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

1
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

2
Disclosure

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

3
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.

4
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.

5
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.

6
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

7
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.

8
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.

9
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

10
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.

11
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

12
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 residents freedom of
  movement, when the movement presents a danger to
  themselves or others.

13
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

14
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.

15
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)

16
(No Transcript)
17
Perceptions of Restraint Use

• Perceptions on the use of restraints varied both
  pre and post intervention and between
  professionally regulated and unregulated staff.
• LPNs placed more importance on using restraints
  to ensure safety and control behaviours than RNs
  when tubes and dressings were involved or in the
  management of agitation.

18
Perceptions of Restraint Use

• Post intervention all caregivers places less
  importance on restraints as a care strategy.
• LPNs were still more likely to consider use of
  physical restraints that RNs and PCAs

19
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.

20
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.

21
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.

22
Chemical Restraints Benzodiazepine

• Overall regular benzodiazepines were increased by
  1.5.
• As needed benzodiazepines were reduced by 0.8

23
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.

24
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.

25
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.

26
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.

27
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.

28
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

29
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.

30
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.

31
Contacts

• Carol Anderson, Manager, Quality Improvement and
  Consultation Services
• carol.anderson_at_capitalhealth.ca
• Sandra Leung, Consulting Pharmacist, Community
  Care Services
• sandra.leung_at_capitalhealth.ca