Physical Health in the Early Intervention in Psychosis Service Page 1 of 18 Version 1.0 July 2017

Standard Operating Procedure 01 (SOP 01)

Physical Health in the Early Intervention in Psychosis

Service

Why we have a procedure?

This Standard Operating Procedure has been developed to ensure standardised processes and safe practice in all aspects of physical health assessment within the Early Intervention in Psychosis Service (EIS) in Black Country Partnership NHS Foundation Trust (BCPFT).

What overarching policy the procedure links to?

Physical Health Policy

Which services of the trust does this apply to? Where is it in operation?

Group Inpatients Community Locations

Mental Health Services

Learning Disabilities Services

Children and Young People Services

Early Intervention in Psychosis

Service

Who does the procedure apply to?

All staff working in Early Intervention in Psychosis Service

When should the procedure be applied?

When conducting a physical health assessment

How to carry out this procedure

1. Service user is referred to EIS for assessment.

2. Service user is accepted to EIS caseload.

3. Baseline physical health assessment using form appendix 1 (assessment form)

will be offered within three weeks of acceptance to the EIS caseload.

4. Assessments will be made as per the latest and best available evidence base

including the NICE Clinical Guidelines for the management of children and young

people with psychosis (CG155)i, the NICE Clinical Guidelines for the management

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of adults with psychosis (CG178)ii, the EIP Self-Assessment Tooliii, the EIP

standardsiv, the Maudsley Prescribing Guidelines for anti-psychoticsv and the

Lester toolvi. The tests will include:

Bloods (U&Es, FBC, Lipid profile, Fasting Glucose, HbA1C, Prolactin, LFT,

CPK, TFT)

ECG

Blood Pressure/Pulse

Weight (Weekly for first 6 weeks on anti-psychotic)

Personal history (cardio-vascular disease, hypertension, LESTER TOOL)

Family history (cardiovascular disease, hypertension)

Lifestyle factors (substance use, alcohol, smoking, exercise/physical

activity, diet/health eating)

Height

BMI

Waist circumference

Hip circumference

Side effects of medication including movement disorder

current side effects if already prescribed medication i.e. GASS tool

Adherence to medication

Would you like written information?

Has verbal information been provided?

Do you take over the counter medications?

Do you take complimentary medications/therapies?

Offer information relating to interactions of above with prescribed

medications/therapy/psychology

Are you prescribed PRN medications? Medication to take as and when

required

Does this take client medication above BNF maximum?

5. Service users under the care of the inpatient services at the point of referral to EIS

should already have baseline assessments undertaken by inpatient staff. In this

case, records to be collated by EIS nursing staff for inclusion in EIS assessment

data.

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6. Physical health baseline assessments using form appendix 1 will be repeated and

reviewed at 3 months, 6 months, 12 months then every 6 months until discharge

from EIS.

7. Cardiometabolic Health Screen and Intervention Framework (appendix 2) will be

completed at the same intervals by the assessing nurse and information gathered

will be inputted onto the QRisk2-2016 form found online at https://qrisk.org/2016/

8. Missing data indicates further assessment should be arranged once information is

available and QRisk2-2016 should be recalculated.

9. QRisk2-2016 score confirmed by website should be inputted onto team physical

health database by assessing nurse. (Note: the tool does not work for <25s – the

reason for exception should be recorded instead).

10. All information gathered at physical health assessment to be inputted into physical

health database by assessing nurse.

11. Assessment forms once complete, to be filed in the “investigations” section of the

service user’s nursing notes.

12. Accurate details of assessments made will be recorded as a clinical entry in the

nursing record.

13. Information/outcomes from physical health assessment to be fed back into wider

MDT via weekly multi-disciplinary team meetings, to include update to prescribing

staff.

14. Feedback to be provided to the service user’s GP using letter appendix 3

(standard feedback letter) within two weeks of assessment.

15. Appendix 3 (feedback letter) to be uploaded onto CareNotes/Oasis systems within

five days of assessment

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Client will be sent a physical health information sheet and letter offering a Physical Health Assessment (PHA). PHA will occur in conjunction with an outpatient appointment if possible and will be conducted by team members with appropriate training. Appointment will take place within three weeks of allocation.

Client accepted by service and allocated a care coordinator following assessment

Member of physical health team will contact GP and other services (e.g. inpatient) for further information regarding physical health needs and assessments conducted.

Information is recorded on the physical health form and presented at MDT and to the consultant if appropriate.

If PHA is declined reasons for this will be explored and reported in notes and MDT meeting. Attempts will be made to address any barriers as appropriate.

Blood results will be obtained from TD Webb within seven days of the assessment by person who has completed it. Results will be printed and checked and signed by team medic. Signed copy will be put in nursing and medical notes. Letter will be sent to GP advising of blood results. Any abnormalities will be immediately raised with team medic and GP. Every effort will be made to contact the client and offer appropriate advice.

PHA assessment conducted and Fasting Blood Form given to client

Is outpatient appointment taking place following PHA?

Yes. Results documented on physical health form and a copy checked and signed by the medic and results reported to GP in the outpatient letter. Signed form will be placed in nursing and medical records. Any concerns will be reported immediately to the GP and appropriate advice given to the client. Handover will be given at the next MDT meeting.

No. Physical health form will be signed at the next MDT meeting and a copy placed in the nursing and medical records. Any concerns will be reported to the GP and medic immediately and appropriate advice offered to the client.

Further PHA’s will be offered to clients at 3 months following allocation and every 6 months thereafter until discharge.

EIP Physical Health Pathway

Pathways For Cardiometabolic Risks

If agreed refer for diet/exercise advice

Health trainers (Wolverhampton)

My time active (Sandwell)

Advise relevant Medical Team for medication review if deemed appropriate

Yes

If agreed, refer for advice and support to;

Recovery Near You (Wolverhampton)

IRIS - Alcohol

Swanswell – Substance (Sandwell)

Brief Intervention/ Lifestyle advice

Brief Intervention/ Lifestyle advice Offer *BHF Leaflets on diet and exercise

If agreed refer for smoking cessation

Health trainers (Wolverhampton)

Quit51 (Sandwell)

Blood Lipids Cholesterol >9, non-HDL chol >7.5 or TG.20)mmol/l) And/or QRISK >10%

Brief Intervention/ Offer *BHF Leaflet on smoking

Glucose HbA1c ≥ 42 mmol/mol

And/or FPG ≥ 5.5mmol/l

Or RPG ≥ 11.1mmol/l

Blood Pressure >140 mm Hg systolic

And /or >90 mm Hg diastolic

Substance Misuse And /or

Alcohol Misuse >14 units alcohol weekly

Lifestyle and Life Skills Poor Diet and/or Sedentary Lifestyle

BMI/Weight BMI>25 and/or weight gain >5kg over 3 month period

Smoking

Yes

Yes

Yes

Yes

Yes

Brief Intervention/ Lifestyle advice Offer *BHF Leaflet on diabetes and your heart

Advise relevant medical team, consider anti-hypertensive therapy, advise GP for action

Brief Intervention/ Lifestyle advice Offer * BHF Leaflet on blood pressure/ reducing salt intake

Advise relevant medical team and GP for action May require repeat monitoring

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Brief Intervention/ Lifestyle advice Offer *BHF Leaflet on reducing cholesterol

Consider lipid modification, advise GP for action

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Patient Name: Or personal details sticker to override this section: DOB: NHS Number: Oasis Number:

Physical Health Monitoring Tool Patient consents to this assessment being undertaken and shared with other members of the multidisciplinary team as relevant

Patient Name: DOB: NHS No: Affix Label Oasis Number: Ethnicity:

Consultant:

Patient Signature:

Assessed By:

Date of Assessment:

Have you had any of the following conditions?

Yes No Yes No

Heart Disease/Stroke

Diabetes Mellitus (indicate type I or II)

High BP

High Cholesterol

Asthma Thyroid conditions:

Any Family History of any of these conditions (First degree relatives)? Detail:

Other details including treatment:

Do you experience any of the following symptoms?

Yes No Yes No Yes No

Chest pain Sexual Dysfunction

Increased thirst

Breathlessness Constipation or bowel changes

Weight gain (unexpected)

Fits/blackouts Increased or frequent urination

Weight Loss (unexpected)

Other details:

Patient Name: Or personal details sticker to override this section: DOB: NHS Number: Oasis Number:

Have you had dental checks in past year?

Yes

No*

Details: *Refer to Dentist directory for local services if required

Have you had optical check-up in past 2 years?

Yes No*

Details: *Refer to Optician directory for local services if required

Have you had a smear test in the last 3 years?

Yes

No*

N/A

Date Last Menstrual Cycle (If Known) *Advise patient to see GP if referral required

Do you have any problems with skin or feet?

Yes

No

Details: Complete pressure sore risk calculator (Waterlow), and request to see skin integument

Do you have any swallowing / speech difficulties?

Yes No

Details:

Do you have any mobility issues?

Yes

No

Details:

Do you have pain which is not managed?

Yes

No

Details:

Do you experience any side effects from your medication? i.e. sedation, tremors, muscle stiffness

Complete Glasgow Antipsychotic Side-Effect Scale (GASS)

Yes

No

Details: Dependent on severity/urgency, refer to consultant or defer to next OPA

Do you have any allergies or sensitivities? Yes No Details:

Enter alert onto CareNotes system

Do you use herbal or over the counter medication? i.e. non-prescription

Yes

No

Details: Advise prescriber of details if “yes”

Are you prescribed any regular or “as required” medication?

Yes

No

Details: Include: does the person take medication as prescribed? Is the dose above BNF limit?

Have you received written or verbal information about your prescribed medication?

Yes

No

Details: Include: written, verbal or both? And if “no” would they like this?

Patient Name: Or personal details sticker to override this section: DOB: NHS Number: Oasis Number:

Are you a smoker?

Yes

No Ex-

Smoker

Details:

Would you like to be referred for smoking cessation advice?

Yes No

N/A

If so, refer via appropriate service. Detail:

Do you take recreational drugs? i.e. cannabis, amphetamines

Yes No Details:

Do you drink alcohol? Recommended daily units: Maximum 2

Yes No

Detail Units Per Week: (Use drinks calculator https://www.alcoholconcern.org.uk/unit-calculator)

Do you want and agree a referral to the Addictions service?

Yes No

Details:

Do you undertake physical activity? - How often? What?

Yes

No

Details:

Do you consider yourself to eat a healthy diet? – i.e. 5 a day

Yes

No

Details:

Do you wish referred for diet and exercise advice?

Yes

No

Already under

services

Details:

Baseline observations: Please record if any observations are refused

Height cm Weight kg BMI kg/m2

Weight Gain >5kg over 3 month period Detail:

Yes No Temp (If indicated)

Blood Pressure mm Hg

Pulse Respirations bpm /min

QRISK-2 score (%) Calculator found at http://qrisk.org

Waist Circumference cm

Hip Circumference cm

Cholesterol (If Known) Cholesterol/HDL ratio – Total Cholesterol – Non–HDL -

Glucose (Random or Fasting) HbA1c – FPG/RPG -

Waterlow Risk Score See SOP for calculator, and action to take

Do you know date of last blood test? Yes No Detail: Check TD Web for blood test results

Do you consent to having bloods taken? Yes No

N/A

N/A – If completed in last 3 months Yes - To include FBC,U&E’s, LFT’s, TFT’s, Lipid profile, HbA1c, glucose

Do you consent to ECG? Yes No N/A N/A – If completed in last 3 months

Has ECG been requested? Yes No N/A

Patient Name: Or personal details sticker to override this section: DOB: NHS Number: Oasis Number:

Return form to medical secretary, to be filed in notes after medic sign off.

Doctor Sign off: ____________________________________________________ Print Name: _______________________________________________________ Date: ____________________________________________________________

Outcome checklist:

Referral to Health Trainers or Clinical Exercise Instructor completed?

Yes N/A Patient refuses

Already under service

Referral required for Addiction service Yes N/A Patient refuses

Already under service

ECG completed (if applicable) Yes No Date of current ECG:

Blood tests completed (if applicable) Yes No Date of recent blood tests:

Referral to any other service? E.g. OT / Physiotherapy / SALT/Dentist

*Details

Any Leaflets given i.e. British Heart Foundation or service leaflets or service

*Details

GASS completed? Yes No Patient Refuses

Physical Health Team Notes

GP Name Address

Sent/Faxed to GP

Yes No Patient Refuses

Patient Name: Or personal details sticker to override this section: DOB: NHS Number: Oasis Number:

Baseline Date:

3 month review Date:

6 month review Date:

12 month review Date:

BP mmHg

Pulse /min

Respirations /min

Blood Glucose mmol/L Fasting/Random

Temperature °C

Weight Kg

Height Cm

BMI Weight Kg Height M²

Waist Circumference Cm

Hip Circumference Cm

Plan

Patient Name: Or personal details sticker to override this section: DOB: NHS Number: Oasis Number:

18 month Date:

24 month review Date:

30 month review Date:

36 month review Date:

BP mmHg

Pulse /min

Respirations /min

Blood Glucose mmol/L Fasting/Random

Temperature °C

Weight Kg

Height Cm

BMI Weight Kg Height M²

Waist Circumference Cm

Hip Circumference Cm

Plan

To be filed in medical notes following completion

Internal Early Intervention Service

Blood Investigations & ECG Request Form

Request Date

Consultant

Requesting Doctor

Prior to request: Please ensure patient is aware & consents to this referral. To avoid duplication, ascertain whether the patient has recently attended GP surgery for these investigations.

Physical Health Team Notes

Date/Time Signed

Reason for request:

Risks:

Medical History: Please complete all sections

Diabetic Yes No On Warfarin Yes No Statins Yes No

On Thyroxine Yes No Known Allergies

Haematology requests: Please Circle

FBC

ESR

B12, Folate

Ferritin

Any other tests:

Clinical Chemistry requests: Please Circle

LFT

U&E

TFT

CRP

Prolactin

Bone profile

Lipid Profile

Glucose Random or Fasting

Lithium

Carbamazepine

Any other tests:

ECG Request Yes No Any Other tests Circle BP Weight

Name: Address: Address Label Postcode: Contact No: Oasis No.

Glasgow Antipsychotic Side‐effect Scale (GASS) Name: NHS No: Age: Sex: M / F Please list current medication and total daily doses below:

This questionnaire is about how you have been recently. It is being used to determine if you are suffering from excessive side effects from your antipsychotic medication. Please place a tick in the column which best indicates the degree to which you have experienced the following side effects. Tick the end box if you found that the side effect distressed you. © 2007 Waddell & Taylor

Over the past week: Never Once A few Everyday Tick this box if times distressing

1. I felt sleepy during the day

2. I felt drugged or like a zombie

3. I felt dizzy when I stood up and/or have fainted

4. I have felt my heart beating irregularly or unusually fast

5. My muscles have been tense or jerky

6. My hands or arms have been shaky

7. My legs have felt restless and/or I couldn’t sit still

8. I have been drooling

9. My movements or walking have been slower than usual

10. I have had, or people have noticed uncontrollable movements of my face or body

11. My vision has been blurry

12. My mouth has been dry

13. I have had difficulty passing urine

14. I have felt like I am going to be sick or have vomited

15. I have wet the bed

16. I have been very thirsty and/or passing urine frequently

17. The areas around my nipples have been sore and swollen

18. I have noticed fluid coming from my nipples

19. I have had problems enjoying sex

20. Men only: I have had problems getting an erection

Tick yes or no for the following questions about the last three months No Yes Tick this box if distressing

21. Women only: I have noticed a change in my periods

22. Men and women: I have been gaining weight

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Staff Information

1. Allow the patient to fill in the questionnaire themselves. Questions 1‐20 relate to

the previous week and questions 21‐22 to the last three months.

2. Scoring:

For questions 1‐20 award 1 point for the answer “once”, 2 points for the answer

“a few times” and 3 points for the answer “everyday”.

Please note zero points are awarded for an answer of “never”.

For questions 21 and 22 award 3 points for a “yes” answer and 0 points for a

“no”.

Total for all questions=

3. For male and female patients a total score of:

0‐12 = absent/mild side effects

13‐26 = moderate side effects over 26 = severe side effects

4. Side effects covered by questions

1‐2 sedation and CNS side effects

3‐4 cardiovascular side effects

5‐10 extra‐pyramidal side effects

11‐13 anticholinergic side effects

14 gastro‐intestinal side effects 15 genitourinary side effects 16 screening for diabetes mellitus 17‐21 prolactinaemic side effects 22 weight gain

The column relating to the distress experienced with a particular side effect is not

scored, but is intended to inform the clinician of the service user’s views and

condition.

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Early Intervention Service 44 Pond Lane

Wolverhampton West Midlands

WV2 1HG Tel: 01902 443993

Fax: 0121 612 3746

Doctor Name

Address

Dear Dr

Re: Name of Patient, DOB Address NHS number: Oasis Number: The above patient recently undertook a physical health assessment with our Service. The results were: Blood Pressure: / mmHg Pulse: /minute Weight: . kg Temperature: . °c Respiration rate: /minute BMI: Hip Circumference: cm Waist Circumference: cm Blood Glucose: . mmol/l pre diet/post diet Summary of history provided Yours sincerely Names of nurses Community Mental Health Nurses Early Intervention Service

Physical Health in Early Intervention in Psychosis Service Page 17 of 18 Version 1.0 July 2017

References i National Collaborating Centre for Mental Health. (2013). Psychosis and Schizophrenia in children and young people: recognition and management: The NICE Guideline on Treatment and Management. CG155. London: National Institute for Health and Clinical Excellence [Online]. [Accessed 13

th October

2016]. Available at: www.nice.org.uk/guidance/cg155 ii National Collaborating Centre for Mental Health. (2014). Psychosis and Schizophrenia in adults: The

NICE Guideline on Treatment and Management. CG178. London: National Institute for Health and Clinical Excellence [Online]. [Accessed 13th October 2016]. Available at: https://www.nice.org.uk/guidance/cg178/resources/cg178-psychosis-and-schizophrenia-in-adults-full-guideline-appendices2 iii Royal College of Psychiatrists (2016). Early Intervention in Psychosis Network Self Assessment Tool.

London: EIPN, Royal College of Psychiatrists Centre for Quality improvement [Online]. [Accessed 13th

October 2016]. Available at: http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/ccqiprojects/earlyinterventionpsychosis/theselfassessment.aspx iv Royal College of Psychiatrists (2016). Standards for Early Intervention in Psychosis Services. Pilot

Edition. London: EIPN, Royal College of Psychiatrists Centre for Quality improvement [Online]. [Accessed 13

th October 2016]. Available at:

http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/ccqiprojects/earlyinterventionpsychosis/standardsforeipservices.aspx v Taylor, D., Paton, C. and Kapur, S. (2015). The Maudsley Prescribing Guidelines in Psychiatry. 12th

Edition. West Sussex: Wiley Blackwell vi Shiers, D.E.., Rafi, I., Cooper, S.J., Holt, R.I.G.. (2014). Update (with acknowledgement to the late

Helen Lester for her contribution to the original 2012 version). Positive Cardiometabolic Health Resource: an intervention framework for patients with psychosis and schizophrenia.2014 Update. Royal College of Psychiatrists London.

Where do I go for further advice or information?

Roles and responsibilities of key staff in relation to this procedure Training Staff may receive training in relation to this procedure, where it is identified in their appraisal as part of the specific development needs for their role and responsibilities. Please refer to the Trust’s Mandatory & Risk Management Training Needs Analysis for further details on training requirements, target audiences and update frequencies Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness.

Equality Impact Assessment Please refer to overarching policy

Data Protection Act and Freedom of Information Act Please refer to overarching policy

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Standard Operating Procedure Details

Unique Identifier for this SOP is BCPFT-PH-SOP-04-1

State if SOP is New or Revised New

Policy Category Physical Health

Executive Director whose portfolio this SOP comes under

Executive Director of Nursing and AHPs

Policy Lead/Author Job titles only

Team Leader Sandwell & Wolverhampton Early Intervention Service

Committee/Group Responsible for Approval of this SOP

CYPF Quality and Safety Group

Month/year consultation process completed

May 2017

Month/year SOP was approved July 2017

Next review due July 2020

Disclosure Status ‘B’ can be disclosed to patients and the public

Review and Amendment History

Version Date Description of Change

1.0 Jul 2017

New SOP developed to support overarching Physical Health Policy specifically for use by Early Intervention in Psychosis Service