Implementing guidelines on physical health in the acute mental health setting: a quality improvement approach

Stuart Green,Caroline Parker,Jenny Trite,Sandra Jayacodi,Anton Manickam,Bill Tiplady,Rachel Evered,Liz Evans,Joanna Williams,Emily Tabb,Rebecca Deere,John Green,Luca Polledri,Ed Beveridge

doi:10.1186/s13033-018-0179-1

Abstract

BackgroundIn the UK, life expectancy for people living with a serious mental illness, such as schizophrenia and bipolar disorder, is reduced by 15–20 years compared with the general population. In recent years, evidence based guidelines/policies designed to improve their physical health have been published, yet a gap remains between recommendations and practice. This case study describes how guidelines to support physical health were implemented using a quality improvement approach.Case presentationA quasi-experimental study explored systems and processes for assessing the physical health of patients admitted to an acute mental health unit. The multi-disciplinary team of healthcare professionals, service users and experts in quality improvement methods developed solutions to improve the assessment of physical health, drawing on existing guidelines/policies as well as professional and lived experience. Three key interventions were developed: a comprehensive physical health assessment; a patient-held physical health booklet; and education and training for staff and patients. Interventions were co-designed by front-line healthcare staff and service users with iterative development and implementation through Plan-Do-Study-Act cycles. Real-time weekly data were reported on five measures over a 15-month implementation period (318 patients) and compared to a 10-month baseline period (247 patients) to gauge the success of the implementation of the physical health assessment. Improvements were seen in the numbers of patients receiving a physical health assessment: 81.3% (201/247) vs 96.9% (308/318), recording of body mass index: 21.55% (53/247) vs 58.6% (204/318) and systolic blood pressure: 22.35% (55/247) vs 75.9% (239/318) but a reduction in the recording of smoking status: 80.1% (198/247) vs 70.9% (225/318). However, 31.7% (118/318) patients had a cardiovascular risk-score documented in the implementation phase, compared to none in the baseline.ConclusionThis study demonstrates the use of a quality improvement approach to support teams to implement guidelines on physical health in the acute mental health setting. Reflections of the team have identified the need for resources, training, support and leadership to support changes to the way care is delivered. Furthermore, collaborations between service users and frontline clinical staff can co-design interventions to support improvements and raise awareness of the physical health needs of this population.

Highlights

In the UK, life expectancy for people living with a serious mental illness, such as schizophrenia and bipolar disorder, is reduced by 15–20 years compared with the general population
This study demonstrates the use of a quality improvement approach to support teams to implement guidelines on physical health in the acute mental health setting
This study focuses on the improvement of processes, and whilst there maybe unrecognised confounders responsible for the observed changes, this does not pose a significant limitation to the study and the ability to determine the success of the quality improvement (QI) initiative

Summary

Introduction

In the UK, life expectancy for people living with a serious mental illness, such as schizophrenia and bipolar disorder, is reduced by 15–20 years compared with the general population. Green et al Int J Ment Health Syst (2018) 12:1 the true nature of the underlying cause resulting in the increased likelihood of developing physical health conditions leading to higher mortality is not yet fully understood there are undoubtedly links to modifiable factors, such as environment and lifestyle; for example high levels of tobacco consumption, poor diet and reduced physical exercise leading to obesity, which itself is often linked to iatrogenic weight gain associated with antipsychotics [4] This is further compounded by “diagnostic overshadowing”, when health professionals fail to take people with mental illness seriously when they raise concerns about their physical health, and the systemic failure to assess, monitor and appropriately manage the physical health of people with a SMI [5, 6]. In 2014, a national clinical audit identified that the monitoring of physical health indicators of people with mental health problems within the hospital setting was poor, with only 16% of patients locally receiving regular monitoring of key metabolic factors [9]

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