bluuebunny/crossref_metadata_2025 huggingface dataset:
The Role of Depression and Anxiety in Explaining the Association Between Cognitive Function and Disability in the General Population
Authors: Lynham Amy , Kendall Kimberley , Walters James , Jones Ian
Published: July 2023

Aims

In the United Kingdom, 14.6 million people reported having a disability in the year 2020–2021. Cognition may be one factor that contributes to disability, as previous studies have shown that cognitive abilities predict later health outcomes and prevalence of disability increases with decreasing cognitive function. Furthermore, studies have demonstrated a link between cognition and common psychiatric disorders, such as depression and anxiety. To our knowledge, no studies have examined the role of current mental health in the association between cognition and disability in a general population sample. The aim of this study was to examine the relationship between cognition, mental health and measures of disability/daily functioning in an online population sample. Our hypotheses were: 1) that lower cognitive performance would be associated with increased reported disability, and 2) that this association would be partly explained by current depression and anxiety symptoms.

Methods

The sample consisted of 3679 participants recruited from HealthWise Wales. Participants completed the Cardiff ONline Cognitive Assessment, a web-based battery of five tasks assessing processing speed, working memory, vocabulary, reasoning, and emotion identification. Disability was assessed using the World Health Organisation Disability Assessment Schedule (WHODAS). Real world measures of functioning were also included (currently employed, living with a partner, children and ever married). Current depression and anxiety symptoms were assessed using the Hospital Anxiety and Depression Scale (HADS). Linear and logistic regressions were conducted to assess the associations between cognitive performance and measures of disability/functioning. Structural equation modelling was performed to assess whether these associations could be partially explained by HADS scores, as well as measures of education and health/lifestyle factors.

Results

Higher cognitive performance was associated with lower overall WHODAS scores (B=−0.1, SE = 0.01, P = 1 × 10–13), living with a partner (OR = 1.13, 95% CIs = 1.06–1.21, P = 4.3 × 10–4) and being in employment or education (OR = 1.22, 95% CIs = 1.13–1.33, P = 2.1 × 10-6). HADS scores partially explained the relationship between cognition and: 1) WHODAS (80%), 2) employment (63%) and 3) living with a partner (37%). In addition, smoking status explained 3% of the relationship between cognition and WHODAS.

Conclusion

Current symptoms of depression and anxiety partially explained the relationship between cognition and three measures of disability/functioning. Alleviating these symptoms may improve patients’ daily difficulties. Future research should establish the direction of causality of these associations.
Recruitment and Retention Survey – What Did Speciality Trainees (STs) Say?
Authors: Mahmood Sajid , Kunigiri Girish
Published: July 2023

Aims

Recruitment and retention of medical staff is a national issue. Leicestershire Partnership NHS Trust (LPT) has significant challenge like many other neighbouring Trusts in this regard. Low level of staff means challenges in provision of adequate and efficient patientcare. There is a lack of flexibility for clinicians to get time for Supported Programmed Activity (SPA). Burn out of existing clinicians and loosing good will is common which increases patients’ complaint and potential risk of near misses and serious incidents. Despite the East Midland being one of the popular deaneries among STs, retention of locally trained STs post CCT remained a challenge. Thus, the aim of this study was to find out proportion of speciality trainees (STs) doctors satisfied with current job and to explore their views on current difficulties and ways to retain and support them post CCT in career progression within the training Trust.

Methods

It was a cross-sectional survey. The target population was STs working in the East Midland deanery. An online questionnaire was developed for data collection. Data were gathered through open (free text) and close (options provided) questions. Information was collected regarding job satisfaction, positive and negative of job, difficulties and challenges in current role, willingness to continue post CCT within Trust and if they would recommend friends or colleagues to join LPT. Results are reported in percentages for descriptive statistics.

Results

About 59% of the STs were satisfied with their current training. Key positive of jobs include helpful colleagues, good trainers and supervision, autonomy, flexibility, good on-call rota pattern, work life balance, and protected time for teaching. Interest is shown for various SPA activities (teaching, audit, QI project, research, leadership and management). However, wide variety of challenges being also reported at individual, team and organisational level.

Over 70% of the participants shown interest to work for LPT post CCT but requested for additional support in term of flexibility of job description and role whereas remaining 30% reported to move into private sector due to better pay and work life balance. Surprisingly only 23.5% clearly stated, they would recommend a friend or a colleague to join LPT.

Conclusion

Majority of STs doctors were satisfied and willing to continue working post CCT in LPT. However, reported challenges need prompt response and early discussion and planning with STs in term of what local Trust can offer and support would ensure their retention and enhance recruitment while they are being advocate for the LPT.
A Systematic Review of Clinical Practice Guidelines on the Use of Deep Brain Stimulation for Obsessive-Compulsive Disorder
Authors: Mazzoleni Adele , Bhatia Shreya , Bantounou Maria Anna , Kumar Niraj S. , Dzalto Monika , Soiza Roy L.
Published: July 2023

Aims

Deep brain stimulation (DBS), an invasive neurosurgical treatment where electrical stimuli are delivered in target brain areas, is an intervention that has traditionally been used for neurological movement disorders, but that has recently been considered for the management of psychiatric conditions, one of these being obsessive compulsive disorder (OCD). This review aimed to identify and assess clinical practice guidelines on the use of DBS for OCD, and, secondly, whether or not recommendations are tailored to individual patient characteristics, such as age, gender and comorbidities.

Methods

A systematic search of MEDLINE, EMBASE, APA Psych Info and Scopus was conducted, along with guideline development organisation websites, using all relevant synonyms of: “Guideline and DBS and OCD”. Studies were assessed by two independent reviewers, and discrepancies managed by a third reviewer. The protocol was registered with PROSPERO, following the PRISMA checklist. Included guidelines were appraised using the AGREE-II instrument.

Results

Nine guidelines were identified in total. Eight recommended DBS as a last-line option in the management of OCD, whilst the National Institute for Health and Care Excellence (NICE) recommended DBS should be used for research purposes only in OCD. Variability in the recommendations was also noted; indeed, only NICE undertook a cost-effectiveness analysis, and only the Congress of Neurological Surgeons (CNS) recommended target areas for electrode placement (i.e. subthalamic nucleus and nucleus accumbens). No guidelines clarified DBS settings, nor peri-operative optimisation measures. Patients’ preferences, age groups differences, ethnicity or comorbidities were not considered by any guideline. The guidelines’ quality ranged from moderate to high (50–92%), as per AGREE-II, with domains ‘scope and purpose’ and ‘editorial independence’ scoring the highest and ‘applicability’ and ‘stakeholder involvement’ the lowest across all guidelines.

Conclusion

Whilst eight guidelines supported the use of DBS for OCD as last-line therapy, a lack of cost-analysis, specific DBS settings, peri-operative procedures, and patients’ circumstances were analysed. Given the lack of randomised controlled trials in this field, more rigorous research is needed prior to wider DBS implementation.
Service Users Experience in the Use of Tele-Psychiatry in Child and Adolescent Mental Health Services in NHS Orkney
Authors: Alli Oluwabukunmi , Patil Chetana
Published: July 2023

Aims/Background

Near Me is a tele-psychiatry platform for conducting video consultation appointment in Child and Adolescent Mental Health Services (CAMHS) in NHS Orkney (NHSO). This model of consultation was introduced in NHSO CAMHS during the COVID-19 pandemic. The performance in offering effective clinical intervention in the domains of quality of care will determined through the experiences of both users and providers of care in this respect.

To assess the perception and experiences of service users (clinicians, patients and their families) on the use of Near Me in NHS Orkney Child and Adolescent Mental Health Services by applying the domains of quality of care as a measure. To enable all stakeholders (policy planners, users and providers) to identify gaps and barriers in the use of Near Me and to inform change in practice.

Methods

A survey was developed using the Telehealth Usability Questionnaire which is a validated tool to generate responses on the key domains of quality of care measures of appropriateness, reliability, access, timeliness, usefulness, effectiveness, interaction, quality, efficiency, safety, satisfaction and possibility of future use for both users and providers of care.

The survey was made available on social media platforms including websites and online adverts for clinicians, patients and their families in Orkney to complete for a period for 10 weeks.

Results

28 responses were received with 14 completed responses (6 staffs & 8 patients and families) and 14 uncompleted responses (4 staffs and 10 patients & families).

A mean rank test was applied to appropriately evaluate the responses received.

Over 50% of respondents show high level of satisfaction in the use of tele-psychiatry services in all domains of quality of care in Orkney NHS CAMHS.

Access, timeliness and safety are highly positively rated by both clinicians and service users.

Improvement in network connections, improved coordination and understanding of technology will enhance the service.

Better understanding of the handling of technical problems in tele-psychiatry services should be addressed

Reduction of in-person interactions was identified by some respondents as concern.

Conclusion/recommendation

Tele-psychiatry is highly useful and accepted as revealed by the survey but network connections for the Near me platform needs to be improved. Face to face consultations should not be discounted and should be available where possible for better engagement.

As the first survey of the use of tele-psychiatry in NHS Orkney, this study will serve to establish a baseline for future evaluation of tele psychiatry services in NHS Orkney CAMHS.
Multiprofessional Caseload Review in the Community Mental Health Team: Improving Patient Safety and Supporting Safe Discharges to Primary Care
Authors: Anwar Zarina , McClure Olivia
Published: July 2023

Aims

To create greater capacity within the general adult psychiatry outpatient clinic to facilitate urgent medical review for patients when needed, and to reduce delays for those receiving ongoing routine care within existing resources by improving joint working processes within the multidisciplinary team. To support safe discharges to primary care and promote ongoing recovery by improving access to community resources and the voluntary sector.

Methods

Caseload review for all patients under the outpatient clinics within South Leicestershire community mental health team began in August 2022. A template was developed in consultation with clinical colleagues and approved by the Trust clinical governance process. This includes salient clinical variables such stability, risk and medication. A consultant psychiatrist and senior nurse spend 2-4 hours weekly reviewing each patient's electronic record chronologically from those waiting the longest for an appointment. Using the template, one of the following for the patient's next appointment is determined, based on patient need:

•

Nurse discharge clinic

•

Outpatient discharge clinic

•

Outpatient clinic for ongoing treatment

•

Transfer to another service (eg ADHD)

A pilot nurse discharge clinic was carried out offering face to face reviews for patients identified as clinically stable for discharge over 4 weeks, with regular senior nursing supervision and medical input as required.

Results

Between August 2022 to January 2023, 700 out of a total of 1717 caseload reviews have been completed. 39% of these are identified as suitable to be reviewed for discharge.

In the pilot nurse discharge clinic, 137 patients were offered appointments: 82 were discharged, 16 did not attend, and 39 subsequently needed an outpatient appointment. There have been no serious incidents, complaints or re-referrals.

The waiting time for an urgent outpatient appointment has reduced from six weeks to one week and for routine outpatient care from six months to four weeks.

No work related absence for staff, and qualitative feedback from the multidisciplinary team has been positive.

Conclusion

Reduction in high outpatient caseloads is achievable through robust multiprofessional caseload review, and patients can be safely discharged from the care of consultant psychiatrists by multidisciplinary team working. This creates greater capacity, flexibility and flow for those who need ongoing outpatient care to receive this is a timely manner, improving the safety and quality of patient care. This has also fostered a greater sense of cohesion for staff within the team.
Monitoring of Physical Health in Patients Prescribed Antipsychotic Medication Within a Medium-Secure Forensic Inpatient Setting: Assessing Compliance With Guidelines and Improving Procedures
Authors: Baker Morven , Canham Robyn
Published: July 2023

Aims

Antipsychotic use is associated with haematological, metabolic and cardiovascular abnormalities. If not monitored and acted upon, these contribute to the increased burden of physical health problems in those with severe mental illness. Appropriate monitoring (including blood tests and ECGs) is required in accordance with NICE guidelines. The aim of our project was to assess our adherence (within a medium-secure forensic inpatient setting) to guidelines, and to improve procedures and processes within the unit. The majority of our patients are taking antipsychotic medication, but prior to our project there was no system in place to determine who was due which monitoring tests and when. Our suspicion was that patients’ physical health was not being adequately monitored especially given the unit's lack of input from general practitioners.

Methods

Our initial audit of patient notes took place in October 2022, assessing whether each of our 35 patients had had appropriate ECG and blood monitoring. After gathering these initial data we then systematically offered patients their monitoring. We set up processes to ensure this would be completed in a timely and organised fashion in the future, via creating a spreadsheet available on the shared drive and a chart within the doctor's office, adding instructions to the departmental junior doctor handbook, and liaising with colleagues.

Results

Of 35 patients, 34 (97%) were prescribed antipsychotics, 18 (51%) of these at ‘high dose’. Of those 34, blood tests for 22 (65%) patients were out of date or not completed as per NICE guidelines. ECGs for 21 (62%) patients were either missing or out of date. Following our gathering of the initial data and systematic completion of patient monitoring, at the time of re-audit in January 2023 monitoring was either completed or offered (with patient refusal) for 34 (100%) of patients.

Conclusion

We identified that monitoring of physical health in those prescribed antipsychotics within our unit was sub-par, with the majority of patients not up to date with bloods or ECGs as per NICE guidelines when initial data were collected in October 2022. Following our project, at the time of re-audit in January 2023 monitoring was either completed or offered to 100% of patients. We have implemented systems to ensure this continues in the future, beyond junior doctor changeovers. This has potential application to other longer-stay psychiatric wards such as general adult rehabilitation wards and other forensic units.
Improving Outcome Measurement and Experience in an Adolescent Inpatient Unit Through Patient-Reported Measures
Authors: Davies-Kabir Megan , Price Ceri
Published: July 2023

Aims

A Quality Improvement project was conducted in Ty Llidiard, a 15-bed adolescent unit in South Wales, over a three-month period to introduce and embed outcome measurement from the perspective of young people (YP) admitted to the unit. This was done to meet two standards set by Quality Network for Inpatient CAMHS: 1. “Outcome measurement tools are completed from the perspective of young people”, 2. “The ward team use quality improvement methods to work on service improvements.” Through use of these measures we hoped to give the YP a stronger voice in the multidisciplinary ward round (MDT-WR) and to improve their experience of attending it.

Methods

A validated patient-rated outcome measure (PROM) and experience measure (PREM) were chosen and adapted in co-production with the YP on the ward. The measures were selected on the basis of being quickly and easily understood and completed. The PROM provided useful ratings in key areas (“school”, “home”, “family”, “me”) and the PREM measured how patients experienced attending the MDT-WR. Outcomes and completion rate of these measures were audited weekly for three months, and several Plan-Do-Study-Act (PDSA) cycles were completed to increase their usage and to improve the YP's experience of attending their MDT-WR.

Results

From an initial baseline of 0% we achieved a maximum of 50% of YP on the ward completing a PROM each week, and a maximum of 100% of YP who attended MDT-WR completing a PREM. Three PDSA cycles improved our completion rate. PROM ratings were used as part of the clinical discussion in MDT-WR each week. Not all YP were well enough to complete it, but for those who were its clinical usefulness (and especially comparing scores in consecutive weeks) was reported in clinician feedback. PREM scores were presented and discussed a number of times in ward improvement meetings and management meetings and four PDSA cycles completed which incrementally increased the PREM average weekly scores.

Conclusion

We were successful in introducing and then increasing the completion rate of patient rated measures. Through use of the PREM we were able to make changes to the ward round and demonstrate the subsequent improvements to the experience of the patients attending. We have demonstrated that outcome measurement from the perspective of YP can contribute usefully to the MDT-WR and can improve YP's experience of the service. Use of these measures will continue as standard practice on our unit and could contribute usefully in future service evaluation projects.
Postgraduate Teaching Programme in Psychiatry in North Wales- a Regional Quality Improvement Project 2022-2023
Authors: Dhandapani Asha , Soundararajan Sathyan , Baker Catherine , Sambhi Rajvinder
Published: July 2023

Aims

We aimed to arrange the local Postgraduate teaching in psychiatry as per the Deanery requirement/ HEIW requirement. We aim to achieve a better target with regard to local teaching as noted from the previous year's GMC trainee survey

Methods

The project started in 2019. 3 sets of audits and PDSA's were done- one each year, before the final PDSA. During these 3 audits, only non-consultants were participants.

During the 4th PDSA, in 2022-2023, a purposive sample was selected to provide the best information possible for the audit. It included Consultant Psychiatrists from all three sites in North Wales, Trainees( Junior/ Senior), SHO, speciality doctors, FY2, GP trainees and Clinical fellows. The criteria for participation were that the doctors should be working in Psychiatry and should have attended the local postgraduate programme. Access to the internet and appropriate device was mandatory as an add-on availability.

An online questionnaire was emailed to the participants. There were only 3 questions for the Consultants and 5 for the non Consultants’ group. 2 weeks window was offered to fill out the forms.

Results

The 3 audits done initially revealed that consistent formal teaching was not provided. The candidates also found the current programme not fulfilling the criteria laid by the deanery and that their educational needs were neglected. The summary of the old audits suggested that the teaching had worsened eventually.

The final PDSA was done in 2022-2023. The overall time to fill out the form was 1.43 minutes. An equal number of Consultants and Non-consultants filled out the form. 31 Consultants rated the new programme as 4.23 for 5. The 31 non-consultants rated the programme 3.68 out of 4 and 95% identified that the new postgraduate programme covered the core trainees' requirements as per the MRCPsych Handbook from the Deanery.

Conclusion

Prioritisation of the most important facilitators and identification of ‘easy wins’ are important steps in this process.

The purpose of this study was to develop a national expert group consensus amongst a range of relevant stakeholders; senior doctors, residents, patients, allied healthcare professionals and healthcare managers allowing us to;

1.

identify important barriers and facilitators of learning in clinical environments and

2.

indicate priority areas for improvement. Our overarching objective was to provide information to guide policymakers and those tasked with the delivery of graduate medical education in tackling the provision of high-quality clinical learning environments in challenging time
Improving Cardiac Monitoring for Patients on Depot Antipsychotic Medication in a Mental Health Service for Homeless People
Authors: Hall Hugh , Ingram Maisie , Kablan Alicear
Published: July 2023

Aims

Patients under the Joint Homelessness Team (JHT) in Westminster have poor health outcomes as they face the double-hit of serious mental health illness (SMI) and homelessness. Many patients are on depot antipsychotic medication to manage their SMI. Depot antipsychotics are associated with increased risk of arrythmias and guidance advises annual electrocardiogram (ECG) monitoring for all (Maudsley: Prescribing Guidelines in Psychiatry, Taylor). However, a proportion of JHT patients are not well engaged with services and do not have an annual ECG recorded on SystmOne. In this QI study, we aimed to improve the percentage of JHT patients on depot antipsychotic medication who have a recorded ECG within the year on SystmOne, from current level to 80% over a 4-month period.

Methods

44 patients at JHT were identified as being on depot antipsychotic medication (1 patient was later excluded due to ongoing inpatient admission). PDSA cycles were used over a 4-month period from October 2022 to January 2023.

Intervention 1: Using available ECGs from GP or secondary care records to update SystmOne records.

Intervention 2: Email to GP requesting they invite patients for annual ECG.

Intervention 3: JHT inviting patients for targeted ECGs.

Results

At baseline only 48.8% of patients had an ECG recorded on SystmOne within the last year. Intervention 1 increased our recorded ECGs to 72.1%. Intervention 2 increased completed ECGs to 74%. Finally, intervention 3 increased completed ECGs to 83.7% by Mid-January 2023. Overall, results show an improvement of 34.9% or relative increase of 1.71 times the amount of recorded ECG over 4 months.

Conclusion

As a result of incorporating dedicated liaison and clinical time, we have improved uptake of annual ECG monitoring of patients on depot antipsychotic medication. We found there was a lot of existing physical health data in the GP and secondary care records that was not readily accessible to JHT. In the future, with the development of shared clinical data systems, both primary and secondary care teams may be able to save time and resources by avoiding duplication of data.

There remains room for improvement with 16.3% of patients still without an annual ECG. This is due to accessibility and engagement difficulties for people with SMI & history of homelessness.

We propose further intervention with a portable ECG machine to improve engagement with

these remaining patients. This project is being used as a business proposal to secure funding for a portable ECG device currently.
EVALUATION of VIDEO CONSULTATIONS in COMMUNITY MENTAL HEALTH SETTING- Pilot Project of Service Evaluation
Authors: Javaid Sadia Tabassum , Belgamwar Ravindra
Published: July 2023

Aims

To evaluate the overall experience and satisfaction with Attend Anywhere video consultations in adult CMHT. The increased use of the digital world is evident via Ofcom Tele Report 2019. UK Government's Five Year Forward View and initiatives, such as ‘Digital First’, aim to reduce face-to-face consultations. Past reports have shown video consultations to be non-inferior to face-to-face consultations in systematic reviews and qualitative studies.The contagious nature of the COVID-19 outbreak limited face-to-face consultations. This led to video consultations via Attend Anywhere (AA). AA is accessed anywhere via the web on Google or Safari with a good internet connection. It provides a single, consistent entry point with an online waiting area on the service's webpage.

Methods

1.

Two separate questionnaires were designed, one each for service users and staff, to capture relevant information at the end of AA consultation. Additional clinical questions for staff included.

2.

Data were collected anonymously for 2 months from 1st April 2020.

Results

Total respondent 44= 20 service users and 24 staff.

1.

For Service Users:

The respondents’ age range was 19-62 years, 80% females. The majority were follow-ups with three new assessments. About half of them had previous contact with the staff. 15 consultations were carried out by the doctor, four by the psychologist, and one was a joint doctor-psychologist consultation.

95% reported their overall experience to be very good-good. 90% found it easy to use: 95% said they would use it again.

2.

For Staff:

The respondents’ age range was 30-50 years, 87% females. The majority were follow-up assessments with one-third new. 16/24 respondents were doctors and eight psychologists. 58% had a previous meeting with service users.

83% reported the overall experience as very good to good: one third felt it's time-saving. 100% reported it's easy to use, would re-use and recommend to others.

For clinical questions, the responses were very good-good as Rapport 87%; Risk assessment 83%; care plan 83%; History taking 78%; Mental state/Cognition 66% and providing support 65%.

Conclusion

Overall, the majority of respondents at an Adult CMHT found video consultations easy to use with readiness to use them again. Video consultations offer several advantages over telephone reviews, e.g. for developing rapport, assessing mental state, etc.

These data are limited to the pilot project and a detailed review is planned for qualitative information with a larger cohort. Following this successful pilot and promising results, video consultations have been rolled out to other trust clinical areas.
A Digital Solution to Improve Safety of Valproate Prescribing in Mental Health
Authors: Mohamed Ashma , Marshall Alison , Smith Nikki , Smith Anna , Sowa Barbara , England Sue , Long Sarah
Published: July 2023

Aims

Valproate is a licensed medicine prescribed within mental health settings for bipolar disorder. It is a known teratogen, affecting approximately 20,000 people and costing the NHS £181 billion. This was a multidisciplinary project involving Surrey Heartlands Medicines Safety Team and Surrey and Borders Partnership NHS Foundation Trust, who developed a solution to reduce human suffering and cost by adhering to the Medicines and Healthcare Products Regulatory Agency (MHRA) valproate regulations through a clinical and digital redesign. The aim was to identify females in primary and secondary care across Surrey who take valproate for mental illness and to implement a pregnancy prevention programme for them by July 2022, using a digital clinical pathway supporting clinicians in the implementation process.

Methods

The method used was a combination of the Model for Improvement, the sequence for improvement from East London NHS Foundation Trust, UX design, and Agile project management. A valproate working group was formed with professionals from multiple disciplines to identify, understand and solve the problem. The solution was designed through co-production and project management methods that ensured a patient-centric solution.

Results

A digital registry of all females of childbearing potential who are prescribed valproate was created. A bespoke electronic GP referral form for valproate reviews was implemented. A one-stop valproate dashboard was developed to support documentation. A live digital visualisation feature was added within the secondary care electronic patient record to ensure compliance with MHRA guidelines. Easy-to-read materials for females with learning disabilities and sensitively worded appointment letters that inform patients of the risks and importance of attending annual reviews were created. In addition, collaboration with the National Valproate Patient Safety Officer allowed the implementation of Systematized Nomenclature of Medicine Clinical Terms (SNOMED) codes to simplify the exchange of clinical information between systems.

Conclusion

The project has the potential to reduce harm and improve the patient experience, serving as a template for other medications with strong regulatory controls. Collaboration between primary and secondary care, clinicians, pharmacists and digital colleagues, and co-design with people prescribed valproate were essential to the success of the project. Ongoing work is required to ensure valproate-related materials are available in an accessible format for every person prescribed valproate. Valproate has also been implicated in paternal adverse effects, and this project solution is future-proofed to identify men on valproate. Through this work, people will only be treated with valproate in a way that safeguards the health of unborn children.
Quality Improvement Project on Improving Patient and Family Experience in Psychiatric Inpatient Unit at Derby (Tissington House)
Authors: Mudiyanselage Irangani Nawasiya , McCormick Paul , Smith Jill , Bhatty Sasha , Dickinson Emma , Aziz Tariq , Panesar Avinash
Published: July 2023

Aims

Admission to a Psychiatric inpatient unit can be a stressful time for patients and families. Patient's and carers have advised staff on the ward that there is a lack of information available regarding the policies and procedures in the unit. This includes information on ward rounds, leave arrangements and discharge planning. The aim is to enhance the ward-based experience of patients and their families by attempting to explore areas to improved, particularly about providing information that will help them to understand the process of admission to an inpatient Psychiatric as well as what to expect throughout their admission and on discharge.

Methods

A questionnaire was distributed to all the ‘current’ in-patients and their families. The questionnaire was kept anonymous to encourage everyone to contribute honestly. Data were collected from 20 patients admitted to the ward from 01.02.2022 to 30.04.2022. Data were analysed and shared with the rest of the team to identify gaps in provision of information.

Results

Half of patients reported not receiving an introduction to the ward on admission and being unaware of the roles of different staff members. 70% of the patients and relatives were aware of the facilities of the ward and how to use them. There was a mixed response about satisfaction with running of Multidisciplinary Team Meetings(MDTs), availability of name nurse and medical team and information provision around MDTs, leave arrangement, discharge planning and follow up.

Conclusion

This quality improvement project has highlighted inconsistencies in the quality of and satisfaction with information provision during admission and has helped to recognised areas that needed to be improved. Several steps have been taken to improve quality of care such as copies of care plan and "Welcome to Tissington" booklet have provided. Discharge pathways and name board displayed in reception. Ward round appointments given to patients in advance and named nurse to support patients in writing MDT meeting plan. Invite families to attend care plan reviews, ward rounds and discharge meeting in person/via online. Additional craft items made available for activity, and exercise and walking groups have been introduced. Additional time made available for carers to speak with ward staff. Recruitment of Psychologist and occupational therapists now in post and Carers meeting to commence.

It is important to repeat this quality improvement project regularly to monitor the progress and get more information from families and patients to improve the quality of care given by the ward.
Quality Improvement Project to Reduce Restraints in Inpatient Wards at Lincolnshire Partnership Foundation NHS Trust 2020- 2023
Authors: Pillai Sophia
Published: July 2023

Aims

This QI was designed in collaboration with Trust's PMVA team to reduce the prevalence of physical restraints across inpatient wards by utilising model of improvement and measuring changes by studying number of restraints every six monthly. Secondary outcome considered were improvisation of recording of restraints, appropriate use of de-escalation measures and improvement in care planning surrounding the use of restraints.

Methods

The baseline audit was carried out to measure the prevalence of restraints and evaluate the practise of restraints in inpatient units during April to June 2020. The audit highlighted although there was 100% compliance in documentation of type and outcome of restraints , there were about 20 to 30 % restraints which did not utilise de-escalation measures, post incident debriefing and reflection within MDT. Only 12% of the restraints involved patients in post incident reflection. Using improvement model Plan- Do- Study- Act, following action plan was devised in 2021- 2022

1.

To improve education and training of inpatient staff in management of crisis behaviour through de-escalation strategies via PMVA training and sharing good practise/ gaps via MDT processes.

2.

To perform root cause analysis via quantitative and qualitative research to understand the clinical and demographic factors that influence restrictive practice.

Results

There has been downward trend or reduction of restraints by 10 to 30% in eleven wards across the trust from 2020 to 2022 and there has been reduction of violent incidents that resulted in restraints by 30% and self harm incidents that resulted in restraints has reduced in average by 10 to 30%.

In parallel there has been 30% improvement in the use of de-escalation measures, PRN medications and use of safety pods.

Re-audit was conducted during April to June 2022 concluded improvement in compliance of post incident debriefing and reflection, and involvement of patients for post incident reflection has increased by 60 % . The use of care -planning, and de-escalation strategies has improved by 10 to 15%.

Conclusion

The project has shown that improvement of training standards, holding monthly restrictive practise hub meetings sharing knowledge and reflection of ongoing practise relating to restraints in inpatient wards and monitoring of practise via continuous staff feedback has reduced the prevalence of restraints by 10 to 30% and improvement in secondary outcome measures as outlined.
A Picture of Health? A Review of the Quality of Physical Healthcare Provided to Adult Patients Admitted to a Mental Health Inpatient Setting
Authors: Shotton Hannah , Koomson D'Marieanne , Docherty Mary , Srivastava Vivek , Mason Marisa
Published: July 2023

Aims

To identify and explore remediable factors in the clinical and organisation of the physical healthcare provided to adult patients admitted to a mental health inpatient setting.

Methods

Data from 291 clinical, 56 Trust-level and 224 Hospital-level organisational questionnaires were completed; 285 sets of case notes were peer reviewed; 168 service user and 79 carer surveys were reviewed to assess the care provided to patients aged 18 years and older who were admitted to a mental health inpatient setting in the UK for at least one week during 01/11/2018 to 31/10/2019, and who:

•

Had existing chronic obstructive pulmonary disease/ asthma/ cardiovascular disease/ diabetes

•

Had experienced a transfer to a physical health hospital

•

Died in the mental health inpatient setting or within 30 days of discharge

•

Specialist commissioned mental health services and suicides, homicides and self-harm related deaths were excluded from this study.

Results

The report highlighted 5 key messages:

1.

Assess patients for acute physical health conditions on arrival at a mental health inpatient setting and then undertake a detailed physical health assessment once the patient is admitted A detailed physical health assessment was not undertaken appropriately for 28/126 (22.2%) patients.

2.

Develop a physical healthcare plan for patients admitted to a mental health inpatient setting A plan for physical health observations was not documented for 48/217 (22.1%) patients.

3.

Formalise clinical networks/pathways between mental healthcare and physical healthcare Local care pathways or pre-existing arrangements with physical healthcare providers were used as part of the care plan for 71/291 (24.4%) patients.

4.

Involve patients and their carers/friends/family in their physical healthcare and use the admission as an opportunity to assess, and involve patients in their general health In 100/188 (53.2%) sets of notes reviewed, there was no record that the physical health review had been discussed with the patient's family/ carers.

5.

Include mental health and physical health conditions on electronic patient records and allow sharing across healthcare providers

6.

20/56 (35.7%) organisations reported that all elements of the clinical record were available in the electronic patient record

Conclusion

The NCEPOD report provided an in-depth review of the quality of physical healthcare in mental health inpatient settings and found that there is room for improvement in physical healthcare of patients. Key aspects of care requiring improvement were treatment of long-term physical health conditions (62/119; 52.1%), documentation of physical health observations (61/119; 51.3%) and delays in identifying acute deterioration (19/119; 16.0%) patients.

The report makes twelve recommendations for clinicians and management to implement in practice.
Quality Improvement Project to Co-Produce Effective Triangulated Communication Between Inpatient Psychiatric Team, Community Mental Health Teams, Patients and Carers to Help Patient Involvement and Positive Step Down Discharge Planning
Authors: Tahseen Hina , Davies Jade
Published: July 2023

Aims

The aim of the QI project was to promote patient involvement, choice and recovery using effective communication and collaborative planning. To achieve this, we aimed to ensure that patient's voice remained central to the decision making process in meetings . Using 5-Why QI methodology, the MDT of Delfryn-House—a private 28-bedded rehabilitation unit, reviewed the communication interruptions between the internal and external CMHT (especially after the pandemic), which in turn was hampering patients’ progress towards positive discharge. It was also noticed that patients' attendance was significantly dropped and they were not showing interest in their CPA/CTP meetings, as they were not seeing any benefits of them. The MDT planned the project to improve the communication for continuity of care and to have better involvement of patients, their families and external teams.

Methods

The Intervention project, based on QI model-of-improvement, established that effective communication was the main aim, to be achieved with new change ideas. The outcomes were both qualitatively and quantitatively measured e.g.using feedback questionnaires from CMHT and patients and carers, attendance and discussion of discharge goals for the admitted patients. Driver diagrams were used for change ideas e.g. Microsoft teams invites to all teams for the patient review and care plan review meetings, MDT adding the progress feedback to the patient review meeting proforma to be shared internally and externally prior to the meetings, informing the care coordinators prior to change in Mental health act status, same day email to CCOs about medication changes, incidents, safeguarding, and ensuring discharge goals are discussed at every meeting. Satisfaction surveys to the CMHTs and patients were conducted pre- and post-intervention. Qualitative data were collated, helping to generate quantitative statistical analysis of the satisfaction ratings. The attendance of meetings and positive discharge from the unit were also used to measure the outcomes.

Results

There was significant improvement in both commissioners and CMHT's satisfaction of improved communication from Delfryn House. There was increase in attendance (44% by patients, 20% by carers, 64%by CMHT and 40% by Commissioners). There was increase (45%) in patients reading and signing their care plans. A notable increase in positive stepdown discharge plans were noted, however, as the QI project was run in a rehabilitation unit requiring longer admissions, there were not many actual discharges to show a noticeable difference.

Conclusion

The QI-project helped in establishing clearer pathways towards positive discharge and continuity of care, signifying the importance of effective communication between teams and co-producing the care plans and meeting agendas with the patients and their carers.
Quality Improvement Project to Improve the Implementation of Mental Health Act Code of Practice Guiding Principles and Patient Knowledge About MHA in In-Patient Psychiatric Unit
Authors: Tahseen Hina , Parry Nicola
Published: July 2023

Aims

To improve the efficiency of MHA documentation, patient education on MHA and implementation of guidelines of Code of Practice in in-patient unit. We also aimed to involve patients at some stages of the QI project to ensure they remain updated about the legal framework and associated documents and their voice remains central.

Methods

The QI Project was started after an initial audit was conducted which included MHA documentation on admission and during the length of stay, patients’ legal rights, section-17 leaves, capacity and treatment forms, tribunal reports, section-117 meetings and arrangement of independent managers hearings prior to Section Renewals. Using 5-Why QI methodology, the medical team and the MHA administrator reviewed the gaps in the initial audit. Using the QI “theory of change” model, three primary drivers of “Responsible Clinician and MHA Administration Liaison”, “Patient Education on MHA” and “Policies and Guidelines Implementation” were established. Secondary drivers for “RC and MHA Administration Liaison” required inputs from doctors, secretaries, nurses and MHA Admin. Change ideas of introducing weekly email template for required MHA actions, section paper scrutiny template made for approval by MHA Admin/ RC prior to patient's admission, Introduction of MHA relevant actions section in the morning handover and patient's review record form.

Secondary drivers and change ideas for “Patient Education on MHA” included discussions with MDT, easy- language information leaflets, discussion slots with pharmacists about medications before consenting for treatment forms, discussion slots with the key nurse and RC about MHA related decisions and going through statutory reports together to understand the nature and degree of illness, and risks necessitating the renewal of admission.

Secondary drivers and change ideas for “Policies and Guidelines Implementation” included teaching sessions for nurses on report writing, giving evidence at tribunals, and how to inform patients about legal rights, and liaison with medical management QI committee to ensure capacity and treatment certificates are up to date and filed in the medical folders. The initial audit tool was repeated on quarterly basis in addition to the PDSAs to measure results.

Results

Results showed 100% score in capacity assessments, treatment certificates and timely reports. There was still improvement needed in organising managers hearing prior to section renewal, likely section renewals left till late. A pre-and-post intervention score on patients’ knowledge of rights and MHA showed an improvement of 68%.

Conclusion

The QI-project helped in implementing MHA code of practice guiding principles and patients’ knowledge about MHA and their rights.
Reducing Restrictive Practice on a Medium Secure High Dependency Forensic Inpatient Unit
Authors: Wong Brandon , Khan Mohsin
Published: July 2023

Aims

Restrictive practice can include physical and chemical restraint and should be utilised as a last resort. It has been found to negatively impact patients causing psychological distress, re-traumatisation, and a sense of helplessness. Restrictive practice also negatively impacts staff, causing emotional distress, moral conflict and the risk of physical harm. Since 2018, there has been a drive to reduce restrictive practice in inpatient mental health wards across England by the National Collaborating Centre for Mental Health, which has been further developed by NHS England in 2021 within the Mental Health Safety Improvement Programme (MH-SIP). This study aims to reduce restrictive practice on a 10-bedded Medium Secure High Dependency Male Forensic Mental Health Unit over a 6-month period, incorporating staff and patient feedback and utilise QI methodology.

Methods

Number of total seclusion hours, seclusion episodes and secluded patients per day were measured at baseline utilising the Rio clinical system and continuously tracked during the study period. Interventions were discussed by a multi-disciplinary team including nurses, pharmacists, health care assistants, occupational therapists, psychologists, and doctors. Patients were invited to give feedback on restrictive practice during ward rounds. Potential interventions were then implemented utilising PDSA methodology with iterative changes tested and analysed. Staff and patients were also invited to complete surveys and semi-structured interviews to give further comments during the study.

Results

Baseline data of monthly activity showed 3,758 total seclusion hours, 10 seclusion episodes and 5.3 seclusions per day. Iterative interventions included; (i) MDT discussions to support positive risk taking (ii) Improved collaborative care planning with patients (iii) Incident calendars for patients (iv) excel spreadsheet indicating progress towards leave / referral to stepdown ward and (v) improving transparency on impact of incidents on progress. Month 6 activity showed 174 total seclusion hours (95% reduction), 1 seclusion episode (90% reduction), and 1 average seclusion per day (82% reduction). A survey completed at the end of the study period showed all patients either strongly agreed or agreed that they understood the process for termination of seclusion, with 100% either responding between “neutral" to "strongly agree” that this had improved.

Conclusion

It was hypothesised that a more collaborative approach with positive risk taking could lead to the reduction of restrictive practice. The interventions enacted have significantly reduced the use of restrictive practice. Further study is recommended into these interventions to review if similar results can be replicated in other inpatient wards.