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Safer Medicines Management

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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

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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 obesity”.

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
• r 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

• 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

Park Ward Physical Health Audit

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

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What next for the as required bundle?

Andrew Walker Lead Clinical Pharmacist NHS Greater Glasgow & Clyde

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

20 40 60 80 100 120 Sticker/Highlight present Date & time Medication Initiated by Reason Post Admin Review Ward % East Ward % North Ward % Lev 4B Ward % Rutherford Ward % Elm Ward % Parkhead Ward 1

Process compliance

10 20 30 40 50 60 70 80 90 Ward (%) EAST Ward (%) NORTH Ward (%) Lev 4B Ward (%) RUTHERFORD Ward (%) ELM Ward (%) PARKHEAD WARD 1

Reason

10 20 30 40 50 60 70 Ward (%) East Ward (%) North Ward (%) Lev 4B Ward (%) Rutherford Ward (%) Elm Ward (%) Parkhead Ward 1

Drug

10 20 30 40 50 60 70 80 90 East North Lev 4B Rutherford Elm Parkhead Ward 1 Ward (%) Patient Nurse Medical

Initiated by

10 20 30 40 50 60 East North Lev 4B Rutherford Elm Parkhead ward 1 Ward (%) Midnight - 6am 6am - 12noon 12noon - 6pm 6pm - midnight

Time of day

5 10 15 20 25 30 35 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Ward (%) East Ward (%) North Ward (%) Lev 4B Ward (%) Rutherford Ward (%) Elm Ward (%) Parkhead ward 1

Day

10 20 30 40 50 60 70 80 East North Lev 4B Rutherford Elm Parkhead ward 1 Ward (%) Much improved Slightly improved No change Worse

Post admin review

• Availability of stickers
• Improving level of sticker use
• Data sharing

Problems in GG&C

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?

• 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?

What next for the ‘as required’ bundle

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

• 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?

Workstream essentials – questions/issues

Andrew Walker David Maxwell Jacqui Scott

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Questions and Answers

Lunch – available outside Strathallan Foyer and opposite Stuart Lounge Storyboard viewing – Strathallan Drop in data surgery - Glenallan