Parkview Home 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 Nancy Fryer, ADOC, Rozalia Szabo, RAI Coordinator, and Kris Savage, Director of Program and Support Services and Chair of the Resident Safety, Quality and Risk Committee to better understand what strategies were effective in achieving this success.
What strategies helped you reduce antipsychotic use so successfully?
We attribute a significant part of our success to the improvements we made to our coding practices. All our staff who are responsible for coding received re-training and will get ongoing training on coding practices. We worked hard to ensure that residents’ diagnoses and antipsychotic medication use were coded accurately and completely to easily flag potentially inappropriate use of antipsychotics. For example, we were able to identify residents diagnosed with hallucinations and delusions and discuss alternative treatments if they were taking antipsychotics.
Our RAI coordinator conducts quarterly audits prior to submission to CIHI. All residents that are coded for antipsychotic medications are checked for accuracy.
What other strategies did you use?
We provide education to staff and family members about antipsychotics, including their risks and benefits. At our Initial Care Conference, which takes place 4 - 6 weeks after admission, and Annual Care Conferences, we address family members’ questions about why their loved ones are started on antipsychotics in the first place.
Medications in general are discussed at Care Conferences by the physician, including what they are used for and why, and whether there is a continuing need for these medications. Families are informed by nursing staff whenever there is a medication change.
Implementing non-pharmacological interventions:
We have two secure units with residents who have responsive behaviours. To better serve these residents, we’ve implemented several non-pharmacological interventions. For example, with funding from Ministry education funding, donation dollars and utilization of nursing funds, we were able to provide training to all our staff on the Gentle Persuasive Approach (GPA), and Montessori training to our Personal Support Workers (PSWs). Providing staff with this education has provided a choice of alternate strategies to best manage behaviours.The emphasis of the training is to guide staff to be less task focused and to focus on more person-centered care.
Our staff-to-resident ratio has been increased to better support the management of responsive behaviours. With more one-to-one support, staff are better able to identify root causes of responsive behaviours through behaviour tracking using tools such as the Dementia Observation Sheet and the PIECES model. All departments are involved in monitoring and documenting any details related to behaviours, looking for trends and triggers, such as pain, hunger, or need for toileting, and address them as needed.
Through donation dollars and allocation of nursing funds, we were also able to add an Engagement Person position to our team. We have seen a decrease in falls, less incontinence and agitated behaviours because of implementing this new role.
We work collaboratively with a mobile Behavioural Supports Ontario (BSO) team who comes to the home at least once every two weeks. We’ve seen positive outcomes as residents are more engaged in their environment through non-pharmaceutical suggestions made by BSO. Some of these suggestions include doll therapy, music, games and meaningful activity tailored to the specific resident.
With the implementation of various non-pharmacological interventions, we have been able to better manage responsive behaviours without unintentionally increasing falls or restraint use among our residents. We have had zero physical restraints in 2016 and 2017, a decrease in falls, a decrease in incontinence, a decline in resident-to-resident incidents from an average of 7 to 2 per month, and a decrease of resident-to-staff incidents from an average of 19 to 5 per month.
Monitoring medication use:
Monitoring of antipsychotic medication use is ongoing to determine if dosages can be decreased or stopped altogether in favour of alternative treatment options. Medication reviews occur upon admission, at our weekly Resident Assessment Instrument Minimum Data Set (RAI-MDS) meetings, monthly with our pharmacist who completes an audit, and quarterly with the RAI coordinator and physicians. A quarterly report is also sent to our Resident Safety, Quality and Risk committee of the Board.This committee is comprised of Board Members, One Family Member, Quality and Risk Lead and one Tenant from Parkview Village.This committee reviews and monitors all quality indicators, initiation of action plans and progress.
Do you have advice for Long-Term Care homes looking to reduce the use of antipsychotics?
Our advice is to complete root cause analyses with residents to identify reasons for responsive behaviours. This has helped us choose appropriate non-pharmacological interventions to manage these behaviours.
From a strategic perspective, we recommend collaborating with the many members of the multidisciplinary care team including family, front line staff, physician, pharmacist, and service partners to provide input on resident care. Often many strategies are needed to manage challenging behaviours.
Finally, we highly recommend the involvement of your medical director in your quality improvement efforts. This was essential for us to ensure this initiative was front and centre with all our staff.
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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