Audit and Practice Survey Posters 278 – 285
278 audit of adequate monitoring and management of cardiometabolic parameters in patients with psychosis and schizophrenia
Aims/objectives: to assess how effectively cardiometabalic parameters are being monitored and managed in patients with psychosis and schizophrenia in a GP setting. content of presentation: a literature review was first performed, which identified clear NICE and Royal College of Psychiatry guidance on effective monitoring and management of physical health. these guidelines were added as criteria to be assessed in an audit of patients in the GP surgery- these included hba1c, lipids, weight, blood pressure, alcohol and smoking statuses.
Relevance/impact: there is a big disparity between the physical health of patients with psychosis or schizophrenia compared to the general population. cardiovascular disease is the biggest cause of death in patients with schizophrenia. this needs to be addressed.
Outcomes: 28 patients were identified. the practice was found to monitor indicators of cardiometabolic health better than the national average, but management of alcohol and obesity needed to be done better.discussion:suggestions were made to expand mental health reviews to a more comprehensive health check and educate GPs and nurses at the practice as to the equal importance of monitoring and management of cardiometabolic health parameters. re audit is proposed after 12 months once this is implemented.
279 Do I really need antibiotics doctor?” A re-audit of antibiotic prescribing for sore throat, acute otitis media and acute cough
After an initial audit of the prescribing of antibiotics in a G.P. practice in Hull during our placement we implemented changes and re-audited to investigate whether it made a difference to the prescribing of antibiotics by doctors in the practice.Our initial audit was carried out using the TARGET (Treat Antibiotics Responsibly, Guidance, Education, Tools) tool kit which we used again during the re-auditing process to be able to compare the parameters. The first audit identified four main problems: Poor history recording – we were unable to determine whether guidelines were properly followed due to lack of information; Immediate prescription when the guidelines suggested a delayed prescription; Incorrect antibiotic prescription; Lack of self care advice.
Due to these problems, we created templates which prompt the doctor to record key criteria in the history e.g. Centor score for sore throat and reminders for safety-net and self-care advice.
Results: Currently, we have results for a month post implementation of templates for both acute cough and sore throat; however there is currently no data on acute otitis media- this is something that will be collected by the conference date. – see results table
In Conclusion The re-audit shows mixed results: there has been some improvement in doctors prescribing of immediate antibiotics when it is not needed; however it seems the use of self care and safety netting has worsened. We would like to collect more data after our templates have been in use for a few more months.This audit is relevant for general practice as 80% of antibiotic prescribing occurs in primary care putting large responsibility on primary care to reduce the inappropriate use of antibiotics contributing to antibiotic resistance.
280 We must work together to do better: physical health monitoring of patients prescribed clozapine
BackgroundClozapine is an atypical antipsychotic primarily prescribed for refractory schizophrenia. Although it is an effective treatment it has a heavy cardio-metabolic side effect profile which requires proactive monitoring of patients’ physical health. This monitoring may occur in either the primary care practice or the psychiatric setting, or be managed between the two in a ‘shared care’ arrangement.
Aim The aim of this audit was to ascertain levels of compliance with published guidelines on the physical health monitoring of patients prescribed clozapine in a community mental health team.
Method Audit standards were drawn from both National Institute for Health and Care Excellence (NICE) guidelines and the Maudsley Prescribing Guidelines in Psychiatry. Electronic records of patients prescribed clozapine were interrogated to establish what physical health monitoring they had received during the previous year. This was supplemented by telephone calls to GP surgeries to ensure a complete data set. Analysis was conducted in Microsoft Excel™ and no formal statistical tests were required.
Results 28 patients were included in the audit. Only one standard, monthly full blood count monitoring, achieved 100% compliance. The remaining standards varied between compliance levels of 36% (annual ECG recording) and 86% (blood pressure monitoring). The average compliance level was 70% across all standards.
Discussion There are many possible causes of these findings, and some of the most remediable are of interest to the primary care physician. These include difference between guidelines, frequently changing guidelines, patient non-attendance, and ambiguity over responsibility for physical health monitoring.
Conclusion There is significant scope for improving the physical health monitoring of patients prescribed clozapine. Closer working between GPs and mental health teams will be central to success.
281 Annual Epilepsy Monitoring in Primary Care
Epilepsy is often managed in primary care with access to secondary and tertiary services for confirmation of diagnosis or if issues occur with control and treatment of the condition.In 2014/2015, the QOF were updated, retiring previous indicators requiring patients on drug treatment for epilepsy to be seizure free for 12 months, and women aged 18-55 years to have information and counselling on contraception and conception annually.
Whilst NICE guidelines still recommend annual monitoring, the removal of these QOF targets may have led to a decrease in adherence to the guidelines. This audit looks into the maintenance of annual review of epileptic patients in the previous year, including advice on driving entitlement, and where relevant, contraception. Using the QOF register of epilepsy patients, consultations and documentation for each patient was searched in the previous year (July 2015 – July 2016) for any mention of epilepsy consultation, review or other related records including consulting for contraceptive advice independently.
A total of 74 patients aged over 18 with epilepsy were registered a large primary care surgery with a total of 9780 at the time of audit. Only 16 of these (22%) were seen within the last year in relation to their epilepsy. Furthermore, only 7 of the 25 eligible females received contraception advice. These findings were presented to partners at a practice meeting, and as a result, a programme to invite patients for review will be instated with 3 ignored invites before patient is exempt. I have recommended a re-audit in 6 months to ensure standards improve to meet guidelines.
282 Adherence to insulin in type 2 diabetes mellitus patients
Adherence to insulin in type 2 diabetes mellitus patientsIntroduction – The socio-economic burden of type 2 diabetes mellitus (T2DM) to the NHS has greatly increased due to the ever-growing prevalence of T2DM in the UK and the increase in the cost of insulin in recent years. Tackling non-adherence to insulin is a means of reducing the health consequences of T2DM and also the significant financial implications upon the health service.
Aims – The purpose of this audit was to assess the degree of adherence to insulin therapy in patients with T2DM in a primary care setting. The secondary goal of the audit was to highlight and address reasons for this non-adherence.
Method – Data was collected retrospectively. Criteria for data collection were patients with T2DM taking insulin with a HbA1c over 75 mmol/mol. Patients were classed as adherent or non-adherent through analysis of electronic patient medication records. Non-adherent patients were followed up with a questionnaire asking them to specify reasons for their non-adherence.
Results – Of the 21 patients who fulfilled the criteria, 17 (81%) were non-adherent (F:M 1.83). Patients stated lack of understanding, problems with insulin administration and social reasons for their lack of adherence.
Conclusion – Female gender was shown to be a predicitve factor for non-adherence with a rate 25% higher than in males. Patients in older age groups were also shown to have a higher rate of non-adherence. Patient disease awareness programmes were highlighted as a tool to improve education in non-adherent patients.
283 An evaluation of GP-led dementia diagnosis
The objective of this evaluation was to undertake a case note audit of primary care dementia diagnoses with the aim of assessing the quality of those diagnoses made in a GP setting.Our local dementia service has been transformed into one delivered predominantly in primary care. Feedback from GPs, patients and specialists has been overwhelmingly positive. However, until now there had been no assessment of the quality of diagnoses made by GPs.
This evaluation aimed to answer the question of whether patients diagnosed under the new system were receiving a ‘quality’ diagnosis.A questionnaire was designed based on a gold standard produced in consultation with old age psychiatrists, memory nurses and GPs. This questionnaire was distributed to the 43 general practices signed up to the enhanced service for Primary Care dementia diagnosis. They were asked to complete the audit for the last five patients diagnosed at their practice in (up to) the last six months.84% of practices responded.
Results showed that 99% of patients diagnosed in primary care received appropriate cognitive testing, 99% appropriate imaging and 96% appropriate blood tests. 82% were documented as demonstrating functional decline. These are the cornerstones of our ‘gold standard’ Pathway.The results of this evaluation provide evidence that a quality diagnosis of dementia can be achieved in a GP-led model. With dementia a growing health problem and the ever-present need to provide a joined-up, quality service that truly works, this could have significant impact on planning future services for patients with memory problems.
284 Preconceptive care advice for newly diagnosed women with diabetes- the role of the general practitioner.
Aims: Discuss whether the current guidance for type 2 diabetes diagnosis leaves room for error in patients who are currently deemed ‘pre-diabetic’. To highlight to GPs that, based on this, more can be done to assist young newly diagnosed women who may be thinking of conceiving.
Content: This poster combines data from two audits, the first into whether a single fasting plasma glucose result correlated with an abnormal HbA1c. This led to discussion into how many prediabetic patients were getting good advice in lifestyle modifications and preconceptive advice. The second audit from a preconception care clinic looks at how women had been managed in the community before being referred to the clinic. These audits have suggested that more guidance can be given early on to women in the community who may otherwise conceive with poorly controlled diabetes.
Relevance: As more young people are diagnosed with type 2 diabetes and thought to have prediabetic traits, good preconceptive advice is vital to protect these high risk pregnancies. It may also encourage better control at an earlier age which can reap lifelong benefits.Outcomes: It seems there is a greater role for the GP in preparing diabetic and prediabetic women for pregnancy, as reliance on specialist preconceptive care and diabetes clinics may not allow enough time to optimise control.
Discussion: The results showed that women with a prediabetic HbA1c were not being given adequate preconceptive advice and those with diagnosed diabetes would often present at specialist clinics with no prior advice on how to manage their diabetes in preparation for pregnancy. This has been resulting in women either entering into difficult to manage pregnancies or struggling to conceive.
285 Title :Glucocorticoid-induced osteoporosis audit are we following guidelines?
Aims/Objectives: To assess the prevention and management of corticosteroid‐induced osteoporosis in our GP surgery in view of the updated NICE Guidelines.
Content of Presentation The presentation will show the standard we used, the data collection and the exclusion criteria, the first audit cycle, the changed implemented, the 2nd audit cycle and the conclusion
Relevance/Impact The audit(2 cycles) has proved a significant change in adhering to NICE guidelines in treated patient with glucocorticoids induced osteoporosis as well as prevention
Outcomes The results of the second audit have shown a significant improvement in adhering to the guidelines.
Discussion The audit has contributed in raising our practice’s awareness of the guidelines and the importance of their implementation for the patient safety and best care. Good communication and team work between primary and secondary care staff is necessary to ensure the best care of the patients and that the correct care is administered.