Long-Term Care Survey Alert

Keep an eye on prevalence of hypnotic use and related negative outcomes.

Your quality indicators and measures can give you a heads up about hypnotic use in your facility and when you need to intervene to promote optimal resident wellbeing.

Consider these five ways to make your QI/QM numbers work for you as an early warning system to make some changes before residents' outcomes have surveyors calling you on the carpet.

1. Compare your QI on the facility's hypnotic use to other facilities. OSCAR data show that about 5 percent of nursing home residents nationwide take some form of sleep medication, says Carla Saxton, PharmD, with the American Society of Consultant Pharmacists.

2. Monitor your QIs for hypnotic and hypnotic/anti-anxiety use to see if they are climbing. If so, figure out why. For example, is the activities program providing less opportunity for residents to exercise? Has the pain assessment and management program fallen off? Is a new attending physician ordering more sleep aids for inappropriate reasons that go unchallenged by the interdisciplinary staff? Are staff requesting physicians to order more medications to ease the workload at night or deal with more residents who have behavioral issues?

3. If the QI for hypnotic use is low, see if residents are receiving antihistamines as sleep aids, which will escape the QI radar screen (you don't code antihistamines used for sleep in Section O4). Check each resident receiving an antihistamine to look for the medical rationale, which should be documented in the medical record. Also check for potential adverse drug reactions.

Beware: Some physicians order Benadryl for sleep but the drug is actually on the Beer's list. "It can cause serious confusion even in people who are totally cognitively intact," cautions Saxton. In fact, the effects of Benadryl can be "so severe and unidentifiable that the nursing staff may think the person who has taken Benadryl to sleep has had some kind of stroke or delirium," she says. Antihistamines with an anticholinergic effect also "dry" the person up and can cause urinary retention and constipation.

Another reason to worry: State survey teams are going to be looking hard for substitutions of antihistamines, including Benadryl, for hypnotics, cautions David Jones, RPh, FASCP, in Baltimore.

4. Check each resident on a sleep aid to see if he has triggered any QI that could be a cause or effect of his receiving the medication. For example, sleep aids can contribute to falls, pressure ulcers, incontinence or urinary retention causing UTIs, etc. Pain and/or depression could cause a resident to experience insomnia or ask for "something to sleep."

5. Correlate any negative trends in your QIs to a change in the prevalence of residents receiving hypnotics or hypnotics/anti-anxiety agents.