6 results
A Digital Solution to Improve Safety of Valproate Prescribing in Mental Health
- Ashma Mohamed, Alison Marshall, Nikki Smith, Anna Smith, Barbara Sowa, Sue England, Sarah Long
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S103
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Aims
Valproate is a licensed medicine prescribed within mental health settings for bipolar disorder. It is a known teratogen, affecting approximately 20,000 people and costing the NHS £181 billion. This was a multidisciplinary project involving Surrey Heartlands Medicines Safety Team and Surrey and Borders Partnership NHS Foundation Trust, who developed a solution to reduce human suffering and cost by adhering to the Medicines and Healthcare Products Regulatory Agency (MHRA) valproate regulations through a clinical and digital redesign. The aim was to identify females in primary and secondary care across Surrey who take valproate for mental illness and to implement a pregnancy prevention programme for them by July 2022, using a digital clinical pathway supporting clinicians in the implementation process.
MethodsThe method used was a combination of the Model for Improvement, the sequence for improvement from East London NHS Foundation Trust, UX design, and Agile project management. A valproate working group was formed with professionals from multiple disciplines to identify, understand and solve the problem. The solution was designed through co-production and project management methods that ensured a patient-centric solution.
ResultsA digital registry of all females of childbearing potential who are prescribed valproate was created. A bespoke electronic GP referral form for valproate reviews was implemented. A one-stop valproate dashboard was developed to support documentation. A live digital visualisation feature was added within the secondary care electronic patient record to ensure compliance with MHRA guidelines. Easy-to-read materials for females with learning disabilities and sensitively worded appointment letters that inform patients of the risks and importance of attending annual reviews were created. In addition, collaboration with the National Valproate Patient Safety Officer allowed the implementation of Systematized Nomenclature of Medicine Clinical Terms (SNOMED) codes to simplify the exchange of clinical information between systems.
ConclusionThe project has the potential to reduce harm and improve the patient experience, serving as a template for other medications with strong regulatory controls. Collaboration between primary and secondary care, clinicians, pharmacists and digital colleagues, and co-design with people prescribed valproate were essential to the success of the project. Ongoing work is required to ensure valproate-related materials are available in an accessible format for every person prescribed valproate. Valproate has also been implicated in paternal adverse effects, and this project solution is future-proofed to identify men on valproate. Through this work, people will only be treated with valproate in a way that safeguards the health of unborn children.
Mental Health and Contraception- Are We Doing Enough? a Study Exploring the Current Practice of Providing Contraceptive Advice by Mental Health Professionals
- Ashma Mohamed, Emily MacDonagh, Ramya Giridhar
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S63
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Aims
Contraception is of increased importance for women with mental health conditions. These women are more likely to experience unplanned pregnancies and are at a higher risk of sexually transmitted diseases. NICE (National Institute for Health and Care Excellence) guidelines recommend discussing the use of contraception with women of childbearing potential with mental health problems. Professionals should discuss how pregnancy and childbirth can impact a mental health problem and how a mental health problem and its treatment might affect the woman, the foetus or the baby. It is, therefore, important for professionals to feel confident when advising these women. In this study, we aim to examine the knowledge, practices and attitudes of mental health professionals in providing contraceptive advice to service users of childbearing potential.
MethodsAn observational quantitative cross-sectional design study was utilised using a 12-item self-report questionnaire. Mental health professionals meeting the inclusion criteria, employed by Surrey and Borders Partnership NHS Foundation, were invited to complete the anonymised survey electronically. Responses were entered into the survey software (Qualtrics) and quantitative data analysis was conducted.
The study was approved by the North West Manchester Ethics Committee.
This is the first arm of the study, and the second arm focuses on service user experience and is currently in progress.
Results76 professionals responded, including 24 consultants, 17 trainee doctors, 16 nurses, 8 non-trainee doctors, 7 psychologists, 3 social workers and 1 pharmacist. Of the 76 responses, 31% said they felt extremely/very familiar with the NICE guidelines. 38% of respondents said they were somewhat familiar, and 30% said they were not so/not at all familiar. Regarding confidence in discussing contraception and family planning 8% responded extremely/very, 28% responded somewhat and 64% responded not so/not at all. 68% said they would like to receive further training. A third of the professionals surveyed said they were not familiar with the NICE guidance. Two-thirds of respondents do not feel confident offering counselling around contraception, planning and spacing pregnancies. Over two-thirds would like further training
ConclusionThe survey showed a lack of confidence in offering reproductive advice and the need for training to improve knowledge. We aim to develop training in contraception advice to improve the care provided for female service users.
Antipsychotic Cardiometabolic Monitoring: Systemic Gaps and Hidden Groups
- Tanya Ansari, Zafrina Majid, Ashma Mohamed, Martin Schmidt
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, p. S103
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To determine whether there are any gaps in cardiometabolic monitoring within primary or secondary care for people prescribed antipsychotic medication. A well-established system of cardiometabolic monitoring and checks has been implemented for patients with psychosis and bipolar in secondary care. It was unclear whether patients without these diagnoses were receiving the same level of monitoring.
MethodsData were collected retrospectively from case notes of service users under CMHRS Reigate. We included all patients from three GP practices (100 patients) and identified all who were prescribed antipsychotics and their diagnoses. The GP practices were contacted to determine whether a system was in place to flag physical health monitoring requirements for service users on antipsychotics regardless of diagnosis. The results were used to calculate the potential number of patients across the entire trust who were at risk of not receiving cardiometabolic monitoring.
Results24/100 patients were prescribed antipsychotics without a diagnosis of psychosis or bipolar. 11/24 had a diagnosis of Emotionally Unstable Personality Disorder. Quetiapine was the commonest antipsychotic. None received routine cardiometabolic monitoring.
The total caseload for all 11 adult community teams in the Trust is 2434. If prescribing and monitoring practices are similar 584 individuals may be affected.
2/3 GP practices responded. Both confirmed that they would only conduct cardiometabolic monitoring when taking over prescribing/on discharge from secondary care if specifically requested to do so.
ConclusionThis service improvement project has identified a significant group of patients who aren't automatically offered cardiometabolic monitoring in secondary care.
Private correspondence from Professor David Taylor confirms that these patients would also benefit from monitoring when prescribed doses that are more likely to cause adverse effects (Quetiapine > 150mg/Olanzapine >5 mg Risperidone >2mg)
Secondary services need to identify these patients and include them in routine cardiometabolic monitoring.
Secondary services need to work closely with primary care to ensure that responsibility for checks is agreed and handed over when necessary.
Chronic Misuse of Paracetamol in OCD Without Hepatic Injury: A Case Report and Literature Review
- Ashma Mohamed, Alexa Wacker, Martin Schmidt
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, p. S123
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Paracetamol is a commonly used antipyretic and analgesic over the counter medication. In acute or chronic overuse it is associated with dose-dependent hepatic injury. There is a narrow therapeutic margin and that consistent use of as little as 7.5 g/day may be hazardous. Unintentional overdose with paracetamol is the most common cause of acute liver failure in the United Kingdom Here we present an unusual case of a 60-year-old lady with a reported chronic history of self-medicating with an above daily recommended dose of paracetamol without evidence of hepatic injury.
MethodsA 60-year-old Caucasian lady known to psychiatric services for 20 years with Recurrent Depressive disorder, Obsessive Compulsive Disorder (OCD), Dependent Personality Disorder with Borderline personality traits. She reported consuming 32 tablets of paracetamol (16gm per day) every day for the past 11 years. She experienced obsessions of fear that if she did not take a particular number of paracetamols in a day then her friends will come to harm and her anxiety was relieved by the compulsion of consuming supratherapeutic doses of paracetamol. There was no evidence of misuse of any other medications other than paracetamol. Her blood investigations revealed liver function tests within normal limits and ultrasound of the liver was unremarkable.
ResultsA literature search of “paracetamol or acetaminophen” and “no liver or hepatic” and “damage or injury” found only one case report. The case reported that studies of paracetamol metabolism were performed in a 58-year-old female with rheumatoid arthritis who had consumed 15–20 g paracetamol daily for 5 years without developing liver damage and data were compared with results in seven normal volunteers. The report concluded that a combination of slow paracetamol absorption, enhanced detoxication of paracetamol (by sulphation) and reduced metabolism to potentially cytotoxic metabolites may have reduced the risk of liver damage in this patient.
ConclusionIn OCD, misusing medications can be an uncommon presentation of compulsive acts to relieve anxiety. The diagnostic dilemma of factitious illness is probable, however supratherapeutic use of paracetamol without physical harm is rare but possible.
Prevention of Hospital Associated Venous Thromboembolism in Psychiatric Inpatients- a Survey of Current Practice Within Mental Health Trusts in England
- Ashma Mohamed, Michael Cheah, Josie Jenkinson, Beverley Hunt, Jo Jerrome, Audrey Purcell
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, pp. S139-S140
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General hospital inpatients are routinely risk assessed for hospital associated venous thromboembolism (HAT) and given appropriate thromboprophylaxis if indicated. However, mental health trusts have not taken a similar approach in psychiatric inpatients, despite known risk factors, including some unique to psychiatric inpatients. We explored current practice of HAT prevention in English psychiatric inpatients.
MethodsA Freedom of Information Act (FOI) request was sent to all 71 English mental health trusts, asking whether there was a Venous Thromboembolism (VTE) policy, whether a VTE risk assessment tool was being used, what is looked like, and the incidence of HAT in their psychiatric inpatients i.e., VTE during admission or occurring up to 90 days post discharge.
ResultsWe received 54 unique responses (76%) to the FOI. Of these, 36 (86%) shared their VTE policy, 26 (72%) of which had been adapted for this population; 38 (90%) shared their VTE risk assessment tool, of which 17 (45%) were adapted from the Department of Health VTE risk assessment tool.
Only five trusts out of 42 (12%) monitored VTE events up to 90 days post-discharge and 4 of these shared their monitoring policy. Only 18 (43%) were able to provide data on the number of psychiatric patients diagnosed with a VTE during their stay and up to 90 days post discharge between February 2016–2021, 6 (14%) said they would incur costs to collect this data and 9 (21%) were unable to access this data. Where information was provided, the number of HAT events ranged from 0–224 within each trust. Of the 18 trusts who provided data, a total of 514 events were recorded between Feb 2016-Feb 2021, but none of the trusts were able to confirm if this included VTE events up to 90 days post discharge.
ConclusionOur FOI survey suggest a high incidence of VTE in psychiatric patients and indicate wide variation in HAT prevention in English hospitalised psychiatric patients. Most had a VTE Trusts had a policy in place, with 45% having a VTE risk assessment tool that listed risk factors unique to psychiatric patients, adapting VTE risk assessment tools in this way may lead to a greater use of thromboprophylaxis. The lack of access to data on HAT by mental health trusts is concerning. Further research is required to understand the rates of VTE, validate a VTE risk assessment tool and conduct trials looking at the benefit of thromboprophylaxis in psychiatric inpatients.
The blues, and an almost shocking surprise – Unexpected PE in a catatonic patient, that almost had ECT
- Michael Cheah, Ashma Mohamed, Anand Mathilakath
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S130
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To present a case of a near-miss, where an unexpected Pulmonary Embolism (PE) was identified in a patient with psychotic depression and catatonia, who almost had Electroconvulsive Therapy (ECT). Our aim is to highlight the importance of Venous-Thrombo Embolism (VTE) risk assessment in all psychiatric inpatients, particularly those with catatonia, and those about to undergo ECT.
MethodA 53-year-old female admitted with her first presentation of psychotic depression, catatonia, poor oral intake, and significant weight loss in the community for months prior to admission. She was recommended for emergency ECT as the severity of her self-neglect was becoming life threatening. Her first ECT session was cancelled due to low potassium levels prior to ECT, which proved to be a fortunate event. She developed sudden onset chest pain the next day, and following further medical investigations; was diagnosed to have a bilateral PE, and subsequently treated with Apixaban. Due to the potential risk of ECT dislodging the clots, treatment was done by optimising medication alone; Venlafaxine 300 mg, Mirtazapine 45 mg, Haloperidol 6 mg. She made a slow but successful recovery, and was discharged home, with ongoing support from Early Intervention in Psychosis services.
ResultWe conducted a literature search, and it is well known that there is an increased risk of VTE in catatonic patients, as well as other psychiatric inpatients; due to anti-psychotic medication. Furthermore, cases have been reported where ECT was associated with increased risk of death in patients with known VTE/PE.
On retrospective review of the patient's risks of developing VTE in the community, it was clear, that she was at very high risk of developing VTE. It was also noted that she should have had a VTE risk assessment on admission, in accordance with NICE guidelines; where all acute psychiatric inpatients should have this assessed as soon as possible.
ConclusionThrough a process of assessment and treatment, VTE is often preventable. Identification of high-risk patients on admission to hospital is therefore crucial. It is thus, imperative that a comprehensive VTE risk assessment is completed on admission and regularly reviewed.
This case highlights the risk of missing VTE assessments in WAA Inpatients, particularly those with catatonia, about to undergo ECT, which could have been fatal. As such, VTE/PE risk assessment in such patients, about to undergo ECT, is particularly crucial.
Clinicians need to have a high index of suspicion of VTE/PE, particularly in patients with catatonia.