Safer Medicines Management Follow us on twitter @spsp_mh #spspmh5
Agenda 11.15 - 11.20 Introduction – Andrew Walker 11.20 - 11.35 Physical health awareness in Mental Health – Jacqui Scott 11.35 - 11.50 As required medication, monitoring and reduction – Andrew Walker 11.50 - 12.00 Questions and Answers – All presenters 12.00 - 12.15 Workstream essentials 12.15 - 12.30 Whole group discussion #spspmh5
Improving Patient Safety in Mental Health Physical Health Awareness in Mental Health Dr Jacqui Scott, NHS Ayrshire & Arran
Physical Health and Mental Health • Mental Health foundation, 2011 • “ Physical health and mental health are inextricably linked ” . • “ People with diagnoses of severe and enduring mental illnesses are at increased risk of physical illnesses and conditions such as coronary heart disease, diabetes, infections, respiratory disease and greater levels of obes ity” .
Life expectancy and Physical illness in Mental illness • Depression is associated with a 50% increased mortality even after controlling for cofounders. • Depression has 67% mortality CV disease, 50% cancer, two fold from respiratory disease and three fold from metabolic disease. • Depression almost doubles the risk of later development of coronary heart disease even after adjustment of risk factors. • People with schizophrenia and bipolar disorder die an average of 25 years earlier than the general population, largely because of physical health problems. • Schizophrenia is associated with 2 fold increase in CV death.
PHYSICAL HEALTH MONITORING IN-PATIENTS The Mental health Strategy 2012-15 committed the Scottish government to develop a national standard for monitoring the physical health of people being treated with clozapine. Based on these recommendations, the plan was to review current physical health assessments of all in-patients and standardize these for all admissions to Park ward. The plan is to gradually implemented for Crosshouse patients. Evidence for example exists, including in Scotland, of low rates of recognition of cardiovascular risk factors among adults with a diagnosis of Schizophrenia compared to the general population, even though this is the most common cause of death in this group.
AUDIT OF PATIENTS PHYSICAL HEALTH ADMITTED TO PARK WARD • No guidance for junior doctors clerking patients and no formalised recording of physical health checks or documenting further investigations required / management plan. • A set of minimum standards developed for physical health monitoring on admission based on SIGN, NICE and Royal College of Psychiatrists guidelines. • SAMPLES - 2 admissions a week from October to December 2014. This led to a random selection of patients which was equal male and female. • 21 patients audited.
PHYSICAL EXAMINATIONS AUDITED • Cardiovascular – HR, pulse, murmurs, oedema etc • Respiratory • Neurological – power/tone/cranial nerves/ tremor, etc • Gastroenterology – including checking for constipation • Smoking status / Illicit substances or legal highs
CLINCIAL INVESTIGATIONS • ECG for all admissions • BP / Weight / Waist circumference (for those on high-dose antipsychotics or clozapine) • BMI – where appropriate
BIOCHEMISTRY / HAEMATOLOGICAL / URINALYSIS INVESTIGATIONS Investigation Action if outside reference FBC Plasma Glucose Offer life-style advice or consider referral if diabetes Blood lipids Obtain HbA, Consult with GP for consideration of treatment Urea & Electrolytes As clinically appropriate Liver function tests As clinically appropriate Lithium levels (where appropriate) Prolactin (where evidence of hormonal dysfunction) Clozapine serum level (where appropriate) Pregnancy Status ( where appropriate) Urinalysis Including proteins, blood, illicit drugs
Park Ward Physical Health Audit - Results • 11/19 (58%) out of hours admissions • 16/19 (84%) informal admissions • 9/19 (47%) admissions female 10/19 (53%) male
Park Ward Physical Health Audit • Height, weight, physical obs • 16/19 (84%) had height and weight on records but many were out of date • 18/19 (95%) BMI not recorded • 19/19 (100%) Waist circumference not recorded • 18/19 (95%) BP recorded • ECG • 9/19 (47%) no ECG in notes, sometimes record that one was done, but no sign in notes
Park Ward Physical Health Audit • Smoking History • 8/19 (42%) No smoking history – many of the others rather brief and lacking in detail • Bloods and urine • 1/19 (5%) had lipid screen, 1/19 (5%) no bloods done • 18/19 (95%) FBC, U&E, LFT • 16/19 (84%) Glucose also done • ? Prolactin, Ca, B12, Folate, TFT, for screen. • 16/19 (84%) urinalysis not recorded
Park Ward Physical Health Audit • PMH • 3/19 (16%) no PMH - many others rather cursory/incomplete • Physical Examination • 7/19 (37%) no physical exam recorded • 1/19 (5%) no neuro exam recorded • Many of those done rather cursory
PHYSICAL HEALTH ASSESSMENT TEMPLATE • Template developed with support from FACE team (SEE SHEETS) • Complicated and unclear • Not user friendly • Plan to develop simplified model and pilot on ward.
CHALLENGES • Education – importance of not ignoring physical health in those who suffer from mental health illnesses. • Educating patients on good diet, smoking cessation, exercise, alcohol use, having annual health checks. • Getting the team to “buy into” physical health monitoring. • Develop system where assessment “is the norm” . • Being aware of the side-effects of medications.
As required medication, monitoring and reduction Follow us on twitter @spsp_mh #spspmh5
What next for the as required bundle? Andrew Walker Lead Clinical Pharmacist NHS Greater Glasgow & Clyde #spspmh14
Contents • Comparative NHS GG&C data • How do we embed this as standard practice?
NHS GG&C Comparative data Wards participating Dykebar East & North Leverndale 4B Rutherford Elm Parkhead Ward
• Weekly data collection - sampling • National spreadsheet • Process data – use of stickers, completion • Clinical data
120 Process compliance 100 80 Ward % East Ward % North 60 Ward % Lev 4B Ward % Rutherford Ward % Elm Ward % Parkhead Ward 1 40 20 0 Sticker/Highlight Date & time Medication Initiated by Reason Post Admin Review present
Reason 90 80 70 60 Ward (%) EAST 50 Ward (%) NORTH 40 Ward (%) Lev 4B Ward (%) RUTHERFORD 30 Ward (%) ELM Ward (%) PARKHEAD WARD 1 20 10 0
Drug 70 60 50 40 Ward (%) East Ward (%) North 30 Ward (%) Lev 4B Ward (%) Rutherford Ward (%) Elm 20 Ward (%) Parkhead Ward 1 10 0
Initiated by 90 80 70 60 50 Patient Nurse 40 Medical 30 20 10 0 East North Lev 4B Rutherford Elm Parkhead Ward 1 Ward (%)
Time of day 60 50 40 Midnight - 6am 30 6am - 12noon 12noon - 6pm 6pm - midnight 20 10 0 East North Lev 4B Rutherford Elm Parkhead ward 1 Ward (%)
35 Day 30 25 Ward (%) East 20 Ward (%) North Ward (%) Lev 4B Ward (%) Rutherford 15 Ward (%) Elm Ward (%) Parkhead ward 1 10 5 0 Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Post admin review 80 70 60 50 Much improved 40 Slightly improved No change 30 Worse 20 10 0 East North Lev 4B Rutherford Elm Parkhead ward 1 Ward (%)
Problems in GG&C • Availability of stickers • Improving level of sticker use • Data sharing
Questions raised about the bundle • How are we using or how should we use this data? • Assuming reliable sticker access how do we improve process reliability? • Do differences in drug use mean anything? • Do variations in initiation mean anything? • What does the increase in use of as required drugs as the day progresses mean? Is it a bad thing? • Do variations across the week mean anything?
What next for the ‘as required’ bundle • Continued data collection • Local action plans in each ward based on issues from their own data • How to reduce as required drug use? • Is this intervention improving patient safety? • Is it supporting better patient care? • Will we/should we look to introduce it universally? • If so, how?
Safer Medicines Management – workstream essentials • As required psychotropic monitoring & review • High risk monitoring & management – lithium/clozapine/polypharmacy • No avoidable treatment breaks • Medicines reconciliation • Error free administration – missed doses • Error free prescribing
Workstream essentials – questions/issues • Are they correct? • If not, what should they be? • What are we already doing? • What change packages, bundles, interventions should be developed and tested to deliver them?
Questions and Answers Andrew Walker David Maxwell Jacqui Scott #spspmh5
Lunch – available outside Strathallan Foyer and opposite Stuart Lounge Storyboard viewing – Strathallan Drop in data surgery - Glenallan
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