RedUSe program could minimise restraint, say stakeholders

Renewed calls for the federal government to roll out an intervention proven to reduce the use of antipsychotics in aged care facilities are going unanswered.

Renewed calls for the federal government to roll out an intervention proven to reduce the use of antipsychotics in aged care facilities are going unanswered.

Researcher Dr Juanita Breen and aged care provider peak bodies are among those again advocating for University of Tasmania’s successful Reducing Use of Sedatives program (RedUSe) following Human Rights Watch’s report last week about the use of chemical restraint in residential care.

In response to questions about government’s intentions to roll out RedUSe, aged care minister Richard Colbeck told Australian Ageing Agenda the government’s strong system-wide action to minimise chemical restraints is informed by RedUSe and UNSW’s Halting Antipsychotic use in Long-Term care (HALT) study.

Dr Juanita Breen

However, Dr Breen, who led the RedUSe project, said she would like to know which aspects of the project they are using.

“They say they are using the key learnings but I haven’t been approached,” Dr Breen told AAA.

The issue of chemical restraint has been in the spotlight lately including at the aged care royal commission.

A Parliamentary Joint Committee on Human Rights is inquiring into restraints after Human Rights Watch and the Office of the Public Advocate (Victoria) challenged recent government legislation to minimise chemical restraint.

The Human Rights Watch report, and other advocates, are calling for a ban on chemical restraint in aged care and training on dementia for the residential aged care workforce (read more here).

“They have a program that is ready to go, which could make a substantial difference,” Dr Breen said

RedUSe achieved significant reduction in psychotropics

RedUSe involved a multi-strategy interdisciplinary approach that included pharmacist-run training in facilities about the correct use of medications and alternative approaches, and bringing nurses, pharmacists and doctors together to reduce the prescribing of antipsychotics and benzodiazepines.

Following a successful pilot in Tasmania, the federally-funded expansion trial in 150 aged care facilities in six states from 2014 to 2016 achieved a “significant reduction” in the use of psychotropic medication (read more here).

“We found that we reduced antipsychotic use by 13 per cent and benzodiazepine rates of use by 21 per cent. When all residents taking psychotropics were tracked over the six-month program 40 per cent had their antipsychotic or benzodiazepine dose ceased or reduced.”

In their final report, Dr Breen and her team recommended the program be rolled out nationally.

“We did a detailed cost benefit analysis, concluding that the cost savings from medication reductions alone  – approximately $3 million per year – would pay for the program,” she said.

The researchers asked for $1 million in the first year to update materials and employ facilitators and about $500,000 per year after that to offer the program.

While the government formally accepted the report, it did not respond to the recommendations, Dr Breen said.

“It’s frustrating as a researcher to see something that can make a difference, that was oversubscribed, that staff really liked and valued and that could be also enhanced – we improved our reductions from the pilot to the expansion – to be just discarded,” Dr Breen said.

Patricia Sparrow

Aged & Community Services Australia CEO Patricia Sparrow said ACSA has called on the government to implement RedUSe many times through its budget submissions and briefs to government when a new government or minister is appointed.

“You need to have the prescribers working with the facility and that’s what the RedUSe trial did. It was well-accepted by both [doctors and providers] and it had an impact, ” Ms Sparrow told AAA.

“We 100 per cent support the reintroduction of RedUSe. We think it could be an effective thing that could be done to address this whole issue.”

Colbeck says research informed new regulations

Richard Colbeck

Minister for Aged Care and Senior Australians Richard Colbeck said that minimising the use of restraint in residential aged care was a top priority for government.

“The Government funded the RedUSe and HALT projects to examine ways to reduce the use of restraint. We are now taking strong system-wide action, informed by the projects, now that they are complete,” Mr Colbeck told AAA.

He cited the new Aged Care Quality Standards and their explicit obligations on providers about the use of restraints and the aged care regulator’s “strong powers to enforce the standards.”

Mr Colbeck said $7.7 million funding in the April 2019 Budget also aimed to reduce the misuse of medicines in residential aged care by:

  • establishing a pharmacy unit within the Aged Care Quality and Safety Commission to work directly with residential aged care providers around best practice use of medicines
  • expanding the National Aged Care Quality Indicator Program to include medication management.

Regulations lack guidance on ‘how to reduce use’

Dr Breen said the funding for pharmacists in the ACQSC and committing to a quality indicator for medication management in two years indicate government has recognised the importance of medication management in aged care homes.

But “it is highly unlikely these initiatives will impact the use of chemical restraint,” she said.

“Likewise, the new quality standards provide minimal guidance on what chemical restraint is, let alone suggest strategies to reduce its use.”

Australian and international evidence shows that targeted initiatives are required to reduce the use of antipsychotics, Dr Breen said. RedUSe made facilities aware of their use of these medications and how they compared to other aged care homes.

“We provided an evidenced-based high-quality training program. It was like a series of strategies but we did emphasise that it was really important to have the three health care practitioners really influencing prescribing.”

Those three disciplines are the nurse in the facility, a pharmacist to ensure appropriate medication use and the prescriber all working together, she said.

“What HALT found and what we found is that in about 80 per cent of people who you trial a reduction you can keep them off it and it makes very little difference,” she said. “That shows you can get four out of five people off.”

Leglislation ineffective in changing culture

Dr Breen said it has been shown internationally that legislation often doesn’t work because people find a way to work around it.

“[Regulations] don’t really change the underlying beliefs and behaviours. It doesn’t introduce a systematic way to look at every person and work out what’s the best way to manage their challenging behaviours.”

Dr Breen also questioned whether rules and guidelines reached the workers providing frontline care, who are the ones “providing the impact”.

Peaks say RedUSe a valuable intervention against restraint

Leading Age Services Australia is also a long-time backer of the program.

Sean Rooney

CEO Sean Rooney said the Australian RedUSe study showed that targeted interventions could significantly decrease the use of antipsychotic and sedative drugs.

“LASA believes that making these interventions available nationally would provide a valuable option to reduce chemical restraint and potentially improve residents’ lives,” Mr Rooney told AAA.

He reiterated recommendations LASA made to government for evidence-based, standardised processes for recording, reporting, monitoring and reviewing physical and chemical restraints as part of any legislation regulating restraint.

Ms Sparrow said if a trial proves effective, the government should look at whether the good outcome will stop or continue if it is taken away.

“And in this instance for what is a relatively small investment with a big impact, why would you actually stop it,” she said.

“Roll it out. Roll it out nationally. Roll it out now. Don’t wait. We have evidence of something that it is effective that has already been effective and will be effective again,” Ms Sparrow said.

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Tags: acsa, aged-and-community-services-australia, antipsychotic-medications, human-rights-watch, juanita-breen, lasa, leading age services austalia, news-8, pat-sparrow, psychotropic-medications, Reducing Use of Sedatives, reduse, Richard Colbeck, Sean Rooney, slider, University of Tasmania,

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