We describe the case of a 62-year-old man with a history of bipolar disorder, previously stable on lithium for over 20 years, who presented with a manic relapse and signs of lithium toxicity in the form of a coarse tremor. Serum lithium levels were in the normal range, and the patient had stage 3 chronic kidney disease. He was admitted for treatment under Section 2 of the Mental Health Act, and after stopping lithium was started on olanzapine. Signs of lithium toxicity improved after withdrawal of lithium. This case highlights the need to treat normal serum lithium levels with caution in patients showing signs of clinical lithium toxicity.
AimsSexual dysfunction should be enquired about as a symptom of mental health disorders and as side effects of commonly used psychotropic drugs. We audited against NICE guidelines the record of sexual dysfunction discussion at initial assessment and follow-up by the community mental health recovery service (CMHRS).BackgroundResearch reports that sexual dysfunction occurs more often in individuals with serious mental illnesses including depression and schizophrenia. Sexual dysfunction is also a reported side effect of antidepressant and antipsychotic medications. NICE guidelines recommend assessment of biological symptoms of mental health disorders and discussion of potential side effects of treatments being considered prior to initiation and at follow-up.MethodOur sample consisted of 71 patients, all new patient assessments from referrals made to CMHRS between January 1st and March 31st 2019.We reviewed all initial assessment and follow-up electronic notes and any correspondence generated from these meetings.ResultOur results showed that no record was made of sexual dysfunction as present or absent by health care professionals (HCPs) completing initial assessment or follow-up.We surveyed the HCPs from the team and observed a high level of confidence in discussing sexual dysfunction and high self report of this discussion being conducted.ConclusionOur audit results show no records of the discussion of sexual dysfunction, we held to the principal that in absence of record the discussion did not take place. Our survey results suggested that HCPs were confident they do assess for sexual dysfunction. We wondered, therefore, if HCPs would be less likely to make record in the event that symptoms are denied, recognizing that the list of potential symptoms and side effects is extensive and documentation of all negative results would be time consuming.Our audit results may show then, that sexual dysfunction is not present in any of the sample; however this would contrast to research findings of higher than average rates of sexual dysfunction in groups with serious mental illness and those using antidepressants or antipsychotics.We propose further assessment is needed for the disparity between our and recognised rates of sexual dysfunction.We propose the standard that recording ‘absence of biological symptoms’ of mental health disorders or recorded supply of medicine information leaflets are adequate record. We also made suggestions for training and recording to assist HCPs initial assessment.
AimsWe audited practice at the Meadows Inpatient Unit regarding physical health assessment, against standards set by Surrey and Borders Partnership and NICE.BackgroundSABP policy states that within 24 hours of admission to inpatient services, physical health assessment should be offered. It should be completed within 72 hours. Refusal should be documented.These guidelines state that within 2 weeks of admission blood tests should be completed, and for specific individuals an ECG should be performed.NICE guidelines state that “physical healthcare needs” should be discussed with newly admitted patients. NICE guidelines regarding physical health monitoring for individuals with psychosis or schizophrenia recommend that assessment includes “full physical examination to identify physical illness”.NICE suggests use of antipsychotics for individuals with dementia who have severe distress, or are at risk of harming themselves or others. Those with behavioural and psychological symptoms of dementia (BPSD) should therefore be physically assessed to ensure safe use of antipsychotics may be implemented.MethodAll admissions to The Meadows over seven months were audited retrospectively. The clinical notes were accessed from Systm1.Consensus medical opinion was reached that full examination should include: GCS/level of consciousness, cardiorespiratory, abdominal and neurological examinations.Age, gender, diagnosis and prescriptions of psychotropic medication at time of admission were recorded.The sample included 35 patients.Result55% of patients had a diagnosis of dementia.63.8% of patients were prescribed antipsychotics on admission, more than other psychotropic medication. This may reflect that the most common diagnosis was dementia, commonly with associated BPSD.97% of patients had a physical examination completed within 24 hours; most excluded neurological examination. 91% of patients had blood tests completed in two weeks, with the most commonly excluded tests being lipids and glucose. 86% of patients had an ECG in two weeks. In general, documentation of reason for not completing an examination was completed.ConclusionWe found good compliance with recommendations for physical health assessment. Areas for improvement include better assessment of neurology and more thorough blood tests.Recommended physical health examination for new admissions is not outlined in SABP policy. We recommend the following:GCS/level of consciousness, cardiovascular, respiratory, abdominal, and neurological examinations, and baseline observations.ECG should be a requirement of admission. In order to facilitate this, staff need to be trained to perform ECGs.NICE guidelines refer to HBA1c rather than glucose, which should be reflected in SABP policy.
AimsTo audit completed liaison service high risk care plans against local and national guidelines.MethodsSample comprised of a snapshot of all liaison patients currently on the case load on 14th December 2021. Electronic notes were reviewed to identify High Risk Care Plans (HRCPs) and audit completion against local guidance. Currently there is no national guidelines.In addition staff from the liaison team were surveyed to consider their confidence in completing HRCPs in order to direct staff training. Acute hospital staff were also surveyed to ascertain positive and negative aspects of the current HRCPs, in order to suggest quality improvements ahead of the upcoming integration of new Digital notes system.ResultsSample size 284. High Risk Care Plans completed 11, with an additional 2 required but not found in the notes.Non pharmacological deescalation advice was specified in only 2/11.Regular medication was documented in 5/11.Specialist rapid tranquillisation medication advice in 8/11.8/11 made reference to the local rapid tranquillisation policy, which was not made available in the notes.Absconsion risk is documented in 8/11 and advised level of observation 10/11.ConclusionAccording to local guidelines High Risk Care Plans were appropriate for 4.6% of the liaison case load, but record was included in the notes for 3.9%. Of those completed mandatory fields including non pharmacological deescalation and rapid tranquillisation advice were not always complete. Reference to rapid tranquillisation policy not immediately available in the notes is largely unhelpful in an emergency.Our local target is for 100% completion of appropriate high risk care plans and full documentation for each of the mandatory fields in the high risk care plan. Improved training and record keeping is required.Staff survey suggested unfamiliarity with document and unclear boundaries between standard and patient specific information impaired utility of high risk care plans. We recommend familiarising staff with the document and encourage highlighted font for key information.
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