Improving physical health care for inpatients with eating disorders

Aims Primary aim – To improve how physical health issues are addressed for inpatients with eating disorders Secondary aim – To improve efficiency within the MDT Background The Yorkshire Centre for Eating Disorders (YCED) is an inpatient unit for the treatment of patients with anorexia and bulimia nervosa. Anorexia nervosa has the highest mortality of all psychiatric disorders with an extensive list of physical manifestations. This project was designed to help better address the physical health concerns of our patients by introducing a primary care style, once weekly clinic that patients could self-refer to. Method Questionnaires were designed to assess whether a once weekly physical health clinic would benefit the service. The clinic was run on a weekly basis from 26th April to 24th June 2019. Follow-up questionnaires were designed and distributed to both patients and staff following this period. Data were analysed with Microsoft Excel to determine if improvement had been made. Result N = 12 inpatients responded to the initial questionnaires, n = 2 were discharged during the 8 week period so were included in the analysis but did not complete the follow-up questionnaire. 100% of the staff (n = 8) felt a once weekly clinic would benefit their patients. 62% (n = 5) stated they felt distracted from their other duties with physical health requests. 33% (n = 4) of the inpatient group felt the clinic would benefit them with 67% (n = 8) stating indifference to the idea. 26 appointments were conducted in the physical health clinic with 80% (n = 8) of the service users accessing at least once. 70% (n = 7) stated their physical health concerns had been better addressed since the clinic had been started. 90% (n = 9) of inpatients and 90% (n = 9) of staff responded that the physical health clinic should remain permanent. 90% (n = 9) of staff stated they had more time for their other duties since the introduction of the clinic. Prior to the clinic 63% (n = 5) of staff responded that in a typical day they were approached between 2-5 times for physical health requests with the other 37% (n = 3) being approached once. Following the clinic 80% (n = 8) of staff responded that they were approached once in a typical working day. Conclusion The qualitative data from the questionnaires indicated success in both improving patient care and reducing nursing workload. The physical health clinic has been made a permanent feature on the ward and has been continued by the incoming foundation doctor and ward ANP.

Aims. Primary aim -To improve how physical health issues are addressed for inpatients with eating disorders Secondary aim -To improve efficiency within the MDT Background. The Yorkshire Centre for Eating Disorders (YCED) is an inpatient unit for the treatment of patients with anorexia and bulimia nervosa. Anorexia nervosa has the highest mortality of all psychiatric disorders with an extensive list of physical manifestations. This project was designed to help better address the physical health concerns of our patients by introducing a primary care style, once weekly clinic that patients could self-refer to. Method. Questionnaires were designed to assess whether a once weekly physical health clinic would benefit the service.
The clinic was run on a weekly basis from 26th April to 24th June 2019. Follow-up questionnaires were designed and distributed to both patients and staff following this period. Data were analysed with Microsoft Excel to determine if improvement had been made. Result. N = 12 inpatients responded to the initial questionnaires, n = 2 were discharged during the 8 week period so were included in the analysis but did not complete the follow-up questionnaire.
100% of the staff (n = 8) felt a once weekly clinic would benefit their patients. 62% (n = 5) stated they felt distracted from their other duties with physical health requests. 33% (n = 4) of the inpatient group felt the clinic would benefit them with 67% (n = 8) stating indifference to the idea. 26 appointments were conducted in the physical health clinic with 80% (n = 8) of the service users accessing at least once. 70% (n = 7) stated their physical health concerns had been better addressed since the clinic had been started. 90% (n = 9) of inpatients and 90% (n = 9) of staff responded that the physical health clinic should remain permanent. 90% (n = 9) of staff stated they had more time for their other duties since the introduction of the clinic.
Prior to the clinic 63% (n = 5) of staff responded that in a typical day they were approached between 2-5 times for physical health requests with the other 37% (n = 3) being approached once.
Following the clinic 80% (n = 8) of staff responded that they were approached once in a typical working day. Conclusion. The qualitative data from the questionnaires indicated success in both improving patient care and reducing nursing workload.
The physical health clinic has been made a permanent feature on the ward and has been continued by the incoming foundation doctor and ward ANP. Aims. The coronavirus pandemic has led to an increased reliance on remote patient-clinician interactions, mainly the use of telephone and video consultations. Video consultations are key in psychiatric care, as telephone appointments do not sufficiently allow clinicians to accurately ascertain a patient's mental status and perform a risk assessment. The aim of our quality improvement project was to increase the uptake of video consultations within a community mental health team, focusing on substituting telephone consultations for video. Method. We accessed Electronic Patient Records to retrospectively quantify the method of contact for 130 consultations delivered over a 4-week period. After collecting baseline data, we conducted focused interviews with 10 care providers, identifying the specific clinician and patient barriers to video uptake that informed our intervention design.

Assessement of a structured technological support intervention on uptake of video consultations
Our intervention consisted of two 4-week Plan, Do, Study, Act (PDSA) cycles.
PDSA 1 involved delivering a focused PowerPoint presentation to the care team, highlighting the benefits of video consultation technology and encouraging clinicians to use it as their primary method of remote communication with patients. Additionally, we conducted qualitative interviews with members of the team to highlight the successes and challenges thus far.
PDSA 2 involved creating a video consultation instructional PDF which highlighted how to operate the technological aspects of both Microsoft Teams and WhatsApp Video Call. This included: how to set-up video calls, accept invitations, and overcome common troubleshooting issues.
The proportion of remote consultations was quantified retrospectively to compare trends in video consultation uptake from baseline to the conclusion of PDSA 2.
Result. Overall, we saw a 15% increase in video consultations with respect to baseline. The greatest change was attributable to PDSA cycle 1, which incurred an 8% increase in video consultation uptake, from 13.85% to 21.9%. PDSA cycle 2 further increased video consultation uptake by 6.97%, from 21.9% to 28.87%. Specifically focusing on remote consultations, the proportion conducted with video rather than telephone increased by 17.3%. Interviewed clinicians reported limited financial access, technological fluency, and issues with patient privacy as the most important barriers to the uptake of video consultations. Conclusion. Our project successfully increased the proportion of consultations conducted by video. This was achieved by targeting interventions to address both patient and clinician barriers to video consultation uptake. Moreover, we understand that motivating and mobilising the care team was a key factor. Possible future work includes improving the sustainability of the interventions and assessing their efficacy in other care teams.
Improving quality and assessment of referrals to the Enfield Crisis Resolution and Home Treatment Team (ECRHTT) Aims. Triaging referrals to crisis resolution and home treatment teams is a significant undertaking requiring experienced and dedicated staff. We observed that the volume of inappropriate referrals to ECRHTT was high, and that staff processing these often felt inexperienced or lacking in confidence to discharge them back to the referrers and signpost them to appropriate services.
The aims of this quality improvement project (QIP) were: a) to reduce the number of inappropriate referrals received by the team b) to reduce the number of inappropriate referrals accepted by the team This would significantly improve access and flow to the service and facilitate better patient care. Method. A pilot study was first completed of the quality (appropriateness/ inappropriateness) and source of all referrals to ECRHTT in January 2019 (n = 177). Subsequently, the consultant psychiatrist for ECRHTT based himself within the assessment team. He was able to closely monitor the referrals, at the same time as providing medical input to patients at their first point of contact. To evaluate the impact of this intervention, the percentage of inappropriate referrals accepted pre-and post-change was compared by re-auditing all referrals received in February 2019 (n = 175).
Further interventions were instigated to improve referral quality. These included continuation of psychiatric medical input to the assessment team, teaching sessions for GPs and the crisis telephone service, and weekly meetings with psychiatric liaison and community mental health teams (CMHTs). Change was measured by reassessing the quality of all referrals made to ECRHTT in February 2020 (n = 215). Result. 46.9% of inappropriate referrals to ECRHTT were accepted in January 2019 compared to 16.9% in February 2019 following the addition of medical input to the assessment team. The absolute difference was 30% (95% CI: 14%-44%, p < 0.001).
Conclusion. This piece of work shows that better engagement with referral sources significantly improved the quality of referrals made to ECRHTT. Interventions included medical input at the point of referral, teaching sessions for general practitioners as well as ongoing liaison with referring teams.
Monitoring and investigation of tachycardia in patients receiving clozapine therapy; a quality improvement project Aims. Clozapine is an antipsychotic agent with a number of significant physical health risks which necessitate monitoring, including cardiac complications such as myocarditis and cardiomyopathy. Reliable detection of cardiac complications requires active vigilance, with consideration for investigations if serious cardiac side effects are suspected (including electrocardiograms, echocardiograms and blood tests). There was dissatisfaction in the outpatient department about delays to taking action on abnormal physical observations, such as tachycardia. This raised safety concerns about how these delays would limit our ability to investigate and diagnose cardiac complications in a timely manner. We set a project aim to reduce the rate of retrospective action on abnormal physical observations, by half in the 4-month project timespan. Method. All correspondence sent to the outpatient department from the local clozapine clinic was monitored and assessed for the need for further action or investigation, and the proportion of retrospective action needed was recorded. This was then monitored during implementation of project interventions, to detect any change in performance. Result. Baseline monitoring showed retrospective action had to be taken on 41.2% of patients attending the clinic with abnormal physical observations, with significant delays up to 51 days later. Our initial intervention was the design of a clinical protocol to guide and signpost clinical staff at the time of the patient's attendance. Unfortunately, due to wider organisational barriers, this was not able to be implemented during the timescale of this project; however increased staff awareness during the protocol implementation process led to a reduction of retrospective action to 26.7%. A follow-up intervention to increase staff awareness and education was carried out, with development of a poster for the clinical room. This approach maintained the improvement, with a further slight reduction to 26.3%, representing a decrease of 37.5% from the baseline rate. A total of 106 patient letters were assessed during the project. Conclusion. We believe that developing a clinical policy to use at the time of the patient's clinic attendance still remains the optimal intervention; a view backed up by this project's identified drivers for change. However, wider organisational barriers prevented the implementation of this policy, and overcoming these barriers are outside the scope and timescales of this project. This project demonstrated maintained, but sub-target, success with measures that increase staff education and awareness. However, it remains to be seen if this improvement will persist, and this would be a potential target for further QIP or monitoring.