ImPE

Why we think this project should take place?

Adverse drug reactions (ADRs) are common in the elderly - they are prescribed large numbers of medications - with increased risk of due to multiple co-morbidities, reduced physiological reserves and altered drug handling.  Common ADRs are falls, sedation, cognitive impairment which links the topic to major national agenda items such as falls, depression, and dementia. Adverse drug reactions have a major impact on the NHS and population health, accounting for 6% of all hospital admissions, 4/100 hospital bed days and costs of £380 - £466 million a year ^1-3.

Nearly half a million older people in England live in care homes. These facilities house some of the frailest, vulnerable and least visible members of our society.

People living in care homes are high users of medication and are at high risk of adverse drug reactions and inappropriate drug use both because they are vulnerable and experience multiple co-morbidities.

For example, there is a particular issue with the overuse of sedatives in nursing homes. A recent study⁴ highlighted that despite safety concerns, antipsychotic prescribing is markedly higher in care homes than in the community, and strongly associated with dementia in both settings. This issue has received national press coverage and organisations such as Age Concern have been particularly vocal about this

Further, polypharmacy is associated with medication errors. A report by the Chief Pharmaceutical Officer in 2004 included in detail the particular types of errors which can occur in the care home setting, including lack of review of therapy. The recent Care homes' use of medicines study (CHUMS) study⁵ was conducted over 55 homes within England. Patients were on a mean of 7.2 medicines demonstrating polypharmacy. In addition, 69.5% of patients had at least one error.  There is an unacceptable prevalence of medication errors in care homes and the authors concluded that monitoring errors require urgent attention and included medication review to rationalise regimes as one of their recommendations.

Finally, a number of national guidelines include the need for high quality prescribing in care homes. However, there are no established systems for medication review/medicines management in care homes.

What are we trying to accomplish?

The aim is to reduce the burden of adverse drug reactions and consequent health problems in the elderly (in the care home setting) by implementing the new evidence based medication review system (based on the STOPP tool ⁶). 

Objectives will include

(1) Increased occurrence of medication review

(2) Reduction in the use of inappropriate medication

(3) Increased knowledge and confidence amongst staff in carrying out medication review, (4) Assurance to organisation(s) that medication review is occurring to appropriate standard including agreement on triggers for Medication Review

(5) Empowerment of patients/relatives/carers with information about medications by using the ‘Medication Passport' and other new initiatives.

How we will know that a change is an improvement?

The project team will judge any improvement by:

• Ensuring that increasing number of patients get a medication review (using the new evidence based STOPP tool). The ultimate aim is to drive this to 100% using standard quality improvement methodology recommended by NIHR CLAHRC).
• Identifying the number of patients for whom medications were stopped and the number of medications stopped.
• Ensuring medication changes are documented in the patient's medical record and communicated at all interfaces.
• Ensuring that all elderly patients (and their families/advocates) get information about medication in the form of a ‘Medication Passport' at the very minimum
• Increased staff awareness, knowledge and confidence in relation to medication review by using staff surveys and other quantitative research techniques
• Increasing sustainability scores over the duration of the project

What changes can we make that will result in an improvement?

• The Medication Review System will be implemented in care homes using methodology based upon that developed in the ImPE project.
• In addition we will develop and produce a patient digital story for the purposes of staff awareness and education.
• A planned awareness campaign will be implemented which will include posters, teaching sessions, regular newsletters and baseline staff and patient surveys to engage all involved. This will exploit any existing staff awareness systems.
• An education programme that will include tailored formal group teaching as well as 1:1 interventions when required to increase knowledge and confidence in carrying out medication review. This will exploit any existing staff training systems.
• Regular progress feedback (re: parameters described above) to facilitate improvement

All the above carried out within the theme of quality improvement, specifically using quick PDSA cycles to monitor, implement changes and achieve sustained improvements.