by Jerry H. Gurwitz, MD
At any point in time, approximately 1.5 million Americans reside in the nearly 16,000 nursing homes across the United States.(1) In 2008, 2.8 million Americans, or 7.2% of the population aged 65 and older, had a nursing home stay.(2)
The nursing home setting provides a very complex set of challenges to providing safe and high-quality care for a vulnerable patient population. A confluence of forces and special circumstances combine to place the elderly nursing home resident at special risk for preventable drug-related injuries and close calls.(3) Nursing home residents are far likelier than non-institutionalized older persons to have multiple chronic medical conditions, be functionally impaired, lack economic resources and family caregivers, have cognitive deficits, and to be taking large numbers of medications. Nearly half of all nursing home residents require extensive assistance with at least four of five activities of daily living (bed mobility, transferring, dressing, eating, and toileting).(2) Nearly 70% are reported to have cognitive impairment and one-third have severe bowel and bladder incontinence. Taken together, these factors make the nursing home environment one of the most complicated and challenging clinical settings in all of medicine and place older persons residing in nursing homes at substantial risk of iatrogenic injury. Paradoxically, the nursing home setting is also one in which there is often remarkably little physician involvement, especially in view of the severity and complexity of the residents cared for there.(4) Moreover, the way in which the financing of nursing home care is currently configured does not incentivize substantial financial investment in interventions that might lead to genuine improvements in the quality and safety of care in this setting.(5)
Adverse drug events in nursing home residents are common and often preventable.(6) A study of residents of two large academic long-term care facilities indicated that the overall rate of adverse drug events was nearly 10 per 100 resident-months, of which 40% were considered preventable.(7) Errors associated with preventable drug-related injuries occurred most often at the ordering and monitoring stages of pharmacotherapy. Residents taking medications in several drug categories—including antipsychotic agents, anticoagulants, diuretics, and antiepileptic medications—were found to be at special risk for preventable adverse drug events.
The quality and safety of warfarin therapy in the nursing home setting have come under particular scrutiny.(8) Approximately 10% of nursing home residents receive treatment with warfarin therapy for various indications, but the percentage of time spent in the therapeutic range is less than 50%. Preventable adverse warfarin-related events and "near misses" (high international normalized ratios [INR] due to errors in management) in the nursing home setting are especially common. Overall, nearly 30% of adverse warfarin-related events (generally bleeds) are preventable. More severe events (i.e., serious, life-threatening, or fatal events) occur at a rate of 2.5 per 100 resident-months on warfarin therapy and 60% of these types of events may be preventable. The opportunity to provide highly effective anticoagulant therapy with newer agents, with equivalent or improved safety, and with reduced dosing and monitoring responsibilities, is an extremely attractive proposition.(9) Unfortunately, the promise of novel oral anticoagulants (e.g., dabigatran) as practical alternatives to warfarin in the nursing home setting has not yet been fulfilled. Unanticipated safety risks continue to emerge (10), and recent guidelines advise that these agents be used with caution in adults aged 75 and older, as well as those with creatinine clearance of less than 30 mL/min.(11)
Communication problems are prevalent in the nursing home setting, where many medical decisions are often made over the telephone, in the context of very brief conversations between the nursing staff and the physician or nurse practitioner. Many prescribing and monitoring errors stem directly from inadequate information at the time of ordering, including information about relevant medical conditions, concurrent medications, potential drug interactions, and pertinent laboratory test results. These difficulties are compounded by the complexity of medication regimens, the involvement of multiple covering providers who have little knowledge of the patient, and an underdeveloped health information technology infrastructure, limiting the ability of the prescriber to access key information about the resident off-site. Transitions between the nursing home, the emergency room, and the hospital are very common in this patient population and add further to increasing the risk of medication errors and preventable adverse drug events.
Potential strategies for improving medication safety in the nursing home setting include enhanced inter-provider communication, improved approaches to medication reconciliation, and computerized provider order entry systems with sophisticated clinical decision support systems that incorporate relevant clinical information. Although computerized provider order entry with clinical decision support has been shown to improve the quality of medication prescribing in the long-term care setting (12), there is not yet clear evidence that these types of interventions reduce the occurrence of adverse drug events in nursing home residents.(13) Structured communication strategies, including the use of SBAR ("Situation, Background, Assessment, and Recommendation"), to guide telephone discussions between nursing home staff with off-site prescribers may hold special promise for improving medication safety. This approach has been used in the nursing home setting with a positive impact on the quality of warfarin management.(14)
Combining multiple different strategies simultaneously may be required to generate a meaningful impact on the quality and safety of medication use in the nursing home setting. Approaches that combine both high- and low- (or no-) technology components may prove particularly beneficial. Even sophisticated computerized clinical decision support systems, when implemented in isolation and exclusive of efforts to improve communication between health care providers, may have only limited benefits. The use of high functioning, multidisciplinary teams, comprised of physicians, nurse practitioners, nurses, clinical pharmacists, and other health professionals, has the potential to improve quality of care across many domains including pharmacotherapy. Unfortunately, there remain many organizational and financial barriers to the widespread implementation of such approaches in the long-term care setting.
Jerry H. Gurwitz, MD
The Dr. John Meyers Professor of Primary Care Medicine
Professor of Medicine, Family Medicine and Community Health, and Quantitative Health Sciences
Chief, Division of Geriatric Medicine
Executive Director, Meyers Primary Care Institute
University of Massachusetts Medical School
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3. Gurwitz JH, Field TS, Tjia J, Mazor K. Improving medication safety in the nursing home setting: the case of warfarin. In: Joint Commission. The Value of Close Calls in Improving Patient Safety. Oak Brook, IL: Joint Commission Resources; 2010. ISBN: 9781599404158.
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