FOR MORE INFORMATION with William Vaughan, BSN, RN VP of Education & Clinical Affairs JENNIFER HARDESTY Pharm.D., FASCP Chief Clinical Officer The Medication Pass: Can We do Better? (part 2) ROB SHULMAN BS, R.Ph., CGP, FASCP Building on information presented in the medication pass, the surveyor observes Director of Consultant Pharmacy Services June issue of the Pulse, we now look at that a clinically stable resident receives her two common misconceptions that can Digoxin at 11:50 a.m. You're now the sur- REBECCA OGDEN BSN, RN, CRNI lead to the erroneous citing of medication veyor … do you cite this as a medication Corporate Account Manager error? According to CMS guidance to sur- veyors at F332, you should not.
Please do not hesitate to contact your Remedi TIMING OF ADMINISTRATION
Consultant Pharmacist or Account Manager Perhaps no aspect of the medication pass The guidance instructs surveyors to "… if you have any questions or concerns.
gets as much attention, from both survey- Count a wrong time error if the medica- ors and staff, as the actual timing of medi- tion is administered 60 minutes earlier or cation administration. Ask any nurse when later than its scheduled time of administra- it's acceptable to administer a medication tion, BUT ONLY IF THAT WRONG TIME
scheduled for 10 a.m. and the universal ERROR CAN CAUSE THE RESIDENT
response will be "anytime between 9 a.m. DISCOMFORT OR JEOPARDIZE THE
and 11 a.m." I was taught this "one hour RESIDENT'S HEALTH AND SAFETY [bold
before / one hour after" concept in nursing type included in original text]. Counting a school some 30 years ago and it remains medication with a long half-life entrenched in nursing practice today. Ask any nurse when it's acceptable to (e.g., digoxin) as a wrong time administer a medication scheduled for 10 error when it is 15 minutes late Strict adherence to this golden hour "rule" a.m. and the universal response will be is improper because this med- "anytime between 9 a.m. and 11 a.m." can, however, lead to the inappropriate ication has a long half-life (be- citing of timing errors. For example, an yond 24 hours) and 15 minutes order is written as follows: "Digoxin 0.125 has no significant impact on the resident. milligrams po once per day." The order is The same is true for many other wrong time transcribed onto the medication adminis- errors."1 This approach requires surveyors tration record and the drug is scheduled to to look beyond the arbitrary one hour time be administered daily at 10 a.m. During the continued on page 4 Taking a Breath: Understanding Inhalers Prepared by: Sarah Brett, Pharm.D., Clinical Consultant Pharmacist Asthma and chronic obstructive pulmonary disease (COPD) are both capsule in the chamber needs to be loosened common respiratory disorders that affect many of the residents for – It is important not to pierce the capsule in the chamber of whom we care. Many therapies used to treat these conditions require these devices more than once in order to avoid degrading the use of one of numerous inhaler devices available. Effectively admin- gelatin capsule and allowing it to pass through the screen to istering medications using each drug-delivery system is essential to the resident's airway ensure optimal maintenance and treatment. Understanding proper • Examples: inhaler technique can also help in recognizing when a device may no – Spiriva HandiHaler, Arcapta Neohaler, Foradil Aerolizer, longer be an effective delivery system for a resident, and prompt a Flovent Diskus, Serevent Diskus, Advair Diskus, Breo Ellip- review to determine if there is a more appropriate choice. ta, Incruse Ellipta, Anoro Ellipta, Arnuity Ellipta, Asmanex Twisthaler, Pulmicort Flexhaler, Tudorza Pressair Although there are many different inhaler therapies available, they can be classified as either pressurized metered dose (pMDI), dry SOFT MIST INHALERS
powder (DPI), or soft mist inhalers. Each class has very similar key • New innovations - becoming more widely utilized drug-delivery points for administration technique. • Generate an aerosol without utilizing a propellant or relying on PRESSURIZED METERED-DOSE INHALERS (PMDI)
the patient's inspiratory flow • Are the most familiar, and include devices that contain the pro- – A spring forces the solution through a nozzle system that pellant hydrofluoroalkane (HFA) produces the mist • Commonly used with a spacer to help assist in coordination of – Since the mist lasts longer than many pMDIs, there is less concern for problems with coordination of actuation and • Considered lower-resistance devices • More appropriate in times of acute exacerbations when a patient • Require less inhalation effort to deliver the medication to the may not be able to generate adequate inspiratory flow necessary for the use of alternate devices • Must first be assembled which involves loading the cartridge into • Prime before initial use by shaking the device and spraying four the inhaler and writing the discard date of 3 months from when pumps into the air the cartridge is loaded • For daily use, pMDIs are shaken and residents should be in- • Must be primed prior to first use structed to exhale completely, then wrap lips around mouthpiece, • Daily use involves turning the clear base, opening the cap, in- inhale a slow deep breath, remove device from mouth, and hold structing the resident to breathe out completely and then placing breath for as long as they can comfortably, or up to 10 seconds lips around mouthpiece, followed by pressing the dose release button as the resident takes a slow deep breath, removing the – ProAir, Proventil, Ventolin, Xopenex, Advair HFA, Dulera, Sym- device from mouth, and having the resident continue to breathe bicort HFA, Flovent HFA, Asmanex HFA, Serevent HFA in and hold breath for 10 seconds or as long as comfortable DRY POWDER INHALERS (DPI)
– Spiriva Respimat, Stiolto Respimat, Combivent Respimat, • Available in several different device styles that might be very Striverdi Respimat familiar to both nurses and residents – The unit dose system utilizes a capsule containing the drug in With all of these devices, it is important to remember the fundamen- powder form along with a corresponding specialized delivery tal basics that help to ensure appropriate medication administration: • Label each device when it is opened – Multiple doses within the device are delivered once the dose • Refer to expiration guidelines to determine a beyond-use date is triggered and the device is activated, such as in a Diskus® • pMDIs should be inspected before use and discarded if the count is at zero in order to ensure appropriate dose delivery, even if it • Do not utilize a propellant or require as vigilant coordination between actuation of the device and inhalation • Assist residents to rinse their mouth and spit out the water after – Rely on the quick, deep breath of the resident in order to inhaling a corticosteroid to help prevent oral thrush aerosolize the drug for delivery • Sequence inhalers so that bronchodilators are administered prior – If a resident is not able to generate adequate inspiratory to steroids in order to optimize inhaled steroid therapy flow, the drug may not be delivered optimally via a DPI - this should be brought to the attention of the resident's care team Residents depend on our expertise in properly delivering medica- • Require more attentive handling once the dose is loaded and the tions through each of these various types of inhalers. device is activated in order to avoid displacing the medication – For the unit dose systems, there should be a noticeable whirring noise upon inhalation --an absence of this noise may Capstick TG, Clifton IJ. Inhaler technique and training in people with chronic obstructive pul- monary disease and asthma. Expert Rev Respir Med. 2012 Feb;6(1):91-101; quiz 102-3. doi: be an indication of inadequate inspiratory flow, or that the 10.1586/ers.11.89. Review. PubMed PMID: 22283582.
2 the Remedi Pulse August 2015 continued on next page Stop the Madness: Rational Medication Administration Times Prepared by: Jennifer Hardesty, Pharm.D., Chief Clinical Officer The seemingly endless medpass cycle-starting early at 6 a.m. and however, an extended-release risedronate (Atelvia) can be often going until midnight, can be challenging to both residents given immediately after breakfast and staff alike! Numerous medication passes can tie up facility • Change resident to a once-weekly or once-monthly formu- staff, and can adversely affect resident quality of life by producing interruptions of activities and disrupting important sleep time. By promoting a resident-centered, rational medpass schedule, indi- THE "HEAVY" MEDICATION PASS
vidual preferences and quality of life can be preserved while still The heaviest medication pass of the day is traditionally the time achieving good clinical outcomes.
that is assigned to "Once Daily" in your facility. Blood pressure medications, stool softeners, vitamins/minerals, cholesterol THE EARLY MORNING MEDICATION PASS
medications, antidepressants- most of the "QD" medications Several medications have traditionally been administered very are slated for this medpass. Staff often times have so many early in the morning. Synthroid, Proton Pump Inhibitors, and medications to administer and document that they run behind Bisphosphonates (alendronate, risedronate), are often scheduled or may be tempted to take shortcuts; and residents have anywhere from 6 a.m. - 8 a.m., but these administration times may numerous medications to swallow. Consider "re-balancing" the require staff to wake a resident early, just to take a medication. For medpass by doing the following: those residents who prefer to sleep in, or are more challenging in the morning - consider these options: • Move vitamin, mineral, and herbal supplements to a med- pass later in the day Proton Pump Inhibitors • Consolidate various vitamin and mineral supplements into a • Some medications in this class may be given without regard to food (e.g., pantoprazole and rabeprazole) • Administer docusate or other routine bowel medications at • For certain residents you may want to consider administering the drug 30-60 minutes prior to lunch or dinner to achieve an empty stomach, as opposed to breakfast LATE NIGHT MEDICATION PASS
• Give medication with breakfast, but monitor efficacy closely for As a general rule of thumb, you should re-evaluate the rationale of any routine medication order administered after 9 p.m. In certain circumstances a strict dosing schedule may be required (e.g., Parkinson's Disease, pain management, antibiotics, etc.). • While Synthroid is best absorbed on an empty stomach, it can A risk-vs.-benefit assessment should be performed for any be administered any time of day as long as it is given under medication therapy that may interrupt or impede a resident's the same conditions each day sleep. Those artificial tears Q2H can wait until morning! • For example, it can be given with breakfast as long as it is always given with breakfast A FINAL NOTE:
• Alternatively, administer Synthroid 30 minutes prior to dinner, If you choose to alter the administration time away from the or at bedtime to achieve the empty stomach condition standard, consider a statement in the resident's record such as, "I have evaluated the risk‐vs.‐benefit of administering DRUGXYZ at 6 a.m., and determined resident quality of life • Medications such as alendronate or risedronate should always may be impacted adversely by waking him/her too early. Please be given on an empty stomach in the morning with a full glass administer the medication at 8 a.m." By doing what is best for of water, the resident sitting upright to avoid adverse GI effects the resident and documenting your rationale, you ensure good • Administration time of this class of medication is not flexible; clinical care with transparent justification. Understanding Inhalers (cont'd) "Respimat Insight." Respimat. Boehringer Ingelheim, n.d. Web. 12 July 2015. <https://www.
"How to Use Inhalers." UPMC. University of Pittsburgh Schools of the Health Sciences, 2011. Web. 12 July 2015. <http://www.upmc.com/patients-visitors/education/breathing/ the Remedi Pulse August 2015 3 Nurse of the MonthKATHY WOODINGTON, LPNSt. Mary's Nursing Center, Leonardtown, MD CONGRATULATIONS to Kathy Woodington, LPN, Charge Nurse
at St. Mary's Nursing Center, Leonardtown, MD, for being chosen Remedi acknowledges a "Nurse of the Month" in each of our as the Remedi "Nurse of the Month." Kathy was nominated by newsletters. DONs/ADONs/LNHAs, now is the time for you to her Unit Manager, Carrie Sager, RN. Per Carrie, "Kathy has been reward the nurse(s) at your facility, who exemplify excellence in a nurse for 35 years and has worked full-time at St. Mary's for 15 nursing practice. The "Nurse of the Month" will receive an award years on the night shift while also working as a medical records and a certificate of commendation from Remedi. Please submit the reviewer part-time. She is extremely thorough in her work and following information: nominated nurse's name/title, facility takes pride in all that she does. Kathy is very skilled with the name, state, years at facility, years of experience and why this use of My Remedi not only for order entry, but also utilizes a nurse should be chosen, such as leadership abilities, clinical variety of reports available to complete 24-hour checks, verify expertise, teamwork, professional and personal strengths. order completeness, and to do her job effectively and efficiently. She consistently makes positive contributions to the care of all Email your Nurse of the Month nomination(s) by the 30th of the residents, is dedicated to her residents and treats them with the month to [email protected]. Nurses Rock!! utmost respect. Kathy is a tremendous asset to Unit 2.
continued from page 1 frame and perform a critical analysis of the entire clinical picture or accepted professional standard and principles.2 Facilities before citing a timing error. Facilities should undertake a similar frequently and appropriately develop policies and procedures analysis, if cited, to determine if the deficiency should be disput- which exceed regulatory requirements as they strive to deliver exceptional care to their residents. Provider's should consider disputing medication error related deficiencies which are cited In 2011, the Institute for Safe Medication Practices examined the based on criteria other than that which is established by CMS. issue of medication timing in the acute care setting and came to two important conclusions. It was determined that "relatively few The timing of medication administration, as is the case with all medications truly require exact timing of doses" and that "many services provided in a long-term care facility, should be deter- nurses reported feeling great pressure to take shortcuts to comply mined based on a resident-centered approach to care. with the [timing] rule, which … led to errors, some harmful." ISMP developed guidelines for the timely administration of medications Note: Bill was a surveyor with the Maryland State Survey Agency from 1988 until 2001. He became Chief Nurse of the agency in 2001 while they were intended for use in the acute care setting, they and remained in that position until joining Remedi SeniorCare in 2013. certainly contain principles that are applicable to long-term care. 1State Operations Manual: Appendix PP - Guidance to Surveyors for Long-Term Care POLICIES AND PROCEDURES
Facilities: F 332 A review of several hundred deficiencies from multiple states 2 State Operations Manual: Appendix PP - Guidance to Surveyors for Long-Term Care cited at F332 (medication error rate > 5%) during 2014 revealed Facilities: F 332 that surveyors often use a facility's own policies and procedures to establish or confirm that a medication error occurred. While examining such documents may have merit in the survey pro- cess, non-compliance with a policy or procedure does not in and of itself meet CMS's definition of a medication error. A medica- tion error is the failure to administer medication in accordance with the prescriber's order, the manufacturer's specification, and/ 4 the Remedi Pulse August 2015

Source: http://www.leadingagevirginia.org/files/public/Legislative%20E-Station/2015%20Legislative%20Newsletter/News%20August/2015-08_Pulse-2.pdf

Manual de rehabilitación de fauna

Aprile, G. & C.Bertonatti. 1996. Manual sobre rehabilitación de fauna. Bol.Téc.FVSA, Buenos Aires. Boletín Técnico Nº 31 Manual sobre Rehabilitación de Fauna Proyecto Rehabilitación de Fauna del Programa Control del Comercio de Vida Silvestre Gustavo Aprile y Claudio Bertonatti FUNDACIÓN VIDA SILVESTRE ARGENTINA


Asian J Androl 2006; 8 (2): 219–224 .Clinical Experience .Long-term treatment with intracavernosal injections in diabetic men with erectile dysfunction P. Perimenis, A. Konstantinopoulos, P. P. Perimeni, K. Gyftopoulos, G. Kartsanis, E. Liatsikos, A. Athanasopoulos Department of Urology, University Hospital, 26500 Patras, Greece Aim: To assess the behavior of patients with diabetes mellitus (DM) and erectile dysfunction (ED) during 10 con-secutive years of treatment with self-injection of vasoactive drugs. Methods: Thirty-eight diabetic men, including 12with type I and 26 with type II diabetes, were followed up regularly for 10 years after they began self-injecting forsevere ED. Real time rigidity assessment was used for the objective determination of the initial dosage and then doseswere regulated in order to introduce an erection suitable for penetration and maintenance of erection for approximately30 min. Patients were followed up every two months, and doses were increased only when the treatment responsewas not satisfactory. Results: The number of injections used per year by the patients was reduced each year (meannumbers: 50 in the first year and 22.5 in the 10th) and treatment shifted towards stronger therapeutic modalities(mixtures of vasoactive drugs instead of prostaglandin E1 alone). Type I diabetic men were standardized to a level oftreatment as early as 5 years after the initiation of treatment. That level was finally reached by type II patients afteranother 4-5 years. Conclusion: Treatment with self-injections of vasoactive drugs in diabetic men with severe ED isa safe and effective alternative in the long term. Diabetic men of both types show the same preferences in quality andquantity of treatment after 10 years. The key point for maintenance in treatment is the adjustment of the therapeuticmethod and dosage to optimal levels for satisfactory erections. (Asian J Androl 2006 Mar; 8: 219–224)