HOPE
Responding to Heatwaves in the Older People Ecosystem
Micro
Main result
Fewer nursing home residents develop dehydration
Title
Guidelines for a temporary diuretic stop in nursing home residents
Date 01-04-2021 (date of implementation)
Objectives
To prevent dehydration in nursing home residents on diuretic therapy
Location /geographical coverage
Rotterdam and its outlying urban areas in The Netherlands.
Organisation responsible for good practice
Aafje, a nursing home organization.
Short summary
During a heat wave, people in general will lose more water from their bodies
through perspiration. People on diuretic therapy (for whatever indication) will not
be able to sufficiently self-regulate their diuresis. This means that they need
medication (diuretics) to be able to excrete water from their body (diuresis). The
dose of the diuretic is set to their individual need, but does not take into account
the increased amount of perspiration during an (extended) heat wave. This good
practice describes a directive to temporarily stop the prescription of diuretics during a heat wave and the way this is implemented.
Medication in the nursing homes of this organization (and lots of others) are
provided to their residents in the form of medication rolls. These are rolls of
connected little plastic bags with each bag containing all the pills a patient needs at a single moment of administering. The bags have print on them that say when to administer the contents of the bag. This system has reduced the amount of medication administering errors and saves a lot of time for the nursing staff as they no longer have to check all the pills individually when administering them. The drawback is that the system is less flexible. The rolls are prepared usually a week in advance and any medication changes take until the next roll is delivered. In addition, the pharmacy has to make extra costs when a roll does need to be changed.
Some medication changes often. The nursing staff however cannot change the
contents of the bags of the medication roll, this has to be done by the pharmacy.
To facilitate acute medication changes, the pharmacy picks up the roll and changes it the same evening. This means the fastest a change can be implemented is the next day (at considerable cost). Sometimes this is not sufficient and then the only remaining option is to do away with that particular bag of the roll and give the pills from individual medication packages. These have to be prescribed to the patient individually and this situation is error-prone. The pills that change most often are therefore put in a separate medication roll. This way, when those pills change, they can be skipped without discarding all the other pills.
This is particularly useful during heat waves, when diuretics are usually paused.
The effect of which is then evaluated every three days whereafter the diuretics can be resumed, or not.
Impact
Fewer nursing home residents develop dehydration as a result of unadjusted
diuretic doses. This prevents correcting the dehydration after the fact by
supplementing water/salt or, in worst case scenarios, admittance to an emergency health service.
Innovation
The heat wave protocol/guideline/directive reminds every health care professional engaged in the care of elderly people, people with acquired brain injury and other risk groups to think about the specific topics that need addressing for this target audience. This is new as not every nursing home has a heat wave protocol/directive because prolonged and intense heat waves are a more frequently occurring phenomenon in The Netherlands.
When prescribing medication for patients, several variables are requested. The
duration is one of them. This governs how long a patient should take the prescribed pills. Some are only needed for 2 weeks, some have no end date at all. When patients have to stop certain medications when they undergo surgery for example, the digital prescription system doesn’t always provide a function to pause administering the medications to the patients and you have to completely remove the line that prescribes it and then later re-add it. This differs from one prescription system to another. The hassle of having to delete medications manually and then re-add them later can cause prescribers to avoid having to do this. Making this easier for prescribers can lead to a lower threshold to pause medication.
Lessons learned
Fluid balance in people on diuretic therapy needs to be carefully monitored,
especially when conditions change, such as during a heat waves. This was already known, but a directive to remind every health care professional to think about this in a structured manner, and a practical way to implement it wasn’t always available. This can lead to medication errors that could possibly have been prevented. An evaluation of this protocol was done during regular meetings and was found to be a positive addition to the nursing home during heat waves.
Sustainability
This good practice consists of a directive to temporarily stop diuretics, and a means to do so easily in the medication prescription system and via the medication rollout system. Therefore, the system that governs all this needs to be able to easily pause medications temporarily and this needs to be communicated to all relevant partners. In this case the doctors that prescribe and monitor medications and the nurses that administer them.
Replicability and/or up-scaling
The directive can be fairly easily rolled out to other organizations. It is a matter of
organizing the requirements with all relevant partners. The pharmacy needs to be involved in the arrangements about the delivery of the medication rolls, the doctors need to be aware of the protocol and a simple way to pause the digital prescription needs to be available and the nurses need instructions about the different medication rolls.
Contact details
Aafje Kralingse Zoom (staff office)
Lichtenauerlaan 162-178 Brainpark II,
3062 ME Rotterdam
088 8 233 233
Marco van Duuren
06-51966678
Related Web site(s)
https://www.aafje.nl/over-aafje/contact/
https://www.nhg.org/thema/farmacotherapie/medicatiegebruik-en-dreigende-dehydratie-bij-hitte/
Related resources that have been developed
Appendix: Aafje Medimo voorschrijven hitteprotocol interval.pdf