bluuebunny/crossref_metadata_2025 huggingface dataset:
Quantitatively Evaluating the Impact of Eliminating Risk Assessment Checklists for Granting Leave in a Specialist Personality Disorder Ward
Authors: Philbey Alasdair
Published: June 2022

Aims

Springbank Ward, in the CPFT NHS trust, is a specialist unit for patients with a diagnosis of emotionally unstable personality disorder (EUPD). Psychiatric wards often use restrictive practices to try and minimise suicide risk. Using risk assessment checklists to decide whether to grant leave is one example. Research shows that it is not possible to predict suicide or self-harm risk at an individual level, regardless of the assessment method used, so we questioned the utility of such an approach. A previous evaluation of our leave protocol showed that patients and staff would favour a less restrictive and more personalised approach. We introduced a new protocol that eliminated use of checklists, replacing them with an optional 1:1 conversation with staff before leaving the ward. Our aim in this service evaluation was to determine whether there was any significant change in rates of incidents on the ward and during leave as a result of this new, less restrictive leave protocol.

Methods

Data were obtained from the records of incidents on Springbank ward from March 2019 to March 2021. These incidents were recorded by members of staff on the ward, and ranked according to the severity of harm that resulted from these incidents. The rankings from least severe to most severe recorded during the study were ‘No harm’, ‘Low (Minimal Harm)’, and ‘Moderate (Short term harm)’. The number of incidents which occurred for the year before and the year after the policy change were compared. The comparison compared both the total amount of incidents and the sub-types of incidents.

Results

In the 365 days following the change in protocol, there was a 15.5% decrease in total incidents and a 51.0% decrease in incidents occurring off the ward compared to the 365 days before the change in protocol. Notably there was a 61% decrease in total (both on and off the ward) Moderate (Short term harm) incidents, the most harmful type of incident recorded, following the change in protocol.

Conclusion

The decrease in incidents following the change in protocol suggests that replacing the use of a formal risk assessment checklist with a holistic alternative improves patient safety.
Improving Patient Engagement in Psychological Interventions
Authors: Sivaji Rajeswari , Belgamwar RavindraB
Published: June 2022

Aims

The aim of this service evaluation project is to gain understanding about the reasons for service user's disengagement in psychological interventions. We felt that the findings of this project will enable services to better understand the experience of service users and help recognise why someone requesting services does not follow through. Around 68% of patients who were referred to psychological therapy did not complete therapy in our community mental health team highlighting a need to improve patient engagement in psychological interventions. Patients under secondary mental health services have complex needs and any referral decision to the most appropriate psychological intervention will need to be carefully considered as a part of their treatment plan. Premature termination from psychological interventions can lead to poor treatment outcome, waste staff time and contribute to unnecessary long waiting lists.

Methods

Random sample of 20 service users who disengaged from psychological therapy were chosen and telephone interviews were conducted to determine their perspectives on reasons for their termination. Introductory letter informing about this project was posted to the service users and they were contacted after a week to gather information. The following themes were included in the interview questionnaire like demographic characteristics, psychopathological difficulties, problems related to therapy or therapist, external circumstantial problems, internal factors and service user views on satisfaction/achievement of therapy goals.

Results

The results showed:

1.

The most frequent reported reason for disengagement from psychological intervention was COVID-19 and internal factors (thinking that therapy would not help, low mood/too anxious, previous bad experience with therapy and feeling unwilling to open).

2.

Number of session's service users attended ranged from 0 to 6 and no one completed the therapy.

3.

Waiting time (from referral to start of therapy) ranged from 2 to 6 months.

4.

37.5% of service users were not aware about therapy details.

Conclusion

The results were shared with staff via local meetings Recommendations were drawn to improve patient engagement and retention in therapy.

1.

Outpatient pack resources developed to offer service users at appointments which has written information sheets about presenting problems, overview of psychological interventions/assessment and diaries for service users.

2.

New template was drafted to improve the referral process to psychology by referrers having access to guides on how to assess a person's psychological needs, readiness for therapy and the provision of consultation slots with psychologists.
Service Evaluation of COVID and Non-COVID Admission Trends to an East Midlands General Adolescent Psychiatric Inpatient Unit
Authors: Tan Sue Fen , Chand Parveen
Published: June 2022

Aims

To explore the differences in admissions between the first COVID-19 lockdown cohort and a pre-COVID-19 cohort.

Methods

23 young people who were admitted to an East Midlands General Adolescent Inpatient Unit during the first COVID-19 lockdown from March 2020 to September 2020 were compared with the 48 young people who were admitted in the same period in 2019. Demographic details, admission duration and reasons, mental health act (MHA) status, diagnoses, functional status, and incidents were obtained retrospectively from the trust's online records.

Results

The unit received more female admissions prior to lockdown (60.4% Vs 47.8%). Approximately 30% of adolescents in the pre-COVID-19 group were not in education whereas those admitted during COVID-19 were all receiving education. More of the pre-COVID-19 group attended school than college and more of the COVID-19 group were employed, consistent with a lower mean age of admission in the former group. Most of the COVID-19 admissions were local and none were out of area. Young people were also more likely to be looked after by their parents during COVID-19 (82.6%) and none were taken care of by their relatives.

Pre-COVID019 admissions were discharged sooner than their counterparts, which had 13% of admissions between 6–9 months. Both cohorts had mainly informal admissions due to risk to self. Most of the COVID-19 admissions were due to anxiety, followed by self-harm while the majority of pre-COVID-19 admissions were due to depression and PTSD. 43% of the COVID-19 admissions had at least one comorbid diagnosis, notably depression. More adolescents in the COVID-19 cohort were not started on any psychiatric medication during and after admission.

The mean number of incidents were two times higher in the COVID-19 group; self-harm was the most common reason. There was more violence towards staff during lockdown. However, absconsion, possession of contraband items, and staff error were higher in the pre-COVID-19 group.

Conclusion

The introduction of COVID-19 restrictions was associated with a change in both the frequency and nature of inpatient admissions to this ward. Less young people were admitted during COVID-19, more frequently with anxiety as the primary reason and stayed for longer. Although the pre-COVID-19 group received more psychiatric medication, it is unclear if this contributed to a better functional status overall. This service evaluation also demonstrated the impact of COVID-19 on young people's mental health and life circumstances. An exploration of these trends in other units across the country would increase the generalisability of results.
Physical Health and Mental Health Comorbidities of People With Functional Neurological Disorders Referred to a Community Neuropsychiatry Service Pre-& Post March 2020 Lockdown Due to COVID-19
Authors: Williams Verity , Olaluwoye Oluwaseun , Dunlop Alan , Faruqui Rafey
Published: June 2022

Aims

Health comorbidities contribute significantly to the development and maintenance of illness in patients with Functional Neurological Disorder (FND). As part of a service evaluation project, we investigated the physical and mental health comorbidities of people referred to a community neuropsychiatry service in East Kent, in one-year periods preceding and following the March 2020 lockdown due to COVID-19.

Methods

We included all people accepted to the service between 23rd March 2019 and 23rd March 2021, where the reason for referral was Functional Neurological Disorder (FND) or Non-Epileptic Attack Disorder (NEAD). Referrals to the service for other reasons were excluded, as were declined referrals. Routinely collected data sources were reviewed and data stored in anonymized fashion. Data were analysed using Statistical Package for Social Sciences (SPSS).

Results

Total number of referrals for FND in the 2-year period was 260, with 161 referrals for NEAD and 99 for other FND.

In the pre-lockdown period, 163 patients were referred due to FND (101 with NEAD, 62 for other FND). There were fewer FND referrals in the post-lockdown period: 60 referrals for NEAD and 37 for other FND. The majority were female (74% pre-lockdown, 81% post-lockdown). Where ethnicity was recorded, White British was the most common (94% pre-lockdown, 90% post-lockdown), with a small number of people from other ethnic groups (3.5% White Other, 1.4% BAME, 1.4% Mixed pre-lockdown; 5.4% White Other, 3.2% BAME and 1.1% Mixed post-lockdown). Ethnicity was not specified in 21 cases (13%).

Of the pre-lockdown group, 15 patients had prior contact with Child and Adolescent Mental Health Services (9%), with 7 patients (7%) in the post-lockdown group. Many patients had previous contact with mental health services (47% pre-lockdown, 53% post-lockdown). The majority of patients had at least one physical illness (69% pre-lockdown, 73% post-lockdown). Most had 1–3 physical comorbidities but 9% (pre-lockdown, 7% post-lockdown) had more than 4. Fibromyalgia (14% pre-lockdown, 12% post-lockdown), chronic pain (23% pre-lockdown, 21% post-lockdown), and epilepsy (11%, 9%) were common. Over 90% had psychiatric illness in both periods. Most patients had 1–3 psychiatric illnesses; a few had more than 4 (6.1% pre-lockdown, 1.4% post-lockdown). Depressive disorder was the most common comorbidity in both groups (41% pre-lockdown, 44% post-lockdown), followed by anxiety (35% pre-lockdown, 36% post-lockdown). PTSD was present in 8% pre-lockdown and 8.2% post-lockdown.

Conclusion

Physical and psychiatric comorbidities are common in people with FND; multidisciplinary working and liaison between services is crucial for care of these patients.
Improving Clinical Care in Tobacco and Smoking-Related Problems: A Report of Clinical Audit and Quality Improvement Project
Authors: Loo Jiann Lin , Raja Jawad , Anyanwu Ugochukwu , Shankar Nikhil Gauri , Elsayed Asmaa , Azahr Zeenish , Clifford John , Graver Faye
Published: June 2022

Aims

Around 40% of people with serious mental health problems smoke, which is significantly higher compared to the general population of the United Kingdom. The Welsh Government has set the target to reduce the overall prevalence of smoking in Wales to 16% from 19. In order to reduce the impact of smoking on the population, the first step is to identify the problem. Hence, a comprehensive history of smoking will help to identify the addiction-related problems. Hence, this combined clinical audit and quality improvement project (QIP) is aimed at the evaluation of the admission clerking around the assessment and management of smoking-related problems in an inpatient mental health unit.

Methods

This clinical audit was carried out at the local inpatient general adult mental health units in Wrexham. It was based on NICE smoking guidelines “Smoking: acute, maternity and mental health services”. Clinically relevant information without personal identification information was collected based on a proforma. The first re-audit was repeated without a specific intervention to see any change in pattern and the need for intervention. This was followed by the first intervention, i.e., the sharing of a PowerPointTM presentation discussing commonly utilised measurement tools in the assessment of smoking-related behaviours and the second re-audit.

Results

The first round of clinical audit involves 32 admissions, the first re-audit was 19 admissions, and the second re-audit was 37 admissions. The baseline showed 71.88% of inpatient admissions were asked about their smoking history, but only less than 10% of them were assessed in detail around the types and quantity of tobacco products, features of dependence and withdrawal, the motivation of the clients to quit smoking, and any help offered to the patients. The number of inpatient admissions which was assessed for their smoking-related behaviour dropped to 36.84% during the first re-audit, and less than 16% of them were assessed in detail. The number improved slightly to 57.14% after the first intervention, although less than 40% of the inpatient admissions were assessed in detail.

Conclusion

There is an inconsistent pattern of change in the percentage, and it seems that the intervention leads to minimal improvement of the assessment of smoking-related problems during admission clerking. The minimal change may be attributable to the change in posting around the intervention period. The future plan includes a more regular intervention arranged around the beginning of new postings for doctors to ensure they have adequate exposure to the assessment of smoking-related addiction problems.
Physical Health Monitoring of Patients Prescribed Depot Antipsychotic Medication in North West Edinburgh Community Mental Health Team (CMHT)
Authors: Klejnotowska Adrianna , Bailey Robyn , Thompson Alexandra , Wojtowicz Jakub , Haggart Josh , Evans Hamsi , Choi Hae-young , Mallis Adam , MacLeod Anna , Murdie Douglas , Argent Vikki
Published: June 2022

Aims

To assess the effect of interventions in the physical health monitoring of patients prescribed depot antipsychotic medications. We hypothesised that compliance with monitoring would improve post-intervention. It is well recognised that patients with severe mental illness have a significantly reduced life expectancy. Depot antipsychotic medication increases the risk of cardiovascular disease, metabolic syndrome, stroke and type 2 diabetes. The SIGN guidelines recommend that all patients on antipsychotic medications should have annual physical health monitoring. Baseline data of patients on depot antipsychotic medication in North West (NW) Edinburgh CMHT in 2019 demonstrated that this was not being achieved. We sought to create interventions to improve compliance with physical health monitoring for patients on depot antipsychotic medication.

Methods

Baseline data were collected in 2019 for all patients under NW Edinburgh CMHT receiving depot antipsychotic medication (60 patients). The data addressed 9 domains including smoking status, blood monitoring, BMI and physical monitoring.

Following the baseline data collection interventions were put in place to increase compliance with monitoring. These interventions included a physical health questionnaire and training of staff in the CMHT to perform phlebotomy and ECGs.

Following these interventions the data (74 patients) were re-audited in 2020 following the same domains.

After this initial re-audit a physical health monitoring clinic was implemented in order to specifically target this patient population. The data (66 patients) were then re-audited in 2021.

Results

Baseline data identified that domains were reached between 8% (Lipid monitoring) and 51% (glucose monitoring). Following the initial interventions 77% of domains improved in compliance. Between the two periods, notable improvements were observed in the monitoring of Blood Pressure (9% to 37%), ECG (20% to 43%) and lipids (29% to 46%). There was however a decline in all domains between the 2020 and 2021 data, with 66% of domains still having improved compared to 2019 data.

Conclusion

Overall, interventions have improved compliance with monitoring of physical health for patients on depot antipsychotic medications. It is likely that continuing effects of the COVID-19 pandemic contributed to the decline between the 2020 and 2021 data. As a result of this audit a weekly physical health monitoring clinic has been set up and once formally established it is hoped that compliance with physical health monitoring will continue to improve. Limitations include effects of COVID-19 pandemic, inconsistency in documentation and patient non-attendance to the monitoring clinic. We recommend further audit cycles, with additional interventions being implemented as identified.
Use of Formulation Information Risk Management in Low Secure Services: An Audit Project
Authors: Burns Alex
Published: June 2022

Aims

Risk assessment is a key component of patient care in forensic psychiatry. This audit aimed to measure the completion of different aspects of the Formulation Information Risk Management (FIRM) risk assessment for patients in the care of Low Secure Services. The FIRM incorporates formulation and a care plan into the risk assessment and should be completed for all inpatients in the trust. It was hoped that this audit would help identify any areas of improvement required in the completion of this risk assessment, and provide recommendations that would contribute to improving standards where required.

Methods

Data were collected on 23rd December 2021 from the electronic patient records of 37 inpatients at a Low Secure Services Unit in Northern England. 5 audit criteria were devised following review of the trust standards regarding the completion of the FIRM assessment. These criteria included the completion of the Current / Historical Risks section, Formulation and Staying Safe / Staying Well Care Plan aspects of the assessment. It also assessed patient involvement in completion of the assessment and whether the assessment had been updated in the last Care Programme Approach (CPA) period. The findings of the audit were presented at a local academic meeting and were distributed to the relevant staff.

Results

100% of patients had the Current / Historical Risks section completed

89% of the patients had the Formulation completed

73% of patients had the Staying Safe / Staying Well Care Plan completed

In 16% the service user had been involved in the risk assessment completion

In 70% of cases the FIRM had been updated since the last CPA (or in the last year if not applicable)

Conclusion

Current / Historical Risks section completion rates matched expected trust standards. Significant improvement was seen in completion of the Formulation and Care Plan compared to auditing done in October 2021. There was room for improvement regarding increasing patient involvement in the completion of the risk assessment, often due to it being completed at night leading to the patient being unavailable. It was recommended that the FIRM should be more consistently reviewed and updated as part of each patient's 6 monthly CPA review. A re-audit would prove useful to monitor the progress of these measures, and the scope of a future audit could also be widened to include the timeliness in which the FIRM is completed for new patients.
A Gap in Psychiatry On-Call Training: Post-Ligature Assessment
Authors: Donaldson Maja , Nizam Ain
Published: June 2022

Aims

1. To assess documented practice on post-ligature assessment following a teaching session and simulated induction session introducing a post-ligature assessment tool. 2. To implement the post-ligature assessment tool, for assessing patients who have tied a ligature, into trust guidance. 3. To support the incorporation of simulated induction teaching on post-ligature assessment into the standard induction timetable delivered to all new trainees in the trust, in order to complete the audit cycle.

Methods

Audit Cycle 1 - Patient data collection November 2020 - January 2021

Action - Locality teaching presenting findings of audit and post-ligature assessment tool developed as part of audit. Concurrent trial of incorporation of post-ligature assessment tool into trust-wide simulation teaching for new trainees.

Audit Cycle 2 - Patient data collection August - October 2021

Results

Audit Cycle 1:

15 incidents

2 involving anchor point/drop

Medic informed in 4 incidents

0 documented in ABCDE format

0 NEWS monitoring

3 follow-up plans documented

3 complications reported

Audit Cycle 2:

10 incidents

0 involving anchor point/drop

Medic informed in 4 incidents

0 documented in ABCDE format

NEWS monitored in 6 incidents

4 follow-up plans documented

3 complications reported

Overall, slight improvement in documentation of NEWS monitoring and follow-up.

Conclusion

Documentation continues to be highly variable. This may be because the teaching done was not trust-wide, simulation session involved only on new doctors in August, some incidents involved locum doctors, and small reach of assessment tool.

We aim to introduce the post-ligature assessment tool as part of trust practice through liaison with the resus teaching team, as well as incorporating it permanently into trust-wide simulation induction teaching.
An Audit on Driving Advice After Hospitalization in a Mental Health Unit
Authors: Elsankary Mohammed , Fawaz Israa , Shazad Farhan , Elashmawy Maged
Published: June 2022

Aims

To ensure driving status is confirmed on admission (Target 100%) and to confirm driving advice is given to all patients deemed unfit to drive (Target 100%) and to ensure adequate documentation is made in online clinical notes with regards to discussions about driving

Methods

The first cycle of data involved collecting retrospective data from two acute adult psychiatric units and one old age mental health ward. The first cycle of data consisted of inpatients admitted over a two month period in 2020 (36). Data were collected from OpenRio progress notes, OpenRio ward round notes and patient discharge summaries. Following the implementation of interventions the second cycle of data were collected over a 2 month period in 2021. 51 patients met the inclusion criteria for this.

Results

Following our interventions, 47% (24) of patients had their driving status confirmed on/during admission compared to 42% (15) in the first cycle. 15 current drivers were identified in the second cycle.

Of the confirmed drivers, there was a 6% improvement of patients informed they were unfit to drive. A 22% increase in patients given DVLA driving advice was also noted. DVLA notifications increased by 18% following the interventions.

Conclusion

This quality improvement project has shown that educational awareness through teaching sessions and written guidance can improve adherence to national legal guidance. However, further work is required to ensure all psychiatric patients receive adequate information regarding their fitness to drive.
Time to Rectify the Neglect? Audit on Prescription Writing the Neglected skill. Audit Ref No: AU/006/01/2021
Authors: Fulmali Amit , Sheik Sara , Suleman Amir-Humza , Rana Faryal , Bloxam Ruth , Abdallah Lubna , Mahanta Ranjit
Published: June 2022

Aims

Prescribing is a neglected skill amongst trainees. Prescription errors can harm patients. A recent Economic analysis published in BMJ Quality & Safety. Estimated that 237 million medication errors occur in England annually. Costing the NHS £98,462,582. Prescribing errors contributed to 21% of the total errors. It is important that all prescribers are aware of principles of safe prescribing. Our aim is to is to establish whether our practice is meeting standards of prescription writing in old age psychiatry ward setup.

Methods

We used prescription standards set by BMA, BNF and SABP (Surrey and Borders Partnership Foundation NHS Trust) to assess all prescriptions. The following parameters were checked: GMC number, Sign, Name of Doctor, Name of drug, Indication, Dose, Route, Frequency, Original start date, current Date, medication timings.

Data collection and handling

We performed a closed loop audit. A retrospective data of 228 prescriptions were collected from August 2020 to January 2021 from patients admitted in Victoria Ward. The data were analysed and presented at departmental meeting. Re-training on prescription writing conducted. New data was prospectively collected comprising of 230 prescriptions from March 2021 to June 2021 to complete the audit cycle.

Excel sheet was used to collect the data and to get the results. All Prescription charts were collected from SystmOne (clinical software system). Data from both the Audit's were analysed and compared.

Results

We found errors in all parameters, except for medication timings. Comparison of the data from the first audit and re-audit showed an increase in prescription errors.

There was an increased 20.33% error in writing GMC number, 16.87% error in writing name of the doctor, 12.94% error in indication and 5% error in original start date. There was improvement of 10.88% in one parameter, “Name of the drug”.

Conclusion

A significant error was found in writing the GMC number and the Doctor's name, despite regular training during induction. There are no clear guidelines on the writing of GMC registration being compulsory on Drug chart. With one exception if online and you are not the patient's regular prescriber, then your GMC registration number is required.

Recommendations

1.

We recommended the trust to issue stamps with GMC number and doctor's name.

2.

Re-audit in 6 months’ time after introduction of the stamps.

3.

Quarterly regular training of new Trainee doctors.

Service improvements

After the Audit was submitted locally, stamps were introduced and issued to junior doctors at Victoria Ward by the Trust.
Audit of Adherence to Prescribing Guidelines of Psychotropic Drugs for People With Intellectual Disability and Behaviours That Challenge -Specialist Support Team -SST-Merseycare NHS Foundation Trust
Authors: Hasan Syeda , Spurrell Mark
Published: June 2022

Aims

There are concerns following the Winterbourne view investigation and from the Learning Disabilities Census that psychotropic medications are being inappropriately given to people with learning disability as a means of managing difficult behaviours. Stopping Overuse of Medication in People with Learning Disability (STOMP) is a key area which has been identified as needing improvement for the Transforming Care Programme which is being supported by the Royal College of Psychiatrists. Members are encouraged include STOMP in their local audits. It is for this reason that the topic has been chosen. The overall aim of this project is to capture the snapshot of prescribing of psychotropic medications for people under SST care. This information has been used for establishing baseline of current practice as they are happening and to develop SST base response to support STOMP agenda.

Methods

The population audited was patients open to the SST LANCS/GM. Patients had to be between 18 and 65 years old, have a diagnosis of a learning disability and be known to have challenging behaviour. Patients were excluded from the audit if they had no challenging behaviour, had been discharged from services. The sample size was 20 (10 from GM and 10 from LANCS). Data were collected using the proforma and then entered into Microsoft excel for analysis.

Results

Four overall standards were audited, each with key lines of enquiry within the standard audited to help determine compliance. Overall compliance for standard one, the indication and rationale should be clearly stated, was 50%. For standard 2, consent to treatment procedure, the third standard, regular monitoring of the treatment response and side effects, and the final standard, review and evaluation of the need for continuation or discontinuation of the psychotropic drug, the compliance was less than 10%. It should be noted that the audit erred on the side of counting in any information that suggested that the theme had been thought about at all: an in depth capturing of any of the themes did not feature in the sample.

Conclusion

This audit highlights important issues for improvement within the SST both in relation to better supporting STOMP and good psychotropic medication management practice, and in relation to its documentation. It also serves as a springboard to a number of initiatives that would help to turn that situation around. In the light of concerns, an early re-audit of practice is recommended.
Psychosis Early Intervention in Southwark – Gold Standard Prescribing vs Reality
Authors: Irvine Jenny , Huang Xiaofei Fiona , Farahani-Englefield Yasamine
Published: June 2022

Aims

The RCPsych Standards for Early Intervention in Psychosis Services documents Gold Standard treatment, including: every service-user with psychosis is offered antipsychotic medication; if their illness does not respond to therapeutic dose of 2 different antipsychotics, they are offered clozapine. The Southwark Team for Early Psychosis (‘STEP’) in the South London and Maudsley Trust (SLaM) treats adults in their first 3 years of psychosis diagnoses. We aimed to compare prescribing practice in STEP to RCPsych Standards.

Methods

STEP's caseload of 296 individuals was reviewed on 7th June 2021. Those excluded: inpatients/under Home Treatment Team; not yet assessed. Final number of outpatients assessed = 269. Data gathered: 1) Taking an AP? If taking an AP, the name and dose of AP. If not taking, trial discontinuation with medical advice or unsupervised refusal? 2) Remission status 3) Total number of AP trials. Uncertainties in categorisation were reviewed by the 2 other contributors.

Results

In 269 outpatients on 7/6/21, 186(69%) were taking an antipsychotic (167:19 oral:depot), with a further 62(23%) recommended but declining. 21(8%) were not recommended, following change in diagnosis or resolution of psychotic symptoms.

7 service-users had down-titrated off AP with medical collaboration. All but 1 remained in remission. 35/47(74%) who discontinued AP independently had relapsed.

172 patients were reliably taking antipsychotic medication as prescribed. 56(32.5%) had ongoing psychotic symptoms (ranging from non-preoccupying residual delusions to distressing delusions/hallucinations). 4 symptomatic service-users were prescribed lower than BNF minimum effective doses.

Of those symptomatic and on hypothetically therapeutic doses (n = 52; median% of BNF Maximum Dose 50%; mean 54%), 26 were on their 1st AP, 26 on or beyond their 2nd AP. 8 service-users had ever trialled clozapine.

Conclusion

Even in an experienced EI team for a highly psychiatrically morbid population, there remain gaps between best practice and actual prescribing.

Close to 1/3 of patients taking their prescription weren't in remission, almost all of whom had room to increase doses or trial an alternative medication. Clozapine is under-utilised in the treatment resistant group. For those who stopped AP, supervised tapering is a reasonable treatment option.

The next steps will be run as a quality improvement project addressing MDT and service-user barriers to assertive medication management:

–

Trial methods to improve adherence (depot prescribing, psychoeducation, peer support)

–

Encourage efficient up-titration and frequent MDT review of AP efficacy (empowering service-users self-management, care-coordinator opportunistic mental state assessments to trigger dose increase, medical review frequency)

–

Identify and refer service-users suitable for clozapine
Making Sense of the Urgent GP Referrals; Audit Into How Many Are Actually Urgent?
Authors: Junaid Minahil , Habeeb Bassem
Published: June 2022

Aims

The trust policy dictates that all urgent GP referrals should be contacted within 48 hours by the duty team. The duty team carries out a telephone screening assessment and offers the patients who are deemed to be urgent, a face-to-face assessment. Those who are not assessed to be urgent are signposted to the right service.

Methods

All the urgent GP referrals of the month of July 2021 were followed up retrospectively and the outcome was recorded to assess the influx and outcome of urgent referrals from primary care. The urgent referrals from all other routes such as Psychiatric Liaison, and Social Services, Police etc were not included in the data.

Results

A total of 124 urgent referrals were received in the month of July 2021. Only 13 out the 124 were deemed urgent following the telephone assessment and they were offered a face-to-face assessment. Fifty three patients were referred to primary care mental health team, 24 were referred to the secondary community mental health, 20 were referred to the older adults team and 10 were discharged back to the GP following. Out of the 13 who were assessed by the duty team, 6 patients were referred to primary care mental health team and 6 were referred to the secondary community mental health team. The urgent referrals came from 20 GP surgeries that cover a wide area of the rural and urban communities and the surgeries with most urgent referrals were highlighted

Conclusion

Trying to work on improving the quality of urgent referrals, the team tried to analyse the results, which proved to be complicated. The efforts to standardise the referral process has depended mainly on the degree of awareness of the GPs about the way the mental health service operates considering there is a percentage of locum GPs who might not be fully aware of how mental health service works.

The recommendation of the audit is to arrange visits to the GP surgeries to work on raising awareness among GPs about the referral system to the Mental Health team. It is also recommended that the GPs should be able to complete a brief risk assessment to justify why the referred patient needs to be reviewed urgently instead of on routine basis.
Prescribing and Monitoring of High Dose Antipsychotic Therapy (HDAT) in the Acute Inpatient Setting
Authors: Buston Gemma , Kay Helen , Nwibe Ife , Edge Oliver , Sparasci Oli , Sindhi Amit
Published: June 2022

Aims

High Dose Antipsychotic Therapy (HDAT) is defined by the Royal College of Psychiatrists as either: a total daily dose of a single antipsychotic which exceeds the upper limit stated in the BNF, or a total daily dose of two or more antipsychotics which exceeds the BNF maximum calculated by percentage. HDAT is defined as ‘off-label’ prescribing and the prescribing clinician should clearly document rationale for its prescription and clear discussion with the patient regarding the risks and benefits. If the patient is deemed to lack capacity, this should be clearly documented, and appropriate legal processes followed as defined by the Mental Health Act 1983. The use of HDAT comes with greater risk of physical health complications and requires regular monitoring of electrocardiogram (ECG), body mass index (BMI) and blood biochemistry. Aims: To re-audit the number of inpatients prescribed HDAT across three acute general adult inpatient wards, and to establish whether guidelines for the prescribing and monitoring of HDAT are adhered to.

Methods

Initial audit was completed in January 2020. Education sessions were provided to rotational junior doctors in the six months following initial audit. For re-audit, medication cards for each patient on the electronic bed-state at 9pm on 27/11/2021 were checked for HDAT prescription. Data were collected from electronic notes of patients identified as being on HDAT.

Results

Initial audit in 2020 demonstrated that 3 of 49 inpatients (6%) were prescribed HDAT, with no evidence of documentation of rationale, and variable monitoring of physical health indicators. Re-audit in 2021 demonstrated that 11 of 47 inpatients (23%) were identified as being on HDAT. Of those, seven instances of HDAT were commenced during review by the multidisciplinary team or the consultant, with only two of these cases noting that the medication prescribed would result in initiating HDAT. Of the remaining cases, the prescriber was unclear. Eight had an ECG within a month prior to commencing HDAT. Only three patients had a repeat ECG within 7 days of initiation. Three patients were noted to gain at least 5 kg in weight following implementation of HDAT.

Conclusion

Education of junior doctors following initial audit had limited impact, likely due to high turnover of doctors. Implementations currently in development include: 1) Departmental teaching session for doctors of all grades, 2) Introduction of stickers on medication charts for patients prescribed HDAT to highlight monitoring recommendations, 3) Development of ward round template to include review of HDAT.
A Survey of Transitions of Young People From Child & Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS)
Authors: Khan Umama , Turk Jeremy
Published: June 2022

Aims

To evaluate current transition service provision from CAMHS to AMHS focusing on information sharing, transition planning and continuity of care. Many young people find service transition from CAMHS to AMHS stressful, sometimes because of there being multiple simultaneous transitions from child centred services to adult oriented models of care. If not handled well, this can lead to drop out from services, repeated assessments, suboptimal treatment and support, and raised likelihood of emergency psychiatric admissions. Longitudinal planning and sensitive management of transition is vital, because of transition being a risk period for young people.

Methods

A retrospective case note survey of service users who had transitioned from 1st February 2020 to 31st January to 2022 was undertaken. Fifteen individuals transitioned: 9 females and 6 males. All were White British except for one who was Sudanese and an asylum seeker. Six out of 15 young people had a diagnosis of Autism Spectrum Disorder (ASD) in addition to other diagnoses making transition more difficult, as more agencies were involved requiring multiple meetings prior to transition to adult services. One case of emerging personality disorder, despite our best efforts for smooth transitioning, had already disengaged from CAMHS.

Results

Most individuals transitioned successfully to adult mental health services. Two were transferred to learning disability, and one to early intervention in psychosis services, the diagnoses having been confirmed by the treating psychiatrist near the patient's 18th birthday. One was transferred to a rehabilitation service. Only one referral was declined.

The transition pathway is patient centred, and provides clear transition plans to young person, family and carers. In the past 4 months AMHS, because of lack of resources, have not been able to identify a named worker till a few weeks before the patient's 18th birthday, which conflicts with NICE guidelines.

Conclusion

An effective transition service was found to include

•

A designated psychiatrist to facilitate smooth transition of complex cases to AMHS, providing continuity of care, good intra and inter agency working and maximising patient welfare.

•

CAMHS preparation of young persons for transition commencing six months before their 18th birthday.

•

Prior researching of best transition destinations.

•

An overlap period of CAMHS/AMHS joint working.

•

Identified CAMHS and AMHS transition coordinators.

•

Patient and family engagement with process.

•

Mindfulness and awareness of AMHS eligibility criteria.
Monitoring of Patients Who Presented With First Episode Psychosis, Under the Early Intervention Team, Against NICE Guidance for Psychosis and Schizophrenia
Authors: Khanna Rahul
Published: June 2022

Aims

To assess the monitoring of patients who present with first episode psychosis (FEP), who are commenced on antipsychotics, under the early intervention team (EIT), in accordance with NICE guidelines. Patients diagnosed with FEP are usually treated with atypical antipsychotic's hence have a higher chance of developing metabolic syndrome, thus screening for physical health is imperative.

Methods

This was a retrospective audit of patients with FEP, started on antipsychotics, under the EIT, between the 1st January 2020 to 31st December 2020. The date range allowed for a complete data set, as well as to assess the impact, if any, of COVID-19. A sample of 26 patients were identified by the EIT of which, once inclusion criteria was applied, 21 were audited.

Compliance was calculated on investigations being completed at every stage, as defined in the standards. For example: blood pressure had to be measured at 12 weeks and 1 year to be compliant with the standard. Data collection and analyses was completed using the IT system ‘Rio’ and Microsoft Excel.

Results

There was an overall compliance rate of 51%. The results showed no patients had their weight/BMI monitored as per guidelines. Waist circumference was not measured in any patients. 43% met the monitoring standards for pulse and blood pressure. On further analysis, by 1 year 90% of patients had their pulse and blood pressure checked. Blood lipids were correctly monitored in 48% of cases, nevertheless when the results were broken down, 86% of patients had been monitored within a year. Prolactin monitoring occurred correctly in 52% of patients. Blood tests including full blood count, urea and electrolytes and liver function tests adhered to guidance greater than other parameters at, 86%, 86% and 90%, respectively. 48% of patients had plasma glucose/HbA1c monitored. An ECG at 1 year was obtained in 67% of the patients.

The compliance rate may have been lower than expected due to COVID-19 preventing in-person appointments, staff redeployment and disengagement from patients.

Conclusion

Monitoring after antipsychotic medication has been commenced requires improvement. Within one year, monitoring was generally met well. However, the monitoring did not always meet the specific time frames provided by NICE, thus current systems need reviewing. Recommendations included disseminating results throughout the EIT, adding waist circumference as an option on the physical health assessment form and create ‘blood sample sets’. Re-audit will allow us to assess the results of interventions and the impact COVID-19 had on monitoring.
Adherence of CAMHS Community Center, Winsford to the NICE Guidelines With Regards to Identification and Management in Depression in Children and Young People (NG134)
Authors: Kour Sanjeet
Published: June 2022

Aims

To evaluate whether the practice in the generic CAMHS team Winsford is in line with the guidelines recommended by NICE in identification and management of depression in CYP. To formulate an action plan that might be needed for the recommendations that are not met currently.

Methods

To collect the relevant information about the identification and management of depression in young people in our community center by following methods:

1.

Review of online case notes, protocols, pathway descriptions, screening forms and proformas

2.

Random review of the last 12 months of practice with random five cases studied per case manager regarding identification and management of depression in the children and young people at the center. To assess this, a proforma will be prepared from the guidelines relevant to the team members. This proforma will be sent to all the clinical workers of the team who will be required to fill it and return it to the lead author.

The population to be included will be all secondary school aged children residing in West Cheshire who are referred to and assessed and managed by the CAMHS community center, Winsford

Results

I am working on this audit currently and will be obtaining the results in two months’ time and hopefully will be able to submit the audit poster well before the International Congress.

Conclusion

This audit will help the team to assess how diligently they are following the recommended NICE guidelines for the identification and management of depression in children and young people and to make appropriate changes in the process to meet the guidelines that are not currently met.
An Audit of Adherence to the Pre-Referral Process for Acute Inpatient Admissions in a Male and a Female Acute Inpatient Unit Over Six Months in Birmingham and Solihull Mental Health Foundation Trust (BSMHFT)
Authors: Lakhani Radhika , Vincent Selvaraj , Nyemitei-Addo Isaac , Patel-Smith Kishan , Ramesh Priyavarshini
Published: June 2022

Aims

In view of the limited number of acute inpatient beds relative to demand in England, a thorough assessment prior to referral is paramount in ascertaining clinical need. A comprehensive risk assessment is crucial in light of patient safety and assessing risk to others. Moreover, the appropriateness of an acute bed should be considered, and whether psychiatric intensive care or forensic services may be more appropriate for the patient. In line with this, the Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) admissions policy details standards of the assessment prior to referral to acute inpatient services. Pre-referral assessment should be carried out by a multidisciplinary team including a senior doctor. It should include rationale and plan of care for admission, risk assessment and section status on admission alongside type of bed being requested. Referrals are accepted from multiple teams including Home Treatment, the Place of Safety and Liaison Psychiatry. Aim: To audit adherence to the pre-referral policy for acute inpatient admissions to a male and female ward in BSMHFT, including comprehensive assessment, plan of care and consideration of appropriate bed type.

Methods

A retrospective audit of pre-referral documentation for all admissions from April to September 2019 to a male and separate female acute inpatient unit at the Zinnia Centre, Birmingham was carried out. This included 83 male admissions and 82 female admissions. Documentation was reviewed on the clinical system Rio. Parameters reviewed included assessing clinician, assessment summary, capacity assessment, consideration of bed type, plan of care and section details.

Results

Overall, almost half of admissions (49%) were assessed by a full Mental Health Act team, 34% by a senior psychiatric doctor and the remainder by psychiatric nurses in the referring department. An up-to-date assessment summary was completed in the majority of cases (67%) prior to referral. Risk assessments were completed in 82% of cases. 35% of cases included a detailed plan of care which met audit standards. Capacity assessment alongside outcome was documented in 13% of cases. The type of bed was only considered in 13% of cases.

Conclusion

Whilst assessment and risk documentation was completed in the majority of cases, few cases had a clear plan of care and appropriateness of bed type was rarely considered in assessment. Greater adherence to the pre-referral process could facilitate treatment decisions during admission and seek to ensure a safer inpatient environment.