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The U.S. Department of Health and Human Services published a new Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics - PDF. Individual patients, as well as the health of the public, benefit when opioids are prescribed only when the benefit of using opioids outweighs the risks. But once a patient is on opioids for a prolonged duration, any abrupt change in the patient’s regimen may put the patient at risk of harm and should include a thorough, deliberative case review and discussion with the patient. The HHS Guide provides advice to clinicians who are contemplating or initiating a change in opioid dosage.
“Care must be a patient-centered experience. We need to treat people with compassion, and emphasize personalized care tailored to the specific circumstances and unique needs of each patient,” said Adm. Brett P. Giroir, M.D., assistant secretary for health. “This Guide provides more resources for clinicians to best help patients achieve the dual goals of effective pain management and reduction in the risk for addiction.”
Clinicians have a responsibility to coordinate patients’ pain treatment and opioid-related problems. In certain situations, a reduced opioid dosage may be indicated, in joint consultation with the care team and the patient. HHS does not recommend opioids be tapered rapidly or discontinued suddenly due to the significant risks of opioid withdrawal, unless there is a life-threatening issue confronting the individual patient.
Compiled from published guidelines and practices endorsed in the peer-reviewed literature, the Guide covers important issues to consider when changing a patient’s chronic pain therapy. It lists issues to consider prior to making a change, which include shared decision-making with the patient; issues to consider when initiating the change; and issues to consider as a patient’s dosage is being tapered, including the need to treat symptoms of opioid withdrawal and provide behavioral health support.
Purpose of Review
To assess adverse events of antidepressants in the treatment of major depressive disorder in adults 65 years of age or older.
In people 65 years of age or older:
Specialized Infection Prevention and Control Training for Nursing Home Staff in the Long-Term Care Setting is Now Available
The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) collaborated on the development of a free on-line training course in infection prevention and control for nursing home staff in the long-term care setting.
The training provides approximately 19 hours of continuing education credits as well as a certificate of completion (i.e., free CME, CNE or CEUs).
The course introduces and describes how to use IPC program implementation resources including policy and procedure templates, audit tools, and outbreak investigation tools.
The course is made up of 23 modules and sub-modules that can be completed in any order and over multiple sessions.
The course covers:
From AHRQ News Now:
Including bedside nurses in antibiotic stewardship activities has been identified by professional nursing groups and the CDC as an important—but missing—element in the success of these programs. To help fill this void, a new AHRQ-funded study published in the journal Infection Control and Hospital Epidemiology identifies several areas where bedside nurses could play an enhanced role in improving antibiotic prescribing practices.
Nurses’ expertise can be used to: ensure appropriate testing for Clostridiodes difficile (C. diff) infection through accurate documentation and medication reviews; assess relevant indications before obtaining urine culture specimens to prevent the use of unnecessary antibiotics; ensure optimal antibiotic administration by helping patients transition from intravenous to oral therapies; obtain and document accurate patient histories of penicillin allergies; and use a team-based review to ensure that antibiotic therapies are not unnecessarily prolonged.
The authors also identified ways to integrate nurses into an organization’s stewardship program, including on-the-job learning about antibiotics, potential drug interactions and adverse drug events.
• The National Partnership & Identification of Late Adopters – Since 2011, the Centers for Medicare & Medicaid Services (CMS) has seen a reduction of 38.9 percent in long-stay nursing home residents who were receiving an antipsychotic medication. Despite the success of the National Partnership, CMS identified approximately 1,500 facilities that had not improved their antipsychotic medication utilization rates for long-stay nursing home residents, referred to as late adopters. In December 2017, CMS notified these facilities of this identification.
• Enforcement for A Segment of Non-Improving Late Adopters with Multiple Citations - As of January 2019, there are 235 late adopter nursing homes that have been cited for noncompliance with federal regulations related to unnecessary medications or psychotropic medications two or more times since January 1, 2016, and who have not shown improvement in their long-stay antipsychotic medication rates. If these facilities are determined not to be in substantial compliance with requirements for Chemical Restraints, Dementia Care, or Psychotropic Medications during a survey, they will be subject to enforcement remedies for such noncompliance.
• Corporate Engagement - CMS is also looking for opportunities to engage with corporate chains that have significant numbers of nursing homes identified as late adopters.
Nurses are critical to the health and well-being of residents in long-term care, overseeing all aspects of care, including residents’ physical, mental, social, and spiritual wellness. Although members of the interdisciplinary team (IDT) assist with their respective disciplines, the nurse is ultimately the one with 24/7 oversight of resident care. Nurses are the eyes and ears of the physician in the long-term care setting and serve as advocates for the residents during the drug regimen review (DRR).
Since the most recently updated CMS guidelines regarding DRR which includes medication reconciliation in the skilled nursing facility were released, facilities have struggled to understand the rules. One of the significant drivers behind these new regulations is the increased rate of medication-related adverse drug events (ADEs). One critical item, however, is still missing from the updated requirements—the resident perspective on medications. The CMS guidelines address DRR and identify the medications that must be reviewed, the scheduling of reviews, clinically significant medication issues, the facility-designated person responsible for conducting the DRR, and communication between the physician and nurse. Little to no mention is made of resident preference and choice related to medications. Do residents want to take all those medications? Is their quality of life improving?
Critically ill patients in intensive care units (ICUs) did not benefit from two antipsychotic drugs used to treat delirium, according to a large clinical trial funded by the National Institute on Aging, part of the National Institutes of Health. The multi-site team that conducted the trial found no evidence that treatment with antipsychotic medicines — haloperidol or ziprasidone — affected delirium, survival, length of ICU or hospital stay or safety. The findings from the Modifying the Incidence of Delirium USA (MIND USA) study were published online Oct. 22, 2018 in The New England Journal of Medicine.
“This is strong evidence from what we consider a ‘gold standard’ clinical trial showing that these two antipsychotics don’t work to treat delirium during a critical illness,” said NIA Deputy Director Marie A. Bernard, M.D. “Antipsychotics have often been used to treat delirium. The evidence from this study suggests the need to reexamine that practice.” Bernard is also NIA’s senior geriatrician.
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