Long-Term Care Survey Alert

Published on Fri Jul 28, 2006 PDF

Double-check how much acetaminophen (Tylenol) your residents are really receiving. It may be more than you think when a resident "receives not only regular Tylenol for pain" but also additional doses of the drug in medications "such as Lortab or Vicodin," cautions Carla Saxton RPh, CPG, with the American Society of Clinical Pharmacists. The latter two medications can contain up to 750 mg of acetaminophen per pill, she says.

"Even if the resident takes those medications PRN in conjunction with a plain Tylenol on a regular basis, he can often exceed the recommended 4 grams of acetaminophen per day," Saxton tells Eli. She notes that "some experts will say 3 grams a day is safer."

New cause for concern: Even daily standard doses of acetaminophen have been associated with elevations in the liver enzyme serum alanine aminotransferase (ALT) in healthy adults after a short course of treatment. That's according to a study reported in a recent Journal of the American Medical Association. "Trough acetaminophen concentrations did not exceed therapeutic limits in any participant," according to the article. After the participants stopped taking the medication, the acetaminophen levels often decreased to "undetectable levels" before the elevated ALT levels resolved.

Play it safe: "If a resident is going to receive ongoing acetaminophen, the nursing staff and prescriber should look at his baseline liver enzymes," suggests Saxton. Also "consider doing periodic liver function tests while the resident receives acetaminophen--especially if he has a history of liver impairment."

Yet even though the new study raises more concerns about acetaminophen-related liver toxicity, the drug is "relatively speaking" safer than NSAIDs, says Saxton. The latter may cause problems for residents who have congestive heart failure, kidney disease or hypertension, she notes. In addition, "NSAIDs can cause gastrointestinal bleeds."

Check out the draft revisions to F309 for pain assessment and management. The draft guidance spells out the Centers for Medicare & Medicaid Services' expectations for facilities' pain management programs. The draft revisions cite a number of examples where facilities could receive immediate jeopardy citations for failing to identify and/or treat a resident's excruciating, continuous pain. One example includes a resident who elects hospice and experiences excruciating pain because he didn't received "designated pain medications" due to "lack of coordination between the hospice and facility."

Editor's note: To receive a copy of the draft guidance, please e-mail EditorMON@aol.com.