5 results
Audit of inpatient smoking cessation advice
- Flensham Mohamed, Mohamed Bader
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S92-S93
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Aims
Audit carried out to assess whether or not patients had been asked about their smoking status during admission onto an acute adult mental health ward, as well as if they had received any smoking cessation advice or offered nicotine replacement therapy.
Background• Physical health outcomes in patients with serious mental illness (SMI) are consisitently worse than the general public This is due to multiple factors; adverse effects of medication (including metabolic syndromes with psychotropics) as well as poor lifestyle factors such as smoking status
• Patients with an SMI are 3–6 times more likely to die due to coronary artery disease. 70% of patients in inpatient psychiatric units are smokers, a strong independent risk factor for cardiovascular disease.
• Smoking cessation is a potent modifiable risk factor that can prevent mortality and reduce morbidity.
MethodA cross-sectional review of all 34 inpatients across four general adult acute psychiatric wards.
Patient records were explored using the Aneuran Bevan Health Board admission proformas to identify evidence of smoking status and whether advice was offered.
ResultSmoker but not given cessation advice n = 13 (38%)
Not asked about smoking n = 11 (32%)
Smoker and given cessation advice n = 4 (12%)
Non-smoker n = 6 (18%)
ConclusionPatients were asked about their smoking status the majority of the time (68%) but provision of advice or nicotine replacement therapy was only done in 14% of potential smokers (identified smokers and patients not asked about smoking status).
A consideration to be taken into account is that on admission, a patient's physical health status may be unknown, with the additional difficulty of a patient's acute distress complicating the physical examination, smoking status and modification of patient's smoking status may not be the highest priory in that context.
Data regarding asking about smoking were different amongst wards, potentially signifying differences between assessors willingness to ask about smoking status.
There is a lack of smoking cessation literature available on the wards and patients are often unaware of what options are available to quit smoking.
The audit simply determined whether or not assessors were documenting smoking status, it does not measure the quantity or quality of smoking cessation advice provided.
Further quality improvement projects should be launched, with focus groups as the intial step at further investigating inpatient smoking rates, as well as attempting to reduce them in a more systemic way.
Trainees' perspective on the best use of supervision-hour in psychiatry training – a qualitative study
- Raja Adnan Ahmed, Mohamed Bader, Mohamed Flensham
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S122
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Aims
This study aims to identify the techniques to improve the quality of the weekly one to one supervision for Psychiatry trainees.
MethodAn open-ended online questionnaire was prepared using principles of critical incident technique and distributed among psychiatry trainees working in various deaneries within the UK. The participants were asked to describe an example of a good and a bad supervision experience they had encountered during their training. In addition, participants were also requested to make suggestions to improve the supervision experience. All qualitative data were analysed using the thematic analysis approach, to identify common themes.
ResultA total of 53 trainees working in various deaneries across England and Wales, responded to the questionnaire. The respondents were at a different level of training in psychiatry from CT1-ST6 level. The supervision hour was reported to be useful for clinical case discussions, reflection on difficult cases and situations, pastoral support and wider issues relating to personal and professional development. Trainees appreciated a holistic scope for supervision rather than a narrow discussion of management of cases.
Trainees reported that the supervision hour should be trainee-led and tailored according to their unique learning needs. Participants also saw supervision hour as a safe space where they can receive constructive criticism and feedback on their performance. At times, trust and genuineness were appreciated, as well as the use of an informal tone by the supervisor. An effective supervision leads to trainees feeling valued.
ConclusionTrainees acknowledged that the supervision hour is an effective tool in psychiatry training. Trainees should get regular, protected and uninterrupted time with consultants for weekly supervisions. Both trainees and trainers need to develop a better understanding of how this supervision experience could be improved and tailored to the individual learning needs of the trainee.
Quality improvement in remote prescribing
- Mohamed Bader, Ibtisam Abbas, Joanna Peacock
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S172-S174
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Aims
To evaluate attitudes in prescribing and utilising 'As Required' (referred to as PRN/Pro Re Nata) sedating medications (Benzodiazepines, Z-Drugs, Anti-psychotics, and Promethazine)
To evaulate current remote prescribing processes and improve safety and transparency
MethodPlan:
Review of remote prescribing policy. It was highlighted that current practice was not in line with NMC guidance of the time as no follow-up written instruction by a doctor was received. Concerns were also raised about the general safety of verbal communication of prescriptions out of hours. A survey was conducted to assess attitudes towards the prescription of ‘PRN medication’ and the role of psychological therapies as an alternative to both doctors and nurses working in ABUHB's Mental Health and Learning Disabilities division.
Do:
Survey results showed a nuanced response from both doctors and nurses but an agreement that there is a role for as required medication, especially in the context of acute mental distress, indicating safety around the process rather than elimination/reduction of PRN medication prescribing would be desired. This lead to an overhaul of the out of hours prescribing process between junior doctors and those receiving the ‘verbal order’ as detailed below: Phone conversation between a junior doctor and ward nurse receiving the verbal order. A digital form is then completed by the ward nurse including current regular medication, PRN medication (including times of use), physical health history, and any additional requested information such as QTc on 12 lead electrocardiogram (ECG) or current vital signs. The junior doctor may assist with obtaining the relevant information but there are clear prompts on the form, to ensure the pertinent questions regarding safe prescribing are considered by both parties. The dose and route of the medication are clearly documented by the junior doctor as well as time of prescription and the form is emailed back to the ward nurse. This process is far more transparent and much less prone to errors due to miscommunication. a. The prompts also save time ensuring the relevant information is on hand prior to discussion as opposed to searching for medication charts, ECGs, etc. b. Highlighting the importance of QTc monitoring to encourage safe prescription of anti-psychotics and Promethazine c. The prompts also highlight the importance of physical health and current vital signs with regards to safe prescribing d. The prompts are stored on a network drive alongside other verbal orders allowing for easier future auditing off remotely off and on site These changes were highlighted via email, junior doctor forums, and induction of new doctors.
Study
A Round 2 survey was drafted to evaluate the new process and forms with an aim to ensure uptake and to identify any issues. Despite using the same channels to identify survey participants, the response rate was much lower than the Round 1 survey. See Round 2 results.
Act
With the limited feedback obtained the main issue identified was with regards to rapid tranquilisation of an aggressive patient who poses a risk to self and others. In this scenario it was deemed a risk to wait for an email form to be completed. Clarification emails were sent to relevant professionals to clarify that the rapid tranquilisation policy does allow for verbal orders with a subsequent digital order form to be completed at a later time when it is safe to do so.
ResultRound 1
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Nurses n = 26
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Doctors n = 27
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Nursing
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92% routinely request Z-Drugs and Benzodiazepines for treatment of insomnia
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88% routinely request Benzodiazepines for treatment of agitation
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73% routinely request Promethazine for for treatment of agitation
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69% routinely request PRN Anti-Psychotics for treatment of agitation
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35% would routinely request Promethazine for treatment of insomnia
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19% would routinely request Haloperidol without a recent ECG (>3 months)
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15% would request Benzodiazepines for treatment of psychotic symptoms
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12% would request Lorazepam above British National Formulary maximum doses
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As required medications dispensed per shift
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54% report 0 to 3 times
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23% report 4 to 6 times
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23% report 6 to 10 times
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Agitation was most commonly defined as
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96% hostile behaviour/physical aggression
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92% hostile/threatening/derogatory speech
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81% visible anxiety
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69% disturbed behaviour that is not threatening/derogatory towards others
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31% patient reported anxiety without objective evidence
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PRN medication use reviewed by doctors
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Daily (8%)
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Weekly (85%)
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Monthly (8%)
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5 most commmonly cited reasons contributing to PRN medication use
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77% Ward atmosphere (ie. volatile ward environment)
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69% Patient depdence (psychological/physiological)
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54% Patient expectation
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42% Limitted expectation of benefit from psychological skill utilisation
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42% Usual habit/culture of prescribing by doctors
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What are your thoughts on the use of psychological interventions in an acute setting? [Open Ended, n = 22]
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Nursing staff feel positively about psychological interventions in the right setting at the right time but find challenges to delivering them. Some staff cite the fact that a patient is admitted indicates their level of acuity requiring PRN utilization. Some responses indicate that patients may be medicating the normal human experience. Ward atmosphere, how ill the patient currently is, patient willingness, staff shortages, paperwork taking priority, lack of training in psychological therapies were all cited as challenges.
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Doctors
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96% routinely prescribe Benzodiazepines for treatment of agitation
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92% routinely prescribe Z-drugs and Benzodiazepines for treatment of insomnia
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63% routinely prescribe PRN Anti-psychotics for treatment of agitation
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38% routinely prescribe Promethazine for treatment of agitation
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29% routinely prescribe Promethazine for treatment of insomnia
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25% routinely prescribe Benzodiazepines for treatment of psychosis
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12.5% routinely prescribe Lorazepam above British National Formulary maximum doses
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8% routinely prescribe Haloperidol without a recent ECG (>3 months)
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Rapid Tranquilisation Policy
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70% of doctors were familiar with the up to date Rapid Tranquilistion Policy
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5 most commmonly cited reasons contributing to PRN medication use
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19% nursing staff shortages
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15% ward atmosphere (ie. volatile ward environment)
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15% nursing staff expectations
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11% usual habit of prescribing
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11% patient expectations
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What are your thoughts on the use of psychological interventions in an acute setting (n = 26)?
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Doctors are somewhat divided in their approach to psychological approaches, the majority stating or alluding to it being a first line management option but some citing staffing levels to be a deterrent. Others had a more nuanced view of it rather than a general first line treatment, requiring risk/benefit analyses before use. The minority did not know enough about psychological interventions or thought it often doesn't work.
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Round 2
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Nurses n = 8
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Doctors n = 8
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Nursing
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Total responded n = 8
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Acute psychiatric ward nurses n = 4
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Psychiatric intensive care unit nurses n = 4
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50% were unaware that physical health emergencies and rapiq tranquilisation can allow for the older process of 'verbal orders' followed by the form due to the imminent risks associated with delaying treatment to complete the form
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100% (n = 8) were familiar with the digital order forms
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87.5% (n = 7) were familiar with the digital order policy
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With regards to form locations
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87.5% (n = 7) had access to blank forms and would store them alongside paper medication charts
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12.5% (n = 1) were not aware that the ‘verbal order’ policy was not digitised
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75% (n = 6) did not report any change the frequency of requesting out of hours prescriptions
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12.5% (n = 1) reported a reduction in requests
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12.5% (n = 1) reported an increase in requests
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75% (n = 6) reported that the digital order form puts up barriers to requesting medication out of hours
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12.5% (n = 1) report that the form helps them formulate their requests
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50% (n = 4) report that the form requires the appropriate amount of information
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12.5% (n = 1) report that the form requires too much information
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37.5% (n = 3) did not comment on the amount of information the form requires
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25% (n = 2) report that the digitised system is safer
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75% (n = 6) did not comment on safety
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87.5% (n = 7) report that the form is more time consuming
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12.5% (n = 1) did not comment on time consumption
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37.5% (n = 3) would like to revert back to the old system
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25% (n = 2) would like to remain on current system
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37.5% (n = 3) did not comment on which system they'd prefer
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Doctors
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Total responded n = 8.
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Consultants n = 2
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Staff Grade doctors n = 1
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Core Trainees in Psychiatry n = 3
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Fixed term appointees n = 2
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100% (n = 8) were familiar with the up to date rapid tranquilisation policy
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With regards to the digital order forms
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62.5% regularly see them in patient files (n = 5)
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37.5% occasionally become aware of them (n = 3)
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0% were unaware of the new digital order forms (n = 0)
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With regards to inappropriate out of hours prescriptions
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37.5% report that there was a reduction (n = 3)
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50% report there being no significant change (n = 4)
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12.5% report there being an increase (n = 1)
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n = 6 reported the new system to be safer
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n = 2 did not comment on safety
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n = 2 report it being more time consuming to use the digital orders
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n = 6 did not comment on time consumption
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With regards to returning to verbal order forms
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n = 3 would like to remain on digital orders
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n = 5 did not comment on returning to verbal order forms
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n = 2 commented in the comment box that this change was overdue
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n = 1 commented that the forms give insight into patient presentations and management
ConclusionDoctors routinely prescribe Z-drugs and benzodiazepines, and would generally consider Haloperidol as a second line over Promethazine (while nurses had a slight preference for requesting Promethazine over Haloperidol). The role of 12 lead electro-cardiogram monitoring would require further exploration in separate audits, as both Promethazine and Haloperidol can cause QTc interval prolongation [4,5].
Doctors most commonly cited expectations by nursing staff as the main driver for PRN medication prescription. Profound differences were present with regards to rationale behind PRN medication use when comparisons between doctors and nurses self-reports were made. The majority of nurses cited ward atmosphere and patient dependence/expectation as main drivers, whereas a minority of doctors shared those views. This represents a concerning disconnect between professionals, although it can be explained by the higher proportion of time ward nurses spend on mental health wards and in direct patient care. Nursing staff, being the dispensers of medication, would also likely be the main professionals contacted for the request of PRN medication by patients.
Nuanced views were given to the role of psychological redirection. This was shared between doctors and nurses, although many cited concerns about nursing staff shortages leading to a possible overreliance on PRN medication. A minority of doctors (n = 2) would recommend psychological redirection after first line rapid tranquilisation was exhausted. The counterargument being that someone admitted onto a ward tacitly implies a high level of acuity and reduced appropriateness of psychological techniques.
Hypnotics most commonly being requested likely reflects the difficult nature to initiate and maintain sleep is an acute ward setting.
On review of the Round 2 results indicate that doctors and nurses agree that the new system is safer although more time consuming. Concerns were raised about rapid tranquilisation and immediate emergencies, although the revised policy would allow for the verbal order policy to be followed with a digital order in these circumstances. This was clarified via further communication with relevant parties.
The changes were more received more positively by doctors than nurses, with some nurses opting for the older system if possible. It was also raised that this may be putting up barriers for out of hours prescriptions, although the required information is arguably succinct and only requests vital information for safe prescribing. Further exploration of these concerns would be indicated. The Round 2 results were limited by the low sample size compared to the first round.
Despite the limitations and concerns about the new system, digitising the system allows for further audits and studies to utilize much more robust methods of measuring out of hours prescriptions than self-reported measures employed in the initial rounds. Although they may not be directly compared to findings of this report, future baselines can be established and compared to in an objective manner.
Future Rounds
Proposed: To design and clearly display information on commonly requested medication by patients, empowering them to make more informed decisions on the medications they request. This could be in the form of leaflets patients could take or posters on areas where patients receive medication. One example is that Zopiclone is a very commonly requested medication on an as required basis although patients may not be as aware of the risks associated with chronic use.
Proposed: To design and clearly display information on psychologically informed techniques in patient areas such distress tolerance and sleep hygiene. This would be on mental health sites which do not currently display this information. To measure impact on PRN medication dispensation.
Proposed: Further exploration of patient perceived ward environment and measures that can be implemented to reduce anxiety/insomnia associated with inpatient admission.
Proposed: Exploration of proportion of inpatient initiated PRN medication progresses to long term use in the community (largely focused on hypnotics and benzodiazepines).
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Physical health audit of gwent specialist substance misuse services (North Team)
- Mohamed Bader, Hayder Al-Hassani
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S5-S6
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Aims
The scope of this audit is to look at the:
1. Completion rates of standard 12 lead electrocardiograms (ECGs)
2. Completion rates of physical examinations
3. Analysis of the reported findings elicited from physical examinations
4. Completion rates of Blood borne virus (BBV) screens; for hepatitis B, hepatitis C, and human immunodeficiency virus (HIV)
MethodPhysical Examination: All patients’ physical GSSMS notes were checked for a Medical Assessment sheet. If no physical examination documentation was found, the generic clinical notes were examined for evidence of a physical examination. All findings were recorded in Microsoft Excel for descriptive analysis. Findings were then grouped into generic categories such as infectious, cardiac, etc. (see Figure 7).
ECG: All patient notes were examined in the ‘Investigations’ section to determine if an ECG was included. Print outs of ECGs done by other agencies/teams were accepted as long as they were within date. If a patient had an ECG on Clinical Workstation (CWS) within date it was not included in the audit unless the ECG was printed and filed in the ‘Investigations’ section.
BBV Screen: All patient notes were investigated to find evidence of the BBV consent sheet or print out of the results. If no evidence was found, CWS was checked for evidence of a blood borne virus screen. 5 Analysis of BBV screen results and completion of consent sheets were beyond the scope of this audit. If a patient had a BBV screen that was different to the standard GSSMS screen, such as a screen with HIV only or a BBV screen as part of an ante-natal screen, it was still included as a completed BBV screen.
ResultTotal patients initially included (n = 125). Patients included in analysis (n = 121). Patient notes not on site (n = 2). Patients assessed on ward but did not engage with service afterwards (n = 2)
Physical Examinations
Received a physical examination by GSSMS (n = 60)
Has not received a physical examination by GSSMS (n = 61)
An abnormality was detected in 77% of patients, charts to be added to display the findings to poster.
Most common findings were Hypertension (n = 9) and Abdominal Tenderness (n = 9).
ECG
Had an ECG (n = 37)
Did not have an ECG (n = 84)
BBV Screen
Had a BBV test in the last 6 months (n = 62)
Did not have a BBV Test in the last 6 months (n = 59)
ConclusionAreas of Good Practice
1. As opposed to previous practice, physical examination rates have risen from 0% to 50%. The 50% rate also likely underestimates true practice as patients were included in these numbers if they: a. Disengaged prior to a medical examination but after a nursing assessment. b. Refused a physical examination
2. The vast majority of physical examinations elicited positive findings, identifying health needs and risks
3. ECG completion rate of 31%, despite being low, represents a significant improvement as the team did not have an ECG machine prior to the audit. Establishing a baseline ECG would also be of clinical value even if normal, as it would allow for future comparisons of QTc intervals compared to pre-treatment baselines. Patients may have had an ECG on mental health wards or in general hospital with the results/ECG being communicated to GSSMS staff, although it would not have been included in the audit as a completed ECG unless a copy was filed in the notes.
4. As previous BBV screen completion rate had not been quantified to obtain a baseline, it is difficult to compare current BBV screen completion rate. 66% of patients had had a BBV screen in the last year. This audit did not account for patients who disengaged prior to their BBV screen or patients who refused a BBV screen. This audit also includes all patients under GSSMS and BBV completion rates included alcohol dependent/neverinjecting patients which would be of lower risk as opposed to Injecting Drug Users. With that context in mind, a completion rate of 66% likely reflects good practice.
Areas for Improvement/Recommendations
1. Development of a checklist which can be placed on the front of a patients notes with dates that can be documented for ECG, Physical Examination, etc. as well as non-physical health documents such as risk assessments and care plans to ensure documents stay in date.
2. Further audits with more data would reveal further information with regards to the needs of patients under GSSMS. If current trends continue with improvements in detection, a larger pool of analysable data would be available. Based on current limitations of this audit a re-audit would benefit from: a. Quantifying BBV screen results to identify percentage of patients who are antibody and PCR positive; this can be done as a standalone project. b. Quantifying actions taken as a result of physical examination findings as that would indicate what additional service requirements (if any) need to be highlighted. The current method of auditing does not comment on severity or chronicity and does not account for the actions taken as a follow-up to the physical examination which may indicate acuity.
3. Further audits may require alterations to data collection may be allow for more specific measurement of health risks and needs. Eg. Highlighting if a patient is injecting substances or on a QTc prolonging medication. This would allow for more specific analysis of patients at risk of adverse outcomes. It is unclear if the improvement in monitoring is targeting GSSMS patients at higher or lower risk of adverse health outcomes.
Lessons Learnt
• Patients under GSSMS commonly were found to have physical examination findings, most commonly abdominal tenderness, potentially highlighting a significant pathology of the abdominal organs. ECG and physical examination completion rates are improving
• BBVs are being done frequently for the majority of patients
• Further recommendations for yearly re-audit would allow for targeting specific questions such as what percentage of patients require hepatology interventions or what percentage of patients are of high risk of cardiac events on Methadone
Audit on prolactin monitoring for patients on oral risperidone, intramuscular risperidone, and intramuscular paliperidone
- Mohamed Bader
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S65
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Aims
The aim of this audit was to investigate whether sufficient Prolactin monitoring was completed in a patient sample in the Torfaen area of Aneurin Bevan University Health Board. This audit targetted patients an oral or intra-muscular formulation of Risperidone in the year 2018 with the hypothesis that Prolactin monitoring is done less frequently than recommended.
BackgroundRisperidone is the anti-psychotic drug most frequently associated with hyperprolactinemia which is often asymptomatic but can present with symptoms of oligomenorrhea, amenorrhea, galactorrhea, decreased libido, infertility, and decreased bone mass in women. Men with hyperprolactinemia may present with erectile dysfunction, decreased libido, infertility, gynecomastia, decreased bone mass, and rarely galactorrhea. The BNF advises monitoring of Prolactin at baseline, after 6 months, and then annually.
MethodRetrospective review of 150 patients’ clinical letters to identify if they are on the above medications, using the local digital records system EPEX. Emails were also sent to community psychiatric nurses asking them if they could highlight any patients they were caseholding on the above medication. Depot clinic lists were also examined. Patients identified as being on the above medication had their blood tests reviewed on the online system Clinical Workstation (CWS) to determine whether they had their Prolactin level tested. A single spot sample of all patients on Talygarn ward in January 2019 was also included.
Result1. 28 Risperidone
2. 23 of 28 never had any Prolactin measurements
3. 2 of 28 patients had the appropriate level of monitoring done for the year of 2018
a. One patient complained of Galacotorrhea
b. Another patient had baseline done while on the ward and isn't due for any further monitoring at the time of writing.
ConclusionThe above results identify that Prolactin monitoring is not being routinely completed for patients on the studied medication at an acceptable compliance level. Limitations around utitlity of prolactin monitoring may be the contributing factors; eg. Prolactin levels or medication dose may not be positively associated with adverse effects.. Further efforts were made to highlight the importance of baseline prolactin monitoring, as well as including a baseline Prolactin as an admission blood test for patients presenting with psychotic symptoms or on an anti-psychotic. A complete audit of metabolic monitoring and Prolactin levels for all patients on anti-psychotics would be an appropriate next step.