Use of Academic Detailing With Audit and Feedback to Improve Antipsychotic Pharmacotherapy.

OBJECTIVE: Second-generation antipsychotics vary in their propensity to cause serious cardiometabolic side effects. In addition, use of two or more antipsychotics (polypharmacy) may lead to additive side effects and has not been shown to be consistently more effective than monotherapy. This study examined the use of academic detailing with audit and feedback to improve antipsychotic prescribing practices, including antipsychotic polypharmacy and utilization of medication with high or low risk of cardiometabolic side effects ("high risk" or "low risk," respectively). METHODS: Four intervention sessions were provided over two years to psychiatric care providers at community mental health centers. Segmented regression within the general estimating equation model framework used Medicaid pharmacy claims to examine prescribing patterns before and after the intervention among all beneficiaries (67,721 person-months) over a five-year period. RESULTS: After the intervention, 10.9% of beneficiaries with antipsychotic claims were on polypharmacy, compared with 13.1% before the invention. Use of high-risk and low-risk antipsychotics did not change. The final adjusted polypharmacy model showed that antipsychotic polypharmacy decreased among young adults and adults ages 40 or older compared with beneficiaries ages 30-39 (ß=-.02, p=.04, and ß=-.02, p=.007, respectively). The raw proportion of beneficiaries on high- and low-risk agents did not change, although final adjusted models demonstrated changes in use of high- and low-risk agents by diagnosis and risk group. CONCLUSIONS: Polypharmacy decreased among young and older adults after academic detailing with audit and feedback. Although further research is needed, this low-intensity intervention may help mental health systems reduce antipsychotic polypharmacy.

Expanding the Role of Psychiatric Mental Health Nurse Practitioners in a State Psychiatric System: The New Hampshire Experience.

Psychiatric mental health nurse practitioners (PMHNPs) are assuming increasing clinical responsibilities in the treatment of individuals with mental illness as the shortage of psychiatrists and their maldistribution continues to persist in the United States. States vary widely in their statutes and administrative rules delineating PMHNP's scope of practice. This column describes the legislative process of incremental changes in New Hampshire statute and rules changes over the past 15 years that have significantly expanded PMHNP's ability to treat individuals with mental illnesses in the state mental health system. PMHNPs have worked closely with physician leaders and policy makers to allow this to occur.

Nurse-police coalition: improves safety in acute psychiatric hospital.

Although police officers protect and secure the safety of citizens everywhere, nurses are the primary guardians of patient safety within the treatment milieu. At New Hampshire Hospital, both nurses and police officers share ownership of this responsibility, depending on the needs that arise specific to each profession. Psychiatric nurses take pride in their ability to de-escalate agitated and potentially aggressive patients; however, times arise when the best efforts of nurses fail, or when a situation requires intervention from police officers. Nurses and police officers at New Hampshire Hospital have worked together for many years to develop a trusting, respectful alliance. This coalition has resulted in a safe, clear, orderly process for transfer of authority from nurses to police during violent, clinically unmanageable psychiatric emergencies. Nurses and police officers work collaboratively toward the common goal of ensuring safety for patients and staff, while also acknowledging the unique strengths of each profession.

Seclusion and restraint use in children and adults: differences between age groups.

This 1-year study of seclusion and restraint in an acute inpatient psychiatric hospital revealed a marked difference in reasons and duration for adults, children, and adolescents. Children and adolescents are most often secluded and restrained in response to identifiable patterns of dangerous behavior, and episodes of seclusion and restraint involving children and adolescents are considerably shorter than episodes involving adults. This information is being used to find ways to improve the care and treatment of all patients, especially for children.

Best practices: The Administrative Review Committee at New Hampshire Hospital: a one-year follow-up.

New Hampshire Hospital implemented an Administrative Review Committee (ARC), a best practice that provides a risk management process to mitigate potential liability for the hospital and clinicians treating high-profile, high-risk patients. This column reports on the first year of the ARC's operation, during which the committee reviewed 206 patients. The authors describe four patient groups and their distinguishing characteristics. The ARC is accepted by clinicians as an important venue to present high-risk clinical cases and to obtain risk management guidance and consultation. The committee has become an integral part of the hospital culture.

Psychiatric patients are at increased risk of falling and choking.

Acutely ill psychiatric patients experience symptoms and take medications that increase their risk of both falling and choking; however, nurses and other caregivers may not be keenly aware of these risks. This article will provide a brief review of the literature related to risk factors for falls and choking and interventions to prevent falls and choking. Increased education for nursing students and staff employed at inpatient psychiatric units has the potential to reduce both incidence and injuries related to falls and choking.

Public-academic partnerships: a program to improve the quality of antipsychotic prescribing in a community mental health system.

State mental health authorities can use public-academic partnerships to create professional roles in which leaders can track trends, identify problems, and carry out quality improvement projects to address key issues. Leaders with positions in both academic institutions and state mental health authorities ensure access to resources, technical expertise, and key relationships to improve quality. The authors describe a public-academic partnership in New Hampshire and a quality improvement program it carried out. The program encourages providers at community mental health centers to adopt prescribing practices that limit the cardiometabolic side effects of antipsychotic medicines.

Transforming the culture of caring.

Direct care staff struggle with the decision of when to physically intervene with patients. There is a widely held belief that they are expected to place themselves in danger of harm to prevent patients from hurting themselves or others. In this acute mental health care setting, an educational program was developed, using principles of adult and transformational learning, to dispel the idea that getting hurt is part of the job. The Staying Safe program strongly discourages staff from physically intervening alone and promotes staff getting enough help and having a plan. Staff are encouraged to interact with patients in helpful ways and to respond to patient requests in ways that do not increase frustration or evoke anger. There has been a positive response to the training program, evidenced by changes in the way staff think about their jobs and a reduction in the number of assaults and injuries to staff.

Best practices: Use of an administrative review committee at New Hampshire Hospital to mitigate risk with high-profile patients.

An increasing number of patients manifesting violent and aggressive behaviors are treated at New Hampshire Hospital. Over the past ten years, the volume of referrals on an involuntary emergency petition has increased 70%. New Hampshire Hospital has successfully initiated its Administrative Review Committee, which confers a risk management process to mitigate potential liability for the hospital and treating clinicians for these high-risk patients. This best practice is viewed as helpful by clinicians and by the hospital's legal counsel. Hospitals treating similar high-risk patients may also benefit from developing a similar committee and risk management process.

Executive-level reviews of seclusion and restraint promote interdisciplinary collaboration and innovation.

Elimination of seclusion and restraint requires support at all levels of an organization, especially from leaders who visibly champion and communicate their vision. Nurses, physicians, educators, and administrators at New Hampshire Hospital, an acute psychiatric inpatient facility, have established a standard meeting time and place for an executive-level review of every episode of seclusion and restraint. The standing meeting demonstrates the organization's commitment to caring for both patients and staff. The daily meetings foster a spirit of interdisciplinary collaboration, where direct care staff have the opportunity to tell their stories and share their ideas and concerns in an environment that is caring, supportive, and devoid of criticism or blame. Narrative descriptions of emergency interventions, including what was learned from debriefings with patients and staff involved, provide data about factors that may contribute to the use of seclusion or restraint. This forum provides visible administrative and clinical support that promotes creative thinking, collaborative problem solving, and the exploration of new ideas recommended by those directly involved in providing patient care. It has fostered exploration and development of strategies that have minimized episodes of aggressive behavior as well as seclusion and restraint.

State mental health policy: Promoting legislation and public policy debates in state legislatures: a psychiatrist's perspective.

Psychiatrists are urged to get involved in promoting legislation and public policy debates in state legislatures to effectively advocate for positive change in legislation and policy making. This column focuses on strategies that New Hampshire Psychiatric Society members have found effective in engaging policy makers and legislators in a dialogue that assertively promotes the views of patients with mental illness and the profession of psychiatry.