PRN Medication Research Articles

The effects of lockdown of work and activities for adults with multiple, complex needs including sensory impairments during the pandemic in 2020.

Sheltered work and leisure activities were locked down in at the Signo centre in March 2020 because of the COVID-19 pandemic. The Signo centre is a Norwegian national centre for adults with multiple, complex needs, including severe sensory loss/impairments. Tension and uncertainty rapidly spread among relatives and workers. To explore the impacts of the pandemic on residents, 24 adults living in Signo Vivo answered a semi-structured interview together with their primary worker. Additionally, reports on staff injuries and PRN medication between April and Aug of 2020 were compared to the period before the lockdown. The reports from the interviews included fewer stressful events for the participants, more rest and sleep, more time spent in their own apartments, and more time with smaller groups of workers. The reports on staff injuries and PRN medication showed decreased occurrence.

Are Opioids Agitating? A Data Analysis of Baseline Data from the STAN Study.

Agitation, a common dementia symptom often arising from untreated pain, lacks comprehensive research on its connection with opioids prescribed for long-term pain. This study investigated the relationship between opioid use and agitation in dementia patients. Participants (n = 188) were categorized into opioid, acetaminophen PRN, or no-pain medication groups. Despite higher reported pain levels in the opioid group, no significant differences in agitation were observed among the groups. In conclusion, opioid use for pain management in older adults with dementia did not significantly impact agitation, emphasizing the ongoing importance of proper pain management in improving dementia care and addressing agitation in this population.

Optimal Treatment of C3 Lamina in Cervical Laminoplasty

Results of C4-C6 laminoplasty with C3 laminectomy and C3-C6 laminoplasty were compared retrospectively. To clarify the difference between C3 laminectomy and C3 laminoplasty in cervical laminoplasty. Intraoperative damage to the semispinalis cervicis has been shown to lead to postoperative axial symptoms and reduced range of motion (ROM). To prevent this event, C3 laminectomy in cervical laminoplasty is considered superior to C3 laminoplasty. A total of 36 patients were included in this study: 20 patients (GroupA) of C3 laminectomy, C4-C6 laminoplasty compared with 16 patients (GroupB) of C3-C6 laminoplasty. We collected patient's background data, operative time, Japanese Orthopaedic Association (JOA) score, VAS score, and radiologic findings such as C2-C7 Cobb angle, ROM, C2 inter-spinous angle, and use of postoperative PRN medication were compared. There was no statistically significant difference in the C2-C7 Cobb angles between the 2 groups before and after surgery (P= 0.315). In ROM, there was a 17.7% decrease from 31.5 preoperatively to 25.9 postoperatively in Group A, and a 6.1% decrease from 29.3 preoperatively to 27.5 postoperatively in Group B. There was no statistically significant difference in ROM (P= 0.683). Postoperative neck pain (VAS) was significantly lower in Group A than in Group B both at 1week (P= 0.015) and 1month (P= 0.035) after surgery. The C2 inter-spinous angle was statistically significantly smaller in Group A than in Group B (P= 0.004). Clinical outcomes and surgical outcomes did not differ significantly between groups. If the C2 interspinous angle is wide and intraoperative semispinalis capitis damage can be minimized, it is worth trying C3 laminoplasty, but if the C2 inter-spinous angle is narrow, C3 laminectomy is recommended from the beginning.

The Red Square: A Healthcare Sterile Cockpit to Reduce Medication Errors.

Medication administration is one of many duties and responsibilities of school nurses and involves both scheduled and as-needed (prn) medications. When administering medications, school nurses also experience unscheduled student health room visits, as well as interruptions such as staff member inquiries, miscellaneous phone calls, and occasional safety drills, to name a few. These distractions, inherent to the school nursing position, can lead to medication errors and pose a risk to students. This article describes the concept of a health care sterile cockpit (red square) and a school district's use of innovation in the health room to improve medication safety and reduce errors. Other benefits of implementing the red square will be discussed.

Nurses' and patient' descriptions about forms of power in pro re nata medication participation in forensic psychiatric care: A qualitative secondary analysis.

Despite there being an emphasis on patient participation in their own care, it has been a challenge in pro re nata (PRN, as the circumstance arises) medication in forensic psychiatric care. The power imbalance in treatment relationships can be a barrier to patient participation and should therefore be further explored. This qualitative descriptive study aimed to explore the aspect of power in the descriptions of patients and nurses interviewed in a Finnish forensic psychiatric hospital about patient participation in PRN. A qualitative secondary analysis was conducted through the semi-structured interviews of the patients (n = 34) and nurses (n = 19). The data were analysed with deductive content analysis. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were used to ensure comprehensive reporting. The findings revealed that patients and health professionals may have conflicting goals in PRN and that they both use power to try to achieve them. Power in PRN was described in different forms, including authority, force, manipulation and persuasion. Based on our results, the power that health professionals have in PRN medication is particularly based on their legitimate authority and the hierarchical structures of the hospital environment. Patients also hold power in the dynamics of PRN medication care, but their position as a power holder can vary individually and situationally. Recognizing different forms of power and supporting patients with a decreased capacity for decision-making is essential for promoting high-quality and patient-centred forensic psychiatric nursing.

Scoping Review on Educational Programs for Medical Professionals on the Management of Acute Agitation.

Agitation is a common reason for psychiatric consultation in the general hospital. The consultation-liaison (CL) psychiatrist is often tasked with teaching the medical team how to manage agitation. The purpose of this scoping review is to explore what resources the CL psychiatrist has for educational tools on teaching about agitation management. Given the frequency with which CL psychiatrists help with on-the-ground management of agitation, we hypothesized that there would be a scarcity of educational resources to teach front-line providers how to manage agitation. Following current Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a scoping review was conducted. The literature search focused on the electronic databases MEDLINE (PubMed), Embase (Embase.com), The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Methodology Register), PsycInfo (EbscoHost), Cumulated Index to Nursing and Allied Health Literature (CINAHL) (EbscoHost), and Web of Science. Using Covidence software, after screening for titles and abstracts, full texts were screened independently and in duplicate according to our inclusion criteria. For data extraction, we created a predefined set of criteria according to which each article was analyzed. We then grouped the articles in the full-text review according to which patient population a curriculum was designed for. The search yielded a total of 3250 articles. After removing duplicates and reviewing procedures, we included 51 articles. Data extraction captured article type and details; educational program information (staff training, web modules, instructor led seminar); learner population; patient population; and setting. The curricula were further divided based on their target patient population, specifically the acute psychiatric patient (n= 10), the general medical patient (n= 9), and the patient with a major neurocognitive disorder such as dementia or traumatic brain injury (n= 32). Learner outcomes included staff comfort, confidence, skills, and knowledge. Patient outcomes included measurements of agitation or violence using validated scales, PRN medication use, and restraint use. Despite there being numerous agitation curricula in existence, we found that a large majority of these educational programs were done for patients with major neurocognitive disorders in the long-term care setting. This review highlights the gap in education related to agitation management for both patients and providers in the general medical setting, as less than 20% of total studies are focused on this population. The CL psychiatrist plays a critical role in assisting in agitation management in this setting, which often requires collaboration between technicians, nurses, and nonpsychiatric providers. It calls into question whether the lack of educational programs makes the implementation of management interventions more difficult and less effective, even with the assistance of the CL psychiatrist.

Live and recorded music interventions for management of delirium symptoms in acute geriatric patients: Protocol for a randomized feasibility trial

ABSTRACT Introduction Delirium is an acute alteration in attention, awareness, arousal, and cognition, precipitated by a sudden illness and highly prevalent in older, frail and acutely hospitalized patients. It is associated with poor outcomes, and few effective treatment alternatives. Non-pharmacological interventions and music show promising effects, warranting further research. This pilot randomized repeated measures trial aims to test feasibility of the trial methodology, acceptability, fidelity and safety of the music interventions, suitability of the effect-outcomes. and preliminary effectiveness. Method Acute geriatric patients with delirium or subsyndromal delirium will be randomized to Preferred Recorded Music (n = 30) or Preferred Live Music (n = 30), delivered for 30 minutes, over three consecutive days. Planned feasibility outcomes will comprise recruitment rate, retention and attrition rates, percentage of adherence, deviations rates, and success of treatment fidelity. Clinical outcomes will include: (a) trajectory of delirium symptoms: level of arousal as assessed by Observational Scale of Level of Arousal (OSLA) and modified Richmond Agitation Sedation Scale (mRASS); attention, assessed using backwards tests and digit span tests; orientation and short-term memory, assessed using recall tasks and orientation questions from Memorial Delirium Assessment Scale, (b) duration of delirium, (c) length of hospital stay, and (d) use of PRN medication (benzodiazepines and antipsychotics). Discussion The trial will provide results needed to design a subsequent sufficiently powered RCT, informing on the expected recruitment, feasibility and acceptability of the interventions and assessments and preliminary effectiveness

The use of physical restraints and PRN medications in adolescent psychiatric inpatient units.

Although physical restraint practices and psychotropic/sedative pro re neta (PRN, as needed) medications have been commonly used for managing inpatient aggression, little is known about the characteristics of adolescents who receive them in psychiatric adolescent inpatient units. We aimed to determine the relationship between the use of physical restraints and psychotropic/sedative PRN medications, and to characterize individual attributes, substance use, clinical factors, and time of the first restraint episodes of the use of physical restraints and psychotropic/sedative PRN medications. A retrospective case-control study approach was used with the data from electronic health records at a pediatric psychiatric hospital in the United States. Descriptive statistics, χ2 , multivariate logistic regression, and Cox proportional hazard model were used. Participants of younger age and participants with a longer length of stay were significantly associated with the use of physical restraints and psychotropic/sedative PRN medications, although the substance-related risks were not significantly associated with the use of restraints. Physical restraints were more likely to have occurred soon after the admission and tapered off as the length of stay increased. This study provides important information in understanding the risk factors of the use of restraints and psychotropic/sedative PRN medications in psychiatric adolescent inpatient units.

Anticholinergic Medications and Parent-Reported Anticholinergic Symptoms in Neurologically Impaired Children.

Children with severe neurological impairment and polypharmacy are exposed to anticholinergic (AC) medications that may have anticholinergic side effects, but this is understudied. Anticholinergic Cognitive Burden (ACB) scores measure total anticholinergic burden for a medication regimen, and scores ≥3 have been associated with increased morbidity and mortality in adults. We assessed the relationship between ACB scores and parent-reported anticholinergic symptoms in children. Cross-sectional study of patients one to 18 years-old with ICD-defined severe neurological impairment and polypharmacy. At routine clinical visits, total ACB scores were computed for all medications. Parent-reported AC symptoms (constipation, drowsiness, difficulty concentrating, dry mouth, or urinary problems) were assessed. Multivariable logistic regression was used to test the association between total ACB scores ≥3 for scheduled medications and the presence of AC symptoms, adjusted for age and recent acute healthcare utilization. Among 123 unique patients, 87% were prescribed AC medications. Common AC medication classes included: systemic antihistamines (64%), anxiolytics (53%), antidepressants (30%), H2 blockers (22%), and muscle relaxants (20%). Total ACB scores ≥3 were observed in 44% for scheduled medications and in 63% of patients for scheduled plus PRN medications. Total ACB scores ≥3 were significantly associated with an increased odds of ≥1 anticholinergic symptoms for scheduled medications (OR: 3.1; 95% CI: 1.4, 6.7) and for scheduled plus PRN medications (OR: 2.9; 95% CI: 1.3, 6.4). If replicated in larger populations, the association between elevated total ACB scores and anticholinergic side effects in children should prompt clinicians to consider deprescribing potentially unneeded anticholinergic medications.

1274. Implementation of Pharmacist-led Medication Reconciliation in Older PLHIV

Abstract Background Older (age ≥ 50) people living with HIV (PLHIV) have a higher prevalence of non-AIDS associated comorbidities and polypharmacy. Optimal care requires accurate knowledge of the number and types of medications older PLHIV take. Most providers use the electronic health record (EHR) to obtain this information, despite reported inaccuracy in other cohorts. Recent efforts have focused on engaging pharmacists to assist with EHR medication reconciliation. This abstract describes the results of a pilot study of phone-based, pharmacist-driven EHR medication reconciliation. Methods Older PLHIV reported via an online questionnaire the number of prescription medications they took, with response options ranging from “0” to “11 or more.” Then, a clinic-based pharmacist called each participant to review the daily and prn prescription medications they were taking. Finally, a physician reviewed EHR pharmacy data to count the number of daily and prn prescription medications listed. Wilcoxon rank sum tests compared the medians between the phone review, the self-reported questionnaire, and the EHR review. Results Forty participants were offered the intervention, and 26 (65%) were reachable by phone and agreed. Of those, the mean age was 61 years (range 51-73), 89% were male, 67% were White, and the mean number of self-reported comorbid conditions was 11.7 (SD=7.7). In 25/26 (96%) cases, both the number and type of HIV medications in the EHR matched what the pharmacist verified on the phone call. Median number of non-HIV medications are reported in Table 1. Assuming that pharmacist phone calls provided the most accurate data, the EHR overestimated the number of non-HIV medications by 5 medications (P = 0.01), whereas patients’ self-report underestimated by 1.5 medications (P < 0.01). Conclusion Among older PLHIV, EHR pharmacy data significantly overestimated, and patient self-report significantly underestimated, the number of non-HIV prescription medications. Phone-based, pharmacy-driven medication reconciliation improved upon both EHR-based and self-reported medication accuracy. Based on these findings, future interventions designed to decrease polypharmacy in older PLWHIV can rely upon pharmacist-led, phone-based outreach to ensure that baseline medication information is accurate. Disclosures Maile Y. Karris, MD, Gilead Sciences: Grant/Research Support|Gilead Sciences: I have received honorarium to speak at conferences|ViiV Healthcare: Grant/Research Support Peter J. Mazonson, MD, MBA, ViiV Healthcare: Grant/Research Support Lucas Hill, PharmD, AAHIVP, Gilead Sciences: Speakers Bureau Emily Huang, MPH, ViiV Healthcare: Grant/Research Support Jeff Berko, MPH, ViiV Healthcare: Grant/Research Support.

3.100 Evaluating the Need for Standardized Recommendations for ECG Monitoring in Pediatric Patients Who Take Psychotropic Medications

The number of pediatric patients on Q wave to T wave interval (QTc)-prolonging psychotropic medications has been on the rise. Although there have been reports of inconsistent ECG monitoring practices among those treating adults, knowledge is limited regarding the guidelines used among those who treat pediatric patients. This literature review sought to evaluate recent data on QTc monitoring practices with a specific focus on patients receiving PRN medications.

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study.

Psychotropic medications administered on an as-needed basis, often designated as pro re nata (or PRN, hereafter as-needed), can alleviate acute symptoms and facilitate deprescribing, although as-needed use is associated with negative outcomes such as polypharmacy and drug interactions. The aim of this study was to examine the extent to which PRN psychotropic medications are prescribed and administered to assisted living (AL) residents, overall and in relation to resident- and community-level characteristics. Cross-sectional study. All AL residents and select staff in 250 AL communities in 7 states. Data regarding prescribing and administration of 5 types of PRN psychotropic medications in the prior 7days (antipsychotics, mood stabilizers and antiepileptics, antidepressants, anxiolytics/hypnotics, and cognitive enhancers) were abstracted and compared across resident and community characteristics. Prescribing of PRN psychotropics in AL is low (10.3%). Of prescribed PRN medications, 2.5% of residents were administered a PRN and 8% had PRN that was not administered in the previous 7days. Anxiolytics were administered PRN more commonly compared with antipsychotics (2.0% vs 0.2%). Of all PRN psychotropic prescriptions (n= 1039), 70.5% had a written indication describing the reason for administration. Among PRN medications administered (n= 242), the proportion with an indication was lower (62.0%). PRN psychotropic medication prescribing was higher among residents with dementia and a psychiatric diagnosis, and in larger AL communities and those with a higher proportion of dementia care beds. The prescribing and administration of PRN psychotropic medications in AL is relatively rare, although more common among residents with dementia. Emerging psychotropic medication policies should be expanded to address mental health care, anxiolytic/hypnotic use for residents living with dementia, PRN prescribing in chart review, and the use of detailed indications for PRN use, especially when medications are administered by unlicensed care staff.

Sustainable Prescribing in Secure Services – a Quality Improvement Initiative

AimsIn 2021 The Department of Health published a report into the safer use of medicines in health and justice mental health services, advocating sustainable prescribing as a way of improving patient care and reducing carbon emissions. Improving prescribing behaviour could lead to a reduction of 170,000 kg CO2e per year across England, along with cost savings which contribute to higher value service provision and improved service user experience. We aim to evaluate and improve the prescribing of antipsychotic depot and ‘as required’ (PRN) medication in a male secure unit.MethodsBaseline data were gathered from the patient population in a male secure unit (1 low and 2 medium secure wards, total 50 beds) in December 2021. This included the number of patients prescribed a depot, the type of depot prescribed and whether or not these were administered at the longest evidence-based interval. As part of a wider trust initiative “prn” medication was moved to a fortnightly review cycle to ensure medication was used for as short a duration as necessary. Over a six-week period medication rationale was analysed and discussed with the Responsible Clinician for the service user to optimise prescribing. Data collected following this intervention was compared with baseline results.ResultsThe project found that 26 patients in the service were prescribed an antipsychotic depot in December 2021. In this group 17 (65%) were prescribed their medication at the longest evidence-based interval. Of the 9 (35%) that were not, 5 had clinical reasons why a change would not be appropriate at present, however it was agreed this could be considered later in their pathway. Of the remaining service users, two had their dose of medication reduced and their prescribing interval increased. “As needed” (PRN) medications of 15 patients were evaluated; 9 (60%) had medications prescribed which were not in use (4 patients had 3 or more prescribed not used within 2 weeks). Following intervention this reduced to 2 patients, both of which had only 1 PRN medication which required review.ConclusionDeprescribing can have a significant impact on patient care and safety and can reduce the environmental impact of a service. This project demonstrated the advantages gained from regular medication reviews and taking into consideration dose and administration interval when prescribing antipsychotic depots. Using protocols for prescribing as needed medications, a structure for reviewing prescriptions, collaboration with patients and utilising patient group directions where appropriate can all aid in improving prescribing sustainability.

Getting on the Same Page: A Quality Improvement Project to Enhance Nurse-to-Resident Communications and Reduce Overnight Sleep Interruptions.

Many residency programs utilize "home call" residents who answer hospital communications and place orders from home. Often, residents are required to live nearby and arrive in-person if needed. Residents work normal daytime work hours while on home call, which can last several nights. This disrupts sleep and creates the potential for increased resident fatigue and patient safety issues. To implement and evaluate a novel program to reduce non-urgent overnight pages from nurses to home call physical medicine and rehabilitation (PM&R) residents between 11 pm and 6 am. At an inpatient acute rehabilitation unit in a tertiary care university teaching hospital, we implemented a 2-step prospective quality improvement study with interventions derived from nurse-physician meetings implemented 9 months apart in 2018 and 2019. The first intervention was a centralized nightly handoff sheet. The second intervention was to display suggested PRN medication lists in resident workrooms. The primary outcome measure was the percentage of nights with non-urgent pages between 11 pm and 6 am. Tracking urgent pages and 7-10 am emergent pages were used as balancing measures. A total of 1835 text-based nursing pages (366 pre- and 1469 post-intervention) were received and categorized by content, urgency, and timing over a 17-month period. Post-intervention, there was a stable 25% decrease in nighttime non-urgent pages. The most common hour to be paged shifted from 11 pm to 8 pm. Pain, constipation, insomnia, and nausea were the most common complaints overnight. By characterizing and studying nighttime pages, residents collaborated with nighttime nursing staff through structured meetings to reduce non-urgent nighttime pages for more than 1 year.

Coercive containment measures for the management of self-cutting versus general disturbed behaviour: Differences in use and attitudes among mental health nursing staff.

ABSTRACTSelf‐harm is common in mental health facilities, and coercive containment measures are sometimes used to manage it. Nurses' attitudes towards these measures have been investigated in relation to disturbed behaviour in general, but rarely to self‐harm specifically. We therefore investigated mental health nurses' use of and attitudes towards coercive measures (seclusion, restraint, intermittent and constant observations, forced intramuscular medication, and PRN medication) for self‐cutting management compared with for disturbed behaviours in general using a cross‐sectional, repeated measures survey design. Participants were N = 164 mental health nursing staff. Data collection was via a questionnaire comprising validated attitudinal measures. The study is reported in line with STROBE guidelines. Physical restraint (36.6%), forced intramuscular medication (32.3%) and seclusion (48.2%) had reportedly been used by individuals for self‐cutting management. Respondents disapproved of using each coercive measure for self‐cutting more than they did for disturbed behaviour in general with the exception of PRN medication. Attitudes to coercive measures differed across target behaviours. Hence, nurses who had used each measure for managing self‐cutting disapproved of it less for that purpose than those who had not. Nurses who had used coercive techniques for self‐cutting management had less desirable attitudes to their use. We cannot say whether prior use of these techniques led to increased approval or whether greater approval led to an increased willingness to use them. Reducing the use of coercive techniques for self‐harm will require attitudes that support its use to be challenged. Less coercive techniques should be encouraged. Harm reduction techniques offer one such alternative.

Symptom Control at the End of Life

Symptom Control at the End of Life Abstract. Patients with advanced disease suffer from multiple physical and psychological symptoms. These include pain, weakness, lack of energy, weight loss, breathlessness, nausea and vomiting, constipation, and depression. In the dying phase, death rattle, delirium and terminal agitation may be additional problems. Palliative care focusses on alleviating these symptoms, taking into account the physical, psychological, social and spiritual dimension. Main principles of symptom control in palliative care are 1) considering differential diagnoses of the causes of the symptom to be able to treat potentially reversible causes, 2) using preventive measures and 3) symptomatic treatment - on its own or in combination with causal therapy. The following should be noted regarding pharmacological treatment: In case of permanent symptoms, the drugs have to be given at fixed times, in accordance with their duration of action, to achieve a constant blood level. In addition to this regular drug administration, prn medication should be prescribed, e. g., for pain, breathlessness, and nausea. If oral administration is not possible, drugs can be administered intravenously, subcutaneously or transdermally via patches. Non-pharmacological measures can be used additionally or primarily for symptom control. This paper presents important aspects of symptom control for pain, breathlessness, nausea and vomiting, constipation, and depression as well as for symptoms in the dying phase. It concludes by adding a few words on sedation in palliative care as a measure of last resort.

Evaluation of medication administration timing variance using information from a large health system's clinical data warehouse.

DisclaimerIn an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.PurposeAn analysis to determine the frequency of medication administration timing variances for specific therapeutic classes of high-risk medications using data extracted from a health-system clinical data warehouse (CDW) is presented.MethodsThis multicenter retrospective, observational analysis of 1 year of medication administration data from 14 hospitals was conducted using a large enterprise health-system CDW. The primary objective was to assess medication administration timing variance for focused therapeutic classes using medication orders and electronic medication administration records data extracted from the electronic health record (EHR). Administration timing variance patterns between standard hospital staffing shifts, within therapeutic drug classes, and for as-needed (PRN) medications were also studied. Calculated variables for delayed medication administration (ie, administration time variance) were created for documented administration time intervals of 30-59, 60-120, and more than 120 minutes before or after medication orders.ResultsA total of 5,690,770 medication administrations (3,418,275 scheduled and 2,272,495 PRN) were included in the normalized data set. Scheduled medications were frequently subject to delays of ≥60 minutes (15% of administrations, n = 275,257) when scheduled for administration between 9-10 AM and between 9-10 PM. By therapeutic drug class, scheduled administrations of insulins, heparin products, and platelet aggregation inhibitors (most commonly heparin flushes and line-management preparations) were the most commonly delayed. For PRN medications, medications in the anticoagulant and antiplatelet agent class were most likely to be administered early (<60 minutes from the scheduled time of first administration).ConclusionThe findings of this study assist in understanding patterns of delayed medication administration. Medication class, time of day of scheduled administration, and frequency were factors that influenced medication administration timing variance.

32.2 Relative Efficacy of Psychotropic Medications for the Management of Acute Agitation in Children and Adolescents in the Psychiatric Emergency Room

Children and adolescents frequently present to the emergency room (ER) with acute agitation and often require physical restraint (PR). Due to a dearth of evidence-based guidelines, clinicians may find it daunting to choose the most appropriate pharmacologic intervention in a given patient encounter. Our retrospective cohort study aims to compare the efficacy of psychotropic medications used to treat acutely agitated youth in our ER, as measured by the subsequent need for PR. A retrospective chart review of patients aged 5 to 17 years who visited our ER from January 1, 2019 to December 31, 2020 was conducted. Data on pharmacologic management of “agitation” or “aggression” were gathered to assess the subsequent need for PR use (primary outcome measure). Data analysis was completed to evaluate the relative differences between neuroleptic, anxiolytic, and combination medication use, and of PR use. We identified 1346 total admissions (630 males, 716 females), of which 59 (47 males, 12 females; average age 14.1 years) required PRN medications for agitation. Thirty-two patients (54.2%) who required medication received a combination of anxiolytics and neuroleptics, whereas 20 (33.9%) received anxiolytics alone, and 3 (0.05%) received neuroleptics alone. Thirty-two patients (54.2%) required PR despite pharmacologic attempts at de-escalation. Specifically, 23 (71.9%) who received combination medications, 7 (35%) who received anxiolytics alone, and 2 (66.7%) who received neuroleptics alone subsequently required PR use. The most common diagnoses among patients requiring PRN medications were ADHD (35.6%), ODD (33.9%), autism spectrum disorder (27.1%), and bipolar disorder (20.3%). Further analysis is being conducted for specific medications, formulations, and dosages. Our results correlate with current consensus guidelines for the potential benefit of anxiolytic medication use alone as compared to combination medication or neuroleptics alone in providing first-line pharmacological management of agitation in this patient population. Through continued research, we aim to give providers confidence to use anxiolytics to effectively de-escalate agitated patients. Further consideration should be given to tailoring pharmacologic approaches to the etiology of agitation and to reproducibly demonstrating these findings through prospective studies.

Patient Participation in Pro Re Nata Medication in Forensic Psychiatric Care: Interview Study with Patients and Nurses

Pro re nata (PRN, as-needed) medication is commonly used in forensic psychiatric inpatient care, but little is known about the participation of patients in its prescription and administration. This study describes patient participation in PRN medication treatment in forensic psychiatric inpatient care. Data were collected during interviews with 34 inpatients and 19 registered nurses in a Finnish forensic psychiatric hospital. The data underwent inductive content analysis. We found that patient participation in PRN was related to patients’ individual needs and health conditions, and the use of PRN involved private decisions made in the social context of the ward. PRN was an integrated part of daily care, and it involved three stakeholders, namely patients, nurses, and physicians; however, the role of patients in this collaboration was undefined. The administration events for PRN were multiform, and depended on the level of agreement between patients and nurses on the need for PRN. In the future, more attention should be paid to how to motivate patients and provide them with equal opportunities to be involved in the planning of PRN, and to optimize shared decision making so that the expertise of both patients and nurses is utilized in the administration and evaluation of PRN.

Quality improvement in remote prescribing

Quality improvement in remote prescribing