optimizing quality of care and improving safety for continuing care centre residents with...

Optimizing quality of care and improving safety for Continuing Care Centre residents with Behavioural

and Psychological Symptoms of Dementia by reducing physical and chemical restraints

Carol Anderson, BScN, Capital Health Community Care Services (CHCCS)

Sandra Leung BSc.Pharm, FASCP, (CHCCS)Cheryl A. Wiens, BSc.Pharm, Pharm. D., University of Alberta

Aimee Bourgoin B.A., M.N., GNC(C), Edmonton General Continuing Care Centre

24 September 2007

04/18/23

Healthier people in healthier communities.www.capitalhealth.ca

Disclosure

• The authors of this presentation hold no conflict of interest that may have a direct bearing on the subject matter of this presentation.

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• Behaviour and psychological symptoms occurs in 60 to 98% of individuals with dementia.

• Media attention focuses on the inappropriate and escalating use if psychotropic medications in continuing care centers.

• An implication of inappropriate restraint use negatively affects quality of life.

Why This Study?

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Objectives

• To discuss the findings and positive impacts of a project to improve safety and quality of care for continuing care centre residents with BPSD by reducing inappropriate restraint use.

• To share the experience of implementing regional restraint standards as guided by CCSMH CPG, Minimum Data Set and provincial standards.

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Patient Safety Project

• Funded for a two year (2004 – 2006) patient safety project.

• Prospective cohort study to improve resident safety and quality of care in continuing care centers by reducing the inappropriate use of physical and chemical restraints.

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Patient Safety Project

• Partnership between -– Capital Health Facility Living– Edmonton General Continuing Care Centre

(Caritas Health Group)– Capital Care Lynnwood (The Capital Care Group)– Central Care Corporation (South Terrace, Jasper

Place and Miller Crossing Continuing Care Centers)

– University of Alberta

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Goals of the Project

• Improve the quality of care for residents experiencing BPSD.

• Reduce resident injuries related to falls.• Assess the nursing care teams perceptions of

restraint use.• Assess the impact of an interdisciplinary

educational mentoring program on restraint utilization.

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Goals of the Project

• Increase the knowledge of the interdisciplinary team regarding psychotherapeutic medications and physical restraints.

• Provide the interdisciplinary team with least restraint strategies to reduce restraint utilization.

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Method

• The project was conducted in three phases over three years –

• Phase I: April 2004 to February 2005– Project planning, collection of baseline prevalence

information and development of the education intervention

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Method

• Phase II: March to November 2005– Implementation of the interdisciplinary team

education program and Phase I data analysis

• Phase III: February 2006 to February 2007– The completion of the post intervention prevalence

data collection, analysis of data, review of the regional falls and major injury quality indicator data. Preparation of the final report and recommendations.

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Data Components

• Nursing staff perceptions of when restraints would be used.– Perceptions of Restraint Use Questionnaire

• Utilization of psychotropic medications and prevalence of mental health diagnosis.– Chemical Restraint Tracking Forms

• Utilization of physical restraints.– Physical Restraint Tracking Form

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Categories of Restraints

• Chemical Restraint: Use of any psychoactive drug to control or limit a particular behaviour or movement exhibited by a resident.

• Physical Restraint: Use of any intervention intended to restrict a resident’s freedom of movement, when the movement presents a danger to themselves or others.

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Categories of Restraints

• Physical / Mechanical Restraint: An appliance that restricts freedom of movement – (lap belts, pelvic restraints, vest restraints, mittens,

geriatric chairs with or without lap trays and sheets).

• Exclusions: – immobilization for medical treatment – temporary immobilization during a nursing

procedure, during transportation

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Interdisciplinary Education

• Developed by Regional and Continuing Care Centers expert clinicians.

• Delivered by a nurse and a pharmacist.• Geriatric Psychiatrist provided similar to

physicians.• Interactive sessions included an algorithm to

guide appropriate use of neuroleptics.

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Perceptions of Restraint Use

• One page questionnaire rating perception of how important use of medication and physical restraints was to manage specific examples of behaviour.

• Questionnaire was adapted from Evans & Strumpf (2003) and Maisey, Kwasny and McCormick (2004)

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• Perceptions on the use of restraints varied both pre and post intervention and between professionally regulated and unregulated staff.

• LPN’s placed more importance on using restraints to ensure safety and control behaviours than RN’s when tubes and dressings were involved or in the management of agitation.

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• Post intervention all caregivers places less importance on restraints as a care strategy.

• LPN’s were still more likely to consider use of physical restraints that RN’s and PCA’s

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Physical Restraints

• Number of residents without restraints increased by 4.4%

• The use of highly restrictive restraints decreased -– Trunk – 6.7%– Pelvic – 0.5%– chairs that prevent rising – 4.0%

• Post intervention fewer residents with more than one restraint.

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Chemical Restraints

• Prevalence of residents with psychiatric diagnosis was collected as antipsychotic medication is required for treatment and management of their illness.

• Utilization of antipsychotic, benzodiazepines, tricyclic antidepressant, tetracyclic and triazolopyridine, sedative and anticonvulsant medications were measured pre and post intervention.

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Chemical Restraints: Antipsychotic

• Overall regular antipsychotic use was increased by 0.5% with a 5.1% increase of residents with psychiatric diagnosis.

• PRN antipsychotic use was reduced (ranging from 3% to 19%) or sustained with an overall reduction of 6.6%.

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Chemical Restraints: Benzodiazepine

• Overall regular benzodiazepines were increased by 1.5%.

• As needed benzodiazepines were reduced by 0.8%

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Falls and Major Injuries

• Number of falls increased by 59%.

• Major injuries of falls resulting in fractures and head / brain injuries was reduced from 4.1% to 2.4%.

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Falls and Major Injuries

• Increase in number of falls likely related to the reduction in use of physical restraints (seat belts, side rails).

• Falls Assessment Protocol was implemented across the region– Improved assessment and management of

residents who fall.

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Project Conclusion

• Education intervention during the project influenced perception of the use of both physical and chemical restraints in the management of BPSD and improving resident safety in continuing care centers.

• Introduction of least restraint practices did result in an increase in the number of falls, however there was a reduction in injurious falls.

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Project Recommendations

• Least Restraint education and mentorship programs – Sustainability of the improvements– focus at the LPN level

• A project to assess appropriateness of psychotropic medication use.

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Regional Initiatives

• Antipsychotic and Chemical Restraint.

• P.I.E.C.E.S. education initiative commenced during the spring 2007.

• Developing a sustainable least restraint regional practice through education and mentorship.

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References

• RovnerBS, German PS, BroadheadJ, Morriss RK, Brant LJ, Blaustein J, et al. The prevalence and management of dementia and other psychiatric disorders in nursing homes. Int Psychogeriatr 1990; 2(1): 13-24.

• Tariot PN, Pdodgorski CA, Blazina L, Leibovici A. Mental disorders in the nursing home: Another perspective. Am J Psychiatry 1993, 150(7): 1063-1069.

• Hagen BF A-EC, Quail P, Williams RJ, Norton P, Le Navenec CL, Ikuta R, Osis M, Congdon V, Zieb R. Neuroleptic and benzodiazepine use in long-term care in urban and rural Alberta: Characteristics and results of an educational intervention to ensure appropriate use. Int Psychogeriatr

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References

• Alberta Association of Registered Nurses (2003). Position statement on the use of restraints in client care settings. Edmonton, AB.: Author

• Evans, LK, Strumpf, NE. 1989. Tying down the elderly: A review of the literature on physical restraint. J Am Ger Society 371: 65-74.

• College of Nurses of Ontario Practice Standards (2000). Restraints.

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References

• Registered Nurses Association of Ontario (2002). Prevention of falls and fall injuries in the older adult. Nursing Best Practice Guidelines.

• England W, Godbin D, Onyskiw J. (1997). Outcomes of physical restraint reduction programs of elderly residents in long term care: A systematic overview. Alberta Professional Council of Licensed Practical Nurses.

• English RA (1989). Implementing a non-restraint philosophy. Canadian Nurse 85(3): 8-20, 22.

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Contacts

• Carol Anderson, Manager, Quality Improvement and Consultation Services– [email protected]

• Sandra Leung, Consulting Pharmacist, Community Care Services– [email protected]

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