Friday, November 4, 2011

Performance Improvement Tip of the Day: Standardization of a PRN Protocol

A simple example of standardization - a short list of PRN (as needed) medications that were most likely to be ordered for inpatients.

What led to the development of this initiative?

Physicians were frustrated that they were getting calls at all hours of the day - and particularly night - for relatively "simple issues".
Nurses were frustrated that they could not give their patients relief for "minor" and common symptoms - for which many of the medications were over-the-counter, until they heard back from the physicians. The delay in some cases could be hours.
Patients naturally bore the impact of this, not getting timely relief.

It took some work to come up with a set of medications that the medical staff and nursing staff could agree upon to be administered for most patients without a direct medical evaluation. However, once the "PRN protocol" was created, and integrated into the General Admission Order Set, it immediately led to a reduction in what was perceived by all staff to be "unnecessary phone calls".

Patients received care more promptly. The "first-line" treatments for "minor" symptoms could now be initiated by nursing judgement, and rarely led to a request for "second-line" treatments.

Standardization by using a common set of medications also improved safety by reducing the complexity of the system, by increasing clinical familiarity, and by having parameters and precautions "built-in" to the order.

It allowed the communication between nurses and physicians to rise to a "higher level of practice" rather than to consume their valuable time chasing each other about the routine.

Caveat: Even "minor" symptoms can turn out not to be minor, particularly in patients admitted to a hospital. Clinicians are right to be worried about over-standardizing care through the use of protocols, however, a well-developed protocol when balanced with continuing exercise of clinical judgment can streamline the care process dramatically.

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