Organization: Sheppard Pratt Health System Solution Title: Lean Methodology: Appropriate Antipsychotic Use on an Inpatient Dementia Unit Problem: For dementia patients, antipsychotic medications are prescribed off-label for management of behavioral and psychological symptoms of dementia (BPSD). Antipsychotic medications may have a small effect size for specific symptoms and may be inappropriate for all patients with BPSD. Psychosis, hallucinations and/or delusions, and some forms of agitation such as physical aggression may be appropriate targets for antipsychotics. Insomnia, social withdrawal, wandering, verbal aggression, apathy or depression may not respond to antipsychotics. Nearly 10 years ago, the FDA issued a black box warning regarding cerebrovascular events (CVEs) such as strokes and transient ischemic attacks (TIAs) associated with the use of all antipsychotics in the dementia population. The Centers of Medicare and Medicaid Services (CMS) has taken steps to help reduce this risk with its initiative to decrease the rate of antipsychotic use for inappropriate indications by 15% in every nursing facility by December 2013 and has similar expectations in an inpatient setting. In September of 2013, the American Psychiatric Association (APA) announced their aim to decrease inappropriate use of antipsychotics by focusing on appropriate initial evaluation. In many states the goals set forth by CMS in Nursing Homes have already been met. To better meet these safety goals for dementia patients we need to coordinate care and goals between outpatient nursing home providers and inpatient teams. Our inpatient dementia team systematized a process for all disciplines to better document assessment of BPSD, consent to antipsychotics medications and use of non-pharmacological behavioral interventions. Identification : A computer generated report of antipsychotic usage from the months of November 2012 through November 2013 identified a total of 1655 prescription orders for both maintenance and PRN usage of antipsychotics for any indication in our patients on the dementia unit. A total of 672 orders were identified with an indication of agitation as standing orders for patients on the dementia unit. Roughly 40% of all antipsychotic orders on the dementia unit had been prescribed for agitation. Goals: Better identify target symptoms for more appropriate indications of antipsychotics in the dementia population. Reduce the number of orders for antipsychotics with an indication of agitation and also reduce the use of antipsychotics in patients by 15% over a one year time frame. Process: The multidisciplinary geriatric team made up of psychiatrists, nurses, music therapist, occupational therapist, pharmacist, physical therapist and rehab therapist followed the Lean Methodology at Sheppard Pratt Health System to create a current process map and identify 5 whys method for root cause analysis. The Lean Method facilitated sessions to include all team members to identify contributing factors for inappropriate use of antipsychotics. We identified 4 main focuses: 1) why are behavioral symptoms not consistently documented? 2) Why are alternative agents not consistently considered? 3) Why are non-
pharmacological interventions not consistently documented 4) Why does the psychiatrist not obtain consent from the patient or family member when initiating antipsychotics? A fish-bone diagram was developed for root cause analysis to further identify reasons of inappropriate use. The team met monthly to discuss current process and potential changes to better identify patient symptoms and coordinate treatment. Solution: The multidisciplinary geriatric team agreed to independently interview patients and document assessments in the electronic medical records. The assigned nurse for the patient was responsible for completing a newly developed form, Geriatrics Neuropsychiatric Clinical Behavior Scale on every shift in the electronic medical record. This form delineates the presence or absence of BPSD, depressive symptoms, anxiety symptoms, pain symptoms, and non-pharmacological interventions that were deemed to be effective or ineffective. Attending Psychiatrist reviewed this form to better identify target symptoms and appropriately select psychotropic agents. Attending Psychiatrist was responsible for discussing risks and benefits of antipsychotics with patients or family members when deciding to initiate one. This discussion was documented in the electronic medical records by using the ACRONYM expand tool in the electronic medical record system. Psychiatrist assigned a target symptom in the indication field of the Computerized Physician Order Entry system instead of agitation. All disciplines applied nonpharmacological interventions when appropriate and documented in Geriatric Neuropsychiatric Clinical Behavior Scale. Measurable Outcomes: We reduced the total number of standing antipsychotic orders with an indication of agitation from 672 to 63 along with reducing the total number of antipsychotic orders for any indication both as standing and PRN from 1,655 to 1,351 on the dementia unit. The average number of monthly orders during the year post implementation was 5.25. We achieved a 90% reduction in indicating agitation when using antipsychotic medication and a 10% reduction in the rate of using antipsychotic medications within the dementia population. Both charts were adjusted for census differences year over year. Prior to implementing our project 40.6 % of all antipsychotic orders were prescribed for management of agitation. Post implementation only 4.6% of all antipsychotic orders on the unit were prescribed for management of agitation without increasing the total number of antipsychotics used on the unit.
1800 1600 1655 1400 1200 1000 800 600 400 200 0 4 9 18 22 298 321 Asenapine aripiprazole Haloperidol Olanzapine Risperidone Quetiapine Total for Agitation 672 Total antipsychotics for 2G 11/01/2012 11/01/2013
Total Number of Antipsychotics for Agitation 11/01/2013-10/01/2014 10 9 8 7 6 5 4 3 2 1 0 Sustainability: In the first 6 months of implementation daily audits for indications of orders were performed. Attending psychiatrists on the dementia unit received an email or phone call from the clinical pharmacist if an antipsychotic with an indication of agitation was ordered. Audits will be completed yearly. All new attending Psychiatrists that join the team will be educated on the process using a standard work document. Nursing staff will be trained by nursing supervisor upon hire. Role of Collaboration and Leadership: Lean Methodology at Sheppard Pratt Health System encourages workers from multiple functions and levels in the organization to work together to address a problem or improve a process. Team members involved in this project included, medical director, lean staff, and all disciplines on the dementia unit. By understanding each disciplines role and input, we identified wasteful steps, areas in the process leading to time delays, and value added steps. From this collaboration we were able to meet our goals of more appropriate use of antipsychotics in the management of BPSD. Innovation: Every facility in the Unites States faces the same challenge in reducing inappropriate antipsychotic prescribing in the dementia population. Our team is unique in following a Lean methodology process to include every team member in the brainstorming and implementation of the new process flow to an inpatient dementia unit to better coordinate the goals of nursing homes. We utilized computer technology to improve communication among staff members, better screen patients symptoms, document nonpharmacological interventions from all disciplines, and improve the documentation of our consent process.
Contact Person:Joshana K. Goga Title: Clinical Pharmacist Email: jgoga@sheppardpratt.org Phone (410) 938-3851