Guidance - PRN medication in care settings

Introduction

When I’ve undertaken audits or inspections of services including care homes, supported living and domiciliary care services one of the areas that often requires attention is around PRN medication protocols. Sometimes I find that not all PRN medication has a individual PRN protocol or if the protocols are in place they lack the required detail. CQC inspection reports very often also contain reference to non compliance around PRN medication and protocols. In this article, I’ll share guidance which you can use to review your current policies, procedures guidance and practice around PRN medication.?

Definition

Pro re nata (PRN) medications are usually prescribed to treat short term or intermittent conditions and are not administered on a regular basis, for example to manage pain, anxiety, insomnia, or inhalers for the treatment of asthma or COPD. PRN medications are sometimes prescribed with varying dosages. Examples ‘Take ONE or TWO tablets FOUR times a day or ‘Take ONE tablet TWO to THREE times a day’.

Don't confuse PRN Medication with homely remedies. A homely remedy is a medicine used to treat minor ailments and are kept as stock to give people access to medicines that would commonly be available in any household. Treatment is limited to 48 hours. Self-care medicines are purchased for an individual resident for their use only and may be on the advice of a healthcare professional, usually to treat a minor ailment, which does not require a prescription. Certain self-care medications may be needed for PRN use e.g. lozenges for a sore throat. in these instances, the usual PRN guidance should be followed.

Prescribing of PRN Medications

If the PRN medication (or condition) is not suitable for treatment via self-care or homely remedy measures, staff should highlight this to their aligned GP practice for clinical review. If a PRN Medication is prescribed, prescriptions should:

? Include the indication for which the PRN medication is prescribed

? Include the maximum dose within 24 hours

? Have clear directions - ‘as directed’ is not acceptable

PRN Protocols

To ensure that the PRN medication is administered as intended, a separate PRN Protocol is needed for all PRN medications (whether prescribed or self-care).

PRN protocols should be person-centred and personalised to the individual resident. Protocols should be kept in an easily accessible location, including when staff are administering medication on the routine medication rounds (e.g. with MAR charts). PRN Protocols should include the following information:

? The name of the medicine

? Route of the medicine (e.g. oral)

? Dose

? Frequency

? Minimal time interval between doses

? Maximum number of doses in 24 hours

? Clearly state which order medication should be administered when there is more than one option and time interval between doses (e.g. variable doses or multiple analgesics)

? What the medicine is for

? Any non-pharmacological interventions (e.g. prunes for constipation)

? If the person has capacity to request or refuse the medication, as per a Mental Capacity Act and best practice principles

? Symptoms/cues to look for (which may be verbal or non-verbal)

? When to refer to a healthcare professional

? Date for review (see ‘Reviewing & Discontinuing PRN Medication section)

Administration of PRN Medications

A system should be in place to highlight to care staff that a PRN medication is available for use by an individual resident/service user. Care Staff should:

? Check the PRN Protocol for clear guidance on what the medication is being used for, what symptoms to look out for and when to offer

? Offer the medication to the person when they are experiencing symptoms. Do not limit the offers to the medication rounds, or the time of the medication round printed on the MAR. However, do not offer more frequently than the minimum interval between doses and the maximum dose in 24 hours allows

? Contact a healthcare professional if unsure of the quantity to administer

? Give consideration to residents who may not have the capacity to refuse medication offered

? Provide decision-making aids such as The Universal Pain Assessment Tool to assist residents/service users in describing their current symptoms

Documentation

When a PRN medicine is administered, the following should be recorded:

? The reason(s) for administering the PRN medication

? The exact time of administration

? The dose given (if a variable dose)

? MAR chart should be signed in usual manner

The administration of all medication should be recorded on the MAR chart immediately to prevent an incident or accidental overdose occurring. It is also good practice to record in the person's daily notes when they were offered each PRN medication. The outcome of giving the medication and if it was effective should also be recorded. Care staff may need to contact a healthcare professional if the medication does not have the expected effects or if the person experiences any adverse effects.

Reviewing & Discontinuing PRN medication

To determine the ongoing need and the efficacy of the PRN medication, regular reviews should take place. Dates for a formal review of the medication should be stated in the person's clinical/health records and the outcome of the review must be documented in the care plan. Time periods between reviews will differ between individual resident/service user's circumstances; however, it is suggested that PRN medications and their corresponding PRN protocols should be reviewed at least every 6 months, unless more frequently required. Reviews should be completed collaboratively, with the care setting, healthcare professional(s) and resident/service user or appointee, as appropriate.

Examples of questions to be considered during a PRN medication review:

? Is the indication for which the PRN medication is being used for still applicable?

? Has the medical condition for which the PRN medication is prescribed deteriorated?

? Is the expected outcome of the PRN medication being achieved?

o If not, should an alternative be considered?

? Is the resident taking or requesting the PRN medication frequently?

o If so, should this be considered to become a regular medication?

? Is the resident/service user requesting/taking the PRN infrequently?

o If so, is this medication still needed?

? Is the current quantity prescribed enough/too much?

If the decision is made to discontinue a medication:

? The discontinued item must be crossed through on the MAR from the date agreed (with a single line through any future administration boxes) and countersigned (following authorisation from a prescriber if a prescribed medicine)

? Do not cross out retrospective doses (where the doses have previously been administered)

? Notes and care plans should be updated

? Community pharmacy should be informed

? Remaining medication should be disposed of, as per the medication disposal policy.

? GP Practice to ensure item is removed from person’s repeat list on the clinical system (to reduce risk of items being issued inadvertently and for clinicians to have an accurate record of current medications)

Reducing PRN Medication Waste

To reduce unnecessary medication waste, care homes should:

? Check medication stock, quantity and expiry dates before re-ordering PRN medication.

? Only request the predicted required quantity of the PRN medication.

? Carry forward any unused PRN medication remaining at the end of the cycle (providing manufacturers expiry dates are followed correctly).

? Record carried over quantities of PRN medication on the MAR chart.

? Store PRN medication in original packaging. This is to maintain manufacturers expiry date information and may lead to a longer shelf life. (‘Date opened’ should be noted on all liquids, creams, and ointments).

It is also important to consider that some PRN medicines are not used or needed as regularly so they may not need to be ordered frequently. Frequent unnecessary ordering of certain PRN medication (for example, salbutamol inhalers or a glyceryl trinitrate (GTN) spray) may inappropriately flag poor symptom control or worsening condition.

CQC have also developed useful information When required medicines in adult social care - Care Quality Commission (cqc.org.uk)

If you need any support around medication audits, themed/mock inspections or compliance related issues across adult social care feel free to contact me via [email protected]