Rapid Fire Presentations:      Golden Nuggets in BCA-MOP: An AntipsychoticMedication OptimizationProgram for Long Term Car...
How low can you go?: Antipsychotics inresidential care – the clinical limbo                  January 18, 2013        Janic...
Objectives   Share a snapshot of The Lodge at    Broadmead team’s journey to apply best    practice dementia care.   Pro...
The Lodge at Broadmead
Population served   Many Veterans   65% male   Average age 88   50% move in from    hospital   ALOS ~ 18 mos   ~80% ...
Care Team   Residents & Family Members   Health Care Workers   Licensed Practical Nurses   Registered Nurses   Therap...
Dignity   Knowing the person   Maintain their comfort – this includes    their psychosocial and spiritual comfort   Par...
Dementia Care   “Supportive Pathways” Education for    all staff   Clinical Program of best practice   Behavioural Care...
Medication Optimization Program   When people    move-in & regular    review of    medication   Beer’s list audits   St...
Antipsychotic Concerns!
A-MOP – QI project                             Regular &Lodge   Residents Regular      PRN       PRN                   Ord...
Results    Context for the prescriptions   Indication for use:     73% - Dementia (AD, VaD, Mixed)     27% - Other psyc...
As the QI project went along…   During the project time frame - 19 people    move in with a prescription for an atypical ...
Project Outcomes - Prescriptions     July 1, 2011 – March 15, 2012   25 residents - drug discontinued   16 residents - d...
Comparison of Atypical      Antipsychotic Use – Time 1 & 2                           Regular &Time   Residents Regular    ...
Project Impacts   Clearer picture of atypical antipsychotic drug    use in this care home   Better understanding of whic...
Can we get lower?   Auto stop for PRNs not used   Continued assessment of the person –    health status and unmet needs...
How low is low enough?   A 50% decrease will be 12-15% at    TLAB [33 residents]   Will those people be the folks who   ...
Final thoughts - Dignity                 Is it dignified to                  have a person in                  psychiatri...
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A-MOP: An Antipsychotic Medication Optimization Program for Long Term Care

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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.ca

Published in: Health & Medicine
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  • The Lodge at Broadmead is a non-profit care home in Victoria, BC serving 225 residents.It is government-funded and residents pay a monthly rate which varies depending on their income.
  • We are very aware of the worldwide concerns about the use of antipsychotic drugs for people with dementia, particularly those living in care homes. Those against the use of these drugs say they are “chemical restraints” and criticize the off label use of second generation “atypical” antipsychotics.Others identify their use as legitimate for treatment of specific Behavioural and Psychiatric Symptoms of Dementia such as psychosis, severe agitation and distress, and behaviours that put people at significant risk of harm. They support the use of “atypical” antipsychotics because of the better side effect profile.The evidence for the use of antipsychotics in BPSD suggests that they are really not very effective for many behaviours. One drug, Risperidone, has an approved indication in Canada but not in other countries.In 2011, the Canadian media joined in the profiling of these issues, and published data suggesting that the use of antipsychotic drugs in Canadian care homes was higher than in other countries such as the UK and USA. The data they obtained suggested that 50% of care home residents receive antipsychotics.Hearing these concerns, we decided to undertake a quality improvement project to examine and influence antipsychotic use in dementia, within our facility. We call the project the A-MOP (Antipsychotic Medication Optimization Program).
  • Time 2 stats 8 months later in March 2012 Again these are for atypical antipsychotic use in the entire population of the Care home25% of residents were receiving an atypical antipsychotic a decline of 7%5% regularly scheduled a 4% reduction15% were prescribed both regular and PRN doses a 1% increase5% had a PRN order only – a decline of 5%The overall data at time 2 did not show much changeWhy was there was so little change in overall antipsychotic use:?Previous QI initiatives since 2007 may have reduced the overall level of drug use to irreducible level given the population servedin the six month period between Time 1 and Time 2, new residents were admitted to The Lodge around half of whom were transferred from hospital, where delirium is a common occurrence and current delirium management pathways include use of an atypical antipsychotics For every resident where an antipsychotic drug is discontinued, a newly admitted resident on an antipsychotic will need structured reviewSimilar use as other care homes in our region with less utilization than some
  • June 2012 – 21%
  • Comment here regarding “weekly bath” - … what are we medicating for????
  • By strengthening policy procedure and practice , we will continue address antipsychotic drug use for BPSD in the population we serve
  • A-MOP: An Antipsychotic Medication Optimization Program for Long Term Care

    1. 1. Rapid Fire Presentations: Golden Nuggets in BCA-MOP: An AntipsychoticMedication OptimizationProgram for Long Term CareJanice Robinson, NP
    2. 2. How low can you go?: Antipsychotics inresidential care – the clinical limbo 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 Fiona.Sudbury@broedmeadcare.com
    3. 3. 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.
    4. 4. The Lodge at Broadmead
    5. 5. Population served Many Veterans 65% male Average age 88 50% move in from hospital ALOS ~ 18 mos ~80% mod - severe dementia
    6. 6. Care Team Residents & Family Members Health Care Workers Licensed Practical Nurses Registered Nurses Therapy Services Social Workers Nurse Practitioner Family Physicians Consulting Geriatric Psychiatrist
    7. 7. Dignity Knowing the person Maintain their comfort – this includes their psychosocial and spiritual comfort Partnering with families Path of Least Resistance
    8. 8. Dementia Care “Supportive Pathways” Education for all staff Clinical Program of best practice Behavioural Care Guidelines Person-centered philosophy of care Dementia Friendly environment
    9. 9. Medication Optimization Program When people move-in & regular review of medication Beer’s list audits Staff education and good practice guidelines Policy development
    10. 10. Antipsychotic Concerns!
    11. 11. A-MOP – QI project Regular &Lodge Residents Regular PRN PRN Order Order Only TotalTotal 225 20 31 22 72 % 9% 14% 10% 33% 23%
    12. 12. Results Context 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
    13. 13. 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
    14. 14. 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
    15. 15. Comparison of Atypical Antipsychotic Use – Time 1 & 2 Regular &Time Residents Regular PRN PRN Order Order Only Total T1 225 20 31 22 72 % 9% 14% 10% 33% 23%T2 225 12 33 13 58 % 5% 15% 5% 25% 20%
    16. 16. 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
    17. 17. 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?
    18. 18. 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?
    19. 19. 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?

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