bluuebunny/crossref_metadata_2025 huggingface dataset:
Physical Health Monitoring of Community Patients Under the Care of Adult Eating Disorder Service at Surrey and Borders Partnership NHS Foundation Trust
Authors: Fulmali Amit , Pathan Tayeem
Published: July 2023

Aims

1.

To determine if the physical health monitoring of patients in the Eating disorder service is done in line with the recommendations of the National Institute of Clinical Excellence (NICE) guidelines and relevant MEED Guidance on Recognition and Management.

2.

To determine if the current local AEDS (Adult eating disorder services) guideline for physical health monitoring of Community patients, including blood tests and ECG is adequate for community patient cohort.

Methods

1.

For every attendance of patients to the Outpatient Physical health monitoring Clinic (PHMC), it is expected that the physical health monitoring to be offered would include:

•

Weight

•

Height (if first attendance)

•

BMI

•

HR (Pulse rate)

•

Sitting/Standing BP and

•

Temperature

2.

Relevant Blood tests and recent ECGs on a schedule based on patient's BMI or as needed based on clinical indication.

24 patients were identified from April 2021 to December 2022. 7 patients were deemed inappropriate due to scant documentation. Of the remaining 17, 9 patients were randomly selected. 9 patients’ documentation were looked at all contacts with AEDS. The monitoring was audited at 3 single point of contact over the course of their first clinic appointment after April 2021, the middle and latest/last monitoring.

Results

1.

At the first clinic after April 2021 the compliance was 100% for all parameters except for the monitoring of BMI and Temperature which was 88.9%.

2.

At the mid-point there was 100% compliance with BMI, weight, blood pressure and pulse monitoring, there was a drop in temperature monitoring to 77.8%.

3.

In the last clinic monitoring for pulse and temperature dropped to 88.9% and 77.8% respectively, all other parameters showed 100% compliance.

4.

The frequency of monitoring ECG and blood tests in the subsequent clinics gradually dropped from 100% to 66.7% and 88.9%.

Conclusion

Reasons for decreased monitoring in Bloods and ECG.

1.

Documentation was missing.

2.

Investigations were delayed from the patient's side.

3.

Due to COVID-19 there was difficulty accessing the primary care appointments for investigations.

4.

The temperature equipment was not working properly.

Recommendations

1.

Keeping a fixed format for documenting PHMC. New format for documentation introduced.

2.

Document all the parameters checked in the patients’ electronic records on the same day.

3.

PHMC clinical team to upskill on ECG via training.

4.

Introduce weekly ECG alongside phlebotomy clinics.

5.

SUSS test to be done for all RED (High risk) patients and should be clearly documented in the notes.
To Profile Patients Who Need Long Term Care Placement Following Admission to Acute Old Age Psychiatry Wards
Authors: Goveas Richard , Yao Fengyuan
Published: July 2023

Aims

The Institute of Mental Health is the only tertiary Psychiatric Hospital in Singapore. It has two 29 bedded inpatient wards which provides acute care for the elderly with severe mental health problem. Over the past year there has been a trend of an increasing number of elderly patients who stay for a prolonged period of time as they require long term care placement and this increased length of stay leads to increasing healthcare costs, a reduction in availability of acute beds which in turn leads to elderly patients needing to be lodged in general adult wards. In 2022 the average length of stay for the elderly wards was 46 days as compared to the target of 21 days set by the hospital. Prolonged inpatient stays can lead to physical decompensation including reduced muscle strength, pulmonary capacity and osteoporosis.

Methods

We conducted a retrospective audit on 30 patients who were admitted between July and December 2022, requiring long term care placements. Our hypotheses were that patients with a diagnosis of dementia, who were frail and with caregiver burnout were more likely to require long term care placement. We subsequently designed a data collection form to collect the latter data and analysed them.

Results

Out of the 30 patients, 27 (90%) had a diagnosis of dementia, 25 (83.3%) were classified as frail (6 or more on the clinical frailty scale) and 23 (76.6%) had caregiver burnout, 12 (40%) family unable to look after patients in spite of community support and 3 (10%) had no next of kin.

Conclusion

Patients with dementia and frailty are more likely to require long term care placements. In the inpatient unit, we find that caregivers of these patients are burnt out because of their behaviour problems. We are embarking on an enriched model of care to reduce severe behavioural and psychological symptoms of dementia thereby reducing the need for restraints and its associated complications, and empowering caregivers to manage their behaviour problems.

This audit also stressed the importance of addressing issues upstream. Referrals to community facilities like day care which provide exercise and rehabilitation for the elderly will help delay the consequences arising from frailty. We are also partnering primary care to assist with early identification of dementia and providing early interventions to prevent caregiver burnout.
A Re-Audit of the Assessment and Management of Patients With Alcohol Use Disorders Following Admission to the General Adult Inpatient Wards in Mersey Care NHS Foundation Trust
Authors: Hyland Declan , Baruah Ranjan , Hussain Mohammed , Buchan Hollie
Published: July 2023

Aims

This re-audit aimed to determine the level of performance in the assessment and management of patients with alcohol use disorders following admission to one of the general adult inpatient wards in Mersey Care NHS Foundation Trust and to determine whether the level of performance has improved compared to the original audit done in 2021 and whether recommendations that were implemented following the original audit have been effective.

Methods

A list of all inpatients on each of the eight general adult inpatient wards in the Trust was obtained. The electronic patient record (on RiO) and electronic prescription card (on EPMA) for each inpatient was scrutinised to obtain the required data. All data were collected retrospectively.

Results

A total of 149 inpatients were identified on the eight general adult inpatient wards. Using specific inclusion and exclusion criteria, 56 of the 149 inpatients formed the final sample. Of the 56 inpatients, 58% were male, 42% were female. An alcohol history was documented in 81% of the 56 inpatients, representing an improvement on the 45% in the original audit in 2021. An average weekly quantity of alcohol for the inpatient was documented in only 8% of cases, a drop from 22% in the original audit in 2021. There was minor improvement in documentation of a CIWA-R score for the inpatient on admission to the ward - an increase from 0.7% in 2021 to 4.0% in 2022. There were improvements on gamma GT and serum Magnesium level being checked on admission for the 2022 audit cohort compared with the 2021 audit cohort. There was also an improvement on referral of the inpatient to community alcohol services - 3% in the 2021 audit vs 7% in the 2022 audit.

Conclusion

The findings from this re-audit indicate an improved level of performance in assessment and management of patients with alcohol use disorders following admission to the general adult inpatient ward since the original audit in 2021. Recommendations from this re-audit are: ensuring that taking and documenting a thorough alcohol history is included in the induction for junior trainees, the provision of education and training to both medical and nursing staff on the wards in using the CIWA-R to assess level of alcohol withdrawal and producing a flow chart on the assessment and management of alcohol use in patients following admission to the ward that can be displayed in the Treatment Room on each ward and in the Junior Doctors’ office.
An Audit on Glycosylated Haemoglobin & Fasting Plasma Glucose Blood Tests Done on Admission to an Older People's Inpatient Ward
Authors: Kyriacou Loui , Navanathan Julian , Anthony Yanik , Abbas Abdul-Rahman , Bansal Saakshi , Albert Michael
Published: July 2023

Aims

The aim of this study was to determine the proportion of patients who had fasting plasma glucose and glycosylated haemoglobin (HbA1c) blood tests done on admission to an older people's inpatient ward at Kingfisher Court, Hertfordshire. Patients undergo a physical health assessment when they are admitted to the ward. This consists of a physical examination, an electrocardiogram and a panel of blood tests, which include a fasting plasma glucose and HbA1c. Given that people with severe mental illness have a greater burden of physical health conditions, such as diabetes, this physical health assessment can aid in optimising patients’ physical health and reducing this health inequality.

Methods

A sample of 40 patients who were most recently discharged from the older people's inpatient ward were included in the audit. Four authors each independently reviewed 10 patient case notes and blood results. An audit collection tool was produced and data logged for each patient. The data collected were reviewed by all authors.

Results

57.5% (23) of the study population had admission blood tests that included a HBA1c level or plasma glucose. An individual with diet-controlled type 2 diabetes mellitus had a HBA1c of 55 mmol/mol and was subsequently started on metformin. Only 15% (6) of the study population had a plasma glucose test on admission. Their case notes did not specify whether these were fasted or random plasma glucose tests. 42.5% (17) of the study population did not have either a plasma glucose test or HBA1c test done.

Conclusion

There was poor overall compliance with the trust protocol for blood tests on admission to the older people's inpatient ward. Plasma glucose tests were rarely done and it was not specified whether they were fasted or random tests, thus limiting their utility. The team therefore suggest that the fasting plasma glucose test be removed from the panel of admission blood tests. The focus should be on obtaining a HbA1c test. Amendments to the clerking proforma and doctors’ induction presentation should be made to emphasise the importance of the HbA1c test.
The Management of Short-Term Insomnia for Inpatients in an Adult Acute Admissions Ward: Audit of Compliance With Local and National Guidelines
Authors: Long Marie , Widdowson Rose
Published: July 2023

Aims

This study sought to establish local adherence to the following recommendations for the management of short-term insomnia (under 3 months duration): 1. Sleep hygiene advice should be utilised prior to pharmacological management. 2. A non-benzodiazepine hypnotic medication should be prescribed. 3. A one-off trial dose of benzodiazepine or Z-drug should be prescribed prior to regular prescription.100% of patients reviewed by medical staff for insomnia are expected to meet the set standards.

Methods

Retrospective analysis of a cohort of patients (n=21), in an Adult Acute Admissions Ward in the West of Scotland. Taken over seven days in January 2023. Electronic prescriptions and chronological notes were reviewed in order to identify patients reviewed by medical staff for short-term insomnia.

Results

Of the patients reviewed for insomnia (n=8):

•

12.5% were offered sleep hygiene advice (n=1).

•

25% were prescribed a trial dose of non-benzodiazepine hypnotic medication (n=2).

•

25% % were prescribed regular non-benzodiazepine hypnotic medication with no trial dose (n=3).

•

50% were prescribed alternative sedative medication for insomnia (n=4).

Conclusion

Commonly, patients were not provided with sleep hygiene advice. The patients who were prescribed non-benzodiazepine hypnotic medication were often not prescribed a trial dose. Half of the patients were prescribed an alternative to a non-benzodiazepine hypnotic medication.

•

Interventions will include:

Creation of a sleep hygiene information leaflet to provide to inpatients, medical and nursing staff.

•

Presentation of data to medical and nursing staff.

•

Ensuring guidelines are available to all medical and nursing staff in the ward environment.

•

The audit will be repeated in six months after the interventions.
Medication Initiation in Children Newly Diagnosed With ADHD, Measured Against NICE Guideline NG87
Authors: McWilliams Emma , Markopoulou Eleni
Published: July 2023

Aims

ADHD is a common neurodevelopmental disorder, which is usually diagnosed in childhood. The aim of this audit is to assess practitioners' compliance with NICE guideline NG87 in relation to the initial assessment and medication choice in children with ADHD (age 5 and over), prior to the commencement of ADHD medication.

Methods

The sample was children aged 5 years and over who have been diagnosed with ADHD and referred for medication initiation, in a Manchester CAMHS community team between May and October 2022. The audit tool used to collect the data included each of the standards and measured each individual patient's compliance. Information was collected from electronic patient records and paper notes.

Results

Sample size was 32 patients.

Standard One stated that 100% of patients, before starting medication, should have a full assessment, including: a review to confirm they meet the criteria for ADHD and need treatment, mental health and social circumstances including coexisting psychiatric/neurodevelopmental conditions, educational/employment circumstances, risk assessment for substance misuse and care needs. Overall compliance was 9%.

Standard 2 stated that all patients should have a physical health review including medical history, medication, height, weight and physical observations and, a cardiovascular assessment. Overall compliance was 0%.

Standard 3 stated that 100% of patients who met specified criteria should be referred for a cardiology assessment prior to starting medication. Overall compliance was 28%.

Standard 4 stated that 100% of patients who met criteria for referral to cardiology or had a co-existing condition treated with a medicine that may pose cardiac risk should have an ECG completed. Overall compliance was 75%

Standard 5 stated that 100% of patients who have a blood pressure consistently above the 95th centile for age and height should be referred to paediatric hypertension specialist. Overall compliance was 9%.

Standard 6 stated that 100% of patients should be offered methylphenidate as first line treatment for ADHD or an alternative if they cannot tolerate stimulants. Overall compliance was 100%

Conclusion

Three major areas of improvement were identified. Cardiovascular risk assessments are not fully compliant due to lack of cardiac examination which could affect rates of cardiology referral as referral criteria include a murmur on examination.

Although 100% of patient had their height, weight and physical observations recorded, a significant proportion did not have these plotted on centile charts as recommended.

A minority of patients had a full biopsychosocial assessment, with a major deficit in risk assessment for substance misuse.
Seclusion Reviews: Audit of Medical Documentation in a Psychiatric Intensive Care Unit
Authors: Middleton Laura
Published: July 2023

Aims

Seclusion is a restrictive intervention used when a patient presents with risks that cannot be safely managed in their current environment. The Mental Health Act 1983 Code of Practice (MHA CoP) provides clear recommendations for both frequency and content of medical seclusion reviews, with compliance previously audited within Cheshire and Wirral Partnership NHS Foundation Trust (CWP). Following the initial findings however, change was not implemented. A new audit has therefore been commenced to reassess baseline practice and identify areas requiring improvement.

Methods

The MHA CoP audit tool outlines the following timeframes for assessment: initial medical review within 1 hour, 4-hourly medical reviews until first internal multidisciplinary review, twice daily medical seclusion reviews with at least 1 by the Responsible Clinician. Documentation should evaluate: physical and mental health, medication adverse effects, observation level, prescribed medication, risk to others and self, need for ongoing seclusion. Data were collected retrospectively for all episodes of seclusion occurring in a CWP Psychiatric Intensive Care Unit during August 2022.

Results

5 seclusion episodes related to 4 patients, ranging from 1 night to 15 days in duration. Regarding medical review frequency, 20% were seen face-to-face within 1 hour of seclusion commencing and 75% were seen 4-hourly until their internal multidisciplinary review. Mental health was more consistently commented on than physical health (97% vs 61% respectively), whilst medication was reviewed in 69% of assessments. Rationale for continuing seclusion was provided in 72%, referring to risk to others in 54%. Adverse medication effects and observation level were the least documented parameters (2%), followed by risk to self (7%).

Conclusion

Assessment time was often not explicitly stated and was substituted with time of documentation, meaning reviews may have occurred earlier than accounted for. The on-call doctor does cover multiple sites overnight, potentially contributing to delays in attending unforeseen time-sensitive tasks. Trust policy dictates constant visual observation must be maintained throughout seclusion and this is therefore not routinely subject to review or adjustment. Overall interpretation of the qualitative information was fairly subjective in a low number of seclusion episodes, however there was a notable lack of recording adverse medication effects and risk to self. Findings will be presented at junior doctor induction whilst a quick reference sheet is designed prior to reaudit. CWP's seclusion policy specifies medical review frequency, but does not outline expected content of documentation. There is scope to extend local policy and align with the MHA CoP.
An Audit Exploring Ethnic Inequalities in Accessing Perinatal Mental Health Services in Southwark
Authors: Morgan Wendy , Butler Joanne
Published: July 2023

Aims

Women from Black and minority ethnic backgrounds have been shown to experience an increased burden of common postnatal mental health conditions and higher rates of involuntary admissions. However, evidence demonstrates disparities in these women accessing perinatal mental health support. Reasons behind barriers to access must be defined and addressed. Our aim was to explore ethnic inequalities in accessing Perinatal Mental Health Services in Southwark (SWK PMHS). We hypothesised that SWK PMHS would meet Royal college of Psychiatrists (RCPsych) gold standards in providing equitable access to care.

Methods

The Trust's local clinical database was used to extract our cohort of women aged 15–44 years with a birth episode in contact with SWK PMHS between September and December 2021. Individual data were collected via local clinical notes system to establish basic measures (demographics and ethnicity) and detailed information (referral outcome, interventions, safeguarding etc). Ethnicity data were compared to King's College Hospital birth records for 2021 and local census data via Office of National Statistics.

Results

105 patients were analysed in total. Overall, there was poor recording of ethnicity and 6.6% of referrals had no ethnicity documented at all. At the point of referral, there was no clear inequity based on ethnicity, with data appearing reflective of local census and maternity records. However, there were concerning inequities in treatment received by women in minority ethnic groups. Out of four hospital admissions in total, three (75%) of the women were from a Black ethnic group and all were detained. There were fewer referrals for psychology intervention for women in minority ethnic groups compared to women in the White ethnic group, with particularly low numbers of referrals for women in Asian and Mixed ethnic groups (2/35 women). 83% of all antipsychotics prescribed (5 out of 6) were to women from the Black ethnic group with the remainder being women in the White ethnic group. There were 31 safeguarding alerts, with almost half (48%) from women in the Black ethnic group.

Conclusion

There were concerning variations in interventions and type of care received by women from minority ethnic groups. Women from Black and minority ethnic groups were underrepresented in accessing psychology intervention though conversely overrepresented for antipsychotic treatment, safeguarding alerts and involuntary admissions.

This suggests that contrary to our hypothesis, SWK PMHS is not meeting RCPsych Gold Standards. Our audit findings reflect literature that there are apparent barriers to women from ethnic minority groups accessing certain specialist mental health services.
Review of Activity Within Unscheduled Care at Royal Cornhill Post-Pandemic
Authors: Mweemba Mutswairo , Lim Ying Tian
Published: July 2023

Aims

We sought to review the changes in assessments within the Unscheduled Care Team (UCT) at Royal Cornhill in Aberdeen since the pandemic. Previous UCT data highlighted an increase in monthly assessments from October 2018 to October 2020 by 18% 240(204). We hoped to identify areas for intervention and reform within the UCT and the wider service.

Methods

An excel spreadsheet was distributed to clinicians on-call from 1st–31st October 2021 and 1st-31st October 2022. Data analysed included time of referral, the role of the clinician, source of referral (Enhanced Access, Acute medical admissions/A&E, Other Hospital Wards, Community Mental Health Teams (CMHT), Police, GP, GMEDS (out-of-hours GPs), and Other Sources), method of assessment, time taken to complete assessments, time taken to discuss assessments and assessment outcomes. The spreadsheet also had space for clinicians to provide additional qualitative data. Following the 2021 data collection, a PowerPoint presentation was given to members of staff with the initial findings from 2021. The UCT added additional practitioners to the twilight period 1700-2100 due to the noted increased demand during this period. They also spoke to CMHTs about Enhanced Access and to the Police directly, as they were the two most frequent referrers. Following the 2022 data collection, the 2021 and 2022 datasets were compared.

Results

The overall number of assessments increased by 10% from 2021 to 2022 - 405(367). Additionally, total assessment time increased by 15% - 299(261) hours. In terms of assessment outcomes, the largest changes were seen in outpatient follow-up with CMHTs, with a 65% increase 238(144); UCT discharge, with a 43% decrease 64(112) and non-specified outcomes, with a 52% decrease 14(24). The largest changes in referral rates were from GMEDs 48(30) 60% increase, CMHTs 4(16) 75% decrease, GP 50(34) 47% increase. Enhanced access 96(95) and police referrals 78(77) remained the most stable, increasing by 1%.

Conclusion

There has been an evident increase in workload for the UCT since the pandemic, which could be managed with additional staffing for the team. The targeted interventions, both for Enhanced access and Police, have limited the increase of their referral rate. Similar targeted interventions and review of referral criteria may mitigate increased demand from other sources. Increasing outpatient CMHT follow-up after assessment may suggest that routine outpatient work may not be back to pre-pandemic levels; further study would be required to confirm this.
Inpatient Ward Review Documentation Audit
Authors: Nurlu Derya , Raoof Abdul
Published: July 2023

Aims

Good medical records are essential to the continuity of patient care. The aims of this audit were to evaluate the quality of ward review documentation in 7 Psychiatry wards in Essex Partnership University NHS Foundation Trust, to identify areas of improvement, to recommend strategies to improve record keeping, and to measure their effectiveness by comparing records in the 1st and 2nd cycles of audit.

Methods

A sample of 10 patients from each of the 7 wards was selected, for a total of 70 patients, in each of the 1st and 2nd cycles of the audit (Data were collected in the 1st cycle between 06-07-2021 and 22-07-2021, and 2nd cycle between 16-10-2022 and 07-11-2022). Samples were selected randomly among patients who were inpatient or discharged recently. The data were collected from the first, middle, and last ward reviews. If the patient was inpatient at the time of the data collection, data were collected from their first review, the last/most recent ward review, and one of the reviews in between. Patients who did not meet this criterion were excluded. Based on 1st cycle results, strategies were recommended to improve record keeping. After 15 months, 2nd cycle results were used to evaluate their effectiveness.

Results

The results demonstrate significant areas of improvements in record keeping: a majority of questions did not meet the standard of 80% completion considered “satisfactory” in previous audits. In the 2nd cycle, 9 questions had a “satisfactory” completion rates. These were mandatory or automated questions and ones essential to immediate patient care. 7 questions had “average” completion rates above 45%. All (17) other questions and subquestions had “low” completion rates. Analysis of variations between cycles shows that question on “Responsible clinician” increased from 23.3% to 99.5% because it was automated. 4 other questions or sub-questions have seen a substantial increase in completion rate between the 1st and 2nd cycle. But our strategies’ effectiveness during the period of the audit has proven limited and difficult to trace.

Conclusion

It can be concluded that more efforts should be dedicated to improving medical record in the psychiatry wards of Essex Partnership University NHS Foundation Trust. The most effective strategy to secure high ward review docummentation rates remains to make questions mandatory or auto-complete when possible. More research is necessary to demonstrate the effectiveness of other strategies such as the education of junior doctors in induction and awareness posters in wards.
Clinical Audit Reviewing Compliance With Respective Trust-Based Physical Health Monitoring Guidelines, Amongst Inpatients Prescribed Anti-Psychotic Medication in Two Distinct Secure Care Facilities: A Low Secure Unit and a Prison Personality Disorder Unit
Authors: Selvaraj Ashvini , Adebowale Falade
Published: July 2023

Aims

1.

To review the current level of compliance with CPFT (Cambridge & Peterborough Foundation Trust) guidelines by inpatients prescribed anti-psychotics at George Mackenzie House (GMH) low-secure unit and likewise, with NHFT (Northamptonshire Foundation Trust) guidelines by inmates prescribed anti-psychotics at HMP Whitemoor's Fens Unit.

2.

To identify any differences or similarities in compliance rates between both sites.

3.

To identify any possible areas of difficulty in ensuring full compliance with said guidelines and suggest possible solutions.

Methods

A retrospective design was used, in which the electronic and hardcopy patient records of service users at both sites, covering a specified time-frame (2nd Dec 2021- 2nd Dec 2022) were screened. Data collected from eligible users included demographic information, names of anti-psychotics used and results of each individual's screening profile measured against the respective Trust's guidelines.

Results

The demographic profiles of eligible service users at both sites were largely similar.

17 out of 18 services users from GMH and 23 out of 50 service users from the Fens Unit were found eligible for the audit.

The majority of eligible service users at both sites (88-100%) were compliant with measurement of relevant laboratory markers, as per Trust guidelines.

However, at both sites, there were notable omissions in monitoring of certain physical parameters, especially waist circumference (100% omission in both sites) and ECG monitoring ( 60% omission in prison,14% in GMH), which is important given the significant comorbidity of cardiovascular risk factors amongst service users at both sites.

Conclusion

We noted disproportionate compliance in the monitoring of different physical health parameters. While laboratory tests were on the whole, satisfactorily monitored, there were gaps in other clinical measurements like waist circumference and ECG recordings. We postulate several reasons for this discrepancy, including:

•

A possible lack of awareness about the importance of measuring parameters like waist circumference, which also indicates a lack of familiarity with Trust guidelines.

•

A lack of time/inconvenience in ensuring adequate recording of clinical parameters

•

Inadequate reminders to conduct relevant physical health checks.

We suggest possible solutions to ensure 100% compliance: for example, creating a teaching session for staff and service users on pertinent topics, like metabolic syndrome or creating electronic aids to remind staff when physical measurements are due.

This audit also engendered further questions on appropriateness of anti-psychotic prescription and importance of educating service users about physical complications of anti-psychotic use. These could be the focus of future audits.
Physical Health Monitoring in Patients Established on Clozapine
Authors: Yousefpour Camelia , Alex Rajesh
Published: July 2023

Aims

We set out to compare the physical health monitoring of patients established on Clozapine within our local mental health team (LMHT) to national and trust guidance. We also compared data collected in this audit with results from a similar audit conducted in 2018 to identify if improvements had been made to services. We then sought to present the findings to our LMHT to shape the formation of a newly set up pharmacy technician led Clozapine clinic.

Methods

National Institute for Health and Clinical Excellence (NICE) and Nottinghamshire Healthcare Trust (NHT) guidelines were reviewed to set criteria for the audit. Where NICE and NHT guidance stipulated similar recommendations, NICE guidance was used to set criteria. Criteria was found to be met if it had been collected within the last 12 months. Data were collected by a single clinician over the period of one month on review of electronic medical records.

Results

30 patients were identified as established on Clozapine within our LMHT. 27 (90%) patients had a licensed diagnosis for Clozapine prescription. Smoking status was recorded in 26 (83.3%) patients and caffeine intake in 21 (70%) patients. Full blood count, liver function tests, urea and electrolytes all met the criteria at the 100% target however one patient was found to have Hba1c and lipid measurement outstanding. Weight was documented for 29 patients (96.7%) however waist circumference was documented in five (16.6%). This was the lowest scoring criteria. Pulse and blood pressure was recorded in 27 (90%) patients. Electrocardiograms were less consistently recorded as completed, with 22 (73.3%) recorded. Physical health monitoring was recorded for 27 (90%) patients, whilst 10 (33.3%) had a GASS-clozapine form completed. Percentages for all criteria that were measured in 2018 were found to be higher in the 2022 cycle.

Conclusion

Findings show that physical health monitoring for the patients prescribed Clozapine in our LMHT does not consistently meet guidance. Development of a ‘Clozapine clinic’ was already planned. Results from this audit were shared within the LMHT and recommendations were made as follows; i) a measuring tape to be placed in each room ii) data such as weight, blood pressure and heart rate to be entered in a way that it can be plotted over time iii)pharmacy technician to work with a healthcare assistant to ensure all criteria can be met in the designated yearly Clozapine clinic
The Effects of Rivastigmine on Neuropsychiatric Symptoms in the Early Stages of Parkinson's Disease: A Systematic Review
Authors: Reilly Siobhan , Dhaliwal Simran , Arshad Usman , Husain Nusrat , Macerollo Antonella , Da Costa Antonio
Published: July 2023

Aims

Neuropsychiatric symptoms including depression, apathy and psychosis are experienced by the majority of patients with Parkinson's disease. A subgroup of patients develop cognitive impairment, which may increase the risk of falls due to reduced attention. Acetylcholine deficit is thought to contribute to neuropsychiatric symptoms in Parkinson's disease. The acetylcholinesterase inhibitor rivastigmine is beneficial in Parkinson's disease dementia (PDD), but the consensus for the use of rivastigmine earlier in the disease course is unclear. This systematic review aims to assess the evidence for rivastigmine in the treatment of neuropsychiatric symptoms in Parkinson's disease without dementia.

Methods

EMBASE, MEDLINE, PsychINFO, Cochrane CENTRAL, NGLC, NICE Evidence and medRxiv.org were searched for studies with terms relating to Population (Parkinson's disease) and intervention (rivastigmine).

1922 references were identified, of which 358 were duplications.

Inclusion criteria were: diagnosis of Parkinson's disease, rivastigmine intervention and the presence of neuropsychiatric symptoms or falls. Articles were excluded if they only related to patients with dementia.

Following title and abstract review, 1331 articles were excluded.

After full text review, 9 articles remained, which underwent a risk of bias analysis.

Results

Outcomes were heterogenous, so were not suitable for meta-analysis. Therefore, the results are presented in narrative form. The articles included 6 Randomised Controlled Trials (RCTs), 2 open-label trials and 1 case-series.

Three of the studies focused on psychosis. Two of these studies indicated a benefit of rivastigmine on psychotic symptoms in Parkinson's disease. However, these studies were an open label trial and a case series, and the results were not reproduced during RCT.

One RCT indicated benefit of rivastigmine in rapid eye movement behaviour disorder (RBD).

One RCT showed improvements in apathy after treatment with rivastigmine.

Two RCTs demonstrated a reduction in falls with rivastigmine treatment compared to placebo.

One RCT showed a significant improvement on a performance-based measure of cognitive ability.

One study identified brain areas that were hypoactive in hallucinating Parkinson's patients, and the reduced activity could be restored with rivastigmine. This restoration of activity was associated with improved attention compared to baseline.

Conclusion

There is evidence that rivastigmine is beneficial for RBD and apathy in Parkinson's disease, independently from the presence of dementia. There is high level evidence that rivastigmine reduces falls, which may be due to improved attention. The impact of rivastigmine on psychotic symptoms is less clear, but is supported by current theoretical models which involve acetylcholine dysfunction in the generation of visual hallucinations in Parkinson's disease.
Multimorbidity and Polypharmacy in Psychosis: Identifying Potentially Significant Drug Interactions in an Old Age Inpatient Psychiatry Setting
Authors: Tewari Abhinav , Pathak Ashish
Published: July 2023

Aims

To determine potentially significant drug interactions in an old age setting among inpatients with psychosis and medical comorbidities over the past 12 months

Methods

Study setting: old age inpatient functional ward

Sample size: 11

Inclusion criteria:

•

Inpatients on psychotropic medications with diagnosis ranging from F20 to F29 (ICD-10)

•

Comorbid chronic medical condition(s) requiring long term drug treatment

Exclusion criteria:

•

Patients with other/co-existing mental health diagnosis excluded

•

Antibiotics , OTC medications, herbal treatments, emergency treatments and other medications requiring short-term administration excluded from analysis

Study tools:

•

Lexicomp® interaction checker

◦

Category X: Avoid combination

◦

Category D: Consider therapy modification

◦

Further categories (In order of decreasing risk ratings: C, B, A) excluded from the analysis

Results

Out of the total 67 inpatients admitted between January 2022 and December 2022, 17 patients had diagnosis ranging between F20 and F29. 4 patients were excluded due to no medical comorbidities and 2 were excluded due to lack of data. Among the 11 patients included in the analysis, the most common medical comorbidities were, in decreasing order, hypertension, hypercholesterolemia and chronic pain. A total of 114 interactions were noted between psychotropic medications and other physical health medications, as follows:

No significant interactions: (category A, B, C): 103

Category D (consider therapy modification): 10

•

7 of these interactions were associated with administering Buprenorphine with other medications (Flupentixol, Gabapentin, Nortriptyline, Olanzapine, Amisulpride, Aripiprazole and Pregabalin) leading to additive CNS depressant effects.

•

Interaction of codeine with Valproate and Flupentixol carried risk of CNS depression.

•

Carbamazepine interacted with Risperidone via CYP enzyme induction.

Category X (avoid combination): 1

•

The interaction between Flupentixol and Glycopyrronium was associated with risk of severe anticholinergic effects

Conclusion

This study is a preliminary investigation towards understanding the drug interactions in a population with long term mental health and physical health ailments. Awareness regarding the potential interactions can help avoid combinations with possible detrimental effects. The limitations of this study, in terms of sample size and quality of available data, can be overcome by conducting a planned study on a larger population.

Financial Sponsorship: none

Conflict of interests: none
An Exploratory Evaluation of Barriers to Study Leave Application Amongst Psychiatric Trainees in the West Midlands
Authors: Cunningham Rebecca , Burlingham Amy , Kelani Bukola
Published: July 2023

Aims

Between 2018–2021 there was a downward trend in study leave applications and the total spending on trainee study leave activities. There was concern that trainees may not be maximising educational opportunities. The authors were aware of anecdotal evidence indicating barriers to applying for study leave and therefore sought to objectively explore this. We aimed to evaluate qualitative and quantitative responses amongst psychiatric trainees within the West Midlands deanery regarding study leave applications. We also endeavoured to identify positive aspects and barriers, to improve knowledge and confidence in the process and identify areas for improvement in making the system more accessible.

Methods

The authors met with Health Education West Midlands to clarify current processes and gather objective data regarding study leave applications between 2018 and 2021. A survey was distributed to all Psychiatric trainees in the West Midlands in December 2021. The survey was open for three weeks and contained closed and open questions. Data were analysed and a thematic analysis was completed independently by the authors to allow for triangulation.

Results

There were 62 responses (response rate of 27%) from trainees ranging from CT1-ST7+. 55% were unclear about the study leave application process, and of these, 79% said this had prevented them from applying. Only 37% of trainees found the process ‘very’ or ‘moderately easy’, with 23% finding it ‘very difficult’. When exploring barriers, worryingly 69% of trainees did not know where to find the list of approved courses. Other themes included too many signatures being required, long delays in forms being returned and money being reimbursed.

Conclusion

The majority of respondents were unclear about the study leave process or found it difficult. This acts as a barrier to application in the majority of cases and may have a knock-on effect on the overall quality of training. By identifying these barriers, we are now able to address these more directly.

The results were presented at a deanery wide level leading to a better understanding of the reduction in spending of study leave funding. Phase two of the project will see the introduction of an electronic application system, aiming for an easier and shorter process, in addition to creating consistency across trusts. There may have been some confounding factors, such as COVID-19 that may have contributed to the decline in study budget being utilised.
Edge-Centric Analysis of Time-Varying Functional Connectivity in Schizophrenia Using the COBRE Dataset
Authors: Gee Abigail , Morgan Sarah
Published: July 2023

Aims

Differences in static and dynamic resting-state functional connectivity have been identified in patients with schizophrenia, individuals at high risk of psychosis and those with psychotic-like experiences. Analysis of dynamic connectivity is important to understand the temporal fluctuations in functional connectivity. Studies of dynamic functional connectivity have been conducted using methods such as the sliding-window technique and co-activation patterns (CAPs). In this study edge-centric analysis has been used to examine differences in time-varying connectivity in patients with schizophrenia compared to healthy controls. This method overcomes some of the limitations of other methods as it has higher temporal resolution and unwraps the data without applying additional modelling or requiring user-defined specification of parameters.

Methods

We analysed resting-state fMRI data from 67 patients with schizophrenia and 81 healthy controls using the Center for Biomedical Research Excellence (COBRE) dataset. The edge-time series for these subjects was calculated by omitting the averaging step when calculating the correlation between time series at each node. This effectively unwrapped the functional connectivity correlations and produced a measure of cofluctuation at each timeframe. The edge time series can be aggregated into a single measure of dynamic whole brain co-fluctuation by calculating the root sum square (RSS). We analysed the frequency and amplitude of the high amplitude peaks of cofluctuation and the patterns of activity seen during peaks and troughs.

Results

The results showed that mean peak amplitude was lower in patients with schizophrenia compared to controls (t-stat= -3.13, p = 0.0021). Patients with schizophrenia also had significantly less frequent peaks (t-stat= -2.80, p = 0.0058).The pattern of activation at peaks in controls was more homogenous between control subjects compared to patients with schizophrenia. We identified networks that were significantly less activated in patients than in controls during peaks, troughs and transitionary time points.

Conclusion

This study suggests that in patients with schizophrenia the whole brain cofluctuations during resting-state are less frequent and lower in amplitude. This is in keeping with previous studies which have identified that patients with schizophrenia spend significantly less time than healthy controls in states of large-scale connectivity. Further studies looking at larger transdiagnostic samples and antipsychotic naïve patients will be important to build on these results.
Hypercalcaemia and Primary Hyperparathyroidism – an Underappreciated Contributor to Psychiatric Presentations
Authors: Ghoneim Fatma , Shanley Ivan , Ford Jennifer
Published: July 2023

Aims

Hypercalcaemia can lead to many neuropsychiatric symptoms from fatigue, lethargy, anxiety, irritability, and insomnia to impaired concentration and memory, depression, delirium, and psychosis. Primary hyperparathyroidism (PHPT), which is the most common cause of hypercalcaemia, is a relatively common disorder affecting 1 in 500 women and 1 in 2000 men aged over 40 years. A patient, with a diagnosis of Alzheimer's disease, subtype mixed, had hypercalcaemia on admission which wasn't corrected until 4 months of the admission had passed. Calcium correction precipitated a marked improvement in the patient's mental state. In order to learn from this incident, an audit was carried out to look at possible gaps in performing blood tests, and how abnormal calcium levels can affect patients’ mental states.

Methods

Retrospective data collection was performed to obtain blood results for all patients -aged 40 years or above- admitted to inpatient wards in South Essex within a six month period (from April 2022 to September 2022). A total number of 333 patients (173 males and 160 females) were identified.

Results

Bone Profile was checked in 248 patients (127 males and 121 females). Twelve patients were found to have hypercalcaemia on admission - mean age 65.7 years, female: male ratio of 3:1. No patients were found to have hypocalcaemia.

Hypercalcaemia was addressed in only 2 of 12 patients. Parathyroid hormone (PTH) was tested either before or during admission to mental health services in 6 patients, PTH was found to be elevated (greater than 9.3 pmol/L) in 4 patients (2 males and 2 females), below the midpoint of the reference range in one patient, and below the lower limit of the reference range in one patient.

Conclusion

Patients with hypercalcemia had different diagnoses - anxiety, depression, adjustment disorder, mania, psychosis, and dementia. It was the first admission for three patients with a mean age of 76 years. Six patients were known to services but it appeared that the recent admissions were associated with hypercalcaemia. Active management of hypercalcaemia in 2 patients resulted in improvement in their mental state.

We found that risk of PHPT in mental health inpatients aged over 40 years old was increased by 1.45% (95% CI: -0.0620% to 5.6256%, P = 0.0390) in females, and was increased by 1.52% (95% CI: 0.3573% to 5.5031%, P < 0.0001) in males. Hereby, testing for bone profile should be routinely recommended for mental health patients.
Order amidst disorder for two-dimensional nanoribbons with various boundary conditions
Authors: Novotny Mark A. , Inkoom G. , Novotný Tomáš
Published: July 2023

We show quantum systems with disordered Hamiltonians may exhibit order in commonly measured quantities. This counter-intuitive situation is demonstrated using a conventional tight binding model for two-dimensional nanoribbons with various boundary conditions. The analysis uses the traditional non-equilibrium Green's function (NEGF) methodology for electron transport. We study quantum dragon nanodevices that exhibit order amidst disorder. Each disordered Hamiltonian nanodevice shows order in both the bond currents and the local density of states (LDOS) of the propagating electrons.