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

Roughly 35% of patients in each group were excluded from the study. The main exclusion criteria included a < 4-week LOS, being admitted to the hospital, being female, and being admitted prior to the study period. Women veterans were treated through different programs prior to the implementation of the PRN medication list; therefore, they were excluded to decrease variability. Only patients in the GEN and SAR programs were included, because they were well established prior to and after the intervention. The other programs, which included PTSD, WOM, OEF/OIF/OND, DCHV, and I-ACT, accounted for about one-third of MHRRTP admissions. However, they were not all available or structured similarly in 2010. Including the other programs would have increased variability.

Survey Results

Although the response rates were low, the patient and nurse satisfaction surveys revealed useful information that may assist in identifying the strengths and weaknesses of the current program. More rigorous surveying needs to be conducted to make the results more generalizable. Fifty percent of patients reported using a PRN medication on a daily basis or 3 times per week. However, 28.6% stated they never used the PRN medication list, which was thought to be an overestimation due to an incomplete understanding of what medications are on the PRN medication list. This finding does not correlate with the high use demonstrated with the actual number of PRN medications used.

Two patients marked “other,” one reported using the list when they “need the medication,” and another did not mark an answer. Similarly, 57.1% of the nursing staff reported offering a PRN medication on a daily basis and discussing the list on admission every time. However, 28.6% of nursing staff stated they do not complete admission assessments or work in the medication room, most likely because they are licensed practical nurses and do not have those responsibilities. Interestingly, when asked about medications that should be removed from the PRN medication list, 1 nurse suggested removing trazodone, which was the second most used drug. Some of the medications patients suggested adding to the PRN medication list included creams for dry skin or fungal infections, calcium carbonate, and pain medications such as tramadol, aspirin, and naproxen. Nurses suggested adding aspirin, diphenhydramine, and nicotine gum. These responses will aid in enhancing the current PRN medication list by potentially increasing the types of medications offered.

Limitations

This study has several limitations that may affect its interpretation. The study was retrospective in nature and had a short study period. The data were collected from a single specialty program, which decreases the study’s generalizability, as not all VAMCs have a MHRRTP. Also, the average LOS in 2010 was longer than in 2013. This was related to the restructuring of the MHRRTP in the spring of 2013 to allow for more condensed programming. As a result, it may be reasonable to infer that there were more ECS visits prior to implementation of the PRN medication list due to the longer LOS in 2010. This confounding variable was minimized by normalizing the calculation for the number and percent of ECS visits avoided.

The patient population was limited to male veterans and the satisfaction questionnaires had low response rates. The low patient response rate may have been due to a lack of incentive, decreased health literacy, or possibly lack of time. The low nurse response rate may have been due to limited time and also lack of incentive. A larger response rate may have increased the PRN medication list use and satisfaction reported. This study looked at the change in the number of ECS visits; but, it did not investigate any changes in the number of primary care visits. Patients were able to go to their primary care appointments during their stay in the MHRRTP and may have received medications listed on the PRN medication list at these appointments, which could have been avoided. Last, the accuracy of the documentation in CPRS may be unclear and may have subjected the study to bias. Unfortunately, ECS does not use bar code medication administration, so the administration of medications has to be manually written into the ECS visit note. This method may be vulnerable to human error.

Future Directions

Future directions from this study include discussing the results with the MHRRTP staff and identifying areas of improvement to enhance the medication list. Some discussion points include the reasoning to remove trazodone and examples of inappropriate use. Furthermore, the questions asked by patients and general
suggestions made by the nursing staff identified that increased patient education of the PRN medication list should be implemented during the admission assessment process. This would improve patient understanding and awareness of the PRN medication list, because some patients did not know about the list or what medications it included. Moving forward, the results of this project may provide incentive for future implementation of PRN medication lists at other VA MHRRTPs.