Antipsychotic medications in long-term care

The Canadian Institute of Health Information (2016) reports that, in 2014, 39 per cent of long-term care residents were prescribed at least one antipsychotic order. This is alarming because antipsychotics may be only partially effective compared to the placebo in treating delirium and behavioral and psychological behaviors in dementia (BPSD). In addition, their adverse effects, which includes increased risk of mortality, may limit their effectiveness. Best practice recommends that residents on antipsychotic medications should be assessed closely for adverse reactions and effects on targeted symptoms of treatment; findings should be documented clearly.

Although our long-term care facility, The Perley and Rideau Veterans’ Health Centre had made some gain in reducing inappropriate use of antipsychotics (17.5 per cent) of residents were receiving at least one antipsychotic in August 2017), we had no active policy or process outlining requirements or standardization of how antipsychotic medication must be administered and documented in geriatric residents.

 

One-on-one interviews with six regular staff nurses and two in-house physicians indicated that a new antipsychotic medication order would likely prompt documentation of resident behavior every shift for about one week, but there were notable variances in process. Twelve month retrospective chart audits on two units indicated, based on three shift rotations charting for one week, only 56 per cent of expected documentation notes were actually written.

 

Monitoring and documentation is mandated when the resident is experiencing a new antipsychotic order, a change in a previous order, has ongoing treatment or is newly admitted with an antipsychotic order. Of these, only 48 per cent contained sufficient evidence that an assessment of targeted behaviors were conducted and only 19 per cent for adverse effects. Both interviewed physicians reported that nursing documentation did influence their prescribing decisions. These practice knowledge deficiencies were alarming and troubling since lack of effective documentation increases the occurrence of faulty decision making about the wellbeing of residents and the benefits of the antipsychotic medications on the residents.

This quality improvement project aimed to improve the monitoring and documentation of residents receiving antipsychotic medications in a long-term care environment. This project was led by a front-line Registered Nurse and supported by our Delirium, Dementia and Depression Quality Improvement Team, an inter-professional group that had been tasked to implement best practice recommendations outlined in the Registered Nurses Association of Ontario’s guideline “Delirium, Dementia and Depression in Older Adults: Assessment and Care” to the long term care sector of our campus. Since structured nursing led medication assessments are thought to improve resident health outcomes, our team opted to develop and implement a documentation tool that would support and standardize comprehensive nursing assessments and documentation of the targeted and adverse effects of antipsychotic use on long term care residents. Implementation was focused on two specialized,

veteran, dementia units with higher frequencies of antipsychotic med use compared to the rest of the facility (43.2 and 12.5 per cent of residents on each unit, respectively, was on at least one antipsychotic medication in August 2017).

The timeframe for the project was from September 2017 to February 2018. We used Plan-Do-Study-Act learning small cycles of change to create and implement a documentation tool which was built directly into our point-of-care electronic health records. Our implementation strategy included multiple components such as just-in-time 30 minute informal education sessions at the bedside, leadership support, pharmacy involvement, audit and feedback, reminders, as well as the availability of reference and resource materials. We designed the intervention to include multiple strategies since multifactorial interventions have been shown to be more effective for practice change than a single strategy. The team also focused on building interventions that were higher on the hierarchy of effectiveness rather than focusing on educational tactics alone.

Use of the tool demonstrated positive feedback from staff regarding usage, workflow management, and standardized nursing practice. Once fully implemented, repeat chart audits showed an increase in expected documentation from 56 to 86 per cent and an increase in the focus on adverse reactions and effects on the resident’s targeted symptoms from 19 and 48 per cent respectively, to 100 per cent for both in a five month period. Implementation, audit and feedback is ongoing. The team hopes that leveraging this tool will support decision making in appropriate use of antipsychotic medications.

This article was submitted by Daniela J. Acosta, RN, GNC(C), BSc, BScN, Jennifer Plant, MSc, BHS, RRT; Mary Boutette BSc, MHA; and Sara Owusu-Sarfo RN, BScN, MScN of The Perley and Rideau Veterans’ Health Centre.