Don't rush to crush: audit of modification to oral medicines for patients with swallowing difficulties

Abstract

Background Oral medicines are frequently modified prior to administration for patients with swallowing difficulties or enteral tubes. The current Australian guideline, the Don't Rush to Crush ( DRTC ) Handbook has been available since 2011, and this study compares practice with its recommendations. Aim To assess compliance with Australian guidelines for the preparation of medications in patients who are unable to swallow solid oral medicines, and to provide nursing education as necessary to improve practice. Method An observational audit was undertaken during morning medication rounds in an 18‐bed medical oncology ward over 4 weeks. For each occasion that an oral medicine was modified, the preparation method was assessed against recommendations in the DRTC Handbook for appropriateness. A number of education strategies were implemented with support and input from senior nursing staff focusing on medication modification for patients with fine‐bore nasogastric tubes. A re‐audit was undertaken to assess practice improvement. Results Education improved the proportion of medications prepared safely from 45% (37/82) to 91% (68/75) and those prepared according to the optimal method of preparation from 33% (27/82) to 60% (45/75). In the initial audit, 52% (43/82) of medications modified were strained prior to patient administration. Practical and collaborative education eliminated the straining of medications, and guidelines for difficult medications for patients with nasogastric tubes were developed. Conclusion Collaborative education that is practical and targeted can improve how oral medicines are modified for patients with swallowing difficulties and enteral tubes.

Knowledge and practice of healthcare professionals relating to oral medicine use in swallowing-impaired patients: a scoping review

“…Two intervention studies assessed nurse knowledge both before and after an education and training intervention . One of these studies that aimed to improve knowledge and drug administration in SI patients reported an overall increase in knowledge scores, including identification of MR codes (0–40%), and an increase from 51% to almost 90% for knowledge relating to the purpose and consequences of crushing MR preparations.…”

“…Pharmacists (75%), nurses (37%) and GPs (34%) correctly identified that certain drugs (in this case azathioprine) can cause harm to the administrator, but few participants identified that modifying antibiotics can also constitute a risk to the administrator. Overall, knowledge levels were found to vary greatly within the nursing profession, as well as between nurses, pharmacists and doctors …”

“…Improved staff training on how to locate and use available resources is needed to reduce the observed high incidence of inappropriate medication crushing . Practice can be improved if training is targeted, practical and meaningful …”

“…An educational role for pharmacists was identified involving the training of fellow health professionals and pharmacists were also included in a multidisciplinary team ensuring optimal management of SI patients . The prevalence of direct pharmacist involvement (individually or as part of a team) in medicines management of SI patients, and their confidence and knowledge to adopt such a role, is unknown.…”

“…Altering the SODF before administration can potentially lead to numerous problems: decreased accuracy of the dose, decreased efficacy, increased toxicity, reduced stability, alterations in pharmacokinetics, unpalatability and potential harm to the user . SODFs should only be modified when either no suitable alternative exists or the alternate medicine poses a greater risk to the patient . This includes suggesting an alternate route of administration, switching the drug to one in the same therapeutic class and ensuring that the same active pharmaceutical ingredient is compounded into a suitable dosage form .…”