tracer Methodology

Medication Management in Hospital Psychiatric Units

H

ospital-based psychiatric units have particular issues that need to be addressed when evaluating their

medication management processes. Most specifically, issues related to transitions in care, storage, administration, and assessment can present particular challenges.

While every aspect of the medication management process should be taken into consideration, certain common problem areas could benefit from additional attention, including the following:

• What types of medications are typically being dispensed?

• How do these medications need to be stored?

• What type of relationship should exist with the pharmacy to facilitate the ordering and delivery of these medications?

• How is medication management factored into discharge planning?

Patients receiving psychiatric care can be hospitalized for a number of reasons, including medical, psychiatric, or a combination of emergencies that may warrant stabilization and medical care in one area of the hospital but could

also necessitate additional care within a psychiatric unit. Regardless of how a patient presents at the hospital, explains Jane Schetter, RN, MSN, CJCP, senior Continuous

Service Readiness (CSR) consultant at Joint Commission Resources, if the patient requires psychiatric treatment during his or her hospitalization, certain key elements should be considered when planning for the medication management needs of the patient.

“Medication management in and of itself represents a complex area of care, and where and how emphasis is placed will largely depend on the patient’s experience and particular medication needs,” she adds. If, for example, a psychiatric patient was taking medication on admission, then medica- tion management should ensure that interactions are safe, appropriate, and factored into care after the patient is dis- charged.

Organizations should be aware that a patient receiving psychiatric care might be admitted to other units in addition to the psychiatric department, depending on the reasons for his or her hospitalization.

Transitions of Care

Another important area for hospitals to consider are transitions in care for psychiatric patients as they move through the organization. “A patient may require intensive care unit (ICU) treatment initially and undergo a specific course of medication,” Schetter says. “But then after they are transitioned into the psychiatric unit there may be additional

medication needs that need to be managed.” Schetter adds that, based on any specific treatments that the patient may have already been receiving, such as participation in an opioid treatment program, specific plans may need to be in place to effectively manage this process. Communication and documentation should also be clear to ensure that the patient is not at risk during transitions from one area of care in the hospital to care in the community or on an outpatient basis.

The assessment and reassessment of psychiatric patients should also be factored into the medication management processes. This is not only important to the ongoing care needs of patients, explains Schetter, but is also helpful when considering actions to prevent suicide. “This is especially important if a patient has expressed suicide ideation or attempted suicide using medication,” she notes. The security of medications and their appropriate administration should be carefully tracked and monitored by unit staff.

Teamwork is also particularly critical in relation to planning for effective medication management in psychiatric units. “When you work as a team, you can better manage and understand the medical needs of a patient through the input of different health care practitioners, particularly if

the patient is being administered medications for psychiatric care,” explains Schetter. Effective teamwork is enabled by clear lines of communication and by ensuring that the

team is comprised of the right members. “Optimize your medication management planning processes by involving as many staff as possible who may be involved in that patient’s care,” she adds.

Above all, the most effective medication management processes are those that consider the different types of patients the hospital serves and the particular risks to their care. By placing specific focus on how the medication management process functions in the hospital psychiatric unit, hospital can reduce the risk of harm to patients that they serve.

The Scenario

This tracer took place in a hospital in an urban area in the southwestern United States. The tracer followed the

experiences of a patient who was admitted to the psychiatric unit via the emergency department (ED) of the hospital. A review of the patient’s record revealed that he was directed to the ED by his private-practice psychotherapist after

he expressed suicidal ideation and had exhibited reckless behavior that resulted in injury, which needed urgent treatment. After being stabilized and treated in the ED, he was admitted to the psychiatric unit. Additional notes in his record indicated that prior to the hospitalization the patient had been taking an antidepressant, an antianxiety

“

The assessment and reassessment of psychiatric patients should also be factored into the medication

management processes. ”

medication, and one antipsychotic medication, as well as a daily antihistamine, an artificial thyroid hormone, and a multivitamin. During the tracer, the surveyor examined the hospital’s medication management processes, particularly

in relation to its psychiatric unit. [1, 2, 3] The tracer also explored suicide risk management, assessment and care planning, and discharge planning.

Exploring medication management processes in the hospital. The surveyor asked to meet with pharmacy staff, the admitting physician in the ED, the social worker assigned to the patient, the patient’s inpatient psychiatrist, and the nurse manager on the psychiatric unit to discuss

not only how a psychiatric patient might be admitted to the unit through the ED, but also to explore what medication management issues are considered on admission to the unit, including ongoing assessment and processes for medication administration and secure storage. [4, 5, 6]

The patient’s record indicated that, while he was hospitalized, his antidepressant dose was increased and a second antipsychotic medication was prescribed and administered. It was expected that he would continue

these medications postdischarge. The surveyor asked the staff how they were planning for and documenting the patient’s discharge. A discussion revealed that the hospital did not have a standardized process in place to document justification for keeping the patient on more than one antipsychotic postdischarge. [7, 8]

Moving forward. The group discussed improving its processes and improving training and communication related to postdischarge medications, such as the patient

continuing on more than one antipsychotic. Going forward hospital leadership decided to review their medication management processes to determine if any modification was necessary. A multidisciplinary team was convened to develop a standardized process for documenting in the electronic medical record when patients are prescribed more than one antipsychotic medication postdischarge.

Sample Questions

The following represent some questions that could be asked during a tracer. Use them as a starting point to plan your own tracers.

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Tracer Methodology 101

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1. What is your medication management process? Who is responsible for its oversight?

2. What specific processes do you have in place to assess medication management needs in relation to psychiatric patients? How is this documented?

3. How often do you evaluate the effectiveness of your medication management system? What is your process to make modifications to the system, if appropriate or warranted? How is this documented?

4. How are psychiatric patients assessed when admitted through the emergency department (ED)? When patients transition to another area of the hospital from

   the ED, how is this handled and documented?

5. What is your process for medication administration? How is this documented?

6. Can you explain how you secure medications? What processes do you put in place to monitor medication administration and usage for psychiatric patients, particularly when monitoring for suicide risk?

7. What do you do when a patient’s medication needs to be reviewed or modified? How is this documented? What

   is your process to reconcile medications?

   

8. What kind of discharge planning do you have in place for psychiatric patients, particularly in relation to any medications postdischarge? TS

Mock Tracer Tracking Worksheet:

Medication Management in Hospital Psychiatric Units

Use this worksheet to record notes and areas of concern that you identify while conducting your organization’s mock tracers. This information can be used to highlight a good practice or to determine issues, which may require further follow-up.

Tracer Team Member:

Tracer Patient or Medical Record:

Staff Interviewed: Unit or Department Where Tracer Was Conducted: