bluuebunny/crossref_metadata_2025 huggingface dataset:
Transitioning of the Northwest Learning Disability (NWLD) Academic Regional Teaching Forum (HEE-NW) to a Virtual Programme With Enhancement of Medical Education for Trainees, Trainers and MDT Professionals During the COVID-19 Pandemic- a Quality Improvement Project - QIP Project Lead & Organiser -NWLD - Dr Syeda Hasan- Northwest HEE
Authors: Hasan Syeda
Published: June 2022

Aims

Despite the challenges posed by the pandemic, several resourceful initiatives were implemented, across the educational landscape. As the lead organiser of the academic forum the expectation was to develop a format for on-line monthly academic teachings with streamlining further innovative ideas of change to best effect. The key objective of this QIP,is to use virtual platform to establish an educational forum that is efficient, safe, reliable, easy to use and replicable

Methods

•

A zoom based online forum was convened using QI framework to identify gaps in the programme along with new ideas of change.

•

The attendees experience new innovative practices within the programme format, in line with the original NWLD forum programme.

•

A ‘think-group’ consisting of the previous NWLD forum lead, ID training programme director and higher trainee facilitators proposed ideas towards a varied educational topic bank, in line with the ID curriculum

•

Qualitative feedback from the forum members collected at baseline and regular intervals.

•

As part of the implementation of these actions, conducted workshops evaluating the impact of COVID-19 on Educational, Psychological and Clinical landscape

Results

•

There were 18 virtual sessions,5 CPD hours per session, conducted monthly.

•

9 sessions in the first PDSA cycle from June 2020 - Feb 2021, and 9 sessions in the second PDSA from March 2021-November 2021.

•

Impact of COVID-19 workshops & Complex case management workshops conducted in the first and second PDSA cycle as part of the monthly academic programme.

•

Participants for the academic regional teaching included Consultant Psychiatrist, higher trainees, Core trainees, Foundation doctor, specialty doctors, Medical Students and MDT professionals.

•

New members regionally, nationally and internationally became part of the academic programme both as attendees and as speakers along with the Chair of the ID Faculty.

•

The academic programme helped with educational and training needs. It helped in improving social participation for our members during COVID-19 pandemic.

•

Qualitative feedback has been collated and analysed. The feedback contains a wealth of comprehensive information that has been used to enhance the programme and training needs for the trainees and trainers.

Conclusion

•

The program is well-received and led to knowledge, skill, and attitude improvements.

•

The depth analysis of the feedback has facilitated a targeted approach that has brought a meaningful improvement, in the quality of training and education.

•

Audience participation and engagement remains a key area for improvement.
Complex Case Management Workshop for Trainees &Trainers - a Quality Improvement Project -to Enhance the Understanding of the Case Management and Complexity in People With Intellectual Disabilities for Senior Trainees and Early Career Consultants
Authors: Hasan Syeda , Spurrell Mark
Published: June 2022

Aims

Whilst there is always more to learn within any speciality, the particular zone of development for senior trainees and early career consultants is the management of the complex case. The factors underpinning complexity are varied, and can range from aspects of the service user such as complexity and severity of disorder and/or multi-morbidity, to aspects of their local social networks, to complexities arising from the service or care environment. The aim of this workshop was to offer a safe space for senior trainees and early career consultants to work through some principles that might be helpful, particularly where things seem to be getting into a pickle.

Methods

•

A 60-minute slot was proposed, as part of the Northwest Learning disability academic teaching forum.

•

The structure of the workshop borrowed the informality and spirit of support from Balint groups.

•

Attendees were prepared to talk about one of their cases anonymously, and why they might be getting into a pickle.

•

Soundings were taken and a particular case chosen to workshop in more detail, as an exemplar for others.

•

Each session focused on one or two themes from the wider set of themes suggested by the CCaRM framework (Spurrell, Potts & Shaw, 2019) currently being used by Greater Manchester and Lancashire SST to expedite their work.

•

Each session concluded with an evaluation discussion of workshop usefulness.

Results

•

There were 6 virtual workshops in first PDSA cycle (June 2021-Nov 2021)

•

Each workshop lasted approximately 100–120 minutes, with 8–12 people attended in each session.

•

The intention for the workshop was to include senior trainees and early career consultants who are within the NWLD forum however junior trainees, senior consultants and other MDT professional also became part of the sessions.

•

Each session concluded with an evaluation discussion of workshop usefulness

•

Qualitative feedback has been collated and analysed from the evaluation discussion.

•

The information derived from the qualitative analysis indicates that there is a substantial need for regular complex case discussions for the purposes of enhanced care delivery and improved patient outcomes

Conclusion

This approach helped in enhancing the understanding of the case management for people with intellectual disabilities among forum members

We consider that the online workshops is a success and are planning further-PDSA 2 in order to create competent and well-rounded ID psychiatrist in the future in Northwest region.
Documentation of Driving Status and of Fitness to Drive Following Admission of Patients to Clock View Hospital - How Are We Doing?
Authors: Abraheem Azmeralda , Barnes Enrica , Hendry Ryan , Martin Cameron , Hyland Declan
Published: June 2022

Aims

Developing a mental illness and being commenced on psychotropic medication are factors that may interfere with the ability of an individual to drive safely as both can impact information processing, psychomotor actions and social interpretation. The Driver and Vehicle Licensing Agency (DVLA) suggests that certain medical conditions require driving licence holders to notify them for further assessment of their ability to drive. DVLA notifiable mental disorders include psychosis, schizophrenia, bipolar disorder, dementia and personality disorders. The doctor's legal duty is to assess the patient for any relevant diagnosis, inform the patient of their duty to report their medical condition to the DVLA and for the doctor to comply with the legal duty to inform the DVLA of any patient who won't or can't notify the DVLA of their medical condition. The authors conducted a quality improvement project to evaluate and improve the number of fitness to drive assessments completed for patients admitted to the five wards (three general adult, one older adult and the Psychiatric Intensive Care Unit) at Clock View Hospital.

Methods

The electronic (RiO) record for each inpatient on the five wards was scrutinised for: whether the patient's driving status was established on admission; whether the patient was notified of the DVLA rules if they did drive; whether the patient agreed to fulfil their duty of notification and, in instances where they were not, whether the medical professional had taken appropriate steps to address this.

Results

74 patients on the five wards were included in the sample. Only nine of the 74 patients had driving status documented on admission. Three of these nine patients were noted to be driving or learning to drive and were not notified of the DVLA rules. Four of the nine patients were no longer driving and so discussion about DVLA guidance was unnecessary. The remaining two patients were confirmed to be driving and informed of the DVLA regulations. Both patients agreed to comply and therefore no further action was indicated.

Conclusion

A review of current practice indicates a deficit in incorporating driving status and fitness to drive assessment into the clerking proforma following admission to Clock View Hospital. The second half of this cycle will implement change and raise awareness amongst inpatient medical and nursing staff of the need to consider this important issue prior to discharge. A re-assessment of the effectiveness of these changes will be carried out in the future.
Evaluating Completeness of Admissions Clerking Procedure for Patients Admitted to an Acute Psychiatric Inpatient Unit
Authors: Karthikeyan Neha , Little Charlotte , Nair Anjali , Sandor Andrew
Published: June 2022

Aims

There is a well-known bidirectional relationship between mental and physical health. A thorough mental and physical health assessment of new inpatients on admission is crucial to assess possible organic causes of psychiatric presentations and enable appropriate treatment to be commenced in a timely manner. We noted a pattern of incomplete clerking, leading to delays in commencing treatment and increased workload pressure on the ward medical team. Our audit aims to assess how thoroughly and in what time frame patients' admission assessments are being completed on an acute psychiatric inpatient unit.

Methods

A sample of 20 patients was used for each cycle. Eight components were identified from the Trust clerking procedure. These were a full psychiatric history, capacity assessment, prescription chart, physical health systems review, physical examination, blood tests, ECG and VTE assessment. The expected standard was completion of all of the above at the point of admission or, if applicable, adequate documentation of patient refusal with documented reattempt within 24 hours.

Electronic patient records were retrospectively reviewed to identify whether each component was completed, the number of days from admission to completion and if completed by the clerking doctor. Evidence of documented patient refusals and the number of incomplete draft entries were noted.

Results

Initial results showed only 20% of patients (n = 4) had the full expected clerking procedure completed at admission. Physical health assessments (ECG, blood test, physical examination) had the lowest completion rates. When components were not completed by the clerking doctor, there was often a delay of several days from admission to completion of by the ward day team. For 50% of patients, some assessments were never completed (without adequate refusal documented). Eight patients did not have a completed VTE assessment by the point of discharge.

Conclusion

Reasons were identified for the poor completion rates of clerking assessments. These included a lack of understanding by on-call doctors about the importance of completing all assessments, unfamiliarity with ward equipment, lack of adequate handover to the ward medical team and staffing pressures. A new handover checklist was introduced for clerking doctors to use and enable better communication with the ward team. Clerking procedure summaries were displayed in on-call rooms and additional teaching was organised.
Quality Improvement Project to Improve COVID-19 Vaccination Uptake on an Old Age Psychiatric Ward (Meridian Ward)
Authors: Khan Fariah , Etherington Emma , Kheder Potan
Published: June 2022

Aims

People with mental health issues have challenges in accessing medical care and it is hypothesised that this may result in a significant number failing to receive protection from COVID -19 by means of vaccination. This study aimed to identify the number of inpatients on a psychiatric general ward (Meridian ward) between May 2021 and June 2021 who were fully vaccinated against COVID-19 so that unvaccinated patients could be offered vaccination during their inpatient stay.

Methods

Data were gathered on the COVID-19 vaccination status of all patients on Meridian ward (inpatient mental health ward) admitted between May and June 2021. This was a total of 10 patients. This information was gathered directly from the patients, their summary care records and GP records. We also audited whether the patient's vaccination status was recorded in the notes.

Results

50% of the patients were fully vaccinated. 20% had received one vaccine and 30% of patients were unvaccinated. 20% of the unvaccinated patients received their first dose during admission.

Conclusion

Patients with mental health issues sufficient to result in psychiatric admission face additional challenges when it comes to receiving a COVID-19 vaccine. It is important that healthcare workers are aware of this and facilitate interventions that maximise vaccination in this at-risk group. To improve uptake among this group it is recommended:

•

Patients’ vaccination status is assessed and recorded during inpatient admissions.

•

GP surgeries should identify patients on their database with mental health issues who are unvaccinated and providing these individuals with support around accessing information, transport or providing vaccinations at patient's homes.

•

There should be clear documentation of vaccination status on summary care record and ward notes.
An Evaluation of Admissions to an Old Age Psychiatry Ward: A Quality Improvement Project
Authors: Cooper Michael , Langan Clare , Haxton Christopher , Andrew Philip , Yazid Mohd
Published: June 2022

Aims

It has been well publicised the pressures on inpatient bed capacity within mental health services in recent years. The RCPsych have stated in their publication ‘Exploring mental health inpatient capacity’ that bed occupancy has risen above their recommended 85% occupancy target in most areas. Waiting lists for beds have also grown. The aim of this project was to identify whether there could have been any extra community resources in place that could have prevented admissions to hospital within an older adult CMHT. This in turn reducing the demand on inpatient beds.

Methods

Inclusion criteria: All patients from the older adult CMHT admitted to either an organic or functional mental health inpatient bed between the 1st September and 31st December 2021.

All patients who met the inclusion criteria were discussed as part of a panel consisting of members of the MDT who were involved in the patients' ongoing care. The panel discussed each patient and individually scored each admission on a scale of 1–5 (where 1 was deemed to be very avoidable and 5 completely unavoidable). Where an admission did not score a 5 we considered whether anything could have been in place to have prevented the admission.

Results

Our search identified 21 patients who had been admitted to the respective old age psychiatry ward during our period of interest. The predominant diagnosis of these patients was vascular dementia (n = 5), followed by Alzheimer's disease (n = 3). Following our consensus panel discussion, we identified that the most common reason for admission to hospital was for management of behavioural and psychological symptoms of dementia (n = 10), followed by increasing patient vulnerability (n = 4) in the community. Carer stress was a theme in 2 admissions. Following panel discussion regarding potential avoidability of admission, we identified that 14 out of the total of 21 admissions scored a 5, 1 scored 4, 1 scored 3, and 5 scored 2.

Conclusion

Behavioural and psychological symptoms of dementia continues to remain a significant clinical challenge and was the most common reason for admission in our patient cohort. The majority of admissions to hospital in our cohort were deemed unavoidable as a result. However, we identified that carer stress was a significant theme in 2 out of our 21 admissions, suggesting potential scope to implement services which may reduce carer stress and ultimately, prevent hospital admission.
“Inside Out”: A Regional Inpatient Joy in Work Project
Authors: Morgan Tammy , Kelly Claire
Published: June 2022

Aims

Inpatient admissions during the COVID-19 pandemic went up in the regional unit by 18%. This included a 50% increase in Eating Disorder Presentations and more complex SMI requiring admission to Beechcroft. Beechcroft is the regional inpatient unit for CAMHS in Northern Ireland. This project aimed to improve staff joy in work by 30% by June 2021, following what was one of the most difficult years to be a health professional with the COVID-19 pandemic.

Methods

We used the IHI Joy in Work methodology along with our own rating scales in the inpatient unit.

Several PDSA cycles were carried out including focus groups, gathering baseline data from different wards, and our change ideas- Beechcroft stars nominations, Virtual Quizzes and Staff recognition certificates.

Results

Baseline data on our run chart demonstrated a bad day median in Beechcroft with 4.3 being the score.

With the PSDA cycle we demonstrated a 33% improvement in good day scores with a median of 1.4.

We have learnt that Joy in work comes from recognising the work already being done and rewarding the efforts our staff go to.

Spread and scale with Beechcroft stars now part of fortnightly MDT meeting and management meeting. Also rolled out to a community mental health team.

Conclusion

Joy in Work comes from the team. Recognising the efforts of the team is central to this. In particular during a pandemic.
Improving Physical Health Data Provided on Discharge Summaries From Sheffield Home Treatment Team
Authors: Nieuwoudt Ross , Bradwell Alex , Slater Gaelle
Published: June 2022

Aims

The aim of this QIP was to identify whether the information obtained during routine physical health reviews was being adequately handed over during discharge from the Sheffield Home Treatment Team within discharge summaries. Individuals with serious mental illness have a significantly higher all-cause mortality rate than those without, much of which is due to preventable physical health conditions. Due to this, the Home Treatment Team aims to complete a Physical Health Review (PHR) for every patient under their care as per guidelines. It is important that these examinations are performed, however, it is equally important that the results of PHRs are communicated to the patient's primary care physician upon discharge. Communication between services is vital for continuity of care and to ensure that identified problems are managed effectively. On discharge, relevant data from these investigations should be communicated to the service user's registered GP surgery for appropriate follow-up care. Performing investigations without informing the service user's primary physician is an inefficient use of resources and may result in unnecessary repeated investigations and procedures. There is not currently an official system in place to assure that the investigations and results of PHRs are summarised and communicated upon discharge.

Methods

There were two steps taken in this stage of the QIP. First, a questionnaire was distributed to all members of the Sheffield Home Treatment Team, including medics, nurses, and STR workers. The responses were compiled and analysed to form the criteria and standards for an audit of previous discharges. Following this, an audit was performed for the months of June-July 2021, data were kindly collected by junior doctors. This data looked to determine whether previous discharges met the criteria and standards set by the questionnaire.

Results

The results of the audit showed that the discharges did not meet the standards set, with many containing little to no information. Only 49% of the service users with physical health reviews had any information provided on discharge. Of these, the contents of the summaries were varies and inconsistent, resulting in a significant amount of information becoming unavailable to the service user's GPs.

Conclusion

1.

The current system is insufficient in terms of handing over physical health information collected during investigations performed by the Home Treatment Team.

2.

A proposed solution will be implemented in the coming months.

3.

A re-audit will be performed to complete the audit cycle and assess the efficacy of the proposed solution.
Attitudes and Experience of Autism and Learning disability(LD): A Survey of Mental Healthcare Staff
Authors: Onwuchekwa Ogba , Davidson Conor , Sharma Vishal
Published: June 2022

Aims

To establish a baseline of staff experience and confidence in autism/LD. To inform how we deliver training going forward. To collect good practice examples of reasonable adjustments. To ascertain knowledge about the appropriate recording for information related to Autism/LD

Methods

All clinical and non-clinical staff of Leeds &York Partnership Foundation Trust(LYPFT), Bradford District Care Foundation Trust(BDCFT), South West Yorkshire Foundation Trust(SWYFT), Voluntary sectors, Local authority and Leeds Community Health Care NHS Trust (LCH)were invited to take part in the anonymised “Staff Autism and LD Survey” through the various trust wide email bulletins. Smart Survey was the platform used. It took about 5–7 minutes to complete, and the survey period was from 21/09/21 to 01/11/21

Results

A total of 225 members of staff across six organisations took part in the survey.

76% (170) were from LYPFT, 16(7%) from Voluntary Sector Organisations, 6%(14) from Local Authority and 3% from LCH 3%(7), Missing 14(6%), BDCFT 1%(2), SWYPFT 1%(2)

The majority were nurses 23% (52), followed by psychologists 10% (22).

18% (41) stated they would be interested in becoming an autism champion for their team/service.

Although 89% (200) had heard of the term “reasonable adjustments”, 36% (81) had never seen a ‘hospital passport’ for an autistic or learning-disabled service user.

Only 24 (11%) said they knew where to record reasonable adjustments on the electronic patient record

In general staff were marginally more confident in making reasonable adjustments for people with autism than those with LD

Majority of staff preferred : face-to-face training, followed by e-learning and then videocall.

Conclusion

Generally, respondents reported feeling neutral or confident with respect to their confidence in recognising, diagnosing, and working with patients with autism. The number of staff that have indicated interest at becoming Autism champions is a testament to the growing interest and increasing awareness about Autism.

Regarding learning disability, respondents generally reported feeling neutral or confident across the three areas of recognising moderate to severe learning disability, recognising mild learning disability, and managing/treating mental health problems in service users with learning disability.

The very high number of staff (89%) that have heard of the term “reasonable adjustments” is quite commendable and is useful to know when planning what level to ‘pitch’ training in this area.

It is interesting however that staff feel more confident at making reasonable adjustments for people with Autism, rather than for LD. One wonders whether it is due to the increasing media publicity about Autism.
Improving Standards of Physical Health Care of Patients in Secure Mental Health Hospital
Authors: Patel Harikrishna , Robinson Kathryn , Kennard Alexandra
Published: June 2022

Aims

Evidence suggests that individuals with serious mental illness (SMI) die up to twenty years prematurely compared to the average population without SMI with the main causes of death linked to preventable cardiovascular disease, respiratory failure, and endocrine disorders. This early mortality remains despite national efforts to recognise the issue and promote development of processes to enhance quality of physical health care in patients with SMI. The National Institute for Health and Care Excellence (NICE) clinical guidelines (CG178) recommendation 1.5.3.5 states that healthcare professionals in secondary care should ensure individuals with SMI receive physical health checks from primary care. This idea may be suitable for patients in the community setting or those who undergo shorter hospital admissions, however the process of psychiatric rehabilitation in secure mental health hospitals is challenged by long average stays resulting in no access to routine primary care facilities. The aim of the project is to introduce tailored measures that would aid in delivering high quality physical health care to patients within secure mental health hospitals.

Methods

Ravenswood House Medium Secure Hospital supported a project to improve the physical health of individuals with SMI. An audit was completed to evaluate the assessment and management of baseline physical health measures that would have usually been completed in primary care as per the standards set out in NICE guidelines. The results showed that not all measures were being met and there was room for improvement.

Based on these NICE recommendations, an annual health check template and a centralised documentation toolkit were implemented and integrated within a new Physical Health Care Pathway in collaboration with General Practitioners, Dentists, Physiotherapists and other Allied Healthcare professionals.

Results

Following implementation of the Physical Health Care Pathway, the number and quality of annual physical health checks in Ravenswood House Medium Secure Hospital increased resulting in significantly better-quality outcomes for patients by completing appropriate referrals and follow-up care.

Conclusion

This collaborative approach of providing a high-quality physical health care was delivered in-house by arrangement with external healthcare practitioners. This pathway of providing care assisted us in overcoming several challenges faced within secure hospitals due to legal sanctions and related security protocols involving the patient group.
A Survey Exploring Gendered Racism Experienced by Junior Doctors Working in Psychiatry
Authors: Rais Aicha , Burton Richard , Rauf Adeel
Published: June 2022

Aims

To measure rates of racism experienced and witnessed by Junior Doctors working at Derbyshire Healthcare NHS Foundation Trust.

Methods

Surveys were sent out via e-mail and WhatsApp to all Junior Doctors from 22 November 2021 to 1 December 2021.

Questions asked about personal experiences of racism, witnessing racism to/from patients and/or staff whilst working in Derbyshire, knowledge of how to report incidents and if routinely reported. Doctor race and gender recorded.

Results

88 Junior Doctors contacted. Response rate 55% (48 out of 88). 63% female, 35% male and 2% gender undisclosed. 37.5% White, 12.5% Black, 37.5% Asian, 6.3% Mixed-race, 4.2% Arab or other ethnic group and 2% Race undisclosed. 13% of doctors experienced racism from staff: 75% of the Black female population, 50% of the Black male population, 8% of the Asian female population and 17% of the Asian male population. 27% of doctors experienced racism from patients: 50% Black female population, 50% Black male population, 58% Asian female population, 16% Asian male population, 100% Mixed-race female population and 1 Race unspecified male. 13% of doctors witnessed racism from staff to other staff: 75% Black female population, 50% Black male population, 11% Asian female population and 16% Asian male population. 63% of doctors witnessed racism from patients towards staff: 75% Black female population, 50% Black male population, 67% Asian female population, 33% Asian male population, 100% of the Mixed-race population, 58% White female population, 83% of the White male population and by 1 male Race unspecified. Two reports of racism witnessed from staff towards patients. 50% of doctors do not know how to report racism. 54% of doctors would report racism if they knew how.

Conclusion

Black, Asian, and Minority Ethnic (BAME) Junior Doctors are disproportionately affected by racism with female gender as an additional vulnerability. Mixed-race females, Asian females, and Black doctors gave highest reported experience of racism from patients. Black doctors gave a higher reported experience of racism from staff and reported witnessing the most racism from staff towards other staff. Mixed-race and White male doctors represent a high number of those that witness patients be racist towards staff. Additional support is required in encouraging allyship, confidence and ability to report racism.
Improving Adolescent Care in a Cross-Sector System
Authors: Ravishankar Aarthi , Holliday Tom , Fraser Lauren , Biggin-Lamming James
Published: June 2022

Aims

Adolescence represents a critical life stage in which there is rapid physical, cognitive and psychosocial development. It is the time where the patterns and foundations for future health are laid and thus presents a unique opportunity to promote health and subsequently improve life-long well-being and reduce health inequalities. Mental health problems represent the greatest contributors to disease burden for this population and this contribution is forecast to rise. The World Health Organisation state that adolescents and young adults (AYAs) need health services that are supportive, equitable and effective. The project aims to scope out Adolescent care at London North West University Healthcare NHS Trust (LNWH) with a view to improve quality of care for this group of patients.

Methods

Quantitative data obtained assessed patterns of presentation to the Emergency department (ED). Qualitative data were obtained through stakeholders Interviews with professionals, adolescent patients and their caregivers. As of January 2022, 113 stakeholders were interviewed. The data obtained informed the creation of the ‘LNWH AYA Manifesto.’ This was converted into a questionnaire for all professionals involved in the care of AYA patients to assess organisational culture around AYA Care.

Results

It was found that AYA care at LNWH lies across a complex cross-sector system. The commonest code for presentation to the ED for those ages 13 to 25 was ‘depressive disorder’. Key themes from stakeholder interviews included: 1) AYAs are not always provided with age-appropriate care 2) Acute Trusts may serve as a catalyst for change for AYA patients and Youth workers may be better placed to connect with them 3) There is a need for an integrated approach to physical and mental health with better relationships needed between the Acute teams and CAMHS. The ‘LNWH AYA Manifesto’ questionnaire found disparate opinions regarding the approach to integrated physical and mental health; of the 34 responses obtained 23.5% reported not feeling confident with recognising and managing mental health and social issues in AYAs and 41.1% believed that physical and mental health problems should be addressed separately by the relevant specialties.

Conclusion

AYA care lies across a complex cross-sector system and thus requires a multifactorial approach to create a culture change towards prioritising this population. One such intervention proposed is the introduction of a Youth Worker outreach model similar to the King's Adolescent Outreach Service as a way to create a shift towards an integrated approach to physical and mental health care.
End of Life Care on a Neuropsychiatric Inpatient Ward for Patients with Huntington's Disease: An Overview of Issues and a Project to Optimise Care
Authors: Roberts Kris , Nielsen Fiona , Dale Maria , Kiani Reza
Published: June 2022

Aims

Mill Lodge is a 14-bed inpatient neuropsychiatric ward in Leicestershire, UK. The service primarily functions for patients with Huntington's Disease (HD), a disorder that significantly reduces life expectancy. End of Life (EoL) care is necessitated in the inpatient setting. This project therefore aims to optimise EoL care in our specialist HD unit. Specific objectives are to: establish the levels of staff confidence in dealing with EoL care; identify specific areas of EoL care that staff felt could be improved; and to introduce a series of initiatives to optimise EoL care for our patients using a QI framework.

Methods

We commenced involvement with the local QI team to develop the project. The first stage of intervention included the planning and delivery of a stakeholder event on EoL care specific to HD with the assistance of regional palliative care colleagues.

As well as our inpatient nursing and medical staff and the palliative care teams, local GPs, district nursing colleagues, speech and language therapists and psychologists attended. The session comprised an educational overview for all colleagues of HD itself and palliation was discussed at length.

The meeting also comprised an open forum where we were able to identify barriers and facilitators to optimal care from all aspects of the assembled MDT.

Results

To date our interactions have revealed that staff confidence in dealing with the different aspects of EoL care was low. This included issues with care-planning; medications; communication with patients and staff; and when to refer for specialist help.

Other processes identified as difficult included paperwork that was not consistent across teams; district nursing colleagues having to liaise with multiple medical team members to ensure continuity of care; and the doses of EoL medications required in this patient group to mitigate involuntary movements that were previously controlled with multiple high-dose oral medications.

Conclusion

Staff without specialist knowledge require support. The efforts made to improve collaboration with external colleagues broke down barriers that were preventing optimal care and allowed all parties to express their opinions and feelings. This allowed us to transparently appraise our current processes and provide guidance on this difficult area.

The journey of optimisation continues, with further practical educational interventions planned, such as syringe-driver training, and efforts to improve shared documentation and enhanced communication and collaborative working between different disciplines.

Optimal, collaborative EoL care from a confident staff-group is possible and a most important part of care for this unique patient group.
Is Attachment Theory the Answer to a Complex Healthcare System?
Authors: Salmoiraghi Alberto , Kerti Amy
Published: June 2022

Aims

This article proposes the need for a theoretical framework that can be applied to underpin the varied idiosyncratic mental health systems.

Methods

Bowlby's Attachment Theory defines a set of values that are required for a developing child to acquire a stable base which allow for healthy psychological development into adulthood. These values and behaviours may serve as a caring and holistic framework for people using mental health services.

Results

The outcomes in mental health remain unsatisfactory and services are overall fragmented and increasingly specialised. Ongoing recognition of the inter-related relationship between a person's immediate and social environment and their mental health are frequently overlooked as services become ever stretched in terms of finances, capacity and limited resources including support for staff. The emphasis of treatment is on illness instead of the multifactorial humanity of the individuals using the services. A key outcome of mental health provision is recovery but instead, recovery is compromised by a reductive approach to care that may paradoxically compromise rights, autonomy, confidence and self-belief when people are at their most vulnerable. This creates feelings of mistrust, uncertainty and a limited sense of safety toward services.

Attachment theory takes into account the individual, their experiences, their social world and the significant people in their lives. The principles required for the developing child to develop a secure attachment from a stable base are similar to those required for people experiencing mental illness to facilitate recovery and develop resilience to help manage and reduce episodes of relapse.

Systems that work well, frequently exhibit values underlying models of care that include continuity, consistency, respect, safety, autonomy, human rights, freedom, supportive, trusting relationships and collaboration. The opposite of that seen in what presents as autocratic and risk-averse approaches of many mental health services.

The principles required to enable a child to develop into a psychologically well-adjusted adult are similar to those required when a person is at their most vulnerable. Episodes of mental illness can be a time for reflection and growth, with the right care and therapeutic intervention, illness can also be a time to learn and develop skills for greater resilience in future.

Conclusion

This paper outlines the implications and cultural changes that are required so that the principles of attachment theory can serve as a theoretical framework across mental health services to provide a stable base for people using the services and staff providing the care.
Moving From Peripheral Project to Integrated Governance: Developing System Sustainability in Excellence Reporting
Authors: Scott Jessica , Ledger Jennifer , Smith Helen
Published: June 2022

Aims

There has been increasing recognition that healthy cultures within NHS organisations are key to delivering high-quality, safe care (King's Fund). A focus towards developing systems which recognise and learn from excellence has been shown to improve services’ safety and contribute to staff's morale (Kelly et al. 2016). In 2019 Secure Services at Devon Partnership NHS Trust (DPT) developed an Excellence reporting system. Once successfully piloted, the intention was to extend to other departments before expanding to the entire Trust. Our aims initially were SMART: for 13 reports per week in Secure services and 8 in Perinatal (a smaller team). As we expanded the aim became qualitative: for a system to be embedded so staff could as readily and instinctively report Excellence as they could an error.

Methods

We developed our Theory of Change using Deming's theory of profound knowledge, ran a series of PDSAs, and introduced an Excellence system. We engaged early adopters, sent hand-written cards and shared data widely.

Learning included understanding setting up the system, and the importance of a team rather than an individual holding the system. We took this forward to bring the system to Perinatal. We continued to run PDSAs, then ran monthly trust-wide meetings providing space to learn from other directorates.

Results

Staff were initially excited, reports submitted, feedback good, then a plateau and slump.

Something was stopping the system perpetuating. When staff received timely thanks, and others heard about it, staff would go on to promote excellence. However, this was not possible without sufficient admin resources.

In early 2021 we changed tact and approached the top: we presented data to Directors who recognised the value and agreed to support. We then set about publicising the system, and demonstrating at trust-wide meetings.

By July 2021 we saw 10 reports per week in the Specialist Directorate.

By early 2022 reports were being inputted from staff across all directorates and our monthly meetings began to focus on sharing the learning.

Conclusion

We recognised the system's potential impact on safety and staff morale but struggled to sustain the system and support dwindled when staff were stretched.

After approaching leaders, then allocated resources, it allowed for more success. However, it is not yet fully embedded in our Trust's culture.

A lot of our work happened during COVID-19 and despite challenges there has been a new-found flexibility to innovate, greater ease to negotiate, and instigate change.
A Quality Improvement Project on Improving Electronic Prescribing System in an Adult Mental Health unit
Authors: Warner Chloe , Caygill Matthew , Prasad Suveera
Published: June 2022

Aims

Medication tasks are an integral part of a junior doctor's job. However, these can often be timely and use hours that could be spent doing other therapeutic work, especially due to the cumbersome nature of SystmOne. Our aim was to review the amount, type, and time spent on medication tasks and evaluate ways in which the system could be made more efficient and time effective, to release doctors to complete other clinical ward activities.

Methods

We used prospective data collection, with two ten-day cycles carried out across the 46 bedded adult mental health unit (AMHU). Data were collected by all junior doctors working on the AMHU and every medication task was recorded on a designated document at the time of completion. This included data such as time the task was created, related ward, sender, type of task, amount of medications per task and minutes taken to complete.

Results

During the first ten-day cycle of data collection, we found that collectively we spent 21.5 hours completing medication related tasks. 10 hours were spent ordering medications, seven of which were ordering ward stock. Tasks involving completely re-prescribing the medication for the action to be completed took 12.6 hours. The data showed that 42% of tasks were completed on Mondays.

Following cycle one we discussed the data with the AMHU pharmacy team, ward managers and consultants. Subsequent alterations were made to the stocklists for the wards, ward timings were aligned and a collective tasks system created to reduce duplication of tasks.

During the second cycle of data, in total 16 hours were spent on medication tasks. There was a total of 7.45 hours spent ordering medications, 3.35 hours were ordering ward stock. Re-prescribing tasks took 9.7 hours.

Conclusion

From the results of the second cycle of data we can see the recommendations from cycle one have been effective in reducing the amount of time spent ordering medications by 25.8%. This highlights the importance of regularly updating the stocklists and utilising MDT working to maximise efficiency. We also confirmed that Monday was the heaviest day for tasks, which should be considered for staffing. As 46% of overall time was still spent ordering medications, we presented this data at the medicines management committee. Following this, recommendations have been taken to SystmOne for IT system alterations to improve efficiency of the system and allow junior/trainee doctors to focus more time on the clinical care of patients and learning.
Open Mental Health: A Mental Health Eco System Developed in Collaboration With Communities
Authors: Yeandle Jane , Oke Sarah , Papadopoulos Andreas
Published: June 2022

Aims

Somerset drew upon the Community Mental Health (MH) Service Framework, and local experience and recognised that too often service user experience of mental health was beset with artificial barriers, gateways and eligibility with people sometimes needing to deteriorate before they got the vital support they needed. In addition, we recognised that the gap between secondary care and primary care was experienced by service users as a “cliff edge”. The radical redesign of mental offers in Somerset aimed to deliver an experience of “no wrong door” and where, via a partnership between health, social care and Voluntary, Community and Social Enterprise (VCSE), people's needs could be met; both in terms of specific mental health offers as well as tackling the wider determinants of mental ill health.

Methods

OMH was launched early 2019, just before the pandemic, and so traditional project methodology did not always apply. Instead all partners focused on standing up the offer at pace in order to support the population within Somerset with the emotional and psychological consequences of the pandemic, and any pre existing challenges. The model was co-produced with Experts by Experience significantly contributing to the shape of the offers.

The model developed comprised of two key facets:

•

A mental health offer, where the needs of individuals, families and carers are met by a range of health, social care and VCSE partners (including the wider determinants of mental well being such as finance / housing)

•

A mental health eco system developed in collaboration with communities (including underserved communities), where support is available throughout geographical communities and communities of identity.

Results

The project has delivered both quantitively and qualitatively. Over 4100 additional appointments are offered to people in Somerset per month and reported outcomes and evaluation has been very positive. Work is underway to collate further Patient Related Outcome Measures. Following a Realist Evaluation methodology, the researcher in residence has highlighted the culture changes that are key to delivering the aspirations of the Community MH Service framework. These include; the narrative of “no wrong door”, an increased and open range of offers and interventions, blended staffing models across traditional organisational boundaries, partnership working, the role of lived experience and the ambition of addressing inequalities.

Conclusion

OMH, the product of Community MH Transformation in Somerset, is a radical and co produced redesign of MH services in partnership with the VCSE and Local Authority that has improved access and support to all people in Somerset.
Prevalence and Correlates of Benzodiazepines' Prescriptions in an Inpatient Setting
Authors: Zahreddine Nada , Chalil Rahna Theruvath , Abrar Sohail
Published: June 2022

Aims

The National Institute for Health and Care Excellence guidelines state that benzodiazepines (BZD) should not be taken for longer than four weeks. However, there are no recommendations specifically addressing the use and misuse of BZD in inpatient settings and their prescription at discharge. A recent study (Panes et al., 2020) recommended aiming for BZD’ total withdrawal or, at least, dose reduction at discharge to reduce the risk of misuse in the community which can lead to dependence and serious side effects. Our study aimed to 1. describe BZD’ prescriptions on an acute female ward, before admission, during admission, at the time of discharge and at four and eight weeks post-discharge, 2. identify potential sociodemographic, clinical and therapeutic correlates/predictors of BZD’ prescriptions, 3. develop a strategy to reduce BZD’ prescriptions or, at least, to reduce the dose of BZD prescribed at discharge.

Methods

Data collection was done retrospectively through electronic medical and prescribing records and included admissions to Avocet Ward, between May and October 2021. Variables collected were age, ethnicity, length of stay, Mental Health Act status, diagnosis, comorbid drugs or alcohol misuse, Home Treatment Team involvement at discharge, community teams, prescriptions of regular and Pro Re Nata BZD and “z-drugs” prior to admission, during admission, at discharge, and at 4 weeks and 8 weeks post-discharge, maximum dose of regular BZD during admission and the dose at discharge.

Results

Among the 59 admissions included, 25.4% had BZD before admission, 81.4% during admission (with a mean maximum dose of regular BZD of 38.8 mg (SD = 17.3) of diazepam equivalent), 50.8% at discharge (with a mean dose of 28.5 mg (SD = 18.5) of regular BZD), 35.6% 4 weeks post-discharge and 27.1% 8 weeks post-discharge. The odds of having regular BZD during admission were 7.4 times more likely for those on regular BZD before admission after controlling for other variables (95%CI: 1.1, 50). The maximum dose of regular BZD during admission was positively correlated with the dose of regular BZD at discharge (r(15) = .67, p < .01). Among the regular BZD prescribed during admission (N = 23), 26.1% were fully discontinued by the time of discharge and 43.5% were titrated down, while 30.4% remained at the same maximum dose prescribed during admission.

Conclusion

BZD prescriptions are common at discharge from inpatient settings and can be associated with BZD misuse in the community. We suggest strategies to avoid this issue.