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Quality improvement project in the NHS example
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- Anglia Ruskin University (ARU)
Quality improvement project on the role of autoantibody testing in the NHS. Attained distinction with a mark of ~90%
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Quality improvement project on increasinguptake of pathological autoantibody screening
to identify patients with autoimmune
psychosis
SID: 2215756
Word count: 4988
,Quality improvement in the NHS MOD006221
SID: 2215756
Introduction
Background
Patients with a psychotic disorder have a predicted life expectancy 13.5 years
shorter than the general population, where only 10% mortality is attributed to suicide
(Sher and Kahn, 2019). As such, underappreciation of an underlying physical
component could be responsible for a proportion of deaths in patients with
psychosis, where psychosis itself describes a complex interplay of symptoms that
include, but are not limited to, thought disorders, hallucinations, and delusions, and
still requires a unified definition (Gaebel and Zielasek, 2015). Part of this definition
could include symptoms beyond its psychological manifestation, as there is thought
to be a 55% increased risk of autoimmune disease in those living with psychosis
(Cullen et al., 2019). Considering this, especially in patients with atypical psychotic
symptoms, an organic (secondary) cause should be rightfully suspected.
Regarding the presentation of primary and secondary psychosis that are largely
similar, with up to 9 classifications of psychosis to distinguish, it is critical that
patients are identified through the means of a comprehensive medical, and not just
psychiatric, history (Table 1).
Table 1. Classification of psychotic disorders based on their primary or
secondary origin (Thara et al., 2008).
Idiopathic/primary Secondary
1. Schizophrenia 1. Substance-induced psychotic
2. Schizophreniform disorder disorders
3. Schizoaffective disorder 2. Psychotic disorders due to a
4. Delusional disorder general medical condition
5. Brief psychotic disorder
6. Shared psychotic disorder
7. Bipolar disorders
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,Quality improvement in the NHS MOD006221
SID: 2215756
Whilst Griswold et al. (2015) states that abnormal vital signs and presence of visual
hallucinations should guide clinicians towards a diagnosis of secondary psychosis,
Steiner et al. (2018) challenges that cases of NMDA receptor encephalitis cannot be
excluded in the presence of normal EEG, cerebrospinal fluid (CSF) profile or normal
MRI results, and so appreciating abnormal baseline investigations is essential but
alone would not be sufficient in diagnosing secondary psychosis. Although valuable,
traditional testing methods fail in their specificity to identify neuroinflammatory
causes of psychosis, where 67–89% of cases are normal on MRI head (Beattie et
al., 2022).
Current practice and existing guidance for psychosis
As there is currently no widely enacted standard in the United Kingdom for
autoantibody screening in psychosis, current practice falls behind Canada, New
Zealand, Australia and other countries who have already published official guidance
(Dorney and Murphy, 2021). Although a lack of national standard regarding
screening is problematic, section 1.3.1.3 of NICE guidance in managing first episode
psychosis (FEP) states that “pharmacological, psychological, social, occupational
and educational interventions” should be adopted in such cases and applies
“irrespective of the person’s age or the duration of untreated psychosis” (Appendix
1). As such, outlining targeted investigations could complement existing guidance,
and be used to create a national framework on autoantibody screening that is
applied in a timely and equitable manner (NICE, 2014). However, this guidance was
last updated in 2014, perhaps demonstrating a lack of progress in evidence-based
methods endorsed by national guidance, or less attention and appreciation is being
brought to this area of psychiatry compared to others (Clementz, 2022).
Principally, where guidance exists, a selected number of autoantibodies are
screened, or the exact screening recommendation is undefined, as is the case for
American, Canadian and Indian guidance (Table 2). Although a positive presence in
some form, British guidance is solely regional, where The Scottish Intercollegiate
Guidelines Network recommends the monitoring of metabolic effects of
antipsychotics through autoantibody screening and Buckinghamshire NHS Trust
states that all patients presenting within 3 months of an acute psychotic episode
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, Quality improvement in the NHS MOD006221
SID: 2215756
must undergo anti-NMDAR and anti-VGKC screening (Buckinghamshire NHS Trust,
2018).
Table 2. Autoimmune screening recommendations from international guidance
(Dorney and Murphy, 2021).
Guideline Autoimmune screening
recommendation
RANZCP clinical Practice Guidelines for the management of Anti- NMDAR
schizophrenia (2016, Aus and NZ) Anti-VGKC
Anti-GAD antibodies
Australian Clinical Guideline for Early Psychosis ANA
APA practice guidelines (2004, USA) Not mentioned
CPA clinical practice guidelines: treatment of schizophrenia (2005,
Canada)
UBC early psychosis care guide (2002, Canada)
The Indian Psychiatric Society Clinical Practice Guidelines
Although currently NHS England states that the psychiatric inpatient pathway
prioritises “care that advances health equality” (Appendix 2), a lack of clarity
contradicts this alleged equality when “clinical need” is ambiguous and leaves “any
other areas” for investigation to the discretion of the assigned clinician without
standardised criteria to refer to (Appendix 3). Better standardisation also extends to
preventing disparities in testing opportunities available to patients and increasing the
likelihood of access to more efficacious treatments (Beattie et al., 2022). This is
apparent when antipsychotics are poorly tolerated in anti-NMDAR encephalitis due
to its link to neuroleptic malignant syndrome, highlighting the importance of objective
tests to confirm true cases of secondary psychosis when a primary cause is to be
confidently excluded, and timely intervention to prevent poor outcomes (Lejuste et
al., 2016).
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