Could a Virtual Clinic Improve the Quality of Physical Health Monitoring for Safe Antipsychotic Prescribing in an Older Adult Community Mental Health Team (CMHT)? Encouraging Preliminary Results From a CMHT in Wales
Authors: Lappas Andreas , Searle Anna , Chalinder Sophie , Chandrika Divya , Anane-Adusei Ata , Moynes Samantha , Willoughby Hannah , Evans Ceri , Rafferty Danika 
Published: July 2023

Aims

Antipsychotics are linked to increased cardiometabolic risk. The National Institute for Health and Care Excellence (NICE) and the Royal College of Psychiatrists have developed guidance on PHM to mitigate this risk. Both risks and guidance are age-blind, and very relevant to Older Adults due to age-related increase in cardiovascular risk. The COVID-19 pandemic boosted digital healthcare, which remains relevant due to rocketing demand and stretched services. This is a Quality Improvement Project aiming to improve physical health monitoring (PHM) for safe antipsychotic prescribing in an Older Adult Community Mental Health Team in South Wales. Baseline data, a virtual clinic model and preliminary results of the first Plan-Do-Study-Act cycle are presented.

Methods

An audit was conducted (06/2021–12/2021), with continuous prospective data collection thereafter. A scoping exercise was conducted to establish available resources. A local protocol/operational framework was developed. Education interventions (03/2022-on-going), a junior-doctor-led virtual PHM clinic and a phlebotomy/electrocardiogram (ECG) pathway (10/2022-on-going) were designed and implemented.

Results

Baseline (06/2021-09/2022): completed lifestyle advice=0%, physical observations=3%, blood tests=3%, ECG=3% of eligible patients. No patient (0%) had the full PHM as per guidance. Mean overall compliance with guidance/patient=9%. Pareto chart: no clear pathway and lack of prescriber awareness were the main reasons (>95%) for poor performance.

Scoping exercise: No Health-Board/Trust-wide approach for Older Adults and PHM is problematic in all localities. General Practitioners assertive regarding no responsibility/funding to deliver PHM for at least the first 12 months or until antipsychotic dose and mental state are stable. Geriatric teams, district nurses, general adult teams stretched and unable to support. Care home staff lack training and resources. Phlebotomy and ECG departments of local hospitals could support but no pathway.

First PDSA cycle (preliminary):

Change idea 1: staff education: clear shift (04/2022 onwards). Proportion of trained staff reached 100% in December 2022, and remains 100% in January 2023.

Change idea 2: virtual PHM clinic (10/2022 to 01/2023) – mean overall compliance with guidance/patient = 69% (vs. 9% baseline). Proportion of patients with complete PHM as per guidance reached 50% in January 2023. 75% patient response rate.

Change idea 3: phlebotomy/ECG pathway (10/2022 to 01/2023) – proportion of patients with bloods and ECG done reached 67% in January 2023.

Conclusion

Preliminary data suggest an encouraging trend for significant continuous improvement which, from a clinical perspective, is already significant. However, more data are required to draw safe conclusions regarding the clinical and cost effectiveness of this model of a virtual PHM clinic.