NADD Bulletin Volume XIII Number 1 Article 2

Complete listing

Implementation of Individualized P.R.N. Protocols in Community-based Settings:  Addressing Concerns around Risk, Rights, and Responsibilities

P. Turcotte, K. Beatty, L. Marwick, K. McEntee and M. Palangio 

 

Abstract

The use of psychotropic p.r.n. (pro re nata, or as needed) medication in individuals with developmental disabilities living within the community is one possible component of a holistic treatment plan.  However, questions arise around procedural and ethical issues such as the role of non-medical staff administering the medication, decision making around its use, documentation, evaluation, level of intrusiveness, and the compatibility of the p.r.n. medication with non-pharmacological interventions such as coping skills training.  To mediate these concerns, the Developmental Disabilities Service developed p.r.n. protocol and evaluation templates.  These tools are discussed, along with two case studies depicting the implementation of the tools. 

Introduction

It is well recognized that interpersonal aggression and self-injurious behaviors in individuals with developmental disabilities can occur in times of crises.  Unfortunately, challenging behavior is one of the most commonly identified predictors of an individual's removal from community-based programs and a precipitant to admission or readmission to institutional or hospital settings (King, Fay, & Croghan, 2000).  These challenges may be further complicated by the presence of a mental health concern.  In a recent article on the assessment of mental health concerns in individuals with developmental disabilities, Hodboden and Leroy (2008) state that approximations from prevalence studies indicate that between 15 % and 50% of individuals with a developmental disability have a co-occurring mental illness (referred to as dual diagnosis).  It is within this context that p.r.n. medication can be used to de-escalate and interrupt behaviors which can be dangerous to the person or others.  As well, administering p.r.n. medication effectively, along with other non-pharmacological interventions, will ideally allow for mental health treatment to be provided in the least-restrictive setting or as close to home as possible.  Unfortunately, there is very little available research on the use of p.r.n. medication with individuals with dual diagnosis in a community setting.

Conversely, the use of psychotropic p.r.n. medication is a fairly common and accepted practice within psychiatric hospital settings. Usher and Luck (2004) comment that:

 the advantage of doctors prescribing medications to be administered 'as needed' means that nurses have greater freedom allowing them to administer rapidly in acute situations or at the patient's request.  It also means that nurses have the ability to identify and act upon early signs of aggressive behaviour in inpatient units by administering a prescribed psychotropic p.r.n., thereby reducing the potential for harm to patients and/or others.

 

Craven, Voore, and Voineskos however had noted in 1987 that a large number of p.r.n. prescriptions include no instructions for use, dosing schedules, or maximum daily dosages. More recently, Curtis and Capp's (2003) review of the administration of p.r.n. medication at a secure acute inpatient mental health unit found inadequate or no documentation regarding their administration, showing 41% of the cases with no results of the p.r.n. administration documented in nursing notes and 9.1% of the cases having no reason given for the administration of the p.r.n. medication.    The research suggests that, for the most part, there is a lack of clarity surrounding psychotropic p.r.n. medication administration practices, confusion surrounding decision making processes related to this intervention, and poor documentation practices even within this relatively controlled and medically oriented setting (Usher, Lindsay, & Sellen, 2001).  Moreover, the research also raises concerns regarding the general use of the p.r.n. medication, noting that relying on psychotropic medication for its sedative effect can make it less likely that individuals will develop the daily living and coping skills needed to function outside the inpatient setting (Donat, 2006). 

To address concerns regarding the ambiguous nature of the prescriptions of p.r.n. medication as well as the wider concerns regarding its use, Jordan (2004) proposes that a systematic and interdisciplinary approach with the administration of p.r.n. medication be utilized as therapeutic treatment to decrease psychiatric symptoms thereby reducing the need for physical restraints.  Further, King, Fay, and Croghan (2000) suggest that a comprehensive p.r.n. protocol or crisis support plan is critical in maintaining the right of the individual with a dual diagnosis to live in safety and harmony in community settings, which optimizes their quality of life.  The Developmental Disabilities Service (DDS), which is a part of the Regional Specialized Mental Health Program of the Northeast Mental Health Centre (NEMHC) and provides psychiatric consultation to adults with an identified developmental disability and suspected serious mental illness living within districts across Northeastern Ontario, embraces the belief that psychotropic p.r.n. medication used within the context of a well designed p.r.n. protocol can reduce the negative impact of crisis to both the individual and others in the situation. The DDS believes that the protocol can be implemented in conjunction with an individualized non-pharmacological wellness plan.  To this end, the DDS created a p.r.n. protocol and p.r.n. evaluation template, which are tools that accompany the prescription of a p.r.n. medication (see Table 1). These templates have been designed to allow flexibility, so that they can be used across environments including home, community residence, school, and hospitals.  The protocol was developed to outline an individualized, consistent, goal directed, sequenced response by the individual, family, and/or direct care staff to a potential crisis.  This ideally would prevent the crisis from occurring or at least minimizing the escalation or the intensity of the crisis, thus minimizing the damage, both physical and psychological, to the individual and others.   

The DDS district clinician and consulting psychiatrist facilitate the creation of a p.r.n. protocol that is based on sound biopsychosocial principles and ensures that the pharmacological interventions work in conjunction with preventative and habilitative approaches.  Input is elicited from the individual, family members, direct care staff, and other team members such as behavior therapists, primary health care provider, or others involved in the circle of care, thus ensuring the protocol is "best fit" for the person at that time, and ideally encouraging mutual accountability.   Under the supervision of the consulting psychiatrist, and using the information from the p.r.n. evaluation tool (see Table 2), the mental health clinician monitors the efficacy of the p.r.n. medication and p.r.n. protocol through regular follow-up with the individual, family members, and their support workers.  It is the DDS' experience that the information gathered also has proven useful in guiding the pharmacological treatment plan. 

 

 

 

 

 

 

Table 1:  p.r.n.  PROTOCOL  

 

Name:Date:

Contributors:Review Date:

Biopsychosocial profile:  brief description of previous diagnosis/assessment results and citation along biopsychosocial spheres (e.g. autism spectrum disorder, moderate ID, hypothyroidism, hx of neuroleptics, PMS)

 

Behavior "A"Behavior "B"Behavior "C"Follow-up

·Brief description of individual's typical presentation. ·Operationally define early signs of escalation.·Continuation of Behavior "B" not alleviated through Intervention "B" within a specified timeframeOR·Operationally define target behaviors of rapidly escalating dyscontrol or high intensity.·With individual; promoting resolution.

Intervention "A"(Preventative)Intervention "B"(Early Intervention)Intervention "C"(p.r.n. Management)Follow-up(Review and Prevention

·Briefly reference guidelines for medical monitoring, blood work, promoting health, avoiding physical distress.·Briefly reference guidelines for behavior therapy (e.g.  skill development, environmental and interactional supports, reinforcement programs).·Briefly reference guidelines for optimizing mental health (Above based on diagnoses, knowledge of individual, person-centred plan)·Support measures (as deemed effective by the team for that individual).·Support and safety guidelines for p.r.n. administration and until effect achieved.·p.r.n. guidelines:  include drug, dosage, titration plans, maximum dosage, expected effects, plan for acute side effects, and plan for non-response (may include scripted statement, medication compliance measure).·Documentation guidelines.·Reports/data required (minimal:  date, time p.r.n. given, latency of effect, any side effects)·Plan for regular team review.·Interim measures to ensure resolution/prevention of reoccurrence.·Resolution with individual's peers.·Resolution for involved care provider(s).

 

Table 2:  p.r.n.  EVALUATION TEMPLATE

Date/Time of start of incident Behavior Observed (follow Antecedent-Behaviour-Consequence format)Response (include support measures given, and times of each)p.r.n. (yes/no and time of administration; requested by whom and given by whom)Time CalmInitials and Comments (around efficacy, side effects including time of onset, follow-up needed, etc)

Case Study 1-Mr. A.

The following case study illustrates the process of decreasing the regular dose of an atypical antipsychotic medication in an individual with a bipolar disorder.  A discussion of how the DDS used the p.r.n. protocol and evaluation templates to guide the pharmacological treatment goals of ensuring mood stability, optimizing medications, and reducing medication adverse effects is examined.  The role of the family and community residential support workers is also highlighted to demonstrate how they were an integral part of the development of the p.r.n. protocol and monitoring of p.r.n. medication.

Mr. A was referred to the DDS at the age of 17 years due to behavioral challenges including intermittent aggression, impulsivity, pressured speech, insomnia, and increased appetite, as well as a need for symmetry, all of which appeared cyclical in nature.  Mr. A functions within the severe range of developmental disability.  At the time of assessment, Mr. A lived at home with his parents and sibling.

The DDS psychiatrist diagnosed Mr. A with a Pervasive Developmental Disorder, Not Otherwise Specified, and Bipolar Disorder with a comorbid Obsessive Compulsive Disorder (OCD).  His pharmacological treatment plan consisted of the initiation of valproic acid as a mood stabilizer.  To address cycles of hypomania, an oral dose of olanzapine 2.5mg at bedtime (hs) was initiated with subsequent increases when Mr. A entered a hypomanic phase of his illness. Ultimately, his total daily dose of Olanzapine was 17.5mg.  Tables 3 and 4 outline the medication timeline of Mr. A's pharmacological treatment.  With the higher doses of olanzapine, Mr. A experienced medication adverse effects including sedation (twelve hours of total daily sleep time), drooling, cogwheel rigidity, tremors, and weight gain.

 

 

 

 

 

 

 

Table 3 

Year 1Aug Year 2Sep Year 2Oct Year 2Nov Year 2Dec Year 2

·DDS referral·Initiation of valproic acid 250mg bid (429umol/L)·Hypomanic symptoms (incl. psychomotor agitation and aggression)·valproic acid increased to 500 mg bid (494 umol/L)·Ongoing hypomanic symptoms·Initiation of olanzapine 2.5 mg hs·valproic acid continued at same dose·Insomnia·olanzapine increased to 5 mg hs, and then increased to 7.5 mg hs·valproic acid continued at same dose·Sleep improved, but mood was irritable·olanzapine increased to 10 mg hs, then to 2.5 mg am and 10 mg hs·valproic acid also increased to 500 mg am and 625 mg hs (589 umol/L)·Irritable mood·valproic acid increased to 500 mg am and then 750 mg hs, then to 500 mg am and 825 mg hs (564 umol/L)·olanzapine continued at same dose

 

 

 

Table 4 

Feb Year 3March Year 3May Year 3April Year 5May Year 5

·Mood stable, but difficulties swallowing·olanzapine decreased to 10 mg hs·valproic acid decreased to 500 mg bid due to level (827 umol/L)·valproic acid level decreased to 444 umol/l ·valproic acid optimized to 500 mg am and 625 qhs·Mood mildly elevated·olanzapine increased to 12.5 mg hs·valproic acid continued at same dose (529 umol/L)·Hypomanic symptoms emerged·olanzapine increased to 15 mg hs·valproic acid continued at same dose (621 umol/L)·Hypomanic symptoms·olanzapine increased and redistributed to 5 mg am and 12.5 mg hs·valproic acid continued at same dose

 

 

Given the adverse effects and potential long term risks, the DDS recommended a reduction in Mr. A's dose of olanzapine.  Concerns were raised that this may pose increased difficulties for Mr. A and for those who were supporting him at home during this process.  To address this, a p.r.n. of olanzapine 2.5mg every 2 hours with a maximum of 2 doses in 24 hours was prescribed to target episodes of agitation, aggression or initial insomnia.  The DDS also planned to track the p.r.n. medication use, as a means of guiding the process of decreasing his regular dose of olanzapine to the lowest possible dose while keeping Mr. A. safe and his mood stable.

As Mr. A was scheduled to move into a community residence, it was agreed that these treatment changes would be deferred until this move took place.  Following his placement, the DDS met with Mr. A's mother and the community residence support workers in order to provide his support team with education pertaining to the p.r.n. protocol and the rationale for decreasing his dose of olanzapine. An overview of Mr. A's Axis I diagnoses as well as the review of the bipolar mood chart previously completed by his mother were also discussed at that time.  The DDS p.r.n. protocol template was also completed using language that was already familiar to the residence support workers (i.e., CPI's Non-violent Crisis Intervention) (Table 5).  Initially, it was the family's request that the residential support workers contact them prior to administering p.r.n. medication; however, as the family became more comfortable with the process, they then requested that they be contacted within 24 hours after the p.r.n. medication was administered.

 

Table 5 

p.r.n.  PROTOCOL

Name:  Mr. A     

Contributors:  Mrs. A, Community residence, DDS

 

Biopsychosocial Profile:  Mr. A has a diagnosis of a Pervasive Developmental Disorder, Bipolar Disorder, Co-morbid Obsessive Compulsive Disorder, and functions within the severe range of developmental functioning

 

Behavior "A"Typical Presentation Behavior "B"Anxiety Behavior "C"AgitationFollow upTherapeutic Rapport 

·Handclapping ·Singing·Sitting and coloring·Going out for Walks· Likes to be helpful (i.e., dusting, carrying laundry)·Sense of Humor·Moving faster·Talking faster·Banging his hands on the arms of a chair·Staring intensely at you/residents and this is then followed by "screeching" Screeching on its own DOES NOT MEAN that he is in a hypomanic phase of his bipolar disorder.  ·Screeching has intensified AND is accompanied by hitting and kicking for no apparent reason·Is unable to concentrate or sit still·An increase in his appetite·His sleep has been disrupted (all behavioural descriptions that Mr. A  may be hypomanic) Other calming measures haven't worked within 15 minutes ·Affect is calm

Intervention "A"(Prevention)Intervention "B"(Early Intervention)Intervention "C"(p.r.n. Management)Follow up(Review and Prevention)

·Reinforcement for appropriate behaviors·Regular monitoring of valproic acid levels·Monitoring of BM's·Monitoring of bipolar symptoms, including sleep·Consistent sleep hygiene routine·p.r.n. if not sleeping by midnight·Keep cool in summer months, apply sun screen and hat ·ELP·Be supportive·Explore what might be bothering him (resident bothering Mr. A, BM, barometric changes)·Give Mr. A his space. Offer to see if he would like to spend some time in his room (he may lay down) but check on him ·Reassure him "you're okay"·Administer p.r.n.:  olanzapine 2.5mg every two hours to a maximum of 2/24, monitor side effects (lethargy, sedation, fatigue, drowsiness, gait difficulties) and efficacy·Document details in agency incident report·Forward mood charts and p.r.n. usage to the DDS ·Redirection to a preferred activity·Contact Mr. and/or Mrs. A within 24 hours after p.r.n. administration·Review p.r.n. protocol during regular  staff meetings

c.c. Mr. and Mrs. A, community residence, family doctor 

 

The DDS proceeded to reduce Mr. A's regular dose of olanzapine in 2.5mg decrements every three months to six months while maintaining his dose of valproic acid (Table 6 and 7). 

 

Table 6

March Year 6June Year 6Sep Year 6March Year 7June Year 7

·5 mg am and 10 mg hs·valproic acid continued at 500 mg am and 625 mg hs (613 umol/L)·2.5 mg am and 10 mg hs·valproic acid continued at same dose (506 umol/L)·10 mg qhs·valproic acid continued at same dose (506 umol/L)·5 mg am and 2.5 mg hs·valproic acid continued at same dose (630 umol/L)·5 mg hs·p.r.n.s used 2x to address initial insomnia ·valproic acid continued at same dose (635 umol/L)

Table 7

July Year 7Oct Year 7Nov Year 7

·p.r.n. medication used 2x·Bipolar charting supported mood stability·Environmental stressor indicated·p.r.n. medication used 5x·Limited bipolar symptoms·Increase in aligning items symmetrically·p.r.n. medication used 5x·No evidence of mood deterioration·Fearful statements·valproic acid dose unchanged (512 umol/L)

 

Table 8

Dec Year 7Jan Year 8Feb Year 8March Year 8

No PRN UsageNo PRN UsageNo PRN UsageNo PRN Usage

 

 

 

 

Mr. A remained euthymic, and p.r.n. medication was not administered until his regular dose of olanzapine was tapered to 5mg h.s.  At that time, the p.r.n. medication was administered on two occasions to address initial insomnia.  The p.r.n. medication also was administered on two occasions during the summer of year 7 for insomnia and psychomotor agitation.  This change in presentation was attributed in part to Mr. A's regular community residence support worker being on holidays as well as his seemingly low tolerance for hot weather.  The p.r.n. medication, although used infrequently, was effective in addressing Mr. A's periodic occurrences of initial insomnia and psychomotor agitation with no adverse effects. 

In the fall of year 7, there was in an increase in the p.r.n. administration, and his community residential support workers were concerned that his mood was deteriorating.  It was noted that Mr. A was engaging in the following behaviors:  Aligning items symmetrically, which had increased in both frequency and intensity, avoiding the dinner table, difficulty waking in the morning, and making statements of a fearful nature.  Through interviews with family and staff, direct observation of Mr. A by the DDS clinician as well as the discussion with the DDS psychiatrist, it was determined that Mr. A's presenting difficulties were not consistent with the previously known symptoms of his bipolar disorder.  In addition, bipolar charting completed by the community residence support workers did not substantiate any sustained periods of mood deterioration or elevation.  Of note, Mr. A had a similar presentation two years prior during a distressing life event.   Upon further exploration of biopsychosocial factors, it was revealed that Mr. A had witnessed a housemate's physical assault and this appeared to coincide with the change in Mr. A's presentation. Through family advocacy, environmental changes were recommended and his housemate who committed the assault was removed from the home.  Supportive measures were also put in place by the community residence support workers.  Soon thereafter, the behaviors of concern resolved and no p.r.n. medication was administered. (see Table 8)  His family asked that Mr. A remain on the olanzapine 5mg dose, as they did not feel that further reductions in his dose were needed, which was respected by the DDS. 

At the time of Mr. A's discharge from the DDS, his affect was bright, and he was beginning to communicate with intent.  Through the combination of regular clinical reviews between the DDS psychiatrist and mental health clinician, and the use of objective charting, direct observation as well as collaboration with Mr. A's family and support team, Mr. A's dose of olanzapine was successfully decreased from 17.5mg daily to 5mg daily over a fifteen-month period.  Consequently, Mr. A lost weight, he experienced less sedation, and his energy improved, which increased his level of physical activity.  There was a reduction in medication adverse effects that previously included cogwheel rigidity, tremors, and drooling. Additionally, the p.r.n. protocol helped community residential support workers manage times of difficulty, as it provided a progression of responses to Mr. A's difficulties as well as when, why and how to use the p.r.n. medication.  The p.r.n. evaluation template also served as a "red flag" in that the increased p.r.n. usage signaled his support team that there was a change in Mr. A's progress.  The focus of his treatment then became one of developing and strengthening his adaptive living skills, celebrating his wellness, and recognizing the important role of eliciting family support in the process of optimizing his mental health care.

Case Study 2-Ms. W

The following case study illustrates the application of the p.r.n. protocol and evaluation templates in the context of a wellness plan for an individual who is diagnosed with schizophrenia and OCD.   Although the DDS had used p.r.n. medications as a part of the pharmacological treatment plan, as trials for higher doses of a medication to determine the amount of drug that could be tolerated in the absence of side effects, and to test tolerability in advance of introducing a maintenance dose, the purpose of this case study is to emphasize the collaboration between the individual, her family, and the DDS as well as to highlight the adaptability of the templates. 

Ms. W was referred to the DDS when she was sixteen years old.  She functions within the moderate range of developmental disability, etiology unknown. The year prior to her referral, Ms. W was admitted to a children's psychiatric facility, as she was experiencing auditory hallucinations involving all five senses, paranoid features, social withdrawal, and mood lability, and she was engaging in ritualistic behaviors such as cleaning, organizing and arranging, and hand washing. She was diagnosed with schizophreniform disorder, and her rituals were attributed to the psychotic disorder.  A trial of antipsychotic medication was initiated with some benefit. 

Following her initial assessment with DDS, Ms. W was diagnosed with schizophrenia and OCD.  The ritualistic behaviors were attributed to the OCD, as the onset of these symptoms predated the psychosis.  There were several trials of medications including neuroleptics, antidepressants, mood stabilizers, and anxiolytics to target ongoing symptoms.  Optimizing Ms. W's pharmacological treatment was an ongoing challenge, as her psychotic symptoms only partially responded to the medications, and it appeared that efforts to treat the OCD symptoms exacerbated her psychotic symptoms.  Moreover, Ms. W experienced numerous adverse effects secondary to her medications including rigidity, tremor, weight gain, urinary incontinence, loose stools, and peripheral edema. Therefore, as a part of her treatment plan, Ms. W was prescribed p.r.n. medication to use during times when she experienced an increase in her auditory hallucinations. 

Prior to meeting with Ms. W and her family to complete the p.r.n. protocol template, the clinician compiled her past and current clinical presentation as well as other known biopsychosocial information. At the meeting, Ms. W and her family were asked to not only give feedback on the information already completed, but to also add information to the template to reflect their thoughts, feelings, ideas, and experiences.  The DDS believed it was essential to capture the experience and knowledge that Ms. W and her family had regarding her struggles and challenges.  As well, to ensure the protocol was a "best fit," it was agreed that the headings would be amended to reflect person-centered language (i.e., "What I am like when I am feeling good," etc.). Additionally, as it was expected that both Ms. W and her family would use the p.r.n. protocol, additional subheadings and known precipitating factors (triggers) were included. There was a significant amount of detail and emphasis placed on the daily wellness tools and non-pharmacological strategies that could be used to help Ms. W feel as good as possible and that could help her when she began experiencing troubling symptoms (see Table 9).  Ms. W and her family also gave direction on the language they wanted to use, the format that would work best for them, and even the color of the paper on which the protocol was printed. 

 

 

 

 

 

 

 

 

 

 

 

Table 9

p.r.n.  PROTOCOL

Name:  Ms. W.     

Contributors:  Ms. W, Ms. W.'s family, DDS

Biopsychosocial Profile:  Ms. W has a diagnosis of a Schizophrenia and Obsessive Compulsive Disorder, as well as a moderate developmental disability 

 "A column" What I am like when I am feeling good"B column" Warning Signs-These are signs of change that indicate I may need to take some action."C column"Things have progressed and are getting worse- I am having trouble copingFollow-up

I &ldots;oAm happy oAm easy to please oLike to laughoLike to smileoAm funnyoLike spending time with family and friendsoEnjoy going out to do things (shopping)oEnjoy listening to music Signs I need to watch out for&ldots;oHearing "bad" voices (such as voices saying they are going to kill or hurt me)oHearing voices or noise from the television, radio or other musicoSeeing things that others can't (such as people, shapes)oScared that others are trying to hurt meThings others might notice:oStaring off or looking back and forthoLooks like reacting to something that isn't there - such as yelling out for no apparent reason, whispering or talking to selfoDoesn't respond or slow to respond when spoken tooSocial withdrawal and lack of interest in activitiesKnown triggers include:oLots of noiseoStressful situations oDeath of a friend or loved oneðIf one or more Warning Signs are still present after 10 minutes AND do not get better with the things that I can do to help me feel better&ldots; then go to my action plan

Things I can do everyday to help me feel as good as possible: Things I can do to help me feel better or relieve troubling symptoms: Action Plan: Follow-up

oGo for my injectionoGet to bed and sleep on time oGo for a walk or other things that get me moving (park with sisters, bike, bowling, swim) oEat healthy foodoDo relaxation exercises that my clinician showed me - tighten up my muscles, release and then pretend to blow up a balloon and then repeat 3 timesoLimit the junk food (pop, chips, sweets)oSpend time with my family and friendsoTalk to people I trust about my thoughts and feelingsoTake a bubble bathoSingoDo the  relaxation exercises that I learned oTalk to people I trust about what's bothering me and how I am feelingoDo something to help me feel safe (such as being around my family, getting a favorite item to hold onto)oLook at my memory bookoListen to music, dance and singoGo for a walkThings others can do to help me&ldots;oTry to find out what I am experiencingoAcknowledge my feelingsoReassure me that I am safe and that you are there for me and trying to help meoAllow me to talk about how I am feeling (if I want to)oReduce unnecessary stress or demands, but try to keep the family's routineoDon't try to convince me that what I am experiencing isn't happening - try instead to focus on the here and nowoRemind me to do the breathing exercise ðTake a p.r.n. Fluanxol - this is the medication that can help with my voices I can also&ldots;.Continue to do the things I can do to help me feel better or relieve troubling symptoms Fill out the p.r.n. protocol tracking form 

 

Initially, the family had been completing the p.r.n. evaluation template as outlined in Table 2, however, this form yielded limited information, as the family found it difficult to complete and were uncertain as to what information to include.  In an effort to facilitate the required charting, the p.r.n. evaluation template was amended to meet the needs of Ms. W and her family.  The formal, clinical language of the headings were changed and replaced with descriptive titles.  The "Warning Signs" or behaviors observed as noted in the p.r.n. protocol were included as checkboxes in the evaluation template, so that Ms. W's symptoms could be more easily tracked.  The column for "Time to Calm" was also filled with checkboxes reflecting 15-minute timeframe intervals up to 60 minutes, as well as a checkbox for no response to the p.r.n. medication.  There was also space left for additional comments or concerns such as location, medication effects (see Table 10). 

 

 

Table 10

DateTime of p.r.n.What was happening before or at the time of the p.r.n.?Time to Calm (decreased behaviours)Comments/ Concerns

qHearing "bad" voices qHearing voices or noise from the television, radio or other musicqSeeing things that others can't qScared that others are trying to hurt meqStaring off or looking back and forthqLooks like reacting to something that isn't there - such as yelling out for no apparent reason, whispering or talking to selfqDoesn't respond or slow to respond when spoken toqSocial withdrawal and lack of interest in activities-qOther:qBetween 5-15 minutesq15 to 30 minutesq30 to 45 minutesq45 to 60 minutesqOtherqNo Response

 

 

Through the years, it has become evident that Ms. W is a bright, cheerful, and cooperative individual.  She is able to communicate effectively, is able to self-report, and has insight regarding her symptoms as well as knowledge about her medications. Ms. W also is motivated toward learning new skills, and she has goals for her future. She has a supportive family and social network.  Despite on-going difficulties relating to her mental health, they remained dedicated to and supportive of her in her recovery efforts. 

The process of creating the p.r.n. protocol has built upon Ms. W's strengths and has helped her and her family gain a better understanding of her needs and wants.  Reviewing the components of the p.r.n. protocol has become a part of the regular follow up discussions and is revised as needed.  Further, this process also provided an excellent opportunity to educate Ms. W and her family not only about her psychiatric symptoms and treatment plan, but also it has provided a common language for Ms. W, her family, and the DDS in describing her symptoms.  Ms. W and her family have also discovered non-pharmacological alternatives that help reduce or alleviate her symptoms and focus on positive strategies and goals rather than the struggles and crises. 

Discussion

The use of p.r.n. medication as part of a pharmacological treatment plan is commonplace in mental health settings, yet the literature suggests that even in psychiatric hospitals there exists confusion and inconsistencies around its administration, documentation, and evaluation.  Service providers may be hesitant to consider the use of p.r.n. medication in community-based settings in the absence of clear procedures around their use, fearing potential medication errors and/or misuse.  It has been DDS' experience that there continues to be some resistance to using p.r.n. medications.  Over the years, the following rationales have been discovered:  

1.The history of over-use or misuse of psychotropic medication with individuals with developmental disabilities is frequently cited as one reason that family members and direct care staff are resistant to administering any medication, let alone p.r.n. medication. 

2.There is often reluctance to using p.r.n. medication to treat symptoms of illness, as there is a preference instead to use non-pharmacological interventions.  

3.The paucity of behavior therapy support (often not involved or only involved sporadically) contributes to uncertainty around optimization of non-pharmacological approaches, and therefore one concern is that there would be an over-reliance on p.r.n. medication.

4.Family members and direct care staff are unclear on what constitutes medication efficacy, in that all behaviors, both positive and negative, are attributed to p.r.n. medication effects.

5.Having to use p.r.n. medication during a crisis situation is viewed as a skill deficit or inadequacy in the community residential support worker's abilities to support the individual during difficult times or mental health crises.  There is also fear that they will be reprimanded for using the p.r.n. medication. 

6.Front-line workers are often uncomfortable with documenting p.r.n. usage, efficacy, and adverse effects, as in many cases, they have received little training in the area of pharmacology and medication administration practices.  Moreover, there appears to be a lack of consistent policies and procedures, and auditing of medication practices across community settings. 

The reluctance to consider the use of p.r.n. medication can in turn potentially expose individuals to delayed treatment of acute symptoms, escalation of mental health crises, and/or unnecessary hospitalizations.   In an effort to reconcile these concerns, the p.r.n. protocol and p.r.n. evaluation templates were developed to provide consistency and predictability for crisis response and p.r.n. medication administration, which may help to alleviate many of the concerns expressed by families and direct care staff.  Moreover, the inclusion of individualized, non-pharmacological interventions helps to shift the focus away from a reactive response to difficult situations to proactive interventions.   The combination of these tools, along with education for the individual, families, and direct care staff on mental illness and/or other diagnoses as well as prescribed medications, have been successfully used by the DDS in Northeastern Ontario to safely achieve therapeutic and systemic goals such as:

1.safely lowering regular dosages of prescribed medication based on the application of sound pharmacokinetic principles (as suggested by King, Wilson, and Atchison, 2008), 

2.collecting information on non-pharmacological approaches to optimize their use,

3.building capacity of individuals, families and direct care staff in the use, monitoring, and evaluation of medication, as well as in skills needed to prevent and/or cope with crises,

4.reducing ambiguity of prescribed p.r.n. medication and lessening the likelihood of errors and misuse, 

5.working in partnership with other services to ensure a biopsychosocial approach to understanding and supporting individuals' needs including safe trials at lower doses to test medication tolerability by tracking the effects of the medication, both positive and negative

6.collecting information on an individual's response to specific classes of medication for consideration for future regular use, and 

7.delivering quality mental health services to individuals with developmental disabilities in community-based settings and avoiding unnecessary hospitalizations.

Conclusion

It has been DDS' experience that the p.r.n. protocol and p.r.n. evaluation templates are effective tools that can be used to educate individuals, families, and team members about the role of p.r.n. medication within a holistic treatment plan.  The p.r.n. protocol template is a tool that can be used by both the individual and their supports to create a practical guide to assist during times of crisis as well as part of an individualized wellness plan.  The p.r.n. evaluation template can assist the clinical team by alerting them that there is a change in the mental health status of the individual.  It also assists in the evaluation of the efficacy and tolerability of the p.r.n. medication.  Using the p.r.n. protocol and evaluation templates, protocols have been successfully developed and used in a variety of settings by people with various degrees of knowledge and experience levels including individuals, family members, and direct care staff. 

The Developmental Disabilities Service is currently developing guidelines and a workbook to assist individuals, families, and direct care staff in creating individualized protocols.  Research is needed on the applicability the p.r.n. protocol and evaluation templates in various environments including inpatient settings.

 

 

Acknowledgements:  The authors wish to thank the individuals and their families who so graciously consented to sharing their experiences with using the protocol, and for teaching us so much.  We'd also like to thank Dr. Paul Eshleman and Dr. Robert King for sharing with us their knowledge and for their support.  Much appreciation to Jay Bruckner for her administrative support.

 

 

 

References:

CPI © (Crisis Prevention Institute), Non-violent crisis intervention. Retrieved from http://www.crisisprevention.com/index.html

Craven, J., Voore P., & Voineskos, G. (1987). p.r.n. medication for psychiatric inpatients. Canadian Journal of Psychiatry, 32, 199-203.

Curtis J. & Capp K. (2003). Administration of "as needed' psychotropic medication: A retrospective study.  International Journal of Mental Health Nursing, 12, 229-234.

Donat, D. (2006). Impact of a clinical-administrative review procedure on reducing reliance on psychotropic p.r.n. medication. Psychiatric Rehabilitation Journal, 29(3), 215-218.

Hodboden  K. & Leroy, B. (2008). Assessing mental health concerns in individuals with     intellectual disabilities.  NADD Bulletin, 11(3), 45-51.

Jordan, J. (2004). Usage of PRN medications in persons with developmental disabilities:  chemical restraint vs. therapeutic intervention. NADD Bulletin 7(2,) 28-31

King R., Fay G. & Croghan, W. (2000).  Pro re nata:  Optimal use of psychotropic p.r.n. medication.  Mental Health Aspects of Developmental Disabilities, 3(1), 1-9.

King, R., Wilson, J. & Atchison, J. (2008). PRN protocols:  Applying pharmacokinetic principles to practice; supporting individuals with developmental disabilities and mental health concerns in community settings. Mental Health Aspects of Developmental Disabilities.  11 (3): 79-84.

Usher K., Lindsay D. & Sellen, J. (2001). Mental health nurses' p.r.n. psychotropic medication administration practices.  Journal of Psychiatric Mental Health Nursing, 1(8), 383-390.

Usher, K. & Luck, L. (2004). Psychotropic p.r.n.:  A model for best practice management of acute psychotic behavioural disturbance in inpatient psychiatric settings.  International Journal of Mental Health Nursing, 13, 18-21.

 

For further information, please contact Jay Bruckner at: JBruckner-Price@NEMHC.ON.CA