Communication Curbs Adverse Events

Abstract

JACQUELINE VANCE is director of clinical affairs for the American Medical Directors Association. She periodically compiles the Medication Management column for long-term care practitioners. ROBIN ARNICAR, who presented the case for this installment of Medication Management, is director of nursing at the Frederick Villa Nursing Center in Baltimore, and is president of the Maryland chapter of the National Association of Directors of Nursing Administration. She is an editorial advisor for this publication. Mrs. P, a 92-year-old woman, has been a resident of a skilled nursing facility for 6 months. Her recorded medical history is significant for mild renal insufficiency, hypertension, Alzheimer's disease, diabetes (type 2, non-insulin dependent), osteoporosis, and hypertension. Mrs. P's current medications include furosemide 40 mg once a day, potassium 20 mEq once a day, metformin hydrochloride 500 mg twice a day, donepezil HCl 10 mg once a day, and a multivitamin once a day. In addition, she is on a no-added-salt, no-concentrated-sweet diet. Mrs. P's blood pressure had become increasingly unstable. The nursing staff reported this to her attending practitioner, who was new to her care. He ordered captopril (an ACE inhibitor) to be started at 6.25 mg three times a day. Four days after starting this medication, Mrs. P began to complain of nausea. Her attending physician was notified and staff were told to observe her for further signs of gastrointestinal flu (which had been surfacing in the community). Her nausea increased over the following 2 days, she did not take her meals, and by the sixth day, Mrs. P had become diaphoretic, was vomiting, and had an increased and irregular heart rate. The attending physician was notified and Mrs. P was sent to the emergency department via 911. Her STAT blood work in the emergency room revealed a potassium level of 6.8 mEq/L (a normal potassium level is 3.5–5.0 mEq/L). ACE inhibitors may increase blood levels of potassium. The use of potassium supplements along with the use of an ACE inhibitor may result in excessive blood potassium levels. In addition, Mrs. P was reported to have mild renal impairment which may exacerbate her inability to clear the potassium effectively. The physician should have been alerted to the fact that the resident was already receiving a diuretic and potassium supplement as the effects on blood pressure may be increased. Furthermore, some diuretics make the increase in potassium in the blood caused by ACE inhibitors even greater. Have the patient discontinue use of the potassium supplement before starting on an ACE inhibitor. At the very least, one should order a basic metabolic panel (BMP) 1 week after the introduction of the drug. In this particular case, due to the patient's renal impairment, a check on the potassium should have occurred earlier, especially at the start of symptomology. The nurse reporting the increase in the resident's blood pressure may have benefited from utilizing the American Medical Directors Association (AMDA) guide, “Protocols for Physician Notification,” on changes of condition. The guide would have assisted the nurse in collecting and reporting all significant data to the physician including the current medication regimen and diagnosis. Had the nurse followed the protocols listed in the guide, both she and the physician would have been instructed to collect the resident's vital signs and would have performed an abdominal exam (which would have revealed a normal abdomen). The nurse would have informed the physician of the following: the patient's age and sex; the onset, duration, intensity, frequency, precipitating and alleviating factors, and any history of similar symptoms; any significant history of gastrointestinal disorders; her food and fluid intake patterns over the past week; her bowel movement frequency and patterns over the previous week; all current medications, including any recent changes, especially those associated with nausea, anorexia, and esophageal or gastric irritation; all current diagnoses; and any recent lab or diagnostic test results. The issues that are italicized here would have spoken volumes to the attending physician. Such a review may have revealed the need for an alternate treatment plan or follow-up testing including a BMP, especially since the attending physician was new to Mrs. P's care. Furthermore, at the onset of this patient's symptoms of nausea, the nurse should have completed a comprehensive assessment of the resident and not reported symptoms in isolation. A concurrent review of the resident's changes, including those recent changes in medication, may have revealed the source of the initial change in status that was exhibited on day 4. You can obtain a copy of AMDA's publication on Protocols for Physician Notification: Assessing and Collecting Data on Nursing Facility Patients-A Guide for Nurses on Effective Communication with Physicians, by going to www.amda.com/order.