Clinical Practice Guidelines: Year 1 Review

Dr. Ilan Fischler MD, FRCPC Psychiatrist, GNP Program and Medical Director Erin Anstey, RN, MN Clinical Practice Leader, Professional Practice Maria Ahmed, RN, MHSc Clinical Practice Leader, Professional Practice

Ontario Shores Centre for Mental Health Sciences • Provides a range of specialized assessments

and treatment from adolescents to seniors • Provides over 50,000 outpatient visits a year • Implemented an Electronic Medical Record

(EMR)system in 2010/2011 • Committed to a 5-year initiative to implement

two Clinical Practice Guidelines (CPGs) every year over five years in a systematic manner

Objectives

• Discuss the process for implementing Clinical Practice Guidelines

• Review the decision support embedded in the EMR

• Develop an understanding of how clinical practice can change with the implementation of clinical practice guidelines.

• Discuss the outputs from the clinical dashboards and how the results impact patient care

What is a Clinical Practice Guideline?

• “Best practice” approaches to assessment, diagnosis and treatment in a particular area of healthcare

• Created at a national or international level • Created by a panel of experts who review the

evidence in the current literature and supplement with consensus expert opinions

Clinical Practice Guidelines at Ontario Shores • Implement Clinical Practice Guidelines (CPGs)

annually over 5 years

• In March 2014 two CPG’s were implemented: – Assessment and treatment of Schizophrenia

(inpatients only) – Metabolic monitoring for individuals on

antipsychotics (inpatients and outpatients)

Assessment and Treatment of patients with Schizophrenia • Realignment of Therapeutic Services

– CBT for Psychosis – Music/Art Therapy – Supportive employment – Caregiver assessment

Clinical Practice Guidelines: Physician Admission Assessment

Approach to improving Metabolic Monitoring at Ontario Shores • Automated physician decision support

through reflex order sets that are triggered by physician documentation

• Clinical dashboard sent monthly to physicians/clinical managers that indicates their adherence to monitoring guidelines compared to hospital average

• Quality improvement projects to improve adherence based on reported results

Metabolic Monitoring

• Key criteria for Metabolic monitoring for patients on anti-psychotics – Waist circumference – Body mass index – Blood pressure – Random glucose – Glycated Hemoglobin – Lipid Profile – Family/Personal History

Percentage of patients on Multiple antipsychotics (excluding clozapine)

0%

10%

20%

30%

40%

50%

60%

Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

% P

atie

nts o

n M

ultip

le

Ant

ipsy

chot

ics

% Patients on Multiple Antipsychotics (excluding Clozapine)

Metabolic Monitoring in 2013/2014 prior to the implementation of CPGs

0%

5%

10%

15%

20%

25%

30%

35%

40%

Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-145/5 25% 34% 36% 35% 29% 32% 35% 37%4/5 31% 28% 29% 27% 25% 31% 30% 32%3/5 25% 22% 23% 23% 29% 24% 20% 18%2/5 12% 13% 7% 10% 11% 7% 10% 9%1/5 5% 2% 3% 3% 5% 4% 4% 2%0/5 2% 2% 2% 2% 1% 2% 3% 2%

Metabolic Monitoring 2013/14

Metabolic Monitoring Adherence after the implementation of CPGs

0%

10%

20%

30%

40%

50%

60%

Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

5/5 25% 29% 27% 41% 52% 44% 42% 46% 43% 40%4/5 30% 25% 25% 23% 28% 27% 30% 28% 27% 27%3/5 24% 24% 28% 17% 10% 18% 19% 13% 19% 20%2/5 14% 17% 9% 11% 6% 6% 6% 8% 9% 11%1/5 5% 4% 6% 3% 3% 3% 3% 4% 1% 2%0/5 3% 1% 4% 4% 1% 1% 1% 1% 2% 1%

Metabolic Monitoring Adherence Rates Adherence indicators: Blood Pressure, Waist Circumference,HbA1C,BMI,Fasting Lipids

Quality Improvement Cycle

Order entered by physician

Order triggers evidence-

based assessments

Documentation of assessment

pulled to report

Report feeds into clinical dashboard

Clinical dashboard sent monthly to physicians and

clinical managers to support increased

adherence to CPGs for metabolic monitoring and

antipsychotic polypharmacy

Clinical Practice Guidelines: Dashboard

Clinical Practice Guidelines: Dashboard

Outcomes

• Improved adherence with recommended protocols for metabolic monitoring. This results in more appropriate utilization of antipsychotic medication, identifying high-risk patients for metabolic syndrome, and early detection of diabetes, hypertension, and hyperlipidemia which allows for early intervention.

• Reduction in the number of patients taking more than 1 antipsychotic. There is no evidence that combining antipsychotics produces better clinical outcomes and there is extensive evidence that it leads to an increased number of side-effects.

Next Steps

• Continue to monitor adherence using the dashboard

• Implementation of Clinical Practice Guidelines for 2014/2015 – Assessment and treatment of Major Depression for

Inpatients – Assessment and treatment of Schizophrenia for

Outpatients • Clinical Practice Guidelines for 2015/16

– Assessment and treatment of behavioural and psychological disturbances of Dementia for Inpatients