. 4). However, the study of Lyne et al. (2011) show that only 5 out of 85 psychiatry outpatients (6.8%) utilized other non-pharmacological treatment before they were prescribed to take hypnotic drugs and that 47 out of 85 outpatients (63.5%) were not properly taught about the use of other non-pharmacological options before they were prescribed to take hypnotic medications. Furthermore, prescription of Benzodiazepines should strictly be for short-term use only (Information Services Division and NHS, 2013, p. 4). Based on Norwegian population of 15,830 elderly people, Nordfjaern (2013) revealed that there are still cases wherein elderly patients are taking Benzodiazepines longer than 4 weeks period and that most of these chronic users end up showing symptoms of more serious anxiety. In fact, some elderly women in France are being prescribed with Benzodiazepines for more than 6 months (Gallagher, 2013). As a common practice, B&Zs should be used in small quantities for a time period of 5 days to 4 weeks (NHS West Essex, 2012, p. 4). Basically, one of the most obvious bases for prescribing B&Zs in small quantities for a short period of ≤4 weeks is the adverse health consequences of using both B&Zs in large dosage for a long period of time. For instance, the administration of Benzodiazepines for more than 4 weeks period of time can cause the patients to develop drug dependence which could eventually cause harmful effects to the patients’ overall physical health, cognitive abilities, and mental health (Tsunoda et al., 2010; Uzun et al., 2010; Ayers et al., 2007, p. 677; Barker et al., 2004). After conducting a meta-analysis which aims to examine the adverse cognitive impact of withdrawing from long-term use of Benzodiazepines, Barker et al. (2004) found out that those patients who received a long-term therapy on Benzodiazepines are unlikely to recover their full cognitive function 6 months after withdrawing from the administration of the said drug. The long-term use of Benzodiazepine can also increase the elderly patients’ risk of having dementia (Billioti de Gage et al., 2012) or a hip fracture (Wagner et al., 2004). Aside from symptoms related to anxiety, depression, insomnia and stress, the long-term use of Benzodiazepines can cause the patients to become highly addicted to the drug (Mehdi, 2012). Eventually, the process of becoming addicted to Benzodiazepines can eventually increase the patients’ risks of drug overdose (Mehdi, 2012; Uzun et al., 2010). Furthermore, the long-term use of Benzodiazepines can make some patients experience side-effects such as the symptoms of flu (Lindsay, 1994, p. 173) and/or depression (Semple et al., 2007, p. 540; Lindsay, 1994, p. 173). Similar to Benzodiazepines, Z-hypnotics should also be prescribed only for short-term use (NHS, 2012; NHS West Essex, 2012, p. 4). Aside from the few cases of insomnia rebound, Touitou (2007) explained that the long-term use of Z-hypnotics can cause the patients to develop drug tolerance or drug addiction. When used on elderly patients, Z-hypnotics can cause more serious health conditions caused by falls, the feeling of tiredness and fatigue, and some signs of cognitive impairment (Joint Formulary Committee, 2013). Furthermore, the use of z-hypnotics can increase the patients’ risks of having road accidents (Pressman, 2011). In relation with the current best practice when prescribing B&Zs to patients, GPs should consider the proper procedure when withdrawing from long-term use of B&Zs. For instance, to avoid experiencing a long-list of withdrawal symptoms, patients who received long-term use of Benzodiazepines or Z-hypnotics should avoid abrupt cessation of these drugs (Loughlin, et al., 2006, p. 432). Basically, withdrawal symptoms from the long-term use of either Benzodiazepines or the Z-hypnotic drugs can cause almost the same symptoms such as drug dependency, anxiety, increase in tolerance, panic, visual hallucinations, confusion, dizziness, loss of balance, etc.) (Loughlin, et al., 2006, p. 432; Brown, 2003). Therefore, failure to observe the proper procedure when withdrawing from the long-term use of Benzodiazepines or Z-hypnotics can lead to serious long-term health consequences on the part of the patients. 2.3 Differences in Patient Population being Prescribed with B&Zs Gender can be a factor related to the prescription of either benzodiazepine or z-hypnotics. For instance, after examining the prescription database on the use of z-hypnotics and benzodiazepines, Hausken et al. (2009) found out that majority with 69,287 out of 73,163 hypnotic users were prescribed with z-hypnotics and that more men were prescribed with benzodiazepines than women. Contrary to the research findings of Hausken et al. (2009), the telephone survey that was conducted by Gallagher (2013) in France revealed that elderly women with low socio-economic status in life are the ones who were repeatedly being prescribed with Benzodiazepines for more than 6 months. Psychiatric illnesses can also be a predictor of either benzodiazepine or z-hypnotics prescription. In line with this, Hausken et al. (2009) explained that one of the possible reasons why benzodiazepines are being prescribed to patients is because of the presence of other psychiatric illnesses which includes anxiety. Furthermore, people with low educational attainment who are suffering from chronic illnesses are most likely to be prescribed with Benzodiazepines (Dell'osso and Lader, 2013). With regards to age as a factor for being prescribed with hypnotics, Hartz et al. (2012) found out that the dosage use of hyponotic drugs normally increases three (3) times as a child reaches the age of 13 to 17 years. In Italy, Gallagher (2013) found out that 90% of 177 patients who are more than 60 years of age were prescribed with Benzodiazepines. 2.4 Differences between Medication Reconciliation and Treatment Plan Medication reconciliation is referring to the process wherein the patients’ current medications are being compared with the list of other prescribed medications that was written on medication orders or patient record (Barnsteiner, 2008). In the process of performing medication reconciliation, it is possible for GPs to know more about the presence of medication discrepancies, addition or deletion of the prescribed medications (NHS Cumbria, 2011). On the contrary, a treatment plan summarizes the patients’ diagnosis, prescribed treatment or medication(s) in terms of its dosage, preferred route, and schedule for administration, anticipated allergy or adverse treatment effects, and the plan or schedule for further re-evaluation (Hewitt and Ganz, 2007, p. 17). In practice, there are cases wherein healthcare professionals failed to send, review, and set date for GPs to review the treatment plan. To avoid medication errors such as duplications, wrong dosage, drug interaction, and omissions which are all necessary to promote patients’ safety; medication reconciliation should be properly observed not only during the patients’ admission process but also in case of the need to transfer of care, discharge the patients from the hospital settings, and/or when entering a residential or nursing care (NHS Cumbria, 2011; Barnsteiner, 2008; Rozich et al., 2004). In general, there are ways to perform medication reconciliation. In line with this, it is necessary to create a list of current medications and a list of prescribed medications. In the process of comparing these two (2) lists, GPs can make necessary clinical decisions concerning the patients’ medication and eventually communicate the updated list to the registered nurses (Barnsteiner, 2008). In most cases, the GPs should rely on the current health condition of the patients as well as the patients’ existing treatment plan. Therefore, failure to complete, review, update and/or set a date for GP’s re-evaluation of the treatment plan can result to the long-term misuse of Benzodiazepines and/or Z-hypnotics. There are also some cases wherein data found on the treatment plan are being manipulated by the healthcare professionals. In line with this, Summers and Brown (1998) mentioned a case wherein data on treatment plan in one of the UK-based psychiatric hospital was manipulated by the healthcare professionals. Back then, the actual dosage of Benzodiazepines stated in the treatment plan as prescribed to patients when they were admitted to psychiatric hospital was increased by two (2) times more than what was officially prescribed to the patients during the pre-admission stage and roughly 1.5 times more upon the patients’ discharge (Summers and Brown, 1998). 2.6 Impact and Causes of Lack of Communication in the Misuse or Abuse of B&Zs Within the intensive care unit (ICU), Kopp et al. (2006) mentioned that medication errors are caused by wrong prescription (77%) and human errors in medication administration (23%) (i.e. wrong dosage (20%), administration of wrong drug (16%), the use of wrong administration route (15%), and the adverse health consequences of drug-to-drug interaction (10%)). In relation to the use of multiple drugs, the high incidence of medication errors can occur due to miscommunication between the GPs and the nurses as well as the nurses and the pharmacists (Kopp et al., 2006; Schmidt and Svarstad, 2002). To avoid errors in drug administration, there should always be a clear communication between the GPs and the rest of the hospital staff. Based on the study of Kopp et al. (2006), Chang (2007, p. 68) mentioned that the mere act of allowing the pharmacists to participate each time the GPs are making their rounds as well as in times when the nurses are staying at the nurses’ station can foster open-communication line among the hospital staff which is essential in terms of preventing medical errors. Therefore, one of the possible ways to avoid internal miscommunication is to promote an organizational culture that practice open communication among the hospital staff (Frankel, Leonard and Denham, 2006). References 1. AWMSG. (2011, April). Educatinal Pack. Material to support appropriate prescribing of hypnotics and anxiolytics across Wales. [Online] Available at: http://www.awmsg.org/docs/awmsg/medman/Educational%20Resource%20Pack%20-%20Material%20to%20support%20appropriate%20prescribing%20of%20hypnotics%20and%20anxiolytics%20across%20Wales.pdf [Accessed 18 June 2014]. 2. Ayers, S., Baum, A., McManus, C., Newman, S., Wallston, K., Weinman, J., et al. (2007). 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