a-mop: an antipsychotic medication optimization program for long term care
DESCRIPTION
On January 18, 2013, the BC Patient Safety & Quality Council invited key stakeholders from across the province to join together in a day of meaningful discussion around: 1. The meaning of dignity in care, with a special focus on more appropriate use of antipsychotics; 2. The current state of antipsychotic use by people living in residential care in BC; 3. An overview of work currently underway throughout BC, nationally and internationally to identify opportunities for alignment as well as learning from others; 4. Envisioning an ideal state whereby more appropriate use of antipsychotic medications can be achieved; and 5. Framing a call to action that will ask teams from residential care facilities in BC to join our initiative. This is a presentation from the event delivered by Janice Robinson, NP. Learn more about this initiative at http://www.bcpsqc.caTRANSCRIPT
Rapid Fire Presentations: Golden Nuggets in BC
A-MOP: An Antipsychotic Medication Optimization Program for Long Term Care
Janice Robinson, NP
January 18, 2013
Janice Robinson, MN, NP(A),GNC(C) Clinical Nurse Specialist/Nurse Practitioner
The Lodge at Broadmead, Victoria, BC
Fiona Sudbury, BScN, MHSc, GNC(C)Director of Care
How low can you go?: Antipsychotics in residential care – the clinical limbo
Objectives
Share a snapshot of The Lodge at Broadmead team’s journey to apply best practice dementia care.
Provide information on a quality improvement initiative to reduce antipsychotic medications.
Stimulate discussion and information sharing regarding the future of medication optimization for frail older adults.
The Lodge at Broadmead
Population served
Many Veterans 65% male Average age 88 50% move in from
hospital ALOS ~ 18 mos ~80% mod - severe
dementia
Care Team Residents & Family Members Health Care Workers Licensed Practical Nurses Registered Nurses Therapy Services Social Workers Nurse Practitioner Family Physicians Consulting Geriatric Psychiatrist
Dignity
Knowing the person Maintain their comfort – this includes
their psychosocial and spiritual comfort Partnering with families Path of Least Resistance
Dementia Care
“Supportive Pathways” Education for all staff
Clinical Program of best practice Behavioural Care Guidelines Person-centered philosophy of care Dementia Friendly environment
Medication Optimization Program
When people move-in & regular review of medication
Beer’s list audits Staff education and
good practice guidelines
Policy development
Antipsychotic Concerns!
A-MOP – QI project
Lodge
Residents
RegularOrder
Regular & PRN
Order PRN Only Total
Total 225 20 31 22 72
% 9% 14% 10% 33%
23%
ResultsContext for the prescriptions
Indication for use: 73% - Dementia (AD, VaD, Mixed) 27% - Other psychiatric diagnoses
Rationale documented for 83% of residents Most common reason - aggression and/or risk to
self or others Care plan review
57% had non-pharmacological strategies identified
Medication history 40% had been trialled on a lower dose in past
As the QI project went along…
During the project time frame - 19 people move in with a prescription for an atypical antipsychotic [38% of new admissions in a 8 month period]
8 current residents had a NEW atypical antipsychotic prescription initiated
Project Outcomes - Prescriptions July 1, 2011 – March 15, 2012
25 residents - drug discontinued 16 residents - dosage reduced 8 residents - dosage increased 8 residents – new order for atypical
antipsychotic drug initiated 14 residents died
Comparison of Atypical Antipsychotic Use – Time 1 & 2
T2 225 12 33 13 58 % 5% 15% 5% 25%
20%
Time
Residents
RegularOrder
Regular & PRN
Order PRN Only Total
T1 225 20 31 22 72
% 9% 14% 10% 33%23%
Project Impacts
Clearer picture of atypical antipsychotic drug use in this care home
Better understanding of which individual “people” are prescribed these medications and why
Increased team awareness of the risks and good practice principles for use of atypical antipsychotics
Made us look at what our assessment and care planning
Can we get lower?
Auto stop for PRNs not used Continued assessment of the person –
health status and unmet needs Provide non-pharmacological
interventions including using the path of least resistance with personal hygiene
Start using other medications classes?
How low is low enough?
A 50% decrease will be 12-15% at TLAB [33 residents]
Will those people be the folks who require these medications or will in just be a “number” to look at – who are the numbers
Are we treating people or are we trying to met a numbered benchmark?
Final thoughts - Dignity
Is it dignified to have a person in psychiatric distress or experiencing an un/under treated psychosis related to brain disease from dementia?