bluuebunny/crossref_metadata_2025 huggingface dataset:
Increased Violent Incidents During COVID-19 on Male Acute Psychiatric Ward
Authors: Esham Zaim Mohd , Harris Natasha , Lankappa Sudheer , Suarez Lori Edwards
Published: July 2023

Aims

This is an audit evaluating the impact of inpatient COVID-19 restrictions on the frequency of recorded violent incidents on a male acute general psychiatric ward. The aim of this study is to compare the frequency of violent and disruptive behaviours between pre-COVID-19, COVID-19 and post-COVID-19 periods on the ward.

Methods

Inpatient adverse incidents on the ward are logged into an electronic system as ‘IR1’ (Incident Reporting) through Ulysses by healthcare professionals. Data on logged incidents between April 2019 and March 2022 were obtained by contacting the Ulysses technical team. The reported incidents were classed into ‘disruptive behaviour’, ‘violence to patient’ and ‘violence to staff’.

We chose to focus on the IR1s submitted between three twelve monthly time periods: Pre-COVID-19 (April 2019–March 2020), COVID-19 (April 2020–March 2021) and Post-COVID-19 (April 2021–March 2022). We opted for these cut off periods to be in line with the local trust guidelines with respect to COVID-19 restrictions.

Results

Out of 155 incidents which occurred during pre-COVID-19 period, 38 incidents were disruptive behaviours, 24 were violence to patients and 93 were violence to staff. Of the 249 incidents during COVID-19 period, 66 incidents were disruptive behaviours, 46 were violence to patients and 137 were violence to staff. Of the 216 incidents during post COVID-19 period, 67 cases were disruptive behaviours, 53 were violence to patients and 96 were violence to staff.

There was 74% increase in disruptive behaviour between pre-COVID-19 and COVID-19 phase but no increase between COVID-19 and post-COVID-19 phase.

There was a 92% increase in violence to patients between pre-COVID-19 and COVID-19 phase and a 15% increase between COVID-19 and post-COVID-19 phase.

There was a 47% increase in violence to staff between pre-COVID-19 and COVID-19 phase, but a 30% reduction between COVID-19 and post COVID-19 phase.

Violence to staff makes up the highest proportion of violent incidents recorded, followed by disruptive behaviours and violence to patients. This trend was seen in all three time periods.

Conclusion

Our study showed that violent incidents in a male acute psychiatric ward increased during COVID-19 period when compared to pre-COVID-19 period. This could be explained by increased ward restrictions and difficulties in communication related to PPE use. Further studies would need to be conducted looking at trend in other services within the Trust. Our findings will be of importance in monitoring risks in similar circumstances in the future.
Documentation of Capacity Assessments for Psychiatric Inpatients
Authors: Ngwenya Keith
Published: July 2023

Aims

How frequently and to what quality are mental capacity assessments being recorded on inpatient acute ward? Capacity is the ability to consent to a particular decision and is defined in law by the Mental Capacity Act (MCA). Capacity to make decisions is an area of particular importance in mental health care, as many mental illnesses can lead to people losing the capacity to make some decisions. Capacity assessment is a two-stage process. If a patient passes Stage 1, then they have capacity. If they fail Stage 1 then the assessment progresses to Stage 2. The person being assessed must then be competent at every step of Stage 2 to then be deemed to have capacity. Documentation of capacity assessments should demonstrate this two-stage assessment.

Methods

The sample included all people who were inpatients during the data collection window of 05 to 09 Sep 2022.

For each person, their MHA status was recorded as this determined whether capacity to consent to admission was relevant. For each patient, their EPR was checked for any Mental Capacity Assessment proformas which were examined and recorded as being for admission, treatment, or something else. The cumulative case notes were then searched for any mention of ‘capacity’ and any additional capacity assessments were examined and added to the tool. All capacity assessments were reviewed against the defined standards.

Results

Sample and demographics - 22 male inpatients. 21 patients subject to the MHA and 1 was an informal patient. The CTT rule applied to 7 patients.

Treatment - 17 of 22 had capacity assessment for treatment at admission. All of these were recorded using the proforma and all were in line with best practice guidance. 7 had the CTT rule applied to at the time of the audit. None of the records for these people included documentation of a repeated mental capacity assessment.

Something Else - 9 capacity assessments recorded for ‘something else’. Five were recorded on proforma and in line with best practice guidance. 4 capacity assessments were as case notes and didn't meet best practice criteria.

Conclusion

Capacity assessment for treatment is being conducted and recorded well at the time of admission, but not at the point that CTT rules apply from.

Most capacity assessments were recorded on the EPR proforma and all of these met best practice guidance. 4 capacity assessments were recorded in case notes and none of these met best practice guidance.
Clinical Audit of the Quality of Care Delivered by Community Mental Health Services for Older People to People Living With Dementia and Their Carers
Authors: Ohioma Karyn Vovwero , Pearce Sarah
Published: July 2023

Aims

This clinical audit aimed to assess how well the local Community Mental health services for Older people (MHSOP) was implementing the latest NICE and Tees, Esk and Wear Valleys (TEWV) guidelines in dementia service delivery, and to identify what impact (if any), the COVID-19 pandemic lockdown had on their service delivery. In the UK, there are over 800,000 people living with Dementia; providing sustainable individualised care for them has significant cost implications for health and social care services. In 2018, NICE published evidence-based guidelines on delivery of dementia care by professional services within a person-centred and supportive framework. These guidelines together with the TEWV guidelines on Person-centred Dementia care pathway published in 2019, set the standards for this audit.

Methods

The first cycle was performed between 7th Nov 2020 and 15th Jan 2021; we included patients who had received an initial and diagnostic assessment from the team by 12/2020.

Second cycle was done from 7th Nov 2021 and 31st March 2022; inclusion criteria were patients who had initial and diagnostic assessments by Jan 2022.

In each cycle, data from 20 patient records were collected using a tool designed from NICE guidelines and Trust policy on Dementia care standards.

Results

In the first audit patients' consents for assessment and information sharing purposes was recorded in 80% of cases; this fell to 65% in the re-audit.

In the first audit at diagnostic assessments, 47% of patients were given relevant information regarding their prognosis and 26% about dementia and driving; these appreciated to 80% and 53% respectively. 16% of patients were given information in readily accessible formats as leaflets, increasing to 50% in the re-audit.

In both audits a carer's assessment was not offered up to the recommended standard, being (26% and 18% respectively).

Conclusion

This study has demonstrated a measurable improvement in the conduct of diagnostic assessments when local and national standards guiding dementia assessments are followed, and when identified action plans on areas needing improvement are implemented. It however shows that for such improvements to be sustained, the Trust and national guidelines and all identified action plans need to be consistently applied in practice. The findings also suggest that the COVID-19 lockdown restricted opportunities for sharing readily accessible information leaflets to patients, as borne out by the relatively poorer compliance of 16% in the first audit.
Audit: Medical Seclusion Reviews at Derbyshire Healthcare NHS Foundation Trust
Authors: Okoro Esther , Adepoju Jane , Ramji Abbas
Published: July 2023

Aims

Seclusion is a psychiatric treatment that is used as a “last resort” in light of deteriorating mental state. It involves the supervised confinement and isolation of a patient, away from other patients, in an area where the patient is not allowed to leave due to possible risk they pose to themselves and others in order to manage severe agitation and chaotic behaviour. The Trust policy defines a procedure for seclusion which encourages decision making in line with the Mental Health Code of Practice 2015 (MHCoP 2015) and encourages the clinicians to adhere to the policy, making decisions and care which should be duly documented following an assessment of ongoing concern, mental state, assessment of physical health, medication review, risk assessment in a timely fashion as stipulated in the policy.

Methods

This was a retrospective review of patients based on incidence reports completed at the commencement of seclusion on the Derbyshire Healthcare Trust between May and November 2022 . The electronic records were reviewed, and data analysed via Microsoft Excel, against trust standards:

•

Timing of seclusion review: 1hour and 4hourly medical review

•

Independent Multidisciplinary Team meeting within 12hours on seclusion

•

Documentation of seclusion

•

Review of ongoing concerns

•

Mental state examination

•

Physical health review

•

Medication review

•

Risk assessment

•

Review of need for seclusion

•

Intervention

Results

107 incidences of seclusion that took place involving 61 patients were reviewed.

34% of patients were reviewed within the 1hour, 41% reviewed 4hourly and 47% had an internal MDT.

57% of medical reviews were documented with 50% clearly stating ongoing concerns, 47% carrying out a mental state examination and 42% had physical health reviews done. 44% had medication review done, 44% had risk assessment, 58% reviewed the need for seclusion and 52% had an intervention recorded.

Conclusion

The audit showed poor adherence to the Trust guidelines both in terms of the frequency of the review and the vital aspects of the review as included in the seclusion review template. There seemed to be poor use of the seclusion template among medics, which is meant to serve as a prompt for the expected standards, hence more awareness is to be created.

The areas of improvement also identified include the education and training of staff about the stipulation of the policy and clear documentation, with emphasis on the frequency as well as the quality of the reviews done.
An Audit on the Prescribing of Antipsychotics Among People With Recorded Emotionally Unstable Personality Disorder (EUPD) Within a Community Mental Health Service in Stroud, Gloucestershire
Authors: Palermo Amir , Dibben Claire
Published: July 2023

Aims

(1)To quantify the prevalence and duration of the prescribing of antipsychotics among people with a record of EUPD, particularly those without a mental health comorbidity that licenses an antipsychotic prescription; (2)To determine whether gender, age, and mental health comorbidities affect the likelihood of being prescribed antipsychotics; (3)To determine whether off-license use of antipsychotics among those with EUPD have ever been reviewed, with the aim of having these prescriptions stopped or reduced.

Methods

Study design: Retrospective cohort study.

Setting: Data sourced from Stroud Recovery's electronic patient record of 287 people. Cohort entry was defined as the date of referral to Stroud Recovery. End of follow-up was the date of audit (20/11/2022).

Primary outcome measures: Prevalence and duration of antipsychotic prescription among people with a record of EUPD within the Stroud Recovery caseload.

Results

Of the 287 people registered with Stroud Recovery, 37 (13%) had a recorded diagnosis of EUPD. 30 (81%) were ever prescribed antipsychotics. Only 6 of these 30 people (20%) have a mental health comorbidity that licenses an antipsychotic prescription (3 with bipolar affective disorder; 2 with severe depression requiring antipsychotic augmentation; 1 with schizoaffective disorder).

The rest belonged to a subgroup of 24 people (80%) with recorded EUPD who were prescribed antipsychotics but with no history of co-morbid illness that licenses their use. This subgroup was predominantly female (75%) and aged 20–29 years (46%). Quetiapine was used in this subgroup the most, followed by olanzapine and aripiprazole. 12 (50%) have had more than one antipsychotic prescribed. None were prescribed for less than 1 week (defined by NICE as short-term use). In fact, the mean duration of antipsychotic prescription in this subgroup was 36.79 months. Only 10 (42%) had these prescriptions reviewed with the aim of having them stopped or reduced. None were offered a routine physical review.

Conclusion

According to NICE guidelines, antipsychotics are not recommended in the treatment of EUPD, not recommended in the treatment of medium to long-term impulsivity and other symptoms of EUPD, and antipsychotics should be reviewed for people with the aim of reducing and stopping unnecessary drug treatment. Contrary to NICE guidelines, in this community mental health service, antipsychotics are frequently prescribed for extended periods to people with recorded EUPD but with no history of a co-morbid illness that licenses their use. An urgent review of clinical practice is warranted, including the effectiveness of such prescribing and the need to monitor for adverse effects, including metabolic complications.
Physical Health Monitoring in the Memory Service
Authors: Pattiata Cara , Olusoga Tolulope
Published: July 2023

Aims

Local guidelines state that pulse rate, weight, ECG if indicated, and bloods (U&E, LFT) are monitored in patients prescribed an acetylcholinesterase inhibitor or memantine. This can affect management as the above parameters can affect medication selection and titration. Aberrant measurements can indicate drug related adverse events. Compliance to standards will optimise patient safety. This audit aims to assess compliance to these guidelines in one Memory Service in the Trust.

Methods

This is a single-centre, baseline, retrospective audit performed on 19/10/2022.

An internal database was used to identify all patients seen for a diagnostic assessment between September 2021 and October 2022. Patients who were prescribed an acetylcholinesterase inhibitor or memantine were eligible for selection. These were randomised to identify 30 cases.

Information was gathered through electronic patient notes, clinician diagnostic letters, referral forms, and pathology specimen result reporting software.

Results

Compliance were as follows:

•

Pulse rate recorded: 97%

•

Weight recorded: 0%

•

ECG requested when indicated: 20%

•

Blood samples taken and the results recorded: 100%

Pulse rate is part of the assessment proforma and blood sampling is a requirement prior to referral. This suggests that having guidelines incorporated to local protocols enhances compliance.

Weight was not routinely monitored: the rationale behind this being part of the guidelines is that rivastigmine can cause weight loss as per the BNF due to loss of appetite. However, on speaking to the Memory Team, this was not routinely done in the service as staff appear to rely on reports of appetite loss.

ECG was not routinely done when patients fall under the criteria for indications. Clinicians appear to judge the requesting on ECGs pragmatically based on their clinical judgment rather than guidelines alone.

Blood pressure is not a requirement in the guidelines for monitoring so cannot be audited. However, this is essential for decision making of treatment commencement, titration, switching, or titration.

Findings suggest that local guidelines may need to be reviewed.

Conclusion

This audit suggests some general learning points as well as service-specific ones.

The incorporation of guidelines into routine practice such as proformas or the pathway itself contributes to good compliance. This may be due to these standards being auditable as well as acting as prompts for staff members or even requirements for patients to proceed in the pathway.

This was also a reminder that clinical judgment may differ from guidelines; this may not necessarily be an indicator of poor practice but may result from pragmatic decision making for individual patients.

The findings were presented at a consultant meeting, the result of which was that the guidelines will be reviewed with likely inclusion of blood pressure monitoring. This is an illustration of the role of audits and quality improvement in improving standards of care.
Mental Health Triage Form Use in Emergency Department Clerking – Audit at Royal Cornwall Hospital
Authors: Pradhan Alisha , Lee William , Batley Nathan , Burton Suzanne , Wyatt Zoe
Published: July 2023

Aims

The aim of this audit is to assess use of the Mental Health Triage Form (MHTF) at the Royal Cornwall Hospital Emergency Department (ED), during June 2021 and to determine whether MHTF use increases rates of psychiatric-specific information being documented by ED staff. Patient attendances to Accident and Emergency (A&E) departments in the UK during 2020-21 decreased by 30.3% in comparison to 2019-20. However, attendances to A&E at the Royal Cornwall Hospital (RCH) in June 2021 increased by 51.2% compared to June 2020. Psychiatric patients accounted for 2% of attendances to A&E at RCH in June 2021. The Royal College of Emergency Medicine (RCEM) have recommended use of a mental health proforma document in line with recommendations from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) document ‘Treat as One’. Based on these guidelines, the Psychiatric Liaison department at RCH have a produced a local Mental Health Triage Form (MHTF) to be used in A&E when assessing and clerking psychiatric patients.

Methods

This was a retrospective audit of clinical records of 125 mental health cases attending the Accident & Emergency Department (A&E) at Royal Cornwall Hospital during June 2021, which were referred to Psychiatric Liaison.

NHS numbers were identified for each referral made during the study period. Each referral's A&E clerking documents were reviewed on an online patient records system. Information was recorded on whether each question in the Mental Health Triage Form had been answered with or without use of the form.

Results

The Mental Health Triage Form (MHTF) was used in 44 out of 125 patients (35%). 15 patients (12%) had missing Accident & Emergency Department documentation on online records. Where the MHTF was used, there was an 25% average increase in information recorded. Over half of the questions on the MHTF were answered more when the form was used versus when it was not used.

Questions relating to the patients ‘Triage Code’, which are used to determine the level of observation, urgency of referral, and appropriate place of assessment, had the highest rates of improvement using the form.

Conclusion

Overall use of the Mental Health Triage Form during June 2021 reduced to 35% in comparison to 46% use during June 2020. This implied that patients attending the Accident & Emergency Department at the Royal Cornwall Hospital with psychiatric presentations were not being assessed fully. This may be due to various reasons such as staff unfamiliarity with the triage form and increasing pressure on Emergency Department services.
Introduction of a Standardised Admissions Template Improves Adherence to Physical Health Assessment Standards on Admission to an Inpatient Psychiatry Unit
Authors: Pulley Rachael , Dillon Shaina , Pillai Roshanna
Published: July 2023

Aims

The risk of omitting an admission Electrocardiogram (ECG) in psychiatric inpatients can be high - patients may be more likely to have comorbid disease or require antipsychotic medication. Lack of an ECG represents inadequate physical health assessment, and may impact on morbidity and mortality from physical illness – impairing the ability to safely treat psychiatric illness, for example with antipsychotic medications. This audit aimed to establish achievement of admission ECG within 24hours, and to improve this if possible.

Methods

Two doctors gathered data retrospectively using written and electronic admission records for 41 psychiatric admissions in a one week period in September 2019.

Following the first audit cycle demonstrating low levels of policy adherence, an admission proforma containing prompts and requiring a signature of the admitting doctor was introduced. Data collection was repeated on 16 admissions during September 2020 using an identical process.

Results

The intervention led to an increase in ECGs performed within 24hours (65% to 83% in 18-65 year olds, 52% to 60% in over 65 year olds), whilst documentation of delayed ECGs being justified and reattempted also improved (28% to 100% in 18-65 year olds, and 50% to 100% in over 65 year olds).

The proforma was utilised in 75% of audited general adult admissions, and 66% of audited older adult admissions.

Conclusion

This admission unit was failing to meet expected standards of physical health assessment, which could result in harm. Reasons for this varied, but were attributed to inconsistent admission processes resulting in junior staff being unaware of the requirement, or miscommunication between staff. Handover of outstanding tasks occurred, but was not taken ownership of.

Data collection was unfortunately impaired by reduced patient numbers secondary to COVID-19 admission processes – particularly in the older adult ward. As such some of the results in those over 65 years are positive, but may be spurious. It would be useful to repeat the audit once admission levels return to normal.

The unified assessment document provided a framework for inclusion of all relevant elements and reminders for the admitting doctor. It required formal responsibility to be taken by the admitting doctor to ensure completion. Qualitative feedback demonstrated that it improved the quality and ease of admission documentation, and enabled thorough assessments which were useful when planning patient care and discharge letters.

This audit demonstrated that use of an assessment proforma results in improved adherence to physical healthcare policies, and contribute towards improved patient care.
A Trust Wide Audit Evaluating Prescribing Practices in Clients With Emotionally Unstable Personality Disorder (EUPD)
Authors: Rangan Tarun , Mishra Monisha , Jaura Taimoor , Wratten Camille , White Andrew
Published: July 2023

Aims

The aim of this audit was to evaluate prescribing practices in patients with EUPD at South West London and St George's Mental Health NHS Trust and compare these to NICE guidance on the management of EUPD. We are aware that for a multitude of reasons including high levels of distress and long waiting times for psychological therapy, clients with EUPD are often prescribed psychotropic medication. NICE guidance states that drug treatment including antipsychotics should not be used specifically for EUPD or for associated behavioural symptoms. Drug treatment for comorbid conditions and short-term use of sedative medication may be considered as part of a crisis treatment plan. If prescribing, NICE recommends that written material be provided to the client along with regular treatment reviews.

Methods

We obtained a list of patients in the trust with a recorded diagnosis of EUPD on their electronic patient record (EPR) system (N=869). 10% of these clients were randomly sampled (N=87).

The notes were assessed for any prescribed psychiatric medication including the documented rationale for prescribing. We also assessed if medication use was consistent with NICE recommended time limited crisis prescribing and whether there was evidence of regular reviews of prescribed medication and of written material being provided to the client.

Results

Of the sampled clients, 81.6% (n=71) were prescribed medication. Of these, 39.4%( n=28) had medication use consistent with NICE recommended time limited prescribing, and 57.7%( n=41) had timely reviews of medication. 4.2% (n=3) of those prescribed medication had evidence on their EPR of written material being provided.

Conclusion

Our results highlight the extent of drug prescribing for EUPD within the trust. Over half of patients sampled had timely reviews of prescribed medication. However, most were not consistent with NICE recommended time limited prescribing. The results were presented to the trust's Clinical Reference Group. A Working Group has now been formed to help bring prescribing practices better in line with NICE guidance, specifically around the provision and recording of written information of drug treatment to patients and reducing inappropriate prescribing and polypharmacy.
Improving Physical Health Monitoring for Patients Diagnosed With Emotionally Unstable Personality Disorder
Authors: Thomas Emily Simon , Smith Ozias , Berry Verity
Published: July 2023

Aims

The aim of this work was to apply the well established standards for patients suffering from diagnoses classed as Severe Mental Illness (SMI) to patients with a diagnosis of emotionally unstable personality disorder (EUPD) in our EUPD psychotherapy service. This patient population is also known to suffer lower life expectancy and greater physical comorbidities than the general population, and indeed than patients with other personality disorders, and this represents part of the holistic care we hope to offer in our service. In order to bring this in line, we were aiming for an annual medical review including: height, weight, blood pressure, blood tests including lipids, up to date information about alcohol and substance misuse.

Methods

One month before a patient's 6-week and 12-month review we liaised with their general practitioner (GP) for the above information. We then followed up as needed. In the first cycle of this work (January through July 2022) we found that we were able to establish contact with patients' GPs and there was qualitative evidence from patient testimonials about improved relationships with their GPs. However, the information that we were receiving was not complete - 0% had all the information that was requested.

Following discussion in the team, a proforma was developed to make it as clear as possible to the GP which information we were seeking. We more proactively engaged GPs and patients' other physical care teams, including neurology teams. Where patients had home monitoring equipment like a blood pressure cuff or scales, we also collected information from these. Compliance was reviewed again at the end of the next six-month cycle (August 2022-January 2023).

Results

Between the first cycle, from January 2022 through July 2022 and the second cycle from August 2022 through January 2023, we improved compliance toward the target of having all these data points documented for all patients from 0 to 57%. This included 100% compliance for blood pressure and pulse measures and 86% compliance for documented weight.

We also note improved relationship between patients and GPs and other healthcare professionals including a patient testimonial “Having not had the support of Waterview dedicated staff and the group I probably would not attend any of the hospital appointments.”

Conclusion

Introducing the proforma significantly improved compliance with physical health monitoring targets from 0 to 57%. Further work within the team and with GPs including education on the diagnosis may improve this further.
A Re-Audit of Teesside On-Call Email System
Authors: Singh Aashna , Ali Mohamed , Kishore Satyam , Dobson Rachel , Atewogboye Oluwatosin
Published: July 2023

Aims

An on-call email system was put in place to facilitate communication between wards and the on-call doctor, allowing prioritisation of duties according to green, amber and red tasks. Information regarding the patient, nature of request and clinical background are expected in the request form. The doctor is expected to respond to the email within 45 minutes. We completed a re-audit to compare if expected standards were reached in practice and attempt to find any areas of practice that could be improved.

Methods

We collected information on request forms, presence of adequate information and response time by reviewing the Teesside on-call email inbox. One day was randomly chosen from each week for a 24 month period and all emails were reviewed from chosen days. This amounted to (N=680) emails. The compliance was measured against local trust criteria with expected standard of 100%. We assessed four parameters of completion of request forms, providing adequate information including clinical information, patient identification and location, and response within 45 minutes by the doctor.

Results

The compliance in all four standards was subpar, with notable decrease in compliance from previous results. Compliance was less than 70% across all standards, where previously three standards were above this mark. There was a notable increase in requests with inappropriate tasks defined as non-urgent tasks as per trust guidelines.

Conclusion

Better communication can be ensured with use of SBAR (Situation, Background, Assessment, Recommendation) in the request forms. Mutual sharing of information between doctors, nursing staff and administration with regard to appropriate written communication could constitute the base for structural change and improvement within the workplace. New staff members and doctors should be inducted with regards to the process of on-call email communication. Regular re-auditing and sharing of results is essential to the monitoring of change in compliance.
Collateral History-Taking on Acute General Adult and Older Person Inpatient Wards: A Quality Improvement Project
Authors: Steptoe Joanna , Deol Harlene , Male Joanna , Riviere Erica , McCarthy Roisin
Published: July 2023

Aims

To investigate current practice of collateral history-taking on inpatient adult and older person wards in Leicestershire Partnership Trust. COVID-19 visiting restrictions raised concerns that the collateral history may be side-lined due to the physical absence of carers. Collateral history is important in developing a working diagnosis and assessing level of function, and is part of ongoing assessment and formulation.

Methods

An initial audit of 46 patient records from 3 inpatient wards (2 adult and 1 functional old age) was carried out in January 2021 when visiting restrictions were in place. In response, a questionnaire was distributed and 2 focus groups of junior doctors conducted later in 2021; the aim being to explore factors affecting collateral history taking. A re-audit was completed in October 2022 when visiting was reinstated. 48 patient records were audited. Old Age organic wards for dementia assessment were not included in data collection, as collateral history-taking is unavoidable for initial assessment of those presenting with significant cognitive impairment.

Results

In 2021 and 2022, 33% and 38% of sampled patients had a collateral history taken in the first 14 days of admission. Where a collateral history was omitted, only 10% and 13% were attempted and 46% and 27% planned. Associated themes were identified from the questionnaire and focus groups including consent; accessibility of contact details; lack of confidence and variability in history-taking; accountability/ clarity on whose role it is to complete the task; lack of time/space and poor consensus on how to document a collateral history.

Conclusion

The results of the re-audit continue to show poor collateral history completion early in admission for both old age and adult inpatient wards despite reinstatement of visiting after the COVID-19 pandemic. Numerous issues affect the completion and documentation of good quality of collateral histories within inpatient settings of Leicestershire Partnership Trust. These have been categorised into staff, system, environmental and other factors.

This audit forms part of a wider quality improvement project. The proposed actions are as follows:

1.

To share findings locally via the Trust Audit and Quality Improvement department, Trust email and Consultant Medical Advisory Committee;

2.

To improve education through Trust induction, regular bitesize teaching and development of a crib sheet to be placed on each ward;

3.

To consider wider quality improvement projects in line with themes identified above;

4.

To undertake a further re-audit in November 2023.
Auditing the Treatment of Post-Traumatic Stress Disorder in Patients Experiencing Inner-City Homelessness
Authors: Christey-Reid Philippa , Thompson Ruth
Published: July 2023

Aims

Post-traumatic stress disorder (PTSD) is a mental health diagnosis resulting in symptoms which make daily functioning challenging and higher cognitive ability often troublesome, resulting in a diminished quality of life that requires specific intervention to improve. The objective of this audit was to evaluate whether evidence based best practice is being met, regarding the treatment of PTSD in 62 individuals experiencing inner city homelessness. The overarching aim of this research was to shine a light on some of the prominent obstacles that are preventing access to healthcare, particularly in a population that historically struggle to raise their hand and ask for help.

Methods

The method used was a classic audit-cycle structure, using quantitative and qualitative measures to visualise outcomes. Data were gathered through retrospective analysis of patient documentation, communications between services and records dating back to each original diagnosis.

Results

The results indicated that best practice in the form of trauma-focused therapies is not occurring as outlined by national guidance within this sample, but instead medication is acting a crutch, allowing individuals to cope with daily life. Over the 13-year period, 11% of individuals received some form of psychological therapy. Possible reasons for this suboptimal outcome were investigated, resulting in recognition of an array of barriers faced by the homeless population in accessing required therapeutic intervention. Results indicated the most common reasons for unsuccessful therapy were lack of contact or engagement by the individual, discharge on the grounds of substance misuse, then lack of record or follow-up within the service records.

Conclusion

In conclusion, barriers to the delivery of effective therapy are multifactorial and recommendations have been made here to promote integration of care across services, possibly providing an alternative pathway for these patients. Forward thinking models of psychologically informed environments may be useful to deliver treatment to people experiencing homelessness, in way that is accessible and approachable to them. Additionally, it has been recognised that improvement in communication across services regarding mental health interventions is required, to allow continual evaluation and improvement of care in the area. Finally, the question was raised whether current guidance is suitable and generalisable to the homeless population, particularly those under complex circumstances and co-morbid with substance or alcohol misuse. All recommendations have been made in the aim of improving provision of care for this population, to avoid deepening of already established health inequalities and to combat the inverse care law.
Audit of the Metabolic Side-Effects on Autistic Inpatients on a Rehabilitation Ward
Authors: Diaz Zurima Toloza , Khan Azmathulla
Published: July 2023

Aims

•

To evaluate current compliance in monitoring metabolic side effects for the patients with the diagnosis of autism, following the recommendations of NICE guidelines.

•

Establish evidence based practices to reduce morbidity and increase quality of life.

•

To identify areas of improvement.

Methods

Springs centre is a male locked secure rehabilitation ward, specialised in treating people with Autistic Spectrum Disorder (ASD), Learning Disabilities (LD) and co-morbid mental health conditions. It is a 17-bedded ward for male adults between 18 and 65 years old. Service users are transferred from hospitals or community placements located at the South East of England.

We collected data from service users admitted to the Springs Centre between 1st of January and 31st of July 2022. The selection Criteria included in patients with a diagnosis of ASD, taking antipsychotic medication, with records of clinical interventions and investigations. We conducted a search to electronic and paper files. Electronic records were available at MYPATH system as well as ward files with physical observations and health Action plans. Data were collected on spreadsheets and later analysed.

Results

A total of 17 patients were identified, we excluded 2 service users that were not taking antipsychotic medication, and 1 of these did not have a diagnosis of ASD. We collected data from 15 participants. All patients have Blood pressure, Body Mass Index and measure of HbA1C (100%), 86.6% had records of lipid profile, but only 60% have a waist circumference.

We analysed individually the risks factors for metabolic syndrome on the 15 selected patients; 79 % of the patients had excess central adiposity (large WC). 20% among males were diabetic type 2 and smokers. About 40 percent (40%) of sampled individuals were obese.

Conclusion

The findings of our study supports the notion that screening for metabolic side-effects needs to be prioritised for individuals. Clinicians need to be aware of the risk of metabolic syndrome. Periodical screening is required across all health services treating people with ASD, especially those taking regular medication. General measures of control such as losing weight, exercising regularly. Eating a healthy, balanced diet to keep blood pressure, cholesterol and blood sugar levels under control. Also, stopping smoking.
Lithium Monitoring in the Community; Mapping, Finding, Improving
Authors: Tremblay Micheline , Jones Kate Megan , Adeyemi Damilola , Robinson Sarah
Published: July 2023

Aims

Lithium is a well-recognised treatment in Affective Disorders. Careful monitoring is required due to its narrow therapeutic index. Adherence to monitoring standards has been generally poor with high levels of incidents reported to the National Patient Safety Agency leading to financial settlements and inclusion in patient safety alert potentially selected on inspection by the Care Quality Commission. This audit aimed at mapping the provision of lithium monitoring for patients stable on Lithium in Vale Royal to facilitate implementation of quality improvements in ongoing transformation of community services. There are twelve general practices in Primary Care (PC) for this area, one specialist mental health Trust Cheshire and Wirral Partnership NHS Trust (CWP) and one Hospital Trust MidCheshire Hospital Trust (MCHT).

Methods

1. Systems inventory

No lithium central register was identified.

All lithium requests were processed by North Midlands and Cheshire Pathology services (NMCPS).

In specialist care lithium was managed by one Consultant Psychiatrist.

In primary care nine practices provided information, all supported by a software overseen by administrative staff working collaboratively with doctors.

b. Data collection.

Anonymised Lithium results for adult patients stable between November 2021–2022 were collected from NMCPS.

Plasma levels and frequency were compared to generally accepted standards of 0.4-1 mmol/L every 6 months for stable patients.

Results

Ninety patients were identified, eighty in PC and ten with CWP, median age 58, females (53%)/males (47%) gender ratio.

Frequency was mostly 3 monthly for 74% of patients in PC and 80% for CWP.

Levels below 0.4 mmol/L were found in 22.5% of levels measured in PC and 27% for CWP, and over 1 mmol/L in 5% in PC and 0% CWP.

Conclusion

This audit revealed that lithium monitoring for stable patients was primarily managed in PC.

Lithium level was measured more frequently than recommended which could be due to automated cues. Levels were often maintained at the lower end of the range. Those findings could be medically related.

Both computer and clinician led systems allowed for meeting, if not exceeding, targets.

Electronic systems are likely cost savings over a specialist clinic but could generate potentially unnecessary automatic checks, still require data reviews and medical oversight. This could be addressed by system amendments and an audit programme.

The absence of formally recognised central register could be remediated by shared agreement and managed by NMCPS.

Systemic approach to lithium monitoring can be collaboratively extrapolated to other localities, medications, or targets .
An Audit Reviewing the Completion and Quality of the Admission, Then Six Monthly ALL-Physical Health Assessments (A Six Monthly Health Check) on a Low Secure, Inpatient Forensic Psychiatric Ward in Sussex Partnership NHS Foundation Trust
Authors: Vogel Elizabeth , Asmat Shumaila , Jones Benjamin , Saoud Moustafa
Published: July 2023

Aims

Background: It has long been known that having a Severe Mental Health Condition is a risk factor for cardiovascular disease. In order to facilitate early intervention, NHS has implemented annual physical health reviews. Within Sussex Partnership Foundation Trust (SPFT), compliance with this is outlined within local guidance and an assessment on admission and thereafter six-monthly is mandatory and called ALL-Physical Health Assessment. Historically, completion of this has been poor and therefore, this audit has been done to review the quality of completion and whether ALL is UpToDate and implement changes to improve the care. The Categorisation of completion into green, amber, and red as errors are linked to potential harm to patient's care. The review of actions taken from areas highlighted as abnormal results.

Methods

This study was done within the setting of Pine Ward, a 17-bed male, inpatient, low-secure forensic psychiatric ward.

Data were collected in November 2022 by reviewing ALL-Physical Health Assessments (six-monthly physical health check) on Carenotes(an electronic record system) and evaluating the quality of completion by categorising it as green(no errors), amber(minor errors, potential for risk to patient care), and red(major error/ missing documentation, which can lead to serious harm). ALL has fourteen categories. Smoking, Diabetes, Cholesterol/HDL ratio, Blood pressure, Pulse, Body Mass Index, Diet, Exercise, Alcohol, Substance misuse, National screening programme, Sexual functioning, Oral health and QRISK. This was compared with the results from February 2022 ALL assessments.

Results

Of the 17 patients, 15(88%) had an ALL done in the last 6 months. When splitting completion of the ALL, 89.9% of completions were green, 4.6% amber and 5.5% red.

In February, overall 76.4% of patients had ALL done and 67.2% of completions were green, 15.5% amber and 17.2% were red.

Improvement was seen in QRISK, Alcohol, diet, and exercise status, as they were 100% documented in November whilst it was 70%, 58%, 82%, and 70% respectively in February. The diabetic and smoking status is now 82% and 88% whilst it was 58% and 76% in February.

Conclusion

This audit has highlighted that certain areas of the ALL that are not completed up to the standard expected. The importance of the assessment needs to be raised to trainees to allow for the best patient care. There is potential for harm to patients if the assessment is completed inaccurately or incorrectly.
Comparison of Management (Non-Pharmalogical Approaches and Rapid Tranquilisation) of Older Adults (≫65 Years) With Dementia Between the Dementia Ward, Acute Medical Unit and the Geriatric Ward in a Rural Health Board
Authors: Wild Adam , Kumar Praveen , Howells Fiona , Emara Hamed , Williams Phoebe
Published: July 2023

Aims

To investigate if current practices by nursing and medical staff in the dementia ward (New Craigs Psychiatric Hospital), acute medical unit and geriatric ward (Raigmore General Hospital) followed the local protocol for managing distress of non-pharmalogical approach and rapid tranquilisation (RT) in older adults (aged >65years). We believe the split between the general and psychiatric hospitals and the different time pressures experienced in these 3 wards will influence the management and RT of their older adult patients.

Methods

Data were collected from 17/09/2022 to 8/10/2022 from case notes and drug charts of older adult patients that received rapid tranquilisation from 3 wards:

1.

Ruthven Ward, New Craigs Psychiatric Hospital

2.

Acute Medical Unit (AMU), Raigmore Hospital

3.

Ward 2C (Geriatrics), Raigmore Hospital

Focus groups and informal discussions were made with the ward nurses and junior doctors to understand their point of view on managing distressing behaviours in patients with dementia using de-escalation techniques.

A table was collated using Microsoft Excel. The parameters used were:

1.

Patient Diagnosis and Legal status

2.

Administration

•

Date and time started

•

If de-escalation techniques were used

•

If discussed with a senior doctor

•

1st and/or 2nd line of drugs administered (route, drug and dosage)

•

If Haloperidol given and if ECG was done

Results

Data collection showed the following:

1.

Ruthven Ward- all 32 patients did not receive RT.

2.

AMU- only 1 out of 280 patients received 4 subsequent RT in 5 hours including 3x haloperidol (total 3mg) and 2mg of Midazolam despite an ECG showing prolonged QT interval. The latter prescribed after consultation with a senior doctor.

3.

Geriatric Ward – all 10 patients did not receive RT.

Conclusion

Focus groups and informal discussions with staff nurses from all three wards concluded that in spite of the stressful environment posed by issues of understaffing and high patient load, de-escalation techniques (recognition of early signs of agitation, distraction and calming techniques, recognising the importance of personal space) were prioritised before moving on to RT as per local protocol. Restraining was often used if patient was at risk to self or others by staff trained in violence and aggression management.

Informal discussions with junior doctors rotating in and out of AMU showed limited awareness of the RT protocol. In general, it was evident that RT was a last resort when psychological and behavioural approaches failed but that further education was required to administer RT safely.