Culture change plays an important role in successful psychotropic reduction. This case study shares ways to reduce psychotropic use in a skilled nursing center and how reducing psychotropic use affects quality measures and outcomes.

Meet Cameron

Let me start with a story. Meet Cameron. When he turned a year old, it was clear that something was not quite right. He was oversensitive to stimulation such as sun, touch, and noise. His speech was delayed, and he was not walking by the age of 18 months. By the time he was two, his behaviors included banging his head on the floor, being up at all hours, hitting out at others, and intolerance of various stimuli.  
Now, what advice would you give me for handling Cam?

It was clear that Cam’s interaction with the outside world was different from the “normal” baseline, that his processing of stimulation was altered, that he was unable to make his wants and needs known through “normal” communication, and that he showed his frustration by screaming.

One wise expert, my mother, who is a speech therapist, counseled changing my approach to communicating with Cam—change his environment, give him a way to communicate his wants and needs, and allow him to have control in his environment, she said. In other words, accommodate him.

Now, when I asked for suggestions, would you have suggested putting an alarm on Cam to keep him in his seat or give him an antipsychotic to sedate him? Probably not, yet these are behaviors that some residents display on a daily basis, and these are our common responses to them.

Segue To Residents

Culture change is essential to making necessary accommodations for residents who in the past might have simply been medicated.

To understand that our residents may not see the world the way they used to requires making changes in care delivery to accommodate this different perception without relying on psychotropic drugs.

In order to be effective and positively impact outcomes, however, culture change must permeate every level of practice in a skilled nursing center. It starts with strong, committed leadership and builds with thorough staff awareness of the issues. The entire center team must buy into the idea that the old ways of doing things (alarms, psychotropic drugs) are no longer acceptable.

This takes thorough education; every staff member must understand why reducing psychotropics is important to the well-being of their residents—and how to achieve it. Each employee must buy into the cause and feel that they are contributing to the success of the initiative.

Employees need tools and skills to treat and manage behaviors without resorting to drugs. As we have found, these do not have to be costly. Emotional support and positive reinforcement from a center’s leaders are important. Transparency must be the rule: Let people know what is working and what’s not. Frontline staff have an important role, as do the administrative and support staff. Huddles and early warning tools such as the INTERACT system for documenting patient condition when transferring from one health setting to another can help.

The Search For Alternatives

Environmental changes, such as eliminating overhead paging and the constant, overstimulation of noise from televisions and radio, are important. Try to keep lighting that matches the natural day; turn on lights in the afternoon during winter. Limit staff chatter outside resident rooms. Consistent assignments help residents to feel a sense of control over their setting while ensuring that caregivers know individual routines and needs. A roommate change may also be in order.

The medical chart for each resident receiving psychotropics must be reviewed. Does everyone have a diagnosis that supports the drug used? Is there a cluster of patients in the building, or do certain staff always ask for a psychotropic? When was the drug started, and has the issue that prompted the order been long resolved?

These are all good questions to ask. Remember, the CASPER minimum data set report indicates who is on a psychotropic without exclusionary diagnosis.

When reducing antipsychotics, start with low-hanging fruit. Check PRNs with infrequent use and limit or eliminate Compazine. Review admissions for antipsychotic use. Ask that antipsychotics without proper diagnosis begun in the hospital be discontinued prior to admission. Do not continue antipsychotics begun as sleep aids in the acute care setting.

Antipsychotics High On List

Don’t forget the basics of a simple head-to-toe exam. Is there a new skin issue causing pain? Is immobility causing discomfort? Is the patient hungry, thirsty, bored, or overstimulated?  Do patients have their glasses or hearing aids?

Before any antipsychotic drug is given, ask one question: What nonpharmacologic interventions were tried? You can be certain that this is the first question a surveyor will ask. If the answer is none, there should be no antipsychotic. Some of the most cited tags when discussing psychotropic medications include F309 (Dementia Care), F248 (Activities), F329 (Unnecessary Drugs), and F241 (Dignity Concerns). The state survey is the No. 1 factor in the Centers for Medicare & Medicaid Services Five-Star report, so just one citation can be a very big deal.

Psychotropic drug rates are reported via the CASPER report. The CASPER then populates the clinical star of the Five-Star rating. The clinical star is second in importance only to the survey star and can assist in improving a Five-Star standing.

The Bottom Line

But improved outcomes are the real winner here. The data are clear: An initiative to reduce antipsychotic drugs has a clear link to overall quality. In centers that were early adaptors to culture change, quality measures improved dramatically and quickly.

In summary, why would providers treat elderly patients differently than young patients? If it is unacceptable to use psychotropics as a first line of treatment for children, why would it be acceptable to do so with elders—given that other approaches are available? By looking at patients in a skilled setting through the lens of culture change that promotes accommodations, it is possible to produce better outcomes.
This isn’t to say that it is easy, it is not—but providers have an ethical responsibility to do the right thing at the right time, every time. 

As for Cameron? He was eventually diagnosed with pervasive developmental disorder and Asperger’s autism. Today, he is a happy, healthy, and communicative 8th grader who has learned to accommodate the world around him.

As with Cameron, making appropriate accommodations within your center will ensure that every resident is functioning at an optimal level while improving overall center outcomes.
Kathleen Lynch Scherer, RN, BSN, is director of nursing services with Exeter Center - Genesis HealthCare, in Exeter, N.H.