A Melbourne facility found that starting a conversation with staff and families has led to significant positive change around the use of antipsychotic medications.
An aged care facility has seen complaints about medications fall from more than 10 per year to zero, combined with an 80 per cent reduction in medication concerns from family members, following its development and implementation of a program on antipsychotics.
Developed by management and clinical staff at San Carlos Homes for the Aged, the program involves the ongoing evaluation of antipsychotics use, via a specially developed assessment tool, combined with an education program for staff and families.
The multidisciplinary program was developed and implemented by a working party that consisted of facility staff as well as local GPs and pharmacists, according to Ann Dewey, clinical coordinator and nurse practitioner at San Carlos, a 106-bed facility in Melbourne caring for seniors of Italian background.
“We noted we had a lot of family queries about medications; we also had a large number of residents admitted on medication regimes that we couldn’t always find the rationale for. We decided to look at our medications,” Ms Dewey told Australian Ageing Agenda.
Involving all staff in project
With two dementia-specific units, the facility has a large number of residents living with dementia. Management decided to involve all staff, along with visiting allied health professionals, GPs and specialists, in the program that would explore the use of antipsychotic medications and the alternatives available. This would be combined with an education program for staff and families.
A 12-member working party was formed consisting of facility staff along with local GPs and pharmacists.
“By the end of 2012 we had developed a strategy for how we were going to evaluate all the residents who were admitted to our facility on these medications, as well as how we were going to educate staff and families,” said Ms Dewey.
That strategy included the development of a new facility protocol that stipulated regular evaluation of current and newly admitted residents being prescribed antipsychotics. The effect of the drugs were evaluated by nursing staff and the rationale for their use was evaluated by Dewey as a nurse practitioner together with the facility’s visiting GP. An electronic evaluation document was created for this purpose.
The education component involved the development of education flyers for staff, coupled with informational posters placed in key locations in the facility. These materials were reinforced by formal education sessions.
The family education component involved the development of a referenced education booklet. Eight family members were involved in providing input and feedback on the resource as it was developed.
“That turned into quite a large project because a lot of the families were very interested. We soon found out the book would become a starting point; it was salient, concise information, without much medical jargon, that referred people to sites where they could get further information if they needed,” said Ms Dewey.
Important conversations
Ms Dewey said that, during conversations with family, staff members were careful not to imply or appoint blame, rather the purpose was to explore why the particular resident needed antipsychotic medications, whether the drug dose or frequency could be reduced, and if there were any suitable alternatives.
Through discussions with the families, staff realised that relatives were often relatively well informed, and many were interested in the drugs, how they worked and their potential side effects. “The internet is an amazing place,” says Dewey. “Although, there is a lot of misinformation out there, which is why the referenced education booklet was so important; it told them where they could go for further, reliable information.”
Ms Dewey said the facility had witnessed enhanced relationships with family members since the project started. The program also had a noticeable impact on staff, with an improvement in their knowledge and attitudes, Dewey says. “They are better at identifying the triggers to behaviours and at stopping those triggers before the behaviour occurs.”
Ms Dewey stressed that the program did not set out to stop using antipsychotic medications but was interested in finding alternatives where suitable. Since the program began the facility has expanded its activity and lifestyle program to the extent it recently hired an external consultant to further develop this area in the dementia units.
Another positive outcome has been enhanced working relationships with the pharmacists, visiting GPs and specialists who support the facility.
Issues to overcome in implementation
Ms Dewey said there were several challenges during the development and implementation of the program. She said:
“Maintaining staff motivation has been a challenge at times, especially when there was staff turnover and we had to ensure that new staff members were aware of the policy, had read the book and maintained that interest.”
Obtaining timely, honest and accurate information regarding new residents upon admission was also an occasional challenge, she said.
The perceptions around antipsychotic drugs, among both staff and families, were another issue at times, said Ms Dewey. “Some people thought the drugs were wonder drugs and some people thought they were horrendous.”
“Lack of time was the hardest thing,” said Ms Dewey of the challenges. “Many of us did a lot of work in our own time, and a lot of families gave up their time looking at documents and giving interviews about their personal experiences.”
Next phases
Ms Dewey said the project was ongoing and the project team was developing a risk assessment tool that aimed to provide data upon a resident’s admission to indicate whether they need an immediate review of their medication dosage.
The project last year won a Better Practice award in recognition of its positive outcomes, and Ms Dewey will again speak at the Better Practice seminars this year to further share the facility’s experience.
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Positive results: outcomes of antipsychotics project
- Reduction in medication-related complaints from 10-plus per year in 2011 to zero in 2014
- Positive feedback received from 21 families during care plan reviews
- Satisfaction surveys indicate an 80 per cent reduction in medication concerns expressed in family interviews
- 97 per cent of families with relatives on antipsychotics have had a discussion with staff at least once
- Since 2011, 67 per cent of residents who were prescribed antipsychotics have seen a reduction in dosage or frequency, or both
- For 29 per cent of those, there has been a total cessation of the drug, which the facility said has occurred with no increase in the incidence or degree of aggression
- 100 per cent of residents on antipsychotics have the rationale and effects regularly evaluated
- Staff have an increased speed of recognition of drowsiness or movement disorders which allows more expedient drug review.
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