Background
The Prescribing Observatory for Mental Health
(POMH) is a network of psychiatrists, pharmacists and nurses
who take a lead on medicines management within mental health
services. The network coordinates a programme of topic-based
clinical audits looking at prescribing practice. The topics
are selected because there is evidence of substantial variation
both with regard to the gap between actual practice and best
practice as defined by guidelines and with regard practice between
different mental health services.
The chosen topic for this improvement work was
the management of metabolic side effects for those on
antipsychotic medication in the community.
Life expectancy for people with schizophrenia
is reduced by approximately 15 years (similar to people with
diabetes). This is mainly due to an increased risk of
cardiovascular and respiratory disease (Brown, 1997). This
risk is exacerbated by the adverse effects of medication used to
treat the condition. Good prescribing practice and, in
particular early recognition and treatment of high blood lipid
levels and hypertension (raised blood pressure) can reduce
mortality, as can health promotion advice focusing on diet,
exercise and smoking.
The overall aim for this improvement work was
to increase the levels of screening for the metabolic side effects
of antipsychotic medication prescribed to those living in the
community. These metabolic side effect screening checks
include raised blood pressure (BP), obesity/body mass index (BMI),
raised glucose and raised lipid levels. This would be
achieved by supporting front line teams to test changes linked to
their systems for monitoring physical healthcare and metabolic side
effects in people who are prescribed antipsychotic drugs.
POMH recommended this as an area for the CTG
team to work on with member teams as it has been subject to five
national audit cycles and seemed to be an area of practice that was
difficult to change: between the baseline audit (2006) and
the most recent re-audit (2010), participating trusts demonstrated
an overall increase in the proportion of patients with all four
measures of metabolic side effects documented from 11% to 24%.
The Improvement Project
The CTG team needed to recruit between four and six teams.
The POMH team identified a number of trusts who had taken part in
the most recent cycle of the audit who would be suitable to take
part in the project: invitations were sent out at the end of June
2010; by mid July, four teams had taken up the invitation - three
Assertive Outreach Teams (AOT) and one Recovery Team.
A ‘Project Management Pack’ was developed and sent to teams
giving them detailed information and guidance about what the work
would entail, including advice about the composition of their local
CTG project team.
The CTG team visited the potential participating teams in August
and early September 2010. These visits were designed to meet
the teams and get an idea of their local context, introduce the
improvement approach
that was being used, and get formal ‘sign up’ to the 10-month
project.
The teams were brought together into a ‘collaborative’ which
worked together on the chosen topic between October 2010 and July
2011. During this 10-month period, the teams came together
for four learning events. Each learning event was followed by
a 3-month action period where teams carried out small ‘Plan Do
Study Act’ (PDSA) cycles and collected simple on-going progress
measures. During the action periods, the CTG team hosted
monthly teleconferences to review progress, discuss challenges, and
agree ways forward. Additional on-site support visits by a
member of the CTG team were also available by
arrangement.
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