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A Troubling Trifecta:
Drug-Drug Interactions, Antibiotic
(Over)Use, and Opioid (Under)Use
in Long Term Care
Carole A. Lambert, MPA, RN
Vice President, Practice Optimization
Cooperative of American Physicians, Inc.
Carole A. Lambert
Carole has been working in the areas of patient safety, risk
management and loss prevention, quality and compliance, and
organizational development throughout her career. At the Cooperative
of American Physicians, Inc. (CAP), Carole uses her experience and
expertise to manage the peer review process and identify
opportunities for supporting the physician members of CAP. She also
directs CAP’s Residents Program, a four-tier program of risk
management and professional education that is presented at medical
centers throughout California, and which began its eighth year in
August 2016.
ACPP 2016
Objectives
1. List three principles of medication
administration.
2. Identify four risk issues associated with
prescribing medications for long term care
patients.
3. Outline a simple strategy for responding to
the challenge of appropriately medicating long
term care patients.
American College of Private Physicians 2016
By way of introduction…
 15,700
nursing homes in the US
 1.4 million residents
 At least 2 and often 3 comorbidities
American College of Private Physicians 2016
3 Principles
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The right drug
For the right reason
At the right time
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4 Risk Issues
Inadequate, incomplete,
inconsistent, or absent:
 Assessment
 Communication
 Documentation
 Informed consent/refusal
American College of Private Physicians 2016
A Simple Strategy
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
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What am I looking at?
What does it mean?
What do I have to do
about it – if anything?
Who do I have to get to help?
How do I have to account for it?
American College of Private Physicians 2016
Drug Interactions
 Drug-drug
interactions – what is the patient
taking currently?
 Drug-food/beverage interactions – is the
patient adequately nourished/hydrated?
 Drug-over the counter medicines interactions
– what is the family giving the patient?
American College of Private Physicians 2016
Drug Interactions
Drug-drug interactions – what is the
patient taking currently? > Digoxin +
Amiodarone
 Drug-food/beverage interactions –
what is the family giving the patient? >
Statin + fresh grapefruit
 Drug-over the counter medicines
interactions – herbs, vitamins

American College of Private Physicians 2016
Antibiotic (Over)Use
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On average, 1 in 10 nursing home residents
receiving antibiotics on any given day
Excessively broad spectrum antibiotics given
for more than a week
Promotes emergence and persistence of
resistant organisms
Infections the most common cause of transfer
to acute care and major source of nursing
home morbidity and mortality
American College of Private Physicians 2016
Antibiotic Use

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Facility calls – wants action
Physician responds:
Patient history
Current concerns
Review of co-morbidities
Other patients being treated for
communicable infections
Treat in place or send to hospital
American College of Private Physicians 2016
Antibiotic Use

Treat in place
Appropriate diagnostic tests
Allergies
Current medications
Dosage and duration of treatment
Monitoring and evaluation of progress
Rx
American College of Private Physicians 2016
It’s Magic…
The right drug for the right reason
in the right amount at the right
time…it’s magic!
American College of Private Physicians 2016
Opioid (Under)Use
For long term care patients We’ll mask their symptoms
 We’ll turn them into addicts
 We’ll get sued
American College of Private Physicians 2016
Opioid (Ab)Use
 Drug
overdose deaths the leading cause
of injury-related deaths in the US
 Widespread abuse of prescription pain
medications by patients, providers,
caregivers and others
 Sale of prescription pain medications
by patients and others
American College of Private Physicians 2016
Opioid Use
 Plan
for chronic pain management:
Appropriate medication selection, initial
dosing and titration
 Consider general health status, previous
exposure to opioids
 Set therapeutic goals and monitor progress
 Proactively prevent adverse events – abuse,
lethargy, change in mental status,
constipation

American College of Private Physicians 2016
It’s Magic…
The right drug for the right reason
in the right amount at the right
time…it’s magic!
American College of Private Physicians 2016
A Simple Strategy
What am I looking at?
 Physical
assessment
 Chart review
 Staff interview
 The best information
 All available information
American College of Private Physicians 2016
A Simple Strategy
What does it mean?
 Evaluation
 Patient
interview
 Environment
 Family situation
 Differential diagnosis
American College of Private Physicians 2016
A Simple Strategy
What do I have to do about it – if
anything?
 Plan
 Intervene/Treat
 Educate
 Set
goals
 Measure
American College of Private Physicians 2016
A Simple Strategy
Who do I have to get to help?
 Patient
 Family
 Staff
 Colleagues
 Community
American College of Private Physicians 2016
A Simple Strategy
How do I have to account for it? By
documenting with:
 Accuracy
 Precision
 Timeliness
 Clarity
 Consistency
American College of Private Physicians 2016
Closing Thoughts
Attributed to…
Nelson Mandela — A Nation should not
be judged by how it treats its highest
citizens, but its lowest ones.
Victor Fuchs – A nation chooses its
mortality rate when it writes its
budget.
American College of Private Physicians 2016
We need to remember…
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The work has meaning beyond the
task.
We need everyone to get the
quality and safety job done.
People are counting on us.
American College of Private Physicians 2016
The prize…
“The prize at the end will be well worth the effort-to
know that we have exceeded the expectations of our
patients and their families and, in so doing, improved the
experience for all of us. Could there be a more noble
cause? As a result, our patients and their families will feel
compelled to tell their friends about [us] and we will be
privileged to help more people lead healthier lives and
fulfill their dreams.”
Scott A. Mason, DPA, FACHE. An Extraordinary Healthcare Experience Means
More than Just a Good Clinical Outcome. The Journal of Lancaster General
Hospital. Fall 2007. Vol.2-No.3; 84-87.
American College of Private Physicians 2016
Thank you.
American College of Private Physicians 2016
Two online sources…
18 Herbal Supplements with Risky Drug
Interactions
TOP 10 PARTICULARLY DANGEROUS DRUG
INTERACTIONS IN PA/LTC
www.paltc.org
American College of Private Physicians 2016
References
AMDA The Society for Post-Acute and Long-Term Care Medicine. Top 10 particularly dangerous
drug interactions in PA/LTC. http://www.paltc.org/top-10-particularly-dangerous-druginteractions-paltc. Accessed August 30, 2016.
Birnstein PM and Lambert CA. The rising risk of major drug interactions.
Birnstein PM and Lambert CA. Responding to the challenge of inappropriate use of antibiotics in
nursing homes. CAPsules, April 2016.
Birnstein PM and Lambert CA. Developing and implementing antibiotic stewardship in long term
care. Today’s Geriatric Medicine July/August 2016.
Drug Interactions: What You Should Know. U.S. Food and Drug Administration, 2013. Accessed
August 30, 2016.
Fuchs VR. Who Shall Live? Health, Economics and Social Choice. Basic Books, New York, 1974.
Lynch T. Management of drug-drug interactions: consideration for special populations – a focus on
opioid use in the elderly and long-term care. The American Journal of Managed Care. Vol. 17,
No.11, September 2011.
Ownby GT. When ruling out, describe your plan. CAPsules, March 2015
Patients in Pain: How U.S. Drug Enforcement Administration Rules Harm Patients in Nursing
Facilities. The Quality Care Coalition for Patients in Pain, 2010.
Principles of drug administration. Pharmacology 2: NURS143 Winter 09, Tacoma Community
College, Tacoma WA. Accessed August 30, 2016
Spotrac. www.spotrac.com/nfl/rankings/average Accessed August 30, 2016
American College of Private Physicians 2016