bluuebunny/crossref_metadata_2025 huggingface dataset:
Audit of Documentation of Lifestyle Medicine Factors in the Leicestershire Early Intervention Psychosis Team Clinic Letters
Authors: Chithiramohan Tamara , Ahmed Shiraz , Gavotsi Dafni , Das Debasis
Published: August 2024

Aims

Lifestyle medicine promotes the use of therapeutic lifestyle interventions to modify disturbed lifestyle factors which are thought to underlie chronic illnesses, including mental health conditions. It is important to identify and manage any disruptions in factors that lifestyle medicine has identified as being contributory towards sustaining good health. Aims were to identify the extent to which the early intervention in psychosis (EIP) medical team in Leicestershire are enquiring about the pillars of lifestyle medicine.

Methods

There are 6 pillars of lifestyle medicine, namely exercise, sleep, diet, refraining from toxins, positive social interactions and quality personal time. Motivation has been added as the 7th pillar for this audit. Gold standard would be to adequately explore all pillars at each medical review. Retrospective analysis was done of electronic patient records (SystmOne) for all patients on the EIP team case load, available on 19th May 2023. Information was gathered from the most recent medical review, using a predefined audit extraction tool. Information on each pillar was assessed based on whether it was fully explored, mentioned with some detail, mentioned with no further detail, or not mentioned at all. Data collection was carried out by three members of the team (TC, SA and DG).

Results

495 patients were identified and 459 had information from a latest medical review found on SystmOne. For all domains, “not mentioned” was the leader, ranging from 48.6–70.8%). For all domains, except for refraining from toxins, the second most common finding was “mentioned with no further details”.

Conclusion

Our results suggest EIP medical staff are either not discussing many of the seven pillars of lifestyle medicine with patients, or not documenting them in sufficient detail. Limitations of the study include that it was the most recent medical review being audited and there could have been more detail documentation in previous reviews. Distribution of the findings and recommendations from the audit were shared with the team and an educational poster detailing lifestyle factors was created. The online system is being adapted to include an option to input lifestyle factors. Re-audit should be done in 12 months.
An Audit of the Prescribing and Monitoring of Antipsychotic Medication in an Older Adult Inpatient Psychiatric Ward Using NICE Guidance [CG178] Psychosis and Schizophrenia in Adults: Prevention and Management
Authors: Shabaka Alaa , Parry Thomas , Ugah Mary , De Souza Stephen
Published: August 2024

Aims

The National Institute for Health and Care Excellence (NICE) offers guidance for prescribing and monitoring of antipsychotic medications. In this audit we sought to investigate if our unit was compliant with this guidance.

Methods

The audit was carried out on a 28 bedded older adult inpatient psychiatric unit. The notes of all patients admitted to this ward on 27/11/2023 were reviewed. Any patient on an antipsychotic was included in the audit. Four standards reflecting the prescribing and monitoring of antipsychotics were identified. These were:

1.3.5.1 The choice of antipsychotic medication should be made by the service user and healthcare professional together, taking into account the views of the carer if the service user agrees.

1.3.6.1 Before starting antipsychotic medication, undertake and record the baseline investigations.

1.3.6.2 Before starting antipsychotic medication, offer the person with psychosis or schizophrenia an electrocardiogram (ECG).

1.3.6.3 Treatment with antipsychotic medication should be considered an explicit individual therapeutic trial.

1.3.6.4 Monitor and record the following (response to treatment – side effects – adherence – physical health) regularly and systematically throughout treatment.

These five areas of guidance were broken down into 22 domains which are outlined in results below.

Results

Of 28 patients admitted to the ward, 22 were on antipsychotic medication.

1.3.5.1: Medication benefits were discussed and documented in 9/19 cases (47%), with 3 patients refusing to engage in this discussion. Side effects were discussed and documented in 5/21 cases (23%).

1.3.6.1: Patients underwent a range of investigations. In some cases, the patient hadn't been on the medication for long enough to require additional tests. Some patients were excluded as they refused testing. Glycosylated Haemoglobin (100%), Weight (100%), Pulse and Blood Pressure (100%), Blood Lipid Profile (86%), Prolactin Levels (77%), Assessment of nutritional status, diet (77%), baseline fasting blood glucose (38%), Level of Physical Activity (31%), Assessment of any movement disorder (22%), Waist Circumference (0%).

1.3.6.2: An ECG was offered in 94% of cases.

1.3.6.3: The rationale of continuing, changing or stopping the medication was recorded in 86% cases and no patients had antipsychotic doses above BNF maximum.

1.3.6.4: Overall physical health monitoring, weekly weights and, pulse and BP at 12 weeks (100%). Adherence and response to treatment were both 95%. Measurement of glycaemic control (57%), movement disorders (14%) and side effects (13%).

Conclusion

While there are areas of good practice, there are a number of significant omissions. Remedies to these deficits will be proposed.
An Audit of the Consistency and Quality of Letters From Choice Appointments in CAMHS South Edinburgh
Authors: Dempsey Eileen
Published: August 2024

Aims

Hypothesis: Choice letters generated by Child & Adolescent Mental Health Services (CAMHS) South Edinburgh are not consistent in quality and content.

Aims:

1.

To assess the consistency and quality of letters generated by clinicians following Choice appointments in CAMHS South.

2.

To observe the range of resources shared in Choice letters.

Methods

Patients were identified retrospectively from the team Choice diary.

Choice or Complex Choice appointments attended between 13th October–27th November 2023 at CAMHS South were included. See Soon appointments and appointments that were not attended or cancelled were excluded.

Standards to which all letters should adhere were devised from the CAPA (Choice & Partnership Approach) Book and the CAMHS South Choice Handbook.

Standards: current concerns, background information, patient goals, clinician impression, choices discussed, choices made, self-help agreed, services required, maximum two sides of A4, copy to patient, copy to referrer, sent within two weeks.

Letters were accessed via electronic records and analysed with a proforma.

A maximum of three letters per clinician was included.

A log of resources and frequency shared was kept.

Results

57 appointments were attended, with 50 letters generated by 22 clinicians.

Adherence to standards in 50 available letters:

Current concerns 92%

Background information 96%

Patient goals 40%

Clinician impression 62%

Choices discussed 22%

Choices made 100%

Self-help agreed 52%

Services required 100%

Maximum two sides of A4 50%

Copy to patient 88%

Copy to referrer 100%

Sent within two weeks 72%

94 different resources were shared in the letters, with minimum 0 resources and maximum 19 resources per letter.

Conclusion

There were areas of good quality and consistency in Choice letters, including documentation of current concerns, background information, and highlighting of required services. These are areas likely to feature in most assessments regardless of clinician background.

There were areas that require improvement, including documentation of goals, clinician impression, self-help agreed, and keeping to a maximum of two sides of A4. These areas are perhaps more obscure for different types of clinician.

A wide range of resources were shared in Choice letters with a considerable amount of variability in number of resources. This suggests differing levels of individualisation of resources to the patient.

Since this audit, CAMHS South have implemented additional Choice training, electronic canned text for letters, and collation of Choice guidance. There is a plan to re-audit following these interventions.
Audit on Antidepressant Prescribing; Documentation of Indication; and Compliance With EIPN Standards in Medication Review, at Hailsham Early Intervention in Psychosis Service
Authors: Di Francesco Daniel , Todd James , Brooke Alice
Published: August 2024

Aims

•

To improve documentation of antidepressant prescribing in our service, aiming to improve frequency of review, and guide measurement of outcomes.

•

Identify patients requiring medical review.

The standards that we audited against are that, for patients under The Early Intervention in Psychosis Service (EIPS), a diagnosis should be recorded alongside each antidepressant prescription and, according to EIPN guidelines, psychotropic medications should be reviewed every 6 months.

Population data from the UK indicates that lack of recording of a diagnosis is associated with increased duration of treatment, and reduced frequency of mental health reviews.

Methods

It was recorded for each patient whether they had an antidepressant prescribed, which medication, the documented indication, and their most recent medical review. Data was collected in a ‘snapshot' cross section of all 89 patients on the caseload in December 2023.

Data was obtained from carenotes by reviewing clinic letters and clinical notes; and cross-referencing with GP records.

Results

33 patients (37%) were prescribed an antidepressant. Of these, 25 (76%) had a recorded indication. The commonest indication was mixed anxiety and depression followed by depression. Sertraline was by far the commonest prescribed antidepressant (52%) followed by mirtazapine. 3 patients were prescribed combination antidepressants. 67 patients (84%) had had a medical review within 6 months.

Conclusion

Among patients with a first episode of psychosis, there is a significant comorbidity of depression and anxiety spectrum disorders.

Our standard was met for most patients but there were several exceptions, and we considered why 8 patients did not have a listed diagnosis. There can be a degree of diagnostic uncertainty in distinguishing anxiety and depressive disorders from negative symptoms, and the affective changes that are an established part of recovery from an acute psychotic episode. In these circumstances it may be appropriate to consider a trial of antidepressants in consultation with the patient. Some of these patients also have been on long-term therapy which preceded their referral to EIPS, leading to uncertainty of the indication and pre-morbid status.

We conclude the following recommendations:

1.

Prompt a review of antidepressant use in those identified without a clear indication, discussing risks and benefits with the patient at next review.

2.

Arrange medical reviews for those exceeding the 6-monthly window.

3.

Record last review for patients under shared care.

4.

Re-audit in 6 months to monitor improvement.
Keeping Up Standards: An Audit of Adherence to Admission Standards on Acute Mental Health Wards in NHS Lanarkshire
Authors: Adam Louisa , Dillon Shaina , Docherty Emma , Guarino Francesca , Lindsay Leanne
Published: August 2024

Aims

We audited the adherence to part of the minimum admission standards for Mental Health, Learning Disabilities and Addictions Services (MHLDA) for 6 acute wards, across two sites (UHH and UHW) in NHS Lanarkshire. We focussed on the section of the standards that the admitting junior doctor/ANP is responsible for. This comprised:

•

An admission assessment (including presenting complaint, history of current episode of illness, medication, mental state examination and risk assessment).

•

Physical health assessment (examination, bloods, ECG, VTE assessment), medicine reconciliation and prescribing on HEPMA - within 12 hours.

Methods

Five individuals collected data across both sites and both cycles. For our first cycle, all admissions in March 2023 were retrospectively reviewed, a total of 94 admissions (UHH 47, UHW 47). Electronic notes/systems were reviewed (Morse, Clinical Portal, Hepma, Trakcare).

This first cycle demonstrated poor adherence to the minimum admissions standards. A proforma for admission statement was created, including prompts for the admission assessment and for the components of the physical health assessment, medicines reconciliation and prescribing. Presentations were made at postgraduate teaching and at ANP teaching. The majority of people were unaware of the existence of the admission standards or did not know where to find them. The admission standards document and the proforma were circulated via email and added to the shared R drive. A second cycle was completed, reviewing all admissions in July 2023, a total of 74 admissions (UHH 41, UHW 33). The proforma has now been included in the induction material for new doctors.

Results

Following interventions, there was improvement in completion of admission statement (90% vs 81%). There was improvement in the inclusion of all components, most notably MSE (91% vs 71%) and risk assessment (59% vs 18%). Where the proforma was used (57%), all aspects of admission statement were present (97–100%). When not used, there was variable inclusion of the different components (7–90%). There was improvement in the completion of all components of physical health assessment (except small decrease in medicine reconciliation). In every case of missing components with no documentation as to why, the proforma had not been used.

Conclusion

Development of a proforma for admission assessment has led to improved completion of admission assessment, physical health assessment, medicines reconciliation and prescribing within 12 hours. Qualitative feedback is being sought on the proforma from junior doctors, ANPs and senior medics to guide next steps and further improvements. Review of the admissions standards guidance is now due.
Clinical Audit of Dementia Diagnosis and Management – According to Disease Severity
Authors: Fatunla Sylvia
Published: August 2024

Aims

The NICE guidelines NG97 (1.5) currently recommend to consider memantine in addition to acetylcholinesterase inhibitors in the management of moderate to severe Alzheimer's dementia, if tolerated, as opposed to the mono-therapeutic management with either class of drug. This management practice was adopted by the trust and updated on Trust guidelines.

I noted that most of the patients on follow up in memory clinic, had a generic diagnosis of dementia subtypes, without a mention of the degree of severity of the illness and as such, on monotherapy.

Aim

This audit serves to establish the practice in recent years, if patients diagnosed with dementia, were diagnosed, and managed according to the severity of their condition.

If not, for necessary changes to be implemented in practice and a re-audit carried out.

Methods

The audit was conducted in February 2023 as a retrospective study. We analysed records of 60 patients seen for a diagnostic appointment in Middlesbrough Memory Service between January 2020 and December 2020.

All referrals made to the memory clinic within 2020 were retrieved from trust electronic records and 5 patients were selected at random from each month using the google random number generator, and analysed on Excel.

Results

The most common dementia diagnosis was mixed dementia (Alzheimer's + vascular disease) with 40% of diagnoses, followed by Alzheimer's disease at 39%, while Lewy body dementia was least diagnosed at 8%.

Assessment: Only 46 records completed the dementia diagnostic pathway (initial assessment, ACE III, CT scan alongside pre-referral blood screen), the other 14 patients were unable to complete this pathway due to functional decline.

Severity of illness: Of the patients evaluated, only 7% had the severity of disease in their diagnosis, which were all Moderate severity. 93% had generic diagnosis.

Pharmacological Treatment: 46 out of 60 patients evaluated, were on medication.

And all were on monotherapy, irrespective of disease severity, with majority being on anticholinesterase inhibitors (Donepezil) being the first and most popular choice.

Conclusion

Severity of disease condition were not identified or documented.

The use of combination therapy is yet to be considered at the diagnostic stage. This should be implemented before discharging a patient with moderate to severe disease. Although, local best practice is to offer this as early as moderate disease is identified.

Combination therapy is yet to be adopted in the organic pathway.
Improving Handover Between Psychiatric and Acute Wards
Authors: James-Thomson Hilary
Published: August 2024

Aims

1.

To develop an understanding of transfers in both directions between Psychiatry and the other Acute wards within FVRH.

2.

To improve compliance with National standards of handover as laid out by NICE and GMC.

Methods

Data was taken from a combination of the care partner, trakcare, and HepMA systems looking at the quality, content and professionals involved in handover. This was done for all transfers in and out of 2 old age psychiatry wards over a 2 week period. The auditing of transfers into MHU and transfers out of MHU initially started as 2 separate projects with staggered data collection; these were combined after baseline data was collected, and the intervention and re-audit phases treated the two as a single project. Data was compared with the standards collated from GMC and NICE guidance.

Results

Transfer handovers in neither direction met audit standards at baseline assessment.

Interventions focusing on behavioural change in the mental health unit did achieve behavioural change but failed to solve issues with handover between departments.

It is worth noting that there was significant delay in some transfers out of mental health being escalated, considering the reduced facilities in mental health wards versus acute wards.

Conclusion

Transfer handover between Psychiatry and Acute Wards is a multi-system issue and as such will require a multi-system approach to achieve meaningful change. New local guidance for handover between mental health and acute wards is being drafted in response to the findings of this audit.
Monitoring of Blood Clozapine Levels After a Change in Smoking Status for Patients Treated With Clozapine: A Clinical Audit From Hull Community Mental Health Team
Authors: Mahmood Kamran , Anakebe Odira , Theobalds-Ward Keshia , Gulati Madhu
Published: August 2024

Aims

According to The Medicines and Healthcare products Regulatory Agency (MHRA) Drug safety update in August 2020 regarding clozapine, monitoring blood clozapine levels for toxicity is now advised in certain clinical situations such as when a patient stops smoking or changes to e-cigarette.

Aim of this audit was to determine whether blood clozapine levels are being performed in patients on clozapine when there has been a change in patient’s smoking status from two localities, East and West Hull community mental health team.

Because there is a risk of significant blood clozapine change within 3–5 days post starting or stopping smoking which consequently increases the risk of toxicity, we also looked at whether a medical review was undertaken post change in smoking status in order to review if any adjustment was required in current clozapine dose.

Methods

A list of Hull CMHT patients on clozapine was obtained from local clozapine clinic. The data comprised patients who were on clozapine from both localities of CMHT between October 2022 to October 2023.

Data was obtained retrospectively from Trust's patient electronic record system.

Eligibility criteria was set for the patient on clozapine to be a current smoker, or have been a smoker over last 12 months. Non-smokers and the ones on clozapine without a change in smoking status over the duration period were excluded.

58 patients were identified to be smokers and taking clozapine. Change in smoking status was documented in 21 instances, and therefore included in final analysis of results.

Results

42.86% patients had a clozapine blood level check post smoking status change.

19% of patients from our sample had a medical review after change in smoking status within the duration time of audit.

Conclusion

We concluded that compliance with current MHRA guidelines in relation to blood clozapine levels and change in smoking status is quite poor in Hull CMHT and measures are needed for improvement.

We recommend that every patient with a change in smoking status must have blood clozapine level checked within a week of any change in smoking status and a medical review in two weeks. We identified some scope of improving current clozapine monitoring form on electronic system and recommend changes by adding a section where change in smoking status is recorded.
Lithium Prescribing on an Older Adult Inpatient Ward and Trialling Improvements to Communication on Discharge
Authors: Patkee Wishwanath , Barclay James
Published: August 2024

Aims

Lithium is the recommended first-line pharmacological treatment for bipolar disorder and as an augmentation of the treatment for depression. Both NICE and local guidelines stipulate the need for patient counselling regarding side effects, interactions and toxicity, alongside strict monitoring requirements for initiation and maintenance.

We aimed to assess compliance with these guidelines for patients prescribed lithium on a functional older adult inpatient ward in Hertfordshire Partnership NHS Foundation Trust (HPFT). Additionally, following feedback from the local crisis and community colleagues, concerns were emphasised around inconsistent communication on discharge. We therefore also aimed to evaluate the introduction of a small-scale intervention to the method of discharge communication.

Methods

A retrospective analysis of electronic patient records was undertaken for the 43 patients within HPFT prescribed lithium during their inpatient stay on a functional older adult ward over a five-year period (2019–2023).

Lithium monitoring on drug initiation was assessed for compliance with the standards set by NICE guidelines for the management of bipolar disorder. For all patients prescribed lithium, we also noted demographics, diagnosis, rate of side effects and toxicity, discontinuation, and documentation of discharge communication to the community. A standardised template for communication with community and crisis colleagues was introduced, and its impact was assessed.

Results

58% (n = 25) of patients were initiated on lithium, with 80% (n = 20) of them having documentation of counselling. Baseline blood tests were consistently recorded for all newly prescribed lithium patients (n = 25), and regular serum monitoring was present in all patients. Common side effects included tremors (26%; n = 11) and polyuria (7%; n = 3), while in 63% of patients (n = 27), no side effects were noted. Toxicity occurred in four cases, leading to discontinuation in 50% of them.

Prior to concerns being highlighted around handovers to community colleagues, there was specific documentation of a handover in 19% (n = 6) of cases. Following consultation with stakeholders and consensus regarding the trial of a template for communication to the patient's community consultant, documentation improved to 75% (n = 6).

Conclusion

All patients in this study who were initiated or maintained on lithium received serum monitoring as inpatients in accordance with NICE guidelines. The introduction of small-scale improvements with a standardised template has been effective, significantly improving discharge communication with community colleagues for patients on lithium. Further research is necessary to elucidate the impact of these changes on patient care in the community by gathering feedback from a diverse group of community colleagues.
An Audit: Compliance of Controlled Drug Prescriptions With Legal Requirements and Approved Home Office Wording
Authors: Saeger Ivan , Sandhu Callum , Kelleher Michael
Published: August 2024

Aims

The completion of methadone and buprenorphine prescriptions, together: opioid substitution therapy (OST), must conform to legal requirements for the prescription of controlled drugs (CDs) as well as Home Office approved wording when writing instalment prescriptions.

Our service uses a part automated printing system for individual prescriptions and uses a manual record to track prescriptions issued for individual clients over time, a “script record”.

We aimed to audit the terms used on the internal script record as well to audit compliance of OST prescriptions with the legal requirements for CD prescriptions and Home Office Approved wording for instalments.

Methods

All prescriptions for methadone or buprenorphine over the course of a week that were prepared for signing were audited.

The prescriptions were audited against the legal requirements for writing CD prescriptions and against Home Office approved wording for instalment prescriptions.

The script record was audited against internal standards for variation of terms used to describe frequency of collection of instalments.

Results

A total of 64 prescriptions were audited.

100% of prescriptions complied with the legal requirements for the prescription of CDs.

7 prescriptions (11%) omitted Home Office approved wording to instruct what should be done on days when the dispensing pharmacist was closed, i.e. that instalments should be dispensed on the prior open day.

46 prescriptions (72%) had additional Home Office approved wording that was not applicable to the script. For example additional wording to allow for pickup of part of an instalment following a missed day, when the prescription was only for daily supervised consumption to begin with.

Audit of the internal script record found a total of 13 different terms used to describe frequency of collection of instalments; there are 6 standardised terms used within the internal script record. On 2 occasions the frequency of collection of instalments was left blank.

Conclusion

It is essential that prescriptions for controlled drugs follow the legal requirements laid out for them; within the scope of our audit these were entirely adhered to.

There was however more variability in the use of the Home Office approved wording for instalments of OST. Scripts here tended to error for including additional wording not relevant to the specific script. Additionally, the service's own internal script record showed variability in the terms used to describe frequency of collection.

It is evidently important that the wording on prescriptions is clear and concise and the terms used internally are standardised.
Audit of Admissions to Acute Psychiatric Inpatient Unit of Patients With Eating Disorders/Disordered Eating
Authors: Sanglikar Roopa , Martyn Gabriela
Published: August 2024

Aims

The aim of this study was to understand current clinical practice, adherence to evidence-based guidelines, and the perceptions, knowledge and attitudes of the multidisciplinary team caring for inpatients with eating disorder/disordered eating on general adult psychiatric ward.

Methods

The audit was undertaken at inpatient general adult psychiatry ward between 1st July 2022 to 30th April 2023. A retrospective method was used to collect data on admissions of patients with eating disorder/disordered eating alongside qualitative data retrieved for perceptions, knowledge and attitudes of the multidisciplinary team (MDT) and use of and adherence to national guidelines. The data was collected from everyday bed state and MDT handover, admission summary, electronic notes which included physical health charts and discharge summaries. The MDT staff involved were nurses, doctors, health care assistants, dieticians, psychologist, and occupational therapist.

Patients were included if eating disorder management was indicated and undertaken at some stage during the admission, even if the eating disorder was not the primary reason for admission. The age group was above 18 years and included male and female patients. Eight discrete admissions (6 females, 1 male and 1 transgender patient) were included in the audit. Adverse events like refeeding syndrome, electrolyte derangement needing Intravenous/Nasogastric tube feeding, self-harm, level of cooperation between medical and community eating disorders team, community mental health teams and outcomes were recorded. Data analysis was done through Microsoft Excel. Percentages of patients who had met each of the standards were calculated. Documented practices were compared in line with standards of NICE (National Institute for Health and Care Excellence) guidelines and MEED (Medical Emergencies in Eating Disorders) guidelines.

Results

The audit concluded that gaps exist between evidence-based practice and patient care. Despite being admitted due to concern about eating difficulties, a substantial number of patients were not given an eating disorder diagnosis on discharge. And the patients who had eating disorder as primary diagnosis had limited inreach support from specialist team.

Conclusion

There is major challenge in management of disordered eating presentations within inpatient general adult psychiatry units and inreach specialist support for those admitted with eating disorders as primary diagnosis. These findings emphasize for targeted implementation strategies to improve patient care and uptake of research into practice.
Audit of Shared Care Guideline Compliance for ADHD Patients: Monitoring Physical Observations by General Practitioners
Authors: Utomi Chinwe
Published: August 2024

Aims

To evaluate the adherence to shared care guidelines for ADHD patients by assessing if their Blood Pressure, Pulse Rate, and Weight have been monitored at least twice within the last year by their GP, as recommended by NICE guidelines.

Following initiation and stabilization on an ADHD medication, shared care with the GP is initiated whereby the GP is responsible for prescribing the medication, and monitoring physical observations every 6 months.

Methods

Data Collection:

a. Collate the list of patients that were due for annual structured review in August and September 2023 from the team's shared drive.

b. Randomly select 50 patients from this list.

Inclusion criteria:

1. Patient must have been on ADHD medication in the past 12 months.

Data Assessment:

a. Access the GP records (Patient Practice Management system) for the selected 50 patients.

b. Review the patient records for each of these 50 patients to identify when Blood Pressure, Pulse Rate, and Weight measurements were recorded within the last 12 months.

c. Record the date and results of the Blood Pressure, Pulse Rate, and Weight measurements for each patient.

d. Determine if each patient had these measurements done at least twice within the last year as per NICE guidelines.

e. Calculate the percentage of patients who met this guideline.

Results

Sample size: 22 patients patients met the inclusion criteria.

•

Blood pressure checked within the last 6 months – 22/22 (100%)

Blood pressure checked within the last 1 year – 19/22 (86%)

•

Pulse rate checked within the last 6 months – 20/22 (90%)

Pulse rate checked within the last 1 year – 18/22 (81%)

•

Weight checked within the last 6 months – 21/22 (95%)

Weight checked within the last 1 year – 20/22 (90%)

8 out of 22 had a “significant” change in their BP reading.

This significance is in keeping with NICE Guidelines that is, an increase of 2–4 mmHg for patients on ADHD medication, but this is generally not significant in terms of risk.

How was the project outcome disseminated?

A letter was sent out to GP practices commending the positive outcome of the audit. Recommendations for further improvement were suggested flagging up a review if there is a reduction of 10% or more in body weight within 12 months of treatment.

Conclusion

The positive outcome of the audit shows the effectiveness of current practices. However, it's important to maintain a commitment to ongoing improvement. Regular evaluations and audits remain essential to adapt to evolving guidelines, address emerging challenges, and sustain a culture of excellence in healthcare delivery.
Community Clozapine Initiation Practice
Authors: Yisa Kabir , Ghaly Adel , Cumming Louise , Adenusi Taiwo
Published: August 2024

Aims

To establish the proportion of CMHT Preston service users with schizophrenia who met the NICE standard (CG 178) of being offered clozapine after inadequate response to treatment with at least two antipsychotic drugs.

Methods

Inclusions – Service users on the CMHT Preston caseload with schizophrenia who attended outpatient clinic between January and June 2023.

Exclusions – Organic psychosis and non-schizophrenic/unspecified psychosis.

Sample size – 50.

Sampling – First 50 service users with established diagnosis of schizophrenia.

Data collection – Retrospective case-note audit from electronic patient records.

Data analysis – Quantitative.

Results

45 service users (90%) met the clozapine eligibility criteria of not responding adequately to or tolerating at least 2 other antipsychotic medications while 5 service users (10%), did not meet the criteria. The proportion of eligible service users who were offered clozapine, and therefore met the standard, was approximately 64%, representing 29 out of the 45 eligible service users. Approximately 36%, representing 16 eligible service users, were not offered clozapine. In one isolated case, a service user who had only 1 previous antipsychotic trial and therefore did not meet the eligibility criteria, was offered clozapine. No reason was given in 13 out of the 16 service users who were not offered clozapine despite meeting the eligibility criteria. In the remaining 3 service users in this group, 2 were not offered clozapine because of cardiac problems and 1 was not offered because of significant history of poor compliance with antipsychotic medications. Furthermore, 25 eligible service users (86%) of those who were offered clozapine went on to initiate it with only 4 service users (14%) in this group not going ahead to initiate clozapine. In all 4 service users who did not initiate clozapine after being offered, the reason given was that the service users declined it.

Conclusion

The findings from this audit indicate that a considerable proportion (64%) of CMHT Preston service users with schizophrenia are being offered clozapine in line with the NICE standard, and 86% of those offered went on to initiate clozapine. However, there is room for improvement in terms of offering and ultimately initiating clozapine in a timely manner as evident from the findings which highlighted an average of three antipsychotic trials before eligible service users were offered clozapine. The existing established local clozapine community initiation pathway can potentially be optimised to improve clozapine access and ultimately enhance clinical outcomes for this subset of service users.
Monitoring the Conformance of Patients Undergoing Electroconvulsive Therapy (ECT) Treatment to Electroconvulsive Therapy Accreditation Services (ECTAS) Standards at Worcestershire Specialist Mental Health Services
Authors: Youssef Nancy
Published: August 2024

Aims

To confirm that 100% of patients treated by Electroconvulsive Therapy (ECT) have weekly assessment of mental state via Montgomery–Åsberg Depression Scale (MADRS).

To confirm that 100% of patients treated with Electroconvulsive Therapy (ECT) have regular assessment of their cognition before treatment and every 4 treatment sessions via the Montreal Cognitive Assessment Scale (MOCA).

Methods

This Audit included all service users attended ECT suite regularly at Worcestershire Specialist Mental health services over a period of 12 months between April 2022 and April 2023.

Twenty patients were included in this audit for whom data was collected from both electronic and paper records to analyse the percentage of compliance with the Electroconvulsive Therapy Accreditation service (ECTAS) standards with regards to the recommended weekly assessment of mental state via MADRS and the recommended regular assessment of cognition before treatment and every 4 treatment sessions via the MOCA Scale.

Results

The Audit included 20 patients having ECT treatment done regularly over a year.

Overall, 87.32% of the patients were found to have MOCA assessment done before their first ECT session and every 4 treatment sessions as per guidelines. While 96.29% of the patients had MADRAS assessment done weekly or every two treatment sessions as per guidelines.

Regarding MOCA assessment, it has been found that 80% of the patients had MOCA done before their first treatment session. 94.73% of the patients had MOCA done after their 4th treatment session. 89.47% of the patients had MOCA done after their 8th treatment session. And 84.61% of the patients had MOCA done after their 12th treatment session.

With regards to MADRAS, 100% of the patients had MADRAS done before the start of the treatment. 90% of the patients had MADRAS done after the second treatment (1st week). 100% of the patients had MADRAS done after 4th treatment (second week). 100% of the patients had MADRAS done after 6th treatment (third week). 93.33% of the patients had MADRAS done after 8th treatment (4th week). 92.85% of the patients had MADRAS done after the 10th treatment (5th week).

Conclusion

Overall, ECT practice at Worcestershire Specialist Mental health services has been found to be in compliance with the ECTAS guidelines.

The majority of patients had MOCA assessments done regularly every 4 weeks with the highest compliance found to be after the first 4 treatment sessions and the lowest compliance was for the MOCA assessment done before the start of the ECT treatment.

In terms of MADRAS assessment, there was an overall adherence with the guidelines with very few patients missing MADRAS assessment only once over their course of treatment.
Cognitive Decline With Low-Dose Procyclidine and Improvement Following Removal of Anticholinergic Burden
Authors: Aboelenien Shaimaa , Cherian Vinu , Philip Joel
Published: August 2024

Aims

A recent Cochrane review published in December 2023 concluded that “no trials found that interventions to reduce anticholinergic burden led to any other improvements in cognition compared to usual care”. We describe the case of a 62-year-old lady who developed significant cognitive decline following the initiation of a low dose of procyclidine, which was rapidly reversed upon stopping the medication.

Methods

We present the case of a 62-year-old lady with a diagnosis of schizo-affective disorder, whose symptoms had been stabilized on a regime of lithium carbonate 500mg nocte, sulpiride 400mg BD and fluoxetine 20mg OD. When the patient presented to the outpatient clinic, she was noted to have bilateral coarse tremors and slight cogwheel rigidity. Procyclidine was started at a dose of 5mg OD to manage these extrapyramidal side-effects.

Following this, family members reported that the patient had difficulty initiating and following conversations. Short-term memory was affected and she was observed to have reduced attention span. These problems were reportedly getting worse with time, with a simultaneous decline in functional abilities. She was no longer able to carry out her daily shop, and family members ensured that she was no longer driving as they had concerns about her road safety. She stopped taking procyclidine after 1 month and notably, these problems ceased within one week of stopping the medication.

Cognitive testing confirmed that the patient was cognitively intact after procyclidine was stopped. The patient scored 96 on the ‘Addenbrooke's Cognitive Examination’ scale, which falls within the normal range. The ‘Instrumental Activities of Daily Living’ scale was administered to assess functioning at the time of the cognitive impairment. This returned a score of 1/8, indicating that there was significant functional impairment secondary to cognitive impairment when prescribed procyclidine. The ‘Informant Questionnaire on Cognitive Decline in the Elderly’ was administered to objectively quantify the extent of cognitive decline as noted by family. This returned a score of 4.3, confirming that the patient's cognition had indeed been worse when compared with her baseline.

Results

Our case report highlights the rapid improvement in cognition with the removal of anticholinergic burden in a 62-year-old female. Our report can, therefore, be a harbinger for more robust trials to determine the efficacy of interventions to reduce anticholinergic burden in preserving or improving cognition.

Conclusion

It is important to monitor for any change in cognition when prescribing anticholinergic medication in at-risk individuals.
Adult Onset Ornithine Transcarbamylase Deficiency: A Rare Cause of Psychosis
Authors: Choi Hoi Ying
Published: August 2024

Aims

Ornithine transcarbamylase (OTC) is an enzyme of the urea cycle catalyzing the condensation of carbamyl phosphate and ornithine to form citrulline. OTC deficiency leads to elevated serum ammonia and presents as different neurological or psychiatric symptoms. OTC deficiency is an X-linked inborn error of metabolism and most cases occur in neonatal period with severe presentation. Lesser known is the late-onset form that remains latent from infancy and only presents with intriguing symptoms mimicking psychiatric disease in adulthood.

Methods

Case report.

Results

We describe a case of adult-onset OTC deficiency in a 40-year-old man with borderline intellectual functioning and a psychotic episode following a protein rich meal. The case was first diagnosed as undifferentiated schizophrenia, until the genetic study was carried out.

Conclusion

Awareness of the adult onset ornithine transcarbamylase deficiency being a rare but possible differential diagnosis in a patient with acute psychiatric symptoms with hyperammonemia. Organic causes such as cerebral, metabolic, toxic causes of psychosis should be actively sought especially when encountering cases of acute psychosis.
Auditory Delusional Misidentification: A Case of Capgras Syndrome During the COVID-19 Pandemic
Authors: Shaw Michael , Durrant Alana , Penfold Leia , Okediran Opeyemi , Tokuma Hideaki
Published: August 2024

Aims

Capgras syndrome is the most common of the delusional misidentification syndromes. It is characterised by the delusional belief that a familiar person has been replaced by an identical imposter. Capgras syndrome is associated with functional conditions, like psychosis, but also with a range of organic conditions such as dementia, brain injury and Parkinson's disease.

The COVID-19 pandemic created a unique situation where patients were unable to see their relatives in person, resulting in their only form of contact being via telephone or virtually.

Methods

We present a case of a 70 year old lady Mrs W, who was admitted with first episode psychosis. She developed Capgras syndrome during her admission, based purely in the auditory modality of talking to her husband on the telephone. She was firm in her conviction that he was an imposter, mainly based of ‘a different tone’ and using ‘different words’. Showing a photograph of her husband was met with full and appropriate recognition. Given that a significant minority of elderly patients with a Capgras delusion have an organic aetiology, neuroimaging and extended laboratory investigations, including auto-antibodies for limbic encephalitis, were performed which were unremarkable.

With psychotropic medication, the Capgras delusion resolved, and on discharge she recognised her husband when they met again.

Results

The aetiology of Capgras syndrome remains unclear, although a range of causes have been suggested. Early psychodynamic theories related to conflict between love and hate towards the relative, which could be relevant in functional conditions but may have less significance in organic conditions.

Other theories examine Capgras syndrome as a mirror of prosopagnosia, where people have difficulties recognising familiar faces. This would indicate a pathological process affecting visual pathways. However, our case challenges this theory, suggesting that deficits in other sensory modality pathways may also contribute.

Although rare, our case is not entirely unique; several cases of Capgras syndrome in people with blindness have been reported. However, our case differs in that our patient was able to recognise photos of her husband despite misidentification based on auditory cues. As Mrs W did not have visual impairment, it is unclear if she would have presented with the more classical visual misidentification in the absence of the unique circumstances of the COVID-19 pandemic.

Conclusion

Capgras syndrome is classically associated with misidentification based on visual cues, however a growing number of case reports challenge this. Further investigation is required to create theories that encompass other sensory modalities.
Administration of Atropine Eye Drops Sublingually for Clozapine-Induced Sialorrhea in Bipolar Disorder
Authors: Garg Shaurya , Kumar Amit , Afroz Omar , Kathiresan Preethy , Deep Raman
Published: August 2024

Aims

The aim of this study is to explore the off-label use of atropine, administered sublingually, for the management of clozapine-induced sialorrhea in a patient who showed inadequate response to commonly used agents. The investigation stems from a clinical scenario where traditional approaches failed, prompting an exploration of alternative and cost-effective options to alleviate sialorrhea associated with clozapine therapy in a patient of lower socio-economic status.

Methods

Mr. A, a 29-year-old with bipolar affective disorder, experienced persistent sialorrhea during clozapine treatment, resistant to trials with trihexyphenidyl and glycopyrrolate. Following a brief discontinuation of clozapine, the patient relapsed into a manic episode, leading to hospitalization. Despite the re-initiation of clozapine, sialorrhea reoccurred. Various doses and combinations of trihexyphenidyl and glycopyrrolate were ineffective, with affordability issues limiting the latter. As sialorrhea persisted, clozapine dose reduction was necessary. Attempts with different antipsychotics were made, and valproate sodium was increased, but sialorrhea remained problematic.

Given the patient's unique case and previous medication failures, an off-label use of atropine via a sublingual route was done after obtaining informed consent. Quantitative measurement of sialorrhea was conducted using a sialometry machine. The patient underwent a trial with sublingual atropine drops, and the salivary rate significantly decreased, indicating a potential efficacy in managing clozapine-induced sialorrhea.

Results

The discussion encompasses the challenges faced in managing clozapine-induced sialorrhea in the presented case. Traditional agents, including glycopyrrolate and trihexyphenidyl, proved ineffective or were hindered by affordability issues. The subsequent reduction of clozapine dose compromised overall treatment efficacy. The introduction of atropine eye drops via sublingual administration emerged as a novel approach, demonstrating a reduction in salivary rate without notable adverse effects except elevated heart rate 2 hours after administration of atropine. The unique pharmacological properties of atropine, despite being an off-label use, provided a potential avenue for addressing persistent sialorrhea.

Conclusion

In conclusion, the off-label use of atropine via the sublingual route showed promise in alleviating clozapine-induced sialorrhea in this particular case. Despite demonstrable efficacy in pre and post-sialometry, the clinical challenges and practical considerations associated with atropine's use in this context raise concerns. The case underscores the need for alternative strategies in managing medication-induced side effects, especially when standard interventions fail. Further research is warranted to explore the broader applicability and safety of this approach in a larger cohort.