Minimum Standards of Physical Health Assessment Policy. Choice, Responsiveness, Integration & Shared Care

Transcription

1 Minimum Standards of Physical Health Assessment Policy Choice, Responsiveness, Integration & Shared Care

2 Worcestershire Mental Health Partnership NHS Trust Information Reader Box Document Type: Document Purpose: Unique identifier: Title: Target Audience: Description: Clinical Policy To ensure that service users admitted to an inpatient unit receive an agreed standard of physical assessment. CP0049 Minimum Standards for Baseline Physical Assessment Inpatient Nursing and Medical staff Contains guidance regarding physical assessment and examination of inpatients Superseded Documents: Ratified by: Quality Committee Ratification date: December 2010 Implementation date: January 2011 Review period: 3 years Version update date: Review date: January 2014 Owner: Responsible group: Contact Details: Medical Director and Non Medical Prescribing Lead Clinical Audit and Effectiveness Non Medical Prescribing Lead PDSI Dept Woodside Perry Wood Walk Worcester. The electronic copy of this document is the only version that is maintained. Printed copies may not be relied upon to contain the latest updates and amendments.

3 Contents Section 1 Introduction 2 Purpose of Policy 3 Responsibilities and Duties 4 Ongoing Assessment and Monitoring 5 Working groups 6 Monitoring Implementation 7 Practise Development and Service Improvement 8 Policy Validation Guidance 9 Minimum Standards of Physical Assessment 10 Clinically Indicated Investigations 11 Recommended Equipment on Psychiatric Wards 1

4 1. INTRODUCTION Research has shown that people with mental health problems or a learning disability are at increased risk of a range of physical illnesses. These are often undetected, resulting in increased rates of morbidity and mortality. This may be for a number of reasons including unhealthier lifestyle choices, medication and the socio-economic consequences of diagnosis. 2. PURPOSE OF POLICY To promote of good physical health care by ensuring that service users admitted to an inpatient unit receive an agreed standard of physical assessment. This includes appropriate physical examination, physical history, and assessment of the impact of lifestyle factors. 3. RESPONSIBILITIES AND DUTIES 3.1 Trust Board is responsible for a. Setting policy for the organisation through powers delegated to relevant committees; b. Ensuring policy is implemented through agreed management arrangements; c. Ensuring they are alerted to relevant issues arising that may affect policy 3.2 Chief Executive is responsible for: 3.3 Directors a. ensuring that arrangements are in place so that employees are fully aware of their statutory, organisational and professional responsibilities and that they are fulfilled; b. ensuring that the arrangements in support of policy are fully implemented through inclusion in Business Unit Performance Reviews; c. In order for this responsibility to be effectively discharged, Executive Directors and senior colleagues will have specific delegated responsibility to support the Chief Executive in this process. Director of Medical Development must ensure that medical staff carry out their duties in respect to this policy 3.4 Medical Staff The lead consultant should ensure that a junior doctor is nominated to carry out an audit of physical health assessments at 12 month intervals Senior House Officer or Staff grade doctors should ensure that all patients admitted to an inpatient unit within the WMHPT have or are offered a comprehensive medical examination within 24 hours of admission, recorded and signed in clinical notes. Exceptions to this are; a. All patients exhibiting symptoms of confusion should have a comprehensive physical examination at the time of admission. b. If a physical examination is not possible within this time frame (e.g. if it would be distressing to the patient to undergo a physical examination due to their mental state), then the reason should be clearly stated in the case notes, any relevant observations documented (e.g. gait, posture, energy levels, levels of hydration, nutritional status), and records made of the continued attempts that are made to undertake the examination. 2

5 Continued attempts should be made at no less than weekly intervals or earlier if the clinical condition indicates d. In a situation where a patient detained under the Mental Health Act 2007 refuses physical examination, then consideration needs to be given to the risks posed by medication, and whether a physical examination needs to be undertaken in spite of refusal, when attempts at persuasion are completely exhausted. e. The risks of restraint without prior information about physical conditions also need to be taken into account in making this assessment and reasons documented f. If any part of the physical health assessment is not completed the reason for not doing so must be stated in the clinical notes. Conduct ongoing assessment and monitoring 3.5 Business Unit Leads Ensure that staff are aware of their responsibilities under this policy Receive the results of audits and ensure that action plans are formulated and implemented to address any deficiencies 3.6 Senior Managers Work with the Business unit leads, nursing and medical staff to ensure that physical assessments are carried out and the results of audits are acted upon. 3.7 Ward Manager Ensure that physical examinations are carried out on inpatients Ensure that resources are made available to support the carrying out of physical health care assessments. Ensure that a female member of staff is available to accompany the service user when a male doctor conducts the assessment. Ensure that all equipment required is available and in good working order 3.8 Individuals Nursing Staff Complete a physical screening form within 72 hrs of admission. This covers a physical health and lifestyle factors which can suggest further assessment or follow up interventions as required. Document the screening in clinical notes Ensure that the service user and environment is properly prepared for the physical examination. Record essential observations weight and blood pressure at monthly intervals and record in clinical notes 4 Appropriate follow up of physical symptoms Incorporate relevant findings into ongoing care plans and seek specialist advice if required. Ensure appropriate follow up of physical symptoms as indicated during the screening and assessment process. 5 ONGOING ASSESSMENTS AND MONITORING Monitor the side effects of medication (especially EPSE, sedation and rapid weight gain) at least weekly and record in clinical notes. 3

6 If on antipsychotics, regular monitoring of prolactin levels should be done routinely Nursing staff to monitor and record weight and blood pressure at least monthly Measure blood glucose at 4 and 5 weeks if sudden weight gain (more than 7% occurs during treatment (especially related to anti psychotic medication) Repeat ongoing physical assessments routinely at 3 months and then 6 monthly intervals or as indicated by presentation or medication (e.g. Lithium, Clozapine) and record in clinical notes Incorporate relevant findings into ongoing care plans and seek specialist advice if required Conduct a review of physical health and continuing health needs as part of discharge planning, incorporate into CPA documentation and communicate to GPs in the discharge summary with clear lines of responsibility indicated. 6 WORKING GROUPS Clinical Effectiveness owns the development, review and sign off of this policy before its submission to the Governance group for ratification. The group will ensure that an audit of physical health care takes place on a 12 month frequency, supported by the audit and research department. 7 MONITORING IMPLEMENTATION An audit of standards of physical health care and physical health care equipment will be carried out at 12 month intervals. Relevant business units are responsible undertaking the audit, supported by the Audit and Research Department. Audit results and action plans will go to the Business Unit Leads and the Clinical Effectiveness Working, Audit and Research. Business Unit leads are responsible for ensuring that action plans are implemented. NHSLA Criteria Lead Monitoring Frequency Committee The sections below will contain all the requirements of the NHSLA risk management standards in relation to this policy. The organisation has an approved documented process for managing the risks associated with the physical assessment, examination and ongoing physical care of service users. As a minimum it must include a description of the, a) Duties Medical Director b) Requirements for physical assessments of service users on admission to a service c) Process for ensuring appropriate follow up of physical symptoms d) Ongoing assessment of physical needs for all service users e) Process for monitoring compliance with all of the above Medical staff and Nursing Staff Medical staff and Nursing Staff Medical staff and Nursing Staff Audit of Physical health care Audit of Physical Health Care Equipment Audit of Physical health care Audit of Physical Health Care Equipment Audit of Physical health care Audit of Physical Health Care Equipment 12 months Audit and Research Clinical Effectiveness 12 Months Audit and Research Clinical Effectiveness 12 months Audit and Research Clinical Effectiveness As above As above As above As above 4

7 8 PRACTICE DEVELOPMENT AND SERVICE IMPROVEMENT The Worcestershire Mental Health Partnership is committed to ensuring its workforce is confident, competent and capable. The Practice Development and Service Improvement Team develop a training prospectus which describes the courses on offer, to whom they are aimed, how often they need to be updated and how to make a booking. The training prospectus can be accessed via the Intranet and internet Attendance Monitoring If a person registered to attend a course does not attend the information is registered with the Practice Development and Service Improvement Team and their line manager is notified of the non-attendance. It is the responsibility of the line manager to ensure staff attend appropriate statutory, mandatory and essential training. 9 POLICY VALIDATION All policies ratified for use by the Trust contain the following information: i) A designated owner with responsibility for ensuring an appropriately skilled professional will lead the development and/or review of the policy in line with timescales set by the Governance Work or Advisory work plan ii) 10 GUIDANCE A Working or Advisory, whose work plan identifies their responsibilities with regard to the development and/or review of the policy, monitoring compliance and signing off the policy within agreed timescales prior to ratification by the Governance Committee. MINIMUM STANDARDS OF PHYSICAL ASSESSMENT Physical assessment should include the following: Medical history Details of past and present physical illnesses. Where there are chronic medical conditions, e.g. epilepsy, asthma etc the type and frequency should be recorded, and also the emergency intervention strategies. Relevant family history, e.g. diabetes, coronary heart disease Current medication and previous medications ( NPSA Medicine Reconciliation) A comprehensive symptom review followed by physical examination Cardiovascular system Gastro-intestinal system Genito-urinary system Respiratory system Neurological system Dental care Height and weight Waist measurement An assessment of the impact of lifestyle factors on physical and mental health Alcohol Smoking Diet /exercise Sexual health 5

8 Recreational drugs Exercise Details of health screening (e.g. cervical, breast) and relevant immunisation (e.g. flu vaccination) 1. CLINICALLY INDICATED INVESTIGATIONS Biochemical and haematological profiles including glucose and lipid profiles (fasting example) Other tests suggested by history or examination e.g. (urine drug screen, CX. thyroid function, prolactin. Some tests should be discussed with the consultant psychiatrist or other specialists e.g CT, MRI, ECG, drug levels, health screening 2. RECOMMENDED MEDICAL EQUIPMENT FOR PSYCHIATRIC WARDS Examination couch - unless an alternative has been agreed ( use of a bed a couch cannot be accommodated ) Stethoscope Sphygmomanometer Thermometer Tendon hammer Tuning fork (256 Hz) Weighing scales Urinalysis sticks Opthalmoscope/Auroscope Alcometer Oximeter Neurological testing pins Snellen chart Height measure Waist measure (tape measure) Disposable gloves Syringes with retractable needles Sharps boxes Torches and adequate examination lights Copy of Glasgow coma scale Equipment to take blood sugars Peak flow meter Spare batteries for electrical equipment. 6