Of the 32 registered nurses and licensed practical nurses working in the MHRRTP, 7 (22%) responded to the nurse satisfaction questionnaire. Of the respondents, 6 (86%) stated they discuss the PRN medication list during admission assessments every time or most of the time. The median rank of satisfaction was 9 on a 10-point scale. Four (57%) nurses felt patients had a clear understanding of the PRN medication list, and 100% of nurses stated they had enough guidance on situations to administer the medications. Seven (100%) stated that the PRN medication list had not caused adverse events; however, 5 (71%) stated that the list had been used inappropriately.
Discussion
This retrospective case-controlled study of 400 patients revealed high use of the PRN medication list and a cost avoidance of nearly $40,000. Although this represents a small reduction of the annual ECS budget, the PRN medication list also improved patient care by providing more efficient and convenient access to medications. The most commonly used medications were acetaminophen, trazodone, and ibuprofen. In addition, the nursing and patient surveys demonstrated an overall satisfaction with the current PRN medication list. It is important to note that the number of avoidable ECS visits decreased significantly after the implementation of the PRN medication list in 2010.
Roughly 35% of patients in each group were excluded from the study. The main exclusion criteria included a < 4-week LOS, being admitted to the hospital, being female, and being admitted prior to the study period. Women veterans were treated through different programs prior to the implementation of the PRN medication list; therefore, they were excluded to decrease variability. Only patients in the GEN and SAR programs were included, because they were well established prior to and after the intervention. The other programs, which included PTSD, WOM, OEF/OIF/OND, DCHV, and I-ACT, accounted for about one-third of MHRRTP admissions. However, they were not all available or structured similarly in 2010. Including the other programs would have increased variability.
Survey Results
Although the response rates were low, the patient and nurse satisfaction surveys revealed useful information that may assist in identifying the strengths and weaknesses of the current program. More rigorous surveying needs to be conducted to make the results more generalizable. Fifty percent of patients reported using a PRN medication on a daily basis or 3 times per week. However, 28.6% stated they never used the PRN medication list, which was thought to be an overestimation due to an incomplete understanding of what medications are on the PRN medication list. This finding does not correlate with the high use demonstrated with the actual number of PRN medications used.
Two patients marked “other,” one reported using the list when they “need the medication,” and another did not mark an answer. Similarly, 57.1% of the nursing staff reported offering a PRN medication on a daily basis and discussing the list on admission every time. However, 28.6% of nursing staff stated they do not complete admission assessments or work in the medication room, most likely because they are licensed practical nurses and do not have those responsibilities. Interestingly, when asked about medications that should be removed from the PRN medication list, 1 nurse suggested removing trazodone, which was the second most used drug. Some of the medications patients suggested adding to the PRN medication list included creams for dry skin or fungal infections, calcium carbonate, and pain medications such as tramadol, aspirin, and naproxen. Nurses suggested adding aspirin, diphenhydramine, and nicotine gum. These responses will aid in enhancing the current PRN medication list by potentially increasing the types of medications offered.