Reducing hypnotic use on two older adult functional wards: an effective audit?

AIMS AND METHOD

We undertook an audit of hypnotic use on two functional olderadult wards, followed by an educational intervention to allnursing staff and junior doctors. We then repeated the audit.

RESULTS

Our pre-intervention audit showed a hypnotic use of 48%. Thisdecreased to 26% for the first month following the educationalintervention. Usage increased gradually in proportion to timefrom intervention. However, over the 4-month post-interventionperiod hypnotic use remained significantly lower than pre-interventionthroughout the time period studied.

CLINICAL IMPLICATIONS

As the study is an audit there is no control group, but ourresults suggest regular staff education is needed to sustaina reduction in hypnotic use.

Introduction

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Introduction

Hypnotic use is widespread in hospitals but the adverse effectsof these drugs are more pronounced in older adults (Gurwitz et al, 2000),with an increased risk of morbidity and falls (Llorente et al, 2000; Grimley Evans, 2003). The BritishNational Formulary (British Medical Association & Royal Pharmaceutical Society, 2003)states: ‘Hypnotics shouldbe avoided in the elderly’. In addition, the NationalService Framework for Older People states that ‘prescribing rates for benzodiazepines should be monitored and reviewedwithin the local clinical audit programme’ (Department of Health, 2001).We undertook an audit with the aim of reducing hypnotic prescribing on two functional older adults wards atthe Queen Elizabeth Psychiatric Hospital in Birmingham.

Method

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Method

Over a 6-month period from April 2001 to September 2001 thenumber of occupied patient bed days were calculated; the datafrom each ward were added together to give an overall total.

We counted the total number of tablets for each hypnotic prescribedover the 6-month period. Patients prescribed hypnotics as dischargemedication were identified. Details of medication pre-admissionwere found by looking at case notes and in-patient drug chartswere consulted in order to determine which patients had beenstarted on a hypnotic while on the ward.

Following the initial part of the audit we set the audit standards:(a) to reduce hypnotic use on the two wards by 20% and (b)that no patients should be discharged while still taking hypnotics.

We designed an educational session which lasted for 1h to outlinethe problems associated with hypnotic use in the elderly andto give details of alternative strategies to use for insomnia.There was time for discussion and a copy of a sleep hygieneleaflet, ‘The golden rules of sleep’, was givenout (Box 1). Although the sessions were based on a lecture style, open discussion and questions were encouraged. The leafletoutlined methods other than the use of hypnotics for dealingwith insomnia, such as providing decaffeinated drinks on theward. The leaflet was adapted from two texts on sleep hygiene(Oswald & Adams, 1983; Kale & Kale, 1984). The lecturewas incorporated into the 6-monthly induction sessions forall senior house officers. Leaflets were handed out at this lecture. All nursing staff on the two wards studied were identifiedand invited to one of four small-group teaching sessions runby either one of two of the authors (I.H. or L.C.). These sessionslasted 1h and followed a similar format to those for the seniorhouse officers. Copies of the leaflet were also left on thetwo wards for staff, patients and their relatives.

Following the educational intervention, we collected identicalinformation to that collected in the pre-intervention periodon a monthly basis for 4 months in 2002.

Results

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Results

A total of 12 of 25 junior medical staff and 23 of 36 nursingstaff attended the teaching sessions (48% and 64% respectively).

Pre-intervention medication use was 48%. One month post-interventionthis use dropped to 27% (Table 1). Hypnotic use increasedin subsequent months but remained significantly below pre-interventionlevels throughout the 4-month period.

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Table 1. Occupied bed days on which a hypnotic was prescribed

In the pre-intervention audit, there were 87 patient dischargesfrom both wards over a 6-month period. In 27 cases the dischargeswere associated with hypnotic use (31% of all discharges).Of the 27 patients, 9 were taking hypnotics prior to admission.Hence 18 of 87 patients (20%) were discharged with a new hypnoticprescription.

In the post-intervention audit, of the 32 discharges from thewards over a 4-month period, 2 of the patients were on hypnoticsprior to admission. There was a significant reduction in thenumber of patients discharged on a hypnotic that had been startedduring hospitalisation in the post-audit period (3 of 30, 10% ${chi}$ ²=2.826, P<0.001).

Box 1. The golden rules of sleep

In older adults the sleeparchitecture is altered.

Older adults have altered perceptionof the quality of their sleep.

Sleep is affected by physicalillness, medication and pain.

Depression, psychosis and dementiacan all affect sleep.

Have regular hours for getting up andgoing to bed.

Plan a regular time to relax and unwind in theevening before going to bed.

Only go to bed when you are sleepy,don’t lie in bed awake.

If you are unable to fall asleepgo to another room and return only when you feel sleepy.

Regularexercise improves your sleep, but don’t exercise within3 h of bedtime.

Avoid stimulants like tea, coffee, cola drinksand chocolate late in the evening.

Avoid smoking/give it up.Nicotine is a stimulant.

Never use alcohol to help you to sleep.

Sleepin a comfortable room, not too hot or cold.

Avoid distractionslike loud noise and bright lights.

Eat meals at regular timesand in the evening eat food that is easily digested.

Hungerdisturbs sleep. Try a light snack at bedtime, like warm milkand biscuits.

Do not nap during the day.

If you have beenprescribed sleeping tablets try not to use them for more than2 or 3 nights consecutively.

Discussion

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Discussion

A simple educational intervention was successful in reducingboth in-patient and discharge use of hypnotic medication. Aimingour intervention at the senior house officers and nursing staffwas deliberate. We felt that the majority of prescriptionsand pressure for prescriptions came from this area. This assumptionis supported by published data (Mahomed et al, 2002). Ourresults show statistically significant reductions in hypnoticuse over time. In the first month following intervention therewas a dramatic reduction in in-patient hypnotic use and, althoughthis reduction diminished over time, it remained significantlybelow baseline throughout. Furthermore, a reduction was alsoseen in the number of patients discharged with a hypnotic medication. However, we were unable to reach our outcome standard of nodischarges on hypnotic medication.

These results are encouraging but should be interpreted withinthe limitations of this work. The main potential confoundingfactor was the fact that junior medical staff changed in boththe pre-intervention and post-intervention periods. It is conceivablethat the changes in hypnotic prescription observed merely reflectdifferences in prescribing practice between different groupsof staff. However, nursing staff remained relatively constantthroughout and arguably have considerable influence on hypnoticuse, particularly with respect to dispensing of medicationas required. In addition, Table 1 suggests the interventionhad a demonstrable impact. Second, the intervention took placeon two wards in a teaching hospital and so the findings maynot be generalisable to other settings. Finally, this was anaudit and had no control group. Despite these limitations,a relatively simple educational intervention appears to havebeen sufficient to raise the profile of this important topic among staff to good effect.

A literature search of Medline and Psychlit using the followingsearch terms: HYPNOTICS; BENZODIAZEPINES; EDUCATION INTERVENTIONS;HOSPITAL; INPATIENT; identified only one study that had attemptedto reduce hypnotic use in a hospital setting (Griffith & Robinson, 1996).However, this study took place in a general hospital rather than a psychiatric hospital. A prescribingpolicy was developed which was incorporated into the juniordoctors’ induction programme. Nursing staff were notselected for education. In primary care an educational interventionleading to a reduction in the prescription of benzodiazepinesby general practitioners (de Burgh et al, 1995) has been described.

Recent guidelines on hypnotic use have suggested that doctorsconsider non-medical treatments for insomnia, such as ensuringregular sleep hours, no coffee and alcohol at bedtime, as wellas cognitive-behavioural therapy and relaxation, before hypnoticsare prescribed. When prescribed, hypnotics should be used inthe short term (National Institute for Clinical Excellence, 2004).In our educational session, the staff leaflet on ‘Thegolden rules of sleep’ advocated that simple sleep hygienemethods should be considered before hypnotics were prescribedor administered. This staff education programme goes some waytowards raising awareness of sleep and hypnotic issues and our results show a reduction in hypnotic use.

In summary, this work suggests that a simple educational interventioncan lead to significant reductions in hypnotic use. These changesappear to reduce over time and so, in order to sustain theinitial impact, the educational package may need to be repeatedat regular intervals and could be combined with a prescribedpolicy intervention, as used by Griffith & Robinson (1996)and the audit cycle repeated.

Acknowledgments

We thank Norah Foster, Directorate Lead Nurse, Martin Read,Chief Pharmacist, Elaine Jones, Pharmacist and Alison Moore,Audit Department.

References

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