Improving Care for inpatients with Severe Mental Illness
(SMI) on Medical and Surgical Wards
Ella Reeves, PhD student, Faculty of Health and Life Sciences, Oxford Brookes University.
Professor Jane Appleton, Department of Sport, Health Sciences and Social Work and Oxford School of Nursing and Midwifery, Faculty of Health and Life Sciences,
Oxford Brookes University
Dr Helen Walthall, Oxford School of Nursing and Midwifery, Faculty of Health and Life Sciences, Oxford Brookes University
Dr Ian Scott, Faculty of Health and Life Sciences, Oxford Brookes University
Severe mental illness (SMI) refers to a diagnosis of schizophrenia, psychosis and bipolar disorder1
Aim: investigating and improving patient safety for inpatients with SMI in acute general hospital wards
Background
People with SMI die
15-20 years earlier
Riskier lifestyles Difficulties diagnosing
(e.g. smoking/ obesity) physical illnesses
This is often attributed to
patient factors such as:
than people in the general population,
mainly from preventable physical
causes2
Not following Side effects
care plans of Medications3
But it’s not just patient factors
There is evidence that people with SMI also receive lower quality care.3
Systematic literature review 4
THEMES
Key finding: hospital inpatients with SMI are more likely to
experience an adverse event than people with no mental illness (NMI)
Definition
More likely to be admitted in an
emergency
Poorer access to treatment
A patient safety incident or adverse event is any unintended/unexpected incident which
could have or did lead to harm.5 The adverse events in this literature review were found on
healthcare records. There was no detail on how adverse events happened and why.
Why are there
differences?
Acute general hospital inpatients with SMI
Surgery is more likely to be invasive
Less likely to receive surgery
•
Unclear. Stigma of mental illness may have an effect.
•
Staff may be hesitant to approach service users with SMI, due to lack
of skills and experience.
•
Patient factors have an effect.
Analysis of patient safety incidents reported by
staff → to compare incident frequency by SMI vs
NMI, using chi-square and multiple logistic
regression analysis.
Significant differences in charts indicated by: * p ≤ .05, **p ≤ .01, ***p ≤ .001
Figure 2: Incident impact: NMI vs SMI
15%
11.38%
10%
0.02%
0.02%
0.03%
0.48%
0.07%
0.78%
0%
NoNo
Mental
Illness
Mental
Illness
SMI
SMI
Minor injury/illness***
No Mental Illness
0.4% 0.7%
0.0% 0.3%
SMI
0.0% 0.2%
Radiation**
Venous
thromboembolism
(VTEs)*
Aggression***
Security/ missing
persons***
Admissions &
transfers**
Medication***
Figure 3: Significant differences in prevalence of incident types: NMI vs SMI
10%
8.0%
8% 6.0%
6.1%
6%
4.1%
2.7%
2.9%
4%
2.5%
1.9%
0.1% 1.0% 0.1% 0.8% 0.5% 0.7%
2%
0%
No harm***
Self-harm***
Moderate effect*
Management*
Major injury
Pressure ulcers***
INCIDENT TYPES
RESULTS
20.3%
14.1%
No Mental Illness
SMI
All incidents***
Figure 1: People with SMI were 1.7 times more likely to experience an
incident in hospital (20.3% compared to 14.1%). [Adjusted Odds Ratio (AOR)
= 1.70, p<.001]. A multiple logistic regression model was applied to adjust the
odds ratio for age, sex, updated Charlson Comorbidity Index (uCCI) score,6
length of stay, admission type (medical/surgical/mixed), admission year.
Statistical analysis approach used in Figure 2. Compared prevalence of incidents
by level of impact, using chi-square.
• Incidents at moderate impact (p ≤ .05), minor impact (p ≤ .001) and no harm (p ≤
.001) were more prevalent for inpatients with SMI.
• Not enough data to determine whether there were differences in the prevalence of
death/major impact.
6.08%
4.31%
5%
Death
DISCUSSION
25%
20%
15%
10%
5%
0%
16.63%
Falls***
INCIDENT IMPACT
RESULTS
20%
INCIDENT PREVALENCE
People with SMI were
consulted about the aims
and methods, and
supported the
project
Figure 1: Prevalence of incidents: NMI vs SMI
RESULTS
METHODS
ETHICS
Secondary analysis of patient safety incident data
Summary
• Inpatients with SMI are more likely to experience an incident. These include incidents related to missing service
users and self-harm, so the difference in overall numbers of incidents may not reflect differences in care.
However, there is no direct link between some types of incidents, such as pressure ulcers and falls, which were
more common for service users with SMI.
• The initial qualitative analysis of incident investigations indicates that there are similar contributory factors to
pressure ulcers for inpatients with SMI and those with NMI.
• Other studies suggest that there are differences in the care provided to inpatients with SMI (e.g there are fewer
dietary consultations/smoking advice offered, despite higher levels of obesity and smoking; and service users
with SMI were more likely to have a surgeon with a higher risk-adjusted mortality rate).4,7,8
• Discrepancies in findings may be due to: differences between studies; or further analysis is needed in this
study; or there are omissions in incident data; or patient factors such as comorbidities have a multiplying effect,
making inpatients with SMI more vulnerable to harm when experiencing the same contributory factors.
• If this study finds no differences in quality of care, the findings remain useful, with wider application to the
overall patient population. Efforts can be focused on more vulnerable service users with SMI.
Next steps
• Qualitative analysis: continue to investigate the contributory factors to incidents and compare SMI incidents to
controls with NMI, to explore:
➢ The contributory factors to patient safety incidents for general hospital inpatients with SMI.
➢ Recommendations for how to provide safer care for inpatients with SMI.
Figure 3: There were 10 types of incidents more prevalent in people with SMI
(analysed using chi-square). inpatients with SMI were more likely to experience an
incident overall (Figure 1), but some of these incidents may be due to the complex
needs of people with SMI, so incident types were examined. There were no
significant differences for other types of incidents in the data set, such as infection
control incidents and blood transfusions.
Pressure ulcers: a closer look
• Most common type of incident for all service users.
• Most hospital-acquired grade 3 and 4 pressure ulcers are investigated at the highest level in the NHS Trust and
reported externally.
• Fishbone diagrams are commonly used in incident investigations to examine causes (Figure 4). There were similar
contributory factors for service users with NMI.
Reduced patient care time
RN = registered nurse.
CSW = clinical support worker.
Staff communication
Patient factors
Between RNs & CSWs
Minimum staffing
Reduced mobility
Comorbidities affect wound healing
New systems taking
time to learn
Lacking at handovers
Similar factors for inpatients with NMI
CSWs unsure what
to record
Unclear how to
order equipment
Notes completed at
shift end
Omissions in
documentation
Lack of staff knowledge
Assessments not acted
upon
Delays receiving specialist
equipment (e.g. mattresses)
Pressure
ulcers:
contributory
factors in SMI
inpatients
Staff did not recognise importance
of completing & repeating
Inadequate pressure area and
nutritional risk assessments
Figure 4: fishbone diagram of contributory factors to pressure ulcers for SMI inpatients.
References
1 National Institute for Health and Care Excellence (NICE) (2015) Indicator Development Programme Briefing Paper.
2 Jayatilleke N, Hayes RD, Dutta R, Shetty H, Hotopf M, Chang C-K and Stewart R (2017) Contributions of specific causes of death to lost life expectancy in severe mental illness. European Psychiatry. Elsevier Masson 43: 109–11
3 Lawrence D and Kisely S (2010) Inequalities in healthcare provision for people with severe mental illness. Journal of Psychopharmacology. 24(11): 61–68.
4 Reeves E, Henshall C, Hutchinson M and Jackson D (2018) Safety of service users with severe mental illness receiving inpatient care on medical and surgical wards: A systematic review. International Journal of Mental Health Nursing 27(1): 46–60.
5 NHS England (2015) Serious Incident Framework: Supporting learning to prevent recurrence.
6 Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, Januel J-M and Sundararajan V (2011) Updating and Validating the Charlson Comorbidity Index and Score for Risk Adjustment in Hospital Discharge Abstracts Using Data From 6 Countries. American Journal of Epidemiology 173(6): 676–682.
7 Briskman I, Bar G, Boaz M and Shargorodsky M (2012) Impact of co-morbid mental illness on the diagnosis and management of patients hospitalized for medical conditions in a general hospital. International journal of psychiatry in medicine 43(4): 339–48.
8 Li Y, Glance LG, Cai X and Mukamel DB (2007) Are patients with coexisting mental disorders more likely to receive CABG surgery from low-quality cardiac surgeons? The experience in New York State. Medical care 45(7): 587–93.