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Clinical case A NMC registered general nurse with first psychosis

Clinical case A NMC registered general nurse with first psychosis. Dr Lisa Curran MRCP MFOM. Summary. 32 year old band 5 nurse Became unwell 18/12 into a critical care-emergency department rotation KCH OHP supported initial Return to Work

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Clinical case A NMC registered general nurse with first psychosis

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  1. Clinical case A NMC registered general nurse with first psychosis Dr Lisa Curran MRCP MFOM

  2. Summary • 32 year old band 5 nurse • Became unwell 18/12 into a critical care-emergency department rotation KCH • OHP supported initial Return to Work • Regular OH attendance - work adjustments and redeployment • Unfortunately, eventual poor work outcome with job loss and NMC proceedings

  3. First management referral • Referred 10.4.2012 ?FFW • Off work 2/52 • employee / manager telephone conversation ‘not coping with life in general’, sounds very low, said she will see GP for sick note LM comments on referral ‘I would very much want to see her back at work, very smart/intelligent /caring nurse, I would like to know how I can support her in whatever she chooses to do once she has appropriate guidance and support’

  4. OHP assessment - 1 • Seen in department 15.6.2012 • off work 10 weeks • From employee – ‘stress induced episode’ • Since Christmas – worrying ++ / ↓ sleep / ‘felt didn’t know what to do outside work / felt could work • Beginning of April 2012 – taken to Canterbury ED (from camberwell) by friend • Not sectioned / discharged to crisis team and care of parents / daily contact ‘early intervention psychosis service’ • PMhx – nil • SH – flat share camberwell • Dhx diazepam / quetiapine (stopped) / aripiprazole 5mg od

  5. OHP assessment - 2 • Occupational hx • 3 A’ Levels grade B 1995-1998 • ‘Year out’ 1998-1999 • Liverpool university 1999-2002 BSc ‘human geography’ • Team leader Princes Trust London 2002- 2005 • Canterbury University 2005-2008 nursing degree • Medway Maritime Hospital 2008-2010 ED nursing • 2010 onwards KCH band 5 nurse – urgent care rotation • MSE • Normal appearance / cognition / attention / mood • No drugs / alcohol • No self harm • Stressors • work – ‘found nights particularly difficult’ – 3/52 nights over xmas • Non work – relationship breakup 12 months ago

  6. OHP assessment - 3 • Management report • There is an underlying health problem relating to attendance • Not currently fit for work • I expect a return to work on adjusted duties in one to two months time • Consent to write to specialist • EA 2010 not currently considered applicable

  7. Specialist information 28.6.2016 • Self presented to ED beginning of April – symptoms of acute psychotic episode – thought disorder / anxiety / low mood • Reporting ‘ TV and radio were sending her messages’ and ‘her decision making was being influenced by an outside source’ • Persecutory ideas • Hearing mumbling voices and noises • Poor sleep, reduced appetite, ↓weight 2 stone since xmas • 1. Olanzapine started / stopped (SE) THEN 2. Quetiapine started / stopped (SE) THEN 3. Aripiprazole • ICD F 23.2 Acute schizophrenia-like disorder • Quoted 80% chance of relapse in first year if stops tx • Do not think fit to RTW ITU – in a month or two could return ‘less stressful’ environment. Not to work nights.

  8. Initial RTW -1 • RTW on adjustments 13.7.2012 • Initially- phased return, non clinical duties • On review 21.9.2012 – return to full time clinical, no nights • On review 18.12.2012 – separate shifts with day off, no nights • On review 4.2.2013 – off work, relapse early January, admitted to psychiatric hospital, now under local CMHT

  9. Case history 2 • 4.2.2013 – redeploy to clinical position outside ITU, no nights • 23.4.2013 – job identified in dermatology – FTW • 2.7.2013 – enjoying role / well / FTW • 28.4.2014 – remains well / promoted to band 6 / ‘cutting down medication’ • 9.6.2014 – called by matron – clinical incident – ‘overdose PUVA treatment’ – caused mild burn • Late June 2014 – sickness absence / low mood / manager cannot contact

  10. Case history - 3 • 23.6.2014 – seen in OH – not fit low mood – EA yes • 29.7.2014 – OH case meeting (matron / OH / HR) – matron wanted full disclosure of mental health condition – OH refused – expect RTW in one month • Seen in OH 5.8.2014 – remains under local CMHT, restarted medication – predict RTW 9.2014 • 22.8.2014 – RTW plan – clear guidelines for compliance and ‘what to do’ if signs of change in behavior • Difficult RTW pattern – high SA rate / difficult to manage • Grievance taken against manager and Trust (stigma/discrimination/bullying) / union involved / outburst in workplace and suspended • OH / care coordinator / LM meeting in OH to attempt resolution 6.4.2015 • Failed to attend multiple OH appointments / failure to engage with CMHT

  11. Resignation and NMC • Resigned from role at KCH Autumn 2015 • Reported to NMC by head nurse KCH • Concern upheld at NMC and suspended from practice

  12. Summary • 32 year old band 5 nurse • Became unwell 18/12 into a critical care-emergency department rotation KCH • OHP supported initial Return to Work • Regular OH attendance - work adjustments and redeployment • Unfortunately, eventual poor work outcome with job loss and NMC proceedings

  13. #Influenza2016 campaign – protecting you, Londoners & London HCW Kenny Gibson, Head of Public Health Commissioning Peer vaccinator – 486 influenza vaccines

  14. London’s influenza hospitalisations: 2015/16 influenza admissions Source: PHE Influenza surveillance

  15. London’s influenza vaccine cohort: long-term conditions 1 in 9 GP registered patients have a long-term condition 1,056,734 8,818,588 people registered with a GP in London (2014) people “at risk” (2014/15) People with mental health issues or learning disabilities are 10% more likely to die from influenza Carers are high-profile this year Source: ImmForm, PHE GP registrations

  16. #Influenza2016 plans for 2016/17 3.49 million Londoners need to be offered • Optimum efficacy is October – mid November; 40 working days (CMO) • 55,000 immunisation per day • 24 hour service • 1 person every 1.4 seconds 2.6 million Londoners need to take #Influenza2016 (75%) £25.5 million (£9.80 activity charge only) Estimates based on data from: ONS population projections, ImmForm, PHE population health profiles

  17. #Influenza2016 • Quarter 3 NHS Provider CQUIN – HCW Influenza @ 70% • Peer vaccinators, including community pop-up clinics • “You wouldn’t care for a patient if you hadn’t washed your hands – why wouldn’t you have your #Influenza2016 HCW vaccine” • www.londonflu.co.uk for an appointment. • 7 days a week and late shift vaccinations. • SONAR – real-time activity reporting (181K vaccines, 10K HCWs) • Open Access for all care staff - homeless; Care Home staff; Special Needs Schools; Prison and Police; Fire Brigade; non-registered and others

  18. #Influenza2016Duty of Care 3 women died of complications in past two years. 45% of ventilated paediatrics 64% of asthmatic kids did not have influenza vaccines Lets profile carers, mental health patients & health care workers

  19. #Influenza2016Celebrate your successes

  20. Findings on hospital arrangements for seasonal influenza vaccination among HCWs with direct patient contact, East of England, 2015/16 influenza season Hannah Evans Field Epidemiology Training Programme (FETP) fellow PHE East of England HPT and Field Epidemiology Service (East) Hannah.Evans@phe.gov.uk

  21. Background Seasonal influenza vaccination lowers • Risk of infection to the individual, patients & family • Sickness absence • Winter pressures on healthcare services 50.6% uptake in 2015/16 among HCWs with direct patient care • Lowest uptake : 44.9% in qualified nurses • 38% to 66% in Acute Trusts (East of England) Acceptance and uptake of vaccine may be influenced by organisationaland/or personal factors London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  22. Organisational factors • Accessibility(e.g. mobile vaccination clinics) • Educational(e.g. online e-learning) • Incentives (e.g. gift vouchers) • Support(e.g. peer vaccinator) • Communication (e.g. regular feedback on uptake) • No current evidence of the impact these arrangements make on vaccine • uptake in acute trusts in the East of England • Edelstein and Pebody (2014) Can we achieve high uptakes of influenza • vaccination of healthcare workers in hospitals? A cross-sectional survey of • acute NHS trusts in England. • https://www.ncbi.nlm.nih.gov/pubmed/23672975 London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  23. National guidance London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  24. What hospital arrangements are associated with higherinfluenza vaccine uptake among HCWs with direct patient contact in acute hospitals in the East of England? London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  25. Objectives For ATs in the East of England for influenza season 2015/16: 1. Identifythe availability of hospital arrangements for HCW influenza vaccination • Compare vaccine uptake in ATs with/without each hospital • arrangement to determine those arrangements associated with higher • HCW vaccine uptake • Describesimilarities and differences in the vaccine uptake data collection methods used by acute trusts London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  26. Why is this important? Provide insight into determinants of achieving higher influenza vaccination uptake Assist the planning and organisation of current and future influenza vaccination programmes Preventing influenza infection London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  27. Data collection • 1) Online questionnaire – 19 Acute Trusts (ATs) 2) Vaccine uptake (ImmForm) • Availability of arrangements • Accessibility • Support • Educational • Incentive • Communication • Other • Type of occupational health service • Influenza vaccination start/end dates • Data collection methods • Awareness, use & application of ImmForm guidance London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  28. Data analysis • Availability of each arrangement (proportions) • For each arrangement: • Compare median vaccine uptakes in ATs with an arrangement to ATs without the arrangement • Statistical test to determine if difference in uptake is significantly higher/lower London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  29. Results • 95% (18/19) ATs completed the questionnaire • 94% (17/18) used internal Occupational Health services • Influenza vaccination started in September (n=6), October (n=11) or November (n=1) • One AT continued to offer vaccination until the end of the influenza season London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  30. Availability of hospital arrangements London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  31. Availability of hospital arrangements London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  32. Differences in vaccine uptake 11% 1% 12% 13% 1% None significantly higher than ATs without the arrangement BUT vaccination available on weekends was significantly lower London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  33. Availability of hospital arrangements London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  34. Availability of hospital arrangements London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  35. Availability of hospital arrangements London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  36. Availability of hospital arrangements London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  37. Availability of hospital arrangements London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  38. Availability of hospital arrangements London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  39. Other arrangements • Trolley tokens • Food/drink incentives • Staff wearing flu t-shirts • Hospital directors speaking to staff • Reporting data at departmental level • Use of a dedicated flu phone/email address London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  40. Data collection methods • Good awareness and use of ImmForm guidance • Heterogeneity in the application of the guidance • staff employed by third parties • staff absent during the influenza season • Uncertainty on definition of support staff with direct patient contact London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  41. Discussion • ATs in the East of England delivered a multifaceted HCW influenza vaccination programme • Innovative approaches employed by ATs to directly engage with HCWs • No arrangements significantly associated with increased vaccine uptake • Effectiveness of offering vaccination during the weekends needs to be further explored London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  42. Limitations • Limited ability to detect significant associations between arrangements and vaccine uptake • Format, timing and delivery of arrangements not captured • Social, personal and cultural factors not captured London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  43. Recommendations • Topic Lead for Influenza, Field Epidemiology Services (East of England) • (with support from PHE national influenza team, Respiratory Disease • Department) • Identify the reasons why ATs differ in the application of the ImmForm User Guide for Survey Data Providers in order to ensure standardised reporting of vaccine uptake data by ATs • Provide further specific guidance to ATs on the definition of support staff with direct patient contact to ensure all staff eligible for vaccination are identified • Acute trusts • Each AT should internally review the arrangements currently delivered to identify and rationalise the arrangements that are most effective in encouraging vaccination so that they are appropriately resourced and to ensure the delivery of a successful influenza vaccination programme London Consortium of Occupational Health Practitioners meeting, 03 March 2016

  44. Acknowledgements • All ATs in the East of England • Mark Reacher, Hamid Mahgoub, Neville Verlander and Giri Shankar • PHE Healthcare Worker Flu Vaccination Task and Finish group • European Programme for Intervention Epidemiology Training (EPIET) and European Programme for Public Health Microbiology Training (EUPHEM) colleagues London Consortium of Occupational Health Practitioners meeting, 03 March 2016

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