Old age psychiatry home treatment team--preliminary audit of a service improvement project

AimsTriaging 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 teamb)to reduce the number of inappropriate referrals accepted by the teamThis would significantly improve access and flow to the service and facilitate better patient care.MethodA 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).Result46.9% 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).71% of referrals from GPs were inappropriate in January 2019 compared to 36% in February 2020 post-intervention (difference 35%, 95% CI: 8.84%–55.4%, p < 0.05). Inappropriate referrals from CMHTs decreased from 55.5% to 12% (difference 43.5%, 95% CI: 9.5%–70.3%, p < 0.05). Overall, the percentage of inappropriate referrals fell from 38% to 27.4%, a difference of 10.6% (95% CI: 1.3%–19.8%, p < 0.05). The percentage of inappropriate referrals from liaison teams did not change significantly.ConclusionThis 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.

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Implementation of treatment escalation plans in an old age psychiatry inpatient hospital

BMJ Open Quality ◽

10.1136/bmjoq-2021-001640 ◽

2021 ◽

Vol 10 (4) ◽

pp. e001640

Author(s):

Anne Y T Chua ◽

Adnaan Ghanchi ◽

Sangeeta K Makh ◽

Jessica Grayston ◽

Stephen J Woolford ◽

...

Keyword(s):

Decision Making ◽

Old Age ◽

Tertiary Hospital ◽

Improvement Project ◽

Inpatient Hospital ◽

Psychiatric Setting ◽

Uptake Length ◽

Old Age Psychiatry ◽

Effective Decision Making ◽

Treatment Escalation

A treatment escalation plan (TEP) enables timely and appropriate decision making in the management of deteriorating patients. The COVID-19 pandemic precipitated the widespread use of TEPs in acute care settings throughout the National Health Service (NHS) to facilitate safe and effective decision making. TEP proformas have not been developed for the inpatient psychiatric setting. This is particularly concerning in old age psychiatry inpatient wards where patients often have multiple compounding comorbidities and complex decisions regarding capacity are often made. Our aim for this quality improvement project was to pilot a novel TEP proforma within a UK old age psychiatry inpatient hospital. We first adapted a TEP proforma used in our partner acute tertiary hospital and implemented it on our old age psychiatry wards. We then further refined the form and gathered data about uptake, length of time to complete a TEP and the ceiling of care documented in the TEP. We also explored staff, patient and family views on the usefulness of TEP proformas using questionaries. TEP decisions were documented in 54% of patient records at baseline. Following revision and implementation of a TEP proforma this increased to 100% on our two wards. The mean time taken to complete a TEP was reduced from 7.1 days to 3.2 days following inclusion of the TEP proforma in admission packs. Feedback from staff showed improvements in understanding about TEP and improved knowledge of where these decisions were documented. We advocate the use of TEP proformas on all old age psychiatry inpatient wards to offer clear guidance to relatives and treating clinicians about the ceilings of care for patients. There are potentially wider benefits to healthcare systems by reducing inappropriate transfers between psychiatry and acute NHS hospitals.

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Using quality improvement to standardise and enhance the use of the national early warning score (NEWS) in an old age psychiatry inpatient setting

BJPsych Open ◽

10.1192/bjo.2021.153 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S38-S39

Author(s):

Fraser MacNicoll ◽

Mong Sun Tung ◽

Brion McGowan

Keyword(s):

Quality Improvement ◽

Old Age ◽

Quality Improvement Project ◽

Assessment Process ◽

Early Warning Score ◽

Post Intervention ◽

Improvement Project ◽

Physical Deterioration ◽

Increased Risk ◽

Old Age Psychiatry

AimsWithin an inpatient old-age psychiatry setting, there is an increased risk of acute physical deterioration secondary to age, comorbidities and reduced physiological reserve. Numerous recent clinical incidents highlighted late recognition of physical deterioration within this population. We assessed the use of the NEWS, a system for scoring physiological measurements, in an old-age psychiatry ward and subsequently attempted to improve performance of obtaining physical health observations in this cohort of patients.MethodRetrospective pre- and post- quality improvement study in a twenty bed Old Age Psychiatry Ward in East Lothian Community Hospital, Haddington, Scotland. Data were collected from 12th October – 16th November, 2020 (pre- period) and from 16th November 2020 to 15th February, 2021 (post- period). The primary process measure was ensuring all patients had at least one full set of physical observations at least once a week, or more frequent as deemed clinically appropriate. Secondary measures included ensuring NEWS scores were accurately calculated and improved documentation. This was tracked using a run chart. Improvement activities focused on increased awareness, effective training, key stakeholder buy-in and reviewing trust policy.ResultThe percentage of NEWS documented for all patients at least once a week improved from a mean of 28.7% (31/108) in the 6 weeks prior to intervention, to a mean of 71.4% (125/175) in the following 13 weeks. The minimum required physical observations required to accurately calculate a NEWS improved from 51.6% (16/31) pre-intervention to 95.2% (119/125) post-intervention and NEWS being calculated correctly increased from 80.6% (25/31) to 96% (120/125). Documentation of a reason why physical observations were not taken increased from 2.5% (2/77) to 62% (31/50) pre- and post- intervention respectively.ConclusionThis quality improvement project highlighted that recording of physical observations and use of NEWS was inadequate in this setting, increasing the risk of a delay in identification of acute physical deterioration and thus increase morbidity and mortality. Introducing simple measures and standardising the NEWS assessment process, along with senior nursing and medical oversight, greatly enhanced acquiring and recording of physical observations and NEWS scores. This quality improvement project has shown that practical solutions and staff education can increase efficacy and are hoping further input can consolidate the gains achieved and lead to continued improvements.

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Sleep Disturbance and the Change from White to Red Lighting at Night on Old Age Psychiatry Wards: A Quality Improvement Project

Archives of Psychiatric Nursing ◽

10.1016/j.apnu.2017.12.001 ◽

2018 ◽

Vol 32 (3) ◽

pp. 379-383

Author(s):

David Martin ◽

Anya Hurlbert ◽

David Andrew Cousins

Keyword(s):

Quality Improvement ◽

Sleep Disturbance ◽

Old Age ◽

Quality Improvement Project ◽

Improvement Project ◽

Old Age Psychiatry

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Improving physical health assessment of old age inpatients on the Oaks Acute Admission Ward

BJPsych Open ◽

10.1192/bjo.2021.536 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S200-S200

Author(s):

Dr Karen Aus ◽

Marilia Gougoulaki ◽

Maja Elia ◽

Emily Wall

Keyword(s):

Vitamin D ◽

Physical Health ◽

Old Age ◽

Thyroid Function ◽

Health Assessment ◽

Glycated Haemoglobin ◽

Cognitive Testing ◽

Full Blood Count ◽

Improvement Project ◽

Old Age Psychiatry

AimsOld age psychiatry patients are subject to increased frailty, comorbid load and medication adverse events than equivalent older age populations without psychiatric illness. Timely physical health assessment and monitoring is therefore an essential part of treatment provision. The Oaks is a 20-bed old age acute admissions ward in Barnet, Enfield and Haringey Mental Health Trust. With this quality improvement project, we aimed to deliver high-quality assessment and treatment of physical health for our patients.MethodUsing NICE guidelines as a blueprint, we devised a list of parameters essential to the management of old age inpatients. This included blood tests (full blood count, urea and electrolytes, liver function, thyroid function, cholesterol, lipids, iron studies, vitamin D, glycated haemoglobin, prolactin), investigations (imaging, ECG, physical examination, cognitive testing) and assessments (body mass index [BMI], functional review, mobility, Rockwood Frailty Score). The implementation goal was to ensure all parameters were acted on within 24 hours of admission (or 48 hours for patients admitted on weekends).We initially audited these parameters in patients admitted to the Oaks in October and November 2020 (n = 24). We subsequently collated all parameters into an online spreadsheet, which was distributed to ward medical staff. For each new admission, parameters could be marked as pending or complete. The spreadsheet was reviewed in daily ward handover. Following implementation, we collected data on the parameters for patients admitted in December 2020 and January 2021 (n = 16).ResultPrior to implementation of the spreadsheet, 42.0% of all parameters had been actioned within 24 hours of admission. Following the implementation of the spreadsheet, 86.2% of parameters had been actioned within 24 hours (mean difference 44.2%, 95% CI 13.5% to 64%, p = 0.006).In detail, there were significant increases in timely actioning of magnesium (increased by 61.7%, p < 0.001), cholesterol (61.7%, p < 0.001), glycated haemoglobin (65.8%, p < 0.001), vitamin D (65.8%. p < 0.001), prolactin (61.7% p < 0.001), lipids (61.7%, p < 0.001), thyroid function (51.7%, p < 0.01), iron studies (80.9%, p < 0.001), imaging (42.5%, p = 0.01), frailty scores (60.0%, p < 0.01), BMI measurement (55.9%, p < 0.001), and functional review (42.5%, p = 0.01).ConclusionImplementation of a monitoring spreadsheet with relevant parameters linked to daily ward handover resulted in widespread and significant improvement in the assessment of physical health among old age psychiatry inpatients.

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