Reducing unnecessary sedative-hypnotic use among hospitalised older adults

Abstract

BackgroundBenzodiazepines and sedative hypnotics (BSH) have numerous adverse effects that can lead to negative outcomes, particularly in vulnerable hospitalised older adults. At our institution, over 15% of hospitalised older adults are prescribed sedative-hypnotics inappropriately. Of these prescriptions, 87% occurred at night to treat insomnia and almost 20% came from standard admission order sets.MethodsWe conducted a time-series study from January 2015 to August 2016 among medical and cardiology inpatients following the implementation in August 2015 of a sedative reduction bundle (education, removal of BSH from available admission order sets and non-pharmacological strategies to improve sleep). Preintervention period was January–July 2015 and postintervention period was August 2015–August 2016. A surgical ward served as control. Primary outcome was the proportion of BSH-naive (not on BSH prior to admission) patients 65 years or older discharged from medical and cardiology wards who were prescribed any new BSH for sleep in hospital. Data were analysed on statistical process control (SPC) p-charts with upper and lower limits set at 3δ using standard rules. Secondary measures included Patient-reported Median Sleep Quality scores and rates of fall and sedating drug prescriptions that may be used for sleep (dimenhydrinate).ResultsDuring the study period, there were 5805 and 1115 discharges from the intervention and control units, respectively. From the mean baseline BSH prescription rate of 15.8%, the postintervention period saw an absolute reduction of 8.0% (95% CI 5.6% to 10.3%; p<0.001). Adjusted for temporal trends, the intervention produced a 5.3% absolute reduction in the proportion of patients newly prescribed BSH (95% CI 5.6% to 10.3%; p=0.002). BSH prescription rates remained stable on the control ward. Patient-reported measure of sleep quality, falls and use of other sedating medications remained unchanged throughout the study duration.ConclusionA comprehensive intervention bundle was associated with a reduction in inappropriate BSH prescriptions among older inpatients.

Sustaining quality improvement efforts: emerging principles and practice

“…Involving pharmacists as additional team members to review new orders for sedativehypnotics and providing 'just-in-time teachable moments' for trainees made it much more effective, combining education and just-in-time audit and feedback. 28 Pharmacists also worked with nurses to minimise interruptions to patients' sleep by rescheduling medication administration times and dimming lights. (education & audit-feedback & workflow)…”

“…For example, in an intervention seeking to reduce sedativehypnotic prescriptions in the hospital, 'education' of students and housestaff was not effective. 28 However, involving pharmacists to review new orders for sedative-hypnotics and providing 'just-in-time teachable moments' for trainees made it much more effective, combining education and just-in-time audit and feedback. It also led to engagement of more members of the healthcare team-distributing responsibilities and simplifying the intervention for individuals.…”

Reducing the use of sleep-inducing drugs during hospitalization by a multi-faceted intervention – a pilot study

“…A strength of the study is that we introduced the intervention in, and analysed its effect for, the entire hospital and not only on selected wards as in many other studies [17, 18]. In these studies, the participating doctors and nurses may have gone the extra mile not mainly because of the intervention but because they felt as pioneers and being observed and singled out (Hawthorne effect) [19].…”

Measuring overuse: a deceptively complicated endeavour

“…For example, in a study to reduce unnecessary sedative initiation among inpatients, it was imperative to review the charts to both identify patients who were not taking sedatives prior to hospitalisation and were prescribed a sedative in the hospital for the indication of insomnia. 5 This nuanced clinical information requires meticulous data extraction and is certainly not accessible from most administrative databases. Fifth, many reports do not include sufficient detail for readers to critically appraise or reproduce data collection and measurement.…”