An audit: fitness to drive assessment in inpatients of general adult and old age psychiatry

AimsTo determine if fitness to drive is assessed on admission and discharge, if applicable, and for this to be documented during clerking and on discharge notifications.To determine if patients are being educated about the impact of their condition on the ability to safely drive.To ascertain if patients are aware of the duty to inform the DVLA if they for any reason are not fit to drive.BackgroundRisk factors include social, behavior and iatrogenic factors such as social withdrawal, increased likelihood of substance abuse and side effects of anti-psychotic medication.MethodThis trust wide audit involved the random sampling of a total of 71 case notes, 4 case notes per Consultant team in general adult psychiatry and old age psychiatry across Dudley and Walsall sites (total of 3 sites). A data collection tool was developed and included relevant questions regarding fitness to drive. Data were collected between October and December 2019.Result18/49 patients had physical health screening prior to medication initiation.ConclusionAn important aspect of good medical practice is to educate patients about their condition, this includes their fitness to drive as this can be affected both by their diagnosis and medication. It is clear that clinicians also need to be educated about this responsibility to ensure assessment is performed especially on inpatient discharge.

An audit into the monitoring of off-label antipsychotics in primary care

AimsTo ascertain whether patients prescribed second generation antipsychotics for off-label indications are being monitored and screened adequately for physical health side-effects.BackgroundThe prevalence of off-label antipsychotic use has increased significantly over recent decades. Common off-licence uses include dementia, post-traumatic stress disorder, adjunctive treatment for unipolar depression and personality disorders. Recent studies have demonstrated that up to 65% of antipsychotic prescriptions are now off-label. Since the metabolic side-effects of second-generation antipsychotics are well-established, guidelines have emphasised the need for active, routine physical health screening of all individuals taking these drugs. However, there have been few studies or reviews which have specifically investigated screening rates of individuals receiving antipsychotic medications for off-licence indications.MethodAn audit of patients taking second-generation antipsychotics for off-label indications, under the caseload of Neighbourhoods 1, 3 and 4 of Lewisham Assessment & Liaison team, was conducted. After isolating individual patients fulfilling inclusion criteria, patient investigation documents were requested from relevant GP practices. 40 patients were isolated in total, and data were successfully collected in 60% (n = 24). Data were collected via a proforma. This consisted of patient information, indications for antipsychotic use, and each variable to be monitored. The audit standard used was the recommendations of the 12th Maudsley guidelines. Data were then entered into SPSS and analysed.ResultThe most common reasons for off-label antipsychotic prescribing were Emotionally Unstable Personality disorder (42%, n = 10) and depression (29%, n = 7). Findings demonstrated that 54% (n = 13) of patients audited had ‘basic’ blood screening (FBC, U&E, LFTs), however glucose (38%, n = 9), Prolactin (13%, n = 3), and Creatine Kinase (0%, n = 0), and monitoring was less frequent. 0% (n = 0) were completely monitored as per audit standard.ConclusionPrimary care monitoring of off-label antipsychotics is unsatisfactory, with no patients having a complete set of investigations. Reasons for this are unclear at this stage, however based on initial discussion with GP surgeries, may be due to lack of education regarding screening investigations, patients lost between primary and secondary care services, and a lack of clarity regarding responsibility and designated roles. This audit will be expanded to also include patients from Neighbourhood 2 of the Lewisham Assessment & Liaison team. A more detailed investigation will be conducted into the barriers to physical health screening, such that a targeted intervention can be implanted.

Interventions to increase access to or uptake of physical health screening in people with severe mental illness: a realist review

ObjectivesTo identify and evaluate interventions aimed at increasing uptake of, or access to, physical health screening by adults with severe mental illness; to examine why interventions might work.DesignRealist review.SettingPrimary, secondary and tertiary care.ResultsA systematic search identified 1448 studies, of which 22 met the inclusion criteria. Studies were from Australia (n=3), Canada (n=1), Hong Kong (n=1), UK (n=11) and USA (n=6). The studies focused on breast cancer screening, infection preventive services and metabolic syndrome (MS) screening by targeting MS-related risk factors. The interventions could be divided into those focusing on (1) health service delivery changes (12 studies), using quality improvement, randomised controlled trial, cluster randomised feasibility trial, retrospective audit, cross-sectional study and satisfaction survey designs and (2) tests of tools designed to facilitate screening (10 studies) using consecutive case series, quality improvement, retrospective evaluation and pre–post audit study designs. All studies reported improved uptake of screening, or that patients had received screening they would not have had without the intervention. No estimation of overall effect size was possible due to heterogeneity in study design and quality. The following factors may contribute to intervention success: staff and stakeholder involvement in screening, staff flexibility when taking physical measurements (eg, using adapted equipment), strong links with primary care and having a pharmacist on the ward.ConclusionsA range of interventions may be effective, but better quality research is needed to determine any effect size. Researchers should consider how interventions may work when designing and testing them in order to target better the specific needs of this population in the most appropriate setting. Behaviour-change interventions to reduce identified barriers of patient and health professional resistance to screening this population are required. Resource constraints, clarity over professional roles and better coordination with primary care need to be addressed.

Towards holistic dual diagnosis care: physical health screening in a Victorian community-based alcohol and drug treatment service

The poorer health outcomes experienced by people with mental illness have led to new directions in policy for routine physical health screening of service users. By contrast, little attention has been paid to the physical health needs of consumers of alcohol and other drug (AOD) services, despite a similar disparity in physical health outcomes compared with the general population. The majority of people with problematic AOD use have comorbid mental illness, known as a dual diagnosis, likely to exacerbate their vulnerability to poor physical health. With the potential for physical health screening to improve health outcomes for AOD clients, a need exists for systematic identification and management of common health conditions. Within the current health service system, those with a dual diagnosis are more likely to have their physical health surveyed and responded to if they present for treatment in the mental health system. In this study, a physical health screening tool was administered to clients attending a community-based AOD service. The tool was administered by a counsellor during the initial phase of treatment, and referrals to health professionals were made as appropriate. Findings are discussed in terms of prevalence, types of problems identified and subsequent rates of referral. The results corroborate the known link between mental and physical ill health, and contribute to developing evidence that AOD clients present with equally concerning physical ill health to that of mental health clients and should equally be screened for such when presenting for AOD treatment.

Systematic computerised cardiovascular health screening for people with severe mental illness

Aims and methodPeople with severe mental illness (SMI) die relatively young, with mortality rates four times higher than average, mainly from natural causes, including heart disease. We developed a computer-based physical health screening template for use with primary care information systems and evaluated its introduction across a whole city against standards recommended by the National Institute for Health and Care Excellence for physical health and cardiovascular risk screening.ResultsA significant proportion of SMI patients were excluded from the SMI register and only a third of people on the register had an annual physical health check recorded. The screening template was taken up by 75% of GP practices and was associated with better quality screening than usual care, doubling the rate of cardiovascular risk recording and the early detection of high cardiovascular risk.Clinical implicationsA computerised annual physical health screening template can be introduced to clinical information systems to improve quality of care.