1. The introduction of a universal blood borne virus (HIV, Hepatitis B and Hepatitis C)
screening program on an 18 bed acute male inpatient psychiatric ward: A Quality Improvement Project
Dr Emmert Roberts CT2 Academic Clinical Fellow and Dr Joanne Noblett ST4 South London and the Maudsley Mental Health Trust
Introduction
Abstract
Introduction
Background
Results and Conclusions
Introduction
Problem: Whilst physical health CQUIN targets encourage monitoring of lipids, weight, blood pressure and diabetic screening for psychiatric inpatients no current policy suggests a similarly structured approach to blood borne virus (BBV) screening.
Background: The standardised mortality ratio for patients with serious mental illness (SMI) in SLaM is 2.15 (95% CI: )1. Improved physical health care has focused on cardiovascular and metabolic risk factors, however the prevalence of HIV in the SMI population is % higher than the general population.2 Estimated prevalence rates of Hep B (23.4%) and Hep C (19.6%) are approximately 5 and 11 times higher than the general population.2
Baseline Measurement: From 18 inpatients in August 2014: Three received HIV screening. Nine received Hep B and Hep C screening, of whom five were candidates for Hep B vaccination but none had been vaccinated.
Design and Strategy: We implemented a universal offer of BBV screening to all inpatients and documented patient’s capacitious consent or refusal or a best interest’s decision in their electronic notes. Candidates for Hep B vaccination as designated by the Green Book3 were offered vaccination on the ward or via their GP.
Results: As of September 2014, 43 patients were offered BBV screening. 38 gave capacitous consent or a best interests decision was made to screen. One case of Hep C, and two of Hep B were diagnosed. Nine patients were candidates for Heb B vaccination. One initiated Hep B vaccination on the ward and three were signposted to their GP.
Conclusions: Universal screening identified new cases of BBV infection and those at risk of Hep B. Vaccination programs have been initiated.
The standardised mortality ratio (SMR) for patients with serious mental illness (SMI) in the South London and the Maudsley mental health trust is 2.15 (95% CI: )1. Improved physical health care has focused on cardiovascular and metabolic risk factors, however the prevalence of HIV in the SMI population is reported as being % higher than in the general population.2 Estimated prevalence rates of hepatitis B are 23.4% and hepatitis C are 19.6% in the SMI population which are approximately 5 and 11 times higher respectively than in the general population.2 A number of factors prevent diagnosis and management of blood borne viral infections in the SMI population including differential take up of services including visits to general practitioners and sexual health clinics and the chaotic lifestyle of some patients with SMI.
Number of patients eligible to be screened 45
Number of patients not asked about screening 2
Number of patients who capacitiously declined or didn’t assent to testing despite a best interests decision being made 7
Number of patients screened for HIV with documented capacitous consent or best interests decision 35
Number of patients screened for Hep B 38
Number of Negative Hep B Screens eligible for Hep B vaccination according to Green Book: 9
Number of patients vaccinated against Hep B or signposted to GP: 4
Number of patients screened for Hep C:
Introduction
Baseline Measurement
Number of patients on ward 18
Number of patients with a documented result on ePJS screened for HIV
3/18
Number of patients screened for HIV with documented capacitous consent or best interests decision
0/3
Number of patients screened for Hep B
9/18
Number of Negative Hep B Screens eligible for Hep B vaccination according to Green Book
5/9
Number of patients screened for Hep C
Number of patients diagnosed with HIV
Number of patients diagnosed with Hep B 2
Number of patients diagnosed with Hep C 1
Implementation of a universal ward based screening program identified two cases of previously undiagnosed hepatitis B infection and one of hepatitis C infection. These cases were subsequently referred to the outpatient hepatology viral hepatitis service at Kings College Hospital. Given the nature of the patient group it is unlikely these would have been diagnosed elsewhere in their patient journey.
Nine patients at risk of hepatitis B according to the Green Book3 were identified during the program. One received a course of vaccination ward and three were signposted to their GP. Universal screening shall continue on the ward, and is expanding to other wards within the hospital. The next stage of the project is to improve vaccination rates on the ward and work with local GPs to ensure the course of vaccination is completed on discharge.
Introduction
Design and Strategy
Introduction
Problem
Yes No
Assess patient’s capacity to consent for BBV screening at ward round and document assessment on ePJS
Negative BBV Serology:
Inform patient
If patient at risk in accordance with the Green Book:
Offer Hep B vaccination with GP or via ES2 Ward
Patient has capacity to consent to BBV screen
Document on ePJS
Patient does not have the capacity to consent to BBV screen
Offer all patients screening for BBV via phlebotomy service on Tuesdays
Patient refuses screening document on ePJS
Patient accepts screen for BBV
Positive HIV Serology: Inform patient
Refer to GUM at Camberwell Sexual Health Clinic
Positive Hep B/C Serology:
Inform patient Refer to Hepatology at Kings
Best Interests discussion with MDT
In the best interests of the patient to test, perform blood screen if patient assents
Not in best interests of patient to be tested, do not perform blood screen
Positive Result/s:
Ensure under appropriate team and clarify next follow up date
NEGATIVE RESULT/S:
Identify if further risk of exposure to BBI infection since last test
Identify if patient has recent blood borne virus infection (HIV, Hep C or Hep B) results
Whilst physical health Commissioning for QUality and Innovation (CQUIN) targets in psychiatric hospitals encourage monitoring of cardiovascular and metabolic risk factors including serum lipids, patient weight, smoking status, baseline electrocardiogram and diabetic screening for psychiatric inpatients no current policy suggests a similarly structured approach to blood borne virus (BBV) screening. Ad hoc tests are done for differing blood borne viruses and people remain concerned about the discussion of HIV tests or how to consistently approach consent for HIV blood tests in psychiatric settings leading to potential under testing in an at risk population.
Introduction
References
1. Chang CK, Hayes RD, Broadbent M et al. All-cause mortality among people with serious mental illness (SMI), substance use disorders, and depressive disorders in southeast London: a cohort study. BMC Psychiatry Sep 30;10:77
2. De Hert M, Correll C, Bobes J et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. Feb 2011; 10(1): 52–77
3. The Green Book: Immunisation against infectious disease. David SalisburyMary Ramsay and Karen Noakes United Kingdom Department of Health 2013.
Acknowledgements: The authors have no competing interests to disclose