Vestibular Physiotherapy Patients May Require Medical Assessment: Results of Vertigo Audit in Hutt Hospital

Introduction: To identify the type of referrals received by vestibular physiotherapists for vertigo and assess whether medical review for these patients would be appropriate. Materials and Methods: We performed a retrospective review of referral forms, vestibular assessment forms, and vertigo clinic letters of patients referred for vertigo or vestibular physiotherapy input between July 1, 2013, to December 31, 2013. Results: We studied 29 patients with a median age of 63 years. A diagnosis was provided in 65.5% of the referrals. Of 14 patients with possible benign paroxysmal positional vertigo (BPPV), Dix-Hallpike had been performed only for 4 patients. Almost half were seen for the medical review in the Vertigo Clinic due to the concerns of possible alternative non-vestibular diagnosis, medication issues, or syncope. Alternative diagnoses identified medically included orthostatic hypotension, stroke, vestibular migraine, medication-induced bradycardia, and phobic postural vertigo. Medication changes in vertigo clinic included treatment for heart failure, migraine, and medication optimization. Conclusion: Medical review is appropriate for some patients referred for vestibular physiotherapy. A medical opinion should be sought by vestibular physiotherapists if there is uncertainty or concerns that the referred patients did not have straightforward vestibular problems, or there were possible alternative diagnoses, concerns with medications, or syncope.

Public perceptions of eye symptoms and hospital services during the first UK lockdown of the COVID-19 pandemic: a web survey study

ObjectiveThis study aimed to explore the British public’s healthcare-seeking beliefs concerning eye symptoms, and assess how the first COVID-19 lockdown influenced these.Methods and analysisAn anonymous web-based survey was disseminated through mailing lists and social media between June and August 2020. The survey sought participants’ views on the severity and urgency of the need for medical review for four ophthalmic and two general medical scenarios on a five-point scale. Participants were asked to answer questions twice: once ignoring the COVID-19 pandemic, and once taking this into account, with additional questions asked to identify factors influencing the decision to seek medical attention and ward admission.ResultsA total of 402 participants completed the survey (mean age 61.6 years, 63.1% female and 87.7% of white ethnicity). Scores for symptom severity and urgency of medical review increased significantly with the severity of the clinical scenario (both p<0.001). However, participants gave significantly lower scores for the urgency of medical attention when accounting for the COVID-19 pandemic (compared with no pandemic) for all scenarios (all p<0.001). Younger age, greater deprivation and non-white ethnicity were correlated with a lower perception of seriousness and urgency of medical attention.ConclusionsDuring the first UK lockdown of the COVID-19 pandemic, reduced urgency of medical review for ocular and systemic pathologies was reported in response to the pandemic, which represents a barrier to healthcare-seeking behaviour. This has the potential to critically delay medical review and timely management, negatively impacting patient outcomes.

P068 Improving patient streaming for Chronic insomnia: Single centre retrospective cohort study

Background Insomnia is a common sleep disorder associated with significant morbidity and psychological distress. Cognitive Behavioural Therapy for insomnia (CBTi) is the gold standard intervention typically delivered by sleep psychologists. High demand has driven an interest in determining the case mix and characteristics of patients referred with insomnia to identify patients that may be suitable for an alternative direct-to-psychology model of care. Methods A retrospective cohort study was performed, including cases referred to the Princess Alexandra Hospital Sleep Centre in 2016 – 2020. Patients were categorised as either “suitable for direct-to-psychology” or “required medical review”. “Direct to psychology” patients were defined as (i) referred for insomnia; or (ii) Insomnia Severity Index score ≥15/28; or (iii) diagnosed with insomnia per ICSD-3 by treating specialist; or (iv) patients referred for sleep psychology. Exclusion criteria were significant sleep disordered breathing (mean SpO2 &lt;85%, Epworth sleepiness scale &gt;16, driving inattention), highly co-morbid patients (neuromuscular weakness, COPD) and diagnosis of hypersomnia. These patients were categorised as “requiring medical review”. The demographic and polysomnographic characteristics of these two groups were then compared. Progress The study protocol is complete, ethical approval obtained (EX/2021QMS/76783), and data extraction has been competed. Analysis underway currently. Intended outcome/impact We aim to establish the characteristics of patients suitable for a direct to psychology pathway. This data will be used for service provision planning, could reduce patient waiting list times, and improve patient care. This model could then be explored for safety and efficacy and form the basis of future service provision work.

525 EVERYONE NEEDS TO POOP: REDUCING CONSTIPATION IN THE ELDERLY INPATIENT POPULATION

Introduction Due to a variety of factors when elderly patients are admitted to hospital they can become constipated. This can impact the entire admission increasing morbidity and mortality for what is a treatable problem. The aim therefore was to assess how prevalent constipation was across the inpatient population; analyse if there were any common themes and implement interventions that might help solve these. Method Data was collected over 15 days across the department (up to 87 patients) using nursing handover sheets to review the date bowels had last been opened. Patients were classified as constipated if they had not opened their bowels for more than 3 days. On two days common themes in the constipated patients were reviewed and analysed. On average 27% of patients were constipated. The majority of these had been deemed ‘Medically Ready for Discharge’. They all had either no or only a reduced range of aperients prescribed. Stakeholders including patients, nursing staff, prescribers and Consultants were surveyed. First cycle intervention was to highlight those constipated at morning Multi-disciplinary Team (MDT) meetings to prompt medical review. Second cycle intervention: an e-prescribing bundle was designed to allow for simple prescription and for nurses to give aperients on an as required basis. A laxative prescribing guide sheet was also written to aid prescribers. Results Aim is to reduce constipation to less than 20% thereby reducing morbidity and mortality in inpatients. Highlighting patients at MDT had little effect partly as it was person dependent. Effect of prescribing bundle yet to be determined but received positively by stakeholders. Prescribing guide received positively by Consultants and junior prescribers. Conclusions Person dependent intervention was ineffective at reducing constipation highlighted by staff sickness due to Covid-19. A prescribing bundle is more system based. If used at admission hopefully will be effective and sustainable.

QI project: Improvement in quality of Seclusion Medical Review

AimsTo establish the improvements in the quality of seclusion medical review after introducing a template to complete the review.BackgroundThe Mental Health Act – Code of Practice outlines the standards of patient care while in seclusion. It also emphasis that supportive engagement/observation schedules should be reviewed in person and continued at the point an episode of seclusion was initiated.Furthermore, NICE also set up standards to monitor side effect profile while prescribing psychotropic for such patients and regular management review. It also gives importance to staff training to ensure these standards.To improve the quality of the seclusion medical review, we completed an audit in July 2019 to ascertain whether medics are following Trust Policy.We identified good results (above 90%) in the following areas:Time of seclusion reviewRecord keepingManagement planGood documentation of risk, mental state examination and physical health.We also noticed that the following areas can be improved:Prescribed Medications. (60%)Medication side effects. (40%)Physical Observations (40%)We used the following audit standards for our audit after our last audit and a template was designed and after discussion with medics incorporated into the existing documentation template.Time of reviewReason and duration for seclusionPsychiatric diagnosisMental State Examination/BehaviourPhysical health (including physical observations)/EnvironmentMedication (prescribed, rapid tranquilisation, side effects, or adverse effects)Risk (to self-DSH or accidental) (risks to others)Plan :(frequency of physical obs./medical review, management, restrictions, exit plan for terminating seclusion, patient's capacity to understand it)MethodWe considered the following aspects:Retrospective data collection from 01.03.2020 to 30.08.2020.Sample selection: random selection of mixture of clinicians on different times and days of the week.Data analysis was carried out by using Microsoft Excel.ResultWe noticed a marked improvement in the quality of seclusion medical review (between 95% and 100%) after introducing a template for it. There were no major concerns identified during the re-audit.ConclusionTo continue to use the template for Seclusion Medical Review which has shown significant improvement in the quality of the reviews which will improve patient care.It also helped us to deliver person centred care and safe practice.To continue teaching and training of doctors.This QIP project motivated nurses to do an audit on nursing seclusion review and made necessary changes.

Quality of seclusion medical review according to trust guidelines

AimsWe accessed whether medics are following Trust Policy while conducting seclusion medical review and identify the strengths in quality of seclusion medical review and identify the areas which need improvements to improve our quality and standards of patient's care and safety and to reduce risks.BackgroundThe Mental Health Act Code of Practice sets an expectation for mental health services for restrictive interventions (use of restraint, seclusion and rapid tranquilisation) by following good standards. Medical reviews provide an opportunity to evaluate and amend seclusion management plan. This clinical audit was undertaken by looking at quality of record keeping about seclusion review by junior doctors, staff grades and consultants at different times (day, night, and weekend).MethodData analysis was carried out by using Microsoft Excel. The audit had Humber Teaching NHSFT approval. We assessed electronic healthcare records. Data collection was carried out or retrospectively in 2019(n = 40) using following parameters: 1)A review of patient's physical and psychiatric health.2)An assessment medication prescribed and adverse effects of medication.3)A review of observations required.4)An assessment of the risk posed by the patient to others.5)An assessment of any risk to the patient from deliberate or accidental self-harm.6)An assessment of need for continuing seclusion, and whether it is possible for seclusion measures to be applied more flexibly, or in a less restrictive manner.7)Time of Seclusion Review: Within first hour after seclusion and then every 4 hours until internal MDT. After MDT twice a day.8)Record Keeping.ResultKey Successes (above 80%)Time of seclusion review (with in first hour or when required)Record keeping (accurate time and place for clinical notes).Plan for continuing need for seclusion.Good documentation of Risk to self and risk to others.Good documentation of mental state examination.Comments on physical health although it can be improved.Key Concerns(Less than 60%):Prescribed Medications.Medication side effects.Physical ObservationsConclusionMedics are missing some important parts in seclusion medical review. We developed a template for seclusion medical review according to trust guidelines which are based on Code of Practice and to incorporate in already existing seclusion review form. We also delivered teaching and training to doctors and also showed junior doctor's an example of documentation. We will re-audit in 1 years’ time to see improvement.

Physical health monitoring in antipsychotic depot clinic

AimsA service evaluation project to look at if annual bloods, ECG, physical examination, and medical review was completed within the last year for patients attending anti-psychotic depot clinic at Bassetlaw mental health services in Nottinghamshire HealthCare NHS Foundation Trust.MethodElectronic notes were examined in October 2020 for 25 patients who attend anti-psychotic depot clinic to ascertain if medical review and physical examination had been completed along with annual bloods and ECG.ResultOut of 25 patients attending depot clinic in 2020 at Bassetlaw Hospital, 21 had all their blood tests done, 1 patient had refused bloods and 2 patients did not have blood tests done. ECG was completed for 3 patients at Bassetlaw hospital and 8 patients had it requested from primary care with 2 patients refusing to have ECG done. For 12 patients there was no evidence of ECG being requested or completed. 8 patients had physical examination completed and rest 17 patients did not have the physical examination completed including due to refusal. Out of 25, only 14 patients had a medical review conducted.ConclusionPatients who attend depot clinic may have an allocated community psychiatric nurse (CPN) or get reviewed by medics in outpatient clinics and would usually have their blood tests, physical health examination and ECGs requested and monitored by them. Patients who do not have any allocated CPN or medic tend to miss out on blood tests and ECG. General Practitioners are expected to complete physical health checks for patients who do not have CPN or regular outpatient review. The results of these investigations may not always be received in depot clinic, hence there is no documentation on electronic RIO system. When these patients disengage from the depot clinic, it is often very difficult to track them. As a follow-up from this service evaluation, all depot clinic patients will be allocated a key worker/CPN. This will ensure that they have a responsible person to facilitate annual checks. This will be reviewed in a years' time to evaluate the effectiveness of this intervention.

Patient-reported outcomes in breast cancer FDA drug labels and review documents

Background Patient-reported outcomes (PROs) can provide valuable information about drug benefit-risk tradeoffs from the patient perspective and are particularly important to patients with breast cancer due to its symptoms and adverse events from breast cancer treatments. The United States Food and Drug Administration (U.S. FDA) has acknowledged PROs as important approval endpoints used in clinical trials of cancer drugs. However, previous studies found that PROs are rarely mentioned in cancer drug labels, a widely used and trusted source of information about drugs. Our objectives were to compare PRO data reported in FDA labeling versus FDA medical review documents for breast cancer drugs approved in the U.S. between 2000 and 2019 to identify possible causes for PRO-data labeling exclusions. Methods We included new molecular entities (NMEs) and biologic license applications (BLAs) initially approved for breast cancer treatment by the FDA between 1/1/2000 and 12/31/2019. Product labeling and FDA medical review documents were collected from the FDA-Approved Drugs database (Drugs@FDA). From these resources, details on PRO measures used in trials, design of trials using PRO measures, PRO-endpoint status, analytical methods, and FDA reviewer comments regarding PRO measurement were extracted. Results Of 633 FDA-approved drugs, 13 were indicated for breast cancer treatment; none of their prescribing information contained information about PROs. However, 11 of 13 (85%) included PRO measures and endpoint information in FDA medical review documents. PRO measures were used in 14 different clinical trials, and FDA reviewers’ comments regarding PRO measurement were related to lack of meaningfulness and clinical significance, lack of content validity, and inadequate analytical methods. Conclusions Despite the importance of PROs to patients with breast cancer, PRO measures were only described in FDA medical review documents of breast cancer drugs, but not in drug product labeling. Therefore, it appears that PRO data are often collected in breast cancer trials, but have not been methodologically acceptable to FDA reviewers. Collaborative efforts between the FDA and industry are warranted to increase the number of breast cancer drug applications with appropriate use of PRO measures and endpoints.