This clinical information sheet has been developed to assist medical practitioners, pharmacists, RACF staff and others involved in the management of medications for residents. The information will be used mainly by health professionals qualified to prescribe medications, dispensing pharmacists, and registered nurses qualified to administer medications.
Approximately 140,000 hospital admissions per year may be related to problems with medicines. People aged over 65 years have higher rates of adverse events as they are the greatest users of medicines and have risk factors related to age and high prevalence of disease [1].
In addition, frailty, cognitive impairment and polypharmacy make many residents dependent on RACF staff for administering their medication according to medication charts. Medication chart rewrite is a major reason for after-hours locum doctor visits to RACFs in Victoria, due to a lack of systematic medication management. Meeting residents’ complex medication needs requires effective partnerships and organisational systems between the prescribing doctor, dispensing pharmacist and administering RACF staff for:
All people have the right to give informed consent or refuse any medical intervention including medication. It is important to discuss treatment issues with the resident/relatives in terms they can understand. If a resident is not capable of giving informed consent, this should be sought from their representative, e.g. medical enduring power of attorney, legal guardian or relative [2] (See Advance Care Planning Clinical Information Sheet for further information).
It is the responsibility of the resident or his or her representative to inform RACF staff of any complementary, alternate and/or self-selected medications being used.
Residents who choose to self-administer medication should be formally assessed, informed in writing of their associated rights and responsibilities, and demonstrate consent by signing an appropriate form.
All health professionals providing medications for residents are responsible for working in partnership with each other, and it is highly recommended that this be achieved through a Medication Advisory Committee.
Figure 1 shows the interactions required between the prescribing GP, the dispensing pharmacist, and the RACF staff administering medication for a resident. The roles of RACF staff in the administration of medications is determined by state regulations and depends on their qualifications (e.g. RN Division 1, personal care worker) and additional training (for administering medication).
Table 1 shows examples of tools available for GPs for rational prescribing and monitoring of medication.
Table 2 shows examples of tools available for RACF staff for medication management.
A Medication Advisory Committee (MAC) is a group of advisors who are responsible for the development, promotion, monitoring and evaluation of policies and activities to assist in the achievement of best possible health outcomes for residents by ensuring quality use of medicines in the facility. Formation of a MAC provides a forum that promotes the active partnership between the GP, pharmacist and the RACF staff in managing medication within the facility.
The MAC should include, as a minimum, a representative from each of the following groups:
The MAC has an important role in the development and monitoring of quality systems to ensure the safe management of medication within the RACF. The MAC should develop systems for and written policies on [3-6]:
As part of its ongoing role in ensuring quality of medication use and management within the RACF, the MAC should monitor and analyse and make recommendations on:
Medication issues in older people [7]
Medication use in the elderly must be carefully monitored because of increased risk of adverse drug reactions and interactions. Adverse effects are noxious and/or undesirable effects associated with the use of a drug at doses normally used. Drug interactions are possible when 2 drugs used together may increase risk of toxicity or when a drug may affect the likely beneficial effect of another.
Predisposing factors for adverse drug reactions and interactions include [1, 7]:
Multiple co-morbidities: Where medication can improve one condition and worsen another;
Reduced renal function: Due to aging and acute illness;
Increased sensitivity to effects of drugs with age: At drug receptors and target organs, and due to reduced compensatory mechanisms;
Reduced hepatic metabolism of drugs: Age-related;
Female gender: This may reflect their relatively smaller size for given doses;
Dose: Many adverse effects are dose-related;
Polypharmacy: Incidence increases with the number of drugs, and certain combinations;
History: Of significant adverse drug effects;
Genetic factors: Relative deficiency of enzyme(s) involved in metabolism of some drugs increases risk; and/or
Noncompliance: Unintentional or intentional due to confusion, complex regimes, adverse drug reactions and cost.
Adjustment of dose in renal impairment [7]
The most important effect of ageing is reduction in renal function, resulting in reduced elimination of renally excreted drugs, e.g. digoxin, and active drug metabolites, e.g. allopurinol. Dosages should be reduced in the elderly.
Check renal function before prescribing any drug that requires dose modification in renal impairment, even if only mild impairment is likely. In patients with severe and chronic renal disease, consider consulting a nephrologist or specialist physician.
Renal function may be significantly impaired in the elderly, despite normal serum creatinine levels. Calculation of creatinine clearance may be necessary to estimate renal function, as an increased level almost always reflects a decrease in glomerular filtration rate (GFR). The Cockcroft–Gault equation estimates renal function in millilitres per minute and has been validated for use in calculation of drug doses in people with renal impairment. The estimate of glomerular filtration rate (eGFR) automatically reported with electrolyte test results is not appropriate for use in dosage calculations.
Acute illness: e.g. MI, UTI, can lead to a rapid decrease in renal function, and a person stabilised on a renally cleared drug with a narrow therapeutic index may rapidly develop toxicity. Monitor renal function and adjust chronic drug treatment in elderly patients with acute illness.
Acute renal failure associated with 'the triple whammy': The combination of ACE inhibitors (or angiotensin 11-receptor antagonists), diuretics and NSAIDs (including COX-2 selective NSAIDs, but excluding aspirin < 150mg), is implicated in reports of drug-induced renal failure submitted to the Australian Drug Reactions Advisory Committee. Avoid the triple whammy if possible and be very cautious combining ACE inhibitors and NSAIDs in patients with pre-existing renal impairment, or renal hypoperfusion, dehydration, hypotension, or cardiac failure [8].
Increased sensitivity to medications
Age-related changes in drug receptors and target organ responses can alter sensitivity to the effect of drugs (e.g. increased CNS effects of benzodiazepines and opioids). Impairment of compensatory mechanisms may predispose to adverse effects (e.g. orthostatic hypotension with diuretics or TCAs) [7].
Rational prescribing
Rational treatment is a five step process:
Define the problem.
Specify the therapeutic objective.
Choose treatment based on: efficacy, safety, cost, suitability for the resident e.g. coexisting conditions and medications.
Start treatment:
Monitor progress regularly: Review the patient and decide whether to stop, continue or change treatment. Repeating prescriptions without review of the patient may lead to unnecessary and unsafe drug use.
When choosing treatment, consider the way the resident views his or her health-related quality of life. Treatment objectives can be affected by phenomena that are more prevalent with increasing age, including reduced life expectancy, cognitive impairment, physical disability, chronic disease, pain and suffering, accumulated losses and social isolation. [4] Involve the patient as a partner in management decisions, and consider the option of not using drug treatment [7].
Prescribing principles
Principles for prescribing medication for older people are [7]:
Whenever possible, use non drug treatments;
Be aware that presenting symptoms may be adverse effects of existing medications; do not assume they are symptoms of old age;
Start with a low dose (often less than half the usual adult dose), and increase slowly according to tolerability and response;
Use the lowest effective maintenance dose;
Prescribe the least number of medications, with the simplest dose regimens;
In general, prescribe from a limited range of drugs, and be familiar with their effects in older people (most doctors use only 40-60 different drugs);
Consider the person’s functional and cognitive abilities when prescribing, avoid childproof containers if resident is self administering medication;
If there is difficulty swallowing, prescribe liquid medications if available or check safety to crush;
Provide simple verbal and written instructions for every medication, including repeat prescriptions, to improve compliance; and
Regularly review treatment effects and dosage, and the patient’s ability to manage the medications if self-administering.
When prescribing new medication, give the resident and RACF staff specific information, including [7]:
The effects of the drug and why it is needed;
Instructions on how to take the drug;
Possible adverse effects and what to do if they occur;
Warnings, e.g. possible interactions, maximum dose;
When to review effects of medication; and
Permission to ring you or your practice nurse if concerned about any issues.
Always write drug names in full, and instructions in English. Table 3 lists abbreviations that are commonly used and understood; do not use other abbreviations [7].
Table 3: Abbreviations used in writing prescriptions and medication charts
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Latin abbreviations and terminology
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English abbreviations
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a.c. = ante cibum = before food
b.d. (bid) = bis die = twice daily
mane = morning
nocte = night
p.c. = post cibum = after food
PRN = pro re nata = when required
q.d. (qid) = quater die = 4 times daily
stat = immediately
t.d.s. (tid) = ter die sumendus = 3 times daily
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aq = aqueous, watery
cap = capsule
g = gram
inj = injection
im = intramuscular
iv = intravenous
mg = milligram
mL = millilitres
tab = tablet
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Monitoring effects of medication
At the time of care planning and prescribing medication, it is important to plan for monitoring for beneficial and adverse effects of treatment (See Section 2). Use reminder systems to schedule the next clinical review, pathology tests, Residential Medication Management Review and Comprehensive Medical Assessment (See Section 3).
Therapeutic goals should be individualised to use only those medicines that achieve desirable outcomes. When monitoring effects of medication ask:
Consider potential adverse effects and drug interactions at the time of prescribing specific medications. Information is available in many medical software programs when writing prescriptions electronically. Consider baseline measures of relevant clinical signs and pathology tests, and repeat measures after an appropriate period on the new or changed medication.
The need to adjust dose or stop a drug because of suspected adverse effects is influenced by the clinical impact of the adverse effect, the indication and strength of indication for treatment, and availability of alternative treatment. If an adverse reaction is found, reassess treatment and consider trialing an alternative medicine rather than adding another one to ameliorate the adverse effect.
Examples of routine biochemical monitoring to consider in RACF are:
Serum electrolytes, renal function tests, liver function tests, full blood examination and Vitamin D level for all residents annually; and
INR for residents on warfarin at least 4 weekly.
Table 4 lists some commonly prescribed drugs, with the frequency of monitoring by GPs to detect adverse effects [9]. See Clinical Information Sheets for monitoring medication effects in specific conditions.
Table 4: Commonly prescribed drugs and monitoring (adapted from [9])
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Drug
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Frequently monitored effects
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Effects not frequently monitored
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Angiotensin Converting Enzyme inhibitors and Angiotensin 11 antagonists
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Blood pressure
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Renal function, cough
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Aspirin (low dose)
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-
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Gastrointestinal effects, bruising
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Bisphosphonates
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Bone mineral density
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Gastrointestinal reflux symptoms, delayed dental healing
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Betablockers
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Angina, blood pressure
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Changes in blood sugar levels, asthma- related breathing difficulties
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Corticosteroids (inhaled)
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Asthma exacerbations
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Thrush, dysphonia
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Digoxin
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Serum concentration
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Anorexia, nausea, low pulse
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Diltiazem, verapamil Blood pressure Constipation, bradycardia
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Blood pressure
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Constipation, bradycardia
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Iron
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Iron studies
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Constipation
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NSAIDs, COX-2s
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Pain relief
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Blood pressure, renal function, fluid retention
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Metoclopramide, prochlorperazine
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Nausea
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Extrapyrimidal effects
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Nitrates
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Angina frequency
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Postural hypotension
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Opiates
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Pain relief
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Constipation, confusion
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Selective serontonin reuptake inhibitors (SSRIs)
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Depression
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Hyponatraemia, in older people, sexual dysfunction, gastointestinal bleeding
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Statins
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Cholesterol
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LFTs, creatinine kinase
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Thiazides
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Blood pressure
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Postural hypotension, incontinence
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Reporting adverse events
The Adverse Drug Reactions Advisory Committee (ADRAC) encourages reporting of all suspected adverse reactions to prescription, OTC and complementary medicines. Reporting seemingly insignificant or common adverse reactions is useful and may highlight a widespread prescribing problem. Reports of suspected adverse drug reactions should be made directly to ADRAC online at http://www.tga.gov.au/problem/index.htm (follow the secure link 'report electronically') or by using a prepaid reporting form ('blue card') found at the front of all recent editions of the Schedule of Pharmaceutical Benefits.
Medication reviews [4,7]
A comprehensive medication review should be conducted and documented when the resident is admitted to the RACF. Medication reviews for existing patients should occur annually and after any significant change in condition.
Regular review of medication can help early detection of problems such as:
Risk of adverse drug effects and interactions due to polypharmacy;
Need to reduce dose if renal function declines;
Need for a change in oral dose formulation if resident develops difficulty swallowing;
When it may be possible to withdraw medication;
Compliance issues;
Monitoring requirements;
Missing therapy, e.g. potassium supplementation, folate, calcium, vitamin D, immunisation; and
Difficulties in handling, storage and use of medication.
The MAC should develop a policy that identifies the frequency of medication reviews. The regular review of medication is an essential component of good quality care and is required by accreditation standards. A medication review should involve consultation between the resident, general practitioner, any other qualified prescriber involved in the resident’s care and pharmacist where possible. Confirmation that a review has occurred should be made on the medication chart and resident’s record. Any medication changes should be documented in the resident’s progress notes as well as on the medication chart.
Refer to the Medical Benefits Schedule or Section 3 on use of MBS items for information on Medicare rebates available for medication reviews, e.g. RMMR, case conference, long consultations, GP contribution to resident care.
Medication charts
All residents should have a record of current prescribed, over the counter (OTC) and complementary medications [3, 5].
Prescribers are responsible for ensuring that medication orders are written with consideration to the best interests of the resident; recommendations provided in this information sheet, and the policies and procedures of the RACF. Qualified prescribers include:
Medical practitioners, e.g. GP, locum doctor, hospital doctor, palliative care physician; and
Registered nurse practitioners and dental practitioners who are qualified to prescribe medications
When writing medication charts, orders must be written in CAPITAL LETTERS in BLACK or BLUE pen. Red pen, pencil or whiteout must not be used.
Include the following information:
Generic name and strength of the medication;
Dose, route and frequency of the medication;
Date of commencement and the duration where applicable;
Any new changes should be written on a new order; and
When ceasing a medication this order must be dated, signed and a line drawn through the remaining space.
It is essential that the resident’s GP and/or other prescribers work in partnership with the RACF staff to maintain a continuum of medication management for the resident. The prescriber should rewrite medication charts at a time determined by the RACF and the MAC, but no longer than 6 months. The MAC should develop a system to ensure that medication charts are rewritten BEFORE the current medication chart expires.
RACF medication chart
Residents who require assistance with medication administration should have a RACF medication chart (electronic or written) that contains:
Complete name and date of birth of the resident;
Any allergies or drug reactions;
Medication orders including time, dose, specific administration instructions and signature of prescriber;
Record that medication was administered;
PRN. (when required) medications;
Once only doses and emergency medications;
Nurse-initiated medication;
Resident-initiated medications if appropriate, including complementary medicines;
An indication of any special medication preparation e.g. crushing instructions; and
Date of the next administration of infrequently administered medicines.
RACF medication charts should be accompanied by:
A recent photo of the resident, with the name and date of birth of the resident clearly printed on the back and the date the photo was taken;
An indication of any additional assistance the resident requires e.g. crushing of medication;
Date of last medication review, name of person who reviewed medications and any tests associated with medication use, e.g. INR;
Any resident allergies.
Hospital discharge interim medication chart
It is acceptable to continue use of a hospital medication chart following the discharge of a resident to the RACF. The MAC should develop guidelines for a recommended time frame in which the resident’s usual GP should conduct a medication review following a resident’s discharge from hospital, e.g. within 7 days.
When a resident is discharged, the hospital is responsible for providing medication, plus written instructions on the details of the resident’s admission; any medication changes (including additions/deletions) from the resident’s medication regime on admission; and arrangements for a follow-up review by the resident’s usual GP or health care team [10].
Self-administered medications
For residents who self-administer medications, a card or record in the resident’s progress notes should be maintained with the details of the resident’s current medication regime, date of last medication review, name of person who reviewed medications, any tests associated with medication use, e.g. INR, and any resident allergies.
Complementary medicines [3, 5]
The RACF’s MAC should develop policies for the management of complementary and over-the-counter medications. It is the responsibility of the resident or his or her representative to inform the RACF staff of any complementary, alternate and/or self-selected medications being used by the resident. Where the resident is taking any over-the-counter or complementary medications this should be clearly indicated on the medication chart and the resident’s GP should be informed. The GP and pharmacist should ensure compatibility of complementary medications with other medications the resident is taking and provide written approval for the administration of complementary medications on the medication chart.
Prescribing non-regular medication
To avoid emergency department presentations and after hours locum doctor visits, it is suggested that residents’ GP and RACF staff plan for anticipated acute exacerbations or events requiring medication [11]. Non-regular medication requirements can be provided through ‘when required’ (PRN) medication orders, provision of nurse initiated medications (N.I.M.), and contacting the GP for medical orders by telephone or fax.
‘When required’ (PRN) Medicines
‘When required’ (PRN) medicines are those prescribed by a medical practitioner for a specific person and recorded on the medication chart, and administered by a person qualified to administer medications using clinical judgement to initiate when necessary. The administration of PRN medicines must be recorded on the person’s medicine record.
Use of PRN medication orders will differ depending on the facility i.e. whether a low-care or high care facility and the availability of Division One nurses to administer medication and /or injections. Examples of those medicines where pre-planning (PRN medication orders and supplies of medicines) for specific residents can assist in optimum management are provided in Table 5 [11].
Table Five: ‘When required’ (PRN) medication orders
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Condition/Event
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Pre-planning of PRN medication orders
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Allergic reaction/anaphylaxis
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Severe allergic reaction is defined as urticaria, angioedema or anaphylaxis after drug administration, most commonly the first or second dose of an antibiotic. Ensure that residents having IV antibiotics have PRN orders for adrenaline and antihistamine. Refer to Reference Card: Anaphylaxis Management.
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Angina
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Ensure that residents have PRN orders for long-acting nitrates and short-acting nitrates, e.g. glyceryl trinitrate (Anginine, Nitrolingual), available for breakthrough angina. Regular checks on dating are essential as Anginine tablets have an expiry of 90 days after opening. Refer to the Cardiac Chest Pain Clinical Information Sheet.
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Asthma, COPD
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Ensure that residents have PRN orders for Salbutamol MDI and access to a spacer for emergency use. Refer to the Respiratory: Asthma Clinical Information Sheet.
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Behaviours of concern, e.g. verbal disruption, physical aggression
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Residents exhibiting behaviours of concern require regular review by the GP and an individualised care plan that incorporates appropriate non-pharmacological management of concerning behaviour. Appropriate PRN medication orders should be provided by the GP, together with instructions on when, why and for how long the medication should be administered.
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Constipation
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Management plans should be put into place to avoid severe impaction. The resident should have PRN orders for appropriate preparations, e.g. Microlax, Glycerin suppositories, Movicol, and a care plan outlining when such preparations should be administered.
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Diabetes
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Residents with diabetes require a care plan outlining action to take in the event of hypoglycemia or hyperglycaemia. The specified blood glucose level for action will depend on the individual patient. A suggested protocol format is:
When BGL falls below:…. mmol/L give … glucose tablets; When BGL falls below:…. mmol/L give glucagon injection (GlucaGen 1mg); or When BGL is above ….give … units of Actrapid insulin
Specify when to notify prescriber.
Emergency stocks of glucose solution, glucagon or insulin should be arranged for each resident.
Refer to the Diabetes Clinical Information Sheet.
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Diarrhoea
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The use of oral hydration solutions may be included in NIMs. If the resident’s requirement for such preparations is predictable they should be included on PRN orders, and used prior to IV or subcutaneous hydration.
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Epilepsy
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PRN orders for seizure management should be developed for individual residents at risk of seizure. Note that the absorption of IM diazepam is erratic. Options may be intrarectal diazepam or midazolam IM. Refer to the Epilepsy and Seizures Clinical Information Sheet.
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Falls
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Nurse or medical examination will be required in most cases. Protocols for prevention should be reviewed following a resident fall, e.g. medication review, physical restraints, use of hip protectors etc. Refer to the Falls Management and Prevention Clinical Information Sheet.
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Nausea and vomiting
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When these are predicted, PRN protocols should be clearly stated, e.g. maximum number of metoclopramide, prochlorperazine to be used before calling prescriber.
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Pain
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Anticipate additional pain needs particularly over weekends with PRN orders with guidelines for staff as to mild, moderate or severe pain requirements. Refer to the Pain Assessment and Management Clinical Information Sheet.
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Palliation and End of Life care
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The GP and RACF staff should work in collaboration to ensure the resident remains pain free and comfortable. The use of protocols to assist in maintaining comfort may improve End of Life care and quality of dying. Refer to the End-of-Life Care Clinical Information Sheet.
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Urinary tract infections
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If frequent consider preventative strategies e.g. increase fluid, prophylactic antimicrobial use, oestrogen creams, frequent changing of pads, hygiene, catheter care etc. Refer to the Urinary Tract Infections Clinical Information Sheet.
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Nurse initiated medications (NIM)
Nurse initiated medication should be from a defined list of drugs developed by the MAC and disseminated to qualified prescribers and nursing staff in the RACF [3, 5]. The facility should develop a policy as to whether NIMs are appropriate for the facility or not.
Nurse initiated medication is the administration of non-prescription (over-the-counter) medication by a person qualified to administer medications when the need arises and with the prior agreement of the resident’s general practitioner. Registered nurses may use their clinical assessment and judgement to initiate administration of over-the-counter medications within their state or territory legislation and according to organisation guidelines. A record of any nurse initiated medicines should be included on the resident’s medication chart. /p>
Nurse initiated medication should be from a defined list of drugs developed by the MAC and disseminated to prescribers and nursing staff in the RACF (and approved by prescribers). Many facilities have nurse initiated medication lists approved by the Medication Advisory Committee. In most cases the medication can be administered once without reference to the medical practitioner [3, 5]. See Reference Card: RACF List of Nurse Initiated Medicines. [8].
Nurse initiated medication protocols should include indication(s) for the drug, dosage and contraindications. Use of nurse initiated medications should be documented on the medication chart. A regular review of nurse initiated medication for each individual resident should be conducted. If nurse-initaited medications are administered more than once this should be discussed with the resident’s GP, and if the nurse initiated medication becomes routine the resident’s general practitioner should conduct a full review of the resident [3, 5].
Emergency medication orders by telephone and fax [7, 8]
The MAC should provide guidelines on the circumstances under which emergency medications may be used and any required documentation and stock control.
In an emergency, a medication order may be given by telephone or facsimile. Emergency medication orders are for emergency use and are not an acceptable substitute for a policy for routine management of medications.
Only RACF staff members who are qualified to administer medications should take telephone orders. When taking a telephone order the following should be verified with the prescriber:
Name of the qualified prescriber;
Details of the resident the medication order is for;
Name, dose and route of the medication;
Timing and frequency of doses; and
Any guidelines for the administration of the medication.
Where possible, if a second person qualified to administer medications is present, they should also check the instruction with the prescriber. The medication order should be recorded on the medication chart in permanent ink and signed and dated by the person taking the telephone order. When taking a facsimile order the medication order should be written onto the medication chart in permanent ink and the facsimile stored either with the medication chart or in the resident’s progress notes.
It is the responsibility of the prescriber to notify the pharmacist. In some RACFs the nurse taking an emergency telephone order may also be required to contact the pharmacist and make arrangements for medication delivery.
The prescriber must confirm emergency telephone or facsimile medication orders in writing within the period of time determined by the MAC in accordance with ‘Drugs, Poisons and Controlled Substances’ Acts and Regulations. Currently the Australian Pharmaceutical Advisory Council recommends that in the aged care setting the prescriber sign emergency medication orders within 48 hours. In determining a RACF policy on signing of emergency medication orders, the MAC should consider that best practice requires a comprehensive medical review be performed when a resident’s clinical condition changes. A collaborative RMMR can facilitate this.
Dispensing, storage and disposal of medication
Pharmacists or other authorised providers, e.g. endorsed rural nurses, usually dispense medications. The correct medicine should be selected and labelled fully and clearly in line with legislative requirements. Consumer specific instructions should be included when needed to indicate the prescriber’s intent. A record that the medication has been issued is made.
Pharmacy services
Pharmacy services to RACFs includes:
Dispensing, supply and distribution of medications;
Provision of information and advice about drugs, with the primary objective being the promotion of quality use of medicines; and
Pharmacists responding to resident’s medication-related needs to help them achieve desired health outcomes.
Twelve criteria have been developed by the Pharmaceutical Society of Australia to assist uniform standards [11]. The pharmacist:
Maintains appropriate systems for the supply of medicines to the facility;
Ensures that the medicines are delivered to the RACF in a timely manner;
Ensures that the medicines are stored within the RACF in accordance with legislative and manufacturer’s storage requirements;
Monitors stock medicines used in the RACF;
Checks the medications brought into the RACF by new patients, as soon as practicable after admission, to ensure consistency with currently prescribed medications;
Conducts a comprehensive medication review of all residents at regular intervals and maintains appropriate records;
In consultation with the medical practitioner identifies residents who may require therapeutic drug monitoring;
Identifies, monitors and documents adverse drug events;
Provides information on medicines that adequately meets the needs of the RACF; and
Provides an education program appropriate to the needs of the RACF.
It is the right of individual residents to obtain pharmacy services form the pharmacist of their choice, however in the absence of any declared intention by the resident the RACF may arrange for an appropriate service to be provided. Pharmacists involved in providing pharmacy services contract with the RACF to work closely with the administrative, medical and nursing personnel. One contract is for the supply of pharmaceuticals and another contract is with an accredited pharmacist to provide Comprehensive Medication Reviews. The contracts require that an effective quality assurance program for pharmaceutical services, appropriate to the level of need is in place. An effective QA system will ensure that systems are working well, identify faults, suggest remedial action and evaluate the new system.
Storage and disposal of medication [3-5]
The pharmacist distributes the medication to the RACF for storage, e.g., using an imprest system, medicine cabinet, refrigerator or bedside locker. Recommended storage conditions for particular medicines should be followed. All medications, including self-administered medication, must be stored securely with consideration to safety of staff, residents and others in the RACF.
The RACF should have a system in place to dispose of expired or unwanted medications in a safe manner.
Medication information
Consumer information about how to use and store medications improves safety and quality use of medicines. Information should also be provided to people administering medication on appropriate preparation and administration. [6]
It is recommended that the RACF have current resources on medicine information (prescriber and Consumer Product Information) available for staff, residents/carers and visiting health professionals [3-58].
Examples of such resources are latest editions of (most are available electronically):
Australian Medicines Handbook, and Drug Choice Companion, Aged Care;
MIMS Annual or APPG (Australian Prescription Products Guide);
Therapeutic Guidelines;
Consumer Medicine Information for medicines used by the residents, available from the pharmacy, prescriber, or electronically;
Pharmaceutical Benefits Schedule; and
AusDI (Australian Drug Information) for the Health Care Professional.
The MAC should develop written policies to ensure this information is available. Consideration should be given to computer linked CMI (Consumer Medicines Information) to facilitate access and ensure accuracy.
Administration of medication
Staff administration of medication [3-5]
No medicine should be administered without:
A legible, signed and dated instruction from a qualified prescriber recorded in the resident’s medication chart; and
Being dispensed by a registered pharmacist into an individual container or pack labeled with the resident’s name, the name and strength of the medicine and the dosage, frequency and route of administration
The RACF MAC should develop standard procedures for the administration of medications. Facility policy for safe medication practice should be based around the use of the five ‘rights’ of medication management:
Right drug;
Right patient;
Right dose;
Right time;
Right route.
A registered nurse, who is suitably qualified and trained, should undertake medication administration. The role of the registered nurse qualified to manage medications includes to [5]:
Supervising staff who administer medications to residents;
Supervise residents who self-administer medication;
Accurately record any medicines administered;
Ensure ompliance with legislative requirements and policies of the RACF;
Participate in medicine quality assurance activities;
Maintain up-to-date knowledge and skills in relation to medication use;
- Exercise professional judgment in relation to medicine use, including knowing why, how and when to administer medication, when not to administer medication, and when to communicate to a medical practitioner or pharmacist;
Monitor and evaluate medicine use, including reporting and recording reactions to medicines and the initiation of required interventions in consultation with medical practitioners and pharmacists;
Monitor and encourage compliance with medicine use;
Provide information and education to residents, relatives and RACF staff in relation to medicine use; and
Advocate for residents in relation to use of medicines.
Medicines must be administered to residents from their own dispensed medicine containers. The registered nurse who removes the medicine from the dispensed medicine container must also administer the medicine to the person and sign the medicine record at the time of administration.
Dose administration aids [3-5]
Dose administration aids (DAAs) refer to a variety of unit or multiple dose packaging systems. Dose administration aids may be used by RACF staff who are qualified to administer from them, and by residents who self-administer medications.
All medications in the DAA should be recorded on the resident’s medication chart. If the prescriber alters any medication order, the entire DAA must be returned to the supplying pharmacist for repackaging.
RACF staff qualified to administer medication should not administer medicine from blister packs containing more than one type of medicine in the blister, unless there is a method to clearly identify the medicine. Any medication that cannot be readily distinguished from other medications in the DAA should not be placed in the DAA.
In those RACFs where state regulations require separate storage and accountability of the administration of Schedule 8 medications, these medications should not be packed in a multi-dose pack.
DAAs should be packed and labeled by a pharmacist and the medications administered directly from the blister DAA to the resident. The DAA should be labeled with:
Details of the person supplying the medication(s);
Date filled;
The name, strength and form of all medicines supplied;
Directions for the use of each medication;
Any specific instructions relating to the use of the medicine, including cautionary advisory labels;
Information relating to alteration of dosage form of any medication;
Information that will enable identification of individual medications e.g. reference to colour, shape and size, manufacturer’s marks).
Resident self-administration of medication [3, 5]
Residents may choose to administer their own medication where it has been formally assessed that they can safely do so. Where the RACF has medication charts for residents who self-administer this should be clearly stated on the medication chart. The RACF must provide safe and secure storage for medications of residents who self-administer.
Assessing a resident’s ability to self-administer medications [3, 5]
Before a resident begins to self-administer medications, an assessment should be carried out to evaluate his or her competency to do so. The MAC should develop a policy regarding the procedures to be used by health professionals for assessing competency of a resident to undertake self-administration of medication. The policy should indicate who will perform assessments. See Reference Card: Assessment of a resident’s ability to self-administer medication.
Reassessment should be undertaken on an as-required basis (e.g. decrease in the resident’s competency is noticed) or as part of an annual clinical review.
Resident responsibilities when self-administering [5]
Residents who choose to self-administer may demonstrate consent by signing an appropriate form.
Where residents have been deemed to be competent to self-administer medication, they should then be informed in writing of their associated rights and responsibilities, including the requirement to:
Inform the RACF staff of any complementary or over-the-counter medications;
Keep the medication(s) secure and safe;
Inform facility staff of any difficulties that they may encounter while self-administering; and
Ensure that they have a sufficient supply of self-administered medications, by informing RACF staff when their supply level is low.
Alteration of oral dose formulations [3,12]
The alteration of solid dosage forms (e.g. crushing tablets or opening capsules) makes it easier to administer a medication to a resident with swallowing difficulties. In some cases the practice of altering the form of medication may result in reduced effectiveness, a greater risk of toxicity, or an unacceptable presentation to residents in terms of taste or texture.
The RACF should have procedures for the alteration of oral dosage forms necessary to facilitate administration to certain residents.
If a medication requires altering for administration, this should be recorded on the medication chart.
The MAC should develop and continuously update a list of medications, which must not be crushed or chewed.
The supplying pharmacy should provide relevant information on new products to the MAC.
Controlled-release medications [13,12]
Many medications are formulated to release drug in a controlled manner over a defined dosing period, usually 12 or 24 hours. Crushing these medications may result in an unintended large bolus dose. Medications labeled with terms such as “controlled release” (CR), “sustained release” (SR), “modified release” (MR) “controlled delivery” (CD), “enteric coated” (EC) are slow-release formulations. These medications cannot be crushed although some can be halved. Opening capsules containing medication formulated into small pellets, where the release properties are built into the pellet and not the capsule, does not affect the properties of the medication, however the pellets should not be crushed. The RACF’s pharmacist should be consulted on the alteration of any slow-release products.
Considerations in altering medication forms [12]
Equipment for crushing medications should conform to these principles:
Permits complete recovery of powdered material;
If shared among residents it should be washed and dried after use for each resident;
Dedicated set of equipment must be used for each resident if cytotoxic medication is being prepared; and
Equipment (e.g. mortar and pestle) should be cleaned with a damp cloth followed by a dry cloth after use for each resident.
When tablets and capsules are to be given together, crush the tablets first, then open the capsule and add the powder or pellets contained therein to the crushed tablets to prevent crushing sustained release or enteric-coated pellets.
Mixing with a small amount of food that the resident likes, e.g., jams, fruit purees, disguises unpleasant taste and promotes compliance. Ensure that crushed tablets or capsule contents are given to the resident as soon as possible after altering and mixing with any food or liquid to reduce medication degradation and minimise risk of medication incidents.
Refer to Reference card: Medications that should not be crushed
‘Compact’ tools for medication management in the RACF [5]
The following table describes the Compact products, and how they are used.
Table Six: Compact tools
|
Product
|
Use
|
Used by
|
|
Medication Charts
|
|
Long Term Medication Chart (LTMCO1)
|
6 month medication chart designed for Nursing Homes who use RN Div 1 nurses to administer medications.
Use as per RACF procedures.
|
RACF
GP
Pharmacist
|
|
Long Term Medication Chart (LTHCO2)
|
6 month medication chart designed for Hostels who use Personal Care Workers to administer medications via multi-dose.
Use as per RACF procedures.
|
RACF
GP
Pharmacist
|
|
Non-packed Medication/ Treatment Sheets (LTTS-1)
|
6 month medication sheet.
Use as per RACF procedures.
|
RACF
GP
|
|
Respite Charts (CR135R)
|
9 week chart designed specifically for RACFs who provide respite care.
Use as per RACF procedures.
|
RACF
GP
|
|
Warfarin Charts
(LTWC1 – Landscape)
(LTWC1A – Portrait)
|
Designed specially for residents who are ordered Warfarin. Includes recording of ‘INR’.
Use as per RACF procedures
|
RACF
GP
|
|
Medication Labels
|
|
Multiple Medication Labels (LTMCMD1)
|
Initial writing and re-writing of medication charts via Medical Director (section 3 of kit)
|
GP
RACF
|
|
Single Medication Labels (LTMCMD2)
|
Medication changes and adjustments between medication chart re-writes via Medical Director (section 3 of kit)
|
GP
RACF
|
|
Multiple Medication Labels (handwritten method)
(LTMCDOL1)
|
Initial writing and re-writing of medication charts via handwritten method
(section 3 of kit)
|
GP
RACF
|
|
Tools for Emergency Medications
|
|
Confirmation of Telephone Orders (CT01)
|
Communication tool between the GP and RACF that is used for medication orders given over the phone and the GP has access to Medical Director. Refer to Reference Card: Confirmation of Telephone Order - Label
|
GP
RACF
|
|
Fax Order Labels (CT02)
|
An alternative to the Telephone Order Sticker System. Refer to Reference Card: Doctors Fax Medication Order - Label
|
GP
RACF
|
|
Handwritten Option
|
Manual communication tool between the GP and RACF that is used for medication orders given over the phone. Refer to Reference Card: Medication Labels for Compact Medication Charts – Handwritten Option
|
GP
RACF
|
|
Others aids for RACF
|
|
Chart Binders
|
Allows for the transport of medication charts to the point of drug administration for signing in accordance with best practice. Provides additional protection and storage for up to 22 medication charts.
RACF staff insert medication charts in binder and store according to RACF procedures.
|
RACF
|
|
Stamps:
|
Various medication chart specific stamps are available to provide legible instructions quickly and accurately. GP uses when updating medication chart at the RACF
|
GP in RACF
|
|
Bookmarks:
|
A system that alerts staff to changed medication requirements.
Upon receiving a change in medication orders, RACF staff updates medication chart and places appropriate bookmark on the page containing the change.
|
RACF
|
|
Medication Incident Reports (CR136)
|
Comprehensive documentation of medication incidents that allows for analytical data to be collected for quality improvement strategies in medication management. Use according to RACF procedures.
|
RACF
|
‘Compact’ have developed a Medication Management System, which records the broad range of information required for optimal medication use and for the maximum safety of residents. It is continually evaluated and upgraded consistent with the latest legal and ‘best practice’ requirements.
The medication management system records essential information in one central place for efficient documentation. [13] It records all medications used over a period of six months under relevant categories as required under Recommendation 2 of the APAC Guidelines for Medication Management in Residential Aged Care Facilities. [3]
The Compact system is included in this kit, as an example of using medication management systems, as it:
Complies fully with the residential aged care accreditation standards and the APAC Guidelines
Is currently being used by most RACFs in Australia
Interacts with Medical Director prescribing software used by most GPs
Is user friendly
Provides a comprehensive range of tools and systems for medication management
Sources of Information
Where to go for more information
For further information the following services can be contacted. Local RACFs and Divisions of General Practice can add to this list.
MIMS online
Provides up to date information on medication management and use.
Website: http://www.mims.hcn.net.au/ (subscribers only)
Pharmaceutical Society of Australia
The society is a professional organisation for pharmacists and provides opinion and policy on medication
management, consultation services and a range of publications and educational resources.
Contact: 1300 369 772
Website: www.psa.org.au
Dept Health and Ageing Therapeutic Goods Administration
A national organisation responsible for assessment and monitoring to ensure therapeutic goods (including medications) available in Australia are of an acceptable standard. The organisation provides information on general categories of medication (e.g. non-prescription, prescription medicines) as well as information on adverse drug reactions, specific medication preparations and other educational material.
Contact: 1800 020 653
Website: http://www.tga.gov.au/index.htm
Schedule of Pharmaceutical Benefits
The Schedule of Pharmaceutical Benefits provides information about prescribing and supplying pharmaceutical benefits.
Website: http://www.health.gov.au/pbs/index/htm
Therapeutic Advice and Information Service (TAIS)
The National Prescribing Service provides a national Therapeutic Advice and Information (TAIS) service for health care professionals. TAIS provides immediate access to independent drug and therapeutics information for the cost of a local call.
Telephone 1300 138 677.
Web site: http://www.nps.org.au
Therapeutic Guidelines
Therapeutic guidelines provide clear, practical recommendations for prescribing therapy, derived from the best available evidence.
Website: http://www.tg.com.au
Compact Business Systems
For further information on medication management tools
Contact: Victoria & Tasmania 1800 134 010, All other States 1800 777 508
Email: Victoria compact@iprimus.com.au
All other States sales@compact.com.au
Website: www.compact.com.au
References
National Prescribing Service Limited, NPS, Medicines and older people: an accident waiting to happen? National Prescribing Service News, 2004. June.
Australian Medicines Handbook, AMH, ed. Drug Choice Companion: Aged Care. 2003, AMH.
Australian Pharmaceutical Advisory Council, Guidelines for medication management in residential aged care facilities (3rd edition). 3 ed. 2002, Canberra: Commonwealth Department of Health and Ageing.
Pharmaceutical Society of Australia, The provision of pharmacy services to residential aged care facilities — Guidelines for pharmacists. 2001, Canberra: PSA.
Australian Nursing Federation, Royal College of Nursing, Geriaction, Guidelines for the management of medicines in an aged care setting. 3 ed. 2002, Melbourne: ANF.
Pharmaceutical Society of Australia, Guidelines for pharmacists. Comprehensive medication review in residential aged care facilities. 2000, Canberra: PSA.
Pharmaceutical Society of Australia, (PSA)., Royal Australian College of General Practitioners, (RACGP)., Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists, (ASCEPT). Australian Medicines Handbook. 2006
National Prescribing Service Limited, (NPS). Indicators of Quality Prescribing in Australian General Practice. 2006., National Prescribing Service Limited, (NPS). Canberra.
Shakib, S., Problems of Polypharmacy. Australian Family Physician, 2002. 31(2): p. 125-127.
Pharmaceutical Society of Australia, National guidelines to achieve the continuum of quality use of medicines between hospital and community. 1998, Canberra: Commonwealth Department of Health and Ageing.
Gowan, J, Consultant Pharmacist Recommendations. 2004
Alteration of Medication Dose Forms Project University of South Australia, Guidelines and standard operating procedures for altering medication dose forms - A resource for staff in residential aged care facilities. 2002, Canberra: APAC.
Compact Business Systems, (ABS), Medication Products. 2004
National Health And Medical Research Council, (NHMRC), Guidelines for the development and implementation of clinical practice guidelines. 1995, Canberra: AGPS.
Levels of Evidence
This Clinical Information Sheet is adapted from three primary sources:
Guidelines for medication management in residential aged care facilities (2002) was produced by the Australian Pharmaceutical Advisory Council on behalf of the Commonwealth government following review by the multidisciplinary working party of guidelines and documents produced by various Australian professional and consumer groups.
Australian Medicines Handbook (2006, and the Drug Choice Companion: Aged Care (2003) produced for health care professionals, particularly GPs, nurses and pharmacists working in aged care settings.
Nursing Guidelines for the Management of Medicines in an Aged Care Setting was developed under the auspices of the Australian Nursing Federation, Geriatrician, and Royal College of Nursing Australia with a goal of establishing best practice in the nursing management of medications in RACFs.
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using an adapted version of the NHMRC (1995) [14] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (Level V) for non-referenced material, e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
The level of evidence of all references used to compile this clinical information sheet is provided in the table below:
|
|
Reference |
Year |
Level of Evidence |
1. |
National Prescribing Service Limited, NPS, Medicines and older people: an accident waiting to happen? National Prescribing Service News, 2004. June. |
2004 |
Level IV C evidence |
2. |
Australian Medicines Handbook, AMH, ed. Drug Choice Companion: Aged Care. 2003, AMH. |
2003 |
Level IV C evidence |
3. |
Australian Pharmaceutical Advisory Council, Guidelines for medication management in residential aged care facilities (3rd edition). 3 ed. 2002, Canberra: Commonwealth Department of Health and Ageing. |
2002 |
Level IV C evidence |
4. |
Pharmaceutical Society of Australia, The provision of pharmacy services to residential aged care facilities — Guidelines for pharmacists. 2001, Canberra: PSA. |
2001 |
Level IV C evidence |
5. |
Australian Nursing Federation, Royal College of Nursing, Geriaction, Guidelines for the management of medicines in an aged care setting. 3 ed. 2002, Melbourne: ANF. |
2002 |
Level IV C evidence |
6. |
Pharmaceutical Society of Australia, Guidelines for pharmacists. Comprehensive medication review in residential aged care facilities. 2000, Canberra: PSA. |
2000 |
Level IV C evidence |
7. |
Pharmaceutical Society of Australia, (PSA)., Royal Australian College of General Practitioners, (RACGP)., Australasian Society of Clinical and Experimental Pharmacologists and Toxicologists, (ASCEPT). Australian Medicines Handbook. 2006 |
2006 |
Level IV C evidence |
8. |
National Prescribing Service Limited, (NPS). Indicators of Quality Prescribing in Australian General Practice. 2006., National Prescribing Service Limited, (NPS). Canberra. |
2006 |
Level IV C evidence |
9. |
Shakib, S., Problems of Polypharmacy. Australian Family Physician, 2002. 31(2): p. 125-127. |
2002 |
Level IV C evidence |
10. |
Pharmaceutical Society of Australia, National guidelines to achieve the continuum of quality use of medicines between hospital and community. 1998, Canberra: Commonwealth Department of Health and Ageing. |
1998 |
Level IV C evidence |
11. |
Gowan, J, Consultant Pharmacist Recommendations. 2004 |
2004 |
Level V evidence |
12. |
Alteration of Medication Dose Forms Project University of South Australia, Guidelines and standard operating procedures for altering medication dose forms - A resource for staff in residential aged care facilities. 2002, Canberra: APAC. |
2002 |
Level IV C evidence |
13. |
Compact Business Systems, (ABS), Medication Products. 2004 |
2004 |
Level V evidence |
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Medication Management
The following reference cards are designed to be used in conjunction with the Medication Management Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
Viewing Reference Cards
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Downloading Reference Cards
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Reference Cards:
RACF medication management policy
RACF list of nurse initiated medicines
Anaphylaxis management
Medications that should not be crushed
Assessment of a resident’s ability to self-administer medication
Doctors fax medication order – label
Confirmation of telephone medication order - label
Medication labels for Compact medication charts – handwritten option
Downloads and Printing
See note on viewing and printing documents.
To download the Clinical Information Sheet and/or the entire Reference Card package for this CIS, use the buttons below. To download, click on the link and select save to disk. You will be asked to select a folder in which to save the document. To download individual Reference Cards use the links above. Downloads are in printable formats.
