scholarly journals High-dose antipsychotics: addressing patients' resistance to physical health monitoring

2015 ◽  
Vol 21 (2) ◽  
pp. 88-97
Author(s):  
Paula Marie Murphy ◽  
Andrew Iles ◽  
Suja Sreedharan
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Physical Health ◽  
Health Monitoring ◽  
Flow Diagram ◽  
High Dose ◽  
Strict Adherence ◽  
Legal Implications ◽  
Case Vignettes

SummaryHigh-dose antipsychotics are sometimes used in clinical practice when patients fail to respond to treatment at standard doses. Owing to the potential physical complications associated with this, strict adherence to physical health monitoring is essential. Challenges arise for clinicians when patients refuse to cooperate with this monitoring. We discuss different interventions to overcome this problem, many of which are coercive in nature, and consider their professional, ethical and legal implications. We include a flow diagram to assist clinicians in their documentation and decision-making in these circumstances as well as case vignettes showing when monitoring under restraint is and is not justifiable.

scholarly journals Physical health monitoring after rapid tranquillisation: clinical practice in UK mental health services

2019 ◽  
Vol 9 ◽  
pp. 204512531989583 ◽  
Author(s):  
Carol Paton ◽  
Clive E. Adams ◽  
Stephen Dye ◽  
Oriana Delgado ◽  
Chike Okocha ◽  
...  
Keyword(s):  
Mental Health ◽  
Clinical Practice ◽  
Mental Health Services ◽  
Health Services ◽  
Physical Health ◽  
Health Monitoring ◽  
High Dose ◽  
Behavioural Disturbance ◽  
Falling Asleep ◽  
Recommended Level

Background: We aimed to assess the quality of physical health monitoring following rapid tranquillisation (RT) for acute behavioural disturbance in UK mental health services. Methods: The Prescribing Observatory for Mental Health (POMH-UK) initiated an audit-based quality improvement programme addressing the pharmacological treatment of acute behavioural disturbance in mental health services in the UK. Results: Data relating to a total of 2454 episodes of RT were submitted by 66 mental health services. Post-RT physical health monitoring did not reach the minimum recommended level in 1933 (79%) episodes. Patients were more likely to be monitored (OR 1.78, 95% CI 1.39–2.29, p < 0.001) if there was actual or threatened self-harm, and less likely to be monitored if the episode occurred in the evening (OR 0.79, 95% CI 0.62–1.0, p < 0.001) or overnight (OR 0.57, 95% CI 0.44–0.75, p < 0.001). Risk factors such as recent substance use, RT resulting in the patient falling asleep, or receiving high-dose antipsychotic medication on the day of the episode, did not predict whether or not the minimum recommended level of post-RT monitoring was documented. Conclusions: The minimum recommended level of physical health monitoring was reported for only one in five RT episodes. The findings also suggest a lack of targeting of at-risk patients for post-RT monitoring. Possible explanations are that clinicians consider such monitoring too demanding to implement in routine clinical practice or not appropriate in every clinical situation. For example, physical health measures requiring direct contact with a patient may be difficult to undertake, or counter-productive, if RT has failed. These findings prompt speculation that post-RT monitoring practice would be improved by the implementation of guidance that integrated and refined the currently separate systems for undertaking and recording physical health observations post-RT, determining nursing observation schedules and detecting acute deterioration in physical health. The effectiveness and clinical utility of such an approach would be worth testing.

An introduction to advance care planning: practice at the frontline

2018 ◽  
Author(s):  
Anjali Mullick ◽  
Jonathan Martin
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Communication Skills ◽  
Advance Care Planning ◽  
Use Case ◽  
Care Planning ◽  
Practical Advice ◽  
Future Care ◽  
Case Vignettes ◽  
Advance Care

Advance care planning (ACP) is a process of formal decision-making that aims to help patients establish decisions about future care that take effect when they lose capacity. In our experience, guidance for clinicians rarely provides detailed practical advice on how it can be successfully carried out in a clinical setting. This may create a barrier to ACP discussions which might otherwise benefit patients, families and professionals. The focus of this paper is on sharing our experience of ACP as clinicians and offering practical tips on elements of ACP, such as triggers for conversations, communication skills, and highlighting the formal aspects that are potentially involved. We use case vignettes to better illustrate the application of ACP in clinical practice.

scholarly journals High dose antipsychotic treatment monitoring audit

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S348-S348
Author(s):  
Jake Scott ◽  
Jose Belda
Keyword(s):  
Side Effects ◽  
Physical Health ◽  
Health Monitoring ◽  
Clinical Benefit ◽  
Health Assessment ◽  
Antipsychotic Treatment ◽  
High Dose ◽  
Health Checks ◽  
Increased Risk ◽  
Multi Disciplinary Team

AimsTo quantify how many patients were prescribed high dose antipsychotic treatment (HDAT) and establish whether guidance for monitoring HDAT was being followed in an Assertive Outreach Team.BackgroundSevere mental health disorders are associated with significant premature mortality, predominantly due to physical health conditions. Antipsychotic medications are associated with side effects, including metabolic syndrome and QT prolongation, which increase the risk of serious physical illness. HDAT is defined as when the total dose of antipsychotics prescribed exceeds 100% of the maximum BNF dose, if each dose is expressed a percentage of its maximum dose. There is limited evidence of clinical benefit with HDAT but an increased risk of side effects. Patients prescribed HDAT should therefore be monitored for side effects and clinical benefit. Sussex Partnership NHS Foundation Trust developed a form specifically for this purpose, to be completed in addition to a physical health assessment.MethodAll patients on caseload were audited using the electronic notes. Current inpatients were excluded, as inpatient HDAT monitoring forms are attached to paper drug charts and therefore were not available for review.ResultA total of 61 patients were audited. Nine were excluded due to being inpatients. 16 were on community treatment orders and 26 were prescribed a long-acting antipsychotic injection. 10 were prescribed clozapine. The median number of medications prescribed was one. Four patients were prescribed HDAT ranging from 117-150% of the maximum BNF dose. Of these four, one had a HDAT form but this was out of date. 39 of 52 (75%) patients audited had had a physical health assessment in the past 12 months. Two of the 13 missing a physical health assessment were on HDAT.ConclusionPhysical health monitoring should be carried out for all patients on antipsychotics, but is particularly important for patients on HDAT. This audit identified a problem in both general physical health checks and HDAT monitoring. On discussion with the multi-disciplinary team a number of barriers to appropriate physical health monitoring were identified. There was a lack of awareness within the multi-disciplinary team that patients were receiving HDAT and regarding the implications for side effects. A reliable system to highlight the need for physical health checks was also missing and the team did not have sufficient equipment to perform the necessary checks. Identifying these barriers should enable improvements in physical health and HDAT monitoring which can be re-audited.

scholarly journals An audit during COVID-19: monitoring of CMHT-patient contact and physical health assessments in a rural Welsh setting

BJPsych Open ◽  
2021 ◽  
Vol 7 (S1) ◽  
pp. S85-S85
Author(s):  
Shreya Jauhari ◽  
Fran Foster
Keyword(s):  
Clinical Practice ◽  
Physical Health ◽  
Health Monitoring ◽  
Primary Objective ◽  
Patient Contact ◽  
Current Clinical Practice ◽  
Nice Guidelines ◽  
Face To Face ◽  
Health Checks ◽  
Secondary Objective

AimsThe enforcement of lockdowns and restrictions on non-essential contact have changed Community Mental Health Team (CMHT) practice. Therefore, this audit carried out its 4th cycle of physical health monitoring for patients on antipsychotics with severe mental illness (SMI) under the CMHT during the period of the COVID-19 pandemic in order to observe its impact on physical health monitoring. In addition, with the increased use of telepsychiatry substituting routine face-to-face appointments during the pandemic, this audit also reviews the effect of lockdown on maintenance of contact between CMHT and people with SMI.Primary Objective: to compare the current clinical practice with the standards derived from NICE guidelines which include parameters like weight, body-mass index, blood pressure, ECG and blood tests, then compare with the previous three audit cycles, which collected identical data.Secondary Objective: to monitor amount of contact between healthcare staff and people with SMI on antipsychotics during the three months of Welsh lockdown and compare current clinical practice with the clinical practice achieved in the identical period in 2019.MethodMethod for Primary Objective: Clinical practice on physical health checks were split into 10 standards derived from the NICE guidelines (NICEQS80, Quality Standard 6). Data collection surrounding physical health checks of patients on antipsychotics from 26th June 2019 to 26th June 2020 were collected and compared with the previous three audit cycles, which collected identical data.Method for Secondary Objective: Retrospective data surrounding amount and type of contact between CMHT and people with SMI was collected from 26th March 2020 to 26th June 2020, a period of enforced lockdown in Wales, and compared with the identical period in 2019.ResultThe audit iterates trends over the last 4 cycles (2016/2017, 2017/2018, 2018/2019 and 2019/2020). The current audit cycle increased in 2/10 standards and decreased in 8/10 standards, compared with the average compliance in the 3 previous audit cycles. Out of the 10 derived standards, certain standards fared worse than others.There was a 79% increase in the number of staff-patient contact during the lockdown period. The majority of the contact in 2019 was face-to-face (84.31%), however, as expected, in 2020 the majority of the contact was non face-to-face (61.75%). However, this was accompanied by an 85.79%ConclusionDespite being in a pandemic, patient contact was maintained. Physical health monitoring has decreased in the majority of standards, therefore greater attention is needed to address this. Recommendations are provided in the audit.

scholarly journals Hyperprolactinaemia: A guide for psychiatrists

2017 ◽  
Vol 23 (3) ◽  
pp. 158-166 ◽  
Author(s):  
Ovais Wadoo ◽  
Aadil Jan Shah ◽  
Rachael Hall ◽  
Yaasir Mamoojee
Keyword(s):  
Decision Making ◽  
Clinical Practice ◽  
Adverse Effects ◽  
Elevated Serum ◽  
Learning Objectives ◽  
Flow Diagram ◽  
Serum Prolactin ◽  
Elevate Serum ◽  
Adverse Health Outcomes ◽  
And Function

SummaryMedications prescribed by psychiatrists are known to elevate serum prolactin levels, but hyperprolactinaemia remains underrecognised, as the adverse effects of an elevated prolactin are mostly not visible. Hyperprolactinaemia can lead to adverse health outcomes, so clinicians need not only to be alert to its symptoms, but to manage the consequences as well. In this article we provide a brief overview of prolactin physiology, regulation and function. We list various factors that can lead to elevated serum prolactin. We discuss the interpretation of blood results and the management of psychotropic-induced hyperprolactinaemia. We include a flow diagram to assist clinicians in decision-making in the clinical management of hyperprolactinaemia.Learning Objectives• Understand prolactin physiology and regulation• Understand hyperprolactinaemia and its causes• Know the consequences of hyperprolactinaemia and appropriately manage it in clinical practice

scholarly journals 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 ◽  
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.

How many CCS- and ACS-patients might reach the newly recommended LDL-C-target <55mg/dl in clinical practice if guidelines were applied – an estimate from the DYSIS II study population

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A.K Gitt ◽  
M Horack ◽  
D Lautsch ◽  
R Zahn ◽  
J Ferrieres
Keyword(s):  
Clinical Practice ◽  
Real Life ◽  
Statin Treatment ◽  
Lipid Lowering ◽  
High Risk Population ◽  
High Dose ◽  
Funding Source ◽  
Pcsk9 Inhibitors ◽  
Target Values ◽  
Coronary Syndromes

Abstract Background The 2019 ESC guidelines for the management of dyslipidemia even further lowered the LDL-C-target values for the very high-risk population from &lt;70mg/dl to &lt;55mg/dl. Population based studies already had shown that the previous target was difficult to reach. It is yet unclear how many patients in clinical practice might be treated to the new target. Methods The Dyslipidemia International Study (DYSIS II) prospectively collected data of patients with chronic coronary syndromes (CCS) and acute coronary syndromes (ACS) (all on statins) in 18 countries in Europe, the Middle East, South- and East Asia to document patient characteristics, medication and a current lipid profile from 2012 to 2014 under real life conditions in physicians' offices and hospitals. We took these real-life lipid profiles and data on the kind/dose of used statins to estimate how treatment escalation such as changing statin treatment to a high dose (atorvastatin ≥40mg / rosuvastatin≥20mg), adding ezetimibe and adding a PCSK9-inhibitor might help to bring LDL-C-levels to the recommended &lt;55mg/dl target. Results A total of 7,865 patients were enrolled into DYSIS II, 6,794 had CCS and 1,071 ACS. Under the documented statin treatment in DYSIS only 12.7% of patients reached an LDL-C &lt;55mg/dl. Putting all patients on high dose statins in combination with ezetimibe, 64.1% would reach the target. If PCSK9-inhibitors would be used in the remaining patients not at goal a total of 94.0% would match the goal. Conclusion Our analysis indicates that in real life practice the use available lipid-lowering medications would substantially increase the percentage of CCS- and ACS-patients reaching the newly recommended 2019 ESC guideline LDL-C-target of &lt;55 mg/dl from less than 20% to more than 90% of the population. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): MSD

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