Virginia nursing home survey*

pharmaceutical service •••

Virginia • nursing home survey *

by Milton L. Neuroth Michael E. Stredler Warren E. Weaver

ommunity pharmacists and personnel in nursing home management all too infrequently seek consultation with each other to determine what constitutes effective, safe economical, legal and adequate professional pharmaceutical service in the nursing home environment. Being the source of medication supply for patient prescriptions or other patient health needs, providing drug stock for maintenance of normal physical well-being and hygiene, instructing in technics in administration of medications, handling prescription orders or preparing patient medication records are all areas where the pharmacist's special knowledge is useful. In addition, specific data are needed on how prescriptions for medication for a patient on a per day basis are handled in the home and how large the total drug volume is that is involved. Also of interest are the types of prescription medication needed per patient per day or per week and the means by which prescription medication orders are prepared or processed prior to patient administration. Information is needed, too, on procedures used by nursing home management for the purchase, storage, distribution and record-keeping of medications. To obtain quantitative information relative to the handling of prescription and nonprescription medication or other health related items in nursing homes in Virginia and to discover the actual procedures in use and any unique characteristics of drug handling in this environment, a study was made of the 162 nursing homes licensed by the Virginia Department of Public Health. The listing of the 162 licensed homes included information as to ownership and patient capacity in terms of available beds. The Virginia Department of Public Health and the Virginia Nursing Home Association were consulted to obtain cooperation and endorsement for the study. The VNHA president was consulted as to the proposed procedure and the homes from which information might best be obtained. The pharmacy consultant of the USPHS nursing homes and related facilities branch periodically reviewed the data and made helpful suggestions. A questionnaire was devised by the investigators approved by the USPHS pharmacy consultant and statistician. While certain specific information was asked for in the questionnaire, the project coordinator was alert to additional data that came to light during discussions on the scene. Once a week the data of the previous week's visitations were discussed and put into suitable form for evaluation. In some

C

*

table I-nursing home personnel 1. Administrators. ....•.......... (6 are owners) 2. Registered (licensed) nurses...................... 3. Licensed practical nurses..... 4. Physicians....................

35 9 6 2 52

instances a nursing home was revisited to seek additional information or to clarify data on hand. Correspondence was used to complete or fill in details when they appeared to be significant to the facts obtained from a particular nursing home.

findings Data given in Tables I and II are for the year 1963-64. Table I classifies nursing home ·management personnel in the Virginia nursing homes visited and Table II shows the patient turnover for the one-year period. No nursing home management personnel had formal education in the field of hospital administration. The 52 nursing homes had a total of 2,523 beds of which 2,216 were occupied for an average of 88 percent occupancy. Approximately 33 patients were admitted per home and 27 patients were discharged or died per home during 1963- 64. The average occupancy is thus on the increase. A total of 3,839 specific infirmities are associated with the patient load, some with multiple ailments. The predominant diagnosis determined from patient charts indicated the majority of nursing home occupants suffered from cardiac conditions, senility, arthritis and visual impairment. prescription medication Available charts showed that 3,318 prescription medications were being administered to 1,203 patients or an average of 2.7 prescriptions per patient. The largest number of prescription medications being administered to a single patient was 10. These data apply to the day on which the project coordinator visited the homes and the medication in use had been used by the patient for at least the previous week. There was no attempt to determine over what greater period of time any particular drug had been administered to an individual patient. The actual number of prescription orders represented in the total was

table II-patient turnover 1. Admissions (35 homes)... 2. Discharge (36 homes). . . . 3. Number of deaths (37 homes)............

1,170 patients 594 patients 400 patients

Supported by Public Health Service grant, contractor's proposal PH 108-64-155(P) .

Vol. NS6, No.5, May 1966

245

practically impossible to determine for several reasons. The quantity in any one prescription would dictate the frequency of renewals. Various pharmacies supply anyone nursing home and the prescription orders cannot be conveniently or accurately traced. Nursing home patient charts frequently do not record the amount of medication requested on a prescription. In all there were 318 different medications represented and it is assumed in each case the drug was administered on the direction of a physician. Patient records were not always clear on this point.

~

Pharmacy educator, Milton L. Neuroth is chairman of the department of pharmacy and professor of pharmacy and pharmacognosy at the Medical College of Virginia. Neuroth has earned his BS, MS and PhD from Purdue University and he is licensed to practice pharmacy in Virginia and Connecticut (honorary). Currently he is a member of the USP Revision Committee and author of the chapter on external liquids in Husa's Pharmaceutical Dispensing text.

stock medications

A number of nursing homes have on hand a stock supply of medications being given to patients under the direction of the physician. The source of supply is chiefly from prescriptions, dispensed from a pharmacy, although in certain instances a bulk supply of drugs was available and from this certain quantities were removed, placed in smaller containers and then stored alphabetically as a floor stock. Patients were given medication from the floor stock as called for on physicians' orders written on charts. The patient chart order for medication often did not record a total amount of medication and only the name and dose of medication was listed. In Virginia dangerous drugs may be distributed at wholesale to hospitals, sanitariums, departments of public health and to welfare agencies, public or private, if these drugs are to be administered under the supervision of a licensed practitioner lawfully practicing his profession. Private nursing homes are not considered in any of the above categories, though there is a question as to whether nursing homes should be considered as hospitals. For a supply source for medications (see Table III) the majority of nursing homes in Virginia preferred to use a local pharmacy. Other means of su pply reported were through physicians, usually as second or third source and occasionally by way of a patient's family. One home indicated a local clinic was the preferred source of supply. Obviously, a wide variety of medicaments are carried as part of a drug inventory, purchased in bulk quantity

246

Registered pharmacist in Virginia, Michael E. Stredler, is presently employed as a community pharmacist in Portsmouth, Virginia, having been graduated from the ~ Medical College of Virginia in 1965. ,. He was project coordinator for the Virginia survey of pharmaceutical services in nursing homes reviewed in this article.

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or as supplied according to prescription from a pharmacy. Some medications were on hand which had been obtained for patients who had been discharged or had died. Presumably the medication might be used should another patient be in need of this same drug.

Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION

Dean of the school of pharmacy and professor of pharmaceutical chemistry at the Medical College of Virginia is Warren E. Weaver. After receiving his BS in pharmacy from the University of Maryland and his PhD in pharmaceutical chemistry, he was employed for five years by the Naval Research Laboratory in Washington, D.C. He then joined the staff at the medical college as associate professor of pharmaceutical chemistry in 1950, subsequently becoming department chairman and professor. He was appointed dean in 1956.

High among the types of drugs found in stock are the barbiturates which, for the 20 homes inventoried, amounted to 28,700 tablets. Laxatives and aspirin (as analgesics) are in good supply as are cardiovascular drugs. These medications are related to the need for prescription medications for patient use as charted but not necessarily in terms of the quantity on hand. A number of medication needs on hand, not classified as of prescription origin, are sometimes referred to as nondefinitive drugs, generally furnished by the home or brought in by a patient's family or otherwise. The type and source of supply is tabulated in Table IV. There may be other nondefinitive drugs in use, but these were the only ones found or inquired about. In

personnel and drug administration

nond~finitiv~drug~ sour~e of supply by number of homes

category Salt substitutes (50 homes) Liniments (51 homes) Dentifrices (51 homes) Body tales (51 homes) Skin lotions (49 homes) Weight control formulas (51 hO!11es) Vitamins (48 homes) Shampoo (26 homes)

nursing homes

patient

onRx only

none on hand

24

1

0

25

0

5

3

0

43

0

12

28

0

10

27

19

0

3

2

36

11

0

1

1

2

46

0

19

3

24

2

0

8

12

0

6

0

most cases, non definitive health maintenance items are supplied by the nursing home. Liniments and weight control formulas are not ordinarily found in medication stock on hand.

prescription medication frequency For most of the therapeutic categories ' involved in prescriptions used in this survey, a few drugs are employed much more extensively than others, yet in anyone group a variety of medications are actually prescribed. Such data might suggest that a minimum essential medication inventory for the average nursing home could be compiled. Based on the number of prescriptions, quantity of drug prescribed and the average number of prescriptions or renewals, the kind and average amount needed of medication supply might be calculated for each home. Among antiarthritic drugs, aspirin (63 percent) is the most frequently used medication; Darvon (25 percent) is in second place in this category. The lack of steroids is noticeable. Once a day dosage predominates and there was no data collected on actual quantity used at a dose. The remaining 12 percent of medications is made up of a variety of other drugs including salicylates and pyrazolidines. Obviously, cardiovascular drugs would take on a special significance in the medication needs of nursing home patients. In Virginia nursing homes the variety of drugs administered to patients includes an extensive array of cardiovascular pharmaceutical preparations. Digitalis, due to its effectiveness, safety and economy, predominates in its several forms; these are given on a once daily dosage schedule. Phenobarbital dominates the barbiturate class and represents an overall total of 3.5 percent of all 3.318

contribution

prescriptions. Here the medication was administered generally (72 of 139 prescription medications) once a day. Of the barbiturate group, phenobarbital accounted for 117 prescription medications; 57 percent of the 10 varieties used. Chloral hydrate led the list of nonbarbiturate sedatives and hypnotics, again administered for the most part once a day. Within the group of antispasmodics, the pattern of frequency of use was rather evenly distributed. However, Donnatal accounts for almost 20 percent of all prescriptions in this category. A greater variety of antispasmodics were used as compared to ataraxics. In general, vitamin, antidiabetic and antinauseant therapy required a large variety of drugs. The number of prescriptions involved in this category is about 14.4 percent of the total number of prescriptions in the survey.

multiple therapy Individual patient prescriptions are recorded to observe the number and kind of medications any single patient may be taking. Records were not available generally for a detailed analysis of all factors which may have been involved with each of these patients. For example, it was not possible to determine how long any patient may have been on a certain medication nor how many renewals had been obtained for any medication. In most instances, it was difficult to learn when the physician had last seen a patient. Stop orders were occasionally found on a patient's chart but not as a regular procedure. Prescription medications in Table V were copied directly from patient charts and represent a few examples of the multiple medications being administered to nursing home patients.

There were 1,641 patients in residence in 43 of the nursing homes visited. All personnel available for patient care of one type or another amounted to an average of one employee for 3.3 patients. Noone type person appears to be responsible for drug administra tion in these nursing homes.

pharmaceutical service Thirteen homes of the 52 surveyed had arrangements with pharmacists to come to the home to receive the prescriptions, to assist in obtaining drug supplies and on occasion to prepare needed solutions. Medication orders were delivered and other pharmaceutical services performed. Four nursing homes (7.6 percent) used a pharmacist to check for outdated prescription medication, drugs formerly used by deceased patients or to check on inventory of narcotics and barbiturates against prescription amounts received and administered. Another four homes indicated that a pharmacist was consulted on physical arrangements related to safe storage of drugs. Five homes of 51 (9.8 percent) stated that a pharmacist was called in to conduct sessions on new drug information. Another eight homes (15.6 percent) used a pharmacist to conduct sessions on drug information generally either on a regular basis or when called in. There were 11 nursing homes (21 percent) where pharmacists visited the home to provide information on federal, state or local laws and regulations that could affect use of prescription only drugs. Handling of dangerous drugs and narcotics by procurement, or prescription, records required, renewals or disposal would be subjects for discussion between nursing home personnel and pharFour homes (7.6 percent) macists. indicated this type of information was provided without visitation. The idea was almost uniform among nursing home management that pharmacists contributed little other than prompt delivery of medication. Nursing home personnel apparently was unaware of the value or availability of a more extensive pharmaceutical service. Generally, there was no formal arrangement with any pharmacist to visit the home regularly to check out-dated medication, proper labeling of containers and accuracy in dispensThere ing prescribed dosage forms. appeared little desire on the part of pharmacists to volunteer services. Most nursing home personnel show little interest in attending seminars on drug information or state, local or national pharmaceutical association meetings where professional pharVol. NS6, No.5, May 1966

247

table VI-personnel employed

table V-ij medications in nursing homes patient

type of ailment Arthritis Arteriosclerosis

II

III

IV

V

VI

VII

Cerebral palsy

Diabetic Senile

Cardiac asthma

Stroke

Multiple sclerosis

Parkinsonism

maceutical or health related services are a topic for discussion.

time and manner of drug administration It was difficult to observe any correlation among nursing homes as to the amount of time per patient required to administer medication, or the total time per nurse or aide required for administering drugs. In most cases no one involved could give meaningful figures. However, the average time per patient per day for 32 homes (61 percent) was estimated at 10.3 minutes. 248

medication

frequency

Equanil Butazolidin Butisol Doxidan Crystodigin Diuril

TID TID BID QD QD QD

Multicebrin Exlax Hydropres Solfoton Dilantin Seconal Butisol

HS PRN QD QD QD HS QD

Stelazine Insulin Digitoxin Naqua Seconal Equanil

BID QD QD QD HS QD

Isuprel Doxidan Kolantyl Butisol Acthar gel Prednisone Calcidrine Naturetin ADC

QID QD QID QID 2 weeks QID QD QD TID

Kenalog ointment Tacaryl Butisol Periactin Phenaphen Tedral Doriden Compazine Temaril

QH TID TID TID Q4H PRN HS

Pabalate Bilron Becotin Thyroid Hydrodiuril Phenobarbital Vito B12 Darvon El avil Bufferin

TID TID QD QD PRN QD 2 X week Q4H BID TID

Artane Multicebrin Benadryl Hyoscine Soma Skelaxin Vito B12 Akineton ASA Sod. Luminal

TID QD QD TID PRN QID QID PRN PRN

A wide variety of containers are employed to deliver individual dosages to patients. Fifty homes (96 percent) reported that medication was removed by staff personnel from the prescription stock container and then delivered to the patient (see table IX). Tablets on hospital plates apparently means that the medication was placed on a food plate at mealtime. Vial caps refers to the tops of medication containers , prescription bottles, etc. emergency kit A nursing home emergency (see table X) kit is not ordinarily described as a

Journ a l of the AMERICAN PHARMACEUTICAL ASSOCIATION

average no. of total patients number attended Lic ensed nurses (RN) 58 Licensed practical nurses (LPN) 63 Nurses aides 330 Volunteer workers 32 Nursi ng home attendants 4

28.3 26.0 4.9 51.2 410.0

table VII-drug administration

Phy sician Licensed nurse Nurses aide Volunteer worker Family

homes

percent

42 40 25 none non e

80

77 48

table VIII-utilization of pharmacists by nursing homes

Full tim e Part time On call On contract By informal arrangement Information not provided

number

percent

none 4 41 none

7.6 78 .8

42

80.8

6

11.5

table IX-drug administration tablets Vial caps Di sposa ble cups Medicine glasses Hospit al plates Drinkin g glasses Waxed paper Cream dispensers Individuals' hands

4 22 18

1 1 2 1

1

liquids Disposable cups Medicin e glasses Teaspoons Fruit glasses

6 38 3 3

distinct and fixed unit. The type, arrangement, storage, availability and quantities of emergency medication were as variable as the number of nursing homes that make any reference to a collection of emergency drugs.

table X-emergency drug kit a Ephedrine Neostigmine Tigan Vitamin K Aramine Sparine Phenobarbital Atropine KCI solution Aminophyllin Cedilanid Quinidine Levophed Crystodigin

c

b Coramine Adrenalin Demerol Dilantin Phenobarbital Compazine Mercuhydrin Prostigmine Wyamine Nembutal Nalline

Thirty-seven (71 percent) of the homes stated that an emergency kit or tray was provided at the home. Another 12 (23 percent) did not have what could be called an emergency kit. In some instances certain medications usually considered part of an emergency kit were in the drug stock but were not grouped together as a unit or prepared in a portable fashion. medication tickets Nursing homes in Virginia that use medication tickets have various forms. The ticket as prepared is obtained from a central location and accompanies the medication to the patient. R ec· ord can be made then that the medication did reach and was administered to the patient. Thirty-four (64 percent) of the 52 homes visited use some form of medication ticket and seven (1 3.4 percent) do not make use of any form. In these la tter instances the m edication is obtained from the prescription container or other dru g source, placed in a unit dosage container and taken d irectly to the patient. These are usually the smaller homes where staff personnel are quite famili ar with each patient. antidote charts The potency of medication now used raises the possibility of individual patient's sensitivity and possible adverse drug reaction. Safety and profess ional responsibility dictate that precaution should be taken to counteract errors or unforeseen complications of drug therapy. One such precaution is the antidote chart. Fourteen homes (27 percent) had an an tidote chart available and another 25 (48 percent) stated that no antidote chart was on hand. The remaining thirteen homes (25 percent) did not indicate whether an antidote chart was available. medication-re-use or disposal In the event any patient discon tinues use of a medica tion, there may be a supply remaining. Economy, safet y,

Aminophyllin Glucose Coramine Caffeine·sodium benzoate Adrenalin 2 tanks of oxygen available at all times

professional ethics and legal implications relating to storage, labeling and possession of drugs are all factors that should be evaluated in considering reuse or disposal of prescription medication. Data on this question was obtained from 46 homes (88.6 percent). Thirty-six (69 percent) indicated all unused medication was discarded and five (9.6 percent) stated that all these medications were placed back in stock for use by other patients. The remaining five homes had various procedures for handling this stock~all unused drugs were discarded except those for welfare patients ~only unused narcotic medication was discarded ~one·half was discarded and the remainder re·used ~drugs were discarded depending upon kind of medication ~the prescribing physician was con· tacted to determine whether to re·use or dispose of the drug.

knowledge of drugs Inquiries were made about the source of drug information available to or sought by nursing home professional personnel. A m ajority stated that the P hysicians' Desk Reference was on hand a nd used. In many homes much information was obtained from the manufacturer's literature. Some nursing home personnel relied on the visiting or attending physician for needed drug information. It was a rather last choice to call the pharmacist for information on medication. Most nursing homes have a professional staff that is informed and seeks additional knowledge of drugs administered to patients. Without access to patients' medical records and nursing home procedures, it is difficult to know just how much a thorough knowledge of drug action has contributed to better use of medications in nursing homes. summary This survey accumulated information rela ti ve to pharmaceutical services in

licensed nursing homes in Virginia, including availability and use of legend as well as non-legend prescription medication and related health items employed for maintenance of personal hygiene and well being of nursing home patients. There are 162 nursing homes in Virginia licensed by the Department of Health with a total bed capacity of 5,815. During a period of 12 weeks 52 licensed nursing homes were visited and responsible persons were interviewed. A questionnaire was developed and used to record data at the time of a personal visit by the project coordinator. At the same time, personal interviews were ob tained with nursing home management for discussion of data collected and other information that came to the attention of the project coordinator. The survey recorded only the actual procedures used to make prescription medication and health items available to patients in nursing homes in Virginia. It did not recommend or comment on the adequacy or safety of drug handling or what constituted good pharmaceutical service or the legality of operations observed. Information which could be used in an educational manner was uppermost in the selection of methods studied. Pharmaceutical services required in a nursing home situation are extensive and not usually under the control of a pharmacy or pharmacists. There is generally an impersonal relationship between pharmacists and nursing home managemen t or professional staff. Certain practices are often performed on the basis of expediency and channels of mutual understanding between parties involved in furnishing any part of the pharmaceutical services usually are not clearly established. This is true in the checking of outdated or unused medication, in programs of drug storage and stability, use and preparation of medication tickets, use of record charts showing drug administra tion, renewal of prescriptions or continued use of prescription medication and laws relative to purchase, distribution, possession and dispensing of legend drugs. Nursing home management has not come to regard these areas of concern as a function of the profession of pharmacy. Neither has pharmacy sought the opportunity to extend such service. Until there is an atmosphere of mutual understanding, there will be a void in the development of a liaison program between the nursing home and pharo macy. But to produce more effective. efficient, safe and adequate procedures for use of medications, sick room supplies and related health items as reflected in the licensed nursing homes in the Commonwealth of Virginia a liaison program is necessary. • Va •. NS6 . No.5 , Ma y 1966

249