bluuebunny/crossref_metadata_2025 huggingface dataset:
Predictors of Readmission to an Acute Psychiatric Inpatient Unit
Authors: Turkington Aidan , Stirling Emily
Published: August 2024

Aims

The Acute Mental Health Inpatient Centre is an 80 bed acute psychiatric inpatient unit in Belfast. The inpatient unit is frequently over capacity resulting in the use of contingency beds or delays in accessing acute inpatient care. Readmissions to hospital after discharge remain a challenge for the service. A service evaluation project was designed to quantify the number of patients being readmitted and determine demographic and diagnostic variables associated with risk of readmission.

Methods

1084 sequential discharges were examined between Jan 2022 and Feb 2023. Age, gender and length of stay (LOS) were determined.

For each case it was determined whether or not the case was a readmission, defined as having been discharged within the previous three months.

Diagnosis was available on 1017 (94%) cases and was categorized as schizophrenia/non-affective psychosis, bipolar affective disorder, non-psychotic mental illness, personality disorder, adjustment disorder, substance misuse disorder and dementia/cognitive impairment.

Social deprivation status was determined for each case based on the address of admission and using social deprivation data from the Northern Ireland census, 2017.

Outcome of discharge was readmission at one week, one month and three months.

Results

For the entire cohort, readmission rates at one week, one month and three months were 5.1%, 13.6% and 20.7% respectively.

Risk of readmission was significantly increased in cases with a diagnosis of personality disorder, a LOS under two weeks and female gender.

Individuals who had been readmitted to hospital within three months of the index admission were significantly more likely to be readmitted in the subsequent three months.

Data on social deprivation is currently undergoing analysis and will be available in due course.

Logistic regression was performed to determine how the variables impacted on risk of readmission at 3 months. In the final model, diagnosis of personality disorder (OR 3.1; 95% CI 2.0, 4.7; p < 0.001), diagnosis of schizophrenia (OR 1.8; 95% CI 1.1, 2.7; p < 0.01), the admission being a readmission (OR 3.4; 95% CI 2.4, 5.0; p < 0.001), a LOS less than 2 weeks (OR 1.9; 95% CI 1.3, 2.7; p < 0.001) and female gender (OR 1.7; 95% CI 1.2, 2.4; p < 0.01) all predicted readmission within three months.

Conclusion

The service evaluation project has allowed individuals at a higher risk of readmission to be identified. This study has informed local strategies now being implemented to target community care and provide timely interventions to those groups at highest risk of readmission.
The Prescribing and Physical Health Monitoring of Antipsychotic Medication for Patients With Dementia in a Community Treatment Team (CTT)
Authors: Alshamasi Nahrwan , Gray Duncan , Clough Selina
Published: August 2024

Aims

The aim of the audit was to assess compliance with prescribing standards for antipsychotics in patients with BPSD as outlined within NICE guidance and with trust policy, Physical Health Monitoring of Patients Prescribed Antipsychotics.

Background

The Bannerjee report published in 2009 highlighted the problem of inappropriate use of antipsychotic medication in the treatment of patients with behavioral & psychological symptoms of dementia (BPSD).

When antipsychotic use is considered appropriate, good practice is imperative to minimize risk and ensure optimal outcomes for patients. This audit looked to assess whether the use of antipsychotics in patients within CTT with a diagnosis of dementia adhered to best practice standards as outlined by the Bannerjee report and NICE guideline. The audit looked to assess adherence to physical health monitoring requirements as per trust policy for patients prescribed antipsychotics. Currently, there is limited guidance around monitoring of antipsychotics for use in BPSD as they are not licensed in the longer term.

Methods

A retrospective audit was undertaken for patients under the care of CTT between September 2020 and September 2021. 49 patients were prescribed an antipsychotic for BPSD.

Results

Within the sample, 84% of patients were prescribed an antipsychotic at 12 months, 94% at 6 months and 98% at 3 months.

Compliance with the Audit standards showed: 82% of the patients had capacity assessed and documented prior to initiation of an antipsychotic.

98% of patients and/or carers had adverse effects of antipsychotics reviewed.

The risks and benefits of antipsychotics are discussed with the patient and/or carer(s) prior to antipsychotic initiation (94%). In 92% of patients, non-pharmacological interventions are tried prior to initiation of an antipsychotic. Clinical indications (target symptoms) are clearly documented (100%).

Conclusion

Although good prescribing practice was demonstrated, there was an area of concern due to a lack of compliance with physical health monitoring requirements. Most patients were prescribed an antipsychotic for longer than the licensed treatment period.

Agreed Actions:

Discussion with all professionals to emphasise the necessity for effective communication and a documented care plan for antipsychotic monitoring and review.

Present and disseminate audit findings within locality groups and wider teams.
A Review of the Quality of Physical Health Care Provided to Adult Patients Admitted to Mental Health Inpatient Settings Across East and Central North Wales in Line With the National Confidential Enquiry Into Patient Outcome and Death (NCEPOD) Recommendations
Authors: Azhar Zeenish , Saima Saima , Muthuvelu Premraj
Published: August 2024

Aims

1.

Measure compliance with NCEPOD Recommendations in the quality of physical healthcare provided to adult patients admitted to a mental health inpatient setting across the East and Central areas of North Wales.

2.

Guide further service development and improvement in the quality of physical health care provided in mental health inpatient settings in North Wales.

Methods

1.

A retrospective case notes audit of 10 patients each who were inpatient for at least one week duration on the adult mental health wards was conducted in April 2023 across the East and Central areas of North Wales.

2.

The audit was conducted using the NCEPOD audit Toolkit for “Physical Health in Mental hospitals”.

Results

1.

Inpatients percentage (%) compliance against NCEPOD recommendation 1, 5, 6, 7, 9 and 11 was 0% for both East and Central areas of North Wales respectively.

2.

Recommendation 2 had 65% compliance for Central vs 61% for East.

3.

Recommendation 3 had 62% compliance for Central vs 25% for East.

4.

Recommendation 4 had 88% compliance for Central vs 40% for East.

5.

Recommendation 8 had 3% compliance for Central vs 20% for East.

6.

Recommendation 10 had 100% compliance for Central vs 94 % for East.

7.

Recommendation 12 had 72% compliance for Central vs 71% for East.

Conclusion

1.

Improve compliance with the NCEPOD recommendations in the quality of physical healthcare provided to adult patients in mental health inpatient settings.

2.

Develop a Trust wide policy document for physical health care in mental health inpatient settings in North Wales as per NCEPOD recommendations.

3.

Develop a new physical health assessment booklet for Betsi Cadwaladr University Health Board Mental Health and Learning Disabilities Division to be used by all inpatient staff for the provision of physical healthcare of mental health inpatients in line with the NCEPOD recommendations.
Improving Pathways for Patients With Disordered Eating in General Acute Hospital, in Accordance With MEED Guidelines
Authors: Bakshi Alisha , Varma Kushal , Barrow Emma , Williams Adelle , Mottershead Marcus
Published: August 2024

Aims

Patients with disordered eating in psychiatry are considered highly complex in the acute hospital setting. In Spring 2023 a pilot for a specialised dietitian was introduced to identify and target such patients; aimed at reducing length of stay to the acute medical wards. Hospital admissions for eating disorder increased by 84% between 2015/16 and 2020/21; with increasing complexity of presentations and a demand for Specialist Eating Disorder (SEDU) beds, there are increasing numbers admitted to acute medical beds for initial treatment and management. In 2021 the Royal College of Psychiatrists published its updated guidance, Medical Emergencies in Eating Disorders (MEED). There is recognition that acute trusts must identify care pathways for the management of patients with eating disorders and severe food restriction for psychiatric reasons. This audit aims to show how these guidelines are being implemented locally and where there is a need for improvements in care pathways focusing particularly on length of stay, frequent attenders and avoiding hospital admissions.

Methods

A retrospective audit of 26 patients presenting between 01/03/2023 and 31/12/2023 was completed. Patients were identified from data collated by the specialist dietitian as having presented with an existing diagnosis of eating disorder or disordered eating in the context of psychiatry. Some patients were detained under the Mental Health Act. Some patients presented on multiple occasions to the acute hospital during this period; each inpatient episode was analysed independently. Data was collected retrospectively by analysing PICS documentation (electronic notes system) and entered into a data collection spreadsheet. A Google Form checklist was created to capture whether key points from MEED guidelines were met.

Results

Demographic data, details of initial presentation and admission events were collated including the team initially referred to and how long after the initial admission this occurred. Outcomes of admission were also recorded. Data was quantitatively analysed to understands trends in referral process, MDT working (inclusion of emergency clinicians, acute medicine, psychiatrist, specialist dieticians and nursing colleagues). Average lengths of stay, number of attendances and planned admissions were also captured.

Conclusion

An overall reduction in length of stay for detained patients with dietetic and wider MDT input was noted from 50 days prior to January 2023, to 29 in the period from March 2023 onwards. Frequent attendance for electrolyte abnormalities was significantly improved though implementing MDT working with teams in the community and planned admissions from inpatient units or SEDUs for medical management reduced overall length of stay for those patients.
Audit of the Completion Rate of BPD Admission Checklist for the Hospital Admitted Service Users With EUPD
Authors: Baruah Ranjan , Graham Simon , Elturky Jehan , Ruth Hannah , Abulais Faraaz
Published: August 2024

Aims

As admissions have the potential to contribute to iatrogenic harm, Mersey Care NHS Foundation Trust (MCFT) introduced an admission checklist to help the decision-making process around admitting people with Borderline Personality Disorder (BPD).

1.

To conduct an audit to review if the admission checklist was being used after its introduction.

2.

To provide data on the context of admission including the use of MHA.

Methods

Data from admissions for people with BPD to nine acute care wards in (MCFT) over a three-month period were collected and assessed for 21 parameters.

A total of 60 admissions were identified for 51 patients (9 patients had more than one admission).

Results

None of the recorded 60 admissions had a completed BPD checklist at the time of admission.

36 (60%) of the decisions to admit took place during the Normal Working Hours (NWH), 24 (40%) out of hours (OOH).

33 (55%) informal admissions, 27 (45%) on Section 2 of the MHA.

NWH admissions were associated with a higher number of informal admissions compared with OOH admissions (24 vs 9 respectively).

3 out of 27 OOH admissions requested by Crisis Resolution and Home Treatment (CRHT) resulted in informal admissions. The remaining OOH admissions were following a Mental Health Act Assessment (MHAA) by trainee psychiatrists.

At the point of admission, 9 (15%) patients were not open to secondary mental health team in MCFT prior to their referral for MHAA; 48 (80%) patients were under Community Mental Health Teams and/or the CRHT; 12 (20%) were open to the Personality Disorder (PD) hub, and 3 (5%) were open to other mental health teams including eating disorders team, Attention Deficit Hyperactivity Disorder (ADHD), Addiction Services and Criminal Justice & Liaison Team (CJLT).

Conclusion

There was no engagement with completing the BPD admission checklist. 40% of ST doctors reported on a separate survey that they cannot locate the Checklist on patient information system.

Admission decisions made during NWH have led to significantly more informal admissions compared with during OOH where the MHA was more likely to be used.

An action plan was designed to improve engagement with the admission checklist:

•

Introductory training was provided to CRHT, approved mental health professionals (AMHPs), MHA second opinion doctors and psychiatry ST doctors.

•

Inpatient teams were asked to complete the checklist.

•

Bed Management to request an updated completed PD admission Checklist prior to admission.

•

Re-auditing in 6 months.
Psychiatric Emergency Bleep Documentation Enhancement Audit
Authors: Davidova Anastasija , Young Scott , Al Sayegh Amal , Halford Jude
Published: August 2024

Aims

West Lothian Psychiatry operates in a district general hospital, fostering a close working relationship between medical and psychiatric practitioners including the Psychiatric 2222 call (akin to medical emergency/cardiac arrest response). No other team like this has been identified in Scotland. Whilst there is a range of scenarios where this is used, there is no ‘gold standard' for defining a psychiatric emergency or how to document these. Preliminary data gathered between August and November 2022 revealed concerns regarding call appropriateness, medical staff proficiency in de-escalation and restraint on medical wards, inadequate handovers, and poor documentation. This prompted a collaborative quality improvement project, undertaken by psychiatric and medical team leaders. Part of this initiative was an audit to improve the documentation of psychiatric emergencies to achieve a 90% compliance rate using a new checklist.

Methods

Cycle 1 of the audit (December 2022 to April 2023) identified patients through the 2222 calls to switchboard (n = 54). TrakCare notes were reviewed to assess call rationale and outcomes, focusing on documentation by the attending psychiatric team. A documentation checklist within the electronic records system was designed and introduced in July 2023, for completion by the junior doctor. Cycle 2 (November 2023 to January 2024, n = 47) aimed to assess improvements by comparing results with the previous cycle.

Results

There was a significant improvement in documentation rates with the checklist (44% to 90%). Indirect enhancements were observed in ward nursing documentation (65% to 83%) and medical ward doctor documentation (39% to 57%). Appropriateness of emergency calls increased from 65% to 74%, with attending doctors' participation in emergencies longer than 10 minutes rising to 68% from 47%. The initial audit revealed a lack of awareness among senior medical staff regarding overnight psychiatric emergency calls, especially in cases of repeated calls for the same individual. The improved documentation played a pivotal role in addressing this issue, facilitating effective information sharing and changes in patient management plans, reducing further emergency calls.

Conclusion

The documentation checklist significantly improved junior doctor documentation, positively impacting patient care and communication among staff. This successful intervention serves as a promising model that can be replicated in other documentation domains. Moreover, this project has set the stage for broader initiatives within a larger Quality Improvement framework. The ongoing efforts are directed towards establishing a shared model for the psychiatric emergency bleep, optimising staffing resources for restraint procedures and improving staff de-escalation skills.
Is Annual Monitoring of Prolactin for Patients on Long Term Antipsychotics Being Completed and Results Acted Upon in Rochdale Community Mental Health Team?
Authors: El-Nemr Rania , Melling Emily , Yasin Saba
Published: August 2024

Aims

National guidelines (NICE) recommend that prolactin should be monitored every 12 months for patients on antipsychotics, excluding patients on aripiprazole, clozapine, quetiapine or on doses of less than 20mg daily of olanzapine. The purpose of this audit was to investigate whether patients under our services who are prescribed antipsychotics implicated in causing hyperprolactinemia, were having regular annual prolactin measurements as per the guidelines and whether abnormal results were being actioned appropriately.

Methods

A total of 61 patients were surveyed, as a random selection from the Outpatient Consultant case load in Rochdale CMHT. This was a retrospective analysis looking at annual prolactin measurements over 5 years between 01/01/2017 and 31/12/2022. This included all patients who had been stabilised on an antipsychotic for more than 2 years, and excluded patients on antipsychotics that did not cause significant prolactin rise (and so do not require annual prolactin measurements as per NICE guidelines).

Results

Our results showed that the majority of patients were not having regular annual prolactin measurements, with only 3.3% of patients having prolactin measured annually 100% of the time. 23% of patients had no prolactin measurements at all while on antipsychotic treatment during the time period assessed. In cases were there was an elevated prolactin reading, only 15% of these readings had a documented action plan.

Conclusion

This audit has demonstrated that the overall compliance with the NICE standards for annual prolactin monitoring for people on antipsychotic medication is of a poor standard, and we highlight possible reasons why this may not be done and areas for improvement.
Carer Engagement and Support in North and West Kent Rehabilitation Services
Authors: Elshafei Ahmed , Heisig Martina , Fuller Amanda
Published: August 2024

Aims

To compare current practice in local Rehabilitation in audit across North and West Rehab Kent units against standards of ‘Triangle of Care’.

Standard 1.3:

Carer's views and knowledge are sought throughout the assessment and treatment process.

Standard 5.2:

An early formal appointment is offered to the carer to hear their story, and history and address the carer's concerns.

Standard 5.10:

The carer is involved in the discharge planning process.

A previous audit was conducted in 2019 using Triangle of Care and AIMS standards. We decided to see whether the standards have been upheld.

Methods

We included all 43 patients admitted over the previous 6-months. No patient had National Opt-Out. The source of information was the RIO system. The data were analysed by 2 investigators.

A data collection form was used:

Question for Standard 1.3: Were the carer's views and knowledge sought throughout the assessment and treatment process? If this was not the case, the reasons were to be specified.

Question for standard Standard 5.2: Was an early formal appointment offered to the carer to hear their story history and address the carer's concerns?

Question for standard Standard 5.10: Was the carer involved in the discharge planning process?

Results

Standard 1.3:

83.72% had contact with a variety of team members throughout their relative's admission. Reasons for non-involvement included lack of consent, unavailable carers, non-attendance, and carer's preference.

Standard 5.2:

Only 60.53% of carers had an early appointment offer, and the expectation that this should occur in 80% of cases was unmet.

Standard 5.10:

(90%) of the patients had carers involved in the discharge planning process, meeting the required standard.

Conclusion

Best Practice:

The audit results demonstrate that carers are involved in their relative's care throughout the admission and discharge process.

Lessons learned:

Compared with the previous audit in 2019, when the criteria for Standard 5.2 were met, carers were offered a formal early meeting significantly less often. Possible reasons could be the pandemic and resulting changes in practice have certainly led to a reduction in face-to-face meetings. Offering individual time to all carers is essential, and efforts should be made to integrate this into practice.

Next steps:

To allocate a team member to offer a meeting with the carer.

To discuss the outcomes with the Carer Champions on each unit, to review what form their support currently takes, and consider how this could link in with the requirements of Standard 5.2.

To re-audit in 1 year.
Prescribing and Monitoring of Pychotropic Medications in a CAMHS Inpatient Service
Authors: Erunkulu Olorunleke , Imran Shermin , Ashraf Wasim
Published: August 2024

Aims

To ensure that there is a clear rationale for commencing service users on psychotropic medications.

To ensure that the prescription of psychotropic medications is evidence-based and that they are in line with the Trusts and NICE guidelines.

Ensure that psychotropic medications are regularly reviewed by the managing team.

To ensure that information about medications is adequately shared with patients and carers.

To ensure that service users are well-monitored for side effects.

Methods

A 2-week retrospective audit on Phoenix ward.

Clinical information from all the current service users on psychotropic medication was reviewed.

The clinical information was collated from all 8 service users’ medication cards, ward round documents, MDT reviews, and electronic notes (PARIS), and these were analyzed by the inpatient specialty registrar.

Results

1.

We attained a 100% mark in some areas of our prescribing such as indicating the rationale, the maximum dose for medication, and also prescribing within BNF limits.

2.

We however could not evidence proper information sharing with patients (only 40% documented).

3.

We could not evidence sufficient information sharing with carers (only 20% documented).

4.

PRN medication was mostly prescribed as a range rather than a clear dose, which gave rise to subjective dispensing bias.

5.

Side effect monitoring was documented for 85% of patients, meanwhile, the standard for this is 100%.

Conclusion

Clinicians are to ensure that medication information is always shared with service users, and their carers, and this is documented.

Clinicians are to also ensure that PRN medications are prescribed as a single dose rather than as a dose range.

Ward staff are to ensure that they are monitoring side effects and documenting these clearly on electronic notes and ward round documents.

The MDT is to ensure that all regular and PRN medications are reviewed regularly during ward rounds.

Present this audit, share relevant findings with the clinical team, and monitor the implementation of the action plans by doing a reaudit in 6 months.
An Audit of Physical Health and Blood Test Monitoring in Patients Under the Care of Mersey Care NHS Foundation Trust Who Are Prescribed Lithium
Authors: Hyland Declan , Chinnari Gopal , Elhaj-Houssen Tawfik , Orrell Rose-Anne
Published: August 2024

Aims

Lithium is clinically indicated for use in the UK for treatment and prophylaxis of mania, bipolar disorder, recurrent depressive disorder and aggressive of self-harming behaviour. In patients who are prescribed lithium, several physical health checks and blood tests must be completed on a regular basis to ensure lithium remains safe and appropriate to continue. Lithium has a narrow therapeutic index and so close monitoring of serum lithium level is required.

This audit aimed to establish whether Mersey Care NHS Foundation Trust’s physical health check and blood test monitoring of patients prescribed lithium is in keeping with NICE guidelines and determine how the Trust’s performance compared with national performance as identified by the Prescribing Observatory for Mental Health (POMH) lithium audit.

Methods

A total of 127 patients under the care of the Trust who were prescribed lithium were identified. The POMH lithium audit tool was used to capture data for each patient as Mersey Care NHS Foundation Trust was participating in the POMH lithium audit. Each patient's electronic record was scrutinised to determine whether the following were measured every six months during maintenance treatment – Thyroid Function Tests (TFTs), serum calcium level, estimated Glomerular Filtration Rate (eGFR) and serum lithium level, and whether the patient had a weight/body mass index (BMI)/waist circumference within the last 12 months.

Results

Of the 127 lithium patients included in the audit, 64% had a serum calcium level done every six months, 78% had TFTs done every six months, 83% had an eGFR done every six months, and 87% had a serum lithium level done every six months. 71% of patients had a weight/BMI/waist circumference within the last 12 months.

Conclusion

Trust performance for TFT monitoring and weight/BMI/waist circumference was above the national compliance level reported in the POMH lithium audit; Trust performance for serum lithium level, eGFR and serum calcium level was below the national compliance level. There is a need to ensure that medical and nursing staff are aware of the physical health checks and blood test monitoring required for patients maintained on lithium. A Quality Performance Alert will be sent to medical and nursing staff in the Trust to raise awareness and lithium monitoring will be included in the junior doctor Trust induction. Future auditing of Trust performance on physical health check and blood test monitoring for patients maintained on lithium will be conducted.
Driving Status in Patients Admitted to Acute Psychiatric Ward and DVLA Advice
Authors: MacDaid Kerenza , Rana Faryal , Tagoe Reuben
Published: August 2024

Aims

DVLA guidance is very clear about patients not driving during or shortly after episodes of acute mental illness. There is an obligation for patients to inform the DVLA if they are unwell. The obligation for doctors to inform the DVLA if the patient chooses not to, and continues to drive when they should not, is also well known.

This audit aims:

1. To identify the number of patients whose driving status was recorded following their admission to an acute psychiatric ward.

2. To identify the number of patients discharged with correct DVLA compliant advice.

3. To identify the number of patients whose notes reflected correct driving status information on discharge.

Methods

Patient ward notes and discharge summary documents relating to their admission on to the PICU ward were examined retrospectively for recorded evidence of patient's driving status and any documented DVLA advice given. Patients admitted from November 2022 and April 2023 were reviewed. 68 patients were identified and systematic sampling techniques identified a sample of 30 patients.

Keyword search included “Driving”, “License”, “Car”, “Driving license”, “DVLA”.

Results

30 patients were reviewed in total.

40% of sample patients had no driving status recorded on their notes.

Of the 60% of sample patients who were confirmed to be driving/held license, nearly half (47%) had no recorded advice documented regarding the DVLA or driving after an acute MH illness on discharge.

A third (33%) of sample patients were recorded as having been given generic advice regarding driving only.

Only 20% of sample patients recorded to be driving, were documented as having been given correct advice as per DVLA guidance on discharge.

Conclusion

This audit demonstrated that driving status is currently poorly recorded in patients admitted to PICU and documentation of correct DVLA-compliant driving advice being given on discharge to relevant patients is also poor. Patients may not be receiving important information that they need.

Providing correct and accurate advice to patients regarding the DVLA rules and psychiatric illness should be part of a safe and robust discharge plan, and forms part of the clinical teams obligations to the patient. Identifying patients as drivers and improved documentation of driving status and evidencing appropriate advice being given is key.

A number of interventions were implemented and a re-audit will be undertaken in Spring 2024. If successful at improving rates of DVLA compliant advice being given, it would be hoped these interventions could be shared across the trust.
Patient-Led Lifestyle Questionnaire to Help Improve Lifestyle Interventions Offered to Patients
Authors: Mandair Kuljit , James Louisa
Published: August 2024

Aims

Maintaining a healthy lifestyle plays a vital role in the prevention and management of many mental conditions. There is also evidence that these patients have a lesser standard of health promotion and physical care and despite national awareness and guidelines early mortality rates have not improved.

The aim of this audit cycle was to firstly establish whether lifestyle interventions are being offered to patients (in a Home Treatment Team) and secondly how could this be further improved. A patient-led lifestyle intervention was introduced whereby the aim was to help patients feel empowered by being able to select an area of lifestyle they would like to improve. A coaching style framework was used and the patient was assisted in setting a lifestyle related goal to help with their mental health recovery.

Methods

An audit was carried out on 20 Physical Health Forms in January 2023 looking at the documentation of lifestyle interventions offered in the following lifestyle domains: smoking, alcohol, substance misuse, diet, exercise and the measuring of waist circumference and weight. This is a form that is usually completed by Psychiatric nurses based in the Worcester South Home Treatment Team during initial patient assessments.

The audit showed low levels of interventions offered to patients for lifestyle domains and therefore staff education on the importance of lifestyle and the importance of measuring waist circumference was delivered within a team meeting setting. A patient led lifestyle questionnaire was also initiated. After implementing this for 3 months, a re-audit was completed of 20 physical health forms in May 2023.

Results

The re-audit results showed an increase in lifestyle interventions offered to patients in all lifestyle domains. There was a 30% increase in patients being offered interventions in exercise, a 40% increase in patients being offered interventions in diet, 20% increase in patients having waist circumference measured, 5% increase in patients being offered substance misuse interventions, 10% increase in patients being offered interventions for alcohol misuse and a 30% increase in patients being offered interventions for smoking.

Conclusion

There is growing evidence that by addressing lifestyle factors we can improve overall patient care outcomes by raising awareness and including lifestyle modification to be a part of the treatment plan. Using a coaching framework can be an effective part of the management plan by helping patients to feel empowered and future focused to improve their lifestyle and therefore their own health.
Consideration of Clozapine in Patients With Treatment Resistant Schizophrenia
Authors: Moazzami Niema , Devereux Aimee
Published: August 2024

Aims

The aim of the audit is to measure the performance of Bradford District Care Trust (BDCT) against the NICE guideline's quality standard: ‘Adults with schizophrenia that has not responded adequately to treatment with at least 2 antipsychotic drugs are offered clozapine.’

Methods

We identified the 273 patients prescribed clozapine in BDCT as of January 2023. 202 had been prescribed clozapine for more than 5 years and these were excluded. Of the remaining 71, 34 were excluded for reasons such as their diagnosis i.e. Parkinson's or personality disorder or inadequate information within the clinical record. The final sample consisted of 37 patients prescribed clozapine within the last 5 years with a diagnosis of treatment resistant schizophrenia (TRS).

To define an ‘adequate trial’ of an antipsychotic, an adequate duration and adequate dose was determined. It is widely recommended in literature that an adequate trial of antipsychotic should last at least 6 weeks and this time constraint was utilised for the audit. The Maudsley Guidelines minimum effective dose table was utilised for establishing adequate doses. For antipsychotics not included in this list the British National Formulary (BNF) maintenance doses were used. A data collection tool was then developed that allowed for retrospective collection of key information relating to the objectives outlined above.

Results

Clozapine was offered at the appropriate time [this includes where clozapine was considered but was not felt to be suitable/was contraindicated/declined by the patient] in 13 cases (35%). In 24 cases (65%) clozapine was not offered at the appropriate time. For 21 patients there was a delay in offering clozapine after 2 adequate trials of antipsychotic medication had been given. Delays ranged between 9 days and 15 years, with the average [mean] delay being 3.7 years. There were 3 patients who were initiated on clozapine without the completion of 2 adequate trials of other antipsychotic medication.

Conclusion

In summary, this audit measured BDCT's adherence to the NICE guideline on clozapine for TRS. Of the 37 patients in the final sample, 35% received clozapine at the appropriate time, while 57% experienced delays with an average delay of 3.7 years. Notably, 8% commenced clozapine without completing the recommended antipsychotic trials. These results emphasize the importance of improving adherence to the guideline, as delays in offering clozapine pose potential risks for patients with TRS. Ensuring timely access to this treatment is crucial, as it has the potential to significantly enhance patient outcomes.
Audit of the Missed Seizure Rate and Management at Northamptonshire Healthcare NHS Foundation Trust (NHFT) Electroconvulsive Therapy Clinic
Authors: Moledina Sanaa , Jani Jaiker
Published: August 2024

Aims

The audit aimed to study missed seizure frequency, management, and restimulation rate at NHFT's ECT clinic.

Methods

We conducted a retrospective analysis of ECT treatments administered between October 1, 2021, and March 21, 2023, collecting data on stimulation frequency and doses, duration of motor seizures and EEG activity, and patients' demographics. The study compared current practice with the NHFT ECT protocol, which defines missed seizures as treatments failing to induce convulsions and EEG activity. Management entails restimulation at least once or twice according to the stimulus dosing protocol during the seizure-threshold (ST) determination phase or by increasing the dose by 10% (50 millicoulombs) during the treatment phase, alternatively recording reasons for not re-stimulating. The ratio of missed seizures to total stimulations was used to determine the missed seizure rate, and the ratio of total restimulations to missed seizures was used to calculate the restimulation rate.

Results

The clinic provided 268 treatment sessions and 26 courses of bilateral ECT to 23 patients aged 17–84 years, primarily female (60%) and Caucasian (74%), with a 12.6% missed fit rate and a 67.5% restimulation rate. Thirty missed seizures occurred during the initial ST determination phase, with twenty-two restimulated. Four of these could not be restimulated due to the maximum limit of three stimulations per ECT session. Seven missed seizures occurred later in the treatment phase, with three restimulated. For restimulations during the seizure-threshold determination phase, only eight of the twenty-two restimulation doses matched the stimulus dosing chart, and over half of these patients were stimulated at a lower-than-recommended dose. Once a seizure was generated and the threshold was identified, suboptimal maintenance doses were chosen, with 47% of patients stimulated on the same dose and 37% on doses only marginally over the ST in consecutive sessions. During the treatment phase, two out of three restimulations were performed with a dose lower than the specified 10% increase. The reasons for deviating from the guidelines were not documented.

Conclusion

National audits of ECT clinics in 1981 and 1992 showed 50% and 25% missed seizure rates, respectively. Bridgend ECT Clinic maintained a missed fit rate of ≤5% over a 6-year period, which is half that of NHFT. Missed seizures have been associated with treatment failure and post-ECT adverse effects; hence, to effectively manage them, we propose that all ECT administration personnel be familiar with the NHFT ECT protocol, including the stimulus-dosing protocol, and document any clinical grounds for deviations.
Interactions Between Lamotrigine and Contraceptives – Communication Practises
Authors: Monir Samina , Atwine Cissy , Hutchings Helen , Harris Michael
Published: August 2024

Aims

This audit assesses communication practices regarding interactions between lamotrigine and oral contraceptives in North West Sussex (NWS) Specialist Perinatal Mental Health Services (SPMHS).

The predicted outcome includes increasing awareness about potential interaction between lamotrigine and contraceptives with resulting impact on patient safety.

Background

Lamotrigine is used for epilepsy and mental health disorders but can interact with contraceptives, affecting efficacy and safety. NICE recommends it for bipolar depression, relapse prevention and recurrent depression. Interactions with hormonal contraceptives can influence effectiveness of either drug and increase the risk of side effects. Patients on lamotrigine should be counselled so they can make an informed decision about taking the medication.

Methods

Reviewed records of all patient on the caseload on 21st June 2023. Collected data for lamotrigine prescription, indication, contraceptive method, and documented counselling. Calculated percentage of patients counselled on lamotrigine-contraceptive interaction.

Results

In 261 patient records, 11.9% were previously or currently on lamotrigine or had a discussion about starting lamotrigine. 6.1% currently and 3.1% previously on lamotrigine. Counselling on lamotrigine's interaction with oral contraceptives was documented with 3.1%, while 74.2% received none. Indications for lamotrigine use were epilepsy 9.7% and mood stabiliser 90.3%. Of 27 patients who weren't currently pregnant, 9 of them were informed of the interaction risk while 18 were not. Contraception methods were documented for 10 individuals.

Conclusion

Findings showed the need for increased awareness about the interaction and documentation of appropriate discussions to inform their choice.
Audit of the Management of High Clozapine Levels Within Solihull Community Mental Health Teams (CMHTs)
Authors: O'Connor Sarah , Hashmat Huma
Published: August 2024

Aims

To review the practice of management of clozapine plasma levels in Solihull CMHTs between April and September 2023. Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) clozapine guidelines were issued in January 2023 and further ratified in December 2023. The standard set out in the January 2023 guideline was that service users with elevated clozapine levels >600mcg/L should be assessed for signs of toxicity and consideration given to a dose reduction. Those with levels above 1000mcg/L should be reviewed urgently.

Methods

Clozapine blood clinic diaries were reviewed in order to obtain a list of 48 service users who had attended for clozapine blood tests between April and September 2023. Blood results were reviewed for clozapine level results. For those service users whose clozapine level had been over 600mcg/L, clinical notes were reviewed to determine whether they had been screened for clozapine toxicity.

Results

Of the 48 service users prescribed clozapine, 24 had clozapine levels over 600mcg/L and 11 had levels over 1000mcg/L. Of the service users with clozapine levels over 600mcg/L, 16 (67%) were screened for toxicity. Of those with clozapine levels over 1000mcg/L, 9 (82%) were screened for toxicity.

Conclusion

Between April and September 2023, Solihull CMHTs demonstrated an understanding of the need for actioning elevated plasma levels as a priority, however, this could be further improved. The risks of adverse effects and toxicity with clozapine increase with raised plasma levels, particularly with levels over 1000mcg/L. Therefore, it is important that raised plasma levels are actioned accordingly. Locally, we have implemented a flow chart which summarises the updated clozapine guidelines, to assist clinicians in interpreting and acting on high clozapine levels and to prompt clinicians to review service users for signs of toxicity. We hope to incorporate this visual aid into the updated BSMHFT guidelines.
Equity on the Mother and Baby Unit: An Audit of Detention Rates and Length of Stay According to Ethnicity and English Language Ability
Authors: Eiman Najla , Senior Morwenna , Jones Sarah
Published: August 2024

Aims

A large body of evidence suggests that experiences of, and access to mental healthcare in England varies according to ethnicity. Inequitable use of restrictive interventions is of particular concern, including within perinatal services: a national-level study of inpatients on Mother and Baby Units (MBU) in 2017 found that 28% of white patients were detained under the mental health act (MHA), compared with 61.5% of Black African, and 66 – 77% of Asian mothers. We carried out an audit with the aim of examining detention rates, length of stay, and time to first section 17 leave on an MBU in South Manchester according to ethnicity and English language ability, to compare with national averages.

Methods

We identified all patients discharged from Andersen Ward (an MBU) between March 2022 and March 2023. Using electronic medical records we extracted information on: ethnicity, language spoken (English vs other), mental health act status (detained under Section 2/3 vs informal), duration of admission, date of detention, date of first Section 17 leave. We calculated the percentage of patients who were detained according to ethnicity (White British, Mixed/other, Asian, Black), and the odds of detention according to ethnicity. Statistical significance was assessed using chi-squared testing. We also compared average length of stay and time to first section 17 leave by ethnicity.

Results

74 patients had been discharged from the MBU within the audit period. 88% of Black inpatients were admitted under the Mental Health act, compared with 72.7% of Asian mothers, 33.3% of Mixed ethnicity or other ethnicities and 28.3% of white mothers. Differences in detention rates according to ethnicity were statistically significant. Of 11 mothers documented as having a language other than English as their primary language, all had been detained. Length of admission and days to first section 17 leave were not significantly different between ethnicities.

Conclusion

Many factors may contribute to the observed higher detention rates among non-White patients: language barriers and a lack of intercultural competence could lead to risk-averse decision-making during MHA assessments, and different help-seeking patterns might mean White mothers seek help earlier, or for less severe mental health problems. Recommendations include expanding access to high-quality interpreters; investigating factors underlying MHA decision-making through qualitative research; and improving cultural competence among section 12 approved clinicians by incorporating feedback from ethnic minority patients into training and refresher courses.
An Audit of Junior Medical Seclusion Review Documentation in the Adult Psychiatric Intensive Care Unit (PICU) setting
Authors: Sharma Anju , Khawaja Afshan
Published: August 2024

Aims

Seclusion facilities are frequently used in adult psychiatric intensive care units (PICUs). Seclusion refers to the supervision of a service user in a secure area.

Aim: To evaluate whether trust standards for seclusion review assessments at Park House Hospital were being met.

Objectives

To measure the quality of junior medical review documentation to determine whether reviews of physical health, risk, medication, and mental state exams (MSEs) were included. The time frames in which reviews were being undertaken and the rationale for seclusion were considered.

Methods

A retrospective audit of notes on the electronic patient information system was completed. Those included were patients secluded between May 2022–October 2022. The majority of seclusions occur on the male PICU, or 136 suite. Eligible patients were identified following consultation with the business intelligence team within Greater Manchester Mental Health (GMMH). For those who had multiple periods of seclusion, the first episode of seclusion was audited. Data were obtained from the last recorded junior review prior to the seclusion episode being terminated. Progress notes and the internal MDT review documents were searched. This was compared against the local trust seclusion policy.

Results

20 patients were included in the audit. The majority had a diagnosis of either paranoid schizophrenia (40%) or schizoaffective disorder (25%). 95% of seclusion reviews had a clearly documented initiation time and rationale for seclusion. Physical health considerations were documented in 75% of reviews. 50% of junior reviews documented an assessment of risk to others, compared with 5% of reviews with documented review of risk to self. Half of all reviews had evidence of a MSE and medication review, including the use of rapid tranquilisation (RT). Of the reviews eligible for initial medical review within 60 minutes, this was completed in 44% of cases.

Conclusion

Junior medical reviews have consistently documented the rationale for seclusion and physical health reviews. Areas for development include clear documentation of MSE however documentation may be limited due to time constraint, lack of engagement from the patient or if patients are asleep. The policy since time of audit has changed to reflect this, where consideration must now be given to “overall psychiatric health”. It was found that risk to self largely remains undocumented, despite trust policy. There is evidence to suggest risk to self may increase during a period of seclusion. Another area of development includes medical review documentation to specifically comment on use of RT.