Nurs­ing home cuts an­tipsy­chotic drug use

Modern Healthcare - - BEST PRACTICES - By Sabriya Rice

Physi­cians at the Dur­gin Pines nurs­ing home in Kit­tery, Maine, had been con­cerned about the use of an­tipsy­chotic drugs for the fa­cil­ity’s res­i­dents. When they pulled data from the pharmacy in July 2012, they found nearly a quar­ter of res­i­dents were be­ing pre­scribed an­tipsy­chotics such as Ris­perdal. But most res­i­dents were re­ceiv­ing the drugs for rea­sons other than psy­chosis, such as to re­duce ag­i­ta­tion or stop ag­gres­sive be­hav­iors.

“I have been frus­trated by this for years,” said Dr. Jab­bar Fazeli, a geri­a­tri­cian who serves as med­i­cal di­rec­tor of the 81-bed for-profit fa­cil­ity. He says the rest of the nurs­ing home staff was shocked.

In April 2005, the Food and Drug Ad­min­is­tra­tion is­sued an alert about the in­creased risk of death in el­derly pa­tients with de­men­tia re­ceiv­ing an­tipsy­chotic drugs fol­low­ing a re­view of 17 tri­als that found in­creased risk of heart fail­ure, sud­den death and pneu­mo­nia.

A few months be­fore Dur­gin Pines started its ef­fort, a CMS pub­lic-pri­vate part­ner­ship on nurs­ing home safety urged fa­cil­i­ties to achieve a 15% re­duc­tion na­tion­ally in non­clin­i­cal uses of an­tipsy­chotic drugs. The CMS es­ti­mated that 39% of nurs­ing home res­i­dents with cog­ni­tive im­pair­ment but no di­ag­no­sis of psy­chosis re­ceived an­tipsy­chotics be­tween July and Septem­ber 2010.

Pa­tients with de­men­tia have limited abil­ity to re­spond to ad­ver­si­ties in their en­vi­ron­ment, said Dr. Susan Levy, vice pres­i­dent of the So­ci­ety for Post-Acute and Long-Term Care Medicine. For years, nurs­ing homes have ad­dressed the prob­lem with med­i­ca­tions de­vel­oped for con­di­tions such as schizophre­nia and bipo­lar disorder. Th­ese pa­tients’ dif­fi­cult be­hav­iors, she said, are fre­quently trig­gered by sub­tle un­met needs. “Peo­ple think a pill can make the prob­lem go away,” she said.

Lead­ers at Dur­gin Pines out­lined a com­pre­hen­sive plan to re­duce the over­all use of an­tipsy­chotics 20% by the end of 2012 and an ad­di­tional 15% by June 2013. The plan in­cluded what the fa­cil­ity called “global stim­u­lus re­duc­tion” to ad­dress en­vi­ron­men­tal fac­tors that made res­i­dents’ ex­pe­ri­ence more stress­ful. “Nurs­ing homes are ex­tremely over- stim­u­lat­ing places,” said Nick Bridges, the fa­cil­ity’s ad­min­is­tra­tor. “Stim­u­lants con­trib­ute to the prob­lem and can of­ten be re­moved.”

Dur­gin Pines got rid of loud alarms used to alert staff about pa­tient falls. Hard-of-hear­ing pa­tients who watched TV with the vol­ume on high were given wire­less head­sets. The en­try doors to the long-term-care unit were opened on week­days so pa­tients did not feel shut in, which also re­duced noise from the dou­ble doors open­ing and clos­ing.

Nurs­ing home lead­ers no­ticed that on-call physi­cians re­ceived more staff re­quests for an­tipsy­chotics in the mid­dle of the night, when de­mented pa­tients were more likely to have be­hav­ior episodes. To im­prove sleep qual­ity and re­duce such episodes, the wattage of hall­way lights was re­duced. Tak­ing vi­tal signs in the mid­dle of the night was dis­cour­aged. And res­i­dents known to show more ag­gres­sion in the evening were given their baths ear­lier in the day.

Even the din­ing ser­vice was re­struc­tured. “Imag­ine hav­ing lunch and some­one is scream­ing right next to you,” Fazeli said. “It’s not a happy ex­pe­ri­ence.” Dur­gin Pines changed the sched­ule so fewer pa­tients dined at the same time, and those need­ing less as­sis­tance could take their meals sep­a­rately from those need­ing a lot of staff at­ten­tion.

Man­agers held meet­ings and walk­throughs on ev­ery shift to ex­plain the new poli­cies, in­clud­ing that physi­cians would ques­tion the ap­pro­pri­ate­ness of ev­ery an­tipsy­chotic drug re­quest.

“The re­sults have been re­mark­able,” Bridges said. Over 13 months, there has been a steady de­cline in an­tipsy­chotic use. In Au­gust 2013, no pa­tient was tak­ing the drugs. No more than 3% of res­i­dents have been on an­tipsy­chotics at any given time since then.

Dur­gin Pines’ ef­forts were rec­og­nized by the Amer­i­can Health Care As­so­ci­a­tion, and its lead­ers pre­sented data on their an­tipsy­chotic drug re­duc­tion pro­gram at the as­so­ci­a­tion’s an­nual con­fer­ence in Wash­ing­ton on Oct. 8.

Last month, the CMS’ na­tional part­ner­ship, which in­cludes the AHCA, an­nounced the pre­vi­ous na­tional goal had been ex­ceeded. Ex­perts say nurs­ing homes across the coun­try have found in­no­va­tive ways—from mu­sic and aroma ther­apy to re­think­ing staffing sched­ules—to achieve the re­duc­tions. The part­ner­ship now is aim­ing for a 25% na­tional re­duc­tion from the orig­i­nal base line by the end of 2015 and a to­tal re­duc­tion of 30% by the end of 2016.

In Jan­uary, the CMS’ qual­ity star rat­ing for nurs­ing homes will be based partly on the per­cent­age of res­i­dents re­ceiv­ing an­tipsy­chotic drugs.

Though Dur­gin Pines staffers ini­tially wor­ried the changes would lead to more pa­tients with un­con­trolled be­hav­iors, “it wasn’t any­thing like we thought,” said regis­tered nurse Kathryn Chick. “In the end, it was a good thing, be­cause it forced us to look at what was re­ally mak­ing the pa­tients up­set.”

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