Nurse-led medicines’ monitoring in care homes: a process evaluation
Research type
Research Study
Full title
Nurse-led medicines’ monitoring in care homes: a process evaluation of the impact and sustainability of the West Wales Adverse Drug Reaction Profile (WWADR).
IRAS ID
213050
Contact name
Sue Jordan
Contact email
Clinicaltrials.gov Identifier
N/A, N/A
Duration of Study in the UK
1 years, 4 months, 0 days
Research summary
Summary of Research:
Preventable adverse drug reactions (ADRs, known as side effects) have caused 5-8% of unplanned hospital admissions for the last decade (Pirmohamed et al 2004, NICE 2015). They cost the NHS up to £2.5 billion each year (Frontier Economics 2014).The West Wales Adverse Drug Reaction (WWADR) Profiles (attached) are designed to identify and ameliorate problems that may be attributable to or exacerbated by prescribed medicines. The WWADR Profile for mental health medicines lists problems that might be associated with these medicines, and asks nurses to monitor these and inform prescribers or pharmacists. It contains a structured template of ~80 items to be completed over 1-4 clinical contacts, as needed. We have shown in randomised controlled trials and observation studies that structured nurse-led medicines’ monitoring using the WWADR Profile benefits patients, for example, by reducing pain and sedation and identifying high risk cardiovascular conditions. We now aim to understand what is needed to sustain implementation of the WWADR Profile in routine practice and explore future directions. There are 2 aspects to the study:
1. Observation in care homes
2. Stakeholder interviews1. The participants of our previous research and 5 newly recruited care homes will be asked to either continue using the Profile in routine practice or adopt it within routine practice. We shall ask to observe this routine practice, debrief in interviews and read reflective diaries/ accounts. We are interested to see if the Profiles are used as intended, participants' experiences of their use, and any barriers and facilitators.
2. We shall interview nurses/ managers, service users (or their families), pharmacists, prescribers and strategic leads to hear their experiences of medication use, medication management, adverse effects and barriers and facilitators of medicine monitoring, and how electronic devices can enhance nurse-led monitoring.
see summary diagram
Summary of Results:
Introduction Preventable adverse effects of medicines often pass unnoticed, but lead to real harm.Intervention
Nurse-led monitoring using the structured Adverse Drug Reaction (ADRe) Profile identifies and addresses adverse effects of mental health medicines.Objectives
This study investigated the implementation and clinical impact of ADRe, and barriers to and facilitators of sustained utilisation in routine practice.Methods
Administration of ADRe was observed for 30 residents prescribed mental health medicines in ten care homes. The study pharmacist reviewed completed ADRes against medication records. Policy context was explored in 30 interviews with service users, nurse managers and strategic leads in Wales.Results
Residents were aged 60-95, and prescribed 1-17 (median 9 [interquartile range (IQR) 7-13]) medicines. ADRe identified a median of 18 [IQR 11.5-23] problems per resident and nurses made 2 [1-2] changes to care per resident. For example: falls were reported for 9 residents, and care was modified for 5; pain was identified in 8 residents, and alleviated for 7; all 6 residents recognised as dyspnoeic were referred to prescribers. Nurses referred 17 of 30 residents to prescribers. Pharmacists recommended review for all 30. Doubts about administering ADRe, sometimes expressed by people who had not yet used it, diminished as it became familiar. ADRe was needed to bridge communication between resident, nurses and prescribers. When barriers of time, complacency, and doctors' non-availability were overcome, reporting with ADRe made prescribers more likely to heed nurses' concerns regarding residents' welfare. Clinical gains were facilitated by one-to-one time, staff-resident relationships, and unification of documentation.Implications
To our knowledge, ADRe is the only instrument that brings a full account of patients' problems to medication reviews. This juxtaposition of signs and symptoms against prescriptions facilitates dose adjustments and de-prescribing and leads to: reduced pain and sedation; early identification of problems linked to ADRs, such as falls; and timely medication reviews e.g. for dyspnoea.REC name
Wales REC 6
REC reference
16/WA/0358
Date of REC Opinion
17 Feb 2017
REC opinion
Further Information Favourable Opinion