ORIGINAL CONTRIBUTION
Can We Improve Physical Health Monitoring for Patients
Taking Antipsychotics on a Mental Health Inpatient Unit?
Elyse Ross, MD,* Rebecca Barnett, MD,*
Rebecca Tudhope, MD, FRCPC,† and Kamini Vasudev, MBBS, MD, DNB, MRCPsych*
Abstract:
Background: Patients with severe mental illness are at risk of medical
complications, including cardiovascular disease, metabolic syndrome,
and diabetes. Given this vulnerability, combined with metabolic risks of an-
tipsychotics, physical health monitoring is critical. Inpatient admission is
Downloaded from http://journals.lww.com/psychopharmacology by BhDMf5ePHKbH4TTImqenVCscvrd+bRBwk4m9f/Lleugew7jwnV01nTXIHIQpkH82 on 02/13/2019
an opportunity to screen for medical comorbidities. Our objective was to
improve the rates of physical health monitoring on an inpatient psychiatry
unit through implementation of an electronic standardized order set.
Methods: Using a clinical audit tool, we completed a baseline retrospec-
tive audit (96 eligible charts) of patients aged 18 to 100 years, discharged
between January and March 2012, prescribed an antipsychotic for 3 or
more days. We then developed and implemented a standard electronic ad-
mission order set and provided training to inpatient clinical staff. We com-
pleted a second chart audit of patients discharged between January and
March 2016 (190 eligible charts) to measure improvement in physical
health monitoring and intervention rates for abnormal results.
Results: In the 2012 audit, thyroid-stimulating hormone (TSH), blood
pressure, blood glucose, fasting lipids, electrocardiogram (ECG), and
height/weight were measured in 71%, 92%, 31%, 36%, 51%, and 75%
of patients, respectively. In the 2016 audit, TSH, blood pressure, blood glu-
cose, fasting lipids, ECG, and height/weight were measured in 86%, 96%,
96%, 64%, 87%, and 71% of patients, respectively. There were statistically
significant improvements (P < 0.05) in monitoring rates for blood glucose,
lipids, ECG, and TSH. Intervention rates for abnormal blood glucose and/
or lipids (feedback to family doctor and/or patient, consultation to hospital-
ist, endocrinology, and/or dietician) did not change between 2012
and 2016.
Conclusions: Electronic standardized order set can be used as a tool to
improve screening for physical health comorbidity in patients with severe
mental illness receiving antipsychotic medications.
Key Words: antipsychotic, physical health monitoring,
metabolic side effects, quality improvement, inpatient psychiatry
(J Clin Psychopharmacol 2018;38: 447–453)
S evere mental illness (SMI) is associated with poorer health and
excess mortality. An average of 15 to 20 years of decreased
life expectancy is seen across most psychiatric disorders.1–3 Ex-
cess mortality is especially high in psychiatric patients with a his-
tory of inpatient admissions.4 These patients are often assessed for
safety risk, when in fact the mortality risk from physical illnesses,
From the *Department of Psychiatry, Western University, London Health Sci-
ences Centre, London; and †Department of Psychiatry, Strathroy Middlesex
General Hospital, Strathroy, ON, Canada.
Received September 7, 2017; accepted after revision June 28, 2018.
Reprints: Elyse Ross, MD, Resident Physician, Department of Psychiatry,
London Health Sciences Centre–Victoria Hospital, 800 Commissioners
Road E, London, ON N6A 5W9, Canada (e‐mail: elyse.ross@lhsc.on.ca).
Supplemental digital content is available for this article. Direct URL citation
appears in the printed text and is provided in the HTML and PDF versions
of this article on the journal’s Web site (www.psychopharmacology.com).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0271-0749
DOI: 10.1097/JCP.0000000000000931
Journal of Clinical Psychopharmacology • Volume 38, Number 5, October 2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
especially cardiovascular diseases, significantly exceeds the risk
of dying by suicide.5–8 Individuals with depression, anxiety, bipo-
lar disorder, and psychosis are all at an increased risk of cardiovas-
cular diseases.9–11 It is postulated that these individuals are
especially vulnerable to cardiovascular diseases because of their
unhealthy lifestyle, including poor dietary habits, obesity, lack of
exercise, caffeine ingestion, self-neglect, and the increased use
of tobacco, drugs, and alcohol.12–14 Mental illnesses also seem
to be independent risk factors for numerous diseases. For exam-
ple, depression is an independent risk factor for hypertension
and stroke,15,16 and schizophrenia is an independent risk factor
for metabolic syndrome, diabetes, coronary heart disease, hyper-
tension, and emphysema.17–19 The use of atypical antipsychotics,
with their associated risks of metabolic side effects, also contrib-
utes to morbidity and mortality.20–23
Given the baseline medical vulnerability of patients with
SMI, combined with the metabolic risks of antipsychotic medica-
tions, appropriate physical health monitoring is critical.24 Numer-
ous guidelines and recommendations have been put forth to
effectively monitor physical health in patients on antipsychotics
as a means of health promotion. Many of the published guidelines,
including those from the Canadian Psychiatric Association, the
American Psychiatric Association, the National Institute for
Health and Clinical Excellence, the Royal Australian and New
Zealand College of Psychiatrists, the Royal College of Psychia-
trists, the Disability Rights Commission, the American Diabetes
Association, and the Centre for Addictions and Mental Health
have come to similar conclusions, indicating that weight, body
mass index (BMI), waist circumference, blood pressure, electro-
cardiogram (ECG), fasting glucose, fasting lipids, and prolactin,
when applicable, should be done on a regular basis.25–32 Unfor-
tunately, patients with mental illness struggle with numerous
barriers to accessing primary care.33–35 Therefore, inpatient ad-
mission may be used as an opportunity to monitor their physical
health and screen for cardiovascular and other comorbidities.36,37
A systematic review and meta-analysis indicated that guidelines
can increase medical monitoring of patients on antipsychotics,
but, even still, most patients do not receive adequate testing.38
In this article, we present the results of a completed audit cy-
cle on an acute psychiatry ward. The initial audit was conducted in
2012 to assess the prevalence of antipsychotic prescribing and
physical health monitoring practices in patients prescribed anti-
psychotic medications. The results of this audit guided us to make
relevant interventions on the ward and a re-audit was conducted in
2016 to assess the impact of these interventions.
MATERIALS AND METHODS
2012 Primary Chart Audit
A retrospective chart audit of all inpatients discharged from
the care of the Adult Psychiatry at London Health Sciences Centre
during the months of January, February, and March 2012 was con-
ducted. The Adult Psychiatry inpatient unit at London Health
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Ross et al Journal of Clinical Psychopharmacology • Volume 38, Number 5, October 2018
Sciences Centre is an acute secondary care service, with an average
length of stay of 2 to 3 weeks. The patient care is provided by con-
sultant psychiatrists, psychiatry residents, nurses, occupational ther-
apists, and social workers.
A clinical audit tool was designed to capture the essential and
necessary physical health monitoring parameters based on na-
tional and international guidelines (see Supplemental Digital Con-
tent 1, http://links.lww.com/JCP/A524). Information was gathered
for 1 year before the index discharge date. Information was cap-
tured from all records during the current or previous admission
(within the previous 1 year) including emergency room records,
the centralized emergency psychiatric services records, nursing
initial contact sheet, graphic records, medical administration
records, nursing patient care profile, progress notes, interdisci-
plinary goals sheet, consultations, discharge summaries, and
electronic patient care records (Power Chart).
The inclusion criteria were patients aged 18 to 100 years, ad-
mitted to the inpatient psychiatric service, and prescribed
a regularly scheduled antipsychotic medication for 3 or more days.
Charts of all patients discharged in the above months were
screened. Charts of those patients who met the inclusion criteria
were selected for the study. Included patients were assigned a
unique code for identification within the data set. A master
spreadsheet of Medical Record Numbers corresponding to unique
codes was stored on an encrypted USB drive in a secure location.
Information was collected on demographic parameters, diagnosis
(es) at discharge, antipsychotic medications prescribed in hospital
for 3 or more days, smoking status, and substance use. Medical in-
vestigations included weight, height, BMI, waist circumference, at
least 2 blood pressure readings, ECG, complete blood count
(CBC), liver transaminases (liver function tests), kidney function
tests, thyroid-stimulating hormone (TSH), blood sugar, lipids,
and prolactin (if prescribed risperidone or paliperidone). Informa-
tion was also collected on whether advice on healthy lifestyle was
given; if any actions were taken for abnormal blood glucose and/
or lipids, including feedback to the patient, referrals to a dietitian,
hospitalist, or an endocrinologist; and if family physician was up-
dated on the abnormal results with request to follow-up.
Interrater reliability was assessed before start of clinical audit.
Two researchers reviewed 5 pilot charts before the clinical audit.
Interrater reliability was calculated as 1.0 (100% concordance).
Quality Improvement Initiatives
The inpatient psychiatrists recognized the suboptimal moni-
toring of physical health of psychiatric inpatients. One of the au-
thors took the initiative to develop a medical directive, which
was approved by the inpatient physicians and other hospital ad-
ministrative bodies. This directive indicated that all patients ad-
mitted to the inpatient psychiatry ward will automatically
undergo the following investigations after 72 hours of admission:
height, weight, BMI, waist circumference, daily vitals for 3 days,
and blood tests including CBC, liver transaminases, kidney func-
tion tests, TSH, serum glucose, and lipids. Glycosylated hemoglo-
bin is also to be measured if the patient is known to be diabetic. To
avoid unnecessary duplication of tests, patients who had under-
gone the above tests within the previous 6 months and were re-
ported normal would not have them repeated automatically
unless there was a clear indication. The attending physician could
repeat these tests at any time to rule out any organic factors con-
tributing to patient's clinical presentation or when starting a new
antipsychotic medication.
Education and training of the nursing staff on the inpatient
ward took place to create awareness of the need for physical health
monitoring and for successful implementation of the medical
448 www.psychopharmacology.com
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directive, which was rolled out in February 2013. Hospital-wide
computerized provider order entry was introduced in the fall of
2013 as part of the initiative “Healthcare Under Going Optimiza-
tion.” The medical directives for physical health monitoring were
made available as a standardized order set for easy use at the time
of admission. Education was provided to the psychiatric clinical
staff (including resident physicians) on the importance of ordering
these investigations and providing feedback to the patients on the
results. Clinical team members were also instructed to encourage
lifestyle/dietary modifications as needed and communicate any
abnormal findings to family physicians at discharge. For any inpa-
tients with urgent physical health concerns, a family physician
hospitalist available twice weekly could be consulted. In addition,
consultations could be requested from inpatient endocrinology
and the inpatient dietician.
2016 Chart Re-Audit
After implementation of the above initiatives, a second chart
audit was performed of all inpatients discharged from the psychi-
atric inpatient unit during the months of January, February, and
March 2016. The same inclusion criteria were used as described
above. One author and 4 medical students completed the chart
review. Interrater reliability was calculated as 0.94 (94% concor-
dance). Data were collected on physical health parameters as de-
scribed above. Information was also collected on classes of other
medications prescribed at time of discharge in addition to the an-
tipsychotic medications (antidepressants, mood stabilizers, anti-
hypertensives, antihyperglycemics, lipid-lowering agents, and
any other medications). During this second chart review, addition-
ally, the Ontario Laboratories Information System (OLIS) was
used to find investigations ordered in the community within the
year previous to discharge. OLIS was not available at the time
of primary audit in 2012. Information was also collected sepa-
rately on each of the specific interventions made for patients with
abnormal blood sugar or lipids (dietician, hospitalist, endocrinol-
ogist, feedback to patient, and/or feedback to family physician).
The Health Sciences Research Ethics Board at Western Uni-
versity approved this project.
Statistical Analysis
Interrater reliability scores were calculated using percentage
of concordance between the raters, as the clinical audit tool was
designed to be highly objective. Descriptive statistics including
mean and standard deviation were used to compute continuous
variables, frequency, and percentages for categorical variables.
T test was used to compare continuous variables and χ2 test for
categorical variables. Significance level was set at P < 0.05.
RESULTS
Health Records at London Health Sciences Centre identified
542 charts of patients discharged during the identified study months
(187 patients in 2012, and 355 patients in 2016). Each chart was
screened, finding 91 (2012) and 165 (2016) patients not meeting in-
clusion criteria. Of the remaining patients, 96 (2012) and 190
(2016) were included in the study for further review.
Demographics and Clinical Characteristics
Demographic and clinical characteristics are outlined in
Table 1. Smoking rate was significantly lower in 2016 as com-
pared with 2012 (P = 0.016). The number of patients with diagno-
ses of psychotic disorders (P = 0.02) and “other” diagnoses
(P = 0.000001) was significantly higher in 2016. Ethnicity was
not recorded most patients. Only 22% and 37% of patients were
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Journal of Clinical Psychopharmacology • Volume 38, Number 5, October 2018
TABLE 1. Comparison of Patient Demographics and Diagnoses
Parameter 2012 (n = 96) (%)
Mean age in years (SD) 42.0 (18.0)
Male 45 (47)
Female 51 (53)
Smoking 56 (58)
Substance use 57 (59)
Psychotic disorder 21 (22)
Mood disorder with and without psychotic features 47 (49)
Other diagnosis 28 (29)
*All discharge diagnoses recorded in 2016 (single primary diagnosis recorded in 2012).
prescribed an antipsychotic for a diagnosed primary psychotic
disorder in 2012 and 2016, respectively. There were 49% and
51% of patients who were prescribed antipsychotics for a mood
disorder with or without psychotic features. Other diagnoses in-
cluded posttraumatic stress disorder, adjustment disorder, demen-
tia, delirium, substance use disorders, intellectual disability, and
personality disorders.
Antipsychotic Prescribing
Data were collected on antipsychotic prescription frequency
(Fig. 1). Quetiapine was the most commonly prescribed antipsy-
chotic medication in both 2012 and 2016. The second most com-
monly prescribed was risperidone in 2012, and olanzapine in
2016. Antipsychotic polypharmacy was common in both study
years, with 19% and 24% of patients prescribed more than 1 anti-
psychotic, respectively. A listing of all antipsychotic medications
prescribed in both 2012 and 2016 was compiled (see Supplemen-
tal Digital Content 2, http://links.lww.com/JCP/A525).
Non-Antipsychotic and Physical
Health Medications
Table 2 outlines percentages of antidepressants, mood stabi-
lizers, antihypertensives, cholesterol-lowering, diabetic, and other
medications prescribed in 2012 and 2016. Chi-squared tests did
not find significant differences in rates of any medication class
prescribed in 2012 compared with 2016.
Physical Health Monitoring
Using the clinical audit tool, rates of physical health monitor-
ing for each parameter were recorded (Table 3). Chi-squared tests
were applied (P < 0.05) to determine whether improvements in
monitoring rates reached statistical significance. Lipids were
FIGURE 1. Comparison of the most commonly prescribed antipsychotics.
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Inpatient Physical Health Monitoring
2016 (n = 190) (%) P (χ2/2-sided t test, P < 0.05)
42.5 (17.9) t = −0.19 (2-sided t test) P = 0.848
92 (48) 0.887
98 (52) 0.887
77 (41) 0.016
103 (54) 0.476
71 (37)* 0.020
97 (51)* 0.777
120 (63)* 0.000001
classified as abnormal if patients had 1 or greater abnormal value
of either (or both) low high-density lipoprotein (HDL) (<1.0 mmol/L
in men or <1.3 mmol/L in women) and elevated triglycerides
(≥1.7 mmol/L), as both parameters are included in metabolic syn-
drome diagnostic criteria.39 Metabolic syndrome criteria were used
to categorize lipid results, as cutoffs provided by the hospital/
community labs did not acknowledge the different sex normal ranges
for HDL. It was not possible to use lipoprotein (low-density lipo-
protein) values to calculate Framingham risk scores, as a signifi-
cant number of study participants lacked one or more parameter
required to calculate the score. Thus, metabolic syndrome criteria
were used to interpret lipid results in a clinically meaningful way.
Most of the patients had height and weight measurements
done, which allowed for BMI calculation. Of the patients with
BMI calculated, 18 (25%) and 47 (35%) were overweight in
2012 and 2016, respectively (BMI, 25.0–29.9 kg/m2). There were
17 (24%) and 36 (27%) patients who were obese (BMI, ≥30.0 kg/m2)
in 2012 and 2016, respectively. Waist circumference (abnormal if
≥102 cm in men and ≥88 cm in women; ranges vary according to
ethnicity39) was not recorded in any 2012 patients and only re-
corded in 2 (1%) patients in 2016.
Monitoring rates for blood glucose, lipids, ECG, and TSH
had statistically significant improvements (Table 3).
Of patients with blood glucose recorded, 3 (10%) had abnor-
mal results (≥7.0 mmol/L for fasting glucose) in 2012 compared
with 11 (6%) in 2016. Abnormal lipids were a common finding,
with 16 (46%) patients and 74 (61%) patients with low HDL
and/or high triglycerides in 2012 and 2016, respectively.
Rates of Intervention for Abnormal Results
Advice given on healthy lifestyle, as recorded on the interdis-
ciplinary goals sheet, was provided in a minority of patients: 11
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Ross et al Journal of Clinical Psychopharmacology • Volume 38, Number 5, October 2018

TABLE 2. Comparison of Non-Antipsychotic and Physical Health Medications Prescribed

Medication Class 2012 (n = 96) (%) 2016 (n = 190) (%) P (χ2 test, P < 0.05)
Antidepressants 52 (54) 110 (58) 0.569
Mood stabilizers 19 (20) 60 (32) 0.053
Antihypertensives 17 (18) 38 (20) 0.718
Cholesterol lowering 10 (10) 18 (9) 0.809
Diabetic 5 (5) 15 (8) 0.390
Other 58 (60) 108 (57) 0.667

(11%) in 2012 and 12 (6%) in 2016. Of patients with abnormal
blood and/or lipids, only 4 (21%) in 2012 and 11 (13%) in
2016 had 1 of 4 specific interventions made, including dietician
referral, hospitalist referral, endocrinologist referral, and feedback
provided to the patient. In 2012, data were not collected separately
for each of these interventions, but in 2016 separate data were col-
lected for each intervention. Three patients in 2016 received more
than 1 of the 4 interventions. In 2016, 3 (4%) patients were re-
ferred to a dietician, 5 (6%) were referred to a hospitalist, and 3
(4%) were referred to endocrinology. Four (5%) patients received
feedback on abnormal results. Feedback to family physician was
provided for 26 (27%) of all study patients in 2012 and 17
(20%) of patients in 2016.
DISCUSSION
There has been a significant amount of literature looking at
interventions that increase metabolic screening,40 but this was
the first large-sized retrospective chart review in an inpatient set-
ting looking at the implementation of a standardized electronic
order set.
Our study demonstrates that electronic implementation of a
medical directive, along with education and training provided to
clinical staff, may improve physical health monitoring rates in
an inpatient setting. In particular, improvements in monitoring
for blood glucose, lipids, ECG, and TSH reached statistical
significance. Other parameters, such as CBC and kidney function,
already had high monitoring rates in 2012 (97% and 95%, respec-
tively); thus, it was expected that 2016 improvements would not
be statistically significant. A similar study implementing an
electronic pop-up alert in an inpatient psychiatric unit showed
significant improvement rates of ordering fasting blood glu-
cose and lipid levels for inpatients treated with second-
generation antipsychotics.37
It is important to note that in our study, the number of dis-
charges that took place over the 3-month audit period in 2016
was almost double the number of discharges in 2012. This reflects
sheer increase in the volume of patients presenting to our service
and higher turnover of patients over the years. The bed numbers
on the acute adult psychiatry unit increased from 74 beds in
2012 to 90 in 2016. As of April 2018, there are a total of 110 acute
adult psychiatry beds.
Despite the increase in the number of admissions, our re-
audit indicated a significant improvement in the rate of physical
health monitoring; this further highlights that using a standardized
electronic order set is an effective way to monitor the physical
health of patients admitted to an acute psychiatry unit with a
high turnover.
Our study demonstrated a high prevalence of overweight and
obesity in both 2012 and 2016. Our chart review in 2012 repli-
cated the concerns raised by other studies regarding suboptimal
physical health care of patients with SMI.34,41 Abnormal waist

TABLE 3. Comparison of Physical Health Monitoring Rates

Parameter 2012 (n = 96) (%) 2016 (n = 190) (%) P (χ2 test, P < 0.05)
Height and weight collected 72 (75) 134 (71) 0.524
Overweight 18 (25)* 47 (35)* 0.123
Obese 17 (24)* 36 (27)* 0.626
Waist circumference 0 (0) 2 (1) 0.994
Blood pressure 88 (92) 182 (96) 0.234
Blood glucose 30 (31) 183 (96) 0.00000001
Lipids 35 (36) 122 (64) 0.000075
ECG 49 (51) 165 (87) 0.00000001
CBC 93 (97) 188 (99) 0.312
LFTs 70 (73) 152 (80) 0.243
Kidney function 91 (95) 179 (94) 0.756
TSH 68 (71) 163 (86) 0.010
Prolactin 10 (25)† 12 (21)† 0.502
Abnormal fasting or random glucose 3 (10)‡ 11 (6)‡ 0.297
≥1 abnormal lipid value (HDL and/or triglycerides) 16 (46)‡ 74 (61)‡ 0.033
*Percentage of patients with body mass index (BMI calculated).
†
Percentage of patients prescribed risperidone or paliperidone.
‡
Percentage of patients with glucose or lipids checked.
LFTs indicates liver function tests.

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Journal of Clinical Psychopharmacology • Volume 38, Number 5, October 2018
circumference is a diagnostic criterion for metabolic syndrome,
yet it was only recorded in 1% of patients in 2016, and not at all
in 2012. During the training period in 2013, nursing staff were
trained on doing a waist circumference, and it was ensured that
measurement tapes were made available in the examination
rooms. However, there has been a large turnover in staff over the
years, and the extremely busy ward environment may force nurses
and the management to prioritize mental health concerns over
physical health interventions. Consistent with our results, Happell
and colleagues42 observed the absence of waist circumference
data in an Australian retrospective file audit. In a 2014 audit of
an intervention to enhance waist circumference measurement,
nursing staff identified patient refusal and desire to minimize
physical contact as perceived barriers.43
The results, though, indicate that we have not significantly
improved intervention rates for abnormal glucose and lipids; these
results must be interpreted carefully because of the relatively small
number of patients who had abnormal results and the challenges
in defining “abnormal” values. In addition, as indicated earlier,
OLIS became available in 2016, through which data were col-
lected on the investigations completed in the community before
admission; however, inpatient psychiatrists may have been un-
aware of abnormal results and thus may not have intervened. It
was particularly difficult to interpret if the lipid abnormalities
were clinically significant to warrant intervention. We had initially
hoped to calculate Framingham scores to clinically interpret low-
density lipoprotein in a meaningful way. It soon became clear,
however, that this could not be done because we lacked some of
the Framingham score parameters. We were unable to find clear
examples in the literature or from endocrinology colleagues about
how to define borderline parameters, and many patients in this
range could be overcalled as abnormal even if not clinically signif-
icant. Because metabolic syndrome parameters include both HDL
and triglycerides, we decided to label a patient as having “abnor-
mal lipids” if either value was abnormal according to metabolic
syndrome criteria.
Our results from the 2016 chart review indicate that the pre-
scription of antipsychotic medications for both psychotic and
nonpsychotic disorders has significantly increased. Therefore,
it is important that patients on these medications are appropri-
ately monitored and treated for physical comorbidities. Despite
resources being created to help guide health interventions in
mentally ill patients,44 abnormal physical results are being inad-
equately managed by treating psychiatrists.45 A number of bar-
riers to psychiatrists following up on metabolic abnormalities
have been identified, including ambivalence about responsibil-
ity, professional norms, resource constraints, skills deficits, and
patient factors46; nevertheless, the importance of psychiatrists
addressing physical illness in their patients is becoming more
recognized.8,47 There is also evidence to suggest that there may
be a lack of awareness or low expectations among the mental
health professionals regarding the physical health needs of pa-
tients with SMI.48,49
Improved collaboration between primary care and psychiat-
ric services is needed to improve physical health care of our vul-
nerable population.50 In addition to the inpatient setting,
community or outpatient settings can also be used as opportunities
for screening for cardiovascular risk factors and improvement in
weight and nutritional status.51–56
As a continuous quality improvement measure, results of the
re-audit were discussed at an inpatient psychiatrist meeting, em-
phasizing the need to complete required investigations and take
action on abnormal results. Each adult inpatient psychiatrist was
provided an anonymized summary table of the rates of physical
health investigations completed by all psychiatrists. The psychiatrists
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Inpatient Physical Health Monitoring
were each provided a unique code to identify data pertaining to them
specifically. A regular training session for the incoming postgraduate
year 1 residents on how to ensure adequate physical health moni-
toring using the admission order set has been introduced. Clear
recommendations were again disseminated to all those involved
in patient care on consistently providing feedback to patients on
their physical health parameters and communicating this informa-
tion to their family physicians through dictated discharge summa-
ries. Use of consultation services such as dietician, hospitalist, and
endocrinology, when appropriate, was also emphasized. The au-
thors hope to conduct another chart review of patients discharged
in 2018 to establish if interventions made above led to further im-
provement in quality of care.
One of the strengths of this study is the considerable effort
made to locate documentation in the paper and electronic charts,
including OLIS for community results. However, the information
obtained from the community in 2016 may have overestimated the
physical health monitoring rate (which cannot be attributed to the
intervention made in the hospital).
There are some limitations of this study which need to be
highlighted. One barrier, inherent to any chart review, is that data
collected are dependent on proper clinical documentation. It is
possible that appropriate measures were taken to address abnor-
mal results, but may not have been documented. If investigations
were ordered but refused by the patient, this may underestimate
monitoring rates. Data on percentage of patients in whom the elec-
tronic order set was used and what percentage of these orders were
completed are not available. It may be helpful to know if the
noncompletion of orders was related to omission by staff or pa-
tient refusal. Another limiting factor is the increased turnover of
patients on the ward over the 4 years; this may make the compara-
bility of the chart audits complicated to interpret.
In conclusion, computerized provider order entry can be used
as a tool to improve screening for physical health comorbidity in
patients with SMI receiving antipsychotic medications. There is
an urgent need to create awareness and behavioral changes among
health professionals on psychiatric wards, to capitalize on the op-
portunity to address physical health morbidity and risk factors in
this difficult-to-treat population. A culture change among mental
health professionals, both at the individual hospital and system
levels, is imperative. Further research on assessing the impact of
these interventions on health outcomes is needed.
ACKNOWLEDGMENTS
We thank Dr Ajay Prakash, Stephanie Fong, Michael
Wodzinski, Matthew Renaud, and Jennifer Zhang who assisted
with the chart audit and data collection.
AUTHOR DISCLOSURE INFORMATION
The authors declare no conflicts of interest.
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