American Psychiatric Nurses Association
Comments on Quality of Care Measures in Inpatient Psychiatric Facilities

These measures are:

  1. HBIPS-2: Hours of physical restraint use (patient safety)
  2. HBIPS-3: Hours of seclusion use (patient safety)
  3. HBIPS-4: Patients discharged on multiple antipsychotic medications (pharmacotherapy)
  4. HBIPS-5: Patients discharged on multiple antipsychotic medications with appropriate justification (pharmacotherapy)
  5. HBIPS-6: Post discharge continuing care plan created (care coordination)
  6. HBIPS-7: Post discharge continuing care plan transmitted to next level of care provider upon discharge (care coordination)

The general consensus from the councils and the membership is:

We support the measures open for comment that will assess the quality of care provided to Medicare beneficiaries in inpatient psychiatric facilities (IPFs).

While these measures are important to psychiatric practice, we note concerns related to the amount of demands we are placing on providers with so much documentation. We feel that this will decrease the amount of time providers have available to spend with patients or coordinating the patients’ care following discharge from the hospital. We want to be careful that we don’t reach a point of diminishing return from providers.

We also support our colleagues from the Geropsychiatric Nursing Collaborative on the following points related to older adults.

HBIPS-2: It will be important that the definition of physical restraint use include any mobility limiting device (not just the usual psych 4-point leather restraints) as adverse effects abound.

HBIPS-4: This should be expanded to indicate special concerns with any antipsychotic use as well as the use of multiple drugs with older adults, e.g., pharmaco-dynamics and –kinetics in later life, critical side effects such as orthostatic hypotension and risk of falls and fracture, etc.

HBIPS-5: It is suggested that a plan be added for titration and discontinuation/reduction in persons with dementia and achieving levels of clinical effectiveness in older persons with depression. Also, the rationale in measures 4 and 5 does not discuss trying non-pharmacologic approaches before trying any antipsychotics. As this is an OBRA guideline, we believe alternative, non-pharmacologic, first line interventions at least need to be mentioned.

HBIPS-6 & 7: It is recommended that a data element that specifies the actual handoff and training of staff on the management plan for persons over 65. Transitions across levels of care are often poorly managed yet critical junctures.

Submitted by the APNA Board of Directors to the National Committee for Quality Assurance (NCQA) on August 30, 2011.