Report on TOP 5

The particular program I present here is called TOP 5.  It is lovely in its simplicity and low cost . . . and in the power of its results. It could be replicated anywhere there is a will. 

The idea is to come up with strategies to help caregivers who are responsible for dealing with people with dementia–and particularly the anxiety and agitation that can characterize this disease in the presence of certain environmental factors.  As described by the CEC, “TOP 5 is a simple process that encourages health professionals to engage with carers to gain non-clinical information to help personalise care. This information is then made available to every member of the care team, thus improving communication.”

Well, now Karen Luxford and her colleagues have published a paper outlining some of the clinical outcomes of the experiment.  Among other things, they wanted to see if there was a documented reduction in falls and also in use of anti-psychotic drugs, but also they wanted to present more subjective measures about clinician and carer perceptions.  The abstract notes the findings:

Clinicians and carers reported high levels of acceptability and perceived benefits for patients. Clinicians rated confidence in caring for patients with dementia as being significantly higher after the introduction of TOP 5 than prior to TOP 5.

Both clinicians and carers reported that following TOP 5 implementation, the patients were less agitated and appeared more settled, providing indirect evidence for an improved patient experience of care. Staff used the TOP 5 tips to deal with agitation in hospitalized patients with dementia, reporting that this approach lessened the need for restraint.

A methodological difficulty was the absence of control groups in many facilities to measure changes in falls. Where it was possible to have a control group, this result was posted:

In the hospital where data from a control ward were available, random effects regression found a statistically significant decrease in all patient falls in the aged care ward using TOP 5, when compared over time with the control ward. Controlling for baseline differences, seasonal effects and existing falls prevention strategies, an average of 6.85 fewer falls per month occurred in the ward using TOP 5 (Ward A) compared with the control ward (Ward B) since the introduction of TOP 5. In the sensitivity analysis where falls were measured as a rate (falls/admissions), we also detected a relative decrease in falls in the ward using TOP 5, with the change in trend in the falls rate per month 23% lower in the ward using TOP 5 compared with the control ward since the introduction of TOP 5. However, this difference is only significant at a 10% level, not at the 5% level. 

On the drug issue, there were other tops of comparison problems, but this result was of interest:

Consistent data about pharmacy stock usage of non-regular anti-psychotics were only available for analysis from two participating hospitals during the TOP 5 implementation period and for the same time period of the previous year. One of these, a major metropolitan hospital, displayed a statistically significant reduction in the use of anti-psychotics following the introduction of TOP 5 with an overall reduction of 68% in average cost of anti-psychotics per month. At the second hospital, a principal referral hospital, there was no difference in overall expenditure or supply of most types of anti-psychotic; however, there was a decrease in the usage of Risperidone quicklets (a quickly dissolving oral medication) of 67 mg per month following the introduction of TOP 5 (P

Our findings indicate that the use of a simple, low-cost communication strategy for patient care is associated with improvements in carer and clinician experience, with early indications of potential benefits for patient safety and potential cost savings to health services. Minimally, TOP 5 represents ‘good practice’ with a low risk of harm or unintended consequences. The TOP 5 strategy has potential for broader application by health services applying patient-focussed approaches to care delivery.

Indeed.  Worth pursing further and elsewhere.