Unnecessary Drugs Part 3: Avoiding Citations

As seen in Consultant Connection November 2012 Issue
Tracey Pierce, RPh., CGP, FASCP, Consultant Pharmacist, ICP, Inc.

Unnecessary Drug Related Articles:

Part1: Just What is an Unnecessary Drug?
Part2: Situations in which an Unnecessary Drug Citation Could be Given.

Appropriate effective medication regimens are the desired goal for every resident requiring  medication therapy. Some words of wisdom from this consultant pharmacist with 24 years of
experience…Document, monitor, adjust, document, monitor, adjust, and document some more,
then continue to monitor and adjust! As our bodies age and diseases present themselves, our ability to metabolize drugs changes, our ability to tolerate physiologic stress diminishes, and our medication therapy needs to change and adjust too. Optimal therapy offers the desired response without the presence of untoward side effects. Drug interactions while often present, are most often are clinically insignifi cant. … But this does not mean that just because the interaction has been dormant for the last 10 years does not mean that the addition of yet another agent is safe.

Just because mom has been taking drug x for the last 25 years without any problems does not
mean it is safe and the best drug today. Status quo is not the answer. Going back to the unnecessary drug defi nition… even if all of the components of the unnecessary drug defi nition are met on paper, it is possible that a change in resident status could change the appropriateness of therapy. For example…JD has diabetes, HTN, CHF, and dementia with agitation (which is treated with an atypical antipsychotic with a clinical contraindication to attempt further reductions documented). JD suffers a stroke and is paralyzed and no longer can strike out at staff during care. The atypical antipsychotic needs to be addressed despite past failures because it was being used for behavioral disturbances which are no longer present due to a change in status. Similarly after the stroke JD is eating very little and his blood sugars are dropping, of course his insulin dose will be lowered, or perhaps there is a change in cardiac function requiring a change in cardiac medications… the underlying theme… document, monitor, adjust, and repeat as needed.

As noted in part 2 of this series, a common area related to medication related problems arise in changes in level of care… from home to the hospital… to home health… to the hospital... to LTC...or where ever in between... Medication errors and miscommunication of information can and do happen under these circumstances. Assuming that a medication listed as a home medication is actually being used regularly is a mistake. Verifi cation with the community pharmacist can help determine compliance prior to admission and alert the facility of high risk medications which may not have been used regularly at home. More people than not, don’t keep a current and accurate medication list. Verifi cation of medication use prior to administration on a routine basis in a LTC facility is critical… in this case, ask questions, document, monitor, adjust, and repeat as needed! On admission to a LTC facility, a good H&P from the home primary care physician is critical in evaluation of medications for appropriate use. The LTC medical director will not know why drug x is used (particularly if it is being used off label, or has several indications for use). The history is the only way to get this information. Many drugs are started during hospitalization as part of written protocols, and often some of these drugs get ordered at discharge from the hospital.

Knowing the hospital protocols will help in evaluation of some of the medications (such as the
need for drugs like pepcid or prilosec, sliding scale insulin in a non diabetic or heparin /lovenox in
a non surgical patient). Addressing medications not listed as home medications prior to ordering
them from the pharmacy can prevent unnecessary costs, decrease drug interactions, and prevent
unnecessary drugs from being used. Ask questions, document, monitor, adjust, and repeat as  necessary! (This is an underlying theme!)

Monitoring medications with lab tests, nursing assessments, etc play an important role in prevention of unnecessary drug citations. There used to be a document called “Appendix N” which outlined some basic monitoring parameters. Appendix N was created sometime before a lot of today’s nursing staff was born. CMS eliminated Appendix N from the documents available to surveyors about 8 years ago because it was so outdated and did not contain any drugs that came to the market in the last 20 years. Without that document, there is little specifi c guidance for nursing staff. Look to the consultant pharmacist for guidance in the necessary monitoring for medications.

Lastly, it is worthy to mentions the Beer’s criteria drugs which have been well documented as  problematic medications in the older adult. They are so problematic, that CMS incorporated the  entire criteria into the survey process with specifi c guidance for surveyors as to what to look for in
persons receiving these medications. Focus on monitoring of the most problematic medications in the older person is a great place to start in identifi cation of medications related problems… ask questions, document, monitor, and adjust!

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