Putting It All Together
Putting It All Together
Quality improvement (QI) programs are necessary in health care to provide structures for continuous work to better patient outcomes. Within each healthcare facility, there is an individual in charge of quality improvement for the facility. This person is responsible to ensure that all measures are taken to help reduce errors and ensure patient safety within the facility. At the facility where I work, our quality improvement supervisor is in charge of making sure the registered nurse assesses each patient on admission noting for current, past, and future use of neuroleptic medications. This is imperative within a hospital that specializes in mental health, as there are many medications to monitor. A plan for quality improvement, based on evidence, clinical experience and values are critical for improving patient outcomes.
Quality Improvement
QI in the workplace incorporates planned systematic and ongoing actions to improve health care and patient/patient group outcomes (Human Resources and Services Administration, 2011). Quality improvement is imperative in healthcare to better care for patients, their families, and friends. The provision of health care is the result of continuous quality improvement of health services to the intended individuals and groups (Human Resources and Services Administration, 2011). It is important for nurses to understand the process, structure, and apply quality improvement systems to better health care outcomes.
QI Methods
Where I work some quality improvement methods include identifying neuroleptic medications patients are on admission, getting informed consents, monitoring for tardive dyskinesia, abnormal movements, and behaviors. We look at their past behaviors along with current behaviors in order to help the doctors identify which medications may work best for the patient. If they have had previous exposure to neuroleptics, along with any signs or symptoms of tardive dyskinesia we limit the amount of neuroleptic medications the patient is on and for how long they are on them. “To ensure a comprehensive way of examining how we can improve care practices, QI studies three different aspects of care: outcomes, process, structure” (Alfaro-LeFevre, 2013, p. 145).
Being able to identify patients who are on neuroleptics if they are first generation or second generation along with if they are currently or previously experiencing tardive dyskinesia is imperative in their care. This is because it will help provide signals of symptoms as early as possible. A Registered Nurse (RN) completes the AIMS (Abnormal Involuntary Movement Scale) test at facility admission for each patient to identify any abnormal movements the patient is having but have not yet noticed. RN’s are able to utilize their critical thinking when completing the AIM’s assessment in order to determine if there are any symptoms of tardive dyskinesia. This helps the doctors be able to prescribe medications that will hopefully not harm the patient or cause them to be in any distress.
Guidelines for QI
The State of Minnesota has guidelines that are identified in our policy and procedure manual under the neuroleptic section. It is important that policies exist that are clear and describe the QI program and process, in addition to being managed by organizational leaders (Finkelstein et al., 2015). Each staff member is responsible for reading the policy and procedure manual every week by Tuesday to ensure they did not miss something and if they do not they are held accountable.
Person Responsible for QI
Surveillance and quality improvement programs are managed by at most facilities by QI nurses and risk managers (Alfaro-LeFevre, 2013). The State of Minnesota has a policy and procedure committee tasked with quality improvement. At each facility, there is one person identified who works in connection with this committee. The person at the hospital where I work, is our nursing supervisor and is responsible for making sure each staff member is in ordinance with each policy. This entails showing each staff member the new policies, allowing them to ask questions, and having them sign off once they meet competency standards.
Top Three Priority Needs
The top three priority needs related to negative patient outcomes with neuroleptic use within an inpatient psychiatric facility include long-term side effects related to medications, neuroleptic malignant syndrome (NMS), and tardive dyskinesia. These side effects can be long or short term. They can affect the patient in a variety of ways. Every medication has a list of side effects whether it is minor, moderate, or major with how it may affect the body. Each medication affects a patient differently and being aware of this is crucial within the mental health field. “Neuroleptic malignant syndrome is a rare but potentially life-threatening reaction to the use of almost any of a group of antipsychotic drugs or major tranquilizers (neuroleptics)” (National Organization of Rare Diseases (NORD), 2015, para 1). According to the U.S. National Library of Medicine (2014) tardive dyskinesia is a condition in which the patient experiences involuntary movements that usually occur in the lower face. Tardive means delayed and dyskinesia means abnormal movement (U.S. National Library of Medicine, 2014). Tardive dyskinesia is important to monitor for as it can happen when a patient is taking medications for as short a time as 6 weeks and within mental health patients are prescribed neuroleptic medications long term in order to help them stabilize and be able to live and work within a community (U.S. National Library of Medicine, 2014).
On admission to our facility as a registered nurse, we are to assess each and every patient for any side effects related to their medications. We also note for any signs and symptoms of neuroleptic malignant syndrome.
Symptoms of neuroleptic malignant syndrome usually include very high fever (102 to 104 degrees F), irregular pulse, accelerated heartbeat (tachycardia), increased rate of respiration (tachypnea), muscle rigidity, altered mental status, autonomic nervous system dysfunction resulting in high or low blood pressure, profuse perspiration, and excessive sweating (NORD, 2015, para 4).
Completing an abnormal involuntary movement scale (AIMS) on admission, monthly, and then as often as needed is vital in diagnosing tardive dyskinesia and attempting to reverse it as soon as possible.
Top One Priority Need
Rural areas within Minnesota are currently struggling with the ability to house patients who struggle with mental illness. Within Minnesota at this current time, a shortage of mental health resources, such as providers, services, distances to mental health clinics and financial support exist (Minnesota Department of Health, 2016). The healthcare facility where I am employed is an inpatient psychiatric facility that holds up to 16 beds. At the current time there is a shortage of nursing staff able to work capping our patients at 10 beds until we are able to find nursing staff capable to work within our facility.
The top priority need related to negative patient outcomes with neuroleptic use within an inpatient psychiatric facility is tardive dyskinesia. Involuntary movements, often in the lower face occur in patients with tardive dyskinesia (Medline Plus, 2016). Many of the patients that we see within our facility have been on anti-psychotics and neuroleptic medications for a variety of years leading them to being more susceptible to tardive dyskinesia. Tardive dyskinesia may not manifest for months or years, however it can present in as little as 6 weeks (Medline Plus, 2016). Some of the patients we see are young and are just starting out on neuroleptics and it is imperative to have the AIMS completed upon the initial start of the medication and throughout the treatment to assess for any involuntary motor movements.
Within the facility where I work abnormal involuntary motor screenings (AIMS) are completed upon admission by the Licensed Practical Nurse (LPN) or Registered Nurse (RN), and the Advanced Practice Registered Nurse (APRN). These assessments once completed are submitted to the psychiatrists and the pharmacists for further review. This helps identify any items that might have been missed by the LPN, RN, or APRN. In order to complete these assessments nurses utilize critical thinking. For example, nurses may recall facts about tardive dyskinesia and then apply when observing in a patient and analyze what corrective actions to take (Alfaro-LeFevre, 2013).
Tardive dyskinesia can be lifelong if not discovered early. Some newer antipsychotic medications are less likely to cause tardive dyskinesia (Medline Plus, 2016). When tardive dyskinesia is detected early enough, the patient may be able to return to their normal functioning without any abnormal motor movements. However, sometimes tardive dyskinesia is permanent and the patient retains involuntary movements that may even worsen (Medline Plus, 2016). It is imperative that the nursing staff utilize their critical thinking when completing AIMS assessments in order to catch tardive dyskinesia early on in order to reverse it or stop it. This is the number one priority need within my healthcare facility.
Research Articles Related to Top Priority Need
The top priority need related to negative patient outcomes with neuroleptic use within an inpatient psychiatric facility would include tardive dyskinesia. Tardive dyskinesia is known as the involuntary motor movements of different areas of the body that can be caused by antipsychotic medications that are prescribed. There are atypical and typical antipsychotic medications. Research evidence to support tardive dyskinesia as a priority is summarized in this section.
Pharmacist Monitoring of Tardive Dyskinesia
The first article that I chose for this topic is titled Effectiveness Evaluation of a Pharmacist-Driven Monitoring Database for Tardive Dyskinesia (Diefenderfer et al., 2014). In the article, tardive dyskinesia is defined and the potential irreversible state is stressed. It explains that antipsychotics and phenothiazines cause tardive dyskinesia. TD affects the extremities, tongue, jaw, and mouth (Diefenderfer, et al., & 2014).
According to Diefenderfer et al. (2014), these involuntary movements must be present and identifiable in an individual for at least 4 weeks prior to the diagnosis of tardive dyskinesia. Almost all patients who suffer from tardive dyskinesia may not recognize or feel any of the symptoms until someone else points them out. However, “approximately 10% of patients will develop moderate to severe symptoms that can lead to significant functional impairment” (Diefenderfer et al., 2014, p. 545). A database for pharmacists to monitor the compliance rates by health care staff for signs and symptoms of tardive dyskinesia. Diefenderfer et al. (2014) reported that compliance rates increased after the pharmacists joined monitoring project.
Having the pharmacist as a part of the team who can help assess for tardive dyskinesia is imperative in the patient’s well-being and diagnosis of tardive dyskinesia. The pharmacist is the individual who is the most educated on the medications and can identify which are atypical and typical antipsychotics just by looking at the medication. Being able to determine which is which is imperative in lowered risks of developing tardive dyskinesia.
Tardive Dyskinesia and Schizophrenia
Othman, Ghazali, Razak, and Husain (2013) studied the severity of tardive dyskinesia and negative symptoms associated with a poor quality of life. This project examines in depth regarding patients with a diagnosis of schizophrenia and tardive dyskinesia. The article focused on a study on 71 patients with schizophrenia, aged 18-65 and their quality of life (Othman et al., 2013). Throughout the article, they also used an Abnormal Involuntary Movement Scale (AIMS) in order to determine a diagnosis of tardive dyskinesia for patients with a diagnosis of schizophrenia (Othman et al., 2013). The AIMS scale has seven items that can be used individually or together to indicate severity of symptoms (Othman et al., 2013). Quality of life was lower in patients who were single or unemployed (Othman et al., 2013). This information provides health care providers with ideas about who may be at higher risk for tardive dyskinesia, so they can have closer assessment checks.
Options for Tardive Dyskinesia
Cloud, Zutski, and Factor (2014) discuss tardive dyskinesia as a common disorder that is serious, and caused by dopamine receptor blockers, such as neuroleptics. There is no treatment for tardive dyskinesia at this point and yet neuroleptics are still prescribed. A few medications may be able to reverse the effects of tardive dyskinesia. Cloud et al. (2014) report on newer medication options that have much less risk of the side effect of tardive dyskinesia, while effective. There is indication for further research to find safer alternatives for patients and less risk of tardive dyskinesia as a side effect.
Consent for Antipsychotic Medications
Consent by patients and families are a critical consideration being administering antipsychotic medications (Joyce, 2011). It is often required by health care facilities to have patients sign a consent form to be prescribed neuroleptic medications. If a patient is under 18, the legal guardian is to sign the papers for the patient. These consent forms describe the neuroleptic medication along with its side effects noting that they may cause tardive dyskinesia which, may be irreversible. It is imperative the patient or guardian understands the consequences to the medications but also understand that the benefits to the medications may outweigh the risks for the consequences.
Atypical Antipsychotics and Tardive Dyskinesia
Continued focus on alternative treatment forms that limit the odds of tardive dyskinesia are worthy subjects. According to Price (2011) there is a lowered risk of tardive dyskinesia with risperidone and olanzapine, which are second-generation anti- psychotics (SGAs) in antipsychotic naïve elderly patients (Price, 2011). Yet, some risk remains. Women, African Americans, and those without prior antidepressant therapy did have a higher risk. Those who were prescribed risperidone and olanzapine in the study were most often men. For this reason, their risks of tardive dyskinesia were lower as they were prescribed these medications more often than women (Price, 2011). Additional study of these effects is necessary to assess for gender consistencies.
Healthcare Facility Policies
Within an in-patient psychiatric hospital, anti-psychotic and neuroleptic medications are common prescriptions. These medications can lead to tardive dyskinesia. Patients and families should have the risk of tardive dyskinesia explained to them at the initiation of therapy (Joyce, 2011). It is imperative that tardive dyskinesia screening is completed upon admission and then regularly thereafter. Nurses must be aware of the facility policy regarding frequency, documentation, and interventions for tardive dyskinesia screening.
Consent to Antipsychotic Drugs
As discussed earlier in the paper, written consent for antipsychotic therapy that stipulates that tardive dyskinesia is a common side effect is required (Joyce, 2011). This article discusses the importance of making sure that patient’s sign consent forms prior to taking neuroleptic or anti-psychotic medications. When prescribed neuroleptic medications, patients need to sign consent forms prior to taking the medication or are often jarvised to take the medication by a judge. A consent form is a necessity to acknowledge and give consent that the medications can cause side effects that are permanent in some cases. This is up to date with the most current nursing practice as it is imperative that patients are informed and sign consent forms prior to the administration of anti-psychotic medications within a healthcare setting.
Psychotropic Medication Induced Rabbit Syndrome
Rabbit syndrome is often mistaken for tardive dyskinesia. Lindsey and Mehalic (2010) describe rabbit syndrome (RS) as dyskinesia of the mouth and lips that is the result of medications. This is not tested for within the psychiatric facility where I work as we focus on tardive dyskinesia. “RS is often mistaken for other dyskinesias of the mouth such as tardive dyskinesia or pseudoparkinsonism. However, RS involves quick, vertical movements of only the lips, whereas tardive dyskinesia and pseudoparkinsonism commonly involve circular motions of the oral region, including the tongue” (Lindsey & Mehalic, 2010, p. 32). This may be worthy of further consideration and monitoring.
Strategies to Improve Nursing Practice
There is a multitude of interventions to improve nursing practice in regards to tardive dyskinesia. RNs who work within psychiatric facilities can ensure that the policies and procedures related to assessments for tardive dyskinesia are completed upon admission, regularly thereafter, and upon discharge. They can notify the doctor, pharmacist, and other members of the interdisciplinary team of any changes that are noted. The RN can take verbal or written orders from doctors regarding discontinuation of medications once tardive dyskinesia is noted in order to stop the medication as soon as possible in order to prevent further complications. The charge RN can also contact the family, friends, and any other contacts the patient has in order to inform them of what is going on and how to stop, correct, or prevent it from happening. Education for the patient, family, and friends is imperative in ensuring that the patient continues to take medications after the fact in order to prevent relapse is imperative. Having the quality improvement specialist following up with the RN to ensure these interventions are complete is crucial for the care of the patient.
Conclusion
Quality improvement methods are imperative in all areas of nursing. QI programs help identify problems and come up with ideas in order to prevent them from happening in the future. Tardive dyskinesia is a serious side effect related to the use of anti-psychotic or neuroleptic medications prescribed for patients who suffer from mental health conditions. This is often times irreversible once the side effect is noted. It can be minimal but can also be serious and lead to other problematic scenarios. Therefore, it was the choice as the priority focus. It is imperative to assess upon admission, regularly thereafter and then at discharge to be able to determine if anything has changed and what, if anything has. The regular assessments for tardive dyskinesia can help catch it before it becomes so severe it is not reversible. Having someone in charge of quality improvement ensures that this process is completed and completed within a timely manner. Once abnormal movements present, it is imperative to notify the doctor and pharmacist immediately so the medication is discontinued in order to prevent further complications. Often time’s tardive dyskinesia is not reversible however, if you catch it soon enough you may be able to reverse it or prevent further complications for the patient. This data collection strategy is imperative in helping the patient have better outcomes (Alfaro-LeFevre, 2013). QI is ever changing and each area of work does things a little differently but it is important to remember that nurses are able to use evidence to improve the quality of patient care.
References
Alfaro-LeFevre, R. (2013). Critical thinking, clinical reasoning, and clinical judgment: A practical approach. (5th ed.). St. Louis, MS: Elsevier.
Cloud, L. J., Zutshi, D., & Factor, S. A. (2014). Tardive dyskinesia: therapeutic options for an increasingly common disorder. Neurotherapeutics, 11(1), 166-176. doi:10.1007/s13311-013-0222-5
Diefenderfer, L. A., Nelson, L. A., Elliott, E., Liu, Y., Iuppa, C., Winans, E., & Sommi, R. W. (2014). Effectiveness evaluation of a pharmacist-driven monitoring database for tardive dyskinesia. Hospital Pharmacy, 49(6), 544-548. doi:10.1310/hpj4906-544
Finkelstein, J. A., Brickman, A. L., Capron, A., Ford, D. E., Gombosev, A., Greene, S. M.. … Sugarman, J. (2015). Oversight on the borderline: Quality improvement and pragmatic research. Clinical Trials (London, England), 12(5), 457. doi:10.1177/1740774515597682
Health Resources and Services Administration. (2011). Quality improvement. Retrieved from http://www.hrsa.gov/quality/toolbox/methodology/qualityimprovement/
Joyce, J. P. (2011). Consent to antipsychotic drugs and tardive dyskinesia after Chester v Afshar. Clinical Risk, 17(1), 12-14. doi:10.1258/cr.2010.010075
Lindsey, P., & Mehalic, J. (2010). Psychotropic medication-induced rabbit syndrome. Journal Of Psychosocial Nursing & Mental Health Services, 48(2), 31-36. doi:10.3928/02793695-20091204-02
Medline Plus. (2016). Tardive dyskinesia. Retrieved from https://www.nlm.nih.gov/medlineplus/ency/article/000685.htm
Minnesota Department of Health. (2016). Children’s mental health rural or frontier areas. Retrieved from http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_167206
National Organization of Rare Diseases (NORD). (2015). Neuroleptic malignant syndrome. Retrieved from http://rarediseases.org/rare-diseases/neuroleptic-malignant-syndrome/
Othman, Z., Ghazali, M., Razak, A. A., & Husain, M. (2013). Severity of tardive dyskinesia and negative symptoms are associated with poor quality of life in schizophrenia patients. International Medical Journal, 20(6), 677-680.
Price, H. (2011). Atypical antipsychotics and tardive dyskinesia: Caution still indicated. Brown University Psychopharmacology Update, 22(8), 1-6. doi:10.1002/pu.20145
U.S. National Library of Medicine. (2014). Tardive dyskinesia. Retrieved from https://www.nlm.nih.gov/medlineplus/ency/article/000685.htm