减少住院老年患者不必要的镇静催眠药物使用。

Reducing unnecessary sedative-hypnotic use among hospitalised older adults.

机构信息

Pharmacy, Sinai Health System, Toronto, Ontario, Canada.

Pharmacy, University of Toronto, Toronto, Ontario, Canada.

出版信息

BMJ Qual Saf. 2019 Dec;28(12):1039-1045. doi: 10.1136/bmjqs-2018-009241. Epub 2019 Jul 3.

DOI:10.1136/bmjqs-2018-009241

PMID:31270252

Abstract

BACKGROUND

Benzodiazepines 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.

METHODS

We 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).

RESULTS

During 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.

CONCLUSION

A comprehensive intervention bundle was associated with a reduction in inappropriate BSH prescriptions among older inpatients.

摘要

背景

苯二氮䓬类药物和镇静催眠药（BSH）有许多不良反应，可能导致负面结果，尤其是在脆弱的住院老年患者中。在我们医院，超过 15%的住院老年患者被不恰当地开了镇静催眠药。这些处方中，87%是在夜间开的，用于治疗失眠，近 20%来自标准入院医嘱集。

方法

我们在 2015 年 8 月实施镇静剂减少套餐（教育、从可用入院医嘱集中去除 BSH 和改善睡眠的非药物策略）后，对医学和心脏病学住院患者进行了 2015 年 1 月至 2016 年 8 月的时间序列研究。干预前为 2015 年 1 月至 7 月，干预后为 2015 年 8 月至 2016 年 8 月。一个外科病房作为对照。主要结局是 65 岁或以上的从医学和心脏病学病房出院的 BSH 初治（入院前未服用 BSH）患者中，有多少人在住院期间被开了任何新的 BSH 来治疗睡眠。使用标准规则，使用统计过程控制（SPC）p 图，将上下限设置为 3δ 进行数据分析。次要措施包括患者报告的平均睡眠质量评分和跌倒率，以及可能用于睡眠的镇静药物处方（茶苯海明）。

结果

在研究期间，干预组和对照组分别有 5805 人和 1115 人出院。从基线 BSH 处方率的 15.8%，干预后期间绝对减少了 8.0%（95%CI 5.6%至 10.3%；p<0.001）。经时间趋势调整后，干预组新开 BSH 的患者比例绝对减少了 5.3%（95%CI 5.6%至 10.3%；p=0.002）。对照病房的 BSH 处方率保持稳定。在整个研究期间，患者报告的睡眠质量、跌倒和使用其他镇静药物的情况没有变化。