bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessing DNA rates for new referrals in older adults
Authors: Cheema Aamina , Pasha Nasir , Gurieli Giorgi
Published: June 2021

Aims

To assess DNA rates for initial assessment medical appointments offered for new referrals within an Older Adults CMHT.

To establish any correlation between waiting time and DNA rates.

To establish if the initial appointments offered were in keeping with the National guidelines (18 weeks) and our local Trust policy (1-4 weeks).

Background

In the Uk 15% of adults 60 and above suffer from a mental disorder. Despite the increasing mental health burden, analysis indicate that a quarter of mental health trust received less investment from 2017 to 2018. Financial pressures have also increased appointment waiting time. The NHS has stated that by 2023 there will be a 4-week waiting time for older adult mental health services. Current national guidelines state that initial referrals should be seen within 18 weeks.

Method

This is a retrospective audit looking at all first time referrals to an Older Adult CMHT in East Birmingham. 110 patients were included in this audit. Factors recorded included age, gender, reason for referral, waiting time for appointment, and whether this complies with guidelines.

Electronic patients' notes (RIO) were used for data collection.

Result

Out of 110 new referrals 11 were not offered any appointments. Out of the remaining 99, 13 cancelled and 8 did not attend.

In total, 78 attended the initial appointment offered, out of which 77 were seen within 18 weeks as per national guidelines. 43 patients were seen within the 4-week period (trust policy). 1 patient was offered an appointment at 19 weeks and 3 days from the referral date. The patients who did not attend their appointments were followed up except for one, to find out the reasons of the DNA. This included 2 (physically unwell), 1 (unaware of appointment), 1 (refused), 1 (forgot), 1 (couldn't get to clinic), 1 (asthma attack). Another appointment was offered to those who could attend.

Conclusion

There was no significant correlation between a longer waiting time and an increased DNA rate for first appointments. Even though the time for an initial appointment was within the NHS guidelines, only 56% of the appointments met our Trust's policy of a 4 week wait.

When discussing the results with the relevant team it was clear that a number of factors affected the waiting time including: number of available clinicians and a large catchment area.
Phew! time to focus on physical health and wellbeing: improving the assessment and management of physical health in an early intervention in psychosis service
Authors: Cole Bethany , Bailey Emma , Ewins Liz
Published: June 2021

Aims

NICE guidelines recommend that patients under Early Intervention (EI) in Psychosis Services have systematic monitoring and intervention of cardiometabolic risk factors. We undertook a Quality Improvement Project (QIP) in the Bath and North East Somerset (BaNES) EI Team to improve rates of compliance with national guidelines. We aimed to increase the percentage of service users with a physical health assessment documented in the past 12 months. Other aims included improving monitoring of physical health parameters in those taking antipsychotic medication and increasing the delivery of interventions for abnormal results.

Background

The most common cause of premature mortality in people who experience psychosis and schizophrenia is cardiovascular disease. The 'Standards for Early Intervention in Psychosis Service' states that patients should be offered personalised healthy lifestyle interventions, including advice on diet, physical activity, and access to smoking cessation services. Physical health should be monitored at least annually, with more frequent assessments if antipsychotic medication is prescribed.

Method

We identified seven key factors for improving physical health: Body Mass Index (BMI), Blood Pressure, Glucose Regulation, Blood Lipids, Smoking, Alcohol and Illicit drug use. Baseline compliance and intervention rates were measured in March 2019. Six ‘Plan, Do, Study, Act’ Cycles were completed over the following ten months. Examples of the changes made included: a new online diary and whiteboard, abbreviation of the assessment form, teaching for the EI team, and a new weekly ‘Physical Health and Wellbeing’ (PHeW) Clinic. This clinic involved phlebotomy, discussions around lifestyle choices, review of medication side effects, and neurological examination.

We measured the compliance with guidelines each month and the total number of interventions delivered at three-monthly intervals. We collected qualitative feedback on these changes in team meetings and with written questionnaires (including feedback from patients).

Result

Documentation of all key factors doubled from 30.2% at baseline to 63.3% in January 2020. The total number of interventions for raised BMI and lipid levels also increased. Feedback from staff and patients was positive. The clinic helped start conversations with patients about lifestyle choices, prompting improvements in weight, physical activity, lipid levels, and alcohol intake. Patient awareness and ownership over their physical health also improved.

Conclusion

This project utilised multiple strategies to reduce health complications for BaNES EI service users. A structural change in the assessment and management of physical health proved to be an effective and sustainable solution to optimise the health and wellbeing of this patient group.
A prescription of information – promoting symptom self-management in people with functional neurological disorder (FND)
Authors: Dadah Hashim , Anthony-Uzoeto Uzoma , Yazdouni Sadat , Aweis-Asanga Ali , Dunlop Alan , Faruqui Rafey
Published: June 2021

Aims

Functional Neurological Disorder (FND) is known to be associated with high healthcare resource utilisation and poor quality of life. Patients’ understanding of the disorder is considered instrumental in improving prognosis.

We produced a symptom self-management patient education strategy with a booklet and FND symptoms recording template in a community neuropsychiatry setting. We embedded this psychoeducation intervention in a post-nursing triage model of care.

Method

A co-production cycle of patient education material was implemented as part of a Quality Improvement Project (QIP) at East Kent Neuropsychiatry Service. Year 4 medical students completed their first QIP cycle involving 4 students, 2 multidisciplinary team members and 4 patients with functional neurological presentations. An FND leaflet and symptom recording template was produced and reviewed using feedback domains such as leaflet readability, perceived usefulness, and template design. The revised version of leaflet was then pilot-tested in second QIP cycle via email or post to 12 patients awaiting their group psychology or neuropsychiatry appointments for treatment of FND. The uptake and impact of leaflet was assessed using telephone-based structured feedback collection.

Result

The first QIP cycle included 10 participants and generated qualitative knowledge domains, providing examples of different types of FND presentations and a biological-psychological-social model explaining onset and/or recurrence of FND symptoms. Group patient feedback and co-production input allowed inclusion of the patient voice and a re-design of leaflet and symptom recording template.

The second QIP cycle involved 12 participants: feedback was collected two weeks after circulation of patient education material. Only 5 participants (42%) had read and used their education leaflet and template during this period. Patients described the booklet as useful overall, but thought it to be more useful at the point of diagnosis and referral to neuropsychiatry. Qualitatively, patients wished there to be more emphasis on FND being explained as “less psychiatric, more a neuropsychiatric problem”, and that it would be “very good for someone who had just been diagnosed”. 80% of responders rated the leaflet quality 8/10 or above. These respondents felt that the leaflet had helped them understand their condition better than they did previously. Usefulness of an additional self-formulation flowchart was rated as 8/10 or below by all patients - with several finding it difficult to use.

Conclusion

Our QIP supports the need for early patient education when discussing diagnosis of FND. The finding of 42% uptake within two weeks of leaflet dispatch is encouraging.
Special Interest- what are trainees doing in the West Midlands?
Authors: Gupta Nidhi , Hynes Fiona
Published: June 2021

Aims

The aim of this survey was to find out how Speciality trainees used their special interest sessions, using multiple choice and open questions

Background

The ST (Speciality Training) curriculum recognises that it is desirable that all higher trainees gain additional experiences that may not be available in their clinical placement. Two sessions every week must be devoted during each year of Speciality training for such personal development, which includes research or to pursue special interests. Special interest sessions are defined as “a clinical or clinically related area of service which cannot be provided within the training post but which is of direct relevance to the prospective career pathway of the trainee”. This experience must be appropriately managed, supervised and assessed.

Method

We conducted a survey of Speciality trainees in the West Midlands region across all psychiatric specialities using an online survey. The survey was open for one month period in January 2021 and reminders were sent intermittently. Following survey closure, quantitative data were analysed using Google Forms and Excel. Qualitative data were collated and reviewed to identify relevant themes.

Result

47 of the total 82 Speciality trainees in all psychiatric specialities including dual trainees responded. Maximum response rate was from General adult/Dual trainees who form the bulk of Speciality trainees. Most trainees discussed their special interest with their supervisors and included this in learning plans. 79% were able to have a weekly session. Most sessions were devoted to gaining additional clinical experience, medical education, gaining leadership competencies and completion of further post graduate qualifications. The majority of trainees chose special interest sessions in their own trust, however 45% had difficulty getting released from their clinical commitments. Trainees demonstrated evidence in their portfolio by reflection, WPBA and reflective notes. Trainees were positive about their experiences and requested more support to access sessions locally.

Conclusion

The Future Doctor report (HEE 2020) recognised that our Future Doctors must have a broad range of generalist skills to meet the population needs, therefore it is essential that doctors in training are supported by trainers and trusts to access special interest sessions to ensure that they achieve a broad range of competencies. To signpost trainees we have developed a booklet advertising available opportunities for ST trainees and other services may wish to consider this.
Are we adequately reviewing confusion inducing drugs in patients referred to the memory assessment service?
Authors: Hegde Siddhant , Negi Rashi , Shanmugaratnam Hari
Published: June 2021

Aims

The aim of this quality improvement evaluation project is to establish the standard of current practice in relation to reviewing confusion inducing drugs (CIDs) at the time of referral, as it has been hypothesised that these medications contribute to short term cognitive impairment. This is essential in order to establish the validity of the diagnostic processes of dementia syndrome in the memory assessment services.

Background

It has long been established that anti-cholinergic medications (ACMs) have contributed to short-term cognitive impairment in patients taking them. This is compounded with the fact that these medications may be continued without review, for longer than was originally intended. The impact of polypharmacy, subsequent anti-cholinergic burden, and the overlapping presence of delirium, may call into question the validity of a diagnosis of dementia in patients who have not been correctly vetted during the course of their assessment. This quality improvement evaluation aims to assess whether patients’ medications are being reviewed before diagnosing a memory disorder. This is in accordance with guidance set out by the NG97 NICE guidelines, The Royal College of Psychiatrists Memory Service National Accreditation Programme (MSNAP), and the National Institute on Ageing and Alzheimer's Association (NIA-AA).

Method

All new referrals to the memory assessment service during July and August 2019 were systematically reviewed and data extracted from the memory referral document and entries on RIO from first point of contact. The following data were recorded: patient ID, GPCOG/6CIT score, final diagnosis, CID prescriptions and CID review.

Result

The results were collated using a data-set of 216 patients (136 females and 80 males,) of which the mean age was 79 years. It was noted that 36% of patients had not had any sort of cognitive assessment before referral, which identifies an area for improvement. However the most substantial finding was that only 10 patients (5%) had a CID prescription review documented in the RIO notes.

Conclusion

Our data suggest that in our memory assessment service, only a small proportion of patients are having a documented review of their CIDs prior to diagnosis of dementia. In order to improve this and thus improve compliance with guidelines from the Royal College of Psychiatrists MSNAP and the NIA-AA, measures will be taken to issue each dementia support worker and nurse with a CID prescription review card, which will list those medications to consider and flag for review.
Quality improvement supervision comparison between training and non training posts
Authors: Jamali Qutub , Khanna Tarun , Thomas Gareth
Published: June 2021

Aims

To explore the level of supervision between training and non-training posts at LSCFT.

Background

•

Supervision is defined as ‘provision of guidance and feedback on matters of personal, professional and educational development in the context of a trainees' experience of providing safe and appropriate patient care’.

•

Along with the trainees, doctors working in non-training posts such as staff grade, specialty doctors, trust grade doctors (TJD)and MTI (Medical training initiative) doctors form an integral part of patient care in the NHS.

Method

•

A mixed method approach was adopted with both qualitative and quantitative data collected simultaneously in the form of an online questionnaire.

•

An anonymous online questionnaire was sent to junior doctors currently in training and non-training posts at LSCFT in 2019 using Meridian software.

Result

1- Quantitative Data: - Participants included were doctors in training post such as Foundation Doctors (5), Psychiatry Core Trainees (6), GP STs (2) and doctors in non-training post such as TJD (4), Specialty Doctors (2) and MTI doctors (4). Based on the Meridian score, 84% of doctors were satisfied with the supervision. It was found that 72% of doctors received weekly supervisions, 10% monthly (1 TJD, 1 Foundation trainee) and16% bi-monthly (1 MTI, 1 SAS, 2 CTs). The data suggested that there was no difference in the frequency of supervisions between training and non-training posts at LSCFT.

2- Qualitative Data: - The feedback was common as there was no major difference between training and non-training doctors.

•

Positives – WPBAs, discussion on reflections, management of complex cases and medication, personal issues affecting work.

•

Negatives – Limited discussion on QI, Audit, Research and Psychotherapy.

- More specific help, need more support at times.

Conclusion

1.

To prepare a checklist of contents to be discussed during supervision.

2.

To prepare a timeline chart of supervision.

3.

Preparing a ‘menu’ of QI projects that junior doctors can sign up to at the start of each post.

4.

To formulate training packages available to support junior doctors with QI/Audits.
Developing a dashboard for use in a forensic and intensive care psychiatric unit: a quality improvement project
Authors: Jamieson Keara , Bennett Daniel
Published: June 2021

Aims

Dashboards provide a visual summary of relevant data to track performance against key indicators over time. They are used in healthcare to monitor the quality of patient care and to identify potential quality improvement projects. There is little published evidence of them being used in mental health services, especially in forensic psychiatric care.

This project aims to design a dashboard for use in a forensic and intensive psychiatric care unit, by specifying measures and ideal features it would include.

To develop a model for a quality dashboard for use

To decide which measures would be reported on the dashboard

To find reliable methods of assessing said measures

To explore staff preferences as to how the dashboard would display data, and how they would like the information to be disseminated

To use blank data to design a mock dashboard interface for feedback

Method

A literature search was conducted on healthcare dashboards and quality improvement projects taking place on low-secure psychiatric wards similar to the Blair unit. Potential outcome measures and methods of assessing them were researched. Staff thoughts on the dashboard, and which measures they would like to see included, were explored in interviews and using a survey

Result

Blank data were fed into excel to create example graphs for a mock dashboard. The results section details: measures to be included, such as staff turnover rate, absences, and patient satisfaction levels; how they can be assessed; and specific features of the dashboard, such as the capability to track trends in selected quality indicators over a period of time. Further development of this project out with the 4 week development timeframe will require cooperation from IT services and unit management staff.

Conclusion

Many staff suggestions, whilst valuable measures, were more suitable for use in a clinical or nursing dashboard, rather than a quality dashboard. COVID-19 factored into reasons why staff requested certain measures, and also meant that less staff were available to be contacted about the project. This project has limitations based on the four-week timeframe, but could be further developed by staff on the unit if desired.
Improving quality and assessment of referrals to the Enfield Crisis Resolution and Home Treatment Team (ECRHTT)
Authors: Kousteni Margarita , Cousins John , Mansingh Ajay , Elia Maja , Ras Yumnah , Chavarri Mercedes , Gougoulaki Marilia , Akande Imo
Published: June 2021

Aims

Triaging referrals to crisis resolution and home treatment teams is a significant undertaking requiring experienced and dedicated staff. We observed that the volume of inappropriate referrals to ECRHTT was high, and that staff processing these often felt inexperienced or lacking in confidence to discharge them back to the referrers and signpost them to appropriate services.

The aims of this quality improvement project (QIP) were:

a)

to reduce the number of inappropriate referrals received by the team

b)

to reduce the number of inappropriate referrals accepted by the team

This would significantly improve access and flow to the service and facilitate better patient care.

Method

A pilot study was first completed of the quality (appropriateness/ inappropriateness) and source of all referrals to ECRHTT in January 2019 (n = 177).

Subsequently, the consultant psychiatrist for ECRHTT based himself within the assessment team. He was able to closely monitor the referrals, at the same time as providing medical input to patients at their first point of contact. To evaluate the impact of this intervention, the percentage of inappropriate referrals accepted pre- and post-change was compared by re-auditing all referrals received in February 2019 (n = 175).

Further interventions were instigated to improve referral quality. These included continuation of psychiatric medical input to the assessment team, teaching sessions for GPs and the crisis telephone service, and weekly meetings with psychiatric liaison and community mental health teams (CMHTs). Change was measured by reassessing the quality of all referrals made to ECRHTT in February 2020 (n = 215).

Result

46.9% of inappropriate referrals to ECRHTT were accepted in January 2019 compared to 16.9% in February 2019 following the addition of medical input to the assessment team. The absolute difference was 30% (95% CI: 14%–44%, p < 0.001).

71% of referrals from GPs were inappropriate in January 2019 compared to 36% in February 2020 post-intervention (difference 35%, 95% CI: 8.84%–55.4%, p < 0.05). Inappropriate referrals from CMHTs decreased from 55.5% to 12% (difference 43.5%, 95% CI: 9.5%–70.3%, p < 0.05). Overall, the percentage of inappropriate referrals fell from 38% to 27.4%, a difference of 10.6% (95% CI: 1.3%–19.8%, p < 0.05). The percentage of inappropriate referrals from liaison teams did not change significantly.

Conclusion

This piece of work shows that better engagement with referral sources significantly improved the quality of referrals made to ECRHTT. Interventions included medical input at the point of referral, teaching sessions for general practitioners as well as ongoing liaison with referring teams.
Improving the physical healthcare of COVID-19 patients in inpatient psychiatric settings
Authors: Lewis Marissa , Dionelis Karolos , Vecida Miguel , Phelps Rebecca , Hopwood Helen , Yong Lawrence , Ng Jason , Veeramah Sara , Lloyd Miranda , Clark Tom
Published: June 2021

Aims

COVID-19 can spread rapidly in psychiatric inpatient settings. Previous studies have found that patients have a higher risk of hospitalisation and death than adults in the community. The aim of this project was to improve the care of patients with COVID-19 in psychiatric inpatient settings.

Method

A baseline audit was conducted of care COVID-19 patients received in wards that experienced outbreaks in January 2021 in a London Mental Health Trust. Clinical notes were reviewed for management plans, including clear documentation of risk of serious illness, frequency of vitals monitoring, and thresholds for escalation to medical teams.

A new protocol was subsequently developed and implemented at one inpatient unit: “COVID-19: Early Identification of Risk and Management”. This included an adjusted 4C mortality score to determine risk of deterioration, and schedules for observation monitoring based on this outcome. Each schedule specified separate frequencies of monitoring of critical observations (oxygen saturations, respiratory rate) and routine observations, thus minimising unnecessary staff exposure. It prompted venous thromboembolism (VTE) assessment and documentation of escalation criteria.

Result

44 patients were identified across three working age (WAA, n = 29) and two older age (OA, n = 15) adult wards. 7.5% of WAA and 33.3% of OA patients were hospitalised. 20% of OA patients died following a positive test. 58% of patients had a documented management plan for COVID-19, but only 56% mentioned observation frequency, 19% escalation criteria, and 9% risk of serious disease. No patient received a repeat VTE assessment following diagnosis. The audit identified inconsistent approaches to COVID-19 management between wards, and found no relationship between risk of deterioration and frequency of observation monitoring. Following implementation of this protocol, 100% (n = 4) of patients had a robust plan for COVID-19 management, and 100% received a VTE assessment.

Conclusion

The audit supported previous findings that psychiatric inpatients are at risk of serious COVID-19 infection. This highlights an urgent clinical and ethical need to optimise COVID-19 care in psychiatric inpatient settings. The results of this audit suggest that risk factors for severe infection and elements of routine care are not widely understood or implemented by clinical staff. Introducing evidence-based protocols to support clinicians in managing the physical healthcare of these patients may be one way of promoting best practice. The improvement in care observed in the pilot study has resulted in this protocol being rolled out across the Trust in an ongoing quality improvement project.
Alcohol hand sanitisers on mental health wards safety risk educational and QI poster
Authors: McMurray Peter
Published: June 2021

Aims

To provide awareness of safety concerns around use of alcohol hand sanitiser on a mental health ward, and to consider ways of improving how learning for a serious adverse incident in one trust can better be communicated to other trusts

Background

DD a male patient with history of paranoid schizophrenia alongside historic illicit drug use and current alcohol dependency admitted detained to Bluestone hospital following bizarre behaviour at a wake. Had been non-compliant with medication. Transferred to PICU due to going AWOL and returning under influence of alcohol.

2nd April overnight staff noted him to become over-sedated, presenting with slurred speech and appeared under influence of alcohol – transferred to A + E due to deteriorating GCS – was intubated, and transferred to ICU. Blood alcohol level was 373. Several empty bottles of hand sanitiser from dispensers on ward found in his room and he later disclosed he had accessed further alcohol hand sanitiser in sluice while washing clothes

SAI learning outcomes from one healthcare trust in Northern Ireland not currently routinely shared with other trusts

Method

Literature review carried out to search for reports of similar incidents – 1 previous review article suggesting one death and 11 other major complications from consumption of alcohol hand sanitiser over 5 year period 2005-2009.

Quality improvement steps implemented to address this risk

Ward policy was reviewed to ensure patients no longer had unsupervised access to wash clothes

Liaised with Infection Control to assess the need for alcohol hand sanitiser to be available to patients given the ward is effectively a community setting

Intoxication policy reviewed and education sessions on this provided to all medical and nursing staff

Regional regular PICU staff update seminar launched for purpose of bringing PICU staff from across Northern Ireland together to share learning from SAIs and cases

Result

Infection control agreed alcohol hand sanitiser dispensers could be removed from wards and kept only in locked nursing office with use of visitors.

Learning from this case shared with other trusts locally at newly launched regional PICU update seminar

No further incidents to date

Conclusion

Patient access to alcohol hand sanitisers found to be a significant safety risk in PICU setting

Following implementation of quality improvement steps no further incidents of patients swallowing alcohol hand sanitiser

Improved awareness of risk of alcohol intoxication on ward with nursing staff escalating concerns to on-call doctor more frequently
Audit of documentation of observations on mental health services for older people (MHSOP) wards following implementation of nervecentre
Authors: Rathi Nitya
Published: June 2021

Aims

Nervecentre is an application that can be used on mobile devices and desktop computers to record and view physical observations amongst other tools. An audit had been done previously assessing the practice of recording observations using paper documentation. That audit had recommended the use of Nervecentre to improve the recording of observations. This audit was undertaken following the introduction of Nervecentre for documentation of physical observations. The aims were to evaluate if the transition to electronic documentation of NEWS (National Early Warning Score) observations on Nervecentre has improved practice in comparison to paper documentation and to evaluate if our practice could be improved by implementing electronic observations for psychiatric observations in addition.

Method

Data were collected over a 10-day period looking at all the documented observations from all inpatients on the MHSOP wards that met the inclusion criteria. Data were collected on the recording of psychiatric observations (recorded on paper charts) and physical observations (recorded on Nervecentre). The data were collated and analysed. The new data were compared to the original data from prior to the introduction of NerveCentre and the findings were presented at a local meeting.

Result

This audit has highlighted that the documentation of physical observations on MHSOP wards has greatly improved since Nervecentre was introduced. There was an improvement in recording of physical observations in almost all domains measured. NEWS scores were correctly documented 100% of the time compared to 87% previously. Raised NEWS scores were correctly escalated to a senior and reviewed 80% of the time compared to 0% previously. It has also highlighted that the quality of documentation regarding psychiatric observations could be improved as we are not currently meeting local or national guidance.

Conclusion

The most likely cause for the improvement in the recording of the physical observations is the implementation of Nervecentre. Nervecentre prompts users when observations are due, removes the risk of calculation errors and allows for observations to be directly escalated. Implementing Nervecentre for psychiatric observations may similarly improve the quality of these observations therefore improving patient safety.
Patient & staff perceptions of animal-assisted therapy in psychiatric rehabilitation
Authors: Sallette Laura , King David , Cowton-Williams Sian , Mohan Rajesh
Published: June 2021

Aims

To study patients' subjective experiences of having access to a therapy dog and to assess the staff perception of the impact of pet therapy. Hypothesis: pet therapy services are acceptable for rehabilitation patients.

Background

Animal-assisted therapy (AAT) is the supervised use of an animal in a therapeutic setting to help in the treatment of physical or psychological disorders in humans. The use of dogs in the context of AAT - ‘dog therapy’ (DT) - has been piloted in the context of stroke rehabilitation; schizophrenia in elderly patients; depression, loneliness and anxiety in elderly patients; Alzheimer's disease; symptom reduction in PTSD; cognitive impairment; and dementia. The impact of pet therapy in long term psychosis care has not been adequately assessed.

Method

This feasibility pilot study used questionnaires to assess patient (n = 12) and staff (n = 10) perceptions of dog therapy in an in-patient psychiatric rehabilitation setting. 24 patients on a rehabilitation ward with complex psychosis were offered the opportunity to interact with ‘Nugget,’ a corgi trained in the United States as a ‘therapy dog.’ A ‘patient questionnaire’ (PQ) and a ‘staff questionnaire’ (SQ) assessed the acceptability and self-rated benefits of the intervention.

Result

All patients (100%) rated highly on the enjoyment, anxiety, calmness, and comfort domains during the dog therapy, and expressed willingness to receive further sessions in the future. The SQ measured staff perceptions of patients’ engagement, enjoyment, comfort and emotional response to the therapy. 100% of staff rated highly on all questions and thought the interventions had recovery value. Engagement was one key factor noted in the feedback. There were no reported adverse reactions to the intervention.

Conclusion

Our preliminary results showed high acceptability and perceived value for Animal assisted therapy in a psychiatric rehabilitation setting. Given the impact of social isolation and need for connectedness, we recommend access to pet therapy where possible to be integrated into individual recovery programmes.
A quality improvement project on timely completion of bloods and ECGs on a tier 4 child and adolescent inpatient unit
Authors: Salter Emma , Snow Philippa , Friel Kiera , Biddiscombe Nicola
Published: June 2021

Aims

Physical health monitoring is paramount to optimal care for psychiatric patients. Blood tests and ECGs are invaluable tests throughout a patient's care. At baseline, they aid investigation of potential organic causes of psychiatric presentations and provide organ and electrolyte status before starting medication. Common psychotropic medications carry physical health risks: bloods and ECGs aid in monitoring potential side effects of prescribed medication.

In this local Tier 4 inpatient unit, anecdotal observation revealed completion of these basic investigations was noted to be suboptimal.

This project aimed to improve timely completion of baseline (within 72 hours of admission) and monitoring (within one week of due date) bloods and ECGS.

Method

This project was completed within a 12-bed child and adolescent inpatient unit. Using Plan Do Study Act (PDSA) methodology, the multidisciplinary team collated driver diagrams to identify potential areas for intervention. Following baseline analysis, colleague communication was considered key. Consequently, a chart for bloods and ECG completion was created.

Each monthly PDSA cycle included the following consecutive interventions:

PDSA cycle 1: chart implementation

PDSA cycle 2: chart simplification and font size increase

PDSA cycle 3: allocated change in team leader for this cycle

PDSA cycle 4: Blood request pocket in office

PDSA cycle 5: chart simplification through removal of dates

PDSA cycle 6: ECG pocket

PDSA cycle 7: box on handover list

Result

Monthly investigations and admission numbers are unpredictable and inconsistent in this cohort: relevant case numbers per PDSA ranged from zero to ten. The results were presented as percentages to allow for direct comparison between cycles.

Baseline and results of each consecutive PDSA cycle described above were as follows (N/A represents a cycle where no investigations were required):

Admission bloods were completed within 72 hours in 50%, 100%, 50%, 80%, N/A, 100%, 100%, 100%

Admission ECG was completed within 72 hours in 30%, 66%, 50%, 70%, N/A, 100%, 100%, 100%

Monitoring bloods were completed within one week of due date in 25%, 33%, 0%, 80%, 100%, 100%, 100%, 100%

Monitoring ECG was completed within one week of due date in 0%, 0%, N/A, 66%, 100%, 66%, N/A 100%

Conclusion

Through close multidisciplinary collaboration and chart implementation, completion of bloods and ECGs improved. Low patient numbers per PDSA cycle resulted in large changes in percentage results, limiting the significance of these findings. Wider implementation of the chart within local Trust inpatient wards is considered.
Redesigning community care for safer staff and patient experiences: quality improvement project to improve safety and reduce incidents of violence and aggression in a community mental health team
Authors: Saxena Sarah , Vozmediano Alberto Gutierrez , Walsh Katrina , Moodie Sarah , Mapfumo Rumbi
Published: June 2021

Aims

Violent or aggressive incidents can be relatively common in community settings, and perhaps more difficult to manage than at inpatient wards due to the relative isolation and peripatetic delivery model, which can put staff at higher risk during incidents. Carshalton and Wallington Recovery Support team was identified as an outlier in the Trust and was invited to partake in a Safety Collaborative across South London Partnership.

Stakeholders agreed on the aim of reducing incidents by 20% over 1 year by the end of 2020.

Method

Data about incidents were analysed and staff surveys conducted to evaluate violent events. Patient discharge was highlighted as a particular time of increased aggression. Involvement of patients and carers through patient focus groups and co-production was essential to elicit areas of improvement. These included staff confidence and awareness of existing guidelines. Additional secondary drivers were communication with patients, care pathway development, discharge process and multidisciplinary approach, which each had associated change ideas.

The team identified change ideas that have been tested over one year using the Quality Improvement methodology of small-scale testing and PDSA. Example ideas tested include multidisciplinary Risk meetings, Safety huddle tool, Staff Safety training, co-produced Welcome and Discharge Packs with informed care pathways.

Result

There has been a 30% reduction in incidents by December 2020 across a total of 280 patients. Surveys have shown an increase in staff confidence and safety protocol awareness from 40% to 70% by October 2020. 100% of patients in focus groups found the Welcome and Discharge Packs helpful.

Conclusion

A structured improvement approach focused on staff safety and minimisation of known and potential contributing factors can lead to a reduction in incidents. Safety huddles and risk meetings allow a formal multidisciplinary approach to management of violence and aggression. Staff feel more reassured about safety policies in the trust, with better communication between senior management and colleagues to highlight risk and provide support. A culture of open discussion and transparency was implemented through provision of Welcome Packs including Care and Discharge Pathways details at point of entry to the service. Support was provided to patients with Discharge Packs including information about community services. This enabled a meaningful support model at the end of their recovery journey and an improved discharge process.

The team is now working with additional teams and administrative and clerical staff to improve safety. We hope to replicate this approach in our Trust.
QI project: Improvement in quality of Seclusion Medical Review
Authors: Shahbaz Shumaila , Ward Richard
Published: June 2021

Aims

To establish the improvements in the quality of seclusion medical review after introducing a template to complete the review.

Background

The Mental Health Act – Code of Practice outlines the standards of patient care while in seclusion. It also emphasis that supportive engagement/observation schedules should be reviewed in person and continued at the point an episode of seclusion was initiated.

Furthermore, NICE also set up standards to monitor side effect profile while prescribing psychotropic for such patients and regular management review. It also gives importance to staff training to ensure these standards.

To improve the quality of the seclusion medical review, we completed an audit in July 2019 to ascertain whether medics are following Trust Policy.

We identified good results (above 90%) in the following areas:

Time of seclusion review

Record keeping

Management plan

Good documentation of risk, mental state examination and physical health.

We also noticed that the following areas can be improved:

Prescribed Medications. (60%)

Medication side effects. (40%)

Physical Observations (40%)

We used the following audit standards for our audit after our last audit and a template was designed and after discussion with medics incorporated into the existing documentation template.

Time of review

Reason and duration for seclusion

Psychiatric diagnosis

Mental State Examination/Behaviour

Physical health (including physical observations)/Environment

Medication (prescribed, rapid tranquilisation, side effects, or adverse effects)

Risk (to self-DSH or accidental) (risks to others)

Plan :(frequency of physical obs./medical review, management, restrictions, exit plan for terminating seclusion, patient's capacity to understand it)

Method

We considered the following aspects:

Retrospective data collection from 01.03.2020 to 30.08.2020.

Sample selection: random selection of mixture of clinicians on different times and days of the week.

Data analysis was carried out by using Microsoft Excel.

Result

We noticed a marked improvement in the quality of seclusion medical review (between 95% and 100%) after introducing a template for it. There were no major concerns identified during the re-audit.

Conclusion

To continue to use the template for Seclusion Medical Review which has shown significant improvement in the quality of the reviews which will improve patient care.

It also helped us to deliver person centred care and safe practice.

To continue teaching and training of doctors.

This QIP project motivated nurses to do an audit on nursing seclusion review and made necessary changes.
Increasing routine HIV testing in low and medium secure forensic settings
Authors: Swain Rachel , Dujic Maja , Leung Timothy
Published: June 2021

Aims

There remain a number of barriers to patients taking HIV tests, and prevalence of HIV in patients with severe mental illness can be higher than those without. Patients in forensic settings may be at even greater risk. National standards state that in areas of high and extremely high prevalence of HIV, testing should be offered routinely on admission to hospital. A review of compliance with these standards took place across low and medium secure male forensic wards in West London, followed by implementation of targeted interventions to increase testing rates. A reaudit was later completed to assess if changes had resulted in lasting effects

Method

A retrospective review of computer records took place to identify all inpatients residing on the low and medium secure wards on the day of data collection. Their pathology records were checked to ascertain if HIV test results were available. If no test was documented here, then patient psychiatric records were searched for documentation of the test being offered.

After the initial audit, education of patients and staff regarding the benefits of HIV testing took place, HIV testing was incorporated into primary healthcare routine admission screening and separate consent forms were eradicated.

The reaudit took place with data collection occurring in an identical manner.

Result

183 patients were initially identified across 5 low and 7 medium secure male wards, and 184 on reaudit. The initial audit found that only 30.6% (56/183) of patients had either been offered an HIV test or had a result recorded on the pathology system, but this rose to 82.6% (154/184) on reaudit. After the interventions, 43.4% of all patients had HIV test results available, compared to 23.5% initially. Even where no test result existed, the number of tests offered rose from 7.1% to 39.1% of all patients.

Conclusion

This study shows that simple measures to normalise HIV testing and make it part of routine admission screening had dramatic implications for the number of patients being offered an HIV test.

There is still room for improvement, however, with 17.4% of patients having neither test results available, nor documentation that a test was offered. This could be a result of poor general engagement with health care services, and would benefit from thorough documentation and assertive outreach.
On-line memory clinic – piloting a hybrid model
Authors: Tomar Rahul
Published: June 2021

Aims

Quality improvement project was undertaken to reorganise memory clinic to incorporate both virtual and in-person consultation (Hybrid Virtual model), as depicted in the following model:

Method

Tele triage conducted to ascertain information from patient and carer. This reduced time for face to face assessment.

Nurse did face to face assessment to complete cognitive test (Addenbrooke's Cognitive Examination III) & carer completed Bristol Activities of Daily Living scale. Nurse would also do BP, PR, oxygen sats & temp.

Nurse discussed the assessment with the consultant (who is in the inpatient unit) on line using MS TEAMS

Consultant would then see patient on line, confirm diagnosis, answer questions, give information on medication and post prescription (if required)

Feedback was collected using Telehealth Satisfaction questionnaire

Result

Hybrid remote memory clinic was started on 29/09/20. A total of 37 patients were seen in this clinic by 31/01/21.

Collected feedback from 21 patients was generally positive –

Information provided on video consultation prior to assessment -18 reported it as excellent

How well you privacy was respected – 21 reported it as excellent.

Information you received on the treatment – 18 reported it as excellent

Conclusion

The hybrid remote memory clinic was more effective than telephone consultation or on line only consultation as it was –

Easy to establishing rapport

Physical examination could be performed

Digital literacy was no longer a limiting factor

Prescribing medication was slightly more difficult but possible
Audit of follow-up within 7 days on discharge from the mental health unit, Forth Valley Royal Hospital
Authors: Turner Matthew , Love Shaun , Douds Fergus , Zebda Anyssa
Published: June 2021

Aims

To determine compliance with the new discharge policy of review within 7-days for all General Adult Psychiatry patients discharged from Forth Valley Royal Hospital.

Background

It is well established that there is an increased risk of suicide following discharge from Inpatient Psychiatric Wards. This risk is significantly increased in the first month, and particularly high in the first week.

In their 2016 Guidance, NICE recommends follow-up within 7 days of discharge. It is not known whether seven day follow-up reduces suicide risk but it is clearly an opportunity for risk assessment and management during a particularly risky period.

This standard was adopted by the General Adult Wards in Mental Health Unit at Forth Valley Royal Hospital in April 2019.

Method

All discharges from Wards 1, 2 and 3, Forth Valley Royal Hospital were reviewed during three distinct, month-long periods:

November 2018 (prior to the introduction of the new discharge policy)

May 2019 (shortly after the introduction of the new discharge policy)

September 2019 (six months after the introduction of the new discharge policy)

A list was obtained from Medical Records of all General Adult patients discharged in these periods. The paper and electronic records were checked for each patient, and the first scheduled care episode post discharge was taken as follow-up.

Result

In the1st round of audit (November 2018): 41 patients were discharged and 26 patients (64%) received follow-up within 7 days.

In the 2nd round of audit (May 2019): 46 patients were discharged, 39 patients (84%) received follow-up within 7 days.

In the 3rd round of the audit (September 2019), 50 patients were discharged and 49 (98%) received follow-up within 7 days.

Conclusion

There has been a clear improvement in the provision of follow-up on discharge from the General Adult Psychiatry Wards in Forth Valley Royal Hospital.

The new discharge policy was implemented in April 2019 and a “Discharge Pause” was introduced (initially a sticker, now an electronic form) to be completed by the medical team at the point when it was decided to discharge.

Community Mental Health Teams have also been reminded of their need to facilitate seven day follow-up as a priority. A flowchart was produced in May 2019, which provided guidance as to who should provide the seven day follow-up.
Mental health clothing bank - adDressing the issue
Authors: Ward Louisa
Published: June 2021

Aims

We often have patients who are admitted to the ward wearing only the clothes they came in. These patients have no way of going to get more clothes due to being detained, poverty/ homelessness or covid restrictions. Many do not have friends or family who can bring them clothes. As such they might wear one set of clothes for a number of weeks which is bad for their physical and mental health. We are creating a clothes bank to provide a change of clothes for these patients, and help their recovery back into the community. Many have clothes that are inappropriate for the current weather, or do not have a set of smart enough clothes for a job interview. We feel that this simple intervention will have a big community impact.

Method

We have obtained support from a number of charities and companies to supply donations. The project will be led by a team of staff and patients.

Result

We will review the usage of this scheme in 6 months time

Conclusion

We hope this intervention will tackle the issue of clothing on mental health wards. In the future we wish to expand this to outpatient mental health service users. We would then like to expand this project countrywide as are unaware of any other areas providing something similar.