Transcript No Slide Title

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
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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Why This Study?
• 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.
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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 –
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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
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Project planning, collection of baseline prevalence
information and development of the education
intervention
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Method
• Phase II: March to November 2005
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Implementation of the interdisciplinary team
education program and Phase I data analysis
• Phase III: February 2006 to February 2007
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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.
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Perceptions of Restraint Use Questionnaire
• Utilization of psychotropic medications and
prevalence of mental health diagnosis.
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Chemical Restraint Tracking Forms
• Utilization of physical restraints.
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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
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(lap belts, pelvic restraints, vest restraints, mittens,
geriatric chairs with or without lap trays and
sheets).
• Exclusions:
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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 of Restraint Use
• 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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Perceptions of Restraint Use
• 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 –
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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
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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
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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
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[email protected]
• Sandra Leung, Consulting Pharmacist,
Community Care Services
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[email protected]
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