Assessment of a Mental Health Residential Rehabilitation Treatment Program As Needed Medication List

In response to the inappropriate ECS use, the ZVAMC created a PRN medication list in 2010, which is offered to all MHRRTP patients, with the goal of reducing the number of patients inappropriately using ECS for minor ailments and providing more efficient and cost-effective patient care.² The MHRRTP PRN medication list is initially evaluated by the admitting psychiatrist or nurse practitioner and mental health clinical pharmacy specialist completing the admission orders for appropriateness based on each patient’s comorbidities, medication regimen, and past medical history. For example, if a new patient with liver dysfunction is admitted to the MHRRTP, acetaminophen would not be made available due to an increased risk of hepatotoxicity. The other PRN medications would still be available for the patient if clinically appropriate.

Once the PRN medications are ordered, the MHRRTP nurse can assess a patient’s condition and administer the medication(s) to the patient as indicated. For instance, if a patient requests ibuprofen for pain, the nurse will document an initial pain score and administer the ibuprofendose. As a result, the patient obtains more efficient and convenient care and does not need to wait for a provider to become available or use ECS. Per ZVAMC policy, the nurse has 96 hours to reassess the PRN medication effectiveness; however, this is typically done within the same shift. Since the implementation of the PRN medication list, no formal assessment has been completed.

To the authors’ knowledge, the ZVAMC is the only MHRRTP in the VHA system that incorporates a PRN medication list in the admission orders to reduce unnecessary ECS visits. After completing a thorough literature review and contacting the national VA mental health pharmacist listserve, no studies discussing the use of PRN medication lists in this setting were identified, and no sites offered information as to a similar practice in place.

Methods

A randomized, retrospective case-controlled study involving a chart review was completed for patients admitted to the MHRRTP at the ZVAMC pre- and postimplementation of the MHRRTP PRN medication list between April 2010 and August 2010 and between April 2013 and August 2013, respectively. The ZVAMC is a teaching institution. This study was approved by the ZVAMC institutional review board.

Patients were eligible for the study if they were male, aged > 18 years, and admitted during the study period for treatment in the GEN or SAR programs at the ZVAMC for at least 4 weeks. Patients were excluded if they were female, admitted to the hospital after being seen by ECS, or if they were receiving treatment in the following programs: PTSD, WOM, OEF/OIF/OND, DCHV, and I-ACT. Patients studied in 2010 served as the control group, and patients studied in 2013 were the treatment group.

Objectives

The primary objective of this study was to evaluate the use of the current PRN medication list. Secondary objectives included the evaluation of the use of ECS by patients admitted to the MHRRTP pre- and postimplementation of the PRN medication list, the potential cost reduction due to avoided ECS use, and nurse and patient satisfaction with the PRN medication list.

Data

A list of all patients admitted to the MHRRTP at the ZVAMC between April and August of 2010 and 2013 was generated using the Veterans Health Information Systems and Technology Architecture (VISTA)system. The Computerized Patient Record System (CPRS) was used to evaluate the patient for inclusion and collect pertinent data. The PRN medication list was implemented on September 15, 2010. Data collection terminated as of September 14, 2010, regardless of discharge status. All data collected for this study were entered and stored in a database created by the authors. A table with set criteria to review was created for the 2010 and 2013 group to ensure standardization. The pharmacy resident reviewed all of the patient charts. The following data were collected for each patient in the 2010 group:

• Demographic data: Patient name, last 4 digits of their social security number, age
• Program information: Admitted to GEN or SAR program, admission and discharge date, duration of stay, reason for discharge
• ECS data: Date, type of visit, chief condition, medications administered during the visit, whether the visit resulted in a hospital admission, and whether the visit was avoidable
• Avoidable visit: visit in which the patient received or could have received medication(s) that are on the PRN medication list at the ECS visit to treat their illness

The same information was collected for each patient in the 2013 group in addition to the following: PRN medication data (medications administered from the PRN medication list and the number of times each medication was administered if applicable); and ECS data (along with the aforementioned data, it was noted if PRN medications were taken prior to the ECS visit).