bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of a novel consultant psychiatric clinic in general practices and its effects on secondary mental health contact and the general practitioners’ perspectives
Authors: Mahmood Kamran , Whitney Daniel , Brookes Guy
Published: June 2021

Aims

To assess whether direct access to a 45 minute screen appointment in a Consultant Psychiatric clinic, based in General Practice, affects; the number of contacts patients have with secondary care pre and post being seen; whether the General Practitioner (GP) would have referred to secondary services if the clinic had not been in operation; the GPs’ views on how helpful the clinic was in understanding the patients’ problems and managing the problems outside of secondary care.

Background

A Consultant Psychiatrist in Leeds offered bespoke 45 minute screening appointment clinics in three sister GP practices, accepting direct referrals from GPs without requiring referrals to the local Community Mental Health Team (CMHT). This model was created to reduce the number of patients moving repeatedly between GP and secondary mental health services as this was leading to patient dissatisfaction and increased GP and CMHT workloads.

Method

We compared the number of mental health contacts (per month), for each of the 57 patients who had been referred to the clinic, in the months pre and post being seen in the clinic. We also asked the involved GPs to complete a brief survey for each patient who had been referred to determine whether, they would otherwise have been referred to the CMHT and whether the clinic has helped with their understanding and management of the patients’ problems.

Result

The mean number of contacts with secondary services before being seen in clinic was 3.30 per month compared to 0.44 after being seen. The mean difference of 2.86 is statistically significant on a paired-test with a P Value of 0.0149 (95% confidence intervals of 0.58 to 5.13). We received 22 survey responses from GPs of patients referred to the clinic including for patients who did not attend. All 22 responses indicated that the patient would have been referred to the CMHT if the clinic had not been available. 95% were rated as being very helpful or moderately helpful in understanding the patient's problems. 91% were rated as very helpful or moderately helpful in managing the patients’ problems outside secondary care.

Conclusion

Our evaluation has demonstrated that a model of direct access for GPs to a Consultant Psychiatric clinic can reduce referrals and patient contacts with secondary mental health services. GPs have found this model helpful in understanding patients’ problems and managing the problems outside of secondary care.
Psychiatric staff training in managing medical emergencies: re-audit
Authors: Abd El Sayed Sarah , Salujha Sudhir
Published: June 2021

Aims

In the UK, people with severe mental illness at a greater risk of poor physical health and have higher premature mortality than the general population, highlighting the importance of responding to physical health problems among patients suffering from psychiatric conditions. However, training for staff on inpatient psychiatric units to meet patients’ physical health needs is sometimes overlooked and has not always been effective.

According to NICE Clinical Guideline 25 (2005) and NPSA Rapid Response Report (2008/RRR010), staff on any psychiatric inpatient setting must be capable of monitoring, measurement, and interpretation of vital signs. They must have both adequate information and skills to identify signs indicating worsening of patients’ health and respond effectively to severely ill patients.

Hence, we aim to re-audit the results of a similar audit carried out in 2016 to review the level of medical emergency training (in terms of life support training) of clinical staff across the inpatient psychiatric wards at our local hospital - Stepping Hill Hospital- in Stockport.

Our hypothesis is that there will be a gap in meeting the required standards for training.

Method

A questionnaire including 6 questions (role of the staff member, level of their life support training, when was their training last updated, whether they know the location of the crash trolley, whether they know the local hospital emergency number and whether they should resuscitate the patient if their training is out of date) was given to staff on acute inpatient psychiatric units in Stepping Hill Hospital.

Result

The sample included 49 staff members from all the 3 wards included in the audit. The level of training of nursing staff on the 3 wards was meeting standards except for nursing staff who were new to the wards or coming back to work from prolonged leaves. There was also a gap identified in the level of training of other staff members on the ward as well as on the remaining standards measured by the audit.

Conclusion

A gap was identified in meeting the required standards of training on the inpatient psychiatric units. Reasons identified for this gap are mainly due to the fact that new or bank staff are asked to cover the wards without providing them with appropriate training and without orientating them about the location of different equipments and policies on the ward.
An audit addressing the quality of prescribing sodium valproate in early intervention service
Authors: Aziz Humaira , Khatri Khushboo , Upadhyaya Sneha
Published: June 2021

Aims

This Audit aims to review prescribing practice concerning Valproate in early intervention services.

Method

The audit was undertaken across four EI hubs in Birmingham. Audit standards were derived from POMH-UK (Prescribing Observatory for Mental Health) QIP. Drug cards of the entire EIS caseload in November 2020 were reviewed to identify patients on any preparation of Valproate. A total of 31 patients were identified. Electronic notes of all the patients on Valproate were reviewed to compare prescribing practices against national standards.

Result

A total of 31 patients were prescribed sodium Valproate. All these patients had target symptoms documented in their notes. Reason for starting Valproate was mostly documented as agitation and aggression rather than elation in the mood. In was unclear if patients had full physical health checked before starting Valprotae as in majority (94%) valproate was commenced as an inpatient. Not all cases had detailed inpatient discharge notes making it difficult to fully understand the rationale for starting Valproate.

55% of the patients were on an off-license valproate preparation. Where used off-license majority (93%)of these patients had no documentation of the rationale behind off-license use. Similarly, in most cases (93%)there was no evidence of off-license use being discussed with the patients. Most patients had received adequate monitoring in the community (74%) although there was limited documentation of screening for common side effects. Prescribers were noted to be using Semi-sodium Valproate and Sodium Valproate interchangeably despite these not being bioequivalent.

Conclusion

We recommend that

1.

Periodic treatment reviews should document the assessment of response and screening for side effects.

2.

Where used clinician should clearly discuss and document the off-license use with patients. 500 mg Semi-sodium valproate (Depakote) is approximately equivalent to 433 mg Sodium Valproate (Epilim). If switching from Semi-sodium Valproate to Sodium Valproate, a slightly higher (approximately 10%) dose of Sodium Valproate should be used.

3.

Unless clear evidence of affective illness is identified, the ongoing need for Valproate should be regularly reviewed by the clinicians.
Audit: lithium monitoring for psychiatric inpatients and community patients during the initiation phase
Authors: Chari Damodar , Abbas Mohammed , Dhesi Kajal
Published: June 2021

Aims

Measure compliance with standards requiring baseline work up before Lithium therapy is commenced and subsequent Lithium level monitoring during the initiation phase

Method

All inpatients and outpatients who were started on Lithium between 2018 and 2019 within the Leicestershire Partnership NHS trust. Case notes were of patients 128 were retrieved from the electronic system and an audit proforma was completed to ascertain adherence to auditing standards as per BNF and trust guidelines. Parameters monitored were full blood count (FBC), renal functions test including serum electrolytes, thyroid function test, and BMI before commencing Lithium, and serum Lithium periodically after. ECG was needed for those patients with cardiovascular illness. Data were systematically compiled and analyzed descriptively using Microsoft Excel

Result

A total of 128 patients were included in the study. 111 (86.71%) had FBC, 118 (92.19%) had renal function test and electrolytes, 114 (89.06%) had thyroid function test while 99 (77.34%) had their BMI/weight recorded before initiating Lithium. 26 out of 36 patients with cardiovascular disorder had their ECG recorded. After Lithium was commenced, 108 (84.37%) had serum Lithium tested a week later, while only 89 (69.53%) had lithium monitored weekly. Trust guidelines recommend weekly monitoring for up to 4 weeks after a stable dose was reached. This was monitored in only 16 out of 128 patients.

Conclusion

Most of the patients had blood test done before being commenced on Lithium. However it was observed that serum Lithium was not adequately monitored at regular intervals after dose escalations. These finding indicate that there has to be greater awareness of the trust and BNF guidelines with regards to Lithium monitoring.
Baseline ECGs done in memory clinics in Leicestershire
Authors: Chithiramohan Tamara , Kido Assad , Marudkar Mangesh
Published: June 2021

Aims

To ascertain the compliance of the Mental Health Service of Older People (MHSOP) memory clinics in obtaining ECGs, based on the agreed criteria.

Background

Cholinesterase inhibitors are a main pharmacological treatment for Alzheimer's dementia (AD). These drugs may worsen pre-existing cardiac conditions or cause significant cardiac side effects. A baseline ECG can be beneficial before starting patients on these medications. Previously in Leicestershire, all memory clinic patients were receiving routine ECGs. However, new standards were set based on the NICE guidelines and criteria outlined in other regions, to reduce the use of this time consuming and expensive investigation for patients who may not require it.

Method

A total of 120 patients attending memory clinics in Leicestershire over a 6 month period (April to September 2019), were randomly selected and their electronic records retrospectively reviewed. The data collection tool was designed to encompass the key aspects of the criteria for obtaining an ECG for those attending the memory clinic. The information was analysed using Microsoft Excel.

Result

Of the 120 patients, 23 (19.2%) were diagnosed with AD, 10 (8.33%) with mixed and 19 (15.8%) with vascular dementia. 68 (56.7%) had a diagnosis of “other” which included mild cognitive impairment or diagnosis still under investigation. 0 patients were diagnosed with Lewy Body Dementia or Parkinson's dementia. Of the total number of patients, only 10 had an ECG done, 2 with a diagnosis of AD, 1 with mixed dementia, 1 with vascular dementia and 6 “other”. The 10 ECGs done were all requested by nursing staff.

Although 27 (22.5%) patients were identified to have a diagnosis of AD or mixed dementia, plus at least one of the criteria for an ECG, only 6 (22.2%) were discussed with the Multi-Disciplinary Team (MDT) following which only 3 of the 27 patients (11.1%) had an ECG

Conclusion

Despite having clear criteria for requesting an ECG for those attending the memory clinic, compliance over the 6 month period was low. The following recommendations may be useful in improving compliance:

Displaying the ECG algorithm in the memory service clinic rooms.

Raise awareness amongst memory service clinicians of the criteria for requesting ECGs.
Walking on sunshine! Vitamin D in psychiatric inpatients
Authors: Davies Emma , Mountford Lucy
Published: June 2021

Aims

We aimed to determine whether vitamin D is being tested on admission for psychiatric inpatients at a local inpatient hospital, to identify the level of vitamin D for this group and to establish whether vitamin D treatment provided is according to NICE guidance.

Emerging evidence suggests that psychiatric patients are more vulnerable to vitamin D deficiency, due to reduced sun exposure, social isolation, long inpatient stays and poor diet. Low vitamin D levels may also increase susceptibility to SARS CoV-2 infection and COVID-19 severity.

Method

Standards were determined by local policies, RCPsych recommendations and NICE guidance. Data were collected retrospectively from electronic patient records and entered manually to a spreadsheet for analysis.

Result

67% of patients had vitamin D tested on admission to hospital. Of the patients that had their vitamin D level tested, 39% patients had their result recorded. 48% either had a low vitamin D level or required replacement. 6 of 12 patients with a documented low vitamin D level had the correct vitamin D treatment, according to NICE guidance.

Conclusion

Of 46 patient records, nearly half had a documented low vitamin D level or were on treatment. We would therefore suggest that vitamin D testing should form part of the routine admission bloods. It is an important opportunity to detect deficiency or insufficiency for a potentially vulnerable group of patients. Intervention is simple and effective.

Results demonstrated room for improvement for vitamin D testing on admission to hospital, thus improving potential treatment and benefits for individual patients. The importance of recording blood results on to the electronic patient record was also highlighted.

We raised awareness and provided further education to all junior doctors, with creative posters and informative communications. Following the implementation of these changes a re-audit of 40 patients showed 75% had vitamin D tested on admission or during and of these, 58% either had a low vitamin D level or required replacement. 7 of 9 patients with a documented low vitamin D level had the correct vitamin D treatment, according to NICE guidance. Within this closed loop audit, we have reported moderate improvement in the testing of vitamin D for patients on admission to hospital along with a significant improvement in the treatment of vitamin D deficiency, according to NICE guidance.
A closed loop two cycle audit investigating the availability and accessibility of physical healthcare equipment on forensic inpatient wards within mersey care's secure division
Authors: Davies Thomas , Owens Stephen , Forjoe Tonia
Published: June 2021

Aims

To evaluate the provision of recommended medical equipment on forensic psychiatric inpatient wards in Mersey Care's secure division, as outlined by the Care Quality Commission (CQC) in their 2019 guidance “Brief Guide: Physical Healthcare In Mental Health Settings”. It has been documented that people with severe and enduring mental illness are at risk of dying on average 15 to 20 years earlier than people without, two thirds of which are due to avoidable physical illnesses. It was our aim to use these data to improve the provision of physical healthcare equipment on the wards of Mersey Care's secure division, in turn allowing for the safe assessment of patients in the acute setting, and the monitoring their chronic health conditions.

Method

We conducted a closed loop, two cycle audit of all forensic inpatient wards in Mersey Care's secure division measuring the provision of physical health equipment against the CQC's 2019 guidance. The intervention was to present our findings and implement physical health equipment boxes in the clinic rooms on the wards. Low, medium, high, and secure learning disability (LD) wards were audited, with a control sample of non-secure wards (addiction, old age, general adult, and LD non-secure) in the initial cycle for comparison.

Result

On initial audit, the mean availability of equipment across the secure division was 66% (range 50.9%-88.9%), and 75% across our sample of wards in the non-secure divisions (range 61.1%-88.9%). Following the intervention in the secure units, the mean availability increased to 73.5% (range 72.2%-77.8%). The mean percentage increase in equipment availability following intervention was 12.5% (range -12.5% to 41.8%).

Conclusion

Following the intervention, the re-audit conducted found an overall improvement with 73.5% of recommended equipment available. Despite this improvement in equipment availability in the secure unit wards, the equipment is still less available than on the non-secure control wards. Due to this, further intervention and another re-audit have been planned. In the second cycle, significant items such as disposable gloves, pulse oximeters, sphygmomanometers, thermometers and stethoscopes were available across all wards. This was an improvement from the initial audit and allows for the safe assessment of patients in the acute setting.
Audit on use of PRN (pro re nata) psychotropic medication for behavioural disturbance in individuals with intellectual disability in the community
Authors: Dhandapani Asha , Soundararajan Sathyan , Jones Claire
Published: June 2021

Aims

Psychotropic medication is commonly used in people with Intellectual disabilities (ID). This may be attributed in part to an increased prevalence of mental illness in this population and the presence of challenging behaviour which has been shown to increase rates of prescribing. Whilst there are a number of studies looking at regularly prescribed medication there are few studies on “as and when” required (PRN) medication.

Psychotropic medication continues to be used to manage behavioural disturbances in people with ID. Where there is no clear cut psychiatric illness, the role of psychotropic medication is an adjunct to a comprehensive multimodal treatment plan.

The aim is to find out if prn psychotropic medication for behavioural disturbance is being used appropriately and safely in these individuals.

Method

Files and PRN protocols of individuals known to be using prn psychotropic medications for the management of acute episodes of agitation and behavioural problems and supported by professional staff teams was studied.

We collected the data by contacting the residential homes, carers, Collecting details from case notes, from the Staff nurse who made the protocol for their patients

A questionnaire based on the standards mentioned above was developed and files and prn protocols were marked against these standards.

Result

The standards from the medical file were 100 % achieved. Thus indicating the importance of the psychotropic prn medication and documentation of the same.

However, the protocol that needs to be with the patient/carers had some lacuna/deficits. Overall only in 53% of the case, standards were achieved. This needs to be highlighted to the team.

The Audit gave an insight into what needs to be improved.

THE FOLLOWING AREAS NEEDED IMPROVEMENT

1.

There should be a prn protocol/ similar instruction to the staff about the use of prn medication(written by appropriately trained professional)

2.

Prn protocol should be accessible to direct care staff

3.

There should be a description of when to use the prn medication

4.

There should be a description of what non-pharmacological de-escalation methods ought to be tried before using prn/ is there a detailed behaviour support plan available

5.

Protocol should describe what the medication is expected to do

6.

Protocol should describe the minimum time between doses if the first dose has not worked

7.

Protocol should state the maximum dose in 24 hour period

8.

Use of prn should be recorded

Conclusion

I hope this audit will help in improving the patient care with the right psychotropic prn medication, with correct doses and further details as mentioned in the standards of the protocol.

We also hope to ensure that in our area, prn psychotropic medication used for agitation and behavioural disturbance is used safely, appropriately and consistently by staff teams. This would be in accordance with the guidelines.
VTE prophylaxis admission assessment full cycle audit and QI project
Authors: Drewniak Krystyna , Fielding Mark
Published: June 2021

Aims

The aim of the project was to assess completion rates for the VTE prophylaxis assessment for patients admitted to Dova Unit, Dane Garth. Another aim of the project was to identify areas for improvement and changes which could increase compliance rates.

Method

In the first cycle of the audit 20 randomly selected patients admitted to Dova Unit, Dane Garth between June and December 2020 were identified and included in the project. Data were then collected from the online patient record system Rio and analysed using an excel spreadsheet.

In the second cycle of the audit 10 randomly selected patients admitted to Dova Unit, Dane Garth between January and February 2021 were identified and included in the project. Data were then collected from the online patient record system Rio, analysed using an excel spreadsheet and compared with the results obtained in the first cycle of the project.

Result

In the first cycle of the audit the overall compliance was found to be 35%. VTE Risk assessment was completed for 50% of patients included in the study. ‘Active VTE on admission’ section of the VTE prophylaxis admission assessment was completed for 30% of patients included in the study. ‘Active VTE at 72 hours’ section was completed for 20% of the patients in the study and the ‘risk assessment for VTE' form was completed for 40% of patients included in the study.

In the second cycle of the audit the overall compliance was found to be 50%. VTE Risk assessment was completed for 60% of patients included in the study. ‘Active VTE on admission’ section of the VTE prophylaxis admission assessment was completed for 40% of patients included in the study. ‘Active VTE at 72 hours’ was completed for 40% of the patients included in the study and ‘risk assessment for VTE' form was completed for 60% of patients included in the study.

Conclusion

There was an overall improvement in the completion rates for the VTE prophylaxis admission assessment as a result of conducting the project. Working with the junior doctors and other healthcare professionals responsible for completing the VTE prophylaxis admission assessment, we aim to improve our completion rates of vital information even further.
A physicians' compliance in identifying patients’ as drivers and providing advice on the Driver & Vehicle Licencing Agency (DVLA) guidelines
Authors: Elisha-Aboh Christiana , Seukeran Amy , Pham Phuong , Musabbir Mohammad , Turner Helen
Published: June 2021

Aims

The DVLA has strict guidelines regarding how long a driver should stay off driving when they have certain mental health illnesses or severity of symptoms. It is difficult to give such advice if we are unaware of the patients’ that drive; especially when they do not volunteer this information for various reasons.

This audit was aimed at identifying people who have been admitted to the Ward 3 at the Mount Hospital and if they were asked about driving. The audit also looked at whether there were discussions around the driving requirements and DVLA guidelines in terms of their mental health diagnosis. The expected outcome of this project was to improve information gathering when clerking in a new patient and to ensure that elderly patients’ who drive are made aware of the DVLA guidelines.

Method

This audit retrospectively examined the care of 50 patients on Ward 3 at the Mount Hospital, a mixed acute psychiatric ward for older people, between 1st April 2020 and 11th November 2020. All patients’ aged 65 years and over who were on admission within that period were audited. Data collection took place between 17th November and 17th December 2020; this involved reviewing patient records throughout their inpatient stay including paper notes and electronic records (on Care Director). Results were compiled using a pre-determined data collection tool and analysed using Microsoft Excel. The audit used the standards within the DVLA Guidance- Psychiatric Disorders: Assessing fitness to drive.

Result

Only 1 (2%) patient had sufficiently documented evidence around driving and the impact of psychotropic medication on driving. DVLA information was given verbally in 3 (9%) patients and only 2 patients had this information passed on to their General Practitioner (GP). Only 3 (6%) patients were made aware of the DVLA guidelines and 2 (4%) patients made aware of their obligation to inform the DVLA

Conclusion

Generally, the compliance of psychiatrists in identifying all patients’ who drive is poor and seems even worse with elderly patients’. There was little documented evidence that patients were asked about their driving status on or during their admission, were given verbal or written information, had discussions around the impact of medication on driving or informed about their obligation to notify the DVLA. This study provides opportunity to improve practice by educating the medical workforce and raising awareness within the wider team. There also needs to be greater involvement and communication with GPs when completing discharge summaries.
Assessing the quality of risk assessment conducted for new psychiatry inpatients
Authors: Handa Nikhita
Published: June 2021

Aims

An audit was conducted to assess if thorough risk assessments had been documented in electronic clinical record notes (ECR) clerking for new patients in two acute mental health wards. Risk assessment is a vital part of admission clerking and when done well it can prevent early incidents and aid the ward nursing team greatly. During induction, junior doctors are advised to document assessed risks when clerking a new patient. A screening of the risks on admission could help determine the levels of observations required to minimise the identified risks whilst the patient awaits their first ward review.

Method

The NHS numbers for the 30 current inpatients across male and female acute psychiatric wards were gathered at the time of the audit (February – March 2020). Admission clerking was analysed for a clear statement of patient risk to self, others or property. Within these categories quantitative results were obtained on how often the risk of self-harm, self-neglect, absconding, vulnerability or aggression was documented. The term ‘risk’ was used for each patient on their ECR notes to search for risk assessments in all entries other than admission clerking.

Result

12 out of the 30 patients had a junior doctor risk assessment documented in their clerking (40%). 14 patients had no mention of risk assessment on admission (47%) and their first formal risk assessment was documented only in their senior ward review. Of the 12 assessments completed in clerking; all assessed self harm/suicide risk and violent risk to others, 1 mentioned risk of absconding, 8 mentioned risk of illicit substance use and 8 mentioned vulnerability. It was unclear if the risks documented were based on current or historic presentation. Junior doctors were anonymously surveyed following this audit and reported they did not feel confident in how to document a risk assessment or whether to document negative findings.

Conclusion

Clear documentation of risk assessment being performed was lacking in over half of junior doctor admission clerkings. When risks were assessed it was mainly violence/self harm risk documented not vulnerability and physical health risks. Based on these findings we have designed more comprehensive teaching on risk assessments and a template for how to complete a risk assessment. We feel the use of a template will ensure all elements of risk are clearly considered even if they are not present currently. This is being reaudited to assess if the changes have impacted the quality of risk assessment conducted.
An audit of high-dose and combination antipsychotic prescribing across the general adult inpatient wards in Mersey Care NHS Foundation Trust
Authors: Hyland Declan , Hemmings Beth , Elagamy Yasmine
Published: June 2021

Aims

To review the number of prescriptions of regular high-dose antipsychotics and combination antipsychotic therapy across the eight general adult inpatient wards in Mersey Care NHS Foundation Trust and examine whether these prescriptions followed Trust recommendations for high-dose antipsychotic therapy (HDAT).

Background

The two main rationales behind prescribing HDAT are pharmacokinetics differ in individuals and so insufficient amounts of antipsychotic may reach the effect site at maximum dose in some patients and variations in the effect site between patients may mean higher doses are required to achieve therapeutic effect.

Method

The electronic prescription records for all patients on the eight general adult inpatient wards were scrutinised. 121 patients were prescribed antipsychotic medication. Any patients on a combination of regular antipsychotic medication or on HDAT were identified. Any patient on combination therapy or HDAT was studied to determine if Clozapine had been considered. The electronic notes of HDAT patients were analysed to ascertain whether tests recommended by Trust guidelines – BMI, blood pressure (B.P), pulse rate, ECG, FBC, U and Es, LFTs, serum prolactin, serum cholesterol and HbA1c level had been performed prior to initiation and following any dose increase.

Result

21 of 121 patients prescribed antipsychotic medication were on combination therapy. 11 were subject to HDAT. 8 of the 11 HDAT patients were on combination therapy. Clozapine was considered before initiating HDAT in 9 of the HDAT patients. Clozapine was considered in 13 of the 21 patients on combination antipsychotic therapy, but only two were initiated on Clozapine (combined with Olanzapine or Risperidone).

100% of HDAT patients had an ECG prior to initiation of HDAT; only 36% had one after dose increases above BNF maximum. 100% of HDAT patients had their BMI measured before initiation. 91% had baseline B.P and heart rate checked. Of the recommended blood tests, 100% of HDAT patients had baseline FBC, U and Es, LFTs and serum cholesterol. Fewer patients had a baseline HbA1c level (91%) or serum prolactin (46%) measured.

Conclusion

Prevalence of HDAT across the general adult inpatient wards in the Trust was 9%, much lower than the 28% reported in the HDAT audit completed by the Prescribing Observatory for Mental Health in 2012. Patients within Mersey Care are more likely to be prescribed combination therapy than HDAT. Not every HDAT patient has been considered for Clozapine. There is a need to ensure Trust monitoring guidelines for HDAT patients are being strictly adhered to.
An audit to assess the measurement of Body Mass Index (BMI) and referral to the dietetics service following admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust
Authors: Hyland Declan , Prime Millie , Khaliq Rabia
Published: June 2021

Aims

This audit aims to establish whether patients have their BMI measured and recorded following admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust and whether, in those with a BMI >30 kg/m2, or >28 kg/m2 in those with weight-related comorbidities, they are referred to the dietetics service for input.

Background

Obesity has an increased prevalence in those with mental disorder. There are many factors that influence this, e.g. sedentary lifestyle and poor dietary intake. Medication prescribed to treat mental disorders may increase risk of weight gain. Patients with severe mental illness are at increased likelihood of developing weight-related comorbidities, particularly type II diabetes mellitus.

Many patients with severe and enduring mental illness do not regularly access primary care services. Admission to the psychiatric ward therefore provides an opportunity to address, not only the patient's mental health issues, but also any physical health issues.

Method

A list of all inpatients on the eight general adult wards was obtained on 3rd of December 2020. Inpatients on the Psychiatric Intensive Care Unit were also incorporated, providing a final sample of 148 inpatients.

An audit tool was designed, to collect demographic data for each inpatient – gender, age, ethnicity, psychiatric diagnosis, as well as BMI on admission and, if applicable, whether a referral to the dietetics service was made.

Result

Of the 148 inpatients, 91 were male, 57 female. Patient age ranged from 19 to 71 years. The majority were of “white British” ethnicity. The most common mental disorder diagnosis was schizophrenia (35 patients). For 14 of the 148 inpatients, no BMI was measured on admission. In the 134 inpatients that had BMI measured, 74 were in one of the “overweight”, “obese”, “very obese” and “morbidly obese” categories. Thirty-four patients met the criteria for requiring referral to the dietetics service. Of these, four were not referred, five were offered referral but declined, 17 referrals were made for other reasons, e.g. BMI <18 kg/m2, and one patient was referred despite no BMI being recorded.

Conclusion

Current practice across the general adult inpatient wards in the trust indicates a proportion of patients do not have BMI recorded following admission. This may result in a valuable opportunity to address obesity being lost. There is a need to emphasise to ward staff the importance of recording BMI as part of the admission physical health screen and of the criteria for referring an inpatient to the dietetics service.
Improving venous thromboembolism risk assessments on an older age psychiatric ward – a complete audit cycle
Authors: JD Syazana , Hart Edward , Mahanta Ranjit , Marshall Alison
Published: June 2021

Aims

Venous thromboembolism (VTE) is a common disease amongst hospital patients. Within acute hospitals, there are well established protocols for risk assessment and prevention of VTE via mechanical and pharmacological prophylaxes.

In psychiatry, assessment of VTE risk is more commonly overlooked despite many inherent risk factors which are unique to acute psychiatric admissions; including antipsychotic medications, physical restraint, catatonic states, and poor nutritional and hydration status[1]. The risk is compounded in older adult psychiatric patients, in which both patient and admission-related risk factors can act synergistically.

Anecdotally, it was reported that VTE assessments were not being completed and documented on the electronic patient record system. Our aim was to introduce a physical VTE risk assessment to attach to paper drug charts, which would act as a prompt for junior doctors, and serve to increase rates of completion.

Method

A baseline retrospective audit of all patients admitted to the older adult inpatient ward over an 11-week period (05/08/2019~20/10/2019) was undertaken. The number of completed electronic VTE risk assessments at admission, and at 24 hours post-admission were calculated.

Subsequently, a new paper VTE risk assessment proforma was developed, combining the Department of Health VTE risk assessment tool[3] with several VTE risk factors associated with psychiatric patients (catatonia, antipsychotic medication, reduced oral intake, psychomotor retardation). Education was provided to the ward doctors, and regular assessments of VTE risk was incorporated into the weekly MDT meetings.

A re-audit was completed to assess the completion rates of the new paper VTE proforma. A snapshot style audit of all inpatients on the ward on Thursday 24th February 2020 was performed.

Result

The baseline audit included 23 patients admitted during the 11-week period, consisting of 21 men and two women. The mean age was 74 years. Three patients (13% of total admissions) had their VTE and bleeding risk assessed on admission.

Following the implementation of a new VTE risk assessment proforma, the re-audit showed that all 19 inpatients (100% of total admissions) had a completed assessment. Although none of the patients required mechanical prophylaxis, one patient was receiving ongoing treatment for pulmonary embolism.

Conclusion

VTE is a preventable disease, which historically has been under-recognised by psychiatric doctors. The introduction of a paper risk assessment proforma increased completion from 13% to 100%. It also prompted regular review of VTE risk during the weekly MDT meetings. This intervention may reduce the incidence of VTE-related pathology on the ward.
Clinical audit of the inclusion of the Lester Tool details in discharge documents at Foss Park Hospital, York
Authors: Jones Kayleigh , McIlrae Shona , Ball Karen , Tahir Rohma
Published: June 2021

Aims

Patients with serious mental health illnesses die on average 15–20 years before the rest of the general population. Anti-psychotic medication, lifestyle and difficulty accessing healthcare services all have a detrimental effect on their life expectancy. To improve outcomes for these patients the Lester Tool; a method to assess the cardiovascular health of patients and implement change, was developed. Including the Lester Tool information in discharge letters allows transfer of information to other care providers (mainly GP's) who can implement and monitor any interventions made, improving outcomes for our patients. With this in mind, discharge documents should contain all of the information listed in the Lester Tool.

We aimed to check if 100% of data required by the Lester Tool is included in discharge documents of the inpatients at Foss Park Hospital.

Method

20 patients from each of the male and female wards at Foss Park hospital, discharged in September or October 2020, were identified. A review of the discharge documents established whether the smoking status, BMI, ECG, blood pressure and blood results of each patient were recorded.

Result

Of the 40 discharges, none had 100% compliance. On average across both wards; only 23% of the Lester tool information was included in the documents. On the female ward, 40% had none of data recorded, while on the male ward, 15% had none of the data recorded. Across both wards, not a single patient had details about their cholesterol ratio recorded, only 50% of BMI's were recorded and only 27% had a smoking status included.

Conclusion

Our results have shown that compliance with the Lester Tool falls short of what is expected. As a result, information about the physical health of our patients is not being communicated effectively with other care providers. This in turn can prevent patients being offered interventions needed to improve their cardiovascular health.

Identifying this shortcoming in the transfer of information will allow us to educate the staff in our organisation and ensure that all the necessary physical health details will be included in future discharge documents. The result being improved outcomes and longer life expectancy of patients with serious mental illnesses, satisfying the purpose of the Lester Tool.
Off-label prescribing of quetiapine in south locality crisis teams
Authors: Kumari Mamta , Gupta Arun Kumar , Clarke Peter
Published: June 2021

Aims

The audit was carried out to determine the frequency of off label prescribing of quetiapine and compliance with standards within Trust Policy (UHM PGN 02 PPT PGN 08) – Physical Health Monitoring of Patients Prescribed Antipsychotics and other Psychotropic Medicines, NICE CG178, General Medical Council Ethical Standards and Royal College of Psychiatrists – College Report CR210.

The main objectives of the audit were to determine if:

Patients have been appropriately informed of off-label status and consent recorded.

Alternative licensed treatment first used/ruled out.

Appropriate communication on transfer of care.

Appropriate physical health monitoring completed.

Background

Quetiapine is associated with various physical side effects. Patients should be fully informed of the expected risks and benefits of treatment, and the limited evidence base for off-label prescribing.

There are additional issues around the transfer of prescribing to primary care.

Method

The sample consisted of 50 consecutive patients selected from the crisis team caseload in the month of December 2018.

Data reviewed in this audit were taken from six months period.

Records audited were obtained from RiO (electronic records) and prescription charts.

Data collection was started in January 2019 and completed in March 2019

The audit tool was a dichotomous scale questionnaire based on NICE guidelines.

Result

4 patients from the sample (8%) were prescribed off-label quetiapine.

100% had physical health monitoring completed as per Trust policy.

100% off-label indication been clearly documented in notes.

100% Consent to treatment was documented.

100% had medication reviewed in the previous 6 months.

75% had licensed medication used or ruled out before considering off-label quetiapine use

25% risks/benefits of treatment were documented as part of a patient discussion.

25% had documented evidence that alternative treatment options were discussed.

25% had documented evidence of Community consultant/GP consent/agreement was obtained before transfer of prescribing

75% had a documented plan for review of quetiapine for treatment efficacy and side effects

50% had a documented plan in place for ongoing physical health monitoring

Conclusion

Suggested a wider audit may be required with greater patient numbers and which specifically filters for patients prescribed quetiapine.

Audit result has been shared with Crisis team members, Medicines Optimisation Committee and South Locality Quality Standards Committee in the trust.
An audit of risk assessments and management for self-harm and suicide in patients with depressive symptoms at a primary care practice in the UK
Authors: Oo Win Let
Published: June 2021

Aims

Over 5 million adults in England are living with depression, with the highest prevalence rates recorded in the North West and North East of England, 12.88% and 11.53%, respectively (NHS Digital, 2019). Depression is also associated with the highest rates of self-harm and suicide (SH&S) (Singhal, Ross, Seminog, Hawton, & Goldarce, 2014). The impact of SH&S on a family ranges from shock and horror to, blame, secrecy and shame. Survivors may also be negatively judged or self-stigmatise (Cerel, Jordan, & Duberstein, 2008). Managing self-harm episodes has a significant financial implication for the NHS (Tsiachristas, et al., 2017). If high-risk individuals are identified and intervened early, it would not only save lives but also potentially reduce financial strains. The aim of the audit is to evaluate the performance of risk assessment and management of self-harm and suicide at the Reedyford Healthcare Group, Nelson, England, and to determine whether the primary care practice is meeting the standards of the National Institute for Health and Care Excellence (NICE) guidelines for adults with depression.

Method

A retrospective audit of 62 patients presenting with depressive symptoms over 3 months was performed at the Reedyford Healthcare Group.

Two criteria from the NICE guidelines for adults with depression were included with associated standards of 100%:

All patients with depression should be assessed for suicidal ideation and intent by asking direct questions.

A patient presenting with significant risk to self/others should be referred to specialist mental health services the same day, as soon as possible.

Result

42 patients were asked direct questions about SH&S. 2 patients presenting with immediate risk were urgently referred to specialist services. Nonetheless, all those patients at increased risk of suicide were given an increased level of support by the practice. The results indicated that the practice could improve, and a quality improvement approach has been planned.

Conclusion

The assessment of risk in patients presenting with depression is vital. This audit shows that it is not always done in practice. The author has not found other published audits on this topic and suggests that this may be appropriate for a national audit. This is particularly prudent with the current concern regarding mental health in the COVID-19 pandemic.
An audit to assess whether patients under the care of a community mental health team who are taking clozapine are having their lipid profile checked annually and are given lifestyle advice and have had a QRISK3 assessment
Authors: Linley-Adams Elisabeth , Harris Bethan
Published: June 2021

Aims

‘All cause’ mortality is higher among patients with serious mental illness than the general population and a significant contributor from this is cardiovascular disease. Mean triglyceride levels have been shown to double and cholesterol levels to increase by at least 10% after 5 years’ treatment with clozapine. NICE guidelines state all patients should have their lipids measured at baseline, 3 months after starting treatment with a new antipsychotic, and then annually.

The first aim of our audit was to identify whether patients who had been on clozapine for at least 3 months from our community mental health team (CMHT) who were not taking cholesterol lowering medication are having their lipid profile checked annually. The second aim was to see whether these patients have high total cholesterol levels and whether they had had a documented discussion about exercise, diet or lifestyle and a QRISK3 assessment.

Method

We constructed a list of 56 patients who were taking clozapine from the CMHT. We excluded 17 patients who were on cholesterol lowering medication and would have excluded any patients who had been on clozapine for less than 3 months. We then looked at whether the patients had had a lipid profile and identified patients with a cholesterol level >5.0 to indicate a ‘high cholesterol level.’ We then searched through the last year of each of the patient's case notes to see whether they had had a QRISK assessment or lifestyle advice by searching for the words ‘diet, exercise, lifestyle and QRISK’.

Result

36 of the 39 (92%) patients had lipid levels checked in the last 12 months. 21 of the 39 (54%) patients had a cholesterol over 5.0. 9 of the 39 (23%) patients had a documented discussion regarding lifestyle, diet or exercise in the last year. 0 of the 39 (0%) patients had a documented QRISK3 assessment.

Conclusion

Most (92%) patients from the CMHT had their lipid profile checked in the last year. 54% had total cholesterol level over 5.0. Only a small proportion (23%) had documented lifestyle discussion and none of the patients had a QRISK3 assessment. The results will be presented to the CMHT and we will organise teaching on giving lifestyle advice and QRISK3 assessments.