Audit of the use of the physical health improvement (PHIT) to document physical health examination on an electronic health record at a mental health trust in Manchester

AimsThe audit aimed to identify: The percentage of patients with Initial Physical Examination (IPE), ECG and bloods on admission being completed; If IPE, bloods and ECG result are documented on PHIT; To identify reasons for these interventions not being completed and review if refusal is being appropriately documented.Background“The Five Year Forward View for Mental Health NHS” report highlighted the poor physical health of those with mental health problems when compared to those without. In order to improve the identification and treatment of physical health problems within mental health inpatients, blood test results, physical examination and ECG results should be recorded and reviewed regularly. Within Greater Manchester Mental Health trust, the electronic records system PARIS contains a specific care document to record physical health interventions, known as the PHIT tool. The inpatient unit Park House, had recently changed to the PARIS system prior to this audit and the use of PHIT tool to monitor physical health parameters was considered a priority by the management team.MethodAll admissions to Park House inpatient unit, Manchester in April 2019 were audited. Patients were identified using a report prepared by Business Intelligence. Electronic notes were reviewed for evidence of physical interventions on admission and input of these data to the PHIT tool. Using a retrospective review of electronic notes, relevant information was anonymised and collected to a spreadsheet for further analysis. Inclusion/exclusion criteria was based on local conditions and practical consideration.ResultAn initial sample of 140 was reduced to 89 patients following application of inclusion/exclusion criteria. Of the 89 patients included, 73% had an IPE, 84% of patients had admission blood tests and 74% had an admission ECG. Recording of parameters on the PHIT tool was lower than expected with information recorded in 33–42% of patients. Where patients had refused IPE, ECG or bloods, a valid reason for refusal was documented between 63–91% of patients.ConclusionThe initial audit identified that most patients had IPE, ECG and bloods but this was documented appropriately in less than 42% had this appropriately documented.Interventions to improve this rate were developed, focussing on increasing completion of IPE, ECG and bloods as well as improving documentation. The completion of PHIT document is now monitored regularly. The re-audit to identify the magnitude of improvements from these interventions is currently underway.

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Audit of physical health monitoring on admission to Mill Lodge (CAMHS Inpatient Unit, York)

BJPsych Open ◽

10.1192/bjo.2021.930 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S352-S352

Author(s):

Andreea Steiu ◽

Emma Diggins ◽

Nagulan Thevarajan

Keyword(s):

Mental Health ◽

Young People ◽

Physical Examination ◽

Physical Health ◽

Health Assessment ◽

Health Problems ◽

Inpatient Unit ◽

Junior Doctors ◽

Blood Tests ◽

Service Specification

AimsThis audit aimed to evaluate the standard of initial physical health assessment that young people receive on admission to Mill Lodge.Adherence to recommendation 2.6.3 of the service specification for Tier 4 CAMHS was assessed. Standard 2.6.3 of the service specification for Tier 4 child and adolescent mental health services states that “on admission all young people must have an initial assessment (including a risk assessment) and care-plan completed within 24 hours. Where admission is for day/in-patient care this will include a physical examination.” In line with this standard this audit will evaluate the use of physical examination, baseline blood tests and ECG carried out on young people.BackgroundMental health problems in children and young people are associated with both short- and long-term physical health problems. It is therefore important that they undergo full physical health assessment on admission to a Tier 4 inpatient unit.MethodElectronic records were reviewed for all patients admitted within a 6 months period, between 1st August 2018 and 1st February 2019. Data were collected in March 2019 and entered directly into an excel spread sheet designed for data collection. A total of 23 patients were identified for inclusion in this audit.Simple statistical analysis was carried out using excel.ResultOver 80% of patients who did not refuse had a completed physical examination (85%), blood results recorded (82%) and ECG (84%) within the first 24 hours of their admission. 100% of patients who did not refuse had bloods and ECG checked at some time during their admission, with 90% having a physical examination.For several patients (3 physical examination, 2 bloods, 3 ECG), no reason was documented as to why the procedure or examination did not take place. For 1 patient, blood tests were delayed due to having no blood tubes available.ConclusionTaken into account the result of this audit and bearing in mind the importance of physical examination as part of the admission process, it is important to try and support both regular Mill Lodge staff and on-call junior doctors to follow Standard 2.6.3's guidance around physical examination on admission to hospital. While good results were seen in many areas, the ward is not yet achieving the standard of 100%. A re-audit will take place in twelve months’ time to review recommendation and compliance.

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An audit cycle of physical health monitoring and record keeping of long term in-patients at male and female psychiatric rehabilitation wards using QI approach

BJPsych Open ◽

10.1192/bjo.2021.318 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S107-S108

Author(s):

Hina Tahseen ◽

Peter Bramall

Keyword(s):

Mental Health ◽

Health Policy ◽

Physical Health ◽

Health Monitoring ◽

Health Improvement ◽

High Dose ◽

Health Examination ◽

Health Clinics ◽

Audit Cycle ◽

Rehabilitation Ward

AimsTo complete an audit cycle to evaluate and improve physical health monitoring practice for in-patients by incorporating small QI based projects between baseline audit and re-audit.BackgroundPeople with mental health illness are at increased risk of physical illness, morbidity and mortality compared with general population, mainly due to adverse effects of psychotropic medications, polypharmacy, poor lifestyle choices and socio-economic difficulties. It is important to recognise the need for active health promotion, including formal health checks for psychiatric in-patients.MethodStandards were obtained from NICE Guidelines, RCPsych Report on Physical Health in Mental Health and Cygnet Health Care's Physical health policy.An Audit tool with simple checklist was generated from key areas of Cygnet's physical health policy. Physical Health Files of 24 patients from Female Rehabilitation Ward and 28 patients from Male Rehabilitation Ward were audited in the initial audit cycle.Checklist included physical health examination within 24 hours of admission, Annual Health Improvement Profile (HIP), Monthly physical health reviews (including observations and weights), High Dose Antipsychotics Monitoring, Bloods and ECG records. After the initial baseline audit in Apr., 2019, some of the Quality Improvement (QI) approaches (4 PDSA cycles, driver diagrams, model for improvement) were used before conducting the re-audit in Oct., 2019.ResultThe baseline audit in Apr., 2019 showed 98% compliance with physical assessment within 24 hours of admission, however, there was a significant gap in the monthly physical health reviews (62%), Annual HIP (30%), High-dose antipsychotic monitoring (10%) and ECG/Bloods for antipsychotic monitoring (64%) as per guidelines. 10 Female and 12 male patients had regularly refused obs, weight checks and physical health monitoring.The re-audit showed an overall improvement of 92% in compliance, with increased High-dose antipsychotic monitoring (100%), Monthly physical health clinics (88%), Annual HIP (75%), Annual antipsychotic monitoring/bloods/ECG(95%).ConclusionInterventions, using QI approaches, between baseline and re-audit, included MDT discussion around strategies to improve patients’ engagement with monthly physical health clinics with Specialty doctor, adding to care plan points, timescales and reminders in doctors’ diaries for next bloods and ECGs due, MDT and patients’ health education and a designated support staff for physical obs and maintaining physical health files. This helped in providing a framework to test recommended changes and evolve design based on repeated date collection between cycles.The QI Interventions helped in implementation of a more holistic approach towards assessments due to which, the re-audit demonstrated a sustained improvement in compliance with all aspects of physical health monitoring.

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The employment and mental health impact of integrated improving access to psychological therapies services: Evidence on secondary health care utilization from a pragmatic trial in three English counties

Journal of Health Services Research & Policy ◽

10.1177/1355819621997493 ◽

2021 ◽

pp. 135581962199749

Author(s):

Veronica Toffolutti ◽

David Stuckler ◽

Martin McKee ◽

Ineke Wolsey ◽

Judith Chapman ◽

...

Keyword(s):

Mental Health ◽

Health Care ◽

Health Care Utilization ◽

Physical Health ◽

Health Problems ◽

Care Utilization ◽

Psychological Therapies ◽

Physical Health Problems ◽

Secondary Health Care

Objective Patients with a combination of long-term physical health problems can face barriers in obtaining appropriate treatment for co-existing mental health problems. This paper evaluates the impact of integrating the improving access to psychological therapies services (IAPT) model with services addressing physical health problems. We ask whether such services can reduce secondary health care utilization costs and improve the employment prospects of those so affected. Methods We used a stepped-wedge design of two cohorts of a total of 1,096 patients with depression and/or anxiety and comorbid long-term physical health conditions from three counties within the Thames Valley from March to August 2017. Panels were balanced. Difference-in-difference models were employed in an intention-to-treat analysis. Results The new Integrated-IAPT was associated with a decrease of 6.15 (95% CI: −6.84 to −5.45) [4.83 (95% CI: −5.47 to −4.19]) points in the Patient Health Questionnaire-9 [generalized anxiety disorder-7] and £360 (95% CI: –£559 to –£162) in terms of secondary health care utilization costs per person in the first three months of treatment. The Integrated-IAPT was also associated with an 8.44% (95% CI: 1.93% to 14.9%) increased probability that those who were unemployed transitioned to employment. Conclusions Mental health treatment in care model with Integrated-IAPT seems to have significantly reduced secondary health care utilization costs among persons with long-term physical health conditions and increased their probability of employment.

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253. Mental health improvement predicts acute changes in physical health outcomes following minimally invasive lumbar decompression

The Spine Journal ◽

10.1016/j.spinee.2021.05.366 ◽

2021 ◽

Vol 21 (9) ◽

pp. S130

Author(s):

Conor Lynch ◽

Caroline Jadczak ◽

Shruthi Mohan ◽

Cara Geoghegan ◽

Elliot Cha ◽

...

Keyword(s):

Mental Health ◽

Minimally Invasive ◽

Health Outcomes ◽

Physical Health ◽

Health Improvement ◽

Lumbar Decompression ◽

Physical Health Outcomes ◽

Acute Changes

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Are we meeting local and national guidelines for physical health assessment following admission to the meadows?

BJPsych Open ◽

10.1192/bjo.2021.805 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S304-S305

Author(s):

Yasmin Abbasi ◽

Ruairidh Morgan ◽

Alice O'Docherty

Keyword(s):

Physical Examination ◽

Physical Health ◽

Psychotropic Medication ◽

Health Assessment ◽

Health Examination ◽

Nice Guidelines ◽

Blood Tests ◽

Healthcare Needs ◽

Common Diagnosis ◽

Level Of Consciousness

AimsWe audited practice at the Meadows Inpatient Unit regarding physical health assessment, against standards set by Surrey and Borders Partnership and NICE.BackgroundSABP policy states that within 24 hours of admission to inpatient services, physical health assessment should be offered. It should be completed within 72 hours. Refusal should be documented.These guidelines state that within 2 weeks of admission blood tests should be completed, and for specific individuals an ECG should be performed.NICE guidelines state that “physical healthcare needs” should be discussed with newly admitted patients. NICE guidelines regarding physical health monitoring for individuals with psychosis or schizophrenia recommend that assessment includes “full physical examination to identify physical illness”.NICE suggests use of antipsychotics for individuals with dementia who have severe distress, or are at risk of harming themselves or others. Those with behavioural and psychological symptoms of dementia (BPSD) should therefore be physically assessed to ensure safe use of antipsychotics may be implemented.MethodAll admissions to The Meadows over seven months were audited retrospectively. The clinical notes were accessed from Systm1.Consensus medical opinion was reached that full examination should include: GCS/level of consciousness, cardiorespiratory, abdominal and neurological examinations.Age, gender, diagnosis and prescriptions of psychotropic medication at time of admission were recorded.The sample included 35 patients.Result55% of patients had a diagnosis of dementia.63.8% of patients were prescribed antipsychotics on admission, more than other psychotropic medication. This may reflect that the most common diagnosis was dementia, commonly with associated BPSD.97% of patients had a physical examination completed within 24 hours; most excluded neurological examination. 91% of patients had blood tests completed in two weeks, with the most commonly excluded tests being lipids and glucose. 86% of patients had an ECG in two weeks. In general, documentation of reason for not completing an examination was completed.ConclusionWe found good compliance with recommendations for physical health assessment. Areas for improvement include better assessment of neurology and more thorough blood tests.Recommended physical health examination for new admissions is not outlined in SABP policy. We recommend the following:GCS/level of consciousness, cardiovascular, respiratory, abdominal, and neurological examinations, and baseline observations.ECG should be a requirement of admission. In order to facilitate this, staff need to be trained to perform ECGs.NICE guidelines refer to HBA1c rather than glucose, which should be reflected in SABP policy.

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Annual physical health checks within a forensic inpatient service

BJPsych Open ◽

10.1192/bjo.2021.232 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S72-S72

Author(s):

Michael Cooper ◽

Partha Gangopadhyay

Keyword(s):

Blood Pressure ◽

Physical Examination ◽

Physical Health ◽

Local System ◽

Health Examination ◽

Inclusion Criteria ◽

The Past ◽

Health Checks ◽

Blood Monitoring ◽

Physical Examinations

AimsPatients prescribed antipsychotics are at risk of ill effects to their physical health. Our aims were to assess whether inpatients within a forensic service, on antipsychotic medications, were receiving annual physical health monitoring in accordance with current NICE and SIGN Guidelines. Based on these Guidelines the following objectives were identified: 1: Physical examination, BMI and blood pressure recorded within the past year2: FBC recorded within the past year3: U&Es recorded within past year4: LFTs recorded within the past year5: HbA1C / random glucose / fasting glucose recorded within the past year6: Random lipids / fasting lipids recorded within the past yearMethodInclusion Criteria: Patients admitted for longer than a year currently prescribed an antipsychotic.Data were collected cross-sectionally on 24/7/20 for all inpatients meeting the inclusion criteria. Medical notes and the blood results system were reviewed for results of any annual physical examinations and blood monitoring over the past year.Anonymized data were analysed using Excel.Result13 out of 17 inpatients fulfilled the inclusion criteria. Of these 13 inpatients, 9 (69.2%) were prescribed clozapine, 1 (7.7%) zuclopenthixol, 1 (7.7%) paliperidone and 1 (7.7%) amisulpride.All patients had BMI and blood pressures recorded within the preceding month. Only 1 patient (7.7%) had an annual physical health examination within the past year.Findings for bloods taken within the past year were as follows:12 patients (92.3%) had an FBC recorded9 patients (69.2%) had U + Es recorded9 patients (69.2%) had LFTs recorded11 patients (84.6%) had HBA1c recorded7 patients (53.8%) had lipids recordedConclusionThere is scope for improvement with both annual physical examinations and blood monitoring.All patients had regular BMIs and blood pressure recorded which is largely attributable to nursing staff protocols. Low compliance with full annual physical examination could be explained by there being no local system in place for annual physical health checks and also frequent changes in junior doctor ward cover.Blood monitoring showed variable compliance with established standards. FBC monitoring had the best compliance, likely because the vast majority of our patients are prescribed clozapine, which necessitates minimal monthly FBC monitoring.This audit was presented to the Forensic Team and thereafter it was agreed for a local system to be put in place for annual physical health checks in the summer each year. This will improve oportunities to optimise our patients health. We plan to re-audit at this time.

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Implementation of physical examination pro forma – a complete audit cycle

BJPsych Open ◽

10.1192/bjo.2021.310 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S104-S104

Author(s):

Deshwinder Singh Sidhu ◽

Guy Molyneux

Keyword(s):

Mental Health ◽

Physical Examination ◽

Physical Health ◽

Medical Records ◽

Psychiatric Ward ◽

City Hospital ◽

National Guidelines ◽

Mandatory Requirement ◽

Audit Cycle ◽

Pro Forma

AimsAim of this audit is to achieve and maintain 100% compliance in physical examination on admission.BackgroundConducting physical examination on admission is a mandatory requirement and is monitored by the Mental Health Commission during yearly inspections. A report published by Inspectorate of the Mental Health Commission recently in 2019 identifies a gap in physical health monitoring. We conducted a complete audit cycle in an inner city hospital psychiatric ward to monitor compliance with physical examination on admission.MethodWe based the audit on Judgment Support Framework (JSF) version 5 standards. A retrospective review of all of the patient's medical records was carried out. 13 medical records were reviewed in the first cycle. The results of the first cycle were presented to the Multi Disciplinary Team (MDT) members, including the Non-Consultant Hospital Doctors (NCHD). Physical health policy was reviewed, in consultation with the committee and Clinical Director, a Physical Examination pro-forma (colour coded) was developed and implemented. It was based on the National Guidelines and the JSF ver.5. All members of the MDT and NCHDs were briefed on the pro forma introduced. A repeat audit cycle was conducted of all patients admitted after first audit cycle. Data were collected using a simple audit tool indicating if physical examination was conducted or refused.ResultA total of 22 medical records were audited. 13 medical records in the first cycle indicted only 3 patients had physical examination on admission. However, prior to admission a total of six patients had physical exam in the Emergency Department (ED). Upon implementation of the pro forma, 9 medical records of all patients admitted post-first cycle were audited. A total of 7 patients had physical examination on admission to the ward. Two patients refused physical examination and this was clearly documented. One patient had physical examination completed in ED. All newly admitted patients had physical examination completed or the reason why it wasn't completed documented clearly.ConclusionPhysical examination pro forma was successfully implemented, raising current compliance to a 100%, with a significant improvement from 23% compliance in the first cycle. Existing pro forma is helpful as a reminder to NCHDs. Colour coding of pro forma improves accessibility and distinguishability during the process of admission and auditing. Physical examination pro forma will be audited every 6 monthly.

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The Commission for Health Improvement (CHI) review of North Birmingham Mental Health Trust: What can we hope for from the CHI?

The British Journal of Psychiatry ◽

10.1192/bjp.180.1.6 ◽

2002 ◽

Vol 180 (1) ◽

pp. 6-7 ◽

Cited By ~ 4

Author(s):

Tom Burns

Keyword(s):

Mental Health ◽

Social Services ◽

Health Improvement ◽

Multidisciplinary Teams ◽

Health Advisory ◽

Advisory Service ◽

Mental Health Act ◽

Audit Commission ◽

Health Trust

If you are working in mental health, you get used to being inspected and commented upon – the Mental Health Act Commission, Audit Commission, Social Services Inspectorate, Health Advisory Service (HAS, as was) and public inquiries into patient homicides. Working in multidisciplinary teams has made us used to operating with a variety of perspectives and for most of us this is a necessary and welcome part of the job. Few psychiatrists, however, are so sanguine about the former HAS or about homicide inquiries. The repeated complaint has been their inconsistency. Their quality and tone (potentially as damaging as their findings) have varied to quite an indefensible degree.

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