Blazing a TRAIL towards improved resident care

The Challenge

In Canadian long term care homes, one in three residents is taking antipsychotic medication without a diagnosis of psychosis. These medications are used to manage challenging behaviours associated with dementia. From 2002 to 2005, Health Canada issued several warnings about the use of antipsychotics in dementia. Research has shown that the medications can increase the risk of mortality, stroke, hip fractures and reduce quality of life. Choosing Wisely Canada, a national campaign organized in partnership with the Canadian Medical Association, is helping physicians and patients engage in conversations about unnecessary tests, treatments and procedures, including antipsychotic medication for patients with dementia.

At the Winnipeg Regional Health Authority (WRHA)’s personal care homes (PCHs), 24 percent of residents were taking antipsychotic medications without a supporting diagnosis of schizophrenia, Huntington disease or hallucination. These antipsychotic medications had limited benefits, posed significant risks to the residents and were also costly.

The Solution

Working with the Canadian Foundation for Healthcare Improvement, an interdisciplinary team from the WRHA Long Term Care Program aimed to reduce the inappropriate use of antipsychotic medication. Pharmacy Manager Allison Bell, Manager of Initiatives Joanne DiNicola and Manager of Resident Assessment Instrument – Minimum Data Set (RAI-MDS) Decision Support, Michael Haip, focused their EXTRA improvement project on optimizing antipsychotic medication reassessment during the quarterly medication review – a team interaction between the nurse, prescriber and pharmacist.

The Team Review of Antipsychotics in Long Term Care (TRAIL) process was implemented to encourage collaboration between the physician, pharmacist and the nurse at the quarterly medication review. It was designed in conjunction with work being spread from a previous EXTRA improvement project that focused on delivering dementia care education using P.I.E.C.E.S, a person-centered, nonpharmacological approach that helps healthcare providers to manage the challenging behaviours of dementia patients without the use of medication, wherever possible.

Through the TRAIL project, physicians received an individualized, confidential prescriber practice report outlining the antipsychotic medications they prescribed from a provincial Drug Program Information Network (DPIN). This was paired with their residents’ characteristics from the RAI-MDS assessment and evidence-based recommendations on antipsychotic medications. The prescribing physician was encouraged to reflect on this information in preparation for the quarterly medication review.

Nurses attended education sessions covering a review of antipsychotic medications, an introduction to the TRAIL process, how to use an antipsychotic monitoring tool (AMT) and how to utilize the RAI-MDS outcome scales. This education ran concurrently with sessions provided to nurses, support staff and families on the P.I.E.C.E.S™ approach. The pharmacists flagged the antipsychotic medications on the quarterly medication review form, which were sent to the PCH ahead of the quarterly medication review. The nurses prepared for the upcoming quarterly medication review by reviewing the residents on antipsychotic medications, discussing potential candidates for reduction with the team on the unit and applying the assessment tools learned in the P.I.E.C.E.S™ education sessions.

During the collaborative quarterly medication review, the healthcare team assessed the appropriateness of the antipsychotic medication and decided whether the residents’ medication should be continued, tapered or discontinued.

The Results

The project achieved success beyond the team’s expectations. Antipsychotic medications were reduced or discontinued in 56 percent of a cohort of 115 residents during the six-month implementation phase at the three PCHs – Extendicare’s Oakview Place and Tuxedo Villa, and Revera’s Heritage Lodge. Many of these residents had cognitive impairment diagnoses, the most common being dementia and Alzheimer’s disease.

The majority of reductions occurred to regularly scheduled antipsychotic medications as opposed to medications administered only as needed. Four different classes of psychotropic medications (hypnotics, antidepressants, cholinesterase inhibitors and mood stabilizers) were also monitored, with a resulting drop in the use of hypnotic medications – a positive outcome due to their significant associated risks, such as falls and fractures, cognitive impairment and sedation.

Overall, positive gains in cognitive performance, social engagement and activities of daily living were observed on the RAI-MDS quarterly assessments. There was no observed increase in the use of physical restraints or the need for constant one-on-one care. Staff report that once the antipsychotic medications were reduced, many residents became more responsive.

The Spread

The resources and lessons learned from both the TRAIL and P.I.E.C.E.S improvement projects are part of sustained improvement work at WRHA, with the goal of improving resident-centred care. The WRHA Long Term Care Program is developing a comprehensive dementia care program and collaborating with more Winnipeg PCHs to implement these improvements. These efforts are bearing fruit: in 2010-11, 29 percent of long-term care residents in the WRHA were on antipsychotic drugs without a diagnosis of psychosis and by 2013-14 this number had dropped to 23 percent – well below the national average of 30 percent.

On the national stage, Allison Bell and Michael Haip are working with CFHI as guest faculty in the Reducing Antipsychotic Medication Use in Long Term Care Collaborative. They are sharing the TRAIL project results and tools with 15 teams from healthcare organizations that are focusing on promoting the appropriate use of antipsychotic medication in over 50 facilities across Canada.

Allison Bell

 

Allison Bell
Pharmacy Manager - Long Term Care Program
Winnipeg Regional Health Authority
Winnipeg, Manitoba

 

Joanne DiNicola

Joanne DiNicola
Manager of Initiatives - Long Term Care Program
Winnipeg Regional Health Authority
Winnipeg, Manitoba

 

Michael Haip

 

Michael Haip
Manager of RAI/MDS Decision Support - Long Term Care Program
Winnipeg Regional Health Authority
Winnipeg, Manitoba

 


To learn more about this project or the EXTRA program, visit cfhi-fcass.ca/EXTRA or email us at info@cfhi-fcass.ca.