Saturday, 8 January 2011

Liaison Work

Acute hospital wards often stuggle with psychiatric problems. Medical and surgical colleagues frequently refer patients with depression who are miserable but not clincially depressed and are not ill. I used to think it odd, doctors (who all trained in some psychiatry as undergraduates) can't usually suss out if someone's ill or not.

I used to think that colleagues should be able to undertake a decent history, examination, ask about informant/contextual history and put together some sort of formulation. Partly through training, partly through prejudice, partly through not being their core business/not routine, and mostly because working on acute wards is now described as beyond grim, even competent colleagues with a will to do so struggle to make sense of psychiatric dimensions to their medical/surgical patients.

If history, assessment and formulation aren't undertaken in a systematic, thoughtful, involved manner then how can care planning be person centred and be effective? Largely it can't.

This generates more difficulties because the culture forced on clinicians through current pressures precludes better ways of working. Nurses know that is someone is wandering around or shouting or pulling drips out or pushing buttons on other patients' syringe drivers that usually drugs makes it worse.

Of course they do. We have no "anti wandering" or "anti shouting" or "anti fiddling" drugs, those are behaviours they're not illnesses. What's sought is abolishing symptoms, without attending to the primary cause of these presentations.

It's ingrained, though, so nursing staff are disempowered/under resourced in managing one to one patient care, call medical staff since it's unsafe and problematic, medics feel they can't do anything but prescribe. What do they prescribe? Usually they prescribe the drugs that don't work/make it worse. If used correctly, as well as usually doing little beneficial and lots that's harmful, the appropriate use of the drug also needs extensive ECG and blood monitoring that ties up even more nursing time, which could otherwise have been used in direct patient care to manage the behavioural disturbance.

There's a bit of an inconsistency, though. On the one hand the acute hospitals generally want a chemical solution, and nothing else, to manage behavioural disturbance. On the other hand, their care pathways for this are very different from most any other care pathway they'd generate.

The Dobbing Doctor explained his hospital has a "Rapid Tranquillisation Protocol" and asked what drug would be better.

A protocol on the administration of a drug to treat a behaviour. Is there an "Inhaled Breathing Protocol" giving the procedure for nebulised n-saline in obstructive airways disease or RSV/croup and the like? Is there a "Bolus Steroid Protocol" for injection of steroids in COPD? No, there's no "Bolus Steroid" protocol but there is a "Rapid Tranquillisation" protocol. Why? Why have a protocol for one class of drugs, major tranquillisers, but for most every other protocol it's about the disease state/care pathway? They have Stroke Pathways, COPD pathways, MI pathways but no delirium/acute confusional state pathway. Instead there's a drug protocol for "rapid tranquillisation."

This is less than ideal since we know medication has a tiny role to play, so if it's the only role your hospital offers in such patients' care then, frankly, patients aren't going to get the right care. Last September's update on National Dementia Strategy outcomes and Banerjee's Time for Action report reiterate the best practice guidance that non-pharmacological approaches must be tried first.

The reality is, they work.

I work with older adults. All my in-patients are ill, with major mental health problems. Almost all of them have physical comorbidity too, such as infections, contributing to their acute deterioration necessitating hospital in-patient care. Most are pretty elderly and pretty frail. Despite being confused, ill, unsettled and presenting with challenging behaviour, use of medication is modest. My last patient with hypomanic features arising through stroke damage was managed and discharged on no psychiatric medication. I've never used our equivallent of the "Rapid Tranquillisation" policy on any of my in-patients patients, ever.

If the frail, elderly, ill, most mentally and behaviourally challening in-patients can be managed with little/no psychiatric medication, it suggests that less mentally ill patients within acute hospitals also should be manegeable without drugs. Which is what best practice guidance, Royal Colleges, patient advocate groups and DoH reports say.

The crunch, of course, is that the environment and nursing ratios need to be fit for purpose. Nurse Anne reckons, ". . . that years of intense research have shown that the maximum number even the best nurse can take and not make mistakes is 4-6 on a general floor." She described how when things went well, "I worked a late shift on a 25 bed ward and there was 4 of us staff nurses and 2 care assistants for the ward." Our wards do have such staffing levels, with one qualified nurse per 4 to 6 patients, plus support workers, plus ward physio time and OT time and ward social worker time.

Rationally, if they're not psychotic, or having abnormal dopamine excess needing pharmacological treatment, why is an antipsychotic indicated?

The right environment and the right staffing obviates the need for antipsychotic medication, most of the time. I reckon that's one for the Ghost of Christmas Future to sort out . . .


Milo said...

I think that you are a fine person and thank you for caring. I don't think any one else on that night could have given a damn.
many regards

pj said...

I think the short answer is - yes, it is obvious that you'd rather have a behaviourally disturbed patient on a ward with staff and an environment set up to deal with this, just as you'd rather have a physically unwell patient on a medical ward.

The longer answer is that I think you are being unfair to staff on medical wards. For a start, general adult and forensic psychiatric wards not infrequently use 'rapid tranquillisation'. Psychiatric wards also have access to things not available to general medical wards like trained mental health nurses, individual or even seclusion rooms, psychiatric ITUs, better availability of staff to supervise patients, etc.

Also, and I think this is where I think you are being particularly unfair, you get to claim that you are 'treating' the underlying 'disease' when using neuroleptics or sedatives in acutely psychiatrically unwell patients whereas using these same medications in behaviourally disturbed medical patients is simply 'treating the symptoms'. Well I think there is an argument to be had over how well targeted you can realistically claim these treatments are in psychiatry anyway, but it is very unfair to castigate medics for using sedation/tranquillisation on the technicality that in psychiatry this tranquillisation is nominally 'therapeutic' - I think it is pretty clear that in early phases of therapy you are just sedating/tranquillising to control behaviour in exactly the same way that medics are. Which is why all mental health trusts have a 'rapid tranquillisation' policy. We cannot forget that we're talking about a field of medicine where we use the mental health act to detain and treat people against their will!

pj said...

Finally, what do you suggest is done on medical wards, which are understaffed and simply not designed, with their isolated single rooms or multiple patient bays, and need for invasive interventions like cannulas, to deal with disturbed patients?

Sure, the behaviour may be delirium secondary to an underlying medical disease, but these things don't just sort themselves out with a slug of antibiotics, they need ongoing treatment for that medical condition and they are behaviourally disturbed now.

I've seen some seriously behaviourally challenging patients with delirium or dementia handled very well, without medication, by nurses and care assistants, particularly if they are 'specialed' (looked after 1:1) and particularly if that is done by mental health staff rather than medical staff. However, a general medical hospital has scores of such patients, many of whom are also acutely unwell, and in addition to all the other acutely unwell patients without behavioural disturbance need looking after.

It is simply not a fair comparison between an old age psychiatry ward and an acute medical ward - how many of your patients need intravenous fluids? (I'm guessing 'none', since psychiatric wards usually have policies against intravenous medication, anyone that sick should be a general hospital etc.) There is a reason we don't keep acutely unwell medical patients on psychiatric wards. So, I agree, sedation is over used, nursing ratios are bad, but sometimes you just have to give someone something to stop them causing serious harm to themselves or someone else. And usually the someone that decision comes down to is the on-call house officer or SHO who is least able to resist such requests because they're inexperienced and worked off their feet.

As I mentioned in the post below - haloperidol is about the only neuroleptic available on a general medical ward (similarly, chlorphenamine is the only antihistamine available, despite its poor risk-benefit ratio compared to later generation drugs) - our local psychiatric trust policy specifies olanzapine or lorazepam as first line sedation - most medical trusts I've worked in would have neither available on the wards (haloperidol and midazolam or diazepam it is). But, similarly, when my patients need antibiotics on a psych ward I can just about get flucloxacillin and amoxicillin and pain relief is limited to ibuprofen and paracetamol.

Antidepressant said...

I am surprised that you have not responded to pj's comments.

Your silence is deafening.