bluuebunny/crossref_metadata_2025 huggingface dataset:
Cardiovascular risk quantification using QRISK-3 score in people with intellectual disability
Authors: Ho Jamie Sin Ying , Rohra Vikram , Korb Laura , Perera Bhathika
Published: June 2021

Aims

The prevalence of cardiovascular diseases (CVD) in people with intellectual disability (ID) is around 14%, higher than the general population. However, CVD risk assessments are not consistently performed. Given the high risk of premature deaths in people with ID, it is important to identify preventable risk factors and follow evidence-based interventions. QRISK-3 is a validated risk-stratification tool, which calculates the 10-year risk of developing a heart attack or stroke (https://qrisk.org/three/index.php). There are no published studies on the use of QRISK-3 in people with ID. This project aimed to understand the use of QRISK-3 in an ID clinic and to quantify individual CVD risks to recommend appropriate management options.

Method

A cross sectional study was performed on 143 patients open to an ID psychiatry clinic. Patients and carers were sent an accessible information leaflet on this study. Basic demographic data and information on psychiatric diagnoses were collected. Patients were grouped according to the presence of severe mental illness (SMI) defined as schizophrenia, bipolar disorder and other psychotic illnesses. QRISK-3 ≥ 10% was defined as elevated risk in accordance with NICE guidelines. Patients who had a high QRISK-3 score were advised to contact their GP.

Result

Of 143 patients, 73 (51.0%) had a mild ID and the remaining had a moderate to severe ID. The mean age was 43.3 years, 53.1% were male. Overall, 28 (19.6%) participants had an elevated CVD risk, of whom 16 (57.1%) were not on statins, which is the recommended treatment. The mean QRISK-3 score was 6.31 (standard deviation [SD] 8.95), and the relative risk is 3.50 (SD 7.13). The proportion of QRISK-3 ≥ 10% and mean score were not significantly different in those with SMI, but those with SMI were more likely to be prescribed statins than those without (14 [31.1%] vs 10 [10.2%], p = 0.002). Statins were given to 24 (16.8%) participants, of whom 12 (50%) had elevated CVD risk. 89% had a blood pressure recording within the past 5 years, 87% had height and 88% had weight recorded. 73% had lipid serology results recorded.

Conclusion

Elevated CVD risk was common in this ID study population, and more than half with elevated QRISK-3 were not on the medical treatment recommended by national guidelines. QRISK-3 could feasibly be implemented in the outpatient setting. Increased routine CVD risk assessment and management should be considered as another measure to reduce morbidity and mortality.
Improving remote prescribing in a CAMHS community team during the COVID-19 pandemic
Authors: Tai Sarah , Huang Hannah Chu-Han , Batham Oliver , Anandakumar Brindha , Abbott Christopher
Published: June 2021

Aims

Prior to the COVID-19 pandemic, prescriptions were usually collected by patients/families in person from the CAMHS community team base. Due to social distancing measures introduced during the pandemic, face-to-face contact between staff and patients had to be minimised. This led to an increase in remote prescribing, including from home. Feedback from team doctors was that the process of following the Remote Prescribing Protocol (RPP) was taking up a significant portion of their day, preventing them from doing other clinical work.

Our aim was to reduce the time taken to complete a remote prescription to pre-pandemic levels (under 15 minutes).

Method

We used PDSA methodology in this QI project:

1)

Plan: Survey sent out to team duty doctors to identify the most time-consuming steps in RPP which could be safely delegated to administrative staff

2)

Do: Email sent requesting administrative staff clarify several details with patients/families when they request a prescription. This included the names and doses of medication, how many days they had left, where they wanted the prescription sent to (home/pharmacy) and the relevant address. If the patient usually received their repeat prescription from their GP, they were re-directed to their GP

3)

Study: Following the intervention above, team doctors recorded how long it took to complete a remote prescription

Result

The average time taken to complete a prescription fell from 31 minutes (pre-intervention) to 22 minutes (post-intervention). The range of time taken also dropped from 10-241 minutes (pre-intervention) to 0-46 minutes (post-intervention). The medications taking above the average time to complete were more likely to be non-controlled drugs rather than controlled drugs (which one may typically think would be more time-consuming to write out).

Conclusion

Whilst we have successfully reduced the time for remote prescribing, we have not reached the target of reducing it down to less than 15 minutes (pre-pandemic timings). As part of the next PDSA cycle, we have carried out a survey to ask what barriers remain. Checking patient's notes and recent prescriptions can still be inefficient. We propose introducing an intervention whereby this can also be safety delegated to administrative staff e.g. including a copy of the most recent prescription in the request.

In the future, we will continue to improve the RPP with further PDSA cycles and carry out an audit on the system on a regular basis to ensure standards are met.
Four-six year clinical follow-up of deep brain stimulation for obsessive compulsive disorder
Authors: Tyagi Himanshu
Published: June 2021

Background

Over the past 20 years a number of robust studies have established the clinical effectiveness and safety of Deep brain stimulation (DBS) in adults with profound multi-treatment-refractory obsessive-compulsive disorder (OCD). However long term (>12 months) outcomes with this novel neurosurgical intervention are still inadequately reported. Our group conducted the first UK study of DBS in OCD between 2013-2017. All participants in our trial achieved a responder status at 15 month endpoint and the main results were reported in 2019. A specialist multidisciplinary clinic was established after the trial to provide life-long aftercare in the form of scheduled clinical and hardware reviews. Here we are reporting a preliminary analysis of the long-term clinical, functional and social outcomes from this cohort.

Method

Long term follow-up clinical data (15–75 months, 2015 onwards) were prospectively collected from the participants who were enrolled in the original MRC-UCL pilot study of DBS for OCD. DBS parameters, battery health and status, social circumstances, mental state and medication adjustments were noted alongside the outcome measures of YBOCS at clinical follow-up encounters. Additional ratings of GAF, SDS and certain qualitative measures were recorded at least once every year since initial study completion.

Result

Five out of six participants continued with DBS treatment and kept responder status. One participant had his DBS switched off and hardware removed. One participant had multiple hospital admissions to manage comorbidity progression to primary condition. One participant had OCD severity scores revised upwards despite continuing gains in QoL. Secondary outcomes generally matched the 15 month end point of initial trial. All participants experienced minor to major changes in their relationships with partners or family. Qualitative feedback indicated that DBS was well tolerated by 5/6 subjects but the burden of specialist follow-up remained significant.

Conclusion

Our long term follow-up data indicate that DBS is safe and conferred a sustained long-term benefit in reduction of obsessive-compulsive symptoms. A non-trivial burden of checking and maintenance of implanted hardware, comorbidity-unmasking following successful OCD treatment, perceived ‘burden of normality’ by the participant, need for life-long follow-ups with specialist multidisciplinary team including DBS nurses, highly specialist psychiatrists from National OCD service, neuropsychiatrists, neurologists and neurosurgeons partially counterbalances the gains offered by this treatment. Overall DBS offers a safe, effective and enduring alternative to participants who do not respond to any other form of OCD treatment and do not wish to undergo ablation surgery.
A UK-wide survey of Balint, support groups and psychotherapy training opportunities for SAS (Specialty Doctors and Associate Specialists) Psychiatrists
Authors: Vaida Alina , Awal Masud
Published: June 2021

Aims

To investigate SAS Psychiatrists’ opportunities for Balint-type, support groups and psychotherapy training opportunities nationwide, for which there is a lack of existing literature or established framework.

Method

An online questionnaire was sent to UK-wide SAS psychiatry doctors with the support of the RCPsych Speciality Doctors and Associate Specialist Psychiatrists Committee (SASC). The survey enquired about location, work experience, future plans, Balint-type groups, psychotherapy opportunities and support.

Result

122 doctors completed the questionnaire, estimated to constitute approximately 8% of SAS psychiatry posts (or more if considering all vacancies), based on the RCPsych Census (2015), from across all UK nations.Time spent in an SAS role varied widely between months (10%) to over 20 years (5%), with the median and mode being 8–12 years (25%). Regarding future career plans 61% responded that they would be considering either the Certificate of Eligibility for Specialist Registration (CESR) route, or applying for future training or both.

24% reported being part of a Balint-type group whilst almost double this number (47%) said they would be interested to join but none were available. 31% were part of a reflective practice or support group whilst 44% reported that they were interested in joining but none were available. Only 7% said that they were not participating or not interested in either a Balint group or a reflective group. Free-response comments suggested these opportunities were usually reserved for trainees and service commitments prevented attendance.

76% of respondents reported access to an SAS Tutor, but only 21% confirmed access to a psychotherapy tutor.

Half of respondents indicated they did not have access to information and guidance they needed regarding accessing psychotherapy opportunities, with only 27% thinking they did.

24% reported managing to gain experience in at least one psychotherapeutic modality, 44% of whom received medical psychotherapist supervision; whilst 13% said they did not intend to pursue this.

Conclusion

The results highlight that interest in joining Balint and reflective support groups significantly exceeds local provision. As these groups are not mandatory requirements for CESR application, the interest expressed (including amongst those reporting to be SAS by choice) suggests that SAS Psychiatrists value these opportunities for their recognised professional developmental and clinical benefits; these include peer support, understanding doctor-patient interactions and having a space to reflect on the emotional impact of clinical work. Trusts should consider supporting SAS doctors wishing to join new or existing Balint-type or other supportive reflective clinician groups.
Prevalence, associated factors and prevention of burnout in psychiatry trainees in Central and North West London NHS Foundation Trust
Authors: Xia Grace , Jayakumar Ahrane
Published: June 2021

Aims

To assess burnout, resilience, professional quality of life and coping mechanisms in Central and North West London psychiatry trainees

Objectives

To determine Key factors associated with stress and burnout in workplace Effects of burnout on patient care and doctors Coping mechanisms used by trainees

Background

Burnout is a well established condition that has been recently reported to affect a third of doctors. Psychiatrists in particular represents a high risk group among doctors for experiencing burnout, alcohol and drug use, posing suicide risk and other forms of work related stress.

Method

The study comprised of a cross sectional questionnaire survey which included measure of stress (General Health Questionnaire), burnout (Maslach Burnout Inventory), and satisfaction with medicine as a career and personality (Big Five). During October to December 2019, core trainee and specialty trainee doctors in CNWL were asked to complete an online survey via emails.

Result

We collected data from 50 CNWL psychiatry trainees. The sample consisted of 20 females (40%) and 30 males (60%). Ages varied from 26–58 years old, with a median age of 28. Core trainees (CT1–3) were recorded as 72% and specialty trainees at 28%.

Of those who responded, around half of the trainees (52%) experienced high levels of stress outside of work in their personal life. The most common causes that trainees felt makes psychiatry a stressful profession were violence and fear of violence, limited resources, dealing with confrontational patients, inability to affect systemic change and increasing culture of blame. Around half of respondents (54%) felt that they have experienced burnout but only 26% of respondents knew where to go to find resources to help cope with burnout. Physical exercise and speaking to colleagues were the most common coping mechanisms used by trainees to deal with stress.

Free text responses on what can be improved in workplace to enhance a positive experience of work included improving multidisciplinary interactions, easily accessible resources and increasing staffing levels. 74% of respondents felt they continued to care about what happens to patients regardless of working conditions.

Conclusion

Half of CNWL trainee doctors who responded have experienced burnout. Some factors associated with stress and burnout in doctors are unique to psychiatry profession. Free text responses were useful in identifying areas for improvement in work places and useful coping mechanisms, which can be used to inform prevention and implement interventions to tackle burnout.
Driving digitisation of the workforce. Junior doctor's digital devices rollout at South London and Maudsley NHS Foundation Trust: an early review of uptake, usage and effects
Authors: Zacharia Tharun
Published: June 2021

Aims

A Quality Improvement Project (QIP) was completed at South London and Maudsley NHS Foundation Trust (SLaM) to provide access of Trust laptops and smartphones (digital devices) to training doctors.

The aim of the study was to assess the views of trainees before and after the rollout of digital devices. Also, to assess barriers of device uptake/usage.

Method

Trainee doctors were surveyed before mass release of digital devices. Trainees were surveyed again 2 months later, providing ample opportunity to request a device.

Correlated survey questions asked about training grade, expectation to request a digital device (and subsequent completed request), expected usage cases (and actual usage cases), expected benefits (and actual benefits), perceived importance of access to each device (before and after access) and barriers for device uptake. Also inquired were general comments about the project and actual lead time on device access.

Result

110, mixed training grade, doctors participated in both surveys combined. There was a high demand for digital devices. Laptop requests were highest, with greater clarity of potential usage cases noted for a laptop. Laptops were perceived to be the more important device to a trainee.

Common usage cases for laptops were clinical work (in and out of working hours). There was also high usage around educational and audit/QIP activities. Smartphones were used only for clinical work (in and out of working hours).

Having access to each device was most beneficial in saving clinician time. Other sizable benefits included improvements in communication with patients and other professionals, as well as benefits toward patient safety. The laptop specifically also improved educational access.

A larger proportion of trainees requested a mobile phone than were previously expecting to. New ways of working due to the pandemic were noted to be motivating factors toward usage of devices.

The biggest barrier to device uptake was the delay from request to acquisition (often over 4 weeks).

Numerous respondents used personal devices for Trust related activities. This was more prevalent with smartphones, than with laptops.

Conclusion

Digital device rollout was a valued endeavour, with enhanced demand secondary to the pandemic. Primary usage and benefits supported clinical effectiveness. The primary access barrier was the delay from point of request to point of delivery. As SLaM, and the NHS as a whole, becomes increasingly digitised, this program is vital to allow the Trust to ensure the trainee workforce are digitally equipped to continue to deliver safe, effective and quality care.
Clozapine & constipation: an audit of bowel habit monitoring and laxative prescribing in inpatients on clozapine
Authors: Boyd Holly , de Zuniga Anna Manso
Published: June 2021

Aims

To establish how often bowel habits are monitored in inpatients on clozapine

To determine how many of these patients are prescribed laxatives and whether these are utilised

Background

It's estimated that 30-60% of patients will suffer from constipation whilst on clozapine; this can lead to ileus, intestinal obstruction and bowel ischaemia, all of which can be fatal. Constipation is much more common than clozapine-induced blood dyscrasias, and has a higher mortality rate. Despite this, there is no strict universal framework for bowel habit monitoring equivalent to the compulsory FBC monitoring. Local trust guidance indicates that bowel habits should be monitored regularly, at least at any point of blood sampling. However, monitoring processes across the trust were noted to be variable, as were laxative prescribing practices.

Method

The data sample of current inpatients on clozapine across the trust was identified from pharmacy records. The patient's Rio notes from the preceding 3 months were searched for predetermined terms relating to bowel habits and constipation, and the notes were then analysed for assessment of bowel habit. The number of FBCs collected during this 3 month period was then used to produce comparison with the audit standard. The data on laxative prescribing were collected from current medication lists on EPMA.

Result

A data sample of 31 current inpatients was identified. The audit found that only 54.8% (17) of patients had their bowel habits monitored at least with every FBC taken. There was significant variability between different wards, with the best performing ward having 100% adherence to the audit standard, and the worst performing having 0%. In terms of laxative prescribing, it was found that 87.1% (27) of patients had at least 1 regular or 1 PRN laxative prescribed. Regular laxatives were prescribed for 61.2% (19) of patients, whereas only PRN laxatives were prescribed in 25.8% (8) of patients. Of those prescribed only PRN laxatives, only 50% (4) ever utilised this medication.

Conclusion

Bowel habits are not consistently monitored across the trust in inpatients on clozapine, leaving room for potentially life-threatening side effects to be missed. Additionally, regular laxative prescribing is not standard throughout the trust, which could further add to the potential for significant constipation-related morbidity to occur. A standard method of monitoring bowel habits throughout the trust, as well as a trust laxative prescribing policy, could be a way of remedying this issue and preventing harmful outcomes for our patients on clozapine.
An audit into the management of COVID-19 in a high security psychiatric hospital
Authors: Carthy Elliott , Sengupta Samrat
Published: June 2021

Aims

Comprehensive and timely data collection during a pandemic is crucial in developing guidelines and policy as well as evaluating their effectiveness. In turn, this will improve planning for future incidents. While this is being undertaken at a national level by Public Health England, more specific information as it relates to psychiatric care is important in understanding the neuropsychiatric, psychological and social effects of the pandemic. The management of patients with COVID-19 presents a unique challenge in inpatient psychiatry settings both in terms of diagnosis and treatment. This is perhaps greater still in forensic settings due to the increased risk of violence and aggression. This audit aimed to firstly assess the consistency of local practice to national guidance from Public Health England. Secondly, it aimed to describe the clinical management of suspected and confirmed cases of COVID-19 in this high security forensic hospital and how readily broad, national guidance can be implemented in this unique setting. We present an audit with three cycles, one from each wave of COVID-19 in England during 2020.

Method

This was a retrospective audit in a high secure forensic psychiatry hospital in the United Kingdom, into the investigation and management of suspected and confirmed cases of COVID-19 compared to national guidelines from Public Health England. It includes three cycles, one undertaken in each national wave of COVID-19 in England in 2020.

Result

Ten patients have been included in cycle 1, 12 in cycle 2 and 21 in cycle 3 as those where COVID-19 was a considered diagnosis. SARS-CoV-2 was detected in one patient in cycle 1 and 12 patients in cycle 3. All patients recovered, most of whom remained on-site with supportive care in self-isolation on a dedicated ward for positive cases. Three patients required additional treated with oral antibiotics and dexamethasone, one of whom required admission to the local general medical hospital for continuous supplemental oxygen.

Conclusion

This is the first study to describe the management of the novel COVID-19 pandemic in a high security forensic psychiatry hospital and how readily national guidance can be implemented in this unique setting. Hospital practice at identifying suspected cases and the management of confirmed cases of COVID-19 was shown to be consistent with national guidance. It also allowed for clinicians to exercise their judgement about testing for atypical cases and for repeat testing where appropriate.
Racial representation of psychological services in a London male remand prison
Authors: Covey Josh , Williams Joanne , Kothari Radha , Bartle Scott
Published: June 2021

Aims

To investigate whether racial groups are proportionally represented in referrals for trauma, hearing voices, emotional regulation and psychological therapy.

To understand the psychological needs across racial groups in HMP Wormwood Scrubs, the UK's 4th-most diverse prison.

To see if the long-established under-representation of Asian males and over-representation of Mixed males in psychological services in the community is also occuring in the prison system.

Method

Psychological referrals were recieved via the medical notes system (SystmOne), whereby a prisoner's name, age, location, racial group and reason for referral are trasnferred into the psychology referrals database.

773 referrals were made between October 2018 and May 2020. As the prison's population throughout this time period was fluid, the month of December 2019 was used as a reference for the general prison poipulation.

Racial groups were specified using the Office of National Statistics' 5-category classification system (White, Black, Asian, Mixed and Other).

Result

There is a consistent under-representation of Asian males in psychological referrals in relation to their general prison population. Whilst this group makes up 17% of the population of the prison, only 10% of prisoners referred to psychological services identified as Asian.

Those identifying as Mixed are over-represented in trauma referrals and psychological therapy referrals. The prison's mixed population is 7%, whereas 16% of those being referred for these two reasons were from the same racial category.

The proportion of patients who identified as Black, White or Other and were referred for psychology input were found to be representitive of the wider prison population, suggesting no clear over or under-representation.

Conclusion

Trends seen in the community in regards to Asian males being under-represented in psychological services are also evident in one of the UK's most diverse prison populations.

Public health campaigning to reduce stigma and promote help seeking in BAME communities is of vital importance to provide the needed support for those silently dealing with psychological problems.

The two largest racial groups in the prison, White and Black individuals, where found to be proportionally represented in their respective referrals to psychological services.

One key finding was in regards to Mixed race individuals, who comprise 7% of the total prison population but 16% of psychology referrals. As this racial group is one of the fastest-growing in addition to be over-represented in referrals, it is vital to understand how provisions can be put in place to appropriately address the needs of this group.
Psychotropic prescribing practices in adults with intellectual disability and autism spectrum disorder in Richmond Neurodevelpmental Services
Authors: Dissanayake Anushka , Davey Nicholas , Patel Rupal
Published: June 2021

Aims

Our aim was to evaluate psychotropic prescribing practices in adults with intellectual disability (ID) and autism spectrum disorder (ASD) across the Richmond Neurodevelopmental Service (NDS).

Stopping over-medication of people with a learning disability, autism or both with psychotropics (STOMP) aims to reduce the potential harm of inappropriate use of psychotropic medications. We aimed to evaluate our prescribing practices in keeping with STOMP and the NICE guidelines.

Method

We collected information from our clinical records on patients that met the inclusion criteria (≥18 years + diagnosis of ID and autism) from October-November 2019. We gathered the following: age, sex, severity of ID, psychiatric diagnoses, psychotropic medication, presence of challenging behaviours, involvement of positive behaviour support (PBS) and documentation of a PBS plan.

Result

32 patients met our criteria (3:1 Male-Female ratio with an age range of 20-74 (Median 33 years old)). All 32 patients showed evidence of challenging behaviours. In the cohort, mild ID represented 18.8% (n = 6), moderate ID 40.6% (n = 13) and severe ID 40.6% (n = 13).

17 patients (53%) had a PBS plan in place. For those without a PBS plan (47%, n = 15), a referral to behavioural analysis had been considered/requested in 67% (n = 10).

31 patients were on psychotropic medication and 84% (n = 26) had an indication documented in the notes although every patient had had a medication review in the last 6 months. 67.7% (n = 21) of the prescriptions were for challenging behaviours.

The average number of medications prescribed was 2 (median 2, mean 2.41) but this was reduced to 1 (median 1, mean 1.76) when additional psychiatric diagnoses and epilepsy were excluded.

Conclusion

Prescriptions are regularly reviewed in keeping with STOMP guidance but there is more scope for utilising behaviour analysis input as well as the need to improve documentation of the rationale for psychotropic medications.
An audit of Individual Care Plan (ICP) in Dublin North City and County (DNCC) child and adolescent mental health service (CAMHS)
Authors: Egbuta Uchechukwu , Howley Cillian , Selvarajoo Anitha , Iqbal Muhammad , Meskauskait Diana
Published: June 2021

Aims

The objectives/aims of the Audit include:

1.

To standardize and implement ICP for service users attending DNCC CAMHS team in accordance with the established policy.

2.

To achieve greater involvement of service users/parents in ICP.

3.

To standardize and improve treatment of care involving all members of one team.

Background

Every patient should have a care plan. Each care plan has a set of needs and goals. These are agreed between the service user and key worker and are assessed and measured frequently. Consultation with each service user/parents, as far as practicable is important. Specification of treatment and care required in accordance with best practice should be recorded. Identification of the necessary resources should be recorded and discussed with service user and key worker. Records kept in one composite set of documentation, and a signed copy should be made available to the service user/parents.

Method

First Cycle commenced 15th October 2019. 166 files were selected from CAMHS team. Data were collected from clinical records from time of admission into CAMHS service to the time of audit. The audit report was prepared on the 6th December 2019, and intervention discussed at the multidisciplinary team meeting and wider DNCC CAMHS academic meeting. Second Cycle 23rd March 2020. 30 files randomly selected and audited. Data were collected by Dr Uchechukwu Egbuta, Mr Cillian Howley, Dr Anitha Selvarajoo, under supervision of Dr Muhammad Iqbal and Dr Diana Meskauskaite.

Method of data input/analysis is IBM SPSS.

Result

For each ICP, the following were looked at: Files with ICP, Identifiable key worker, Formulation, Goals, Action plan, Copy of ICP to young person/parents, Next Review Date, Projected discharge date.

Overall compliance shows 62% in first cycle, and 68% in second cycle after intervention.

There was a 6% quality improvement of ICPs in terms of overall compliance in applying the various components of ICP.

Conclusion

Each service user should have an individual care plan. Each individual care plan should be measured regularly. To develop a therapeutic individual care plan, a formulation of the case from history taking is essential looking at the bio-psychosocial model and should be service user focused. Care plans are part of clinical governance, therefore continuous re-audit every three months was recommended. The follow-up audit will be carried out by the multidisciplinary team members.
Constipation and clozapine: a QI project in Leicestershire Partnership NHS Trust, (LPT)
Authors: Evbuomwam Ehimwenma , Kinnair Dan , Mirza Mohammad , Coleman Julian
Published: June 2021

Aims

Constipation in patients on Clozapine is the biggest cause of mortality. We have no set protocol in LPT for how to manage and monitor Constipation in Clozapine initiation in the inpatient setting. Internationally protocols, (such as the Porirua protocol) exist but have not been widely used locally.

We wanted to assess local compliance with monitoring constipation in patients admitted to hospital and started on Clozapine. We also wanted to assess whether patients are prescribed PRN or regular laxatives, before considering implementing a local protocol.

Method

In LPT we use the ZTAS system for prescribing Clozapine. They provided us with a list of patient IDs who had recently started on Clozapine.

We captured data on patients started on Clozapine.

1.

What date was this started?

2.

What date was either PRN or regular laxatives started?

3.

Was a bowel chart recorded?

4.

Any evidence of constipation or significant bowel issues relating to Clozapine?

Result

We initially analysed 30 patients, (20 of whom were initiated on Clozapine as inpatients, and 10 as outpatients). A bowel chart was started in only 1 inpatient. Laxatives were started in 50% (15, only 3 of whom were outpatients). 14 were regular and 1 was a PRN prescription. 12 inpatients had constipation, and 1 outpatient suffered with constipation. 2 patients suffered with diarrhoea but there were no other significant issues with bowel problems.

Conclusion

From our initial data we can see that there are many inconsistencies in practice.

Existing patients on Clozapine attend a local clinic, (Clozapine clinic) where ongoing monitoring of constipation, (and other parameters, e.g. ECGs etc are completed).

We have written a new protocol which we will share, that the trust has implemented, that identifies when PRN and regular laxatives should be prescribed. We have also expanded the protocol to agree for initiation of Olanzapine bowel charts and PRN laxatives should be used.
Audit on availability, quality and frequency of clincal and educational supervision
Authors: Gnanasekaram Gayathri , Hoar Amanda
Published: June 2021

Aims

GMC defines clinical supervisor as a trainer who is responsible for overseeing a specified trainee's clinical work throughout a placement in a clinical or medical environment and is appropriately trained to do so¹.

This AUDIT aimed to review the frequency, content and quality of clinical supervision for psychiatric trainees within Somerset NHS Foundation Trust. Both Severn deanery and Somerset NHS Foundation Trust both recommend psychiatry trainees have one hour of supervision per week, involving exploration of trainee clinical and educational needs.

Method

All trainees working in Somerset NHS Foundation Trust psychiatry from February 2020 were invited to participate. A survey was designed to quantify the frequency of supervision amongst this cohort. Survey online software, SurveyMonkey, was chosen for the accessibility and user friendly modality and disseminated via email to all junior doctors (n = 27). Survey responses were collected in the last month of the placement (July–August 2020).

Questions on accomplishing workplace based assessments (WPBA), managing e-portfolio requirements were asked, with Likert scale responses available. Quality of supervision was explored via white space answers.

Surveys were reviewed by the AUDIT authors and descriptive data collected.

Result

63% trainees responded (17 out of 27). Educational objectives were discussed at the beginning of the placement. Over half the respondents stated that time was not set aside to look at e-portfolio.

Workplace based assessments (WBPAs), and Case based discussions (CBDs) were more frequently achieved than observed assessments of clinical encounters (ACEs/Mini-ACEs) (assessment of clinical encounter).

30% core psychiatry trainees respondents (4 out of 7) discussed their audits/QI projects with their supervisors most/always. 42% (3 out of 7) had a discussion sometimes.

2 GP and foundation trainees stated they were unable to obtain community mental health experience. The response rate to this question was disappointing and we think it may be secondary to the pressures of the pandemic.

100% respondents described educational supervisors as supportive and approachable.

Conclusion

Whilst all respondents found their supervisors approachable and supportive, completion of formal WPBAs and portfolio reviews was suboptimal.

Following regional presentation of results, the pertinence of these findings for all trainees was highlighted. A supervision template has been created and extension of this initial audit to a regional quality improvement project is underway.

Specific recommendations included brief and regular supervisor check-ins with trainees regarding projects and psychotherapy competencies and a mid-placement review of portfolio.
Are medications with anti-cholinergic properties prescribed and reviewed appropriately on a male older person's organic ward?
Authors: Greenhalgh Ben , Anwar Hina , Hedley Rosemary , Perkins Celine , Shaw Rachel
Published: June 2021

Aims

Patients admitted to Roker ward (male organic psychiatric ward) should have a decreased anticholinergic burden of medication on discharge compared to admission. This will be demonstrated by a reduced score on the Anticholinergic Cognitive Burden (ACB) scale on discharge compared to admission. Target: 80%.

Where new medicines with anticholinergic burden are prescribed during admission, there should be evidence that the anticholinergic properties of these medications have been considered prior to prescribing (via documentation in care co-ordination reviews or progress notes). Target: 100%

Method

Electronic records were searched for all discharges from Roker ward between 1/1/2019 – 31/12/2019. For each record the follwing information was recorded: demographics; primary diagnosis; total ACB score on admission; and total ACB score on discharge. For all new medications started with an ACB score of over zero, records were searched to establish whether there was evidence that the anticholinergic properties of these medications had been considered.

Result

47 patients were identified who were discharged over the time period in question. 30 patients had no difference in ACB score between admission and discharge; 10 patients had a reduction in ACB score and 5 patients had an increase. A total of 9 new medications with ACB scores over zero had been started during all admissions; there were no occasions where there was documented evidence to show that the anticholinergic burden of these medications had been considered.

Conclusion

27% of patients had a reduction in their total ACB score during admission; the target was 80%.

The reasons for starting medications with an ACB score of greater than 1 were documented in 0% of cases; the target was 100%.

As both targets were missed by a significant margin, it was recognised that there were significant areas for improvement. The following plan was therefore implemented:

1.

Following discussion with the ward consultant and ward pharmacist, regular prescriber meetings have been set up which involve senior nursing staff, medical staff and pharmacy – anticholinergic burden is calculated for each patient as part of these meetings

2.

A re-audit is recommended after 6 months.
A review of documents assessing capacity and treatment needs to safeguard adults with incapacity
Authors: Hoggard Tereza , Holliday Robin , Julyan Everett
Published: June 2021

Aims

To audit the completion of Adults with Incapacity (AWI) documents (Assessment of Capacity, Section 47 Certificate of Incapacity and Treatment Plan) to ensure they met the legal standards required. We hypothesised that the forms were not all completed comprehensively, particularly with regards to the Treatment Plans.

Method

In addition to being legal documents, AWI documents provide an important framework to guide clinicians when giving treatment and balancing patient safety with patient autonomy. Correctly completed documents help provide vulnerable patients with ethical and lawful treatment that allows them to be treated with respect and dignity.

An audit was conducted across two Old Age Psychiatry wards at Ayrshire Central Hospital during October 2020. We assessed all AWI documents available on the wards (n = 20) using criteria based on the standards set by the Mental Welfare Commission for Scotland to ensure legal competence.

Result

95% of the forms were signed and dated, and the nature of the incapacity was given in 100% of the documents. On the other hand, 35% of the forms gave no indication of the presence or absence of a guardian. Only one of those identified as having a guardian was consulted with regards to the treatment plan. Another member of staff was consulted on the Treatment Plan in 45% of cases. 30% of the Treatment Plans were not precisely worded enough to be considered justifiable for treatment. In the Certificate of Incapacity, two out-of-date certificates were found, and staff were notified immediately. 45% of certificates were considered over-generalised with regards to the description under medical treatment.

Conclusion

Overall, the forms were mostly signed and dated, with the nature of incapacity given. The two areas that appeared to be the most problematic were the issue of identifying and discussing plans with a guardian, and the specification of treatment covered by both the Certificate of Incapacity and the Treatment Plan.

Discussion with members of the healthcare team found some confusion over how to complete the forms and many cited a lack of formal training as the main reason for their uncertainty. In addition, accessing clear information online or on the wards on how to complete the forms was challenging. We intend to improve the completion of these documents by implementing teaching and a guidance poster, based on the areas that we identified as being problematic, and completing the audit cycle.
Off-label prescribing of quetiapine in HMP Elmley, a Category B remand prison: a re-audit
Authors: Igbinomwanhia Nosa , McCurdy Kathleen
Published: June 2021

Aims

This was a re-audit of off-label prescribing of quetiapine in order to identify the number of patients on off-label quetiapine in HMP Elmley, to monitor compliance by the Mental Health Inreach Team (MHIRT) psychiatrists with the Royal College of Psychiatrists guideline on off-license prescribing, to compare findings with the baseline audit and to identify areas for improvement.

Method

All patients on quetiapine in HMP Elmley were identified and their electronic patient record was reviewed against the standards outlined in the Royal College of Psychiatrists “Use of licensed medicines for unlicensed applications in psychiatric practice (2nd edition).

Result

There were 60 residents on off-license quetiapine prescription in HMP Elmley.

Of this number, four had their prescription initiated by a general practitioner, either while in prison or in the community. Two residents were on quetiapine first prescribed while they were on admission in hospital. 5 patients had been initiated by the MHIRT psychiatrists. 38 residents were commenced off-license quetiapine by another psychiatrist, either while they were in the community or in another prison. In 17 patients, electronic records were inadequate to determine who had prescribed the quetiapine.

The number of inmates prescribed off-label quetiapine in HMP Elmley had dropped from 82 to 60 in the 1 year since the initial audit. Of these figures, prescriptions initiated by the MHIRT psychiatrists, had dropped from 28.1% (23/82) to 8.3% (5/60).

For those prescribed quetiapine by the HMP Elmley psychiatrists, notes were audited against the RCPsych guidelines:

Licensed medication was considered first in 80.0%

Risks and benefits were considered and documented in 80.0%

The benefits and potential risks were explained to patient in 80.0%

There was documentation of informed consent in 80.0%

Quetiapine was started at a low dose and monitored in 100%

No residents required withdrawal of medication due to ineffectiveness or adverse effects.

Baseline physical health assessment was performed in 80.0%, though all had an ECG done.

Conclusion

Over the past year there has been an improvement in off-label antipsychotic prescribing practice within the MHIRT.

However, the number of off-label antipsychotic prescriptions still remains high throughout the prison. There should be continued effort at minimizing off-label prescribing within the MHIRT, monitored by auditing. However, work needs to be done jointly with other prescribers, such as GP colleagues, in order to avoid unnecessary prescriptions and to monitor regularly the physical and mental health of those on off-label quetiapine.
Vitamin D monitoring and management in the inpatient services – reaudit
Authors: Krishnan Vasudevan , Doyle Ciara , Rusilowicz Maciej
Published: June 2021

Aims

To survey the prevalence of monitoring of vitamin D on an inpatient ward.

To audit the treatment if there is identified vitamin D deficiency or insufficiency

To compare differences between findings in audits

Method

All inpatients admitted to Milford centre between August 2019 and August 2020 were selected as part of the sample size.

Data were collected by FY1 and FY2

Patients’ laboratory results were accessed to determine vitamin D levels.

E-notes were used to conclude who were vitamin D sufficient or deficient for treatment

The standard for the audit were as per:

Management of vitamin D deficiency or insufficiency in adults – CKS (2018)

The above was based on National Osteoporosis Society (NOS) guideline Vitamin D and bone health: a practical clinical guideline for patient management [National Osteoporosis Society, 2013] and Scientific Advisory Committee on Nutrition (SACN) guideline

Result

2017

48/188 patients had vitamin D levels measured

36/48 patients had sufficient vitamin D levels

12/48 patients were either deficient or insufficient

12/12 patients were treated where found deficient or insufficient

2020

90/115 patients had vitamin D levels measured

47/90 patients had sufficient vitamin D Levels

43/90 patients had either insufficient or deficient vitamin D levels

22/43 patients had treatment documented in noted where found deficient or insufficient

Conclusion

Difficult to make comparisons with previous audit due to difference in number of patients tested

Vitamin D is routinely tested on Milford ward on admission hence the large number compared to the last audit

52% had noted to have sufficient levels of vitamin D

Concerning were results that only 51% of those deemed to have insufficient or deficient were treated based on notes

Potential reasons could be:

Prescribed in medication card and not documented in notes.

Vitamin D results checked in another ward, no supplementation given, and then transferred to Milford house.

Patients refused treatment but not documented adequately.

Patient discharged before results were received due to quick around

Results were deemed insufficient in terms of the range but very close to normal hence decision made not to start supplementation

Results to be disseminated with medical and nursing colleagues

Re-audit in September 2021
Antipsychotic prescribing in dementia
Authors: McLoughlin James , Roemmele Emma , Cryan Marguerite , Dolan Catherine , McCarthy Geraldine
Published: June 2021

Aims

The majority of people with dementia will develop one or more behavioural or psychological symptoms of dementia (BPSD) as the illness progresses. Treating these symptoms in diverse residential environments is a challenge, with frequent prescribing of antipsychotic medications. The risks and limited benefits of antipsychotic use in this context are well recognised, prompting national guidelines in Ireland to improve prescribing patterns.

1) Assess the frequency and appropriateness of prescribing of antipsychotic medication in older adults with BPSD referred to Psychiatry of Old Age service in the West of Ireland (Sligo) by comparing with best practice guidelines.

2) Address identified deficits via quality improvement initiatives within department.

Method

Audit standards were set using draft National Clinical Guidelines and NICE guidelines for prescribing in dementia to develop a study specific audit tool.

Items assessed included: the frequency of review of antipsychotic use, whether or not non-pharmacological methods were trialled, if there was an assessment of benefit of the antipsychotic and discussion or risks, if a reduction/discontinuation of antipsychotic was considered, if metabolic monitoring was achieved.

Clinical records for all patients actively under the care of the clinical team with a diagnosis of BPSD were assessed using this tool at the time of the study.

Result

49 patients with BPSD were attending the service in this time period. 58% (n = 29) of the entire cohort were prescribed an antipsychotic, most commonly quetiapine. Patients cared for at home showed the lowest levels of antipsychotic use at 50% (n = 18), while those who were in nursing home (80%, n = 8) and hospital care (100%, n = 3) showed higher rates, though this sample size was too small to demonstrate statistical significance, χ2 = 5.12 p = 0.077.

Exploration of non pharmacological management of BPSD, documentation of discussion of risks of AP medication (metabolic, cardiovascular, falls, sedation, extrapyramidal), attempt at dose reduction or antipsychotic withdrawal were all achieved in less than 45% of cases (range 33–45%).

Conclusion

This audit revealed higher than expected rates of antipsychotic prescribing in our BPSD cohort. It also revealed suboptimal documentation around the use of antipsychotics in this population during clinical interactions.

A subsequent intervention to the proforma assessment tool to prompt these discussions improved these behaviours, there was no impact on the rates of antipsychotic prescribing.

Despite increased attention regarding the limited benefits of antipsychotic medication in BPSD their use remains widespread. Due attention must be given to changing this practice in order to protect this vulnerable patient group.