Background: Due to the burden and negative impacts of psychotic disorders, treatment alone is ins... more Background: Due to the burden and negative impacts of psychotic disorders, treatment alone is insufficient to reduce the gap in psychosis care thereby highlighting the need for greater investment in prevention strategies which are targeted towards an entire population to detect risk factors early and prevent adverse health outcomes at scale. This work evaluates the technical feasibility of implementing electronic audit and feedback (eA&F) to support population health management in mental health care by facilitating the visualisation of clinical health records to provide relevant summaries for eA&F. Methods: A Participatory Design approach was adopted as an integral framework throughout the design and development of an eA&F platform. The eA&F platform, VIEWER, was evaluated for its technical feasibility. The feasibility testing of the platform was carried out with clinical teams in the context of three different clinical use cases to support eA&F for managing the psychosis patient po...
Background Anticholinergic medications are drugs that block cholinergic transmission, either as t... more Background Anticholinergic medications are drugs that block cholinergic transmission, either as their primary therapeutic action or as a secondary effect. Patients with dementia may be particularly sensitive to the central effects of anticholinergic drugs. Anticholinergics also antagonise the effects of the main dementia treatment, cholinesterase inhibitors. Our study aimed to investigate anticholinergic prescribing for dementia patients in UK acute hospitals before and after admission. Methods We included 352 patients with dementia from 17 UK hospital sites in 2019. They were all inpatients on surgical, medical or Care of the Elderly wards. Information about each patient’s medications were collected using a standardised form, and the anticholinergic drug burden of each patient was calculated with an evidence-based online calculator. Wilcoxon’s rank test was used to look at the correlation between two subgroups upon admission and discharge. Results On admission to hospital, 37.8% of...
Variation in healthcare processes is widespread in mental health care and can lead to inefficient... more Variation in healthcare processes is widespread in mental health care and can lead to inefficient processes and unnecessarily long inpatient stays. This study aimed to identify sources of variation and implement a huddle intervention to increase system efficiency on a psychiatric inpatient ward in London. Using a Lean Six Sigma approach, areas for improvement on the authors' ward and processes working well on other wards were identified through process mapping and stakeholder interviews. The huddle intervention was implemented, then evaluated and improved through four Plan Do Study Act cycles based on feedback from staff and green-to-red methodology. Inconsistencies in multidisciplinary team communication was identified as the most prominent area of concern and inefficiency. The huddles were found to improve staff communication and increase ward activity. Concerns regarding the huddles' duration and focus on tasks were identified and addressed. Huddles are a useful means of ...
Background Electronic Audit and Feedback (eA&F) interventions aim to improve patient care by pres... more Background Electronic Audit and Feedback (eA&F) interventions aim to improve patient care by presenting clinicians with summarised information of clinical performance over time. We created an eA&F intervention to assist clinicians in the management of psychosis in the community. Methods The eA&F intervention was created collaborative between informaticians, computer scientists and clinicians and summarises population-level data on service useage, medications, psychological interventions and physical health on an interactive platform. We evaluated its usability usingt he systems usability scale (SUS), outcome data on physical health monitoring (Body Mass Index and Blood Pressure) using difference-in-difference analysis and interviewed clinicians, interpreting the data using thematic analysis. Results The system showed good usability (72 on SUS), although did not lead to improved recording of physical health or improved patient outcomes during the course of the study. Thematic analysi...
Aims and methodWe assessed venous thromboembolism (VTE) risk, barriers to prescribing VTE prophyl... more Aims and methodWe assessed venous thromboembolism (VTE) risk, barriers to prescribing VTE prophylaxis and completion of VTE risk assessment in psychiatric in-patients. This was a cross-sectional study conducted across three centres. We used the UK Department of Health VTE risk assessment tool which had been adapted for psychiatric patients.ResultsOf the 470 patients assessed, 144 (30.6%) were at increased risk of VTE. Patients on old age wards were more likely to be at increased risk than those on general adult wards (odds ratio = 2.26, 95% CI 1.51–3.37). Of those at higher risk of VTE, auditors recorded concerns about prescribing prophylaxis in 70 patients (14.9%). Only 20 (4.3%) patients had a completed risk assessment.Clinical implicationsMental health in-patients are likely to be at increased risk of VTE. VTE risk assessment is not currently embedded in psychiatric in-patient care. There is a need for guidance specific to this population.
Aims and methodMedication with anticholinergic action is associated with potentially serious adve... more Aims and methodMedication with anticholinergic action is associated with potentially serious adverse effects in older people. We present an evaluation of a novel anticholinergic burden scale introduced into routine practice in older adult services in the South London and Maudsley (SLaM) NHS Foundation Trust. Our aim was to assess whether this tool improved the accurate identification of anticholinergic medication and guided safer prescribing in cognitively vulnerable older people.ResultsThe introduction of the anticholinergic effect on cognition (AEC) tool into clinical practice led to an increase in the identification and reporting to general practitioners of anticholinergic medication from 11 to 85% of cases (P = 0.0015).Clinical implicationsApplication of the AEC tool led to improved detection of anticholinergic medication and advice to primary care on when a medication review is necessary. This is an important step towards improving the safety of prescribing in this patient group.
Polypharmacy has been linked to higher risks of hospitalisation and death in community samples. I... more Polypharmacy has been linked to higher risks of hospitalisation and death in community samples. It is commonly present in people with dementia but these risks have rarely been studied in this population. We aimed to investigate associations between polypharmacy and emergency department attendance, any and unplanned hospitalisation, and mortality in patients with dementia. Using a large mental health care database in South London, linked to hospitalisation and mortality data, we assembled a retrospective cohort of patients diagnosed with dementia. We ascertained number of medications prescribed at the time of dementia diagnosis and conducted multivariate Cox regression analyses. Of 4668 patients with dementia identified, 1128 (24.2%) were prescribed 4-6 medications and 739 (15.8%) ≥7 medications. Compared to those using 0-3 medications, patients with dementia using 4-6 or ≥7 agents had an increased risk of emergency department attendance (hazard ratio 1.20/1.35), hospitalisation (haz...
IntroductionThe UK has longstanding problems with psychiatry recruitment. Various initiatives aim... more IntroductionThe UK has longstanding problems with psychiatry recruitment. Various initiatives aim to improve psychiatry's image among medical students, but involve research and none are student-led. Providing opportunities to take part in psychiatry research and quality improvement could increase the number of students who choose to enter the speciality.ObjectivesWe have developed the student psychiatry audit and research collaborative (SPARC), a student-led initiative for nationwide collaboration in high-quality research and audits.MethodsOur model is inspired by the success of the UK Student audit and research in surgery (STARSurg). Area teams, located in medical schools, take part in multi-centre projects. The area teams consist of medical students, who have the main responsibility for collecting data; a junior doctor, to supervise the process; and a consultant, with overall responsibility for patient care. The data collected centrally and analysed by a team of medical studen...
Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, Dec 17, 2017
IntroductionAnticholinergic medications block cholinergic transmission. The central effects of an... more IntroductionAnticholinergic medications block cholinergic transmission. The central effects of anticholinergic drugs can be particularly marked in patients with dementia. Furthermore, anticholinergics antagonise the effects of cholinesterase inhibitors, the main dementia treatment.ObjectivesThis study aimed to assess anticholinergic drug prescribing among dementia patients before and after admission to UK acute hospitals.Methods352 patients with dementia were included from 17 hospitals in the UK. All were admitted to surgical, medical or Care of the Elderly wards in 2019. Information about patients’ prescriptions were recorded on a standardised form. An evidence-based online calculator was used to calculate the anticholinergic drug burden of each patient. The correlation between two subgroups upon admission and discharge was tested with Spearman’s Rank Correlation.ResultsTable 1 shows patient demographics. On admission, 37.8% of patients had an anticholinergic burden score ≥1 and 5....
Background: Due to the burden and negative impacts of psychotic disorders, treatment alone is ins... more Background: Due to the burden and negative impacts of psychotic disorders, treatment alone is insufficient to reduce the gap in psychosis care thereby highlighting the need for greater investment in prevention strategies which are targeted towards an entire population to detect risk factors early and prevent adverse health outcomes at scale. This work evaluates the technical feasibility of implementing electronic audit and feedback (eA&F) to support population health management in mental health care by facilitating the visualisation of clinical health records to provide relevant summaries for eA&F. Methods: A Participatory Design approach was adopted as an integral framework throughout the design and development of an eA&F platform. The eA&F platform, VIEWER, was evaluated for its technical feasibility. The feasibility testing of the platform was carried out with clinical teams in the context of three different clinical use cases to support eA&F for managing the psychosis patient po...
Background Anticholinergic medications are drugs that block cholinergic transmission, either as t... more Background Anticholinergic medications are drugs that block cholinergic transmission, either as their primary therapeutic action or as a secondary effect. Patients with dementia may be particularly sensitive to the central effects of anticholinergic drugs. Anticholinergics also antagonise the effects of the main dementia treatment, cholinesterase inhibitors. Our study aimed to investigate anticholinergic prescribing for dementia patients in UK acute hospitals before and after admission. Methods We included 352 patients with dementia from 17 UK hospital sites in 2019. They were all inpatients on surgical, medical or Care of the Elderly wards. Information about each patient’s medications were collected using a standardised form, and the anticholinergic drug burden of each patient was calculated with an evidence-based online calculator. Wilcoxon’s rank test was used to look at the correlation between two subgroups upon admission and discharge. Results On admission to hospital, 37.8% of...
Variation in healthcare processes is widespread in mental health care and can lead to inefficient... more Variation in healthcare processes is widespread in mental health care and can lead to inefficient processes and unnecessarily long inpatient stays. This study aimed to identify sources of variation and implement a huddle intervention to increase system efficiency on a psychiatric inpatient ward in London. Using a Lean Six Sigma approach, areas for improvement on the authors' ward and processes working well on other wards were identified through process mapping and stakeholder interviews. The huddle intervention was implemented, then evaluated and improved through four Plan Do Study Act cycles based on feedback from staff and green-to-red methodology. Inconsistencies in multidisciplinary team communication was identified as the most prominent area of concern and inefficiency. The huddles were found to improve staff communication and increase ward activity. Concerns regarding the huddles' duration and focus on tasks were identified and addressed. Huddles are a useful means of ...
Background Electronic Audit and Feedback (eA&F) interventions aim to improve patient care by pres... more Background Electronic Audit and Feedback (eA&F) interventions aim to improve patient care by presenting clinicians with summarised information of clinical performance over time. We created an eA&F intervention to assist clinicians in the management of psychosis in the community. Methods The eA&F intervention was created collaborative between informaticians, computer scientists and clinicians and summarises population-level data on service useage, medications, psychological interventions and physical health on an interactive platform. We evaluated its usability usingt he systems usability scale (SUS), outcome data on physical health monitoring (Body Mass Index and Blood Pressure) using difference-in-difference analysis and interviewed clinicians, interpreting the data using thematic analysis. Results The system showed good usability (72 on SUS), although did not lead to improved recording of physical health or improved patient outcomes during the course of the study. Thematic analysi...
Aims and methodWe assessed venous thromboembolism (VTE) risk, barriers to prescribing VTE prophyl... more Aims and methodWe assessed venous thromboembolism (VTE) risk, barriers to prescribing VTE prophylaxis and completion of VTE risk assessment in psychiatric in-patients. This was a cross-sectional study conducted across three centres. We used the UK Department of Health VTE risk assessment tool which had been adapted for psychiatric patients.ResultsOf the 470 patients assessed, 144 (30.6%) were at increased risk of VTE. Patients on old age wards were more likely to be at increased risk than those on general adult wards (odds ratio = 2.26, 95% CI 1.51–3.37). Of those at higher risk of VTE, auditors recorded concerns about prescribing prophylaxis in 70 patients (14.9%). Only 20 (4.3%) patients had a completed risk assessment.Clinical implicationsMental health in-patients are likely to be at increased risk of VTE. VTE risk assessment is not currently embedded in psychiatric in-patient care. There is a need for guidance specific to this population.
Aims and methodMedication with anticholinergic action is associated with potentially serious adve... more Aims and methodMedication with anticholinergic action is associated with potentially serious adverse effects in older people. We present an evaluation of a novel anticholinergic burden scale introduced into routine practice in older adult services in the South London and Maudsley (SLaM) NHS Foundation Trust. Our aim was to assess whether this tool improved the accurate identification of anticholinergic medication and guided safer prescribing in cognitively vulnerable older people.ResultsThe introduction of the anticholinergic effect on cognition (AEC) tool into clinical practice led to an increase in the identification and reporting to general practitioners of anticholinergic medication from 11 to 85% of cases (P = 0.0015).Clinical implicationsApplication of the AEC tool led to improved detection of anticholinergic medication and advice to primary care on when a medication review is necessary. This is an important step towards improving the safety of prescribing in this patient group.
Polypharmacy has been linked to higher risks of hospitalisation and death in community samples. I... more Polypharmacy has been linked to higher risks of hospitalisation and death in community samples. It is commonly present in people with dementia but these risks have rarely been studied in this population. We aimed to investigate associations between polypharmacy and emergency department attendance, any and unplanned hospitalisation, and mortality in patients with dementia. Using a large mental health care database in South London, linked to hospitalisation and mortality data, we assembled a retrospective cohort of patients diagnosed with dementia. We ascertained number of medications prescribed at the time of dementia diagnosis and conducted multivariate Cox regression analyses. Of 4668 patients with dementia identified, 1128 (24.2%) were prescribed 4-6 medications and 739 (15.8%) ≥7 medications. Compared to those using 0-3 medications, patients with dementia using 4-6 or ≥7 agents had an increased risk of emergency department attendance (hazard ratio 1.20/1.35), hospitalisation (haz...
IntroductionThe UK has longstanding problems with psychiatry recruitment. Various initiatives aim... more IntroductionThe UK has longstanding problems with psychiatry recruitment. Various initiatives aim to improve psychiatry's image among medical students, but involve research and none are student-led. Providing opportunities to take part in psychiatry research and quality improvement could increase the number of students who choose to enter the speciality.ObjectivesWe have developed the student psychiatry audit and research collaborative (SPARC), a student-led initiative for nationwide collaboration in high-quality research and audits.MethodsOur model is inspired by the success of the UK Student audit and research in surgery (STARSurg). Area teams, located in medical schools, take part in multi-centre projects. The area teams consist of medical students, who have the main responsibility for collecting data; a junior doctor, to supervise the process; and a consultant, with overall responsibility for patient care. The data collected centrally and analysed by a team of medical studen...
Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, Dec 17, 2017
IntroductionAnticholinergic medications block cholinergic transmission. The central effects of an... more IntroductionAnticholinergic medications block cholinergic transmission. The central effects of anticholinergic drugs can be particularly marked in patients with dementia. Furthermore, anticholinergics antagonise the effects of cholinesterase inhibitors, the main dementia treatment.ObjectivesThis study aimed to assess anticholinergic drug prescribing among dementia patients before and after admission to UK acute hospitals.Methods352 patients with dementia were included from 17 hospitals in the UK. All were admitted to surgical, medical or Care of the Elderly wards in 2019. Information about patients’ prescriptions were recorded on a standardised form. An evidence-based online calculator was used to calculate the anticholinergic drug burden of each patient. The correlation between two subgroups upon admission and discharge was tested with Spearman’s Rank Correlation.ResultsTable 1 shows patient demographics. On admission, 37.8% of patients had an anticholinergic burden score ≥1 and 5....
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