Recognising and Responding to
Psychiatric Deterioration
A/Prof Richard Newton
Medical Director, Mental Health,
Austin Health, Victoria.
Melbourne University
Monash University
Death of a Young Man with Schizophrenia
• 18 yo, FEP, community case managed with moderate response to oral Olanzapine, but marked weight gain,
• 2 years later reduced adherence with medication recognised but not acted on
• Slow deterioration in mental state two months later not recognised, - withdrawal, low grade persecutory beliefs,
worsening of auditory hallucinations
• Six months later further escalating aggression and dangerous driving whilst intoxicated incorrectly attributed to
personality issues
• Family increasingly contacting case manager with concerns about mental state and risk but feel unheard
• Service response is to provide phone number of drug detox service
• Three months later patient admitted floridly psychotic, intoxicated with amphetamines,
• Aggressive to police prior to admission and secluded for three days on admission
• detoxed and the same oral antipsychotics reinitiated, response partial returned home after three weeks.
• Drug abuse continues, ceases medication, family can’t cope
• 2 years later loss of home, move into poor quality rooming house, ongoing contact with service however
• Gradual relapse of psychosis secondary to non compliance
• Case manager documents worsening hopelessness and demoralisation, ongoing substance use, grief and
anger with family, aggression risk assessed but no suicide risk assessment.
• Found hanging in his bathroom a week later 5 years after first diagnosis. In continuous contact with service
throughout this deteriorating course.
National Safety and Quality Health
Service Standards
Recognition and Response to the Deteriorating Patient in Mental HealthIHI.ORG
National Standards For Mental health
Services
National Standards For Mental health
Services
Recognising and Responding to Psychiatric Deterioration
Scope of the issues
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Acute Care Settings / Continuing Care Settings
Mental State / Physical Health / Psychosocial Deterioration
Risk to Self / Risk to Others
Time lag between change and response often months
Lack of objective measures to assess deterioration and reliance on
subjective measures
• Incongruence between documentation and clinical reality
• families and carers as informants Vs Patient as informant
Makes tools such as risk assessment and other traffic
light systems for recognition and rapid response to
deteriorating patient hard to implement
• Effect size for interventions 20% difference at best from placebo
• Treatment that objectively does not meet adequate standards of care
often leads to good outcomes
Recognising and Responding to Psychiatric Deterioration
Complexity in Mental Health Care Practice
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Quality of individual clinical practice
Adherence to professional standards
Culture and attitudes that develop in a team or a service
Service setting standards of care – use of pathways etc
Service systems to support best care
Individuals and teams accountable to practice within these
systems whilst professional standards and individual best
practice supported.
How can we learn from adverse event reviews
• Use of CIR methodology to review and act upon findings
from review of
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Sudden and Unexpected Death
Seclusion
Readmission
Assault
Self Harm
Absconding
• Common theme is lack of recognition or response to the
deteriorating patient
Case Study_ Reducing Seclusion
•Primary prevention
–Organisational philosophy that articulates nonviolence in policy, procedure and practice
–Risk assessment tools – Risk Assessment and
Management Plan
–Comfort rooms and self soothing activities
–Communication tools and handover tool
developed
–Protected Therapeutic Engagement Time
Seclusion Reduction
Case Study_ Reducing Seclusion
Leg
LOS
Invol
60
RCTO
58
Vol
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ob s
HSA
57
60
LB 27
For Assesment
urb
Ris k
Non-Compliance
Schizophrenia
20
Sub
LB 32
17/4/12
DOA
18/4/12
20
UR
LB 45
20/4/12
s
Con
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Ag e
BE D
Nam
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Thursday, 14 June 2012
55
Tasks / To Do
Do Not write patient family name anywhere . Place in Confidential waste at completion of shift
LSA Trials
SW r/V next week
Endo R/V pending
Protected Therapeutic Engagement Time
• Contact Nurse will ensure that that they introduce themselves to their patients each shift.
• They will arrange a time with the patient to catch up with them during their 8 hour shift to
engage in a conversation with them – aim for 20 mins of contact time
• The themes raised during that time will be documented in the clinical file under the heading of
P.T.E.T
• Where there are requests and or questions made by the patient these will be noted in the
above section
• Should a patient decline the offer of the P.T.E.T then this will be recorded in the clinical file.
• P.T.E.T should be offered to all patients in the acute programme every morning and afternoon
shift 7 days per week.
Case Study_ Reducing Seclusion
• Secondary Prevention
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Recognise deterioration respond to prevent escalation
Personal safety plan
Avoid power struggles and coercive responses
Maintain a soothing environment
• Tertiary Prevention
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Explore precipitating factors
Post seclusion counselling
Review/update treatment plan
Restraint for shortest time possible
Review of seclusion and restraint events to inform new practice
Case Example – Recognising and Responding to Psychiatric Deterioration - Specialist Eating Disorder Unit
• Acute Adult In-Patient Unit with 5 Specialist Eating Disorder Beds
• 2008 Situation
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Staff not confident to manage AN patients with physical health problems.
Perceived lack of support for physical health problems
Average BMI of IPs to specialist Eating Disorder beds >17.5, average BMI change 0.1
High rates of NG tube refeeding and long stays in acute medical ward
Constant presence of eating disorder patients in medical beds
High rates of Dissatisfaction from staff and patients in unit
Recognising and Responding to Physical Deterioration- Eating Disorders
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Medical rescue identified as specialist role for unit
Medical Unit identified to provide specific support to Eating Disorders Programme
Nursing team trained to insert and manage NG tube refeeding on unit
Specialist meal support and other groups established
Team provided with education regarding the adaptive physiological response and
maladaptive health risks associated with starvation
Twice weekly ward round with review tool adapted to the unit. Clearly specifies
medical and psychiatric risks, frequency of investigations, frequency of visual and
physical observations
Traffic light system to identify observations that require a clinical response
Nutrition
CVS
Test/
Investigation
Concern
Alert
BMI
<14
<12
Weight loss per week
>0.5kg
>1.0kg
Albumin
<35
<32
Creatinine Kinase
>170
>250
Systolic BP
<90
<80
Diastolic BP
<70
<60
Postural drop
>10
>20
Pulse
<50
<40
QTc
Temperature
>450msec
<35°
<34.5°
Bone
Marrow
Electrolytes
Liver
Function
Investigation
Concern
Alert
WCC
<4.0
<2.0
Neutrophils
<1.5
<1.0
Hb
<110
<90
Platelets
<130
<110
K+
<3.5
<3.0
Na+
<135
<130
Mg+
=0.5-0.7
<0.5
PO4
=0.5-0.8
<0.5
Urea
>7
>10
Glucose
<3.5
<2.5
Bilirubin
>20
>40
ALP
>110
>200
AST
>40
>80
ALT
>45
>90
GGT
>45
>90
2011 Eating Disorder Programme
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mean admission BMI = 14.5
Mean discharge BMI = 16
BMI change 1.5
Frequency of medical transfer 7.5%
Case study - Recognising and Responding to Psychiatric
Deterioration in an Acute General Health Setting
• Prevalence rates of significant psychiatric comorbidity
in general acute wards varies between 20 – 60%.
• Prevalence rates in the general community much
lower 17-20%
• Referral rates from general wards to liaison psychiatry
services low - <5% but varies greatly
Case study - Recognising and Responding to Psychiatric
Deterioration in an Acute General Health Setting
• Adverse outcomes secondary to absence of a systematic
structured approach to identifying, assessing and responding to
deteriorating mental state in acute health wards
• Recognised as issue by hospital wide governance processes
• Need for structured mental health risk assessment and
management identified
• Clear agreement of broad principles
• Failure to agree over one year of specifics of risk assessment and
process for implementing
Case study - Recognising and Responding to Psychiatric
Deterioration in an Acute General Health Setting
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Need for high level leadership and oversight
Risk Tool developed over one year and then abandoned.
Use hospital wide of mental health risk assessment and management tool agreed
General hospital flow chart for use developed
Training incorporated into HMO and Registrar teaching
Referrals to Liaison Psychiatry require risk assessment to triage urgency of response
Death of a Young Man with Schizophrenia
• 18 yo, FEP with moderate response to oral Olanzapine, but marked weight gain
– General Health and Metabolic monitoring, shared care processes with Primary Care, Dietetics on site
• 2 years later reduced adherence with medication recognised but not acted on
– Training on assisting patients with adherence, clinical review policies and tools include explicit statements
on adherence
• Slow deterioration in mental state two months later not recognised, - withdrawal, low grade
persecutory beliefs, worsening of auditory hallucinations
– All clinical contacts require explicit statement on Mental State and impression of change. Multi
Disciplinary Clinical review requires MSE presentation, review of appropriateness of treatment plan, and
tracking of activities to implement treatment plan.
Death of a Young Man with Schizophrenia
• Six months later further escalating aggression and dangerous driving whilst intoxicated attributed to
personality issues
– Dual diagnosis workers embedded in service, shared care protocols in place with Drug and Alcohol Services,
Improved Psychiatrist EFT to allow for review of all patients and diagnoses. Clinical review process as before
and culture of easy escalation of care when patients deteriorating
• Family increasingly contacting service with concerns about mental state and risk
– All staff trained in Family sensitive practice, culture and attitudinal change encouraged to be open to carer report
being an important part of clinical information
• Service response is to provide phone number of drug detox service
– Triage and clinical review processes in place to monitor quality of care provision.
• Patient admitted floridly psychotic, intoxicated with amphetamines,
• Aggressive to police prior to admission and secluded for three days on admission
– Seclusion processes in place to ensure safe respectful care with seclusion use as an exception rather than norm
Death of a Young Man with Schizophrenia
• detoxed and antipsychotics reinitiated, response partial returned home after three weeks.
– In Patient clinical information integrated with community care
• Drug abuse continues, ceases medication, family can’t cope
– Family support processes and easy referrals in place
• Loss of home, move into poor quality rooming house, ongoing contact with service however
– Partnerships with PDRSS to assist better quality housing, and support of family
• Gradual relapse of psychosis secondary to none compliance
– Adherence, clincal review, easy escalation as before
• Case manager documents worsening hopelessness and demoralisation, ongoing substance use,
grief and anger with family, aggression risk assessed but no suicide risk assessment.
– Risk assessment tool requires systematic approach to risk assessment and appropriate response monitored via
team review processes
• Found hanging in his bathroom a week later
– Prevented by all the above
Recognising and Responding to Psychiatric Deterioration
Conclusions
• Much can be learnt from Acute Health
• Lack of objective measures for deterioration has to be
managed
• Reliance on subjective measures places greater
burden on quality of systems
• Team Culture, attitudes, individual practice needs to be
in alignment with service standards and systems for
those systems to be implemented adequately
• Role of mobilising values of staff to get commitment to
quality care Vs Role of standard setting and
compliance systems