The role of the psychiatrist is to focus on the mental health needs of the MHRRTP patients, not the primary care medical concerns, which are the main reason for ECS visits. With the current model, providers are sometimes unavailable to meet the emergent needs of patients in the MHRRTP, and patients may be forced to choose between using ECS or leaving the concern unaddressed. Patients’ needs vary from mild to serious emergent needs but may not necessarily require full emergency assessments. For example, if a patient has a headache and a physician is not available to write an order for acetaminophen, the patient may need to visit the ECS to obtain a medication that otherwise would have been readily available at home. The restrictions are designed to promote medication safety, prevent medication diversion and misuse, and be in compliance with regulatory agencies (eg, The Joint Commission and the Commission on Accreditation of Rehabilitation Facilities).
ECS Use
During fiscal year 2010, pharmacy administrators discovered that many patients were using ECS to obtain medications for nonemergent conditions. Inappropriate and unnecessary use of ECS by MHRRTP patients delayed treatment, increased wait times for veterans in need of emergent care, and increased the cost of caring for simple ailments. To put this into perspective, the average cost of all conditions at the ZVAMC during the 2013 fiscal year was $657 per ECS visit, while the total cost of ECS was about $14 million.
In response to the inappropriate ECS use, the ZVAMC created a PRN medication list in 2010, which is offered to all MHRRTP patients, with the goal of reducing the number of patients inappropriately using ECS for minor ailments and providing more efficient and cost-effective patient care. 2 The MHRRTP PRN medication list is initially evaluated by the admitting psychiatrist or nurse practitioner and mental health clinical pharmacy specialist completing the admission orders for appropriateness based on each patient’s comorbidities, medication regimen, and past medical history. For example, if a new patient with liver dysfunction is admitted to the MHRRTP, acetaminophen would not be made available due to an increased risk of hepatotoxicity. The other PRN medications would still be available for the patient if clinically appropriate.
Once the PRN medications are ordered, the MHRRTP nurse can assess a patient’s condition and administer the medication(s) to the patient as indicated. For instance, if a patient requests ibuprofen for pain, the nurse will document an initial pain score and administer the ibuprofendose. As a result, the patient obtains more efficient and convenient care and does not need to wait for a provider to become available or use ECS. Per ZVAMC policy, the nurse has 96 hours to reassess the PRN medication effectiveness; however, this is typically done within the same shift. Since the implementation of the PRN medication list, no formal assessment has been completed.
To the authors’ knowledge, the ZVAMC is the only MHRRTP in the VHA system that incorporates a PRN medication list in the admission orders to reduce unnecessary ECS visits. After completing a thorough literature review and contacting the national VA mental health pharmacist listserve, no studies discussing the use of PRN medication lists in this setting were identified, and no sites offered information as to a similar practice in place.