Safety of People with Intellectual Disabilities in General Hospitals: How the pharmacist can help reduce health inequalities

By Bernadette Flood, MPSI
Daughters of Charity Service

People with intellectual disabilities (ID) are vulnerable in healthcare environments and general hospitals. For example, they have the following: 1) health and healthcare inequalities; 2) different health profile from the general population and often do not get their needs met; and, 3) a greater risk of patient safety incidents when admitted to general hospitals. Pharmacists working in general hospitals are ideally placed to increase awareness of the many patient safety issues in this vulnerable group.

What did you do in your research?
I work full time as a pharmacist with people with ID who live in long-term care. I am researching medication use in people with ID and behavior disorders. From my own experience and during my literature review, I became aware of ways in which pharmacist in general hospitals can help ensure quality care for people with ID in hospitals. I presented a poster of what I learned at an educational conference for hospital pharmacists in the Republic of Ireland in 2014.

What can the pharmacist in a general hospital do?

1. All pharmacy staff should be aware of specific vulnerabilities of people with ID, such as having the following difficulties:
a. communicating/expressing needs and choices;
b. understanding diagnosis and treatment options;
c. knowing how their decisions will affect their health status; and,
d. adapting to a hospital environment and the expectations of hospital staff.
2. Flag ‘intellectual disability’/vulnerability on pharmacy computer system and on pharmacy paper recording systems.
3. Consider ‘expert’ pharmacist with interest/expertise in care of people with ID.
4. Include full and accurate prescription of medication on inpatient Medication Prescribing Administration Recording system (MPARs).
5. Clarify any confusion with prescribed epilepsy rescue medication.
6. Question ‘nil (nothing) by mouth’ on patient’s bed and medical records. For example, “Does this mean that medication is not being administered? If so Why?” “Is the patient receiving hydration?” “Is the patient being fed?”
7. Let nursing staff know the importance of anti-epileptic and mood stabilizing medications.
8. Include information that patient has ID on medication incident reports.
9. Flag instructions such as “Feeding, Eating, Drinking, and Swallowing)(FEDS) difficulties on pharmacy computer system, MPARs, medical notes, etc.
10. FEDS equipment, as advised by Speech & Language Therapist (SALT) should be available to ensure adequate hydration, nutrition, and medication administration 
11. Change on medication form should be safe and appropriate (i.e. crushing tablets, opening capsules, etc., pharmacist consultation)
12. Effective written communication/transmission of information with healthcare team (i.e. SALT, dietician, prescribers, etc.)  13. Follow SALT recommendations for thickening of fluids, liquid medications. Understand which thickener is recommended.
14. Make ‘reasonable adjustments’ when communicating with a person with ID (i.e. more time for consultation, do not use medical ‘jargon’, use ‘easy read’ and other patient centered information resources.
15. Recognize caregiver (family/paid) as a valuable and essential source of information concerning medication/care and support for the person.
16. Ensure that each person with ID is involved in any discussions about medication to the best of their ability; and, that they have an opportunity to give consent to medical treatment.
17. Ensure changes in medication are communicated clearly to patient, caregiver and on written prescription leaving hospital. This should include medications discontinued, dosage changes, medications added, etc. Use ‘ Health Passport’ if available.
18. Complaints made by people with ID and/or their caregivers should have high priority.
19. Advocate for employment of ID Liaison Nurse in hospital.
20. Understand that communication of pain may be difficult and pain management may be inadequate for people with ID.
21. Be aware that when people with ID have emergency admissions, they are at more risk than planned admissions.
22. Ensure “Do Not Attempt Cardiopulmonary Resuscitation” orders correctly interpreted by all staff (administration medication, hydration, nutrition).


What are the take-home messages?
Improving the quality of care for people with ID must be done on multiple levels across all health care personnel. All healthcare professions, including pharmacy, need to work on innovations within their care to meet the needs of people with ID. Pharmacists should be aware of the population with ID to ensure quality medication use. Further research is also needed to determine the role of pharmacists in improving health outcomes and reducing health inequalities in this vulnerable population when they are admitted to general hospitals.

To learn more about these findings contact Bernadette Flood.

Resources
Safety of people with ID General Hospitals Poster
Safety of people with ID in General Hospitals in Ireland – How the Pharmacists can Help Reduce Inequalities