Policy: P15 Physical Healthcare Policy - West London NHS Trust · Linda Nazarko Consultant nurse...

Policy: P15 Physical Healthcare Policy

EIA / Sustainability

Equality Impact Assessment

For completion when covering; policy reviews and development restructuring and redesigning services organisational change

PART 1: PRE-CONSULTATION SERVICE CHANGE / POLICY RATIFICATION

EQUALITY ANALYSIS

1 Name of the policy / service change being assessed:

Main purpose of the policy/service:

Physical Health

Date: 21st December 2017

2 Name of the person undertaking the assessment:

Job Title:

Name of Service User Representative: (If service users are directly affected)

Linda Nazarko

Consultant nurse physical healthcare

Other Related Procedure or Documents include: See section 15 for complete list

Physical Health Strategy

Procedure: I17p Initiating and reviewing Long Acting Injections (LAIs) and Depot Antipsychotic

Medication (Local Services)

Procedure: H9p. The Use of High Dose Anti-psychotic Therapy (HDAT)

M2 medicines policy

M15p - National Early Warning Score Policy (previously MEWS)

F8: Prevention of inpatient falls and care and treatment of a patient following a fall or head injury

C2 :Care Programme Approach Policy CPA policy

WLFS35 Management of CPAs within the WLFS

Version: P15/05

Ratified by: Clinical Governance Group

Date ratified: 16th May 2018

Title of Author: Nurse Consultant Physical Healthcare

Title of responsible Director: Medical Director

Key Policy Stakeholders Director of Primary Care & General Practitioner HSS Consultant CID Community Services CT2 Doctor (PICU) Specialist Nurse Lakeside MHU Date issued: 16th May 2018

Review date: June 2019

Target audience: All staff trust-wide

Disclosure Status: B: Can be disclosed to service users and the public

West London Mental Health NHS Trust of 49

Policy P15 | First issued in February 2009 This is version P15/05 May 2018

Infection Prevention & Control Strategy 2014 – 2017

P16 Pressure Ulcer Prevention Management Policy Dysphagia policy

I11p Inpatient risk assessment and treatment to prevent Venous Thromboembolism (VTE)

D17p: Management of Diabetes Mellitus (in adults and young people)

Equality & Diversity statement

The Trust strives to ensure its policies are accessible, appropriate and

inclusive for all. Therefore all relevant policies will be required to undergo

an Equality Impact Assessment and will only be approved once this

process has been completed

Sustainable Development Statement

The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All relevant policies are therefore required to

undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be

approved once this process has been completed



P15 - PHYSICAL HEALTH POLICY

Version Control Sheet

Version Date Title of Author Status Comment

P15/01

06.02.09

Deputy Director of Nursing

New Policy as working document

Approved at Feb 09 ED meeting. Under consultation ending 3rd April 09

P15/02

11.06.09

Deputy Director of Nursing

New Policy issued

Following consultation the working document policy was reviewed and approved at 22.05.09 CSSG meeting.

P15/03 2.4.12

11.04.12

19.06.13

Director of Primary Care

Revised Policy

Re-issued 19.06.13

Policy takes into account new NHSLA criteria

Ratified on 11.04.12 at Trust Management Team Meeting

Additions made at 4.4 & 7.2

P15/04 April 2015 Director of Primary Care

Approved at April TMT subject to EIA being completed.

Issued 14th May 2015

P15/04 January 2016

Director of Primary Care

Re-issued 14.01.16

Additions made to 5.4 Re-issued 14.01.16

P15/05 May 2018 Nurse Consultant Physical Healthcare

Ratified and issued

This extensive review has taken into account comments from a wide range of stakeholders including junior doctors, consultants, nurses and service users stakeholder groups. Ratified outside Clinical Governance Group using voting buttons 20180516



Contents Page No:

1. Flowcharts 5

2. Introduction 8

3. Aims and Objectives 9

4. Scope 9

5. Duties 10

6. Blood Tests 18

7. Promoting Parity 25

8. Education and Training 26

9. Inpatient Monitoring Requirements 26

10. Care Planning and Review 27

11. Care Programme Approach (CPA) Reviews 29

12. Service user and carer participation 31

13. Monitoring and Governance 31

14. Fraud statement 33

15. Supporting documents 33

16. Acronyms 34

17. References 35

18. Appendices 38

Appendix 1 Lester Tool 39

Appendix 2 Physical Healthcare Training on Induction 43



1. Flowchart One

Inpatient Admissions and Transfers: Role of doctor

NB. When patients are transferred internally within the service it is not necessary to complete a new physical health care clerking. The receiving team should be fully aware of the patient’s physical status and on-going intervention needs.

On the Homeward team nurse practitioners with advanced physical assessment skills may clerk patients.

Inpatient admission

Begin physical healthcare assessment within four hours of admission.

Complete within 24 hours of admission

Record on physical healthcare portal

Essential blood tests on admission unless recently

undertaken by another healthcare provider.

Must be completed within 48 hours of admission

ECG on admission unless recently undertaken by

another healthcare provider.

Must be completed within 48 hours of admission

Physical health history, physical examination. Risk assessment VTE. Allergies, adverse reactions and alerts

Record on physical health portal

If concerns regarding physical healthcare discuss

with duty ST/Consultant and A&E colleagues if

appropriate.

Discusss physical healthcare issues and review National Early Warning Score

(NEWS) on ward rounds with consultant.

Record discussions and NEWS review in progress notes

On discharge provide details of physical

healthcare screening and interventions to primary

care providers e.g. GP and district nurse

Medicines reconcilliation. Write up medicine chart



Flowchart two

Inpatient Admissions and Transfers: Role of nurse

NB. When patients are transferred internally within the service it is not necessary to

complete new physical health care assessments. The receiving team should be fully aware

of the patient’s physical status and on-going intervention needs. Some assessments e.g.

NEWs will be ongoing and some such as BMI will be carried out at least once a month for

inpatients.

Inpatient admission

Begin physical healthcare assessments within four hours of admission.


NEWs

Must be completed on admission/return from

A&E or post acute admission

Do at least 12 hourly for first three days of

admission

Falls risk screen.

Must be completed within 24 hours of admission, 6 hours in CID, Homeward,

Meridian

Weight, height BMI. If history unintentional weight loss ,

reason for concern e.g poor intake or BMI 18.5 or less

complete nutritional screen (MUST).

Record on physical health portal

Dysphagia screen

Tobacco screening

If concerns refer to medical, dietetics, therapists or specialist nursing staff as appropriate

Waterlow pressure ulcer risk assessment

MRSA screening



Flowchart three

Community Flowchart for Recovery Teams for physical health care

Initial assessment at Recovery Team

Physical healthcare assessment to be

completed as part of the initial

assessment process.

Complete within 28 days of referral


CPA – physical health

assessment to be completed

Record on physical healthcare

portal

Medication initiation or significant

change to medication regime

Physical health care assessment to be

completed.

Record on physical health care portal

Physical health assessment:

Smoking status

Lifestyle (exercise, diet, drug and alcohol use)

Height and weight

BMI

Glucose regulation (either HbA1 or fasting glucose)

Blood lipids

Waist circumference

Allergies

If concerns regarding physical health

inform patient and GP of assessment

outcome and request GP to follow up

as appropriate.

Admin to request encounter record




2. Introduction

The Trust provides mental health and community services across a wide range of settings including High Secure Services, Forensics services as well as within the boroughs of Ealing, Hammersmith & Fulham and Hounslow. The trust provides assessment and treatment for people experiencing severe and / or enduring mental health problems. The Trust works with primary care and acute providers to provide specialist mental health input for people experiencing an acute physical illness or those living with a long term condition A number of community physical health services are also provided, including intermediate care services, with step up beds, and a number of public health initiatives.

2.1 People with Serious Mental Illness (SMI) have much higher morbidity and mortality rates,

compared to the general population (Hennekens et al, 2005: Public Health England 2014a: Public Health England 2014b).

2.2 Service users within mental health services, inpatient and community, do not always

receive the physical health care intervention they require and that this contributes toward the increased morbidity and mortality (Department of Health, 2016:Hardy & Thomas, 2012: All Party Parliamentary Group on Mental Health, 2015).

2.3 People with physical healthcare problems are greater risk of developing SMI and the

effects of SMI and medication such as anti-psychotics lead to increased risk of physical healthcare problems (eMC, 2016: Velligan et al, 2009: NICE, 2009: RCPSYCH, 2013a: RCPSYCH, 2013b). People with SMI often find it more difficult to manage health problems and can have higher levels of hospitalisation and hospital re-admission for physical healthcare problems as a result (Knapp et al, 2008: Velligan et al, 2009: Chwastiak et al, 2014 Orellana, & Slachevsky, 2013: Schmitt et al 2011). People with severe mental illness are more likely to have poor oral health than the general population. They are 2.8 times more likely to have lost all their teeth and have higher numbers of decayed, missing or filled teeth (Kisely et al, 2015). Poor oral health has been linked with systemic illnesses such as coronary heart disease, diabetes and respiratory disease, which impact on mental health. Humphrey et al, 2008). Dental hygiene affects eating and speech, and affects physical, social and psychological well-being (Mirza, 2001).

2.4 This policy is based on the West London Mental Health Trust (WLMHT) strategy and

aims as set out in the NHS Constitution (DH, 2015). The service is designed to improve, prevent, diagnose and treat both physical and mental health problems with equal regard…..it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population’ (DH, 2016)

2.4.1 In accordance with this West London Mental Health NHS Trust will address physical health with the same regard as it does mental health.



2.4.2 This policy sets standards relating to physical healthcare all service users under the care of WLMHT and staff must follow associated procedures in relation to specific aspects of physical healthcare assessment, monitoring and treatment.

2.5 The policy is based on national strategy and the CQC Quality and Safety Outcomes

standards in relation to the physical healthcare of people with mental health problems (CQC, 2015:DH, 2012: DH, 2016: NICE, 2015: NICE, 2014a: NICE, 2014b: NICE, 2013).

2.6 The policy describes the governance arrangements for physical health care within the

Trust, where it fits within the governance structure, and how the Board can be assured that the Trust is providing the best available care.

3. Aims and objectives

3.1 This policy aims to meets standards set out in the Five Year Forward View (NHS England, 2016) and all relevant NICE standards and guidance.

3.2 The policy aims to ensure that assessment of all service users under the care of WLMHT includes their physical health, including any monitoring and interventions required.

3.3 Assessment is undertaken in line with Trust policies and procedures guidance and adheres to best practice, including good standards of recording on the electronic patient record (RiO).

3.4 The policy also aims to provide direction and guidance for the planning and

implementation of high quality physical health care interventions within the organisation.

3.5 It sets out the expectations of interventions that should be provided by staff employed within WLMHT, and those that require advice and / or intervention from other specialist services.

3.6 The policy aims to enable and empower service users to access services and

information that will enable them to reduce the risks associated with SMI and promote well-being.

3.7 Underpinning this policy is the recognition that appropriate equipment, education and training are required and provided to enable staff to provide high quality treatment and care.

4. Scope

4.1 This policy applies to all staff employed or contracted within WLMHT working within a clinical or managerial role. It applies to all service users receiving care from WLMHT, whether this is from community or inpatient services.

4.2 The level of input and interventions vary according to clinical settings. It is important to note that not all community patients will have the same level of need, some will require intensive community support, others a moderate level of support and others a minimal level of support.



5. Duties

5.1 The Board has a duty to ensure that physical healthcare is represented at board level

(Royal College of Psychiatrists, 2016).

5.1.1 It has a duty to ensure (through performance monitoring of clinical outcomes) that all appropriate care is provided for those people who are long term residents of the Trust, and for whom the Trust is the only provider of health care.

5.1.2 The Board has a duty to ensure (through performance monitoring) that there is effective communication between the Trust and primary care services, for those service users for whom the Trust provides mental health care, but is not the sole responsible provider of physical health care.

5.1.3. The Board has a duty to ensure (through performance monitoring and leadership) the implementation of national public health policies that will improve the health outcomes of the vulnerable population groups for which the Trust provides mental health care. Such policies include the Trust’s Food, Nutrition & Hydration Policy (F7), Prevention, Identification & Management of Overweight & Obesity (O5g), and Smoking Reduction & Cessation Guideline (S34g)

5.1.4 The Board has a duty to ensure that sufficient resources are available so that physical health care services can be delivered to a level that is clinically safe, and will deliver the outcomes that are required in this policy.

5.2 The accountable directors

5.2.1 The Medical Director and the Director of Primary Care are the accountable directors. They are responsible for establishing the standards for physical healthcare monitoring within the organisation and seeking advice from relevant specialists as required.

5.2.2 The Physical Health Consultant Nurse will:

Lead developments of the Trust’s priorities regarding physical health

Support services in operationalising the policy

Support services on the management of physical healthcare for service users

Identify priorities, themes and risks concerning physical healthcare that arise from Serious Untoward Incidents, National Confidential Inquiries and work with services to develop systems to minimise potential harm to patients

Review complaints concerning physical and public healthcare and make recommendations to improve patient experiences.

Develop strategies and guidance arising from NICE and other National/ Professional Guidance

Identify and develop and work with Learning and Development and the nursing and medical directorates to develop competency requirements of clinical and non-clinical staff to ensure that they are competent to manage people with physical health care conditions



Support services to identify the physical and public health requirements of their local

populations and support them to develop local partnership arrangements with other NHS

providers and local commissioners

5.3 Clinicians and health professionals

5.3.1 Community

5.3.1.1 The care co-ordinator is responsible for recording service user’s engagement in the Care Programme Approach (CPA) Review. This will normally be carried out at least annually and more frequently when there are complex physical and mental health needs.

Clinicians working in community teams are required to perform a core set of physical heath investigations and examinations for conditions that our patients are at greater risk of developing (see flow chart three). Community dwelling service users will have their physical health care needs considered by clinicians working in the community teams and their care coordinator. Current guidance Identifies eight key actions in relation to improving health, smoking cessation, tackling obesity, improving activity levels, sexual & reproductive health, medicines optimisation, dental and oral health and reducing falls (Department of Health, 2016: P53). This will include checking:

Height, weight, BMI

Completing nutritional screening using MUST tool if there are concerns regarding weight loss, poor dietary intake or low BMI.

Blood pressure and pulse rate

Blood tests e.g. blood lipids, blood glucose or HbA1c

Table one summarises Medical and Nursing responsibilities in relation to Physical Health Check

Table one: Community Medical and Nursing responsibilities in relation to Physical Health Check

What needs to be done Who is responsible?

Time Scale

Physical health history, obtained from GP and at clinic by administration staff, Recorded on physical health care portal.

Lead Healthcare Practitioner

Within 28 days of referral

Comprehensive physical health assessment incorporating 1. Smoking status 2. Lifestyle and life skills, i.e.

diet and activity 3. Height, weight and BMI 4. Blood pressure 5. Glucose regulation ie,

HbA1c should be < 42mmol or random blood glucose should be < 11.0mmol

6. Blood lipids and Q risk 3 score


Within 28 days of referral



Table one: Community Medical and Nursing responsibilities in relation to Physical Health Check

What needs to be done Who is responsible?

Time Scale

Review essential bloods Doctor clinic Within 12 weeks of assessment. Check if recently undertaken by another healthcare provider.. Arrange for these to be done if not done

ECG Medic or Nurse lead clinic

Within 12 weeks of assessment. Check if recently undertaken by another healthcare provider. Arrange via GP if not done

Medicines review Doctor Within 4 weeks of referral at first medical review.

Substance and Alcohol Use (DAST) screening

Original assessor

Within 28 days of referral completed as part of initial assessment

Tobacco use screening Original assessor

Within 28 days of referral completed as part of initial assessment

Clustering incorporating HoNoS


By second face to face contact

NB: These are to reviewed within 6 months and/or at CPA

If the reviewer notes that the patient has oral health or dental problems the patient should be encouraged to seek dental treatment. When at a CPA or any other performed review, the patient discloses other complaints, the clinician or social worker would then record the details of this on the physical health portal (PHP) and record in the care plan, signposting for any additional primary or secondary physicians to follow up. The clinicians are responsible for follow-up to ascertain the outcome of that action. The essence of our interventions is not to take on all physical health investigations, but to ensure these needs are not neglected as traditionally they have been for a variety of reasons within primary, secondary and mental health services leading to the higher morbidity and mortality rates.

If the reviewer is not a clinician and is for example a social worker and identified a health problem, this would be either discussed with the GP or medical staff in the team. This will enable the identification and addressing of health problems by the team via primary, intermediate care or secondary care.

Physical Health Risk Status The physical healthcare risk status section of the Physical Healthcare portal incorporates the LESTER tool. This assesses cardio metabolic physical health risks. Please see appendix one (The Lester Tool) for additional guidance on interventions that can be offered. The Lester Tool requires blood results and if relevant blood results are not available on admission to the service this tool should be completed when they are available. The Lester tool should be completed on admission to a community service unless it has already been completed during a recent inpatient admission.

5.3.1.2 This will be subject to regular review as part of the CPA planning process. The assessment will be recorded on Rio.



5.3.1.3 The responsible consultant (RC) is responsible for ensuring treatment, advice or ensuring an appropriate referral to the person’s General Practitioner (GP) or in certain circumstances to a hospital specialist. These are when assessment by a member of the mental health team or review at the CPA identifies physical health needs

5.3.1.4 Addressing physical health is a shared responsibility with the patients GP. The GP is best placed and informed on physical health. However some patients do not attend their GP and even if they do there is evidence to suggest more can be done to screen and treat physical health. Accordingly both providers should screen and treat physical health at every opportunity. .The service user’s RC is responsible for ensuring effective communication with the person’s GP takes place. The RC is responsible for ensuring that the results of any physical healthcare tests assessments and interventions are shared with the patient’s

5.3.1.5 Shared responsibility for prescribing various medications, e.g. anti-psychotic medication, lithium etc., are set out in documents agreed between the Trust and the CCGs, and LMC.Those documents include physical health assessments, and should be read in conjunction with this overarching policy.

Community actions in relation to abnormal cardio-metabolic risk factors

The RC and the community team will work with the patient’s general practitioner to promote a healthy life style and to address modifiable cardio-metabolic risk factors. Table two outlines abnormal results and appropriate evidence based actions.

Table two: Recognition and treatment of cardio-metabolic risk factors

Risk factor Actions Review

Currently smoking Brief intervention Refer to smoking cessation service

If still smoking consider combined NRT and or varenicline

Poor diet and or sedentary lifestyle

Brief intervention: Nutritional counselling: Reduce take-away and “junk” food, reduce energy intake to prevent weight gain, avoid soft and caffeinated drinks and juices, and increase fibre intake. Brief intervention: Physical activity: structured education-lifestyle intervention. Advise physical activity such as a minimum of 150 minutes of ‘moderate-intensity’ physical activity per weekly Suggest 30 minutes of physical activity on 5 days a week. Refer to One You Ealing, Hounslow or Hammersmith as appropriate to improve diet and activity levels

Has quality of diet and or level of exercise improved. Consider further interventions.



Elevated BMI 25 kg/m2 (≥23 kg/m2 if South Asian or Chinese)

Brief intervention: Nutritional counselling: Reduce take-away and “junk” food, reduce energy intake to prevent weight gain, avoid soft and caffeinated drinks and juices, and increase fibre intake.

Brief intervention: Physical activity: structured education-lifestyle intervention. Advise physical activity such as a minimum of 150 minutes of ‘moderate-intensity’ physical activity per weekly

For example suggest 30 minutes of physical activity on 5 days a week. Refer to One You Ealing, Hounslow or Hammersmith as appropriate to improve diet and activity levels

Elevated BMI 25 kg/m2 (≥23 kg/m2 if South Asian or Chinese) AND / OR Rapid weight gain >5kg over 3 month period

Elevated BMI: Follow NICE guidelines for obesity

http://www.nice.org. uk/CG43

Rapid weight gain

Review of antipsychotic and mood stabiliser medication:

Discussions about medication should involve the patient, the general practitioner and the psychiatrist.

Blood pressure >140 mm Hg systolic AND / OR

>90 mm Hg diastolic

Brief intervention: Nutritional counselling: Limit salt intake in diet Lifestyle advice as above to improve quality of diet and increase physical activity. Refer for investigation, diagnosis and treatment by appropriate clinician if necessary. Medication review

Remains hypertensive: Consider antihypertensive therapy. Follow NICE hypertension guidelines http://publications. nice.org.uk/hypertension-cg127

Glucose regulation

HbA1C or Glucose threshold:

HbA1C ≥42 mmol/mol (≥6%)

AND / OR

Fasting PG ≥5.5 mmol/l

OR

Random PG ≥ 11.1 mmol/l

Brief intervention: Nutritional counselling: Lifestyle advice as above to improve quality of diet and increase physical activity . Refer for investigation, diagnosis and treatment by appropriate clinician if necessary.

Medication review

Treatment of those at high risk of diabetes: FPG 5.5-6.9 mmol/l; HbA1c 42-47 mmol/mol (6.0-6.4%)

Follow NICE guideline PH 38 Preventing type 2 diabetes: risk identification and interventions for individuals at high risk (recommendation 19) – http://guidance.nice.org.uk/PH38.

Where intensive lifestyle intervention has failed consider a metformin trial (normally GP supervised). off-label use requires documented informed consent as described in GMC guidelines,

http://www.gmc-uk.org/guidance/ethical_guidance/14327.asp.

GMC guidelines are

http://guidance.nice.org.uk/PH38


http://www.gmc-uk.org/guidance/ethical_guidance/14327.asp





recommended by the MPS and MDU, and the use of metformin in this context. has been agreed as a relevant example by the Defence Unions. Adhere to BNF formulary guidance on safe use in particular ensure renal function is adequate. Start with a low dose of 500mg daily and build up as tolerated to a maximum of 1.5 – 2 grams daily

Diabetes HbA1c ≥48 mmol/mol FPG ≥7.0 mmol/l RPG ≥11.1 mmol/l Endocrine review Follow NICE diabetes guidelines

https://www.nice.org.uk/guidance/CG87

Blood lipids

Total chol/HDL ratio to detect high (>10%) risk of CVD based on QRISK-3 Tool.

http://qrisk.org

Brief intervention: Nutritional counselling: Lifestyle advice as above to improve quality of diet and increase physical activity. Refer for investigation, diagnosis and treatment by appropriate clinician if necessary.

Follow NICE guidelines for lipid modification Refer to specialist if total cholesterol >9, non-HDL chol >7.5 or TG>20 (mmol/l)

Consider lipid modification for those with CVD or Diabetes

https://www.nice.org.uk/guidance/cg181

5.3.2 Inpatients

5.3.2.1 Medical staff1 will begin the physical healthcare assessment on the physical healthcare portal on Rio within four hours of admission and completed as soon as practicably possible, but should be within twenty four hours of admission. This must be recorded in the physical healthcare portal.

5.3.2.2 The doctor who clerks a service user into hospital will undertake the following and record this on RiO under the physical healthcare assessment. This is to be commenced within four hours of admission and completed within twenty four hours of admission.

1 On Magnolia Ward, part of the Homeward Service, nurse practitioners (nurses with qualifications in

physical examination, history taking and diagnostic reasoning) may undertake clerking.



http://qrisk.org/





Physical Health History

Physical Examination including oral health

Substance and Alcohol Use (DAT) screening

Risk Assessment for VTE

Alerts

Allergies and Adverse Reactions

Medicines reconciliation

Completion of medication chart.

If the service user refuses or they are absent from the ward there should be a care plan on how the issue will be addressed and when assessment will be carried out.

Oral health If the person has oral health problems including dental problems the care plan should specify how these will be addressed. In local services the person will be encouraged to attend his or her dentist and medical staff will be responsible for arranging emergency dental treatment. Emergency dental clinics are available in some acute hospital services e.g. Charing Cross hospital. In West London Forensic Services and High Secure Services weekly dental sessions are provided. Inpatients at the Limes are treated by a local dentist.

5.3.2.3 The admitting nurse will complete the following assessments and record these on RiO under the physical healthcare portal: National Early Warning Score Nutrition – weight, height, BMI. Assess BMI + percentage unintentional weight loss+/or likelihood future impaired intake. People with a BMI of less than 18.5, people with more than 10% unintentional weight loss within the last 3–6 month or BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3–6 months should be screened using the Malnutrition Universal Screening Tool (MUST) on Rio (NICE, 2017). Falls risk screening within 24 hours of admission (six hours in high risk areas, Magnolia, Meridian, Limes and Jubilee). If at risk of falls a falls risk assessment within 48 hours (24 hours in high risk areas, Magnolia, Meridian, Limes and Jubilee). See F8: Falls policy. Dysphagia screening within 48 hours of admission and if at risk a fall assessment within 72 hours of admission. In high risk areas Magnolia, Meridian, Limes and Jubilee screening within 24 hours and full assessment within 48 hours if clinically indicated

Tobacco use screening

MRSA screening see ICP1 Infection control policy

Pressure ulcer risk assessment –Waterlow See P16: Pressure ulcer prevention policy

Table three summarises Medical and Nursing responsibilities in relation to admission



NB: When an inpatient returns from accident and emergency or is re-admitted following a stay in an acute hospital the nurse in charge must carry out a full set of observations using NEWS and inform the ward or duty doctor immediately of the patient’s return. This should be recorded on Rio

Table three: Medical and Nursing responsibilities in relation to admission

What needs to be done

Who is responsible?

Time Scale

Physical health history

Admitting Doctor Commence within four hours of admission and complete Within 24 hours of admission. Record allergies, adverse reactions and alerts.

Physical Examination

Admitting Doctor/ Commence within four hours of admission and complete Within 24 hours of admission

Essential bloods Admitting Doctor/ Within 48 hours of admission. Check if recently Undertaken by another healthcare provider

ECG Admitting doctor. Nursing Staff may be able to assist.

Within 48 hours of admission. Check if recently undertaken by another healthcare provider

VTE assessment

Admitting doctor Within 24hrs

Medicines reconciliation and write up medication chart

Admitting doctor/ Within 4 hours of admission

LESTER tool Admitting doctor Essential bloods within 48 hours of admission. Check if recently undertaken by another healthcare provider. If relevant bloods not available on admission Lester tool to be completed within 5 days of admission.

Substance and Alcohol Use (DAT) screening

Admitting doctor Within 24hrs.

Clustering incorporating HoNoS

Admitting doctor Before 2nd night of admission

National Early Warning Score (NEWS)

Admitting nurse Within four hours of admission and record a minimum of 12 hourly for first three days of admission If patient has returned from A&E or acute admission carry out immediately and inform doctor of admission


Admitting nurse Within 30 minutes of admission. If smokes ensure Nicotine Replacement therapy (NRT) commenced without delay


Admitting nurse Within six hours of admission

MRSA screening

Admitting nurse Within 24 hours of admission if clinically indicated

Height, weight and BMI

Admitting nurse Within 24 hours of admission. MUST screen if at risk of malnutrition



Table three: Medical and Nursing responsibilities in relation to admission


Who is responsible?

Time Scale

Falls Risk Screening Assessment

Admitting nurse Within 24hrs of admission. 6 hours in Limes, Jubilee, Homeward, Meridian. If at risk full assessment within 48 hours of admission. 24 hours in Limes, Jubilee, Magnolia & Meridian.

Dysphagia screen

Admitting nurse Within 48hrs of admission. If at risk full assessment within 72 hours of admission, On the Limes, Jubilee, Homeward, Meridian screening to take place within 24 hours of admission and a full assessment within 48 hours if clinically indicated

Urine Drug Screen

Admitting nurse Within four hours of admission if clinically indicated

Urinalysis Admitting nurse Within four hours of admission if clinically indicated

NB. When patients are transferred internally within the service it is not necessary to complete new physical health care assessments. The receiving team should be fully aware of the patient’s physical status and on-going intervention needs. Some assessments e.g. NEWs will be ongoing and some such as BMI will be carried out on admission and at intervals during care according to clinical risk. . When patients are transferred to or from community services the physical healthcare portal should be used and transfer documentation should highlight any difficulties or outstanding issues in relation to physical healthcare.

6. Blood tests 6.1 Essential blood tests are carried out in admission unless recently undertaken by another

healthcare provider.

HBA1C (if not taken in last three months)

Lipids profile

FBC

U&Es

LFTs

TFTs

Prolactin if on or due to start antipsychotic.

HIV

Hepatitis B HIV and Hep B will not be repeated every six months. They can be repeated anytime if there are concerns that the person is at risk. Long term inpatients will also have vitamin D checked. In those over the age of 65 additional bloods will be taken. These are:

B12

Folate

CRP



6.2 The doctor will review any recent blood tests and take any clinically indicated blood tests. Blood tests should be taken within 48 hours of admission. If this is not possible the reason for this must be recorded in Rio. It is not Trust policy to send patients out for these tests. The person ordering investigations is responsible for checking and acting on results. If this is not possible due to rostering then the doctor will record this on Rio and indicate who will be responsible.

6.3 ECGs will normally be carried out on admission unless recently undertaken by another healthcare provider and available for review. ECGs should be carried out within 48 hours of admission. If this is not possible the reason for this must be recorded in Rio. ECGs are also carried out when clinically indicated. It is the responsibility of the doctor or Advanced Nurse Practitioner (in community and community bedded services) to undertake ECGs. Nursing staff are being trained to take ECGs and may be able to assist. It is not Trust policy to send patients out for these tests. The person ordering investigations is responsible for checking and acting on results. If this is not possible due to rostering then the doctor or will record this on Rio and indicate who will be responsible.

6.4 In frail elderly patients and those with a history of fracture following a fall from standing height the diagnosis of osteoporosis should be considered and treatment instigated when clinically indicated.

6.5 Care must be taken to make the best use of finite resources. Investigations and referrals must be clinically indicated for that particular patient. There is no place for indiscriminate and undifferentiated use of blood tests, ECGs, imaging and wider secondary care resources. Clinicians are expected to be able to explain and justify the use of such resources.

West London Forensic Services (WLFS)

In WLFS in-patients who are medically stable may only have their NEWS score calculated monthly. When there are concerns regarding a patient’s physical health the NEWS score will be taken and reviewed by the nurse in charge. Staff should then follow the escalation process outlined in the NEWs policy and ensure that doctors are contacted on a timely basis to carry out physical examination and address health issues. If there are concerns about a NEWS score, or the physical health of a patient, this should not wait until the ward round. However, NEWS scores should be reported and discussed within the ward round and compliance with the policy monitored through the ward CIG and directorate CIG meetings.

The Limes Dementia Unit

The Limes cares for people with dementia, some may have advanced dementia and have a Do Not Attempt Resuscitation agreement (DNAR) and a documented ceiling of care. It may clinically inappropriate to carry out ECGs or certain physical healthcare monitoring for these patients. The responsible consultant in consultation with the team may determine that certain provisions in this policy are inappropriate for patients receiving end of life care. If this is the case any such deviations from the policy will be recorded in RiO.



On Admission: New patients (not transferred from within the Trust) will have a physical assessment by medical professional and bloods and ECG as appropriate within 48 hours of admission Patients who have been transferred from within the trust will have a physical assessment by health professional in consultation with medical professional and review of documented information on medical health history and any necessary investigations will be completed. All patients: All patients will have a review of their physical healthcare every 6 months (this is in addition to regular monitoring and NEWS as appropriate). Bloods, ECG and other investigations will only be done if that is established as necessary and in the patient’s best interest and any potential distress to the patients will be weighed against potential benefit. This will be co-ordinated with CPA reviews of individual patients. In relation to frequency of monitoring of vital signs will be decided by the MDT on a case by case basis and any deviation from policy will be documented in that individual’s care plan

3.2 Adolescent In-patients

Young people are admitted to the Wells and the junior doctor will carry out a simple physical examination, with a nurse chaperone. It is not possible to have a parental or carer as they are not present on admission and subsequent examination. Every young person coming into the Wells Unit will also have a primary care assessment and this will be governed by primary care principles and a chaperone will be present at first assessment. Normally the young person is not undressed however the top may be removed to carry out examination of the heart and lungs and to perform an ECG. Trousers would be removed for a sensory neurological examination with the young person’s consent but the young person would be fully clothed on top.

Physical Health Risk Status assessment and intervention

The physical healthcare risk status section of the Physical Healthcare portal incorporates the LESTER tool. This assesses cardio metabolic physical health risks. Each cardio-metabolic risk factor is Red, Amber, Green (RAG) rated. Please see appendix one (The Lester Tool) for additional guidance on interventions that can be offered. The Lester Tool requires blood results and if relevant blood results are not available on admission this tool should be completed when they are available. This will normally be within 5 days of admission. If for example the individual smokes cigarettes nursing staff will offer nicotine replacement therapy and medical staff will offer varenicline if clinically indicated. The individual will be referred to smoking cessation services. If the individual is hypertensive investigation and treatment will be provided in line with NICE guidance on the management of hypertension (NICE, 2011). Table four outlines actions in relation to abnormal cardio-metabolic risk factors.



Table four: Inpatient actions in relation to abnormal cardio-metabolic risk factors

Risk factor Actions Review

Currently smoking Brief intervention

Refer to smoking cessation service

Offer Nicotine Replacement Therapy

If still smoking consider combined NRT and or varenicline

Poor diet and or sedentary lifestyle



Suggest 30 minutes of physical activity on 5 days a week.

Refer to physical activity co-ordinators during inpatient stay

Refer to One You Ealing, Hounslow or Hammersmith as appropriate to improve diet and activity levels on discharge

Has quality of diet and or level of exercise improved? If not offer further interventions.



Elevated BMI 25 kg/m2 (≥23 kg/m2 if South Asian or Chinese)



For example suggest 30 minutes of physical activity on 5 days a week.

Refer to physical activity co-ordinators during inpatient stay Refer to One You Ealing, Hounslow or Hammersmith as appropriate to improve diet and activity levels on discharge

Elevated BMI 25 kg/m2 (≥23 kg/m2 if South Asian or Chinese) AND / OR Rapid weight gain >5kg over 3 month period

Elevated BMI: Follow NICE guidelines for obesity

http://www.nice.org. uk/CG43

Rapid weight gain

Review of antipsychotic and mood stabiliser medication:

Discussions about medication should involve the patient, the general practitioner or primary care provider when relevant and the psychiatrist.

Blood pressure >140 mm Hg systolic AND / OR

>90 mm Hg diastolic

Brief intervention: Nutritional counselling: Limit salt intake in diet Lifestyle advice as above to improve quality of diet and increase physical activity. Refer for investigation, diagnosis and treatment by appropriate clinician if necessary. Medication review

Remains hypertensive: Consider antihypertensive therapy. Follow NICE hypertension guidelines http://publications. nice.org.uk/hypertension-cg127



Glucose regulation

HbA1C or Glucose threshold:

HbA1C ≥42 mmol/mol (≥6%)

AND / OR

Fasting PG ≥5.5 mmol/l

OR

Random PG ≥ 11.1 mmol/l

Brief intervention: Nutritional counselling: Lifestyle advice as above to improve quality of diet and increase physical activity Refer for investigation, diagnosis and treatment by appropriate clinician if necessary.

Medication review

Treatment of those at high risk of diabetes: FPG 5.5-6.9 mmol/l; HbA1c 42-47 mmol/mol (6.0-6.4%)

Follow NICE guideline PH 38 Preventing type 2 diabetes: risk identification and interventions for individuals at high risk (recommendation 19) – http://guidance.nice.org.uk/PH38.

Where intensive lifestyle intervention has failed consider a metformin trial (normally GP supervised). off-label use requires documented informed consent as described in GMC guidelines

http://www.gmc-uk.org/guidance/ethical_guidance/14327.asp.

GMC guidelines are recommended by the MPS and MDU, and the use of metformin in this context. has been agreed as a relevant example by the Defence Unions. Adhere to BNF formulary guidance on safe use in particular ensure renal function is adequate. Start with a low dose of 500mg daily and build up as tolerated to a maximum of 1.5 – 2 grams daily

Diabetes HbA1c ≥48 mmol/mol FPG ≥7.0 mmol/l RPG ≥11.1 mmol/l Endocrine review Follow NICE diabetes guidelines


Blood lipids

Total chol/HDL ratio to detect high

Brief intervention: Nutritional counselling: Lifestyle advice as above to improve quality of diet

Follow NICE guidelines for lipid modification Refer to specialist if total cholesterol >9, non-HDL chol >7.5 or TG>20









(>10%) risk of CVD based on QRISK-3 Tool.

http://qrisk.org

and increase physical activity . Refer for investigation, diagnosis and treatment by appropriate clinician if necessary.

(mmol/l)

Consider lipid modification for those with CVD or Diabetes


Physical Health of Trust Optimiser (PHOTO) Guidance (see figure one) In order to facilitate effective and comprehensive handover of the physical health status of a patient the following tool may be used as an aide-memoire for junior doctors. It is the responsibility of the junior/ward doctor to ensure these aspects are recorded and should a patient be transferred out of hours that the transfer of information is completed the next working day. In the absence of the ward/junior doctor this responsibility falls on the registrar and then consultant ultimately if needed.

Figure one: Physical Health of Trust Optimiser (PHOTO)

http://qrisk.org/





‘Perfect 10’: The 10 Ps of physical health optimisation Past: Record any pending results of investigations e.g. blood tests or imaging upon admission to mental health unit Present: Determination of current physical health conditions (acute and chronic) Possible: Consideration of emerging physical health concerns for duration of hospitalisation e.g. metabolic syndrome Problems: Identify and address side-effects. Utilisation of Glasgow Antipsychotic Side-Effect Scale (GASS) as appropriate Prescription: Review rationale for physical health medication on admission and at least every 6 months Peripherals: Ascertain status and accessibility of visual/hearing/dental aids and documentation of last eye test Pyramid: Escalate physical health status and pending actions to attention of Responsible Clinician in ward round Potential risks: Highlight any particular areas of concern with management of physical health or outstanding issues with clinical care Passport: Checklist of pending physical health tasks to ensure continuity prior to transfer/discharge to ensure forthcoming investigations are not missed Professional Support: seek senior advice or medical opinion if in any doubt for clarification

Community Services

Rapid Response Teams in both Home ward and Community Independence Service have Advanced Assessors and Non-Medical Prescribers who complete the initial assessment of the patient. The services are an alternative to an acute hospital admission and the teams will treat the patients for up to 5 days at home or 7 days in Magnolia Ward (Ealing residents only).The assessment includes a history of presenting complaint, past medical history, NEWS score, a full physical examination and some initial diagnostics. FBC / U&Es are completed and ECGs can be completed where indicated. In addition to the above Magnolia Ward will also complete MRSA screening, a Waterlow Score, MUST and falls assessment.

NB All patients admitted to Magnolia must have an MRSA screen.

7. Promoting parity

7.1 Primary Prevention – people with mental health problems experience increased morbidity and mortality as principally as a result of two modifiable risk factors tobacco use and obesity. WLMHT is committed to supporting patients with smoking cessation, weight management, healthy eating and undertaking exercise. WLMHT will support staff in adopting healthy lifestyles so that they can act as role models and support patients.

7.2 Screening and secondary prevention – tobacco use and obesity increase the risks of cardiovascular disease, diabetes, cerebrovascular disease and cancer. WLMHT will screen for these conditions, manage them directly or establish a clear pathway with other providers to ensure that these needs are met.



8. Education and training

8.1 WLMHT currently provide a comprehensive physical health training programme for student nurses, registered nurses, health care assistants and junior doctors on induction. The registered nurse and HCA programmes are run two days each month. Addition extended skills programmes encompassing ECG training; venepuncture and urinary catheterisation run throughout the year for nursing staff. Junior doctors training takes place throughout the year. Education and training programmes take place in the inpatient units to ensure all existing staff receive training. All training is delivered in accordance of the needs of the staff being trained i.e. the training that is delivered to junior doctors is in accordance with their role. Appendix two gives details of current training and this will be reviewed at least annually and more often if appropriate, by the Physical Health Care Group.

9. Inpatient monitoring requirements

9.1 Inpatient nursing staff are required to offer and undertake the following physical health

monitoring of service users.

9.1.1 Physical observations and the calculation of NEWS should be undertaken as specified in the M15 NEWs policy. This varies according to clinical risk and clinical setting from a minimum frequency of 12 hourly on Jubilee, the Limes, Meridian Ward and Magnolia Ward to weekly for inpatients and monthly in West London Forensic and High Secure Services if stable. At the Limes the frequency of monitoring of vital signs will be decided by the MDT on a case by case basis and any deviation from policy will be documented in that individual’s care plan.

9.1.2 Weekly Weight and calculation of BMI other than in High Secure Services (HSS) where weight will be checked monthly unless there are clinical indications to check more often. The side effects of antipsychotics include weight gain and an increased risk of DMT2 and hypercholesteraemia (eMC, 2016). Certain antipsychotic medication such as risperidone are associated with significantly more weight gain than other antipsychotics (Leucht et al, 2009). This weight gain leads to an increase in cardio-metabolic risk factors (RCPSYCH, 2013a: RCPSYCH, 2013b). Please see relevant Trust policies and procedures. Procedure: I17p Initiating and reviewing Long Acting Injections (LAIs) and Depot Antipsychotic Medication (Local Services), Procedure: H9p. The Use of High Dose Anti-psychotic Therapy (HDAT) and M2 medicines policy. Adults at high risk of developing type 2 diabetes should be directed to an effective and appropriate intensive lifestyle-change programme to prevent or delay the onset of type 2 diabetes. If this is ineffective or contraindicated consideration should be given to the prescribing of metformin (NICE, 2012)

9.1.3 Repeat of MUST screen as clinically indicated

9.1.4 Monitoring of fluid and food intake if there are clinical indications for this and escalation of clinical concerns as outlined in the “Make it Safe – Dehydration, January 2018 and the Medical Directors Bulletin on dehydration, dysphagia and acute kidney injury January 2018 and Think Kidneys (2016).

9.1.5 Blood glucose monitoring if clinically indicated and escalation of clinical concerns as outlined in the D17p: Management of Diabetes Mellitus in adults and young people policy.



10. Care planning and review

10.1 Physical healthcare will be centred on the specific physical healthcare needs of the individual. Each patient will have a care plan that addresses their identified physical health needs. Staff will follow the escalation process in relation to NEWs as clinically indicated. The NEWs score will be reviewed by the consultant on each ward round (other than in WLFS where an immediate review will be carried out if clinically indicated). This will be documented on RiO. Discussion of physical health needs will be included in ward round, medication reviews and whenever there is a change in the service user’s physical wellbeing.

10.2 Documentation that the service user’s physical health needs have been considered and attended to will be documented in RiO following each ward round.

10.3 Discharge Requirements

10.3.1 At the point of discharge from inpatient services, any physical health related abnormalities / findings and interventions should be shared as part of the discharge summary

10.4 Physical healthcare for children and young people under 18 in CAMHS

10.4.1 Role of Primary Care 10.4.1.1The GP has primary responsibility for the child’s health. No routine physical

examination for patients referred to CAMHS is expected as this falls outside the remit of the service (with exceptions). However, enquiry should be made at initial assessment about the child’s physical health and development, including medical history, family history, medication, other medical treatments, and allergies. This should be clearly documented on RIO in the agreed sections. All children on medication should have their medication details recorded on RIO (even if not prescribed by CAMHS).

10.4.2 Health Promotion 10.4.2.1 Responsibility for health promotion lies across Health services. CAMHS services should

display leaflets in waiting areas on health issues affecting young people such as nutrition, smoking, sexual health and substance misuse. CAMHS clinicians should be aware of services which provide specific support/treatment for such issues and should signpost young people to appropriate services in the local area where indicated.

Looked after children The specific needs of Looked After Children (LAC) must be taken into account. It is important to communicate with the young person’s allocated social worker. It is also important to check that recorded details of GP are current as young people who are LAC may have more frequent changes of GP as a result of any placement moves – particularly over Borough borders

10.4.3 Specific patient groups within CAMHS: 10.4.3.1Physical ill-health may develop in a child or be a complicating factor of their mental

health problem or treatment.



10.4.3.2Where the physical health problem is related to or has an impact on the child’s mental health or treatment, the CAMHS clinician has a duty to ensure there is a mechanism for such problems to be identified and managed. This may be undertaken directly by CAMHS, or via GP, paediatrics etc. Where the physical healthcare management is devolved to primary care or paediatrics, the CAMHS clinician should ensure there is clear communication to ensure clarity of roles and responsibilities. NICE guidance 155 recommends that for children and adolescents with psychosis or schizophrenia receive physical healthcare from primary care as described in recommendations 1.7.2–1.7.4. CAMHS clinicians should continue to maintain responsibility for monitoring and managing any side effects of antipsychotic medication

10.4.3.3Main groups which may involve CAMHS clinicians undertaking a more active role in physical health management are:

Children and adolescents receiving stimulant medication for ADHD.

Children and adolescents receiving antipsychotic medication.

Children and adolescents with eating disorders.

Children and adolescents with existing physical health problems. Children and adolescents who have substance misuse issues are generally

managed by specialist services outside CAMHS but where there is comorbidity and joint care with CAMHS.

For this group of patients, local team procedures regarding physical health assessment, monitoring and management should be followed.

10.4.4 CAMHS Clinician roles and responsibilities, including limitations

All clinicians should be able to measure weight and height.

All registered nurses and doctors should be able to measure temperature, pulse and blood pressure, height , weight and interpret findings

More detailed physical examination by medical staff may be carried out; however this should be limited to and not exceed the individual’s competency. Referral to a GP or specialist should be considered for cases that require specific expertise in physical examination and interpretation of investigations results.

The gender of the examiner must be considered and the wishes of the young person sought when carrying out a planned physical healthcare examination. There may be occasions, such as in an emergency situation, where the immediacy of the response means that it is not possible to seek the young person’s views. Every effort should be made to prevent this from happening.

In any case the person carrying out the examination will be the one to seek consent; they should be suitably trained and qualified, have sufficient knowledge of such an examination and understand the risks, benefits and any alternatives.

Ongoing relevant training to keep skills and knowledge up to date is required according to individual and service needs, in accordance with Trust policy M7.

Clinicians should be sensitive to cultural differences in patient attitudes to the body and physical health.



10.5 Chaperoning in outpatient CAMHS

10.5.1 It is good practice to have a parent or another clinician as a chaperone while conducting a physical examination.

10.5.2 A chaperone should always be offered and the name of the chaperone present must be

recorded on RiO. 10.5.3 If a chaperone is declined, (e.g., a young person who is deemed to be competent may

make the decision not to have a chaperone), the reasons for this should be clearly documented in RIO.

10.5.4 Most physical examinations in CAMHS are limited to height, weight, heart rate and blood

pressure assessments. Occasionally, a more systemic examination may take place but intimate examinations must never be undertaken. Young people should be weighed / examined in light clothing and must not be asked to undress to underwear

10.5.5 Clinicians should always use a chaperone in the following situation:

Physical health examination which involves wider system examination, e.g. chest, abdomen

If the young person is posing a risk of harm to others

If the young person is considered at risk of making allegations against staff We now would not examine outpatients in underwear

10.5.6 However, in an event where the 3 points above are not relevant to the particular

physical health examination, as a general rule, children under 16 years old may give consent for themselves if they have competence to consent to this decision. This means that they can say if they do not want their parent / responsible carer or another member of the healthcare staff to be in the room at the same time. This conversation and rationale must be recorded in the RiO record.

10.5.7 If the child is aged 16 or 17 years old, the law states that they must be the person who is

asked to give consent unless they are legally unable to consent for themselves, either due to their mental health, emotional maturity or learning disabilities. For young people aged 16 years or older, their ability to consent for themselves is judged by the Mental Capacity Act 2005.

10.5.8 The person carrying out the examination will be the one to seek consent; they should be

suitably trained and qualified, have sufficient knowledge of such an examination and understand the risks, benefits and any alternatives.

10.5.9 The seeking of consent and subsequent action taken must be recorded in the child’s

RiO record. The name of the chaperone present must be recorded.

11. Care Programme Approach (CPA) Reviews

11.1 When a service user has a long term condition the responsible inpatient team will ensure that secondary care reviews take place at the appropriate intervals as indicated by the



specialist. For service users who are inpatient for six months or more, their physical health must be reassessed a minimum of every six months for the first year and annually thereafter. This assessment will be recorded on RiO using the Physical Healthcare portal. Table Five summarises responsibilities.

Table Five: Medical and nursing responsibilities in relation to biannual or annual review


Who is responsible?

Time Scale

Physical health history

Consultant Psychiatrist/ Doctor

Update at least annually

Physical Examination

Doctor Update at least annually

Essential bloods

Doctor Update at least annually. Check if recently undertaken by another healthcare provider

ECG Doctor Nursing Staff may be able to assist.

When clinically indicated. Check if recently undertaken by another healthcare provider

Medicines review

Admitting doctor Update at least annually

LESTER tool Doctor Update at least annually


Doctor/Nurse Update at least annually


Nurse When clinically indicated

Height, weight and BMI

Nurse Update at least annually. NB Although height does not normally change in adults the nurse must re-enter height in order to calculate BMI on Rio – a note of last height is given but height (in cm) must be re-entered

Falls Risk Screening Assessment


Dysphagia screen


Urine Drug Screen


11.2 When assessment, and/or review at the CPA or any other occasion identify physical health needs, the responsible consultant (RC) should ensure that either treatment and advice is provided by the mental health team itself, or by an appropriate referral to:

The physical health care service at Forensic Services

Physical Health Department at Broadmoor hospital

To the service user’s registered GP

To a secondary care specialist team



11.3 It should be noted that in the Forensic Services and at Broadmoor, all referrals for a routine specialist opinion should be first directed to the primary care service.

11.4 All staff should be aware that for those who use the services provided by the Trust, physical health care is as important as the delivery of mental health care.

12. Service user and carer participation

12.1 At all levels the lived in experience and expertise from service users and carers will be sought to improve and develop the provision of physical health services. People admitted to inpatients are provided with a leaflet detailing how physical healthcare will be provided in the inpatient units. We have co-produced a teaching resource on how inpatients and outpatients can reduce their risk of type two diabetes and how they can manage diabetes well if they develop diabetes. This is being delivered by the recovery college. We anticipate further co-production work in the future.

13. Monitoring and governance

13.1 Monitoring

13.1.1 The aim of this policy and associated procedures to ensure that service users receive appropriate assessment and evidence based treatment to reduce cardio-metabolic and other risk factors and experience improved health outcomes. Trust will conduct audits, including the quarterly NEWS audit, the physical healthcare documentation audit, the review of medical emergencies audit, the slips trips and falls audit to monitor practice and outcome measures. The monthly Safety Thermometer will also be used on Meridian, the Limes, Jubilee and Magnolia and reported on quarterly.

13.1.2 For those service users for whom the Trust is entirely responsible for health care the nationally recognised Quality and Outcome Framework (QOF) data is used. For the inpatients for which WLMHT is responsible for managing physical health in the absence of access to GMS care, namely the secure settings at Broadmoor Hospital and Ealing locations, QOF is used to benchmark with standards set out for primary care. EMIS Web is used for consultations and accordingly relevant data is coded which in turn is incorporated within the population reporting used for QOF submissions. In the absence of a GMS contract the data is not submitted to NHSE but instead used as a continuous audit for the clinical teams to measure quality of the service provided and to identify patients who may benefit from further physical health review. Such data is also used to benchmark practice as per primary care such as the submission of data to the National Diabetes Audit. The process is overseen by the Director of Primary Care.

13.2 Governance Figure two illustrates the governance process.



Figure two: The governance process.

13.2.1 Each Clinical Service Unit (CSU) has a Physical Healthcare, Infection Control, Medical Equipment and Patient Environment Meeting. This report into the Trust clinical governance group a sub-group of the Quality Committee. In this way the Board of the Trust, which receives the minutes of that committee can be informed of both the quality and the quantity of provision of physical health care.

13.2.2 The implementation and monitoring of the Physical Health Care policy will be managed at local level by the CSU groups and overseen by the Trust Physical Health steering group. This group will report to the Quality Committee which reports to the Board of the Trust.

13.2.3 The Trust Physical Health steering group will be chaired by the Medical Director and or the Director of Nursing and Patient Experience, and will meet monthly. The minutes of the meeting will be sent to the Quality Committee as a standard agenda item.

13.2.4 The Medical Director will act as sponsor for the work of the Trust Physical Health steering group and will assist in the implementation and monitoring of its work. The Medical Director will also ensure that the priorities and work programmes elsewhere in the Trust co-ordinate effectively with this group.

13.3 Audits and Reviews of Policies

13.3.1 There are a number of audits and reviews which each Clinical Service Unit (CSU)

Physical Healthcare, Infection Control, Medical Equipment and Patient Environment Meeting will carry out. These are:

Quarterly review of incidents relating to slips, trips, and falls

Quarterly review of incidents relating to medical emergencies

Physical Healthcare, Infection Control, Medical

Equipment and Patient Environment Meeting

Trust Physical Steering Health Group

Quality Commitee (QC) QC

PHSWG

Local Services West London

Forensic Services

High Secure Services



Quarterly review of incidents relating to the development of pressure sores

Quarterly audit of NEWS

Quarterly audit of Venous Thromboembolism (VTE) assessment

Quarterly audit of physical healthcare documentation

Quarterly reviews of nutritional audits and MUST tool completion when a person is vulnerable to malnutrition

Quarterly review of CQUIN targets where appropriate

13.3.2 The Trust Integrated Patient Physical Health and Environment Committee (IPHEC) will advise the clinical audit team of the need for any additional CSU or Trust wide audits that may be required in relation to clinical concerns or service improvement.

14. Fraud statement

N/A

15. Supporting documents

15.1 The following policies are those that relate to physical health care, and need to be

reviewed and included in the terms of reference of the Physical Health Care Group:

Physical healthcare strategy

Procedure: I17p Initiating and reviewing Long Acting Injections (LAIs) and Depot Antipsychotic Medication (Local Services)

Procedure: H9p. The Use of High Dose Anti-psychotic Therapy (HDAT)

M2 medicines policy

F8: C2 :Care Programme Approach Policy CPA policy

WLFS35 Management of CPAs within the WLFS

Infection Prevention & Control Strategy 2014 – 2017

P16 Pressure Ulcer Prevention Management Policy

I11p Inpatient risk assessment and treatment to prevent Venous Thromboembolism (VTE)

D17p: Management of Diabetes Mellitus (in adults and young people)

F3; First Aid

B4; Basic Life Support

S5; Smoke Free



F7; Food and nutrition

F8; Prevention of inpatient falls and care and treatment of a patient following a fall or head injury

M7; Medical Equipment

M15: NEWS policy

I11P VTE procedure

ICP1 Infection control policy

P16: Pressure ulcer prevention policy

O5g Prevention, Identification & Management of Overweight & Obesity

F7 Food, Nutrition & Hydration Policy

D16 Dysphagia Policy

S34g Smoking Reduction & Cessation Guideline

15.2 All the above policies need to be included as part of the overall physical health care strategy, and are compatible with both that strategy and national best practice.

15.3 Guidance documents, which will inform part of the work of the Food and Drink Strategy

Group

D16 Dysphagia policy

O5g Prevention, Identification & Management of Overweight & Obesity

16. Acronyms

ANP Advanced nurse practitioner. A nurse who has recognised qualifications in history taking, advanced physical assessment and diagnostic reasoning.

GP General Practitioner

CIG Clinical Improvement Group

CPA Care Programme Approach

CQUIN Commissioning for Quality and Innovation

DH Department of Health



LMC Local Medical Committee

Consultant nurse physical healthcare

Nurse qualified to master’s level who has recognised qualifications in history taking, advanced physical assessment and diagnostic reasoning and prescribing.

NEWS National Early Warning Score

NICE National Institute for Health and Clinical Excellence

NHS National Health Service

WLMHT West London Mental Health Trust

17. References

All Party Parliamentary Group on Mental Health (2015). Parity in progress? The All Party Parliamentary Group on Mental Health’s inquiry into parity of esteem for mental health. www.rcpsych.ac.uk/pdf/APPG%20on%20Mental%20Health-%20Parity%20in%20Progress.pdf

Care Quality Commission (CQC) (2015). Regulations for service providers and managers. CQC, London. http://www.cqc.org.uk/content/regulations-service-providers-and-managers

Department of Health (2012). No Health Without Mental Health: Implementation Framework. Department of Health, London www.dh.gov.uk/health/files/2012/07/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf

Department of Health (2015). The NHS Constitution., Department of Health, London https://www.gov.uk/government/publications/the-nhs-constitution-for-england

Department of Health (2016) Improving the physical health of people with mental health problems: Actions for mental health nurses. Department of Health, London https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/532253/JRA_Physical_Health_revised.pdf

Electronic Medicines Compendium (eMC) (2016). RISPERDAL CONSTA 25 mg powder and solvent for prolonged-release suspension for intramuscular injection. eMC, Surrey. https://www.medicines.org.uk/emc/medicine/9939/SPC/RISPERDAL+CONSTA+25,+37.5+and+50+mg+powder+and+solvent+for+prolongedrelease+suspension+for+intramuscular+injection/

http://www.rcpsych.ac.uk/pdf/APPG%20on%20Mental%20Health-%20Parity%20in%20Progress.pdf

http://www.rcpsych.ac.uk/pdf/APPG%20on%20Mental%20Health-%20Parity%20in%20Progress.pdf

http://www.cqc.org.uk/content/regulations-service-providers-and-managers

http://www.dh.gov.uk/health/files/2012/07/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf

http://www.dh.gov.uk/health/files/2012/07/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf

https://www.gov.uk/government/publications/the-nhs-constitution-for-england

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/532253/JRA_Physical_Health_revised.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/532253/JRA_Physical_Health_revised.pdf

https://www.medicines.org.uk/emc/medicine/9939/SPC/RISPERDAL+CONSTA+25,+37.5+and+50+mg+powder+and+solvent+for+prolongedrelease+suspension+for+intramuscular+injection/





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Hennekens CH, Hennekens AR, Hollar D et al (2005). Schizophrenia and increased risks of cardiovascular disease. Am Heart J 150:6:1115–1121

Humphrey, L. L., Fu, R., Buckley, D. I., Freeman, M., & Helfand, M. (2008). Periodontal disease and coronary heart disease incidence: a systematic review and meta-analysis. Journal of General Internal Medicine, 23:12, 2079–2086. https://link.springer.com/article/10.1007/s11606-008-0787-6#page-1 Kisely, S., Baghaie, H., Lalloo, R., Siskind, D., & Johnson, N. W. (2015). A systematic review and meta-analysis of the association between poor oral health and severe mental illness. Psychosomatic Medicine, 77:1: 83–92. https://journals.lww.com/psychosomaticmedicine/Abstract/2015/01000/A_Systematic_Review_and_Meta_Analysis_of_the.11.aspx

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Leucht S, Corves C, Arbter D (2009). Second generation versus first generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet 373(9657): 31–41

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2808%2961764-X/abstract

Mirza, I. (2001). Oral health of psychiatric in-patients: A point prevalence survey of an inner-city hospital. Psychiatric Bulletin. 25:4: 143–145.

NHS England (2016) Five year Forward View for Mental Health. NHS England, London https://www.england.nhs.uk/wp-content/.../Mental-Health-Taskforce-FYFV-final.pdf

Institute for Health and Clinical Excellence (NICE) (2012). Type 2 diabetes: prevention in people at high risk.[PH38] Updated 2017. NICE, London https://www.nice.org.uk/guidance/ph38

National Institute for Health and Clinical Excellence (NICE)((2011). Hypertension in adults: diagnosis and management . Clinical guideline [CG127] Last updated: November 2016 NICE, London https://www.nice.org.uk/guidance/cg127

NICE (2013). Psychosis and schizophrenia in children and young people: recognition and management. Clinical guideline [CG155]. Last updated: October 2016


http://onlinelibrary.wiley.com/doi/10.1111/j.1447-0349.2012.00823.x/full

https://link.springer.com/article/10.1007/s11606-008-0787-6#page-1

https://journals.lww.com/psychosomaticmedicine/Abstract/2015/01000/A_Systematic_Review_and_Meta_Analysis_of_the.11.aspx

https://journals.lww.com/psychosomaticmedicine/Abstract/2015/01000/A_Systematic_Review_and_Meta_Analysis_of_the.11.aspx



https://www.england.nhs.uk/wp-content/.../Mental-Health-Taskforce-FYFV-final.pdf




National Institute for Health and Clinical Excellence (NICE) (2014a). Psychosis and schizophrenia in adults: prevention and management Clinical guideline CG178. NICE, London https://www.nice.org.uk/guidance/cg178

National Institute for Health and Clinical Excellence (NICE)(2014b) Bipolar disorder: assessment and management. Clinical guideline [CG185] Last updated: February 2016 . NICE, London https://www.nice.org.uk/guidance/cg185 National Institute for Health and Clinical Excellence (NICE) (2015). NICE Quality Standard QS 80 - Psychosis and schizophrenia in adults. NICE, London https://www.nice.org.uk/guidance/qs80

National Institute for Health and Clinical Excellence (NICE) (2017). Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition Clinical guideline [CG32] Published date: February 2006 Last updated: August 2017. NICE, London https://www.nice.org.uk/guidance/cg32

Orellana, G., & Slachevsky, A. (2013). Executive Functioning in Schizophrenia. Frontiers in Psychiatry, 4, 35. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3690455/#B110

Public Health England (2014a). Adult obesity and type 2 diabetes. Public Health England, London https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/338934/Adult_obesity_and_type_2_diabetes_.pdf

Public Health England (2014b). Adult obesity and socioeconomic status data factsheet. . PHE publications gateway number: 2014264. Public Health England http://www.noo.org.uk/securefiles/160516_1452//AdultSocioeconomic_Aug2014_v2.pdf

Royal College of Psychiatrists (2013a). Lester UK Positive Cardiometabolic Health Resource. Adapted from Curtis J, Newall H, Samaras K. © HETI 2011. Royal College of Psychiatrists, London. https://www.rcpsych.ac.uk/.../RCP_11049_ Positive%20Cardiometabolic%20Health%20chart-%20website.pdf

Royal College of Psychiatrists (2013b). Improving physical healthcare for people with mental illness: what can be done? Royal College of Psychiatrists, London www.rcpsych.ac.uk/pdf/FR%20GAP%2001-%20final2013.pdf

Royal College of Psychiatrists (2016). Improving the Physical Health of Adults with Severe Mental Illness: Essential Actions. Royal College of Psychiatrists London: http://www.rcpsych.ac.uk/mediacentre/adultswithsmi.aspx



https://www.nice.org.uk/guidance/qs80


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3690455/#B110

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/338934/Adult_obesity_and_type_2_diabetes_.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/338934/Adult_obesity_and_type_2_diabetes_.pdf

http://www.noo.org.uk/securefiles/160516_1452/AdultSocioeconomic_Aug2014_v2.pdf

http://www.rcpsych.ac.uk/pdf/FR%20GAP%2001-%20final2013.pdf

http://www.rcpsych.ac.uk/mediacentre/adultswithsmi.aspx



Schmitt A., Hasan A., Gruber O., Falkai P. (2011). Schizophrenia as a disorder of disconnectivity. Eur. Arch. Psychiatry Clin. Neurosci. 261(Suppl. 2), S150–S15410.1098 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3207137/ Think Kidneys (2016). Guidance for mental health professionals on the management of acute kidney injury. https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2016/02/Guidance-for-mental-health-patients-version-v18.pdf

Velligan DI, Alphs L, Lancaster S, et al (2009). Association between changes on the Negative Symptom Assessment scale (NSA-16) and measures of functional outcome in schizophrenia. Psychiatry Res. 169:97-100.

18. Appendices

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3207137/

https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2016/02/Guidance-for-mental-health-patients-version-v18.pdf

https://www.thinkkidneys.nhs.uk/aki/wp-content/uploads/sites/2/2016/02/Guidance-for-mental-health-patients-version-v18.pdf



Appendix 1



Appendix 2

Physical healthcare skills taught on induction

Registered nurses and healthcare assistants who attend induction on the Ealing site will now receive physical healthcare training on induction. The training runs on two days as part of the induction. Current staff who have not attended any of these sessions are welcome to attend.

Programme

Time Subject Summary

9:30-10:30

National Early Warning Score (NEWS)

People with mental health problems are more likely than the general population to have long term conditions and have greater difficulty in managing these conditions. People with long term conditions can deteriorate and require urgent medical care. The NEWS score enables staff to detect deterioration. This session aims to enable staff to calculate a NEWS score, understand its significance and to escalate physical health concerns using the Trust policy. It covers the care and physical observation of people following rapid tranquillisation.

10:30-11:30

Situation Background Assessment Recommendation and Decision (SBARD)

This communication tool originally developed by the US navy and widely adopted in healthcare settings aims to enable staff to communicate effectively escalate in emergencies and use in day to day communication.

11:30-11:45

Break

11:45-12MD

Dysphagia awareness Around 30% of people with mental health problems experience swallowing difficulties this is around 4 times the national average. This interactive session explains why this occurs, how to identify dysphagia and actions to take when there are concerns regarding swallowing.

12-13:00

Diabetes and management of diabetic emergencies

Around 15% of people with Serious Mental Illness (SMI) have diabetes mellitus (DM). This is twice the national average. People with SMI and DM are more likely to have problems managing diabetes and the incidence of emergencies and complications is much greater than in the general diabetic population. Awareness of Diabetes mellitus, common diabetic emergencies, the diabetes procedure, actions to be taken when emergencies occur

13:-00-13:30

Lunch

13:30- Catheter care This session aims to enable staff to understand the fundamentals of caring for a person with an indwelling



14:30 urinary catheter

14:30-15:30

Falls and head injury This session aims to enable staff to understand the fundamentals of why people fall, what care treatment and observation is required following a fall and how to do the Glasgow coma scale observations

15:30-15:45

Break

14:45-16:45

Pressure ulcers and wound care/ LN or Elaine Smith

This session aims to enable staff to understand why people develop pressure ulcers, what care treatment and observation is required to prevent and treat It also covers simple wound care

Dates 2017: 11th and 12th January, 8th and 9th February, 8th and 9th March, 12th and 13th of April, 10th and 11th

of May, 14th

and 15th

of June, 12th

and 13th

of July, 9th

and 10th

of

August, 13th

and 14th

of September, 11th

and 12 of October, 8th

and 9th

of November, 13th

and 14th

of December

Venue: Ash Room, Learning and Development, St Bernard’s Dates: 2018

Wednesday Thursday Jan 10th Jan 11th

Feb 14th Feb 15th

Mar 14th Mar 15th

Apr 11th Apr 12th

May 9th May 10

th

June 13th June 14th

July 11th July 12th

Aug 8th Aug 9th Sept 12th Sept 13th

Oct 10th Oct 11th

Nov 14th Nov 15th

Dec 12th Dec 13th

Jan 9th Jan 10th

Feb 13th Feb 14

th

Mar 13th Mar 14

th

Takes place in Ealing LDC E BLOCK

Ealing LDC St Bernard’s or fire training centre



Current onsite training: Head injury and falls

15th December Staff = Available = 150 excludes 1 Horizon and 1 Avonmore LTS + 1 Avonmore ML+1 Horizon =LTS + 1 Jub + 1 Mott LTS not available Total trained = 124 trained = 83%. To be trained = 26 Total no training sessions = 42

Unit Total RNS Total trained To be trained Percentage trained

Training sessions to date

Wolsey 14 12 2 86% 9

Limes 9 8 1 89% 3

Lakeside 45 41 4 91% 13

H&F 63 48 15 76% 17 Jubilee 13 11 3 85% 9

Mott House 6 (1 LTS) 5 1 83% 9

Totals 150 124 26 83% 42

Community training dates:

Wednesday 1st November ERTE – Avenue House

Wednesday 15th November ERTW – The Limes

Wednesday 22nd November HRT – London Road

Wednesday 6th December H&F - Claybrook



Community training for staff in post working in community

9AM: Registration, Quiz, introductions and aims of day 9:20-10AM. The importance of physical healthcare Improving the physical health of people with SMI, essential actions for mental health nurses. Why patients with SMU die earlier. What can be done? Introduction to the Lester tool 10-10:30 AM: Support to give up smoking Evidence base, activities to achieve change, NICE guidance, supporting tools. How to document on Rio 10:30-10:45: Break 10:45-11:15. Lifestyle and life skills Promoting a healthy diet and an active lifestyle 11:15-12md. Weight management Practical: how to measure height and weight and calculate BMI. Significance of BMI. Recording on Rio. NICE guidance and actions to take if BMI abnormal. https://www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx http://www.bapen.org.uk/screening-and-must/must-calculator 12md – 12:45- Lunch 12:45 -1:30: Blood pressure Practical session. What is the significance of blood pressure. What is normal and what requires treatment. How to record on Rio NICE guidance, special groups; older people, Afro-Caribbean those with diabetes and cardiovascular disease. Recording on Rio. Actions to take.

https://www.nhs.uk/Tools/Pages/Healthyweightcalculator.aspx



1:30-2:30PM Diabetes and those at high risk of diabetes. What is diabetes how is it diagnosed and treated. How can we reduce the risk of diabetes? Blood glucose levels and HbA1c. Prevention and treatment options. How to check blood results on ICE How to calculate risk of diabetes; https://riskscore.diabetes.org.uk/start 2:30-2:45: Cardiovascular disease and the role of lipids. What is good, bad and total cholesterol? How is this treated? 2:45-3:15: Break 3:15: 3:45: Don’t just screen intervene Putting it all together, calculating Q risk score. https://qrisk.org/2017/index.php Over 10% actions required. Recording on Rio. What’s your heart age? https://www.bhf.org.uk/heart-health/risk-factors/check-your-heart-age 3:45-4 Final quiz, evaluation and close

Other training

Time Subject Summary

One day Five courses a year

Male and female catheterisation (Held at Ealing Hospital L&D)

This one day training is for nurses who may need to change indwelling urinary catheters. There is one day training, a workbook and a competency assessment. After the training staff attend an acute setting and are observed to carry out three male and three female catheterisations. They are signed off as competent and the competency document certified by the nurse consultant a certificate of competency is issued and the competency is registered on the Exchange

½ day morning Eight courses a year

Venepuncture (Held at Ealing Hospital

This half day training is for nurses who may need to take blood samples There a workbook and a competency assessment. After the training staff attend an acute setting and are

https://riskscore.diabetes.org.uk/start

https://qrisk.org/2017/index.php

https://www.bhf.org.uk/heart-health/risk-factors/check-your-heart-age



L&D) observed to carry out 5 venepunctures. They are signed off as competent and the competency document certified by the nurse consultant a certificate of competency is issued and the competency is registered on the Exchange

90 minutes Taking an ECG This session consists of theory and practice and aims to enable nursing staff to take an ECG. Attendance is recorded on the Exchange

Two hours Catheter care This session aims to enable staff to understand the fundamentals of caring for a person with an indwelling urinary catheter

One hour Falls This session aims to enable staff to understand the fundamentals of why people fall, what care treatment and observation is required following a fall and how to do the Glasgow coma scale observations

One hour Pressure ulcers LN or Elaine Smith

This session aims to enable staff to understand why people develop pressure ulcers, what care treatment and observation is required to prevent and treat

One hour Wound care LN or Elaine Smith

This session aims to enable staff to understand how wounds heal and to enable them to provide simple wound care

Venepuncture dates: 2018

RNs HCAs

16th January 26th January

27th February None

3rd April 23rd March

22nd May 25th May

3rd July 27th July

7th August None

18th September 28th September

13th November 30th November



Catheterisation dates 2018 all day at EHT L&D 31st January 23

rd March

14th

May 20

th July

27th

September 29

th November

ECG training at Clayponds at 3pm 21/12/17 18/1/18 16/2/18 Junior doctors induction: QRisk 3 & Lester Tool VTE assessment Diabetes NEWS, SBARD and escalation of deteriorating patient Dates: Hounslow – 28

th Feb

Ealing – 14th

March – H&F – 28

th March –

Additional dates added through the year

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