Recognising and Responding to Psychiatric Deterioration

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Recognising and Responding to Psychiatric
Deterioration

• A/Prof Richard Newton
• Medical Director, Mental Health,
• Austin Health, Victoria.
• Melbourne University
• Monash University

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Death of a Young Man with Schizophrenia

• 18 yo, FEP, community case managed with moderate
  response to oral Olanzapine, but marked weight
  gain,
• 2 years later reduced adherence with medication
  recognised but not acted on
• Slow deterioration in mental state two months
  later not recognised, - withdrawal, low grade
  persecutory beliefs, worsening of auditory
  hallucinations
• Six months later further escalating aggression
  and dangerous driving whilst intoxicated
  incorrectly attributed to personality issues
• Family increasingly contacting case manager with
  concerns about mental state and risk but feel
  unheard
• Service response is to provide phone number of
  drug detox service
• Three months later patient admitted floridly
  psychotic, intoxicated with amphetamines,
• Aggressive to police prior to admission and
  secluded for three days on admission
• detoxed and the same oral antipsychotics
  reinitiated, response partial returned home after
  three weeks.
• Drug abuse continues, ceases medication, family
  cant cope
• 2 years later loss of home, move into poor
  quality rooming house, ongoing contact with
  service however
• Gradual relapse of psychosis secondary to non
  compliance
• Case manager documents worsening hopelessness and
  demoralisation, ongoing substance use, grief and
  anger with family, aggression risk assessed but
  no suicide risk assessment.
• Found hanging in his bathroom a week later 5
  years after first diagnosis. In continuous
  contact with service throughout this
  deteriorating course.

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National Safety and Quality Health Service
Standards
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Recognition and Response to the Deteriorating
Patient in Mental HealthIHI.ORG
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National Standards For Mental health Services
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National Standards For Mental health Services
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Scope of the issues
Recognising and Responding to Psychiatric
Deterioration

• Acute Care Settings / Continuing Care Settings
• Mental State / Physical Health / Psychosocial
  Deterioration
• Risk to Self / Risk to Others
• Time lag between change and response often months
• Lack of objective measures to assess
  deterioration and reliance on subjective measures
• Incongruence between documentation and clinical
  reality
• families and carers as informants Vs Patient as
  informant
• Makes tools such as risk assessment and other
  traffic light systems for recognition and rapid
  response to deteriorating patient hard to
  implement
• Effect size for interventions 20 difference at
  best from placebo
• Treatment that objectively does not meet adequate
  standards of care often leads to good outcomes

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Complexity in Mental Health Care Practice
Recognising and Responding to Psychiatric
Deterioration

• Quality of individual clinical practice
• Adherence to professional standards
• Culture and attitudes that develop in a team or a
  service
• Service setting standards of care use of
  pathways etc
• Service systems to support best care
• Individuals and teams accountable to practice
  within these systems whilst professional
  standards and individual best practice supported.

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How can we learn from adverse event reviews

• Use of CIR methodology to review and act upon
  findings from review of
• Sudden and Unexpected Death
• Seclusion
• Readmission
• Assault
• Self Harm
• Absconding
• Common theme is lack of recognition or response
  to the deteriorating patient

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Case Study_ Reducing Seclusion

• Primary prevention
• Organisational philosophy that articulates
  non-violence in policy, procedure and practice
• Risk assessment tools Risk Assessment and
  Management Plan
• Comfort rooms and self soothing activities
• Communication tools and handover tool developed
• Protected Therapeutic Engagement Time

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Seclusion Reduction
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Case Study_ Reducing Seclusion
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Protected Therapeutic Engagement Time

• Contact Nurse will ensure that that they
  introduce themselves to their patients each
  shift.
• They will arrange a time with the patient to
  catch up with them during their 8 hour shift to
  engage in a conversation with them aim for 20
  mins of contact time
• The themes raised during that time will be
  documented in the clinical file under the heading
  of P.T.E.T
• Where there are requests and or questions made by
  the patient these will be noted in the above
  section
• Should a patient decline the offer of the P.T.E.T
  then this will be recorded in the clinical file.
• P.T.E.T should be offered to all patients in the
  acute programme every morning and afternoon shift
  7 days per week.

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Case Study_ Reducing Seclusion

• Secondary Prevention
• Recognise deterioration respond to prevent
  escalation
• Personal safety plan
• Avoid power struggles and coercive responses
• Maintain a soothing environment
• Tertiary Prevention
• Explore precipitating factors
• Post seclusion counselling
• Review/update treatment plan
• Restraint for shortest time possible
• Review of seclusion and restraint events to
  inform new practice

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Case Example Recognising and Responding to
Psychiatric Deterioration - Specialist Eating
Disorder Unit

• Acute Adult In-Patient Unit with 5 Specialist
  Eating Disorder Beds
• 2008 Situation
• Staff not confident to manage AN patients with
  physical health problems.
• Perceived lack of support for physical health
  problems
• Average BMI of IPs to specialist Eating Disorder
  beds gt17.5, average BMI change 0.1
• High rates of NG tube refeeding and long stays in
  acute medical ward
• Constant presence of eating disorder patients in
  medical beds
• High rates of Dissatisfaction from staff and
  patients in unit

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Recognising and Responding to Physical
Deterioration- Eating Disorders

• Medical rescue identified as specialist role for
  unit
• Medical Unit identified to provide specific
  support to Eating Disorders Programme
• Nursing team trained to insert and manage NG tube
  refeeding on unit
• Specialist meal support and other groups
  established
• Team provided with education regarding the
  adaptive physiological response and maladaptive
  health risks associated with starvation
• Twice weekly ward round with review tool adapted
  to the unit. Clearly specifies medical and
  psychiatric risks, frequency of investigations,
  frequency of visual and physical observations
• Traffic light system to identify observations
  that require a clinical response

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  Test/ Investigation Concern Alert
Nutrition BMI lt14 lt12
Nutrition Weight loss per week gt0.5kg gt1.0kg
Nutrition Albumin lt35 lt32
Nutrition Creatinine Kinase gt170 gt250
CVS Systolic BP lt90 lt80
CVS Diastolic BP lt70 lt60
CVS Postural drop gt10 gt20
CVS Pulse lt50 lt40
CVS QTc   gt450msec
Temperature Temperature lt35 lt34.5
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  Investigation Concern Alert
Bone Marrow WCC lt4.0 lt2.0
Bone Marrow Neutrophils lt1.5 lt1.0
Bone Marrow Hb lt110 lt90
Bone Marrow Platelets lt130 lt110
Electrolytes K lt3.5 lt3.0
Electrolytes Na lt135 lt130
Electrolytes Mg 0.5-0.7 lt0.5
Electrolytes PO4 0.5-0.8 lt0.5
Electrolytes Urea gt7 gt10
Electrolytes Glucose lt3.5 lt2.5
Liver Function Bilirubin gt20 gt40
Liver Function ALP gt110 gt200
Liver Function AST gt40 gt80
Liver Function ALT gt45 gt90
Liver Function GGT gt45 gt90
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2011 Eating Disorder Programme

• mean admission BMI 14.5
• Mean discharge BMI 16
• BMI change 1.5
• Frequency of medical transfer 7.5

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Case study - Recognising and Responding to
Psychiatric Deterioration in an Acute General
Health Setting

• Prevalence rates of significant psychiatric
  comorbidity in general acute wards varies between
  20 60.
• Prevalence rates in the general community much
  lower 17-20
• Referral rates from general wards to liaison
  psychiatry services low - lt5 but varies greatly

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Case study - Recognising and Responding to
Psychiatric Deterioration in an Acute General
Health Setting

• Adverse outcomes secondary to absence of a
  systematic structured approach to identifying,
  assessing and responding to deteriorating mental
  state in acute health wards
• Recognised as issue by hospital wide governance
  processes
• Need for structured mental health risk assessment
  and management identified
• Clear agreement of broad principles
• Failure to agree over one year of specifics of
  risk assessment and process for implementing

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Case study - Recognising and Responding to
Psychiatric Deterioration in an Acute General
Health Setting

• Need for high level leadership and oversight
• Risk Tool developed over one year and then
  abandoned.
• Use hospital wide of mental health risk
  assessment and management tool agreed
• General hospital flow chart for use developed
• Training incorporated into HMO and Registrar
  teaching
• Referrals to Liaison Psychiatry require risk
  assessment to triage urgency of response

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Death of a Young Man with Schizophrenia

• 18 yo, FEP with moderate response to oral
  Olanzapine, but marked weight gain
• General Health and Metabolic monitoring, shared
  care processes with Primary Care, Dietetics on
  site
• 2 years later reduced adherence with medication
  recognised but not acted on
• Training on assisting patients with adherence,
  clinical review policies and tools include
  explicit statements on adherence
• Slow deterioration in mental state two months
  later not recognised, - withdrawal, low grade
  persecutory beliefs, worsening of auditory
  hallucinations
• All clinical contacts require explicit statement
  on Mental State and impression of change. Multi
  Disciplinary Clinical review requires MSE
  presentation, review of appropriateness of
  treatment plan, and tracking of activities to
  implement treatment plan.

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Death of a Young Man with Schizophrenia

• Six months later further escalating aggression
  and dangerous driving whilst intoxicated
  attributed to personality issues
• Dual diagnosis workers embedded in service,
  shared care protocols in place with Drug and
  Alcohol Services, Improved Psychiatrist EFT to
  allow for review of all patients and diagnoses.
  Clinical review process as before and culture of
  easy escalation of care when patients
  deteriorating
• Family increasingly contacting service with
  concerns about mental state and risk
• All staff trained in Family sensitive practice,
  culture and attitudinal change encouraged to be
  open to carer report being an important part of
  clinical information
• Service response is to provide phone number of
  drug detox service
• Triage and clinical review processes in place to
  monitor quality of care provision.
• Patient admitted floridly psychotic, intoxicated
  with amphetamines,
• Aggressive to police prior to admission and
  secluded for three days on admission
• Seclusion processes in place to ensure safe
  respectful care with seclusion use as an
  exception rather than norm

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Death of a Young Man with Schizophrenia

• detoxed and antipsychotics reinitiated, response
  partial returned home after three weeks.
• In Patient clinical information integrated with
  community care
• Drug abuse continues, ceases medication, family
  cant cope
• Family support processes and easy referrals in
  place
• Loss of home, move into poor quality rooming
  house, ongoing contact with service however
• Partnerships with PDRSS to assist better quality
  housing, and support of family
• Gradual relapse of psychosis secondary to none
  compliance
• Adherence, clincal review, easy escalation as
  before
• Case manager documents worsening hopelessness and
  demoralisation, ongoing substance use, grief and
  anger with family, aggression risk assessed but
  no suicide risk assessment.
• Risk assessment tool requires systematic approach
  to risk assessment and appropriate response
  monitored via team review processes
• Found hanging in his bathroom a week later
• Prevented by all the above

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Conclusions
Recognising and Responding to Psychiatric
Deterioration

• Much can be learnt from Acute Health
• Lack of objective measures for deterioration has
  to be managed
• Reliance on subjective measures places greater
  burden on quality of systems
• Team Culture, attitudes, individual practice
  needs to be in alignment with service standards
  and systems for those systems to be implemented
  adequately
• Role of mobilising values of staff to get
  commitment to quality care Vs Role of standard
  setting and compliance systems