Schizophrenia is one of the most common mental health conditions that is associated with various psychological symptoms. Hallucination is one of the situations. It is the situation where people perceive things which do not exist at that time. Patients with a diagnosis of schizophrenic frequently exhibit a range of delusions accompanied by drastic changes in their behavior. In this case, delusions occur when people cannot distinguish between reality and imaginations. Despite the psychiatric deinstitutionalization policies being solidified in mental health care (to keep psychiatric patients, like schizophrenic patients away from the hospital), the phenomenon of psychiatric readmission poses challenges to the deinstitutionalization policy (Machado, 2012).
Accordingly, the high readmission rate of psychiatric patients in general and schizophrenic patients, in particular, is a huge challenge that the mental health professionals experience. According to Baindera et al. (2003) and Lay et al. (2006), this development is what some call a revolving door, while others have termed these patients to be frequent users. In a study by the Agency of Healthcare Research and Quality, and hospital readmissions involving psychiatric disorders as cited by Healthcare Cost and Utilization Project (HCUP,2015) showed that within 30 days, 15.7 % of initial inpatient stays for patients with a diagnosis of schizophrenic were readmitted with a principal diagnosis of schizophrenia. Consequently, more than 18.6 % were readmitted with diagnosis of schizophrenia, and 22.4 % were readmitted for any cause (Kaplan, Casoy, & Zummo, 2013). To portray the extent of hospitalization, there has been the belief that this issue of readmission characterizes a new form of institutionalization. Therefore, one cannot ignore that this issue can pose serious clinical consequences for the patients, who may suffer from a condition of institutionalism. Machado (2012) revealed that patients who are frequently readmitted might suffer from a series of functional, social, and psychological losses. In addition, this situation may be a recurring pattern for patients and can lead to result insufficient provision of mental health services. Multiple readmissions to the healthcare facilities may demoralize the health caregivers in the provision of mental health services.
Burning Clinical Issue
As a psychiatric nurse for almost five years and two years of experience at a city hospital in the North Central US, there have seen many schizophrenic patients admitted to the hospital. Currently, there is a high rate of readmission of these patients. However, there is no plan to address why the rate of admission is high. Even so, there is the need to question why there is documentation of the readmission rate, but there is no intervention to manage the rate of readmission (Das, Malik, & Haddad, 2014). Bringing the issues to the attention of caregivers is of particular importance considering the frequent readmission patterns of these patients can lead to psychological trauma, deterioration of their condition, and lack of mental health services and networks.
Admittedly, it is paramount to address some of the reasons, why providers do not follow the American Psychiatric Association (APA) guidelines for the treatment of schizophrenia. Kross (2016), revealed that clinician adherence to clinical practice guidelines in schizophrenia remains suboptimal, and uncertainty exists regarding how best to implement guidelines for maximum benefits. According to the American Psychiatric Association (APA) guidelines for schizophrenia, long-acting injectable medications (LAIs) are thought to be especially helpful in the stabilization and stable phase of schizophrenia. The use of long-acting injectable medication helps to improve adherence, which is a critical issue during the stable and stabilization phase (Das, Malik, & Haddad, 2014). The APA recommends that patients with recurrent relapses related to nonadherence, are candidates for a long-acting injectable antipsychotic medication, as are patients who prefer this mode of administration (APA, 2016). The subject is relevant in the current practice as it is vital that the practice promotes positive patient outcomes and is evidence-based. In addition, the practices must be in line with the recommended practice guideline and regulations (Kaplan, Casoy, & Zummo, 2013). Recently, hospital readmission rate has been used to measure the quality of care provided by hospitals. Medicare reports spending 17.8 billion dollars on readmission of patients whose readmission could have been prevented (Center of Medicare and Medicare, 2012). As a result, Medicare established an admission readmission program that was effective on October 1st, 2012. If it is possible to prevent readmission of schizophrenic patients, it is necessary that the practice should be established. However, the hospitals do not charge the patients additional costs when they are readmitted.
Already, researchers have identified that if schizophrenic patients adhere to LAI medication, the rate of relapse and readmission will decrease. According to Kane et al. (2013), many chronic diseases, such as psychotic disorders like schizophrenia, affect patients who suffer from enormous problems in medication adherence. Such effects lead to countless avoidable emergency room visits and days in the hospital, as well as suboptimal overall outcomes. In addition, Kane et al. (2013) further mentioned that approximately 50% of patients suffering from chronic illnesses are not taking medication as prescribed after six months and about 70% of patients who have schizophrenia will relapse within the year of their medication. In addition, long-acting injectable antipsychotics are theoretically very powerful tools for assuring adherence (Kane et al., 2013). Hence, the formation of this PICOT which proposes the education providers on the management of schizophrenia. The admission rates at the hospitals range between 10% and 20%. The rates depend on the number of times patients visit healthcare facilities.
For psychiatric providers in a metropolitan hospital in a mid-sized city in North Central US, who provide care for patients with schizophrenia from age 18 and older, (p) will a comprehensive, evidence-based, educational program to address the use of long-acting injectable antipsychotics (I), compared to present practice (c), increase the number of patients offered long acting injectable medications as noted in a chart review (o) over a six-month period (T)?
It is important for people to seek changes in provider's behavior to improve patient outcomes. However, people should also look at what patient behaviors could be changed to achieve an improved outcome (Das, Malik, & Haddad, 2014). An appropriate outcome for patients would include being compliant with the medications/ treatment ordered by the provider, which plays an important role in decreasing rates of readmission.
Will schizophrenic patients age 18 years or older, who are admitted in a city hospital in North Central US (P), who receive an evidenced-based, educational program from providers and staff on the need to be adherent to medications and the improved health outcomes for patients who use LAIs (I), compared to present practice (c), will accept LAIs in greater numbers and have lower readmission rates over a 2-3 month time period.
Research databases, such as University of Michigan-Flint Summons, CINAHL, PubMed, National Center for Biotechnology Information (NCBI), Biomed Central, and ProQuest were utilized to obtain information about the PICOT questions. The advanced search was utilized to ensure that the search results yielded recent articles with high relevance to the research questions. The keywords searched were long-acting antipsychotic medication, oral antipsychotic medication, schizophrenia medications, readmission rates, education, and quantitative research. The results yielded in CINAHL, PubMed, Biomed Central did not relate to the PICOT question. However, the other databases yielded both primary relevant sources and relevant non-primary sources. The Melnyk & Fineout-Overholt (2011) level of evidence was utilized to assign the level of evidence to the five chosen articles.
Schizophrenia, Non-Adherence and Remission
Barrio et al. (2013) studied readmission of patients used in the study reveal the need to consider the health condition of people in need of quality healthcare. The article takes the context of a case-control study, according to Melnyk and Fineout-Overholt (2011) level of evidence. It discusses the efficacy of LAIs, adherence to medication regimens as a major issue for schizophrenic patients, and the importance of long-acting improved injectable Risperidone in helping to promote adherence that in turn promotes recovery of patients with a diagnosis of schizophrenic and prevents readmission. According to McNally and McCarley (2016) schizophrenia is a severe and chronic psychiatric disorder with a variable course that requires long-term treatment to achieve and maintain remission. One of the major challenges identified by the authors in the treatment of schizophrenia is the issue of medication non-adherence.
McNally and McCarley (2016) stressed that medication adherence had been studied as an issue since the first steps in the pharmacological treatment of the disease were taken. In addition, the authors pointed out that previous studies have shown that 50% of patients with schizophrenia take less/fewer than 70% of their prescribed doses, making medication non-adherence rates in schizophrenia one of the highest compared with other chronic psychiatric conditions (Kross, 2016). This results in a major concern as evidence suggests that nonadherence is the greatest predictor of relapse in first-episode psychosis (Machado et al., 2012). The authors revealed that in line with the above findings, a recent meta-analysis found that nonadherence among those with first-episode psychosis increased the risk of relapse four-fold leading to readmission (Barrio et al., 2013).
Efficacy of LAI in Decreasing Readmission Rates
Furthermore, MacEwan et al. (2016) carried out a research study on all patients with the schizophrenic conditions psychiatric unit from 2004 to 2008 who were on long-acting injectable Risperidone and were followed for two years. After 2 years the variables related to efficacy of the antipsychotic treatment were collected. There was no statistically significant difference between the two groups looking at the variable of hospital readmission and illness remission according to the symptom-based criteria, but two times fewer readmissions were seen in the intervention group as the control group.
Schizophrenia, Medication Adherence, Relapse, and Hospitalization Rates
The other article reviewed by Kane et al. (2013) is a systematic review of descriptive and qualitative studies. It is a level five article according to the Melnyk & Fineout-Overholt (2011) level of evidence. The authors provided a comprehensive, up-to-date review on long-acting injections on different subjects.
According to Kane et al. (2013), the e-STAR is an international, multicenter, prospective, observational registry that assesses the use of LAIs in patients with schizophrenia or schizoaffective disorder in a clinical practice setting. The study that was completed using1659 patients showed that at 12 months 89.1% vs. 67.0% did not require hospitalization after switching from oral to LAI antipsychotics (Kaplan, Casoy, & Zummo, 2013). The authors pointed out that there is a signi...
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