As the COVID-19 pandemic continues to pick up speed in many states without waiting for a fall/winter surge, nursing homes across the country are looking for ways to streamline and improve systems so that they can provide high-quality, patient-centered care that also prioritizes infection prevention and control. “One way to achieve this goal is to have open conversations about what is important to residents and families with regard to medications—and also be mindful of the time and infection control burdens that medication management can impose on overstretched, overstressed staff,” suggests Nicole Brandt, PharmD, MBA, BCGP, BCPP, FASCP, executive director of The Peter Lamy Center on Drug Therapy and Aging and professor of Pharmacy Practice and Science at the University of Maryland School of Pharmacy in Baltimore.
Working with the U.S. Deprescribing Research Network, The Peter Lamy Center pulled together a multidisciplinary task force, co-chaired by Brandt, that developed Optimizing Medication Management During the COVID-19 Pandemic: Implementation Guide for Post-Acute and Long-Term Care to provide a framework of guiding principles for this conversation.
“The goal of the guide is patient-centered—to improve outcomes for older adults living in post-acute and long-term care facilities,” says Michael Steinman, MD, professor of Medicine with a focus in geriatrics at the University of California – San Francisco and the San Francisco VA Medical Center, and co-principal investigator at the U.S. Deprescribing Research Network. Steinman also co-chaired the multidisciplinary task force that created the guide. “The task force wanted to make the guide as useful as possible in improving those outcomes while still recognizing that healthcare providers and staff are incredibly busy during this time of the pandemic.”
Medication changes should be able to help nursing homes in three key ways:
Reduce unnecessary medications
“This is a great opportunity to reduce medications that probably are not providing much benefit in the first place or whose harms may exceed their benefits,” says Steinman.
Reduce burden on residents and improve staff efficiencies
“If you can take medications that are distributed at multiple time points throughout the day and consolidate them to a smaller number of times, that is helpful on multiple levels,” says Steinman. “First, it is less burdensome to the residents, who may have to be prodded to have their medications administered, as well as having to endure monitoring, such as finger-stick blood glucose checks, that may not always be necessary.”
“When you prescribe more medications, it not only puts the resident at risk, it requires nursing administration time and nursing documentation time,” says Joseph Ouslander, MD, professor of geriatric medicine and senior advisor to the Dean for Geriatrics in the Schmidt College of Medicine at Florida Atlantic University in Boca Raton, FL, and the primary creator of the free INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program.
“If there are monitoring parameters, that takes additional time away from staff. For example, if you are giving a resident a blood pressure medicine and there is a hold parameter (e.g., hold the medication if systolic blood pressure is less than 110), that requires documentation,” he explains. “The bottom line is that the more medicines, the more doses, and the more monitoring parameters that are in place, the more time medication management takes from staff.”
Saving staff time is a priority for nursing homes, notes Ouslander, who was an external advisor for the guide. “Many facilities were short-staffed prior to COVID-19, but with the pandemic, nursing and other staff shortages often have become—and will remain—critical. These shortages will continue until widespread testing is available, allowing nursing homes to quickly identify even asymptomatic COVID-19 positive staff and keep contagious staff off work until they test negative.”
“On a good day, a medication pass takes a long time,” adds Brandt. “Even if you can just simplify the number of medication passes so that there are fewer medication passes throughout the day or actually reduce the amount of time spent on medication passes, that time savings may give nursing staff and others more direct-care opportunities to meet other needs besides passing medications.”
Reduce opportunities for infection transmission
“Every time you are in close physical proximity to a resident, especially for medications that require a lot of hands-on use, that increases opportunities for disease transmission either from residents to staff or from staff to residents,” says Steinman. “You want to reduce opportunities for infection transmission. This can be done by reducing medication administration touches between nurses and residents. It also can be done by employing certain medication strategies, such as using hand-held inhalers instead of nebulizers, to reduce possible vectors for disease transmission.”
Keys to implementing Optimizing Medication Management successfully include the following:
Focus on nursing workflow first
“Directors of nursing services (DNSs) are handling a lot of different stressors,” acknowledges Brandt. “So start with the big-picture changes that you can make that improve your nurses’ workflow. For example, what changes may help your nurses pass medications? What changes may help your nurses improve their infection control approaches? Pay attention to the different elements of the guide that you can quickly incorporate into your staff’s workflow.”
Don’t DIY—engage the entire team
“Sometimes as a leader, you want to be able to do it all. However, medication management is so complex that DNSs really need an entire team to address all aspects of it. You don’t want any one discipline, including nursing, to be overburdened,” says Brandt.
“Tap into some of the partners you have worked with on various quality initiatives over the years. In other words, talk with your consultant pharmacist, your medical director, and different physicians or nurse practitioners,” she suggests. “Really think about what aspects of this guide could be championed by these other team members. Who can help you communicate with residents and families? Who can review medication passes, administration times, and formulations?”
Adapt, adapt, adapt
“The recommendations in the guide are not meant to be a mandate or to be universally applicable by any stretch,” says Steinman. “Every nursing home is different. The recommendations provide a framework that you can adapt and tailor to local circumstances in your facility.”
Every resident also is different, he notes. “Some recommendations will be true for many residents, but may not be applicable to every single individual. Therefore, the recommendations should be implemented in an individualized and patient-centered format to meet the care needs of each resident.”
Avoid speed traps
“When providers are under pressure, there often is a tendency to do too much too fast,” says Brandt. “Rather than recommending that you make multiple changes at one time, Optimizing Medication Management purposefully guides you to start with medication changes that potentially have the least harm to residents. For example, you may want to consider discontinuing long-term preventive medications (e.g., statins) if you determine that the resident’s goals of care are comfort measures only or if they’re near the end of life.”
A stepwise approach is an important tool in reducing unintended consequences, says Brandt. “Some medications may be more challenging to stop right now because there may be unintended consequences. For example, a resident may have withdrawal if you stop some medications too quickly. So start with the low-hanging fruit. Then use the mitigation strategies in the section, ‘Avoiding Unintended Consequences,’ when you have the time to address those more challenging medications.”
A stepwise approach also helps DNSs keep a lid on monitoring time, says Brandt. “When you stop a medication—just like when you start a medication—there are potential problems that your staff will need to monitor for. Not all medication stops would require the same level of monitoring, but if you avoid discontinuing multiple medications at one time, you can better control the impact of those monitoring requirements on your nursing staff.”
Create and follow a communication plan
Both research and on-the-ground experience have shown that changing medications without establishing strong communication with the resident, their family, and even their physician can lead to conflict and distrust, says Steinman. “It’s not enough for the interdisciplinary team to make an executive decision to stop or change a medication. You must establish good communication and explain the reason behind the changes you are making so that any concerns can be addressed. That takes a little more time upfront, but it can improve acceptance of the recommendations and satisfaction of all parties in the long-term.”
Without adequate communication, there is, understandably, an opportunity for residents and families to misinterpret the goal, points out Steinman. “Residents may feel upset because their medications were stopped, and no one told them why. Also, sometimes the optics of consolidating or withdrawing medications can create a perception that you are rationing or reducing their care. Many residents are attached to medications even if they don’t serve a very useful therapeutic purpose. You need to be upfront that your goal is to improve the resident’s care, including reducing their infection risk, by reducing unnecessary medications—not because you want to save money or because the resident isn’t worth your time.”
Optimizing Medication Management includes the section, “Communication Around Medication Strategies,” to help providers understand how to explain medication changes and address the concerns of residents, their families, and prescribers, says Brandt. “It also has sample letters that you can edit to fit your local circumstances. You want to be sure that everyone involved is aware of the changes you plan to make and the person-centered reasons behind those changes.”
Track changes to each resident’s medications
“It is really important to keep track of any changes that you make to a resident’s medications,” says Steinman. “First, it ensures that you can monitor the resident to see how they are doing with the change. For example, if you change a medication from a short-acting to a long-acting medication, is the person tolerating that medication? Are they having any adverse effects?”
The task force specifically chose recommendations in the guide that were very likely to be tolerated and were low-risk, says Steinman. “However, the unexpected can happen any time you change a medication, so your staff members need to be attentive to what is happening after a change to make sure that residents are being well-served.”
The second reason to track changes is to remember when to re-start medications that are stopped temporarily, says Steinman. “Some medications may be clinically appropriate for a resident to take in the long-term, but in the short term, it may be wise to temporarily withhold them to decrease disease transmission risks during periods of high COVID-19 activity. For example, these types of medications could include medications that require extra doses to administer, that have a high likelihood of making a resident cough, or that require close contact between nurses and residents.”
When such medications are temporarily withheld, providers must have a rigorous system in place to ensure they can be reintroduced once the COVID-19 threat has decreased, says Steinman. “Avoiding unintended consequences is critical to optimizing medication management, and forgetting to restart a medicine that you intended to stop only temporarily may lead to an unintended consequence.”
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