Equally Well champion Anna Birkenhead has been leading a cardio-metabolic screening project at Waitemata DHB, and getting some real traction over the last year or so. Anna shared her experience in shifting organisational culture through system change with Candace Bagnall from the Equally Well team at Te Pou o te Whakaaro Nui.
A recent study on metabolic screening practice in Australian mental health services1 concluded that it is, in a word, “inadequate”. Of the 955 psychiatrists who responded to a national survey (a 31 per cent response rate), 76 per cent reported that there was no reliable system in place to remind them when to monitor. Unsurprisingly, fewer than half routinely checked weight, fasting glucose or lipids in people who were on antipsychotics, and under 30 per cent checked blood pressure.
In the absence of similar New Zealand research it’s fair to say that we are probably no better at screening mental health service users for what’s known as ‘the metabolic syndrome’ (MetS) – a group of risk factors for cardiovascular disease and type 2 diabetes.
Metabolic screening in New Zealand mental health services
Equally Well members have been debating the issue online via Loomio lately, and it seems we have no current national standards or guidance for metabolic screening in mental health and addiction services here. District health boards (DHBs) have been developing their own clinical pathways for this and other areas, but it’s hard to know how many have done this, and whether it’s a priority for mental health services around the country.
But at least one DHB mental health service has been quite proactive in this area. Waitemata DHB developed a draft policy about ten years ago, but over the last couple of years, clinical practice has been under closer scrutiny.
Cardio-metabolic screening has been a focus for Anna Birkenhead’s professional life for many years. Since qualifying as a comprehensive (NZCpN) nurse in 1990, she has been working in various mental health clinical roles with much time spent as a crisis team clinician, as well as in leadership roles – co-ordinator and team manager.
Anna’s interest and passion in her current role developed when she was a clinic nurse for metabolic screening two years ago. She could see first-hand the significant difference that could be made to people’s lives, with ordinary interventions to help mitigate risk – healthy lifestyle education and support.
“Nearly every client I saw was interested and engaged in the process, and as a result, motivated to make positive change” she said. “Healthy lifestyle and CVD risk mitigation is relevant to us all, but especially our people who have significant additional risk overall,” Anna said.
Supporting people to engage in primary care is also important.
“One other positive benefit I noticed was that the interaction in a physical health setting seemed to be more comfortable for our service users, perhaps less stigmatising. Many were able to talk about other (important) aspects of their lives and illness as a result.”
Quality improvement project at Waitemata DHB
The 2014 Equally Well summit was timely for Anna. She reflected again on the importance of improving the physical health of service users at Waitemata, and was vocal in expressing concerns about progress in this area at WDHB mental health services. Director of mental health, Dr Murray Patton, and then regional manager Helen Wood decided they would set up a project to improve their performance in cardio-metabolic screening, and Anna was appointed into the role on a half-time basis.
Her first task was to do a stocktake on what was working, and what wasn’t. She discovered that screening numbers had been declining in the two to three years prior. This was disappointing, since draft policy had been in place since 2005 and screening started around then, initially with a small project involving Waitemata PHO and the University of Auckland. Following the stocktake, the policy was finalised and an implementation plan was put in place. This involved screening of all adults admitted to the service, on entry (if they had not been screened during the previous 12 months in primary care) for cardiovascular disease (CVD) and metabolic risk.
“We want clinicians to be supporting service users overcome barriers and engage with primary care,” Anna explained.
“For some people it’s difficult or impossible to get them to primary care, so they continue to be screened annually by mental health services until they are engaged. The idea is that every year an electronic reminder in our clinical record pops up, indicating the person is due for screening, so either we do it or they do it in primary care. We need to know what their CVD risk is so we can help support them mitigate the risk and understand how best to deliver treatment.”
Cardio-metabolic screening policy
The project included an internal policy review, backed at a senior leadership level within the mental health service. The revised policy has been in place for a year now, and has doubled the number of screenings from the previous year. Anna posted the policy recently on Loomio in response to a request and invited others to use or adapt it for their own services.
She is the first to admit that there is still a long way to go, and while many service users have elements of screening completed, only about 10 per cent of service users are being screened at Waitemata using the CVD software tool PREDICT, which is being enhanced in functionality for mental health services. Waitemata DHB appears to be one of the few mental health services using the tool, which is used widely in primary care to assess cardiovascular risk. A regional CVD tool is also being developed, led by Health Alliance. It’s not yet clear whether PREDICT will be adopted for the whole of Auckland.
The policy provides a clear summary of best practice including visuals explaining the screening pathways. It’s complemented by related guidance such as prescribing psychotropic medication, and use of metformin (for pre-diabetes), all in the same place on Waitemata DHB’s intranet. Guidance and professional support has also been made available for mental health staff on how to interpret and respond to electro-cardiograms (ECGs).
Training for 135 nurses has been undertaken, with plans for additional workforce development well under way. A “very streamlined and basic training package” has been developed which includes a section on service user education on lifestyle changes.
Using the Equally Well banner
Equally Well has become an umbrella for this kind of activity at Waitemata. There is now an Equally Well Champion Group – more than 20 nurses across forensics and adult mental health services. This has resulted in the merge of smoke free and cardio-metabolic screening services. Three-monthly auditing will be part of new care standards so cardio-metabolic screening will be built into the system.
As part of the project, Anna managed a small point of care testing (POCT) pilot in the largely rural Rodney district. A portable device was used that enables a full lipid profile and HbA1c to be completed in 11 minutes, using a finger prick blood test, and with no need for fasting or visiting a lab. Ten service users considered to be at risk of metabolic syndrome or cardiovascular disease were offered the service, and encouraged to have their weight and blood pressure taken at the same time. The results were impressive, and as a result the approach may be extended. Clinicians found that POCT enabled health education to be undertaken, where there would not otherwise have been an opportunity, and the majority of service users responded positively in terms of engaging in further follow-up or intervention.
Anna is clear that the culture of the organisation and its core business has shifted.
“We have to be clever and work smarter to get it done. In the face of heavy caseloads and emergencies, people need to see the importance of physical health and understand the evidence about how intervening in lifestyle can reduce risk. It can be quite profound and motivating.”
1. Laugharne, J., Waterreus, A. J., Castle, D. J., & Dragovic, M. (2016). Screening for the metabolic syndrome in Australia: a national survey of psychiatrists’ attitudes and reported practice in patients prescribed antipsychotic drugs. Australasian Psychiatry, 24(1), 62-66.