‘Lessons from Mid Staffs must not be forgotten’
STEVE FORD, EDITOR
06 December, 2021
After a tragic incident in which an older adult with known dysphagia aspirated on medication which contributed to a decline and subsequent death, a campaign was launched to improve awareness of medication management in people with dysphagia, This article comes with a handout for a journal club discussion
Older people with swallowing problems are more likely to encounter medication errors than those without dysphagia. Although recommendations on diet and fluids are considered after a swallowing assessment, medication formulation is often overlooked. A multidisciplinary approach is needed to ensure safety in medicines administration, particularly in this population. This article outlines why there is an identified need to improve and standardise practice in this area of care.
Citation: Hansjee D et al (2021) Ensuring medicine administration safety in older adults with dysphagia. Nursing Times [online]; 118: 1, 27-30.
Authors: Dharinee Hansjee is programme lead and senior lecturer in speech and language therapy, University of Greenwich; David G Smithard is consultant in elderly and stroke medicine, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, and visiting professor, University of Greenwich; David J Wright is professor of health services research, University of Leicester, and professor of clinical pharmacy, University of Bergen, Norway.
Many long-term conditions involve swallowing problems, and specifically oropharyngeal dysphagia (OD). Neurological, cardiorespiratory and musculoskeletal conditions, as well as frailty and malignancies, can lead to OD. As individuals age, physiological changes affect the swallowing mechanism and physiology (Baijens et al, 2016), so the prevalence of OD is likely to increase greatly in older populations (Smithard, 2016).
The physiological role of the swallow is to prepare the food bolus and ensure it can pass from the mouth to the stomach, without compromising the airway. In older adults, tongue pressure (Ono et al, 2009) and laryngeal elevation, as well as anterior rotation and the opening of the upper oesophageal sphincter, are reduced (Dejaeger et al, 2015). A smaller upper oesophageal aperture, combined with weak pharyngeal stripping wave pressures (reduced pharyngeal constriction or squeeze), could result in a swallow that is less safe than it would be for younger adults (Dejaeger et al, 2015). This may lead to food, fluid or medication residue staying in the pharynx after the swallow, thereby increasing the risk of aspiration after swallowing (Omari et al, 2013). Inadvertent and repeated diversion of food, liquid and medicine into the lungs can cause both upper and lower respiratory tract infections.
A serious incident occurred at a local NHS trust when an older adult with known dysphagia aspirated on a tablet, which contributed to a deterioration in health and their subsequent death. With multimorbidity, including a diagnosis of severe dysphagia, the robust protocols in place to reduce risks failed to prevent this. A discussion with the patient’s close relative revealed that no one had spoken to them at any point about the impact of the severe dysphagia on how they took their medicines. A small-scale audit at the same hospital then found that, although medication reviews were being recommended, there seemed to be little patient-related activity in this regard. Reviews of patients with dysphagia were also found to focus on the modification of diet and fluids, not on medication.
This article describes the main audit cycle that took place after educational activities were held with the pharmacy team. The results led to the creation of a campaign to improve the awareness of, and training on, medication management in people with dysphagia across all disciplines, including nursing and medical teams.
The management of OD requires a multidisciplinary, problem-solving approach, which includes speech and language therapists (SLTs), dietitians, nurses, pharmacists and doctors. The purpose of this approach is to not only formulate a care plan that enables the person with dysphagia to eat and drink adequate food and liquid, but also to determine how essential medication can be administered safely. The care plan will outline whether this can be done orally and/or via enteral means. Although the consistency of food and drinks are often modified, evidence suggests that the concurrent administration of medicines is often overlooked (O’Keeffe, 2018; Manrique et al, 2014).
English and international guidance – such as that by Malagelada et al (2015), the European Society for Swallowing Disorders (2013), Speech Pathology Australia (2012) and Wright (2002) – recommend that when a patient is diagnosed with dysphagia and prescribed medicines, the first action should be to review their medicines to determine whether:
With continuing evidence about the inappropriate use of medicines in older people (Delgado et al, 2021; Lucchetti and Lucchetti, 2017) and the potential harms associated with this (Xue et al, 2021; Muhlack et al, 2017), identifying dysphagia also provides an opportunity to address these additional concerns through medication review.
Inappropriate prescribing of medicines that increase anticholinergic burden, as discussed by Yrjana et al (2021) is of particular concern for patients with dysphagia, as these are known to affect the ability to swallow (Castejón-Hernández et al, 2021). As such, any review process should make sure such medicines are stopped wherever appropriate. Where possible, alternative routes of administration should be considered, including the use of creams, melts and patches. If there is no alternative and food is taken orally, a dispersible or liquid formulation should be considered.
“Crushing a tablet is an off-label use, which needs an evidence base and responsibility assumed by the person administering it”
A large-scale observational study based in older people’s wards across four hospital trusts in the UK found that people with OD were more than three times more likely to be at risk of medication administration error than those without (Kelly et al 2011; Kelly et al, 2009). Errors are often caused by a multitude of environmental and individual factors.
Medication errors may occur because practitioners often resort to crushing, cutting or dispersing medications that are not available in liquid form. Stubbs et al (2008) reported that medications were opened (capsules) or crushed (tablets) in 25.5% of solid-form doses. Of these, 44% were not authorised by the prescriber or pharmacist, tablet crushing was avoidable in 57.5% of instances by correctly using more suitable preparations and 4.5% were crushed against manufacturers’ recommendations. Altering a medication that has been specially designed for a patient, protecting the active ingredients or releasing them in a certain manner may result in patient harm (Barnett and Parmar, 2016).
Medicines that are prescribed as modified release or enteric coated/gastro resistant should never be altered. Administering a crushed or dispersed tablet or capsule in water exposes the patient with dysphagia to two different textures simultaneously, which makes aspiration more likely (Barnett and Parmar, 2016).
Medication-related errors in hospital could also be attributed to the fact that many medications are dispersible but have pharmacological properties that alter if the medication is left in water for a prolonged period. In Kelly et al’s study, the delay in waiting for dispersion to occur meant nurses moved to the next patient and forgot to go back to administer the dispersed medicine (Kelly et al 2011; Kelly et al, 2009).
One of the most common errors in hospital is a result of interruption of the medication round (Yoder et al, 2015). Medication rounds, both in care homes and hospitals, can take a long time and are often done by a single member of staff. That member of staff may dispense medication but not make sure it has been taken until later. In an institutional setting, the medication round needs to be completed in a certain timeframe, and complicated drug administration creates more pressures (Holland et al, 2008).
Another area cited as a cause for concern is the lack of education around medicines management in the context of dysphagia.
To set audit standards on the information handover at the time of discharge, discussions took place with the lead pharmacist for older people, as well as the head of speech and language therapy. Continuing professional development (CPD) sessions were set up for pharmacy and SLT for education and learning purposes. Previous audit results were shared to identify areas for change. Using a standards-based audit, the process shown in Fig 1 was applied. The agreed standards were that:
The audit was conducted retrospectively using electronic patient records. Patients were included if they had been referred to an SLT for a review of their dysphagia, and excluded if they did not have dysphagia, had a resolving dysphagia, or had alternative nutrition/hydration in place.
A pharmacist reviewed the medication counselling and special instructions on medication modification, while the SLT reviewed medication instructions in the medical discharge summary and the inclusion of a medication review in the SLT discharge report.
During the review period, 34 patients were referred to the speech and language team, and 20 older patients who met the inclusion criteria were audited. Twelve patients died before discharge. Table 1 gives a summary of the adherence to standards.
The impact of the CPD activities between the pharmacists and SLTs is not reflected in the results of the audit; the reason for this could be twofold. First, for a change of practice to occur, all disciplines that play a role in medicines administration should be involved in education activities; however, nursing and medical colleagues were not included in CPD sessions. Second, the audit was conducted at the start of the Covid-19 pandemic and a number of patients in this study cohort had died having contracted the virus. The large number of deaths directly affected the results – particularly in counselling and the handover of information in the discharge summaries and reports for both pharmacy and SLT.
The results may also reflect the linear nature of the current process. While nurses and doctors were referring patients to the SLT team, the SLTs were often not recording a need for a medication review or a request for the formulation to be considered. As such, it may be more appropriate to refer to the pharmacist in parallel, rather than in series. The pharmacist needs to be aware of any SLT recommendations about food and liquid consistency. Although medical practitioners or nurses can make referrals to SLTs, it is ultimately the nurse who administers the medicines. It may be appropriate for nurses to assume responsibility, therefore, for ensuring that all patients with dysphagia are referred to the pharmacy and SLT teams.
Also evident was a reduction in changing medicine formulations for older people with dysphagia, compared with previous audits. This might also have been related to the outbreak of Covid-19, as it was a time of learning new processes and practices, which were highly changeable. To protect themselves, nurses should always question the need for tablet crushing or dispersing and, at this point, seek a medication review to make sure medicines are optimised and the best formulations are selected for the patient.
Patient management is a partnership between health professionals and the patient. From a patient perspective, accepting any treatment involves trust in the professional and, at times, accepting that a treatment may involve risks. To fail to rationalise medication and consider alternatives may be considered a failed duty of care, particularly when oral administration is compromised and causes harm.
This study revealed that, for many patients, formulations were not switched to liquid or dispersible equivalents, but it was not established whether the medication was adapted further (for example, crushed) for ease of administration. Not all medicines are available in a licensed liquid form but, in such circumstances, unlicensed products can be manufactured in the pharmacy department or ordered from ‘specials manufacturers’. These products are often short dated, do not have bioavailability data, are not designed with patient palatability or texture in mind and can be exceedingly expensive, which is why practitioners often resort to tablet crushing, cutting or dispersing.
Altering a medication before administration – either by mixing the components, breaking the capsule, or cutting or crushing a tablet – is, in effect, a manufacturing process (which requires certification) and an off-label use of the medication, which needs an evidence base and personal responsibility assumed by the person administering or dispensing the medication (James et al, 2010). In addition, patients have to provide consent to such administration and alteration of formulation (Logrippo et al, 2017). Complications include overdosing and underdosing, and can lead to significant harm. Health professionals have a duty of care to make sure the relevant benefits and risks of a treatment are explained.
Many older people will be cognitively and physically frail, and personal knowledge of the indication for their medication is very poor. In line with the Mental Capacity Act 2005, if a person lacks capacity to make decisions about medicines, the medical team must act in that person’s best interests. If the medication needs to be administered covertly, a formal best-interests meeting and independent scrutiny under the Deprivation of Liberty Safeguards is also needed.
For all these systems and processes to be effective and accounted for, education and training initiatives should extend to all disciplines involved in the medicines management for these individuals. A systematic review of interventions to improve medicines administration in people with dysphagia carried out in 2017 found limited evidence for clinical effectiveness or sustainability (White, 2017). Interventions were usually focused on one profession or one element of the process, and evaluations were largely process based.
To raise awareness about medication in the management of dysphagia across all disciplines, the SLT team embarked on a Mind the Medication Gap campaign. The team devised a London Underground ‘Tube’-style map of reminders on harnessing the management of medicines in patients with swallowing problems (Fig 2). The initiative was launched on Swallowing Awareness Day (18 March) 2020 by delivering a poster to the wards, along with a bitesize training session to the multidisciplinary team at the local NHS trust.
The plan for the future is to continue to audit practice to ensure medication is considered through to discharge, and the handover of recommendations is appropriate.
Medication management is included in all multiprofessional dysphagia education sessions. Our experience suggests that, while dysphagia is a responsibility for all members of the ward team, when it comes to medicines, it is the nurse who should take responsibility for ensuring patient safety and preventing critical incidents.
There is a recognised need to guide, improve and standardise practice in the management of medicines for older people with dysphagia to minimise the likelihood of the risk of aspiration and harm caused by medication errors in hospitals. Education and awareness raising is essential to improve communication across disciplines and settings.
For long-term sustenance of change, audit cycles with identified areas for change must be built into practice. More research is needed into a behaviour change multidisciplinary approach to improving medication administration practices in hospitals for older people with dysphagia.
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