John Baker

1

• John Baker
• Health Foundation Research Fellow
• The University of Manchester

2
Overview of presentation

• Project aims
• Project methodology
• Progress to date
• Plans for completing the project, including
  dissemination

3

• Project (PhD) Aims and Objectives
• To identify, devise and test a clinical protocol
  to enhance the use of psychotropic PRN (pro re
  nata) medication within acute mental health
  settings.

Research supported by the Health Foundation.
4

• Approximately
• 2.9 million doses of PRN
• are given out in England
• per Year
• in
• Adult Acute Mental Health Services alone.
• Assumes 14,000 beds, average 2 week stay, and
• 80 will receive 10 doses.

5

• This common current common practice has no
  support from randomised trials. Current
  practiceis therefore difficult to justify.
• Cochrane review
• (Whicher et al., 2003).

6
How do you get a Clinical Protocol?
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Project methodology

• A mixed methods approach
• Narrative literature review
• Interviews with Service Users the MDT
• Ask expert opinion
• Syntheses of data into a Clinical Protocol for
  testing
• (Exploratory trial Phase II, MRC framework)

8
Evidence (data) from many sources.
Interview Service Users
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
9
Evidence (data) from many sources.
Explore the Literature
10
Narrative Literature Review

• Search for all relevant literature found 51
  papers (from 7,601).
• Poor quality research,
• Mainly retrospective case note analysis.
• Few studies of prospective research.

Baker JA, Lovell K, Harris N (submitted)
Administration of psychotropic pro re nata
(p.r.n.) medication in adult inpatient mental
health settings A narrative literature review.
International Journal of Nursing Studies.
11
Narrative Literature Review key themes

• PRN is routinely prescribed on admission.
• PRN contributes to High doses, these are often
  hidden.
• PRN contributes to polypharmacy.
• Typical antipsychotics and benzodiazepines are
  most likely to be prescribed.
• Agitation insomnia and patient request most
  cited.
• PRN is most likely to be given out evening/night
  time, within the first 4 days.

Baker JA, Lovell K, Harris N (submitted)
Administration of psychotropic pro re nata
(p.r.n.) medication in adult inpatient mental
health settings A narrative literature review.
International Journal of Nursing Studies.
12
Narrative Literature Review key themes

• A sub-group continue with PRN and lots of PRN.
• With a dose range the higher one is more likely
  to be chosen.
• Effectiveness of PRN (32 to 80) - ill defined
  concept.
• Lack of documentation
• all aspects and disciplines.
• Review of PRN lacking.
• No systematic recording of side effects/negative
  effects associated with PRN.

Baker JA, Lovell K, Harris N (submitted)
Administration of psychotropic pro re nata
(p.r.n.) medication in adult inpatient mental
health settings A narrative literature review.
International Journal of Nursing Studies.
13
Narrative Literature Review key themes

• In conclusion, our findings indicate that the
  use of PRN orders may expose psychiatric
  inpatients to unnecessary psychotropic
  medications. Given the objective of regulatory
  bodies to minimise the use of chemical
  restraints in the population of vulnerable
  patients, these findings have important policy
  implications
• Thapa et al (2003) p 1286.

Baker JA, Lovell K, Harris N (submitted)
Administration of psychotropic pro re nata
(p.r.n.) medication in adult inpatient mental
health settings A narrative literature review.
International Journal of Nursing Studies.
14
Evidence (data) from many sources.
Explore the Literature
15
Evidence (data) from many sources.
Ask Experts (Delphi Project)
Explore the Literature
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• Delphi Panel (experts)
• A number of experts (n33) were identified for
  inclusion within the study.
• 18 participated.
• Asked 4 questions in 3 rounds about issues and
  best practice for prescribing and administering
  PRN.

Baker JA, Lovell K and Harris N (2006) How
expert are the experts An exploration of the
concept of expert within Delphi panel
techniques. Nurse Researcher 14, 1,
59-70. Baker JA, Lovell K, Harris N (submitted)
Determining consensus in Delphi studies. Nurse
Researcher.
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Delphi Research
Baker JA, Lovell K, Harris N, Campbell M
(submitted) Multi-disciplinary consensus of best
practice for Pro Re Nata (P.R.N.) psychotropic
medications usage within acute mental health
settings a Delphi study. Journal of Mental
Health.
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Delphi research 34 items to 7 themes

• Service user focus.
• Transparent correct process (from prescription to
  administration).
• Clear process of review.
• Correct prescriptions.
• Side effect monitoring.
• Use of alternatives.
• Improvements to knowledge.

Baker JA, Lovell K, Harris N, Campbell M
(submitted) Multi-disciplinary consensus of best
practice for Pro Re Nata (P.R.N.) psychotropic
medications usage within acute mental health
settings a Delphi study. Journal of Mental
Health.
19
Research project
Delphi Project
Scoping Literature Review
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Research project
Delphi Project
Scoping Literature Review
Interviews with Multi-disciplinary team
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Interviews MDT

• 59 members of MDT
• 6th April to 5th July 2005
• 49 interviews
• 1690 minutes of data
• Range 18-74 minutes

Baker JA, Lovell K, Harris N (submitted) Mental
health professionals p.r.n. psychotropic
medication practices within acute mental health
care A qualitative study. General Hospital
Psychiatry.
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Interviews Main themes

• Advantages relieving distress, preventing and
  managing violence , removal of doctors from the
  process.
• Disadvantages misuse by nursing staff or
  patients, quality of prescription.
• PRN has become a first resort option, used when
  alternatives would be preferable.
• Information about PRN to service users limited.
• PRN probably reviewed at ward round.
• Benzodiazepines dichotomous response.
• A lack of clinical responsibility for PRN
  medications.

Baker JA, Lovell K, Harris N (submitted) Mental
health professionals p.r.n. psychotropic
medication practices within acute mental health
care A qualitative study. General Hospital
Psychiatry.
23
Evidence (data) from many sources.
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
24
Evidence (data) from many sources.
Interviews with Service Users
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
25
Interviews Service Users

• Total 22 (from 27) service users (9th May 21st
  June).
• 3 Interviews terminated due to mental state.
• 406 minutes of data, range 555 to 4152
• Variations in ages, diagnosis, ethnicity, gender
  and mental health act status.

Baker JA, Lovell K, Easton K, Harris N (2006)
Service Users experiences of 'as needed'
psychotropic medications in acute mental
healthcare settings. Journal of Advanced Nursing
56(4), 354362 Baker JA, Lovell K, Easton K,
Harris N (2006) Poster at National Psychiatric
Nursing Research conference, Oxford University,
UK.
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Interviews Service Users - Main themes

• Value of PRN.
• Preferences of some medications.
• Enables control.
• The process is perceived as confusing,
  stigmatising, and embarrassing especially in
  public areas.
• Dislike for forced medication begrudging
  acceptance.
• Information provision poor.
• Despite identifying alternatives, few had tried
  them, perceived lack of support.
• Link between PRN and low resources.

Baker JA, Lovell K, Easton K, Harris N (2006)
Service Users experiences of 'as needed'
psychotropic medications in acute mental
healthcare settings. Journal of Advanced Nursing
56(4), 354362 Baker JA, Lovell K, Easton K,
Harris N (2006) Poster at National Psychiatric
Nursing Research conference, Oxford University,
UK.
27
Evidence (data) from many sources.
Interview Service Users
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
28
THE NEXT STEP
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Synthesis into clinical protocol.
Interview Service Users
Ask Experts (Delphi Project)
Explore the Literature
Interview the Multi-disciplinary team
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9 Principles of good practice

• 1. Remaining focused on the patient
• 2. Prescription quality
• 3. PRN as part of the clinical management plan
• 4. Evaluating the use and effect of PRN
• 5. PRN requires frequent review
• 6. Enhanced documentation by the
  Multi-disciplinary team
• 7. Preventing distress when using PRN
• 8. PRN as a last resort
• 9. Training and education in the use of PRN for
  all clinical staff

Baker JA (2006) Enhancing the use of as
required/extra (prn) medication within acute
mental health settings. Good practice
guidelines, supporting manual. PelicanPress,
Manchester.
31
(No Transcript)
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The protocol and manual testing

• Feasibility study
• (based on MRC framework for complex
  interventions).
• 2 wards recruited in Greater Manchester.
• MDT approach
• (focus prescribing and administration).
• Sept - Dec 06

Baker JA (2006) Enhancing the use of as
required/extra (prn) medication within acute
mental health settings. Good practice
guidelines, supporting manual. PelicanPress,
Manchester.
33
The protocol and manual testing

• Pre post design for 4 weeks either side of a
  two week intervention period, this involves
• A questionnaire about individual PRN practices at
  the beginning and end of the study.
• An audit form each time you either prescribe
  (yellow form) or administer (blue form) a PRN
  psychotropic medication.
• Weekly audit of case notes.
• The use of the clinical protocol in practice.
• Evaluating the clinical protocol (interviews and
  questionnaire).

Baker JA (2006) Enhancing the use of as
required/extra (prn) medication within acute
mental health settings. Good practice
guidelines, supporting manual. PelicanPress,
Manchester.
34
Plans for completing the project, including
dissemination

• Data collection finishes end of November 2006.
• 9 months to finish analysis and write-up.
• Significant work already completed (via
  publications).

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Plans for completing the project, including
dissemination

• The outcomes from the project will be a
  validated, patient-focused clinical protocol and
  manual.
• Feedback to the NHS mental health trusts in
  Greater Manchester where different stages of the
  research project have been conducted via
  effectiveness days.
• Publications of findings and methodology in
  papers in professional and academic journals and
  at conferences (internationally).
• The development of a one day feedback conference.
  
• A short report will be published on a website to
  enable wider access.

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• John Baker
• Health Foundation Research Fellow
• John.a.baker_at_manchester.ac.uk