QUALITY IMPROVEMENT IN LONG TERM CARE:

APPROPRIATE USE OF ANTIPSYCHOTICS

Dr. Joy Masuhara

Older Adult Mental Health and Substance Use Service

Vancouver Coastal Health Community

Member, Frail Elder Care Committee – Vancouver Division of FP

Disclosures

• None

Objectives:

• Understand how collaborative quality improvement guided

care can improve long term care for residents and their

caregivers.

• Understand basic QI concepts

• Apply a simple step wise approach in managing

behavioral and psychological symptoms of dementia.

2012

• In 2012, BC Ministry of Health released:

• Best Practice Guideline for Accommodating and

Managing Behavioural and Psychological Symptoms of

Dementia in Residential Care

Recommendations:

• Non-pharmacological treatment is 1st line for BPSD

• Use antipsychotics only if BPSD severe

• Use antipsychotics carefully noting the limited efficacy and

potential risk

• Review use regularly and withdraw antipsychotics

Other guidelines:

• Recommendations of the 4th Canadian Consensus Conference

on the Diagnosis and Treatment of Dementia (2012)

• APA Practice Guideline on the Use of Antipsychotics to Treat

Agitation or Psychosis in Patients with Dementia (2015)

• A Consensus Guideline for Antipsychotic Use for Dementia in

Care Homes (2015)

• Deprescribing Antipsychotics for Behavioural and

Psychological Symptoms of Dementia and Insomnia (2018)

CIHI data: Potentially Inappropriate Use of

Antipsychotics in Long Term Care

• 2013/14

• Canada: 30.3%

• BC: 33.2%

• Alberta: 25.3%

CIHI data: Potentially Inappropriate Use of

Antipsychotics in Long Term Care

• 2013/14

• Canada: 30.3%

• BC: 33.2%

• Alberta: 25.3%

• MY FACILITY: 40%

Physician Quality Team VCH/PHC

What is Quality Improvement?

• The systematic approach to making changes that

create better outcomes, experiences and processes

• In health care, QI is focused on achieving better

patient* outcomes and system performance*

IHI Quadruple Aimwww.ihi.org

KEYS TO SUCCESS IN

QUALITY IMPROVEMENT

• Understanding the system in which we function

• Attending to the complexities of dealing

with people

• Continuously learning and developing

knowledge about how to make things better

The Model for Improvement

Associates for Process Improvement

Just enough data……

PDSA CYCLE

(Adapted from Langley et al, 2009)

Determine what you want to learn and how

Test and measureCompare the prediction to the actual result

Determine next steps

PDSA REALITY

Opportunity

• VCH was rolling out PIECES training and the facility was

selected in the first round

• Timing completely coincided with our QI project

P.I.E.C.E.S. Lite

BehaviourMonitoring

• Dementia Observation System

• ABC charting

3 Question Framework

• 1. What has changed?

• 2.What are the risks and possible causes? Use PIECES

• 3. What is the action?

Dementia Observation System (DOS)

Case Example 1

• Bob

• 82 yo widowed retired high school teacher, with a several

year history of progressive dementia, with quite severe

aphasia. Admitted from hospital on loxapine which was

used for delirium there. Used to live in his own apartment

prior to hospitalization, with lots of support from family.

• Staff brought him to attention as he was very responsive

with care, grabbing, hitting, swearing, requiring 3 person

assist

Case Example 2

• Li

• 96 yo widowed Chinese speaking female with a several

year history of dementia. Had been admitted from home,

family sees daily. Currently on quetiapine regular and prn

as often wandering around SCU, spitting, yelling at her

image in the mirror of her bathroom, hoarding food in her

room, going into others rooms, often speaking in a loud

voice to others and staff.

PDSA REALITY

PDSA Cycle 1

• Plan: Meet with DOC, Medical Coordinator, Pharmacist.

Agreement that could try a reduction in antipsychotic use.

Reviewed the guidelines. Decided measurement monthly

of all residents on any antipsychotic prn, regular, or

regular and prn.

• Do: First intervention was to stop prn only antipsychotics

for those residents who hadn’t needed in 3 months or

more.

PDSA Cycle 1

• Study: We took 4 people off antipsychotics, less than

what we hoped, but it was pretty easy (low hanging fruit).

• Act: What next? Assess those residents who are still on

antipsychotics but BPSD has largely settled. Attempt

withdrawal.

PDSA Reality

• Opportunity: PIECES training for staff and adoption of

DOS behaviour monitoring tool

• Challenge: no regular review of data by team

• Cycle 2: monthly interdisciplinary rounds

• Challenge: not all staff trained, continuous education

needed and reinforcement of what had been learned

• Cycle 3: weekly Mental Health mini-rounds

PDSA Reality

• Opportunity: GPA training and peer care aide mentor

• Challenge: care aides couldn’t leave floor to attend

rounds

• Cycle 4: weekly mini-rounds on the floors to include care

aides

• Challenge: evening staff not included in rounds

• Cycle 5: mini-rounds alternate each week am/pm

The Model for Improvement

Associates for Process Improvement

CIHI data: Potentially Inappropriate Use of

Antipsychotics in Long Term Care

• 2013/2014 2015/16

• Canada: 30.3% 23.9%

• BC: 33.2% 28.0%

• Alberta: 25.3% 18.1%

• MY FACILITY: 40% 7.2%

How do we know a change is an improvement?

• No significant change in Aggressive Behaviour Scale

• No significant change in Worsening Behaviour or

Improving Behaviour

• In the first two years, only 2-3 residents restarted on

antipsychotics

• Trend towards lower % of persons whose ADL

performance worsened

• Trend in lower falls rate

From the literature:

• HALT trial:

• No significant increase in restart of antipsychotics or other medications

• No change in BPSD

• Brodarty, H et al. J Am Med Directors Association 2018;19:592-600.

• In those receiving antipsychotic review:

• 50% reduction in antipsychotic use, 30% reduction in

mortality

• But…..

• Decrease in quality of life, mitigated by person centred

social interaction

• Ballard et al. Int J Geriatr Psych 2017;32:1094-1103.

Other outcomes

• Job satisfaction

• Improved teamwork

• Shift in culture

• Trust and confidence building

• Staff feeling heard

• Creativity and fun

Lessons Learned

• Involve all team members including family

• Have a regular process of review

• Keep modifying, be creative and curious

• Have a good system of documenting behaviours

• Positive feedback to staff

• Listen to everyone’s ideas