28/10/20
Our project was to implement point of care (POC) testing devices in patients with severe mental illness in the community and to compare outcomes to similar patients managed by a team without access to these technologies. The POC testing covered blood glucose (HbA1c) and Lipid POC testing and portable ECG monitoring.
Professor Belinda Lennox of University of Oxford’s Department of Psychiatry provided the clinical leadership, working with partners from NIHR MIC (Gail Hayward, Phil Turner, Margaret Glogowska) who provided the quantitative and qualitative evaluation of the devices. Mike Denis led on the system integration of the POC devices with the clinical electronic patient record systems.
Gail Hayward, Associate Professor and GP, Department Primary Care, University of Oxford
Phil Turner, NIHR MIC coordinator, Department Primary Care, University of Oxford
Margaret Glogowska, Qualitative Researcher, Department Primary Care, University of Oxford
Mike Denis, Chief Executive Akrivia Health
People with severe mental illness die on average 15 years earlier (Hjorthøj et al. 2017). The increased mortality is partly due to physical health comorbidity, which is largely preventable. In addition, patients with severe mental illness can under-prioritise their own health and the mental health issues can distract medical staff from other health issues.
NICE, in its guideline on psychosis and schizophrenia (NICE, 2014) recommends the monitoring of physical health and a physical health check is a NICE quality standard of care for early psychosis. The physical health check involves a physical examination, blood test for lipids and HbA1c and an ECG. Mental health services are expected to provide this check in the first year of treatment by the mental health service, and the GP is expected to undertake this.
However, an audit of NHS South revealed only 38% of people in early intervention services had received a full physical health check (South Region annual report 2017) and that only 20% of those at high risk of cardiometabolic disease were offered the NICE recommended physical health interventions.
The findings from community mental teams is even lower (CQUIN audit data 2018).
Point of care lipid and HbA1c tests and ECGs on mobile devices provide a potential way of increasing this figure.
Our aim was therefore to implement point of care testing devices into clinical services and evaluate their use. We aimed to obtain both quantitative data on the use of the devices, and qualitative data on the attitudes of both staff and patients on the use of these devices.
We embedded the ‘Afinion’ device for HbA1c and lipid testing into an Early Intervention Team and an Adult Mental Health Team in Oxfordshire for six months. Training was provided to care coordinators with ongoing support to facilitate engagement with the device.
We compared rates of blood test and full physical health check completion in the intervention teams to a matched early intervention team and adult mental health term in Buckinghamshire. We performed semi-structured interviews with patients receiving POC-augmented care and clinicians from the intervention teams.
We convened a task and finish group of informatics teams in Oxford Health NHS Foundation Trust (FT) and Oxford University Hospitals NHS FT to enable the automatic feed through of results from the point of care testing device to the electronic patient records in the mental health trust.
We trialled the use of a hand-held ECG monitor ‘RhythmPad’ alongside the use of 12 lead ECG tracing in people attending an emergency medical assessment unit.
Data from the intervention period showed that whilst the Oxfordshire Adult Mental Health team did not engage with the device and saw no change in outcomes, the Oxfordshire Early Intervention Team did engage and increased rates of physical health check completion from 22.6% to 40.3% of their caseload per six months. Completion in the control Community Mental Health Team in Buckinghamshire was 7.8%.
Qualitative interviews with clinicians explored engagement with POC and illustrated that the existing provision of physical healthcare, usability of POC devices, and their impact on the therapeutic relationship influenced uptake. Clinicians who did use the device enjoyed the increased autonomy and ability to make a difference in their client’s care.
Qualitative interviews with service users revealed universal support for POC, with benefits cited of reduced anxiety, a more efficient service and more engagement and understanding with physical health.
Our main findings are therefore that POC testing can dramatically improve the physical health care of people with mental illness, but that this is not universal, and the attitude of clinicians in the teams is the critical factor as to whether this new technology is adopted.
Our evaluation of pilot ECG data showed that there was reasonable agreement in important measurements between the 12 lead and RhythmPad, but that further pilot data from a larger number of participants is required before the device can be implemented into clinical services.
The integration between the POC device and the Electronic Patient Record (EPR) was delayed by COVID, but is currently being finalised.
Publications
Butler, J, de Cassan, S, Glogowska, M, Fanshawe, T R, Turner, P, Walton, D, Lasserson, D, Bale, R, Lennox, B, and Hayward, G, ‘A mixed methods evaluation of the introduction of a point of care device on physical health check uptake in mental health services’, British Journal of Psychiatry Open, in press.
Butler, J, de Cassan, S, Turner, P, Lennox, B, Hayward, G, and Glogowska, M, ‘Mental healthcare clinician engagement with point of care testing; a qualitative interview study’, BMC Psychiatry, in review.
Butler, J, de Cassan, S, Turner, P, Lennox, B, Hayward, G, and Margaret, G, ‘Attitudes to physical healthcare in severe mental illness; a patient and mental health clinician qualitative interview study’, British Journal General Practice Open, in review.
Presentations
NHS England Mental Health programme board, June 2020
South West Society Academic Primary Care Bristol, March 2020
Oxford Health Physical Health Conference, November 2019
Schizophrenia International Research society biannual meeting online, April 2020
We submitted a proposal for implementation and evaluation of a point of care testing programme across South East of England, and this has been funded by NHSE for a one year project, starting 1 January 2021 (£218,608).
Use of point of care testing devices is now in routine use within early psychosis service in Oxford Health, benefitting 100 people/year with first episode psychosis.
The ECG project is still underway, with further validation of the handheld device before the introduction into clinical services.
Further point of care testing devices are currently being evaluated in mental health services, including point of care full blood count measurement (using Sight Diagnostics’ OLO).
Providing a focus and tight timeframe for delivering the interoperability of systems. The project helped to focus attention, when discussions about how it was a good idea had been going on for at least the last eight years. This project actually managed to make it happen.
Recruiting a clinician as the clinical fellow was very helpful, as he could get buy in from each of the partners easily, as he could ‘speak their language’.
Collecting qualitative data alongside data on use of devices was invaluable in understanding why the devices weren’t used in some teams. This was around the culture and beliefs of the mental health teams around their role in physical healthcare, rather than any technical issue.
Integration of the electronic patient records has been achieved, between the acute hospital and mental health trust, due to the inclusion of Mike Denis in the team. He was able to span across the boundaries of the different organisations and manage the integration.
Pitch-in has really galvanised a collaboration to produce some important results, and make a difference to clinical practice. The integration of the data across systems, while it sounds a small achievement, is a game changer for the people using the devices – they can instantly see the value and time saving from using them. This would not have been achieved without Pitch-In.
Professor Belinda Lennox – University of Oxford
Oxford University Hospitals Biochemistry team