Bridging the gap between mental & physical healthcare in general hospitals

The Woodland is full of many different Elves; all with their own identities and needs. We have one thing in common though, we are all part of the National Elf Service and as such we look after all of our needs whether they be overlapping or independent. Can we say the same about our National Health Service?

This blog is about the report recently published by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD): Treat as One – Bridging the gap between mental and physical healthcare in general hospitals. The study was proposed by Dr Natasha Robinson, formerly Associate Medical Director and Consultant Anaesthetist at Northampton General Hospital. The full report is 112 pages long, but worth a read for the details.

For those of you who haven’t come across NCEPOD before, their purpose is to assist in maintaining and improving standards of care for adults and children and they do this by very well coordinated national surveys and research. They have completed studies on a wide range of healthcare topics, all of which can be found on their website.

So, Treat as One looks at the fact that high quality mental healthcare offered to patients in general hospitals should be the aim; something I’m sure we would all agree on. The study looked to identify and explore remediable factors in the overall quality of mental health and physical healthcare provided to patients with significant mental health conditions who were admitted to a general hospital.

The study intentionally only looked at patients on an acute inpatient pathway and so mainly looked at the care offered to the patients by the physicians and nursing staff from the general hospital and from staff in the liaison psychiatry service (if present). As people may know, I am a Liaison Psychiatrist and our services (by their very name) expose the gap in the way the services are commissioned and provided, as they describe a service reaching from one place to another. However, we are only part of the solution.

This new report highlights the quality of mental and physical health care for adults with a significant mental disorder who are admitted to a general hospital.

Methods

Patients were identified retrospectively from hospital central records relating to admissions to hospital during the study period: 13th October – 13th November 2014. Patients needed to be aged 18 or older who were admitted to a general hospital for a physical health condition, who also had a significant, known mental health condition and/or who were detained under mental health legislation either at the time of admission or during their hospital stay.

Questionnaires were then completed by general hospital clinicians and liaison psychiatry clinicians in relation to the care received on a sample of this identified group. In addition, an organisational questionnaire was sent to the Medical Director of the Trust/Health Board. Finally, a multidisciplinary peer review group reviewed case notes to grade the overall care each patient received.

Results

11,950 patients from 200 hospitals were identified with a selection of 1,064 cases (5 per hospital) for inclusion. 782 (73.5%) general hospital clinician questionnaires were returned, 346 completed liaison psychiatry clinician questionnaires were also returned. 788 (74%) sets of case notes were returned to NCEPOD and case reviewers assessed 552 cases.

Admission

351/552 (63.6%) were admitted via the Emergency Department (ED)
80 (14.5%) were referred by their GP
57 (10.3%) were transferred from a mental health or another general hospital

Smoking, alcohol and substance use

164/413 (39.7%) were current smokers
104/552 (18.8%) had a history of alcohol misuse
88/552 (15.9%) had a history of substance misuse

Mental health documentation

Case reviewers were of the opinion that the ED notes should have but did not mention the mental health condition in 47/96 patients at triage and 24/47 patients at a subsequent senior review
101/471 (21.4%) lacked adequate mental health history on admission to hospital ward
206/531 (38.9%) had medicines reconciliation at this stage
51/279 (18.3%) noted drug interactions

Mental health risk assessments

161/476 (33.8%) had a risk assessment documented
106/224 (47.3%) adequate risk management plan available to treating team

Assessment and management of mental capacity

66/479 (13.8%) noted during initial assessment

Liaison referrals and reviews

103/458 (22.5%) patients were referred to the liaison psychiatry team after their initial physical assessment
Of those not referred, 30/301 (10.0%) should have been at this time and their care was believed to have been impacted as a result.
256/552 (46.4%) patients received a liaison psychiatry team review during their hospital stay.
There was room for improvement in the following aspects:
- mental health risk assessment (22/125; 17.6%),
- mental capacity assessments (11/53; 20.8%),
- prescription of medications (11/48; 22.9%) and
- advice to nursing staff (20/86; 23.3%).
Liaison psychiatry assessment was substantially delayed in 74/199 (37.2%) patients. This impacted the quality of care in 22/51 patients. The most common reason for the delay in the liaison psychiatry assessment was that “the liaison psychiatry team would not attend until the patient was declared medically fit” (26/74).

Mental health legislation

65/541 (12.0%) patients were detained using mental health legislation
In 15/65 of these patients there were issues in the documentation of the process.

Safety

23 cases security staff were involved
Room for improvement in this process in over 1/5 of these
13/552 required use of physical restraint.

Multidisciplinary discharge planning

209/423 (49.4%) had MDT discharge meetings
Management plans for the patient changed following MDT meetings in 45/107 patients
20/107 (18.7%) liaison psychiatry were involved in the MDT meeting
65/443 (14.7%) were delayed discharges
95/343 (27.9%) discharge summary lacked the mental health diagnosis
90/308 (29.2%) discharge summary lacked the mental health medications
No discharge summaries were copied to the relevant out of hospital psychiatry consultant

Overall quality of care

46.0% (252/548) good
Examples of good clinical practice were noted for 17.9% (93/521) of patients in this study
23.7% (130/548) room for improvement in clinical care
16.1% (88/548) room for improvement in the organisation of care
Room for improvement in both clinical and organisational aspects of care was noted in a further 11.7% (64/548) of the cases reviewed

Good practice in the quality of mental healthcare

40.8% (20/49) with no liaison psychiatry team
46.2% (97/210) with a Non-PLAN accredited liaison psychiatry
59.8% (58/97) with a PLAN accredited liaison psychiatry team
The effect of having a liaison psychiatry team, especially one which was PLAN accredited was positively associated with better quality of care

The results can make for rather grim reading in some areas, but I don’t think any of them are a particular surprise. I think it is useful to have an honest appraisal of where we are at and what we can do to move things forward.

Patients who present with known co-existing mental health conditions should have them documented and assessed along with any other clinical conditions that have brought them to hospital.

Key recommendations

There were 21 recommendations from the report, however they can be summarised into the following areas:

Liaison psychiatry services should be fully integrated into general hospitals
All hospital staff who have interaction with patients, including clinical, clerical and security staff, should receive training in mental health conditions in general hospitals
Patients who present with known co-existing mental health conditions should have them documented and assessed along with any other clinical conditions that have brought them to hospital
And when seen by mental health services (liaison psychiatry) the review should provide clear and concise documented plans in the general hospital notes at the time of assessment
National guidelines should be developed outlining the expectations of general hospital staff in the management of mental health conditions, such as the point at which a referral to liaison psychiatry should be made and what triggers the referral
Record sharing (paper or electronic) between mental health hospitals and general hospitals needs to be improved.

There is a very useful self-assessment checklist within the documents that you can use to see where you are within your hospital – why not do it today?

You can follow #TreatAsOne on Twitter to read more about the discussion around the launch of this report.

The Mental Elf

Bridging the gap between mental and physical healthcare in general hospitals #TreatAsOne

Methods