Westmount Long-Term Care Residence met and surpassed their target for reducing potentially inappropriate use of antipsychotics among their resident population, as outlined in their Quality Improvement Plan progress report from 2017/18.
Health Quality Ontario was impressed by this great work and had a chance to catch up with Carol Marchand, Co-DOC and Melanie Negru, BSO RN to better understand what strategies were effective in achieving this success.
What strategies helped you reduce antipsychotic use so successfully?
There were a number of strategies we used to reduce antipsychotic medication use in our home.
Working with our Behavioural Supports Ontario (BSO) team:
We attribute a large part of our success to the BSO team that spearheaded this work. We received extra funding from our LHIN for extra BSO hours, which allowed the BSO team to be on-site. With this model, the BSO team concentrated their efforts and completed more intense QI work with residents and staff members. The BSO team includes a nurse and personal support worker. We’ve worked with the same two individuals since the start of the BSO initiative in 2012.
Education was also a big part of our success. Our pharmacist and psychogeriatric resource consultant (PRC) provided education to our physicians, nurses, staff, residents and families about antipsychotic use. The education provided a review of the different types of antipsychotics, the effects of antipsychotic medication, appropriate and inappropriate use, and awareness that not all behaviours can be altered by these types of medication.
Our psychiatrist also delivered education to residents’ families about the benefits, risks and alternatives to antipsychotics. We found that families were more receptive to this message from a trusted source. The education was done in an informal environment so that families would be comfortable to ask questions.
Initially there were some concerns from staff and some family members, fearing that removing the medication may cause behaviours to escalate. Our education provided data and insight into the benefits of being off the medication, as well as, how we were going to implement alternatives.
Implementing non-pharmacological interventions:
With the reduction of antipsychotic use, the home chose to implement non-pharmacological interventions to manage responsive behaviours among our residents. We used the Montessori program, which we tailor to our residents. We rolled out the program one unit at a time to determine how to successfully de-escalate responsive behaviours.
Aromatherapy was another approach we used in individual resident’s rooms. Anecdotally, we have seen positive impacts on anxiety and responsive behaviours.
Monitoring medication use:
Finally, medication monitoring was another important strategy we used. At admission, use of antipsychotic medications and behaviours are flagged and automatically sent to the BSO team and pharmacist. These residents are then monitored for three months to determine the possibility of weaning off of antipsychotics. The BSO team also makes suggestions to our physicians about trialing a reduction in antipsychotics among certain suitable residents.
Our BSO nurse also completes the psychotropic drug use Resident Assessment Protocol (RAP) for each resident found on the RAI-MDS assessment tool. This gives her the ability to focus on these residents and complete a thorough assessment of their needs and capabilities with regards to psychotropic drug use reduction.
Did any of your initiatives focus on changes to coding?
Previously, staff members were responsible for coding. We then changed this role to the BSO nurse who now completes all the coding for psychotropic medications. As a result, residents are coded more accurately.
We also have the BSO nurse and RAI Coordinator double-checking that hallucinations and delusions are being captured through the weekly resident care huddles, progress notes, etc.
Do you have advice for Long-Term Care homes looking to reduce the use of antipsychotics?
Go slow. Use the “one resident at a time” mantra. Work closely with your physician, residents and family members to get them on board and discuss alternative interventions. This type of quality improvement work requires a multi-pronged approach. Engage with all your stakeholders to achieve collective success.
Do you have questions or advice for reducing antipsychotic use in long-term care? Add your comments below to share with the QI community.
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