bluuebunny/crossref_metadata_2025 huggingface dataset:
A Clinical Audit of ECT Documentation in NHS Grampian
Authors: Ball Rachel , Smith Murray
Published: August 2024

Aims

Electroconvulsive Therapy (ECT) is a treatment used for patients with severe depression, mania, catatonia, and schizophrenia. National Institute for Clinical Excellence (NICE) guidance for the use of ECT advises that for all patients, a risk/benefit assessment for the treatment should be made and documented with particular reference to anaesthetic risk and the adverse effect of cognitive impairment.

For patients who can consent to treatment, NICE recommends the use of patient information leaflets to help people to make an informed decision about their ECT treatment.

For patients who cannot consent to treatment, psychiatrists can authorise the use of ECT using the Mental Health Act. However, NICE recommends that any advance directive should be fully taken into account, and someone who speaks on behalf of the patient should be consulted.

This project aimed to audit whether the documentation of the consent process of patients undergoing ECT in NHS Grampian was in line with the above NICE Guidance.

Methods

The clinical notes and ECT folders of the six patients undergoing ECT treatment in NHS Grampian in January 2023 were reviewed in reference of the following domains:

1)

The clinical indication for ECT.

2)

If the patient (or their family/advocate) had the opportunity to receive the RCPsych Patient Information Leaflet for ECT.

3)

If a discussion about the risks/benefits of ECT had taken place with a patient, their family or advocate.

4)

If specific risks and side effects – namely anaesthetic risk and cognitive impairment – had been discussed with the patient, their family or advocate.

The project had been registered with the NHS Grampian Quality Improvement & Assurance Team prior to data collection beginning.

Results

All of the notes reviewed (100%) had the clinical indication for ECT clearly documented.

Three (50%) of the patients had received the RCPsych Patient Information Leaflet for ECT.

A clear risk/benefit assessment discussion was documented in three (50%) of the patients' notes.

Specific discussion of side effects including cognitive impairment and anaesthetic risk was documented in three (50%) of the patients' notes.

Conclusion

There is a clear need for improvement in the documentation of the consent process for ECT in NHS Grampian. While the indication for receiving ECT is being clearly recorded, documentation of the risk/benefit assessment, discussion of specific side effects, and involvement of family or advocacy is less consistent. The introduction of the NHS Grampian standardised consent form is being considered as an option to improve this documentation. The documentation of the consent process for ECT can be re-audited once this form has been introduced.
Audit of the Use of Outcome Measures Within Child and Adolescent Mental Health Outpatient Services in Rotherham, Doncaster and South Humber NHS Foundation Trust
Authors: Bell Lydia , Thomas Mohan
Published: August 2024

Aims

Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) has 28 Promises as part of its Strategy.

Promise 16 is to: Focus on collating, assessing and comparing the outcomes that our services deliver, which matter to local people, and investing in improving those outcomes year on year.

This audit in November 2023 looked at the practice of using outcome measures for CAMHS patients in order to highlight areas of development for the service to work toward achieving the promise.

Methods

We wanted to understand if young people were having outcome measures completed and if so, when, what and how often. We achieved this by using a dip sample of five patients each across the three different localities (Rotherham, Doncaster and Scunthorpe).

A report was generated to include all patients discharged from CAMHS in the preceding three months to September 2023. Young people who had been with the service less than six months were excluded from the audit. Five patients were chosen randomly from each locality and their electronic patient record on System One was studied.

Information in the patient records was compared against the audit standards and recorded in Excel so the data could be analysed.

Results

The results showed that 11 of 15 young people had an outcome measure completed at some point during their episode of care. All five young people in Scunthorpe had an outcome measure recorded in their clinical records however this tended to only happen at the very start, meaning there was no basis for comparison. Four out of five patients in Doncaster had outcome measures in the clinical record and these were undertaken throughout the episodes of care. In Rotherham, two of five young people had outcome measures recorded in the clinical records.

The most frequently used outcome measure was the RCADS but the SDQ was also used.

Conclusion

There is work to be done to ensure the use of outcome measures becomes routine, and also to standardise both the type and frequency of use. The Trust is aiming to increase their use by utilising SystmOne's capabilities to interface with service user mobile devices to send out outcome measures to patients. There is also a plan to inform staff within the service about the expected use of outcome measures. This audit will be repeated in 2024 to see if the Trust are moving closer to delivering their promise.
Introduction of the DUNDRUM Triage Urgency Tool to a Medium Secure Unit in Bed Crisis
Authors: Duthie Leanne , Morris Alistair
Published: August 2024

Aims

At a time of increased pressures across the whole forensic estate, The Orchard Clinic Medium Secure Unit faced the additional challenge of having to close multiple acute admission beds.

This led to challenges in determining how to triage patients in the face of multiple external pressures, frustrations for clinicians managing severely ill patients in prison and human rights concerns for those unfit to stand trial but remanded to custody to await a bed.

The need for an objective tool to aid triage decisions became apparent. We therefore piloted the use of the DUNDRUM triage urgency manual, a structured professional judgement tool to aid triage decisions for forensic units.

The aims of introducing this tool were to ensure decisions are more consistent and reliable, ensure scientifically valid items are not forgotten, make decision making processes more transparent, demonstrate equality of access to services and reduce chance of serious error.

Methods

This audit reviewed all acute admissions to The Orchard Clinic between Aug 22–Aug 23. This covered a period 6 months prior to the introduction of the tool and 6 months after.

In order to determine if the use of the tool improved our triage making decisions the Dundrum score was retrospectively calculated for admissions and those on the waiting list during the first 6 month period of the audit. The same information was recorded for those following the introduction of the tool in the second 6-month period.

Results

Prior to introduction of the DUNDRUM, the team's triage decisions were not in line with validated tools, those with lower DUNDRUM scores were prioritised over those with higher scores. Following introduction of the tool our triage decisions improved. Common themes emerged when we analysed the reasons why our triage decisions were out of line with validated tools. These included patients in hospital settings taking precedence over those in prison, patients admitted without prior discussion at bed management meetings, legal urgency taking precedence over clinical and lack of available HDU space.

Conclusion

Prior to the introduction of the DUNDRUM triage urgency manual the audit demonstrates that the team's triage decisions were not in line with validated tools. This improved following training and use of the tool at bed management meetings. The Orchard Clinic has now formalised use of this tool within bed management meetings. We are currently in the process of re-auditing over a 12-month period.
The Time to Psychology Assessment and Provision of Psychological Interventions for Perinatal Women in the Specialist Perinatal Community Mental Health Team
Authors: Ibiwoye Oluwaseun , Joshi Snehita
Published: August 2024

Aims

According to NICE guidelines on antenatal and postnatal mental health, recommendation 1.7.3:

•

To identify the proportion of women referred for psychological interventions in the perinatal period who are assessed for treatment within 2 weeks of referral.

•

To identify the proportion of women referred for psychological interventions in the perinatal period who start psychological interventions within 4 weeks of assessment.

•

To identify the barriers to accessing psychological interventions within 6 weeks of referral of women with mental health problem in the perinatal period.

Methods

The sample cohort were perinatal women referred for psychology interventions in the central specialist perinatal community mental health team (SPCMHT) between 12th June 2023 and 15th November 2023. Data was collected quantitatively and qualitatively. Quantitative data was collected retrospectively from the central psychology SPCMHT database shared drive and on Rio. Qualitative data was obtained through a purposeful sampling technique. Psychologists working in the central SPCMHT were identified. Survey link with specific questions was sent to the identified participants to complete. The SPCMHT psychology pathway was reviewed to clarify the local arrangement in place for women to start psychological intervention within 6 weeks of referral.

Results

25 patients were identified in total in the 6-month review period. 16 had been assessed and 9 were on the assessment waiting list. The elapsed time for assessment waitlist was between 3 and 23 weeks. Of the 16 assessments, only 2 were done within 2 weeks of referral. The time to assessment for the remaining 14 patients was between 3 and 18 weeks. Following assessment, there were 11 cases on the therapy waiting list, 4 open cases, and 1 wait and watch case. The elapsed time for the therapy waitlist was between 4 and 22 weeks following assessment. None of the open cases started therapy within 4 weeks of initial assessment. Overall, none of the 25 patients were assessed or provided psychological intervention within the recommended timeframe. The qualitative theme suggests “understaffing” as the major barrier to prompt service provision. It also suggests a lack of awareness of the current NICE standards timeframe for provision of psychological intervention for perinatal women. The trust SPCMHT psychology pathway has no timeframe for the start of psychological therapy following assessment.

Conclusion

The audit findings suggest massive delays in service provision. The major barrier to this is limited capacity compared with the number of referrals. Hence, there is need for more resource allocation for perinatal psychology service provision.
Audit on Monitoring of National Early Warning Scores 2 (NEWS2) in Old Age Patients
Authors: Javaid Sadia Tabassum , Brace Bethan , Lee Bethany
Published: August 2024

Aims

NEWS 2 is integral to post-admission physical health monitoring, guiding baseline establishment and observation frequency decisions. MDT discussions, involving medics or nurses per guidelines, ensure tailored care. Trust Standard Operating Procedure (SOP) and Physical Health policy, provides detailed procedures for assessment, recording, and actions. Adhering to NEWS 2 and SOP 1.62a, aligned with Trust standards, facilitates prompt escalation in case of patient deterioration, reinforcing our commitment to superior healthcare.

AIM

•

To evaluate if NEWS2 monitoring is done as per set Trust standards/guidelines.

•

To identify areas of improvement in the use of this observational tool.

•

To improve the services and care of patients.

Methods

We conducted a comprehensive review of each section of NEWS 2 charts for 39 patients admitted to Ward 6 and 7 at Harplands Hospital over a 3-week period. Patient stays varied from 21 to 67 days. No pregnancies were noted; all patients were aged between 59–96, with a near equal gender distribution. Utilizing SPSS, we conducted data analysis, comparing results against Trust-set standards.

Results

Of the 39 charts, 37 were completed at admission, with notable issues: 9 lacked demographics, 13 had date/time missing. Weekly NEWS was predominant, but challenges included 6 missing signatures, 9 illegible entries, and 12 incomplete sections (4 without connecting observations). GCS completion issues were identified in two charts if CPVS score was more than 3. Escalation patterns varied: scores 1–4 were often routed to a Registered Nurse before medics, while scores >4 were mainly escalated directly to medics. Most charts were uploaded to electronic records, yet the electronic versions were frequently left unfilled.

Conclusion

In conclusion, the implementation of NEWS charts at admission, consistent chart uploads to Lorenzo, and effective escalation practices underscore a commitment to patient monitoring. The detailed procedures, including demographics completion, trend identification, and weekly reviews, contribute to a comprehensive approach. The incorporation of printed patient information labels and targeted education sessions for ward teams further reinforces the emphasis on standardized and meticulous documentation practices, enhancing overall patient care and safety. Discussions with ward management will further support the ongoing success of these initiatives.

Above recommendation has been completed and Re-Audit in planned few months.
Improving Health System Engagement in Patients With Substance Use Disorders: Audit of Care Plans in the National Drug Treatment Centre
Authors: Keenan Mary , Rooney Siobhan
Published: August 2024

Aims

The National Drug Treatment Centre in Dublin is the longest established treatment service for drug users in Ireland. Led by Addiction Psychiatry teams, it provides specialist multidisciplinary input for patients with complex medical and psychiatric needs secondary to substance use. Many patients attending the centre engage poorly with other healthcare services in the community. The aim of this audit was to improve physical healthcare engagement in a caseload of 60 patients, through improving GP registration rates and possession of medical cards (providing access to free public health services).

Methods

The comparison standard for the audit was the Irish Health Service Executive (HSE) Clinical Guidelines for Opiate Substitution Therapy: 2016. These stipulate that all drug users entering treatment and rehabilitation should have a care plan based on assessed need. Specific domains covered include: Drug and Alcohol use, Physical Health, Psychological Health and Social Functioning.

During the initial audit cycle, electronic care plans in a caseload of 60 patients were reviewed for information on their GP and medical card status.

Intervention: Following the initial cycle, results were presented and discussed at a multidisciplinary team meeting. A combined MDT effort was made to discuss medical card and GP status with patients during each interaction. Patients were referred to social work for support in application/renewal of medical cards and GP registration where required.

Results

Results following re-audit:

The percentage of patients with GP registration clearly displayed on their care plan increased from 66% to 93%.

The percentage of patients with an up to date medical card increased from 12% to 45%.

The percentage of patients whose medical card status was unknown reduced from 72% to 44%.

The percentage of patients with their medical card number displayed on their care plan increased from 25% to 55%.

Conclusion

There was a significant improvement in the number of patients with GP and medical card information documented clearly on their electronic care plan. This has assisted National Drug Treatment Centre staff in supporting patients' physical health needs more effectively, through close liaison with primary care providers and onwards referral to other services where required. It was noted that further efforts were required to build upon these results and reach 100% compliance. Recommendations and an action plan were developed to ensure ongoing improvement in standards.
Prolactin Monitoring for Inpatients on Antipsychotic Drugs: A Clinical Audit
Authors: Kotait Farida , Parmar Sheena , Kar Nilamadhab
Published: August 2024

Aims

Many antipsychotics are known to adversely affect prolactin levels causing hyperprolactinemia. National Institute for Health and Care Excellence (NICE) guidelines have suggested monitoring of prolactin levels. It specifies that prolactin should be checked 6 months after starting treatment, then every 12 months; and to ask about symptoms of raised prolactin which include low libido, sexual dysfunction, menstrual abnormalities, gynaecomastia, and galactorrhoea. This also mentions that it is not required for aripiprazole, clozapine, quetiapine, or olanzapine (less than 20 mg daily). We intended to audit the monitoring of prolactin in a sample of inpatients who are on antipsychotic drugs and to check whether action was taken in the event of a high prolactin level.

Methods

All the adult inpatients of a general psychiatric hospital on a specific date (34, 16 (47.1%) female and 18 (52.9%) male patients), who were on antipsychotics were considered for the audit. We checked the antipsychotic drugs, prolactin assessment within one year and level, action taken if there was hyperprolactinemia. The data was collected from electronic patient records and medication charts.

Results

The mean age of the sample was 39.1 ± 14.2 years (range 18–63). Most inpatients (91.2%, 31/34) were on antipsychotics and 25.8% (8/31) were on two antipsychotic drugs. Prolactin was measured in 80.6% (25/31) patients in the last year, with 48% (12/25) having hyperprolactinemia; and amongst these action was taken in 5 (41.7%). Hyperprolactinemia was present in 58.3% of female and 38.5% of male patients. Specifically, out of 31 patients, 14 (45.2%) were on antipsychotic drugs that need monitoring, and 9 (74.3%) of them had taken it for at least one year. Out of these 9 patients, prolactin was measured in 8 (88.9%) patients in the last year, it was elevated in 5 (55.6%), action was taken in 3 (60%) and action was not clear in 2 (40%) patients.

Conclusion

Almost half of the patients on antipsychotic drugs had hyperprolactinemia, highlighting the need to monitor prolactin levels. Along with this, symptoms of hyperprolactinemia should be consistently checked in routine clinical evaluations. Clinician and patient education regarding hyperprolactinemia and its symptoms might improve its monitoring.
Use of Antipsychotics in Emotionally Unstable Personality Disorder
Authors: Kuriakose Deepak
Published: August 2024

Aims

Emotionally unstable personality disorder (EUPD) is characterized by affective instability, unstable interpersonal relationships, poor self-image and marked impulsivity. Patients may present with a variety of symptoms including impulsivity, suicidal behavior, affective instability and intense anger. This makes the treatment very patient specific.

Treatment guidelines support the use of Dialectical Behavior Therapy (DBT) as the first line treatment of EUPD. Currently, no medications are indicated for the treatment of EUPD which leads to off label use of medicines by clinicians.

More than 90% of individuals receive a variety of pharmacologic treatment with psychotropic medications, especially second-generation antipsychotic drugs for the treatment of cognitive perceptual symptoms and impulse control behavior. Additional psychotropics are usually added leading to psychotropic polypharmacy which should be avoided.

Aim of this study is to assess the frequency of prescription of antipsychotic medications in patients with a primary diagnosis of emotionally unstable personality disorder.

Methods

Protocol was registered with the Audit and Quality Improvement project team of the NHS trust and the audit registration certificate was obtained.

Case records of 42 patients with EUPD who attended psychiatric outpatient department from June to August 2023 were collected and screened. A retrospective study was carried out.

Inclusion criteria

Patients above 18 years of age, with a primary diagnosis of emotionally unstable personality disorder.

Exclusion criteria

Patients with comorbid diseases like Attention Deficit Hyperactivity Disorder, Bipolar Affective Disorder and Psychosis where use of antipsychotics is warranted.

All other personality disorders.

After screening 42 case records, 20 cases of EUPD which fulfilled the inclusion and exclusion criteria were found and analyzed. Descriptive statistics were used.

Results

Retrospective data of 20 patients with a primary diagnosis of EUPD were analyzed which included 18 females and 2 males. The mean age of the participants was 27.1.

70% (14) of the patients diagnosed with EUPD were treated with antipsychotics. 20% (4) patients received antidepressants. 10% (2) of the patients received only DBT.

Quetiapine was the most commonly used antipsychotic – 43% (6) followed by Olanzapine – 22% (3), Risperidone – 21% (3) and Zuclopenthixol long-acting injection – 14% (2).

Conclusion

Dialectical behavior therapy is the first line treatment of EUPD. National Institute for Health and Care Excellence (NICE) guidelines do not recommend the use of antipsychotics in the treatment of EUPD. Contrary to the guidelines, antipsychotics are prescribed long term for patients with EUPD who are without any comorbid conditions. This audit has found that 70% of patients with a primary diagnosis of EUPD are being prescribed antipsychotic medication. This needs to be kept in check so that polypharmacy can be avoided.
Audit of Electroconvulsive Therapy Service Provision in Lincolnshire Partnership Foundation Trust: Current Standards and Adherence to National Guidance
Authors: Kyaw Sandar , Butt Ayesha , Priya Anita , Kunigiri Girish , Kumar Praveen
Published: August 2024

Aims

To improve the quality of care received by service users of Electroconvulsive Therapy (ECT) treatment in Lincolnshire Partnership Foundation Trust (LPFT) by measuring the compliance of the local ECT clinic in Lincolnshire in accordance with National Institute of clinical excellence guidance and ECT accreditation services standards.

Methods

Pre-audit work up includes consultations with ECT clinic lead and stake holders to ensure ethical and governance standard are met. This audit is conducted with the permission of trust quality and safety team.

Sample population is identified from ECT clinic registry, Lincoln. A total of 10 patients who received ECT treatment between January 2023 and August 2023 are included regardless whether the necessary information is available on the clinical system or not, to minimise selection bias. Retrospective data collection by using Rio electronic case records. Descriptive analysis of data using Microsoft Excel and evaluation of results is based on 3 key domains such as indication, consent process and monitoring.

Results

A total of 10 service users, comprising 30% males and 70% females, underwent treatment in both inpatient (80%) and outpatient (20%) settings, primarily for severe depressive illness. In 70% of cases, a pre-ECT assessment was documented to evaluate potential risks and benefits. The consent procedure was completed by a psychiatrist in 70% of instances. However, ongoing consent was not consistently reviewed at each ECT treatment.

Baseline monitoring using the Clinical Global Impression and Comprehensive Psychopathological Rating Scale was conducted in 20% of cases, with no follow-up assessments performed after each treatment. The Montgomery–Åsberg Depression Rating Scale was employed at baseline for 40% of patients, yet there was no evidence of weekly monitoring. While the Montreal Cognitive Assessment was administered to all patients at baseline, it was not conducted after every four treatments.

Post-ECT follow-up data revealed that less than a quarter of patients underwent clinician reviews. Validated rating scales were utilized in no more than a fifth of patients at both one week and two months after treatment.

Conclusion

The findings suggest the need for improved documentation of the entire consent process and in regularly assessing the ongoing validity of consent. Moreover, there is a need for stronger monitoring at baseline, during, and after ECT treatment. It is recommended to revise the local ECT record pathway by December 2023, with a follow-up re-audit scheduled for March 2024 to evaluate the effectiveness of the implemented changes.
Unsuccessful Presentations for Involuntary Admission to an Irish Approved Centre During 2019 and 2021
Authors: McCaffrey Cathal , Daubaras Mark , Ab Karim Shahrizal , Lee Alyson
Published: August 2024

Aims

Ireland's Mental Health Act 2001 (MHA) outlines the procedure and criteria for referring patients for involuntary admission. After consultant psychiatrist examination, if appropriate, a referred individual is admitted involuntarily under an admission order (AO). Involuntary admission is only appropriate if the person meets criteria for a “Mental Disorder”. It's unlawful to detain a person solely because they suffer from personality disorder, are socially deviant, or are addicted to drugs/intoxicants. AOs aren't completed if these criteria aren't met, referral forms are incorrect, or individuals agree to voluntary admission. We aimed to determine (1) the rate of unsuccessful referrals for involuntary admission to an Irish approved centre (Lakeview Unit) during 2019 and 2021, (2) the reasons AOs weren't completed, (3) the source of unsuccessful referrals and (4) the time such referrals were made.

Methods

Unsuccessful referrals for involuntary admission during 2019 and 2021 were identified. Data were collected retrospectively by chart review. We identified the documented reason AOs were not completed, and the time and source of these unsuccessful referrals. In March 2021, authors delivered teaching on appropriate use of the MHA to local Police (Gardaí) and out-of-hours General Practitioners (GPs).

Results

Of 78 referrals for involuntary admission in 2019 and 115 in 2021, 19% and 44% respectively were unsuccessful (AO not signed). In 60% of unsuccessful referrals in 2019, the person presented with no mental disorder meeting criteria for involuntary detention. The same figure in 2021 was 27%. Individuals presented with substance misuse disorder in 73% and 27% of unsuccessful referrals in 2019 and 2021 respectively. In 2019, 93% of unsuccessful referrals came from Gardaí, 100% came from medical practitioners other than the patient's own GP and 73% came outside of normal working hours.

Conclusion

Unsuccessful referrals for involuntary admission are not uncommon. Audit cycle 1 highlighted that those subject to unsuccessful referrals frequently present out-of-hours, with substance misuse disorder and/or no mental disorder meeting criteria for involuntary admission. In 2021 a smaller proportion of unsuccessful referrals presented with no mental disorder and substance misuse disorder. This suggests that Gardaí/GP education offered benefit. We observed an increase in both the overall number of referrals and the percentage of unsuccessful referrals in 2021. This possibly reflects an impact of the COVID-19 pandemic. There is a need for ongoing education, discussion and feedback with Gardaí and GPs on the process of making referrals for involuntary admission. A limitation is that separate registrars completed each audit cycle.
Assessing Adherence to Antipsychotic Prescribing and Monitoring Guidelines in a Psychiatric Unit for Older Adult Females in Kent and Medway NHS and Social Care Partnership Trust (KMPT): A Retrospective Audit
Authors: Moisan Maria , Dixon Bianca , Ajiteru Ayebatonye
Published: August 2024

Aims

Antipsychotic medications are commonly used in the management of psychiatric disorders, including in older adults. However, the use of these medications in older adults can be associated with a higher risk of adverse effects such as cardiovascular event and extrapyramidal symptoms.

This retrospective audit aimed to evaluate adherence to antipsychotic prescribing and monitoring guidelines in a Psychiatric Unit for Older Adult Females in Kent and Medway NHS and Social Care Partnership Trust (KMPT).

Methods

The audit criteria encompassed various aspects of documentation and medication management, including diagnosis documentation, indication, age, comorbidities, consent, baseline assessments, monitoring, review, and follow-up care. Data from two months’ records were analysed leading to an action plan with slight amendments to the user-friendly template for ward round and a physical health monitoring poster for junior doctors and ward staff. These initiatives aim to improve patient care, streamline documentation, while accommodating the rotation of junior doctors. A re-audit is planned post implementation.

This audit’s limitations included the study’s single-site nature, potential sample size constraints and reliance on accurate documentation.

Results

The audit achieved 100% compliance in documenting patient age and MHA status, meeting legal requirements. Weight, BMI, and baseline blood pressure exhibited full compliance. Baseline ECGs had an 86.66% compliance rate, while QTc interval documentation reached 100%. Antipsychotic indication and weekly reviews were documented at 100%, with an 83.33% rate for rationale documentation for medication changes. Comorbidities were fully documented, but extrapyramidal symptom and sedation monitoring showed a 46.66% compliance rate. Baseline blood tests, including glucose, bA1c, lipid profile, electrolytes, renal and liver function, thyroid function, and prolactin levels, generally had high compliance, but lipid profile and liver function achieved 73.33%. Repeat blood tests varied, with electrolytes and renal function at 100%, while thyroid function and prolactin levels scored lower at 26.66% and 46.66%. Continued monitoring of weight, BMI, and blood pressure remained fully compliant. Compliance for repeating ECGs within recommended timeframes reached 53.33%, and recommendations to GPs for yearly ECGs and blood monitoring achieved 50%.

Conclusion

In summary, the audit identified areas of commendable high and medium compliance with antipsychotic prescribing guidelines in a Psychiatric Unit for Older Adult Females in KMPT. An action plan has been formulated to not only enhance patient care but also to refine the documentation process positively further, fostering continued progress in the provision of high-quality care.
Audit Regarding the Physical Health Workload for Doctors at an Older Adult Psychiatry Unit in Leeds
Authors: Morris Eleanor
Published: August 2024

Aims

The Royal College of Psychiatrists provides guidance regarding the experience of Foundation Doctors and Core Trainees, during their Psychiatry rotations. At The Mount, an Older Adult Mental Health unit in Leeds, it was observed by trainees that management of physical health conditions was occupying a large portion of their time.

Aims:

1.

Measure how much time is spent on physical health activities, between Foundation Doctors and Core Trainees at The Mount.

2.

Consider the impact of physical health workload on the doctors’ experience of Psychiatry.

3.

Explore the mental health experience of doctors during this rotation.

Methods

This Audit was conducted in three stages:

1.

Anonymous collection of quantitative data regarding the proportion of time spent on physical health work. This data was collected for current doctors across all wards, for a two-week period in October 2023.

2.

A focus group of junior and senior doctors, to consider onward actions.

3.

An anonymous qualitative survey regarding mental health experiences and suggestions for improvement. This was circulated to any Foundation Doctor or Core Trainee who worked at The Mount in the past 12-months, via an online survey.

Results

The quantitative survey showed that Foundation Doctors and Core Trainees at The Mount were spending at least half their time on physical health jobs, such as: clinical reviews, skills such as blood tests and ECGs, and referrals to other clinicians or specialties. This was considered unsurprising by doctors at all levels during the focus group.

The qualitative survey explored this further, with observations that doctors were sometimes unable to attend MDT meetings, tribunals or CPAs due to the high physical health workload. It was felt that senior staff were proactive in offering support, however trainees still felt that opportunities for mental health experience were limited.

Suggestions for improvement were made during the survey, including:

1.

Increased input by senior medical staff, such as GPs or Geriatric Trainees.

2.

Additional staff to support with upkeep of equipment, or skills such as phlebotomy.

3.

Increased use of technology rather than paper charts.

4.

Greater clarity regarding minimum staffing and whether locum doctors can be arranged to cover gaps.

Conclusion

In summary, the physical health workload for Foundation Doctors and Core Trainees was noted to be significant and impacting their mental health experience. Following this Audit, consultants at The Mount will be meeting with Senior Leadership to discuss methods for improving the training experience.
Clinical Audit of Standard for Electronic Recording of Dementia Diagnostic Assessments in Stockton Mental Health Services for Older People
Authors: Ohioma Karyn , Krishnan Mani , Rose Rachael , Rosiji Oluwabukola , Sodiya Olusegun Temitope
Published: August 2024

Aims

This clinical audit aimed to assess if the recording of patients seen for their diagnostic appointments in memory clinic measures up to the minimum standards required in the delivery of dementia services. This standard mandated primarily that a minimum body of key information must be promptly recorded by clinicians, in patient electronic records within 24 hours, as stipulated by Trust and NICE guidelines.

Methods

The first cycle was conducted from 16 October 2022 to 10 February 2023. In this cycle random sampling was used to select 25 patients on the caseloads of the mental health services for older people. Before the start of the second phase all diagnosing clinicians within the team were informed about the project and the expected improvements against which compliance would be audited. The second phase was conducted between 10 February 2023 to 31 March 2023 and another 25 patients on the caseloads were obtained via random sampling for the second cycle. Inclusion criteria for both phases were patients who had received a diagnostic assessment in these periods.

Results

In the first set of records, the minimum body of information was recorded in 90–100% of cases according to the team's recommended standards namely diagnostic information, prognostic information, treatment plans, post-diagnostic contact plans and documentations being made within 24hrs of consultation. In the Set 2 the minimum body of information was recorded in 95–100% records studied. That is, diagnosis, treatment, medication treatment plans (prescription plans), and post-diagnostic contact plans were covered in the diagnostic sessions. In particular, case note documentations were made within 24 hours in all but one of the records applicable.

Conclusion

Given that a diagnosis of dementia can be life-changing, not discussing prognostic information would not prepare patients and carers adequately with information on how to live well with dementia following their diagnosis. This could potentially lead to poor adjustment to the condition and anxiety for some. At a trust-wide level, this means there is still room for improvement for the trust as regards dementia care ideals recommended by NICE.
Child and Adolescent Mental Health Service (CAMHS) Black Country Healthcare Foundation Trust (BCHFT) Trust-Wide Audit on Adherence to NICE Guidelines in Prescribing Medications for Children With Autism Spectrum Disorder (ASD)
Authors: Osman Mazin , Sundhar Reka Ajay , Wheeldon Helen , Smith Zaynah , Ujrebail Suma
Published: August 2024

Aims

This comprehensive study seeks to evaluate the adherence of (CAMHS) service, Black Country Healthcare National Health Service (NHS) Foundation Trust to National Institute for Health and Care Excellence (NICE) guidelines in prescribing medications for children diagnosed with Autism Spectrum Disorder (ASD). Our primary objectives include identifying variations in prescribing practices across different localities within the trust and identifying specific areas that may benefit from improvement.

Methods

A meticulous retrospective analysis was conducted on 142 randomly selected cases involving children diagnosed with ASD and prescribed psychotropic or sleep medications. A comprehensive analysis of patient records, encompassing progress notes and clinic letters, facilitated the gathering of extensive data. The evaluation centred around benchmarking adherence to NICE guidelines. Throughout the process, strict adherence to ethical standards was maintained.

Results

Within the cohort of 142 children diagnosed with ASD, 44% underwent alternative interventions before medication initiation. Notable variations were observed across localities, with 87% receiving psychological therapy as an alternative intervention. Documentation of consent for commencing medication was present in 62% of cases. Specialists consistently initiated psychotropic medications at the minimum effective dose, and 70% of cases had a follow-up within 3–4 weeks. Sleep medications were prescribed to 77% of the cohort, with 55.5% of those undergoing alternative interventions before prescription.

Conclusion

The study's findings underscore significant variations in adherence to NICE guidelines, emphasizing the critical importance of exploring alternative treatment modalities before resorting to medication. Furthermore, collaboration with supporting agencies is highlighted as a crucial aspect of comprehensive care. The documentation of consent forms for all patients is deemed imperative, and adherence to specified intervals for reviewing medication side effects, as outlined in the guidelines, is considered crucial for optimal and safe patient care.
An Audit of Antidepressant Prescribing in a Single-Centre Child and Adolescent Mental Health Service (CAMHS)
Authors: Pattiata Cara , Prosser Anthea
Published: August 2024

Aims

The audit aims to check compliance of prescribers to the following National Institute of Clinical Excellence (NICE) guidelines:

•

NG134, CG31: Antidepressants are prescribed in conjunction with psychological therapy.

•

NG134: A risk-benefit discussion took place.

•

NG134 Written information was given.

•

NG134, CG31: First-line medication was prescribed in the first instance.

•

NG134: An off-licence medication is only prescribed after a review.

•

NG134: A consent form is signed if an off-licence is prescribed.

Methods

All patients under CAMHS and receiving antidepressant therapy was considered. People on the caseload currently an inpatient were excluded. The audit was performed in October 2023. 86 eligible patients were randomised; 30 were selected for case review. Clinic letters and internal case notes were reviewed to check compliance.

Results

Areas of good compliance: antidepressants prescribed with psychological therapy, risk-benefit discussions took place, first-line medications prescribed in the first instance, off-licence medications prescribed only afer review.

Areas of moderate compliance: written information given with prescriptions.

Areas of no compliance: consent form does not form part of standard practice or local guidelines.

Conclusion

The local CAMHS service showed good compliance to NICE guidelines around antidepressant prescribing. Presentation to the local team is required to remind clinicians of the need to document parts of the consultation such as giving written information. A discussion with the regional consultant body yielded the outcome that the service will adhere to local Trust guidelines of internal case notes documenting consent rather than a signed form. The standards for the re-audit in 6 months will reflect this.
An Audit to Assess Compliance With DVLA Guidelines on a Mental Health Rehabilitation Unit
Authors: Popoola Olusegun , Baruah Ranjan , Gilbey Sion , Pentz Oliver
Published: August 2024

Aims

Patients with serious mental disorders like psychosis may pose a significant risk to themselves and others when they drive. The DVLA has set out guidance for driving for patients with psychiatric disorders, substance use disorders, and for those taking psychotropic medications. It's good medical practice to identify risks associated with driving, discuss, advise appropriately, and document the same in the clinical notes.

To assess the compliance of the mental health professionals at Rathbone Rehabilitation Centre (RRC) with DVLA guidelines regarding patients about driving restrictions, documenting this appropriately and to increase awareness of the DVLA guidelines.

Methods

Data of all the discharged patients from RRC over a 12-month period was collected following a standardised process and assessed for 6 parameters.

A total of 51 discharges were identified and audited against the DVLA guidelines.

Results

51 (100%) patients had a mental health diagnosis documented on patient electronic records (Rio).

9 (18%) of patients had their driving status documented. 42 (82%) did not.

Of the 9 patients whose driving status was recorded, 6 did not drive and are thus labelled not applicable for subsequent criteria. The type of vehicle driven was not documented in any of the cases and therefore was 0%.

Of the 3 patients who drive, 2 (67%) had been informed that their condition may affect their ability to drive.

67% had documented evidence of receiving advice on driving restrictions.

67% had documented evidence that the practitioner has informed the patient that they have a legal duty to inform the DVLA about their condition.

Conclusion

An action plan was designed to improve compliance with DVLA guidelines for practitioners managing inpatients.

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On admission all patients should be asked for their driving status and the result documented on Rio. This could be done on the clerking admissions proforma on Rio.

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For all patients that do drive, the types of vehicles they drive should be documented–this can also be included in the clerking admissions proforma on Rio.

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At their first ward review/discharge meeting and whenever relevant, patients should be informed whether their condition affects their ability to drive and if so, what the restrictions are. They should be informed of the legal requirements regarding informing the DVLA and documented.

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To consider driving status when assessing risk.
Antipsychotic Prescribing for In-Patients With Dementia at University Hospital Llandough to Look for Good Prescribing Practice in Line With NICE Guidelines
Authors: Puli Rakesh , Chakrabarti Arpita
Published: August 2024

Aims

NICE guidelines stipulate that alternative causative factors for Behavioural and Psychiatric Symptoms of Dementia (BPSD) must be considered before starting antipsychotic treatment. The symptoms of BPSD include agitation, aggression, wandering, hoarding, sexual disinhibition, shouting, repeated questioning, sleep disturbance, depression, anxiety and psychosis. Those who do develop non-cognitive symptoms or behaviours should at first be assessed to exclude alternative causes, such as physical health issues (pain/infection), side effects of medication, environmental factors, psychosocial factors, individual biography (e.g. religious beliefs) etc. Then, non-pharmacological approaches should always be used as the first line in treating behavioural problems before antipsychotics (e.g. haloperidol or risperidone) are started at a low dose and titrated up. Once these have been started, the patient should be reviewed at 6 weeks. The rationale for conducting this audit is to try and understand if the antipsychotic prescribing in the ward is in line with the NICE guidelines.

Methods

A retrospective study to compare the treatment of all the patients admitted for dementia in the Old age psychiatry wards located in University Hospital Llandough from November 2022–April 2023 with the NICE guidelines.

Results

Out of the 39 patients who met the criteria, the results indicate a predominant prevalence of Alzheimer's (46%), followed by mixed dementia (23%) and vascular dementia (21%), among the diagnosed cases. In 67% of instances, healthcare professionals have considered alternative causative factors for the observed symptoms beyond the identified dementia subtypes. In 62% of cases, patients received treatment for alternative causes, while non-pharmacological approaches were attempted in 51%. The utilization rates among patients indicate a predominant prescription of risperidone at 77%, followed by quetiapine at 31%, olanzapine at 10%, and aripiprazole at 5%. 95% of patients were commenced treatment at the lowest dose, while information for 3% (1 patient) was not available. 62% were monitored according to guidelines and 56% were reviewed every 6 weeks.

Conclusion

There is room for improvement in terms of considering other causes of behavioural symptoms, utilizing non-pharmacological approaches, and adherence to monitoring and review intervals outlined in the guidelines. These findings underscore the importance of continuous evaluation and refinement of clinical practices to enhance the overall management of BPSD in dementia patients.