Carol Anderson, BScN, Capital Health Community Care Services (CHCCS) Sandra Leung BSc.Pharm, FASCP, (CHCCS)

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. Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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 Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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 Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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 Healthier people in healthier communities. www.capitalhealth.ca

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 resident’s freedom of movement, when the movement presents a danger to themselves or others. Healthier people in healthier communities. www.capitalhealth.ca

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 Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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) Healthier people in healthier communities. www.capitalhealth.ca

16. Healthier people in healthier communities. www.capitalhealth.ca

17. 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. Healthier people in healthier communities. www.capitalhealth.ca

18. 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 Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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%. Healthier people in healthier communities. www.capitalhealth.ca

22. Chemical Restraints: Benzodiazepine • Overall regular benzodiazepines were increased by 1.5%. • As needed benzodiazepines were reduced by 0.8% Healthier people in healthier communities. www.capitalhealth.ca

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%. Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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 Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

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. Healthier people in healthier communities. www.capitalhealth.ca

31. Contacts • Carol Anderson, Manager, Quality Improvement and Consultation Services • carol.anderson@capitalhealth.ca • Sandra Leung, Consulting Pharmacist, Community Care Services • sandra.leung@capitalhealth.ca Healthier people in healthier communities. www.capitalhealth.ca