May I Have Your Attention, Please?
I’ll be brief here. I am very, very busy and really don’t have time to blog today but I have a message and an insatiable desire to share it.
Ladies and Gentlemen: Please give your patients’ medications the attention required to ensure a safe and therapeutic outcome!
In reviewing clinical records for multiple clients, these are just a few of the things that I have seen with alarming frequency in the recent past:
- An abundance of Tylenol ordered to the extent that patients took all that was ordered, they would likely die of liver failure. But most don’t die of liver failure, so that begs the question of whether or not we are really checking medications as well as we should.
- Far too many narcotics and sedatives in the elderly population. If you stop and consider that falls are the number one cause of accidental death in persons greater than 65 yrs of age and that narcotics and other sedatives can only increase their risk of falls, all the little pieces start to add up to a lot of dead Medicare beneficiaries. If that doesn’t disturb you (and the fact that it might not, disturbs me), then remember, you cannot bill on patients after the date of death.
- Grossly inappropriate doses on the plans of care. What’s wrong with these orders?
- Scopolamine 10 mg i PO three times a day for dizziness.
- Lortab 10/650 one or two tabs every 4 hrs prn pain
- Duplicative drug therapy. Seriously, how many inhalers does one patient need especially if they all contain albuterol? Does Prilosec work better with Nexium enhanced by Zantac? Did I miss an FDA alert?
- Finally, how is it that a patient can go for an entire episode with no new orders for medications and yet the next 485 med list is radically different from the prior one? Does the patient routinely go to the doctor the day before the recert visit and get his meds changed? Surely, we aren’t missing any changes along the way. That would be so unlike a good home health care or hospice nurse.
Sorry for the sarcasm. I am barely keeping my head above water with all these clinical record reviews. One thing for certain is that as more and more agencies go to computerized point of care charting, bad information is going to be even more readily available to caregivers. And that scares me.
So, do me a favor. Write a comment about a medication error or potential error that you caught before harm was done to the patient. Tell the rest of us how you caught it and how you fixed it so we can learn, too.
Patient on multiple blood pressure meds though BP had been running consistently low (Systolic 90-120, diastolic40s). Checked BP faithfully but was never instructed or even discussed with Dr. what to do if BP was low. Faithfully took meds and even ended up in the hospital with profound dizziness and weakness due to so many BP meds. How does this happen? A single high BP check in the office when we know that BP is often higher in times of stress such as at the doctor’s office?
This is a perfect example of the advantage we have in seeing patients in the home setting; and how we assume things are obvious to us – such a normal blood pressures – are obvious to the rest of the world. We either have to take the time to assess the patient’s prior knowledge of his disease process or assume he knows nothing. This is a great example of a hospitalization that could have been prevented.
First, tell me what you mean by, “One thing for certain is that as more and more agencies go to computerized point of care charting, bad information is going to be even more readily available to caregivers. And that scares me.”
First of all, I love computers. I am seldom without one and get chest pain if none is available to me. But what I have been seeing is that when we rely upon field computers, careless work is rapidly available to everyone! Or, if we do not enter orders in the computer, it is available to no one. Here is an example. A nurse entered a medication change incorrectly. The case manager should have caught it but didn’t. I go to review charts and the wrong dosage of a medication is available for all to see. Another example: wounds were documented incorrectly on the OASIS assessment. Thus, orders were incorrect. Wound care was done incorrectly for an entire episode. This happens with hard copy paper charting, too. But the speed at which bad information is disseminated is faster using the computer.
Does that mean we should go back to paper charting. I think not. What it means is that we need to pay more attention to the quality of the nurses in the field. Those agencies who have point of care software have given the nurses an enormously valuable tool. But if you consider that a hammer is a tool as well, consider the difference between smashing your thumb and creating a magnificent piece of architecture.
And since you asked……. education is obviously key to computer use. But, I have worked with many agencies during the implementation of Point of Care. This is what I have found. If the agency has a ‘cheerleader’ type who really ‘sells’ the computer enthusiastically – never missing an opportunity to show the field staff how useful it can be, Point of Care is a wonderful tool. Thanks to Beth Heilreigle for showing me that first hand over ten years ago. On the other side, I have been at agencies where an administrative decision has been made without total and complete buy in from the clinical side and it failed piteously. That was actually going to be a blog post.
Me? As a consultant I love it. I have several clients using Healthcare First which is available on any computer that has internet. I love spying on them when there is a lull in my day – catching new trends real time:) It is kind of like being a CIA agent without the risk of being shot all the time. And yes, I have permission and my own passwords to get into their systems. Do not try this without proper authorization.
wow. Thanks for the prompt and enthusiastic reply. We are looking at systems right now, so the remark scared me a little. You are right, the system is no better than the users. We will be sure to follow your advice when we initiate whichever system we decide on. We are not deluded into thinking that we won’t have to “monitor” what our nurses are inputting or documenting. This will still be ongoing; but hopefully just faster and more efficient. Again, thanks.
P. S. We hang on every word.
P.P.S. And since you so kindly answered my question, I will attempt a comment re; medication errors/potential errors. Our field nurses are tasked with reviewing the patient’s medications with them each visit. They carry a copy of the patient’s “current” meds as last recorded. They also are tasked with asking the patient about any changes or new medications since the last visit. Our audits show that since this simple task was instituted our “discrepancy” rate dropped from 33%, to 13.5%, to 10% and now rests at 5%. Yes, this is somewhat time-consuming, but what can be more important than assuring that the patient is medication compliant? Hopefull, the Point-of-Care will expedite this process…good information in, good information disseminated!!!
We have 3 such “cheerleaders” on our team. The clinical staff is ready for something to ease the paperwork load, and administration is on-board. (It was a joint administrative/nursing endeavor to seek out, evaluate, and decide on the course of action.)Wish us luck!
Yes, it is amazing. I have a client – the only client who has received a deficiency free survey this year, coincidentally, that does this. I know that they are more than paper compliant because I see where duplicate prescriptions are discovered and where patients’ family members have promised to pick up meds but they are noted to be absent on the visit, etc. I cannot imagine any field nurse who does not routinely incorporate this practice into her visit routine on each and every visit. I was reviewing a chart the other day. The patient was on Lortab, Soma, flexeril, ES tylenol, phenergan with codeine syrup, bitibital-APAP, Ultram with APAP and a new doc had just ordered a med I never heard of before. I looked it up and it was a generic for Lortab. If I were a gambler, I would set up a pool and give odds on whether the patient died of liver failure or narcotics overdose first. The saddest thing is that the patient was in his 40’s.
Many of these drugs, I think, meant to be replaced by the doc. As in, the Soma isn’t working, let’s try Flexeril. But the nurses just marked down whatever was in the home at recert and didn’t question the doctor. Alternatively, it could just be that the doctor was one of ‘those’ doctors. Either way, we should hold ourselves accountable for drug profiles like this as much as physicians are held accountable.
Oh, and if your point of care has a drug feature, that would be even more ideal. As noted – even a common drug like oxycodone/APAP has so many different names that I am still caught by surprise at times.
My suggestion to everyone concerning this matter is to urge your visit staff to do the following upon admission of a polypharmacy home health patient
1. have your clients use one pharmacy to fill all medications
2. have your visit staff use that pharmacy to assist in documentation and mediation review. USE YOUR PHARMACISTS
3. consider hiring a pharmacist, for select patient chart reviews and have the pharmacist document their review in the patient record. for a small investment, your patients may get a healthy return, and your agency will shine when surveys from various regulatory agencies take place.
In response to your request for medication error prevention, I have advocated the following to my HHC agency clients for the last 17 years.
Please considert the following when reviewing your home health care patients’ medication profile. Medicare age patients primarily 65 or older:
Age related decrease in renal function using Cockroff Gault equasion for creatinine clearance ( cr cl) will allow decrease in dosing for most medications especially antibiotics, non steroidal anti inflammatories and other meds that are primarily excreted by by kidney. This is just age related decrease in renal function, Patients with disease associated decrease in renal function will allow further reduction in dose. What does this do for the patient
1. Decreases the chance of a medication related adverse event by decreasing dose of medication.
2. Increases compliance to the medication regimen, more seniors will tolerate the lower doses
3. Decreases the cost of the medication for the patient
Do not think that this is advanced pharmacology. If you have a serum creatinine, and the patients age, the equasion is very easy
140 – age x wt ( kg ) / 72 x serum cr = cr cl . For women use the same and x 0.85. Any pharmacist will assist you in estimating a patients renal function useing this method.
AGE RELATED DECREASE IN RENAL FUNCTION CAN BE USED TO DECREASE REQUIRED DOSE FOR MANY MEDICATIONS GIVEN TO OUR SENIORS.
Your responses are invaluable. Thank you so much. I must admit I was a tad intimidated by the Crockoff Gault equation for for creatinine clearance until I read the instructions. It doesn’t seem to be any more difficult than estimating ideal heart rate at the gym where you subtract your age from 200, etc., etc. This is something I will definitely teach going forward.
As far as your comment about having a pharmacist involved in reviewing charts, I think it is a great idea. For agencies that can get a 5th year student who will benefit from the experience as much as the agency, there is NO reason not to do this. For agencies that are budgeting for costs, consider that even if the cost per hour is 200.00 for a pharmacist to sit in on case conference, it is only 10 percent of one episode and if you can reduce hospitalizations by even one, it should be considered. If your hospitalization rate is greater than 40%, I believe it will provide a huge return on investment.
And YES, use the pharmacists. I have an IV pharmacy client. Until then I knew that pharmacists were smart and all – I had worked in critical care for years. But adopting their pharmacists as my own personal resource has been an invaluable tool.
One thing I don’t like about the chain pharmacies is that they can be so very, very busy. I have been to get my own prescriptions filled and had to wait an unbelievable amount of time even after calling in the refills to get my meds. Sometimes the pharmacists are stretched as thin as they can go. If cost is not critical to the patient or if there is a smaller locally owned pharmacy that takes Medicaid, the attention may be a little more personal.
You mentioned “Healthcare First” earlier in the blog. Just curious, have you worked with any clients using other systems?
I have worked with clients using any number of systems. Lewis Computer Services originated in the South and so most Louisiana clients use Prompt or Patron. I have a few that have transitioned over to Healthcare First after they purchased Lewis. I am so far pretty content with them. However, it is never good to assume that one program will work for all agencies. I personally like web based. As a consultant, I really like having access to charts so I can keep an eye on what my clients are doing and I imagine this is even a greater benefit for managers. Ease of use is critical. The program should be no more difficult than checking email. I know that the client I looked at yesterday has nurses often come to the office to get assistance with ‘syncing’ devices but I don’t know if it’s because they are so rural or what.
The device that the nurses use in the field must be easy and easily replaceable. Read inexpensive. No one screams louder than I do when people use cheap technology. It costs more than it’s worth to skimp. On the same time, most of my clients have budgets and we can expect the devices to be stolen, lost, broken or thrown up on in the home environment.
The reporting feature must be superb. I know that ‘the reporting feature’ sounds very boring but this is where you get your information. It should be easy for you to ask the computer a question about your patients as a whole and get the answer you want – not the one some geek in Research and Development thinks you need. If you want to know how many patients have CHF and diabetes, you should be able to get the answer in a second. If you want to know average number of visits, average HHRG, Average HHRG per nurse, that information should be no harder than ordering a book online at Amazon.
Data integrity has always been important. What i am seeing as more and more agencies go to Point of Care charting is that bad data gets transferred and put in place much faster. Apparent discrepancies in data needs to be pointed out by the system.
Here are a couple of things I would like to see on Planet Julianne that are not currently available unless you buy very expensive programs. I want a graphic trend line at the top of every patients screen showing weights, vital sign, etc. so that the nurse sees immediately when a weight is up or down. It would be really cool, if the program alerted the user to a weight change of greater than three pounds. If the nurse is okay with it, she has to enter her code to get rid of it. That would solve a ton of problems. Also, I use a variety of programs that all require a learning curve. Surveyors do not like to learn new things on site. What i really, really want is a ‘print all in sequence’ button so that when a chart is requested, the agency can hit one icon and print the entire chart. Finally, I want the ability to scan documents such as lab, hard copy order, etc. and put them in place in the chart.
Care Anywhere is making a big dent around here. I have a couple of clients wanting to go to that. I am quite happy with what i am seeing with Healthcare First. I have no clue as to the prices on any of them. Good luck. Send me your thoughts on any programs you look at. There are certainly others out there that are looking to catch up with the times.