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Avoiding Admissions to Hospitaldue to Problems with Medicines

-Information for Care Homes

March 2012

This presentation updates a previous publication “APT 14 – Admissions Avoidance”

from September 2009

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sWhat are we covering?

o What are the issues?o Adverse drug reactions

• Causes• Who’s at risk?

o Specific medicines causing ADRs• NSAIDS• Diuretics• Antiplatelets• Warfarin• Antidiabetic drugs

o The role of the prescribero The role of the care homeo A note about falls

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sWhy are we looking at this?

• In 2010/2011 there were 2,043,532 admissions to hospitals in the West Midlands.

Data: HES

• Some hospital admissions could be avoided including some of those related to adverse drug reactions (ADRs). o For example patients who experience stomach bleeds due to the

use of Non-Steroidal Anti-inflammatory Drugs (NSAIDs) such as ibuprofen or aspirin.

• ADRs affect patient’s health and wellbeing and are associated with significant costs (costs of care and costs of potential litigation).

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sAdverse Drug Reactions

• Some common adverse drug reactions that may increase a patient’s risk of being admitted to hospital are1:

o stomach problems such as bleeding, constipation and diarrhoea

o heart complications and symptoms such as: • shortness of breath or trouble breathing • new or worsening chest pain • new or worse pain in legs when walking

o breathing problems (respiratory symptoms)

o poor control of blood sugars (glycaemic control)

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sADRs: which drugs are most commonly

associated with preventable hospital admissions?

• Drugs that can cause preventable hospital admissions2,3: o Non-steroidal anti-inflammatory drugs (NSAIDs) e.g. diclofenaco Antiplatelets (which may be used for thinning the blood) e.g. low

dose aspirin and anticoagulants (to prevent blood clotting) e.g. warfarin

o Diuretics (water tablets) e.g. furosemideo Angiotensin converting enzyme inhibitors/angiotensin receptor II

blockers (to reduce blood pressure) e.g. ramipril or losartano Antidiabetic drugs e.g. insulino Drugs affecting the central nervous system (CNS) e.g.

antiepileptics, opioid analgesics and antidepressantso Digoxin – for irregular heart rhythm/beats

• The following four drug classes account for >50% of preventable drug related admissions2:o NSAIDs, antiplatelets, anticoagulants, diuretics.

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sCauses of preventable ADRs4

• Incorrect selection of drug, dose, frequency or route

• “High risk” prescribing (e.g. use of drugs when there are contraindications/cautions/allergy)

• Inadequate medication monitoring

• Inadequate medication review

• Badly designed repeat prescribing systems

• Carer and patient not understanding how to take the medicine regularly and correctly

• Poor communication across organisations e.g. community (GP and wider healthcare teams, pharmacy and care home), hospitals and social care

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sADRs: which patients are most at risk?

• Risk of an ADR resulting in hospital admission is particularly high in the following groups of people1,4:

o Elderly people

o Patients with multiple diseases and conditions (co-morbidities)

o Patients taking several drugs

o Patients with acute medical problems

o Patients with impaired memory or understanding (cognition – sometimes these are patients with dementia or learning difficulties)

o Patients who may be in a muddle with their prescribed medicines (with poor adherence)

o Patients with impaired kidney (renal) function

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sAvoiding ADRs: NSAIDs5

If an NSAID is needed prescribers will:

• try to use the NSAID with the safest track record, at the lowest effective dose for the shortest period of time e.g. ibuprofen or naproxen.

• try not to prescribe an NSAID with drugs such as:o citalopram/fluoxetine (antidepressants from the class of drugs

known as selective serotonin re-uptake inhibitors – SSRIs)o anticoagulantso antiplatelet drugso corticosteroids (e.g. prednisolone) as they can increase the

chance of stomach bleeds o If NSAIDs are prescribed with the above drugs they may also use

a proton pump inhibitor (PPI) such as omeprazole to protect the stomach

• monitor kidney function if they are obliged to use an NSAID at the same time as certain classes of antihypertensive drugs as there is an increased risk of kidney damage or failure.

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sAvoiding ADRs: diuretics6

If prescribing a diuretic prescribers will:

• carefully consider the need for a diuretic as they are often overused in the elderly.

• try not to prescribe for certain conditions for example ankle swelling not associated with other conditions. o Ankle swelling will usually respond to increased movement

(getting up and walking about where possible), raising the legs or even support stockings.

• regularly review the use of diuretics for the treatment of hypertension or heart failure.o They will assess the patient’s hydration status, kidney function

and blood electrolytes.

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sAvoiding ADRs: antiplatelets such as aspirin

and clopidogrel7

• Prescribers will carefully weigh up the risks and benefits of the use of an antiplatelet drug as it can increase the risk of bleeding complications, particularly stomach bleeds.

• If aspirin is needed the prescriber will:o use 75 mg daily unless a higher dose is indicated.o For patients at high-risk of stomach complications, a PPI (such as

omeprazole) can be added.

• If clopidogrel is needed the prescriber will:o check if the patient is at high risk of GI bleeding then consider a

drug to protect the stomach.o consider PPIs other than omeprazole or esomeprazole*.

*Omeprazole or esomeprazole may reduce antiplatelet action of clopidogrel8

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sAvoiding ADRs: warfarin9

In order to prevent ADRs related to the use of warfarin prescribers will:• Check:

o is INR (blood clotting test) being monitored regularly?o is the INR level okay?

• Watch out for interacting drugs o and exercise care when starting, stopping or altering the dose of an

interacting drug.

• Check if there are any disease states or lifestyle changes that will affect INR?o Carers should notify the GP if the patient has changed their eating habits

i.e. lack of appetite resulting in less food consumed – because this can affect the patients INR.

• Provide additional information so that care homes can ensure they have written safe practice procedures for administration of warfarin.

• Risk assess monitored dosage systemso Dose changes more difficult using these systemso Use of anticoagulants in these dosage systems not recommended

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sA note about patients with diabetes for

care homes

• Diabetes is a chronic and progressive illness. If untreated or not managed well, patients with diabetes may develop serious complications.

• People with diabetes are twice as likely to require a hospital admission compared with the general population. At any one time, at least one in 10 people in hospital has diabetes.10

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sAvoiding ADRs: antidiabetic drugs

• Prescribers will exercise care when prescribing insulin and some oral antidiabetic drugs (such as gliclazide and repaglinide) because:o they may cause low blood sugar levels (hypoglycaemia) which

could lead to a patient needing to go to hospital.

• Factors that increase the risk of hypoglycaemia include11:o inappropriately high doses of insulin or some antidiabetic drugs. o forgotten or delayed meals, or insufficient carbohydrate intake. o excessive alcohol intake (or drinking alcohol without food).o more physical activity than usual.

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sAvoiding ADRs: antidiabetic drugs

• Prescribers, pharmacists and care homes should discuss and reinforce information on hypoglycaemia.

• Carers should ensure that they11:o are aware of situations that increase the risk of hypoglycaemia.o encourage residents to eat regularly and include a portion of

starchy carbohydrate with each meal.o are able to recognise early symptoms and how to treat promptly.o check correct insulin has been dispensed.o always have treatment and information for hypoglycaemia readily

available for residents and other carers (e.g. if going out to day-centres, hospital appointments, trips out).

o encourage patients to have identification to alert others (e.g. identity bracelet or card).

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sAvoiding ADRs: antidiabetic drugs

More information on insulin….

• Insulin treatment is an important cause of hospital admissions, mainly as a consequence of severe hypoglycaemia.

o Insulin errors (wrong insulin product, wrong insulin dose, omitted or delayed insulin dose) account for 60% of insulin-related adverse events reported in the UK.12

o One report shows that for the period 1 November 2003 to 1 November 2009, there were 16,600 incidents relating to insulin including six deaths and 12 resulting in severe harm.12

o Some organisations have access to specialist diabetic services in the community for further support

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sAvoiding ADRs: antidiabetic drugs12,13

• National guidance and recommendations for the safer use of insulin include:

o Insulin doses must be measured and administered using an insulin syringe or commercial insulin pen device

o Intravenous syringes must never be used for measuring or administering insulin.

o The term ‘units’ should always be used. Never use abbreviations such as ‘U’ or ‘IU’

o Adult patients on insulin should receive a patient information booklet and Insulin Passport

o When prescriptions of insulin are prescribed, dispensed or administered always check that you have the correct insulin

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sThe role of the Prescriber4

• Before prescribing a drug the prescriber will carefully assess potential harms and benefits and consider whether the medicines is appropriate for the patient.

• Prescribers should:o consider co-morbidities or allergies, adverse effects to the drug

and interactions with other medicineso check if the patient is taking any Over The Counter (OTC)

preparations that could interact with the prescribed agent?o consider any non-drug interventions or options

• Where possible they will:o involve patients and carers in prescribing decisions and inform

them of potential adverse effectso explain clearly directions for use of medicines.

• They will also:o use appropriate formulations e.g. if the patient has difficulty

swallowing, consider liquid /dispersible formulations

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sSafe prescribing – the prescribers strategies4

The prescriber will aim to:

• Review medication regularly o Medicines which appear to have no benefit or have unacceptable

side effects should be discontinued – the care home should keep the prescriber informed of how their residents respond to medicines, especially if an ADR is suspected.

• Undertake blood tests to ensure the body is operating appropriately and/or the drug is working properlyo Liver function tests (LFT) to check the health of the liver.o Urea and electrolytes (U&E) to check the kidneys are working.o Blood tests to check if the drug is working properly (e.g. INR for

warfarin).

• Ensure effective communication across organisations e.g. community (GP and wider healthcare teams, pharmacy and care home), hospitals and social care o Review process for actioning medication changes.

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sTips for safe medicines management

systems in care homesThe role of the care home:

• Check medication and ensure you have information needed to safely administer medication. Ask for further information if you need it.

• Share and communicate necessary information.o Check medication records match at the surgery, home and

pharmacy. Inform pharmacist of any changes to medication as soon as possible.

o Ensure all monitoring is up to date • find out if monitoring is needed for a particular medication e.g. INR for

warfarin

o Ensure you have defined the allergy• sometimes what has been recorded as an allergy was a reaction or

expected side effect to a medication e.g. diarrhoea when taking erythromycin.

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sTips for safe medicines management

systems in care homes• Make sure residents take their medicines at the correct time

(this doesn’t apply to all medicines but it will with some).

• Residents taking quetiapine, risperidone or other antipsychotics should be reviewed regularly.

• If a resident is taking a diuretic and is dehydrated from not drinking, check with the GP whether the diuretic should still be given.

• If the resident is taking diabetic medicines and not eating, check with the GP if diabetic medication should be given.

• If a resident is prescribed citalopram and another drug such as aspirin or alendronate, they may also be prescribed omeprazole to protect their stomach. (If not, you may want to check this out with the GP).

• Find out where on the body and how often emollients should be applied.

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sA note about falls for Care Homes

• Falls are a major cause of disability and mortality in older patients.

• Studies found that in people older than 60 years, falls may be associated with the use of some medications including:14 o benzodiazepines e.g. diazepamo other sedatives and hypnotics e.g. temazepamo antidepressants e.g. fluoxetine/citalopramo antipsychotics e.g. quetiapineo NSAIDs e.g. diclofenaco antihypertensives e.g. ramipril

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sA note about falls for Care Homes

• NICE recommend that older people should be asked routinely whether they have fallen in the last year.15

• Patients reporting a fall or considered at risk of falling should be considered for an individual multifactorial intervention including15:o strength and balance trainingo home hazard assessment and interventiono vision assessment and referral o medication review with modification or withdrawal

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sReferences

1) Leendertse AJ, Egberts AC, Stoker LJ et al. Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. Arch Intern Med 2008;168:1890-6.

2) Howard RL, Avery AJ, Slavenburg S et al. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol 2007;63:136-47.

3) Purmohamed, M, James S, Meakin S et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18.820 patients. BMJ. 2004; 329: 15-19

4) Avery AJ. Top tips for GPs. Strategies for safer prescribing. National Prescribing Centre. 2011. http://www.npc.co.uk/evidence/resources/10_top_tips_for_gps.pdf <accessed 2/2012>

5) Non-steroidal anti-inflammatory drugs. Chapter 10. Section 10.1.1. British National Formulary 2011. 62 nd edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.

6) Diuretics Chapter 2. Section 2.2 British National Formulary 2011. 62nd edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.

7) Antiplatelet drugs Chapter 2. Section 2.9 British National Formulary 2011. 62nd edn. London: British Medical Association and Royal Pharmaceutical Society of Great Britain.

8) Clopidogrel and proton pump inhibitors: interaction-updated advice. Drug Safety Update. Volume 3. Issue 9, April 2010

9) Medicines and Healthcare products Regulatory Agency. 2010. http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON087711 <accessed 2/2012>

9) National Patient Safety Agency. Actions that can make anticoagulant therapy safer. Patient Safety Alert. No. 18. 2007 http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59814

10) Diabetes in the UK 2010: Key statistics in diabetes. http://www.diabetes.org.uk/Documents/Reports/Diabetes_in_the_UK_2010.pdf Diabetes UK

11) Recognition, treatment and prevention of hypoglycaemia in the community. NHS diabetes. 2012. http://www.diabetes.nhs.uk/news_and_events/new_publication_recognition_treatment_and_prevention_of_hypoglycaemia_in_the_community/ <accessed 2/2012>

12) The adult patient's passport to safer use of insulin. Patient Safety Alert. National Patient Safety Agency. 2011. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=130397 <accessed 2/2012>

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sReferences

13) New insulin safety guidance issued to reduce wrong dosages. National Patient Safety Agency (NPSA). 2010. http://www.npsa.nhs.uk/corporate/news/the-national-patient-safety-agency-npsa-has-today-issued-guidance-for-all-nhs-organisations-across-england-and-wales-aimed-at-re/ <accessed 2/2012>

14) Woolcott JC, Richardson KJ, Wiens MO et al. Meta-analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Intern Med 2009;169:1952-60

15) Falls:the assessment and prevention of falls in older people. CG21. National Institute for Health and Clinical Excellence. 2004. http://www.nice.org.uk/nicemedia/live/10956/29582/29582.pdf <accessed 2/2012>

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