International Journal of Mental Health & PsychiatryISSN: 2471-4372

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Research Article, Int J Ment Health Psychiatry Vol: 2 Issue: 4

Physical Health Monitoring and Care of Inpatients with SMI in a Rehabilitation Setting

Senthil FSS1* and Chesterman LP2
1Specialty Doctor in General Psychiatry, Lincolnshire Partnership NHS trust, Lincoln, United Kingdom
2Consultant Forensic Psychiatrist
Corresponding author : Dr. FS Sophia Senthil
MBBS, MRC psychiatry, Specialty Doctor in General Psychiatry, Lincolnshire Partnership NHS trust,Lincoln, United Kingdom
E-mail:
[email protected]
Received: August 16, 2016 Accepted: September 01, 2016 Published: September 06, 2016
Citation: Senthil FSS, Chesterman LP (2016) Physical Health Monitoring and Care of Inpatients with SMI in a Rehabilitation Setting. Int J Ment Health Psychiatry 2:4.doi:10.4172/2471-4372.1000132

Abstract

Background: Physical health monitoring and care is important to improve the quality of care of in-patients with severe mental illness.

Aim: The aim of the audit project that was undertook in May to June 2015 was to assess whether the standards of the physical health monitoring and care in an inpatient low secure and general adult rehabilitation unit met current recommended clinical guidelines into delivery of appropriate care and interventions for patients with severe mental illness.

Method: The audit chose standards from NICE guidelines 2014 for Schizophrenia and Psychoses in adults and Lester cardio-metabolic resource, quality improvement tool from National audit of schizophrenia project 2014.

Results: The audit found while there was 100% compliance of the standards for monitoring of individual physical health parameter in the inpatient rehabilitation setting there were gaps in the implementation of appropriate of health care promotion initiatives where there were identified concerns.

Conclusion: The audit results recommend changes in inpatient physical health policy in assessment and treatment to include appropriate delivery of heath promotions.

Keywords: Physical health monitoring; Severe mental illness; Physical health parameters; NICE guidelines; Lester cardio metabolic health source; CQUIN goals for inpatients

Keywords

Physical health monitoring; Severe mental illness; Physical health parameters; NICE guidelines; Lester cardio metabolic health source; CQUIN goals for inpatients

Background

Evidence confirms that risk of physical health problems and reduced life expectancy is higher among people with severe mental illness compared to general population. The life expectancy in people with schizophrenia is 20% less than the general population; 60% of the excess mortality caused by the same broad range of conditions that cause deaths in the general population [1]. The poor physical health has been attributed to decreased health awareness, altered lifestyle, fewer opportunities for healthier lifestyle, high rates of smoking and the health risks associated with some psychotropic medications [2].The consistent risk factors are obesity, lack of exercise, quality of physical health care and interventions.
Physical health of patients on long stay psychiatric units is reported to be suboptimal, with high rates of obesity, smoking and significant weight gain following admission to these units [3].
The National institute of guidelines for Schizophrenia and psychoses in adults [4] recommend regular physical health monitoring and advice for patients with severe mental illness.
In secondary care improving physical health care to reduce premature mortality in people with severe mental illness is one of the commissioning for quality and innovation (CQUIN) mental health goals of 2015.

Aim

The aim of the audit was to assess the standards of monitoring of physical health problems in in-patients with severe mental illness at Cambian Ansel clinic, an independent sector low secure and general adult rehabilitation unit measured against standards recommended by the NICE and Royal college of Psychiatrists.

Method

The audit sample included all inpatients (n=24) in the unit during the period May to June 2015. The data were collected from electronic individual case records using a structured collection tool derived from the guidelines of physical health monitoring from Lester UK adaptation of positive cardio-metabolic health source tool [5].
The Royal College of Psychiatrists recommends the use of the Lester UK adaptive version tool kit to improve the physical health monitoring and care of inpatients with severe mental illness.
The tool provides guidance for clinicians relating to assessment and monitoring of cardio metabolic parameters as recommended by NICE guidelines for psychoses and schizophrenia in adults. It supports implementation of physical health CQUIN which aims to improve collaborative and effective physical health care monitoring of patients experiencing severe mental illness focusing on antipsychotic medication.
It recommends as a minimum those prescribed a new antipsychotic at baseline and at lease once after 3 months supervised and monitored for weight, waist circumference, fasting blood sugar, lipid profile, blood pressure, life style status and family and personal history of cardiovascular disease. Weight should be assessed weekly in the first six weeks of taking a new antipsychotic, as rapid early weight gain may predict severe weight gain in the longer term.
It further recommends where there are concerns medication should be considered as a possible causative factor, and if so, whether alternatives could be offered weighing the clinical benefits, patient preference and side effects. It is advised that any side effects as well as the rationale for continuing, changing or stopping medication is clearly recorded and communicated with the patient
• The audit assessed six parameters of physical health which include body mass index (BMI), smoking, life style or levels of activity, blood pressure, fasting blood glucose and lipids profile.
• For each cardio metabolic parameter whether assessment was documented at baseline and annually.
• Patients who were at need for intervention whether they were offered further referral or treatment as appropriate.
• Patients who were on antipsychotics (either when a first agent is prescribed or whenchanged to a different antipsychotic)whether the monitoring was completed at baseline and at three months, including measurement of weight every week for first six weeks.

Results

There was 100% compliance of the documentation of data on all individual physical health parameters on admission and once every twelve months. Body mass index, fasting or random blood glucose, lipid profiles, blood pressure, smoking status and life style such as amount of exercise every week were documented for all patients.
• Of 24 inpatients 17 (70%) had unhealthy BMI with 30% being obese.
• 64% were offered advice on weight management or referred to the life style management program as recommended by the NICE guidelines for obesity.
• 22 (90%) were smokers of those 3 (1%) were initiated on nicotine replacement therapy.
• 5 (2%) patients had high blood pressure, 6 (2.5%) had dyslipidemia and 6 (2.5%) had high blood sugar levels. These patients were offered treatment or referred to the specialist clinic as per the current clinical guidelines (Table 1).
Table 1: Patient interventions..
The audit recorded that all of 24 inpatients were prescribed either an antipsychotic or mood stabilizer. Of those, 14 were changed or initiated on a different antipsychotic medication during their admission. The audit found that there was 100% compliance on the monitoring of physical health parameters at baseline, at 12 weeks and annually but weight was not recorded weekly for first six weeks. Further there was only 80% of documentation of assessment for side effects of the medication but when medication changed for one patient because of the side effects there was documentation of the rational for change.
Antipsychotic medication monitoring
The audit recorded that all of 24 inpatients were prescribed a antipsychotic or mood stabilizer among them fourteen have been changed or initiated on a different antipsychotic medication since their admission. The audit concluded there were 100% on the monitoring of physical health parameters as recommended at baseline, at 12 weeks and annually but weight was not recorded weekly for first six weeks for the patients who have been initiated or changed to a different antipsychotic.

Conclusions

While the clinical practice at Cambian Ansel clinic appear to be in line with current standards for physical health monitoring of patients with severe mental illness. The audit results revealed smoking, overweight and lifestyle factors such as exercise need to be addressed collaboratively and vigorously with individual patients where there’s a concern.
The audit highlights need for range of health promotion strategies include smoking cessation, dietary and physical activity advice and management to be adapted as an integral part of the patient’s assessment and treatment plan.

Recommendations

• To update current admission assessment and discharge summary template to include details of all the parameters in physical health section.
• To develop an inpatient protocol outlining standards in relation to the assessment and treatment of individual physical health parameter.
• To update current physical health review template to include weight monitoring once every weekly for six weeks when patients are initiated on newer antipsychotic medication.
• To repeat the audit in 12 months.

References






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