A Drug-related Problem Risk Assessment Tool (DRP-RAT) for use by - - PowerPoint PPT Presentation

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A Drug-related Problem Risk Assessment Tool (DRP-RAT) for use by home care practical nurses

Maarit Dimitrow, PhD (Pharm) University of Helsinki Finland

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Background

• The demand for long-term home health care

services for the aged is growing

• Those needing home care (HC) are increasingly
• lder and have more complex health problems
• In Finland, practical nurses (PNs) have 3-year

vocational education that concentrates mainly on technical nursing rather than pharmacotherapy

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Background

• PNs working in HC are those who make regular

home visits to the elderly

=> PNs are in a key position to monitor and notice changes in their clients´ health status including positive and negative outcomes of possible drug treatments

• Due to lacking physician resources in HC, the

physician-conducted home visits are rare

=> PNsʼ role in medication risk management is pronounced

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DRP-RAT

• PNs need a practical tool for identifying problems

related to drug treatments =>

• Development and validation an easy-to-use Drug-

related Problem Risk Assessment Tool (DRP-RAT) for PNs caring for home-dwelling aged ≥65 years

• PNs need training to use the Tool
• PNs conduct the risk assessments during their

normal home visits in collaboration with the HC client (if possible)

• PNs report their risk assessments to other

healthcare providers

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Development of the draft DRP-RAT

• 1. Two systematic literature reviews
• 2. Expertice of the research group
• 3. Consultation of a geriatrician not

involved in the research group Content validation of the draft DRP- RAT

• 3-round Delphi survey with a

panel of 18 experts in geriatric care and pharmacotherapy Feasibility of the final DRP-RAT

• Conducted among practical

nurses in home care of two towns in southern Finland Testing the validity of the final DRP- RAT in clinical practice

• An experienced geriatricianʼs

reliability evaluation of PNsʼ risk assessments

• Geriatrician identifyed the clinically

most significant DRPs

Phase I Development

Phase II Validation process

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Is there anyone who determines whether the client takes his/her medicines? (added based on the feasibility study)

Polypharmacy ”High risk” medicines

OTC

Symptoms suggestive of ADRs

Fall tendency

Involving the client and his/her proxy to clientʼs care

• Clientʼs health status
• Potential problems with transfer of clinical patient

data

Involving the client/care giver in clientʼs care Adherence

• Interventions for resolving the problems
• Increases the awareness among PNs and the aged of
• ptions to improve medication safety

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Symptoms suggestive of ADRs

• When developing the DRP-RAT we had to take into

account the PNʼs ability to answer the items of the tool

• It is not useful to ask the PNs if the clients uses

anticholinergic medicines, sedatives or medicines that may cause hyponatremia etc.

• Thus, we decided to ask the PNs if their clients have

symptoms suggestive of adverse drug reactions (ADRs) that these problematic medicines may cause

• The symptoms listed in the Tool include ADRs of a wide

range of medicines (e.g., anticholinergics, sedatives, neuroleptics, diuretics, hypoglycemic, diuretics, blood pressure medications, etc….)

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• Participants: 36 PNs
• Time spent to complete the DRP-RAT
• 10-45 minutes; mean 20±8 minutes
• The PNs identified 88% of the risk medicines listed in the

Tool

• Challeges the PNs met in completing the tool
• Generic names of medicines
• Time resctrictions
• Short client contacts

Main results of the feasibility study

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Geriatricianʼs reliability evaluation

• f PNsʼ risk assessments

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Participants:

• A clinically experienced geriatrician
• 26 home care PNs
• 46 home care clients
• 1. First phase of the study:
• The PNs conducted risk assessment for their clients

using the DRP-RAT during their normal home visits

• The PNsʼ risk assessments were forwarded to the

research geriatrician

Outline of the study

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• 2. Second phase of the study:

DRP risk assessments and medication reviews by the geriatrician

The geriatrician reviewed the same clientsʼ medications using three different review methods:

• Method 1: Review based on the PN-completed DRP-RAT

information and the medication list printed from the health centerʼs medical records

• Method 2: Review based on the health center’s medical records

(“gold standard”) of the study)

• Medical records encompass the following patient data: a) visits in

health center, b) clinical examinations (health status, anamnesis, conclusions), c) medication lists, d) laboratory test results, e) hospitalizations, f) HC workers’ open comments about their home visits

• Method 3: Review based on Methods 1 and 2 together = all

client information available

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Geriatricianʼs assessment of clinical importance of the items in identifying risks for clinically significant drug-related problems in study sample

• Based on each review the geriatrician was asked to

classify the patients “as an risk patient” or “not an at risk patient”

• Risk patient: a patient is at risk for clinically significant

DRPs needing more comprehensive medication review

• If the geriatrician classified the client as “an at-risk

patient” based on Method 1 (PN-completed DRP- RAT information and medication list) she was asked to tick those PN-identified risk predicting notes in the Tool that she regarded as clinically significant risk factors

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”Traffic lights” of risks

Risk predicting factor Prevalence in the study sample Clinical Importance of the of the questions in identifying risks for clinically significant drug-related problems Has the client had any of the following symptoms in the last 4 weeks? drowsiness, fatigue, skin rash or itch, dizziness, urination problems, muscle pains, nausea, diarrhea, constipation, dizziness when getting up, recurrent falls, swellings, memory problems, confusion, visual problems, stiffness, troubles in walking, low blood pressure; systolic pressure under 110 mmHg (n=44) 40 (yes) (91%) 26 Does the client have more than one physician involved in his/her care? (e.g., general practitioners, specialists, private practitioners) (n=44) 22 (yes) (50%) 20 Has the client had more than one fall in the past 12 months? (n=44) 18 (yes) (41%) 18 Does the client use any of the following medicines (please check the ones used)? amiodarone, carbamazepine, digoxin, fluoxetine, lithium, methotrexate, theophylline, warfarin (n=44) 16 (yes) (36%) 14

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”Traffic lights” of risks

Risk predicting factor Prevalence in the study sample Clinical Importance of the of the questions in identifying risks for clinically significant drug-related problems Has the client had troubles in a) remembering to take the medicines? b) following the medicines regimen? c) knowing what his or her medicines are used for? d) affording the medicines (i.e., economic problems)? e)

• pening the drug bottles or packages or managing with

medicines related therapeutic devices? (n=44) 30 (yes) (68%) 11 Does the client use medicines that a) relieve pain by reducing inflammation (does not apply to paracetamol)? b) elevate the rate of urination (diuretics)? c) are intended to lower the cholesterol level (statins)?) d) the physician does not know about? (n=44) 35 (yes) (80%) 8 Have the client's relatives/proxies expressed their concern about the client's medicine use? (n=43) 7 (yes) (16%) 7 Has the client started a new medicine in the last 4 weeks? (excluding different brands of the same active incredient) (n=44) 7 (yes) (16%) 6

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Implications for practice

• DRP-RAT:
• Can assist in identifying clients needing medication

review

• Provides additional information for pharmacists who

conduct medication reviews

• Educational implications

An example of an operational model

(case Lohja, Toivo et. al. 2017)

Practical Nurses

• Update of the

medication lists

• Risk assessment

with DRP-RAT

• (Clinical tests)

Coordinating pharmacist Preliminary assessent of the medication using

• Medication lists
• Risk

assessments

• Available

databases (pharmacokinec and -dynamic interactions) Coordinating pharmacist and physician Shared decision- making for further actions Physician, nurse, pharmacist

• Case-spesific

actions, e.g., prescription review, MR, CMR (physician)

• Carrying out the

decided actions (pharmacist)

• Follow up after 3

months (nurse)

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• Think ideas how to implement

the DRP-RAT in your health care system?

• Other ideas to benefit the DRP-

RAT?

First assignment

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• Mrs. K is an 86 years old lady, living alone in her own house. Home care practical nurse Miss. A visits her 3

times a week. Mrs. K suffers from cardiac failure, hypertension, diabetes mellitus, osteoarthritis, depression, troubles with sleeping and constipation. Earlier, she also has had several urinary tract infections. Most of her medicines are dispensed by automated dose dispensing (i.e., regularly used medicines are machine packed into unit dose bags for each time of administration), home care practical nurse administers the rest (i.e., buprenorphine plaster, local estrogen). Mrs. K takes her daily tablets (except the plasters and local estrogen) on her own. During the last weeks Miss. A has noticed that Mrs. K has been tired and forgetful, from time to time she has not taken all her dispensed medicines. Miss. A wondered if the used medicines could cause these symptoms. As Miss. A had been trained on the content and use of the DRP-RAT by her home care organization, she conducted the medication risk assessment during her next home visit to Mrs. K. She also printed Mrs. K medication list from health centre’s medical records and compared the medicines Mrs. K. really uses with the medication list.

Second assignment The case of Mrs. K

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• Which do you think are the most essential PN-reported risk

predicting factors in the completed DRP-RAT? Justify your

• pinion
• Which medicines and/or what combination of medicines

that Mrs. K uses may cause her symptoms?

• Use databases, Beers criteria etc.
• Do you agree with the PNʼs recommendations for action?
• If not, what would you prefer Mrs. K for further actions?

Justify your opinion

The case of Mrs. K

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Tha Thank You! nk You!

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