Enhancing the use of 'as required' (PRN) medication in acute mental health wards: the development and testing of a good practice manual by Baker, John APublication Date: 2007
Background: Pro re nata (PRN) psychotropic medication is regularly prescribed and administered in inpatient mental health care. Approximately 80% of inpatients receive PRN psychotropic medications during an admission. The most frequently administered PRN medications are benzodiazepines and typical antipsychotics. The use of antipsychotic medications as PRN contributes to polypharmacy, high doses and potentially dangerous drug interactions. Previous research into this area has mainly been retrospective analysis of case notes, and has been hampered by poor quality and imprecise documentation. A Cochrane review concluded that PRN as a clinical intervention does not have a robust evidence-base. Aims: The aim of this study was to contribute to improving the practice of prescribing and administering psychotropic PRN medication in acute mental health wards through the development and testing of a good practice manual. Methods: This thesis employs a two phase design based on the Medical Research Council's complex intervention framework. The first phase developed a good practice manual. Four studies contributed to this, which included a literature review (best-evidence synthesis), interviews with the multi-disciplinary team (n=59) and service users (n=22), and a Delphi study with experts (n=18). The second phase used a pre-post test design to undertake an exploratory and acceptability trial of the manual. Results: In phase one (theory and modelling phase) nine themes of good practice emerged. These were: a) considering the patient (knowledge, preferences and choices); b) improving prescription quality; c) PRN as part of the clinical management plan; d) evaluating the effects and side effects of PRN; e) frequent review of PRN; f) enhanced documentation by the MDT; g) preventing distress when using PRN; h) PRN as a last resort encouraging the use of non-pharmacological interventions; and i) additional training and education is required for all clinical staff. In phase two (the exploratory and acceptability trial) 28 of 35 patients received 484 doses of PRN in the 10 week period. Patients had a mean of 3.6 prescriptions of 14 different PRN medications in 34 different dose combinations prescribed. Medication errors beyond poor quality of prescribing occurred in 23 of the 35 patients (65.7%). Prescription quality improved following the introduction of the intervention but quality of nursing notes reduced. Acceptability of the manual to both nursing and medical staff was high. Conclusions: This thesis demonstrates a systematic and rigorous mixed method approach to the development and testing of a good practice manual designed to enhance the use of PRN psychotropic medication.
Themes: Acute mental health; pro re nata (PRN); psychotropic medication