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During the last 20 years there has been increased focus on the problem of premature mortality among people with schizophrenia. This has resulted in a focus on weight gain, the development of metabolic problems, the need to understand the mechanisms behind these and the need to identify strategies to manage these problems. Audit programmes have highlighted the poor quality of monitoring for, and management of, physical health problems in people with all types of mental health disorder but particularly for those with psychotic illnesses. Further, weight gain also reinforces service users’ negative views of themselves and may lead to poor adherence with treatment (Faulkner et al., 2007; Lester et al., 2011; Weiden et al., 2004).
Recent years have seen a surge in interest in mental healthcare and some reduction in stigma. Partly as a result of this, alongside a growing population and higher levels of societal distress, many more people are presenting with mental health needs, often in crisis. Systems that date back to the beginning of the National Health Service still form the basis for much care, and the current system is complex, hard to navigate and often fails people. Law enforcement services are increasingly being drawn into providing mental healthcare in the community, which most believe is inappropriate. We propose that it is now time for a fundamental root and branch review of mental health emergency care, taking into account the views of patients and the international evidence base, to ‘reset’ the balance and commission services that are humane and responsive – services that are fit for the 21st century.
Concerns have repeatedly been expressed about the quality of physical healthcare that people with psychosis receive.
To examine whether the introduction of a financial incentive for secondary care services led to improvements in the quality of physical healthcare for people with psychosis.
Longitudinal data were collected over an 8-year period on the quality of physical healthcare that people with psychosis received from 56 trusts in England before and after the introduction of the financial incentive. Control data were also collected from six health boards in Wales where a financial incentive was not introduced. We calculated the proportion of patients whose clinical records indicated that they had been screened for seven key aspects of physical health and whether they were offered interventions for problems identified during screening.
Data from 17 947 people collected prior to (2011 and 2013) and following (2017) the introduction of the financial incentive in 2014 showed that the proportion of patients who received high-quality physical healthcare in England rose from 12.85% to 31.65% (difference 18.80, 95% CI 17.37–20.21). The proportion of patients who received high-quality physical healthcare in Wales during this period rose from 8.40% to 13.96% (difference 5.56, 95% CI 1.33–10.10).
The results of this study suggest that financial incentives for secondary care mental health services are associated with marked improvements in the quality of care that patients receive. Further research is needed to examine their impact on aspects of care that are not incentivised.
We conducted a secondary analysis of data from the National Audit of Psychosis to identify factors associated with use of community treatment orders (CTOs) and assess the quality of care that people on CTOs receive.
Between 1.1 and 20.2% of patients in each trust were being treated on a CTO. Male gender, younger age, greater use of in-patient services, coexisting substance misuse and problems with cognition predicted use of CTOs. Patients on CTOs were more likely to be screened for physical health, have a current care plan, be given contact details for crisis support, and be offered cognitive–behavioural therapy.
CTOs appear to be used as a framework for delivering higher-quality care to people with more complex needs. High levels of variation in the use of CTOs indicate a need for better evidence about the effects of this approach to patient care.
Users of mental health service are concerned about changes in clinicians providing their care, but little is known about their impact.
To examine associations between changes in staff, and patient satisfaction and quality of care.
A national cross-sectional survey of 3379 people aged 18 or over treated in secondary care for schizophrenia or schizoaffective disorder.
Nearly 41.9% reported at least one change in their key worker during the previous 12 months and 10.5% reported multiple changes. Those reporting multiple changes were less satisfied with their treatment and less likely to report having a care plan, knowing how to obtain help when in a crisis or to have had recommended physical health assessments.
Frequent changes in staff providing care for people with psychosis are associated with poorer quality of care. Greater efforts need to be made to protect relational continuity of care for such patients.
In the UK and other high-income countries, life expectancy in people with schizophrenia is 20% lower than in the general population.
To examine the quality of assessment and treatment of physical health problems in people with schizophrenia.
Retrospective audit of records of people with schizophrenia or schizoaffective disorder aged ⩾18. We collected data on nine key aspects of physical health for 5091 patients and combined these with a cross-sectional patient survey.
Body mass index was recorded in 2599 (51.1%) patients during the previous 12 months and 1102 (21.6%) had evidence of assessment of all nine key measures. Among those with high blood sugar, there was recorded evidence of 53.5% receiving an appropriate intervention. Among those with dyslipidaemia, this was 19.9%. Despite this, most patients reported that they were satisfied with the physical healthcare they received.
Assessment and treatment of common physical health problems in people with schizophrenia falls well below acceptable standards. Cooperation and communication between primary and secondary care services needs to improve if premature mortality in this group is to be reduced.
To assess whether a home treatment team acute relapse prevention (ARP) strategy reduces admissions to hospital with mania. A retrospective design was used to analyse records for manic admissions since 2002. The number and length of admissions and detentions pre- and post-ARP were determined and rates of admissions and detentions calculated from this.
We found reductions in admission and detention rates following the introduction of the ARP: 0.3 fewer admissions per person per year (95% bootstrap CI 0.09–0.62) and 0.25 fewer detentions per person per year (95% bootstrap CI 0.0–0.48). Wilcoxon signed-rank tests gave P < 0.0001.
A person-centred care plan such as the ARP which enables quick action in response to relapse-warning signs of mania appears to reduce rates of admission to hospital. The ARP could be used anywhere in the UK and fits with current mental health policy.
Agitation in dementia is common, persistent and distressing and can lead to care breakdown. Medication is often ineffective and harmful.
To systematically review randomised controlled trial evidence regarding non-pharmacological interventions.
We reviewed 33 studies fitting predetermined criteria, assessed their validity and calculated standardised effect sizes (SES).
Person-centred care, communication skills training and adapted dementia care mapping decreased symptomatic and severe agitation in care homes immediately (SES range 0.3–1.8) and for up to 6 months afterwards (SES range 0.2–2.2). Activities and music therapy by protocol (SES range 0.5–0.6) decreased overall agitation and sensory intervention decreased clinically significant agitation immediately. Aromatherapy and light therapy did not demonstrate efficacy.
There are evidence-based strategies for care homes. Future interventions should focus on consistent and long-term implementation through staff training. Further research is needed for people living in their own homes.
Decades of research on social skills assessment and intervention indicates the importance of social skills in improving academic achievement. Additionally, a strong evidence base promotes the inclusion of social–emotional learning into the whole school curriculum. In recognition of this evidence, the new Australian Curriculum, under Personal and social capability, calls for students to develop social skills. For many students with additional needs, it is hoped that the development of social skills will enable increased connectedness and a greater sense of inclusion. To meet developmental expectations of social skills, teachers need to measure these skills, develop effective teaching strategies for them, and evaluate their progress. The multi-tiered assessment and intervention components of the Social Skills Improvement System (SSiS; Elliott & Gresham, 2007) seem to offer a comprehensive system to support this process (Elliott, Frey, & Davies, in press).
Vapor movement of synthetic auxin herbicides can injure desirable plants outside the treatment zone. Vapor movement of the synthetic auxin herbicides aminocyclopyrachlor and aminocyclopyrachlor methyl was compared with that of the relatively volatile herbicide dicamba and the low volatile herbicide aminopyralid with a soybean bioassay under greenhouse and field conditions. Soybean is very sensitive to these active ingredients. Under greenhouse conditions, 82 (61 to 104) mg ae ha−1 of aminocyclopyrachlor, 26 (18 to 33) mg ae ha−1 of aminocyclopyrachlor methyl, 82 (69 to 95) mg ae ha−1 of aminopyralid, and 61 (47 to 75) mg ae ha−1 of dicamba produced an estimated 25% visual soybean phytotoxicity response when soybean was treated POST at the V3 growth stage (GR25 [95% confidence interval]). In field studies, aminocyclopyrachlor, aminocyclopyrachlor methyl, and aminopyralid were applied at 70 g ae ha−1 and dicamba was applied at 560 g ae ha−1 (labeled application rates) to soybean at the V3 growth stage. All herbicides were applied within an enclosed chamber (3 m by 3 m by 1 m) to mitigate movement of spray droplets. The enclosures were removed shortly after spray application and soybean response immediately surrounding the treated area was recorded in each of eight directions approximately 10 d after treatment. On the basis of bioassay responses, relative amount of vapor movement was dicamba > aminocyclopyrachlor methyl > aminopyralid ≈ aminocyclopyrachlor. Vapor movement of aminocyclopyrachlor was very low indicating that the risk of phytotoxic response of sensitive plants due to volatility of aminocyclopyrachlor is negligible.
End tidal CO2 (ETCO2) has been established as a standard for confirmation of an airway, but its role is expanding. In certain settings ETCO2 closely approximates the partial pressure of arterial CO2 (PaCO2) and has been described as a tool to optimize a patient's ventilatory status. ETCO2 monitors are increasingly being used by EMS personnel to guide ventilation in the prehospital setting. Severely traumatized and burn patients represent a unique population to which this practice has not been validated.
The sole use of ETCO2 to monitor ventilation may lead to avoidable respiratory acidosis.
A consecutive series of patients with burns or trauma intubated in the prehospital setting over a 24-month period were evaluated. Prehospital arrests were excluded. Absence of ETCO2 transport data and patients without an arterial blood gas (ABG) within 15 minutes of arrival were also excluded. Data collected included demographics, place and time of intubation, service performing intubation, ETCO2 maintained en-route to hospital, and ABG upon arrival. Further data included length of stay, mortality, and injury severity scores.
One hundred sixty patients met the inclusion criteria. Prehospital ETCO2 did not correlate with measured PaCO2 (R2 = 0.08). Mean ETCO2 was significantly lower than mean PaCO2 (34 mmHg vs 44 mmHg, P < .005). Patients arriving acidotic were more likely to die. Mean pH on arrival for survivors and decedents was 7.32 and 7.19 respectively (P < .001). Mortality, acidosis, higher base deficits, and more severe injury patterns were all predictors for a worse correlation between ETCO2 and PaCO2 and increased mean difference between the two values. Decedents and patients presenting with a pH <7.2 demonstrated the greatest discrepancy between ETCO2 and PaCO2. The data suggest that patients may be hypoventilated by prehospital providers in order to obtain a prescribed ETCO2.
ETCO2 is an inadequate tool for predicting PaCO2 or optimizing ventilation in severely injured patients. Adherence to current ETCO2 guidelines in the prehospital setting may contribute to acidosis and increased mortality. Consideration should be given to developing alternate protocols to guide ventilation of the severely injured in the prehospital setting.
CooperCJ, KraatzJJ, KubiakDS, KesselJW, BarnesSL. Utility of Prehospital Quantitative End Tidal CO2?. Prehosp Disaster Med. 2013;28(2):1-6.