bluuebunny/crossref_metadata_2025 huggingface dataset:
Junior doctors rate online simulation as ‘good enough’ but not as good as face to face sessions
Authors: Bachra Josh , Ludvigsen Anna , Junaid Kehinde
Published: June 2021

Aims

To compare the feasibility and acceptability of delivering a simulation-based learning (SBL) programme for Junior Doctors virtually versus face to face.

Method

The Nottinghamshire Healthcare Simulation Centre has been delivering a SBL programme for Foundation Year 2 doctors on behalf of Health Education East Midlands for the past three years. Since face to face teaching was not possible during the COVID-19 pandemic the programme was delivered online using the same content and format as for prior cohorts. Feedback questionnaires from 128 face to face participants (F2F) and 133 virtual participants (V) were compared.

Result

There was a decrease in Likert scale ratings across all domains in the virtual group. This was most apparent when examining the ‘strongly agreed’ responses: the venue/remote format was suitable for the session 34% decrease, the course length was appropriate 24% decrease, the pace of the course was appropriate 20% decrease, the simulation was helpful and relevant 15% decrease, the content of the course was organised and easy to follow 13% decrease, the learning objectives were met 10% decrease, the presenters were engaging 6% decrease, the trainers were well prepared 3% decrease. The virtual group included responses in the ‘strongly disagree’ and ‘disagree’ categories relating to the virtual format, length and pace, which did not occur in any domain for the F2F group.

Combining the ‘strongly agree’ and ‘agree’ statements also showed a decrease in satisfaction with 72.5% of responses falling into this category for the V group and 88.3% for the F2F group. Fewer participants in the V group would recommend the course to a colleague (98% V vs 99% F2F).

Conclusion

Providing the SBL programme using an online format was feasible while also being acceptable to most participants. However, participants did not rate this experience as highly as face to face teaching. The largest decreases in satisfaction were in areas related to the virtual format. An interesting finding is that participants rated the pace and length of the online course as less agreeable, despite the content and scheduling being the same as for the face to face group.

Based on these findings face to face teaching should resume when practicable. In the meantime, the virtual delivery may be improved if the course length was reduced. Analysis of qualitative feedback may provide insights into why participants did not rate the virtual simulation as highly as the face to face equivalent.
Can probiotics benefit young people with autism spectrum disorders?
Authors: Ramani Pooja , Sala Regina
Published: June 2021

Aims

The aims are to evaluate the effectiveness of Probiotics on young people with Autism Spectrum Disorder.

We hypothesized that there will be an improvement of the comorbid gastrointestinal symptoms that can accompany Autism Spectrum Disorder.

We believe that the use of probiotics can exert bidirectional effects on the gut-brain axis which may result in improvements in core Autism symptoms.

Method

A literature search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We used databases including OVID MEDLINE, Pubmed, EMBASE, AMED and the Cochrane register of controlled trials. Studies using Probiotics as a treatment for children with ASD were identified by key search terms; Child*, young person*, adoles*, teenagers, ASD, Autism Spectrum Disorder, Autism, Pervasive developmental disorder, PDD, Probiotics, Supplements, Lactobacillus, and Bifidobacterium. Inclusion criteria: Children of age range 2-18 with a diagnosis of ASD and having at least one gastrointestinal symptom were included. Exclusion criteria: The following were excluded: studies looking at Autism with interventions aside from Probiotics; studies where Probiotics were tested in conjunction with other interventions; studies where there were additional neurodevelopmental disorders.

Result

Twelve studies identified all utilized probiotics. This included 7 Randomised Control Trials, 2 Open-Label studies, 1 pre and post-intervention design and 1 Case study. All RCTs gave probiotics or placebo to children.

Ten studies showed an improvement in gastrointestinal symptoms. Six studies showed improvements in various behavioral measures. Four studies showed improvements in core autism symptoms. However, the sample sizes in these studies were not large enough to prove statistical significance.

Conclusion

No studies showed an adverse reaction which indicates probiotics can be considered a safe treatment.

The improvements in a variety of parameters imply probiotics a suitable adjunctive intervention that may help improve ASD core symptoms in young people as well as improving physical and behavioural comorbidities which in some cases was noted by parents.

However, due to high dropout rates and generally small sample sizes, larger-scale trials are needed to critically confirm the efficacy of probiotics for children with ASD.
A review of serious untoward incidents (SUIS) of patients with personality disorder (PD)
Authors: Reid Harry , Lee Tennyson , James Charlotte , Hancox William , Stoikos Stefanos
Published: June 2021

Aims

The aim of this paper is to describe key findings and recommendations of SUI reports regarding patients with a diagnosis of PD in East London NHS Foundation Trust (ELFT). Patients with a diagnosis of PD are often involved in SUIs with regards to risk to themselves or others. Contributing factors might be the nature of their disorder in terms of mood instability and impulsivity, self-harming or antisocial behaviour, and the difficulties posed to assessing clinicians in predicting risk.

Background

Patients with PD present severe challenges to services. SUI findings thus serve as a lightning rod for issues in their management. With the emergence of NICE guidelines for borderline PD [2009] and antisocial PD [2009] regarding risk assessments, there has been greater optimism for management of PDs.

Method

A case series of 50 SUI reports of patients with a diagnosis of PD were identified from the governance and risk management team of ELFT. Themes were categorized as positive practice, contributory factors, and recommendations. Findings are related to guidelines in NICE and RCPsychiatry. Any patient with a diagnosis of PD (of any sub-type) that was involved in a SUI in ELFT met the inclusion criteria. There were no exclusion criteria.

Result

The most frequent themes in positive practice were ‘continuity of care’ and ‘clinical practice’. The most frequent subthemes in clinical practice were ‘assessments’ and ‘follow-up’. ‘Continuity of care’ included examples of collaborative working between various teams, as in joint assessments, good communication, and timely referrals. In contributory factors ‘poor documentation’ was the most frequent theme. 14 reports found no contributory factors. In recommendations the most frequent theme was the need for development and implementation of PD policies and for improved risk management.

Conclusion

NICE guidelines stress the importance of continuity of care and good clinical care and it is commendable that these were findings in positive practice. The importance of documentation being accurate and timely needs underlining in hard pressed time poor clinicians. Services would do well to review PD policies specifically regarding risk management at a wider Trust and local service level. Our findings point to the ongoing need for workforce development as recommended in the RCPSych position statement on PD published in January 2020.
Long admission waiting list at the Orchard clinic-why?
Authors: Sayeed Hannah , Brown Johanna , Lenihan Fionnbar
Published: June 2021

Aims

The Orchard clinic is one of the three medium secure units in Scotland. This project was completed:

To gain an understanding of the causes of the Orchard clinic's long admission waiting list.

To use this information to improve current clinical pathways, service development and further research and development.

Method

To study the longitudinal traffic flow through the clinic from January 2017 to December 2019, data were collected for this time retrospectively from electronic minutes of fortnightly bed management meetings at the Orchard clinic.

This was cross checked with the Orchard clinic's record of admissions and discharges during this time and approved by the Forensic Research and Audit Group, NHS Lothian.

Result

November 2018 onwards, a surge of 90% was observed in the admission waiting list.

Looking at the trends of traffic flow through the clinic during this time, the following observations were made:

1. More admissions than discharges, especially November 2018 onwards.

2. New referrals for medium secure care at the Orchard clinic peaked twice during this time.

3. Delayed discharges peaked in July 2018 and further in January 2019 running parallel to the surge in admission waiting list thereafter.

4. 42% patients on the delayed discharge list belonged to other health boards awaiting local low secure/community placements.

Conclusion

Delayed discharges were identified as a constant parallel to the long waiting list and hence identified as the main factor contributing to it. Out of area (non-NHS Lothian) admissions were noted to be linked to these delayed discharges.

Regular peaks in new referrals was also noted to be contributory.
Tolerability of a single IV administration of a methylene blue challenge in patients with bipolar disorder: preliminary data from a pharmaco-MRI study
Authors: Sharp Harriet , Russo Alfonso , Colasanti Alessandro , Pinna Antonello , Nwaubani Prince , Marco Riccardo De
Published: June 2021

Aims

To summarise the tolerability profile following an infusion of methylene blue (MB), including subjective effects on mood and energy levels and haemodynamic changes, in patients with Bipolar Affective Disorder (BPAD).

Background

BPAD is associated with mitochondrial dysfunction and impaired cellular energy production. MB is proposed to enhance mitochondria function via rerouting electrons and intracellular reduction of oxidative stress, and is therefore a candidate compound for use as a probe to reveal alterations in brain oxygen metabolism in vivo in patients with BPAD. Although there are reports of MB used as treatment for BPAD, the tolerability and subjective effects of a single IV dose in this population has not yet been defined.

Method

Using a single-blind, randomised, within-subject design, 7 patients with BPAD on stable pharmacological treatment and 6 healthy controls (HCs) received an infusion of 0.5mg/kg MB and a placebo glucose solution one week apart. Visual Analogue Scales (VAS) assessing ‘Mood’ and ‘Energy’ levels were completed by 11 participants, and blood pressure (BP), heart rate (HR) and any subsequent side effects were recorded before and after infusions.

Result

A significant, albeit very small, effect of MB on ‘Mood’ levels relative to placebo was demonstrated, independent of groups (change relative to baseline: 5.5% ± 11 increase (placebo) vs -1.6 % ± 9.5 reduction (MB); p = 0.027). Although there was no effect of MB on energy levels in either group, there appeared to be a trend for a general group difference in ‘Energy’ levels across all trials, with lower ratings in BPAD patients (p = 0.058).

There was a trend for significantly lower post-infusion HR relative to pre-infusion (-6.4 ± 8.8 bpm, p = 0.07. Diastolic BP was higher (3.0 ± 7.8mmHg, p = 0.039). These effects were independent of groups and drug. The most common side effect with MB was mild/moderate pain at infusion site (n = 10/13), resolving within median 32.5 minutes (IQR 6-102), and discoloured urine in 7/13 subjects lasting median 44.5 hours (IQR 36-59). No difference in frequency of side effects reported between groups.

Conclusion

Although limited by small sample size, this tolerability analysis demonstrates a acceptable profile of effects of MB on subjective ratings and blood pressure, in both BPAD and HCs. Common side effects of discoloured urine and pain at infusion site are in line with previous reports in the literature. We observed a small effect of MB on mood ratings which could be related to the discomfort experienced during infusion.
Dramatic portrayal of suicide: a critical analysis of Netflix's 13 Reasons Why
Authors: Sutton Anna , Overshott Ross
Published: June 2021

Aims

The aims of this project were to assess how well the Netflix drama 13 Reasons Why portrayed suicide, in terms of both accuracy and safety, and to discuss the potential effect this could have on viewers.

Background

Psychiatric content within dramatic media can have measurable effects on the population, such as reinforcing stigma around mental illness. Given the show's focus on a character's suicide, the most serious effect here would be suicide contagion.

Guidelines and regulations for the portrayal of suicide in media are in place to protect those who might be vulnerable to suicide contagion.

Method

We formed our own pro-forma of 42 criteria using existing guidelines written for both news and dramatic media. These criteria were formatted into positive and negative pairs; positive being instances of guidelines being followed, negative as guidelines being broken. These were further organised into 7 categories.

Each episode of seasons 1-2 was then assessed against the criteria. Cumulative instances of guidelines being followed or broken were compared within and between seasons. Context of each instance was taken into account by the primary researcher, and we also highlighted instances of exceptional breach of these guidelines.

Result

The results showed an over-all breach of the guidelines, with no significant improvement between the seasons. Some categories of criteria, such as “asking for help” and “mental health”, were portrayed well overall. Other categories, such as “blame”, performed extremely badly.

The most significant breach was the graphic suicide scene at the end of the first season, which completely disregarded Samaritans’ guidelines.

Conclusion

The breaching of guidelines in this show was overwhelming. In terms of severity, although there were some positive themes running through the seasons, there were also worrying instances of guidelines being completely disregarded. This led to the conclusion that the producers of the show did not take their responsibility to young, vulnerable viewers seriously regarding the dangers around portraying suicide.

Suggestions from this study are that more guidelines around suicide are needed specifically for dramatic media, and that existing guidelines should be conflated and have stronger implementation by regulators. This implementation should potentially include overseas providers such as Netflix. Ethically, a significant challenge here is maintaining balance between safety and allowing artistic licence.
Basic clinical equipment for physical health assessment in mid Essex inpatient units
Authors: Abdelkhalek Hesham , Griffiths Tamsin , Motley Kim , Ramjan Raisa , Harrop Sophia
Published: June 2021

Aims

It is trust policy that the Basic Clinical Equipment for Physical Health Assessment should be available on each unit. The standard for this audit is therefore 100% completion.

Background

This was a cross-sectional study of six mental health units across Mid Essex. We audited equipment and consumables in comparison to trust policies. For the purpose of the audit we designed an audit tool.

Method

Overall compliance across all wards for all audited items was 77.5% (64.9% – 87.5%). Average compliance for equipment provision 83.3% (73.9 %– 91.3%) was greater than that for consumables 72.1% (58.8% – 82.4%).

Result

When looking at the compliance on each unit separately, our data show that no unit has met the standard of 100% for equipment or consumables. From all units, one of the two older adults’ inpatient units had the highest overall compliance and highest compliance for consumables at 87.5% and 82.4% respectively while the perinatal unit had the lowest overall compliance and lowest compliance for consumables at 64.9% and 58.8 respectively. For the equipment compliance, intensive care unit and one of the older adults tied for the highest compliance at 91.3% while male inpatient unit and perinatal inpatient unit were tied the lowest compliance at 73.9%.

Conclusion

This is an audit to assess the availability of Basic Clinical Equipment for Physical Health Assessment on inpatient units in Mid Essex. With an audit standard of 100% completion, it shows that overall compliance on all units was 77.5% which is not meeting our standard.
Assessing the delivery of smoking cessation interventions in adult inpatients
Authors: Barnes Katie Blissard , Westmoreland Richard
Published: June 2021

Aims

To assess level of compliance with national and local guidance with regards to the recording of service users smoking status and offering of interventions.

Background

Across the general population, prevalence of smoking is decreasing but in those with severe mental illness, the prevalence hasn't significantly changed. LYPFT are working towards becoming a smoke-free trust. The Trust Guidance expects that Trusts should ask 100% of service users if they smoke (which should be recorded on their physical health CQUIN) and of those that do, should be offered nicotine replacement therapy and cessation advice. Public Health England is working towards all hospital trusts across the UK being Smoke-free.

Method

All service users on each of the 4 adult inpatient wards at the Becklin Centre, Leeds, were included in the audit. A total of 78 service users were included in the audit.

We reviewed the digital records for every service user, specifically looking at the physical health CQUIN. We recorded if smoking status had been documented and what interventions (if any) had been recorded as given. Possible interventions included offering brief advice and offering Nicotine replacement therapy. We then reviewed medication charts to see if any nicotine replacement therapy had been prescribed.

Result

The audit found that approximately half of all service users in our audit smoked cigarettes and that the vast majority of these had their smoking status documented in their digital medical records.

Three quarters of those that smoked were offered brief cessation advice and half of them were offered Nicotine Replacement Therapy. Only a third of service users that smoked had NRT prescribed on their medication chart. This represented 65% of those recorded as being offered NRT.

Conclusion

There are numerous possible reasons for the above outcomes. These include a lack of knowledge and confidence in delivering smoking cessation interventions, conversations having taken place but not recorded and confusion regarding the appropriate staff member to deliver the intervention. In addition, whilst only medical professionals typically prescribe NRT, the physical health CQUIN is recorded by nurses. Therefore, this may reflect a lack of communication between staff groups.

Our trust will become smoke free in the near future. To facilitate this, we hope to reduce the discrepancy between the number of service users who smoke and the number prescribed NRT.
Adherence to Public Health England (PHE) guidance for the use of personal protective equipment (PPE) in north Wales mental health unit- a regional audit
Authors: Dhandapani Asha , Soundararajan Sathyan , Salmoiraghi Alberto , Ginty Shona , Mitu Tajnin , Akinlua Justina , Thomas Catrin , Malhotra Rahul , Azhar Zeenish , Bhutta Haseeb , Taib Hanani , Shankar Nikhil Gauri , Bhangu Vikram , Kamau Gathoni , Chamberlain Elizabeth , Mackenzie Anna , PAHLEN Henrik , Lock Hannah , Rymansaib Aniis , Mclean Pauline , Trujillo Rodrigo , Simiyon Manjula , Chappell Adam , Gross Agnieszka , Gaskell Gaynor
Published: June 2021

Aims

To ensure that the PPE guidance is strictly adhered to.

To ensure that patient care is not compromised.

To help us in areas of need in order to educate the staff regarding the techniques of PPE and thus ensure patient and staff safety and care during the pandemic.

Method

Novel coronavirus 2019 was first described in December 2019 in Wuhan in China. Since those initial few cases, it has rapidly proliferated to a global pandemic, putting an inordinate amount of strain on healthcare systems around the world. We believe that the technique of donning and doffing if followed as per PHE guidelines would be of help in both preventing the infection and improve the care and safety of both patients and staff.

This Audit includes both In-patient and Out-patient units in Psychiatric services across North Wales. Data were collected from 19 units out of 39. We observed covertly 325 staff members belonging to various cadres. Apart from the Donning and Doffing techniques, we also observed the availability of designated areas for this purpose and the availability of PPE as well.

Data collection was by junior and senior doctors from various sites of the mental health unit in North Wales. A proforma was provided, the standards were based on PHE guidelines.

Result

It was noted that just about 50% of the staff followed donning as per guidance. Amongst all three sites, the Central team showed a better adherence with 85% of them donning PPE correctly. whereas only 22% adhered to donning in the West team.

Only 21% of them managed to doff PPE as per guidance amongst all 3 centres in North Wales.

It was also noted that there are no designated areas to Don and Doff in outpatient units. Staff, in general, seem to not adhere to the guidance of utilising a mask, especially when within 2 meters distance of other staff.

Conclusion

We will be presenting the Audit at the regional meeting. After discussion with the infection prevention control team and Health and safety lead, we intend to improvise the wards with designated areas for donning and doffing. Teaching sessions for the staff in all three sites, reminders in various areas of the community mental health units and inpatient units.

We are hoping that these recommendations will help us in achieving our aim of health and safety during this pandemic.
Audit of pharmacological management of borderline personality disorder as per NICE clinical guidelines CG78
Authors: Dudley Bethany , Bellam Shakina , Lawrie Andrew
Published: June 2021

Aims

To audit the current practice of pharmacological management of Borderline Personality Disorder with NICE Clinical guideline [CG78]: Borderline personality disorder:

Objectives:

23 patient records were analysed in the last 18months with a diagnosis of EUPD to compare current practice against NICE clinical guidance. (2009)

Standards:

When prescribing

1)

Use a single drug.

2)

Use the minimum effective dose.

3)

Agree with the person the target symptoms, monitoring arrangements and anticipated duration of treatment. Antipsychotic drugs should not be used for medium, long term treatment.

Indication:

4)

Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated. (Repeated self-harm, marked emotional instability, risk taking behaviour and transient psychotic symptoms).

5)

Short-term use of sedative medication may be considered cautiously as part of the overall treatment plan in a crisis. The duration of treatment should be no longer than 1 week.

6)

When considering drug treatment, provide the person with written material about the drug. This should include evidence for the drug's effectiveness in the treatment of borderline personality disorder and for any comorbid condition, and potential harm.

Review:

7)

Review the effectiveness and tolerability of previous and current treatments.

8)

Discontinue ineffective treatments.

Background

Borderline Personality Disorder is common in psychiatric settings with a reported prevalence of 20%.

As per NICE Guidance (CG 78), no medications have been found effective for the longer term treatment of personality difficulties.

This audit was carried out to review if patients were offered psychiatric reviews to discuss the medications they are using, the effectiveness of these, and any potential side effects.

Result

Good practice compliance of 90-100% was noted where >90% compliance was seen in areas where the effectiveness and tolerability of current and previous medication was reviewed by the clinicians under Structured Clinical Management. Also was noted that antipsychotics were not used for medium to long term in patients with Borderline Personality Disorder in the cohort.

The following areas were non-compliant with the NICE recommendations where a compliance <79% has been achieved.

When prescribing, use a single drug (avoid polypharmacy), agree target symptoms, monitoring and duration, provide written information, discuss evidence for effectiveness in treatment of borderline personality disorder.

Partial compliance was achieved (80-89%) with use of sedatives for less than 1 week and discontinuation of ineffective treatment.

Conclusion

Distribute key cards to clinicians.

Provide written information to patients.

Re-audit in 6 months.
Suicides in Barnsley – an IHBTT project
Authors: Imran Nadia , Niaz Omair
Published: June 2021

Aims

We wanted to see whether an increase in IHBTT(Intensive Home based treatment team) case load correlated with the recent increase in suicides. We also wanted to investigate the common factors between patients who died by suicide.

Background

This was a study completed by IHBTT in Barnsley (South Yorkshire), looking into recent suicides with the caseload from April 2009 to November 2019. There were a total of six suicides.

Method

We Calculated mean IHBTT caseload size from November 2008 to November 2019 . There were 6 suicides in this period. We plotted this against caseload, investigating if increase in caseload correlated with these. We also analysed the common themes and trends associates with these patients who died by suicide. We compared the trends we found locally against a National Survey. (National Confidential Inquiry into Suicide and Safety in Mental Health; Annual Report: England, Northern Ireland, Scotland, Wales October 2018 University of Manchester).

Result

We found that four out of six suicides occurred during periods of high activity.. Common themes we found around patients who had died by suicide included middle aged men who lived alone, with a diagnosis of adjustment disorder, recent financial stress and relationship breakdown, upcoming court case, abusing drugs or alcohol. This does compare somewhat to national trends, however alcohol and drug misuse, upcoming court case and financial stressors and relationship breakdown are higher in our patients who died by suicide compared to nationally.

Conclusion

We acknowledge the small sample size and hence the need to take results cautiously. However there is a clear increase in suicides as caseload increases, we hypothesised this was due to the same levels of staff despite increase in caseload. We were also able to conclude the factors our patients who died by suicide had in common locally, and how this compared to national data. We wondered if this could be used to guide resource allocation, i.e. interventions to help patient manage their finances, accommodation and substance misuse. Consideration may need to be given to reviewing IHBTT staffing levels, given the significant decrease in inpatient bed numbers.
Suburban vs urban: do the attendee's demographic profile influence the emergency department's mental health characteristics presentation?
Authors: Jain Sudha , Mcloughlin Caoimhe , Cooney John , McLoughlin Aoibheann , Abdalla Ahad , MacHale Siobhan
Published: June 2021

Aims

To compare the Emergency Department (ED) referrals to psychiatry in a suburban versus an urban setting over a one-month to evaluate mental health presentations characteristics across two locations.

Method

This study was a retrospective cross-sectional study examining ED referrals to psychiatry in an inner-city and suburban centre over one month; - one based in an inner-city setting, the other based in a suburban area outside the city. The anonymised data were collected from both hospital's electronic patient records and analysed. The authors collected data on gender, age, employment, housing, the clinical problem at presentation, time of assessment and admissions. Descriptive data and hypothesis testing were performed where appropriate using Statistical Package for Social Sciences SPSS® version 26.

Result

The total number referred was 213: inner-city n = 109 and suburban n = 104. The inner-city saw a younger population; 47/109 (43%) were aged between 20 and 29 years, compared with 28/104 (27%) of suburban presenters (P-value 0.0134). A higher number of presenters were aged over 60 years in the suburban centre n = 13/104 (12.5%) versus the inner-city centre 3/109 (2.8%) (P-value 0.0084). In the inner-city, the proportion of homeless presenters was significantly higher at 30/109 (28%) versus 5/104 (4.8%) in the suburban setting (P < 0.0001). Presentations related to substances were highest, a total of 73 (34.3%) across both centres, with no significant difference in clinical presentations across the two centres. The majority were seen in the on-call period, 74/109 (67.9%) in the inner-city centre and 66/104 (63.5%) in the suburban centre. The psychiatric admission rate was significantly different between the two centres, with 33/109 (30.3%) patients admitted to the inner-city centre and 13/104 (12.5%) patients admitted to the suburban centre (P-value 0.002).

Conclusion

A large proportion of ED referrals to psychiatry constitute patients with unmet social and addiction needs. The variance in capabilities of liaison psychiatry (LP) and ED services means the local population's needs may not always be adequately catered for within a typical LP setting, which in the Irish context is predominantly driven by medical and nursing staff. This study highlights many patients attend the ED who may be better assessed directly by the community as per our National Emergency Program policies. This prompts consideration of expanding both ED and community services to comprise a more integrated, multidisciplinary-resourced, 24/7 care model.
Audit on venous thromboembolism risk assessment in mental health inpatient wards
Authors: Malhotra Rahul
Published: June 2021

Aims

From May 2015 NHS organisations in Wales are expected to report the number of VTE cases associated with hospital admissions which are possible hospital acquired thrombosis (HAT) per calendar month. NICE Quality Standards (QS3) recommend that All patients, on admission, receive an assessment of VTE and bleeding risk using the clinical risk assessment criteria described in the national tool.

Background

VTE is a condition in which a blood clot (thrombus) forms in a vein, most commonly in the deep veins of the legs, known as a deep vein thrombosis (DVT). The thrombus can dislodge from its original site and travel in the blood (embolism). If it becomes lodged in the lungs, a condition known as a pulmonary embolism (PE) arises and can cause sudden death. Hospital acquired thrombosis is avoidable and unfortunately kills patients under our care.

Method

Collected data using a standardised form for 131 patients from 3 inpatient mental health units on documentation of a VTE risk assessment in the inpatient notes. For those patients who had a documented risk assessment, further data were collected on documentation of contraindications, eisk factors, sign and date of prescription and the appropriateness of prescribing.

Conclusion

8% of patients from one mental health unit (n = 48) had a documented risk assessment in the notes. The subsections of documented risk assessment including contraindications, risk factors, sign and date of prescriptions and appropriateness of prescribing were complete at 100%. No patients from the other 2 mental health units (n = 39,44) had a risk assessment documented in the notes.

Recommendations: All adult inpatients in Mental Health units must receive a venous thrombo-embolism risk assessment. This must be documented on the Inpatient Medication Chart. Consider adding a risk assessment checklist tool mapped from the Department of Health guidelines into the Mental Health Inpatient Clerking in pro-forma.
The role of telephone consultations in psychiatry
Authors: Packer Jonathan , Fisher Emma , Simons Anne-Marie , Bolochowecki Kirsty , Roff Benita , Khurmi Sanjay , Jones Luke
Published: June 2021

Aims

Telephone consultations have been in clinical use since the early 1960s and are increasing in frequency and importance in many areas of medicine. With the advent of the COVID-19 pandemic in 2020, the use of telemedicine consultations increased dramatically alongside utilization of other digital technologies. Despite promise and potential advantages for clinicians (including remote working, improved time management and safety) there are known drawbacks to telephone consultations for psychiatrists. This includes limitations to assessments of mental state and risk, with loss of non-verbal communication often cited as a point in favour of more sophisticated technologies such as video calling. By adopting telephone consultations to a greater extent during the initial months of the COVID-19 pandemic in the Coventry Crisis Resolution and Home Treatment Team (CRHTT), we aimed to assess the patient experience in telehealth, through a patient survey.

Method

After an initial assessment or follow-up consultation with a medical practitioner from the crisis team, patients were invited to take part in a short questionnaire with a member of the administration staff. This consisted of eight questions on a Likert scale and three open questions for comments. Results were collated and analyzed via Microsoft Excel.

Result

Most patients found the telephone consultations satisfactory, with more than 90% returning positive scores in understanding, convenience and overall satisfaction. All patients felt listened to and that their confidentiality was maintained; with all but one respondent willing to engage in further consultations via the telephone. Negative scores were typically returned for practical telephonic problems including poor signal, interference and background noise. In their comments patients expressed largely positive views about their experience with their clinician; analysis revealed key insights into the patient experience, demonstrating the convenience, comfort and flexibility possible with ‘telepsychiatry’.

Conclusion

Patient experience of telemedicine in a UK psychiatric crisis team is mostly positive, with clear advantages for both patients and clinicians. Our results show telephone consultations can be expanded to new patient assessments alongside follow-ups, enabling the team to reach a greater number of service users. This includes service users who are housebound due to infirmity, required to shield or have significant anxiety about the pandemic.
Profile, referral pathways and re-attendance of psychiatric patients attending the emergency department: focus on suicidality & self-harm
Authors: Pandian Haridha , Kar Nilamadhab
Published: June 2021

Aims

The number of patients presenting to Emergency Departments (EDs) in the UK with acute psychiatric issues is a major concern. This project aimed to explore the outcome of patients assessed by Mental Health Liaison Services (MHLS) in a large district general hospital ED in the UK, with a focus on patients with self-harm or suicidality.

Method

Data were extracted from electronic patient records on 100 consecutive attendees to MHLS in July 2020. Data were collected on demographics, index of multiple deprivation (IMD) by postcode, time and reason for attendance, known ICD-10 diagnoses, self-harm history, alcohol/substance misuse at time of presentation, recent psychosocial stressors and outcome of MHLS assessment. Assessments by MHLS in the preceding 12 months and reattendance to the service within 3 months following this assessment were also recorded.

Result

The sample included 44 male and 56 female patients, with a mean age of 35.3 years. 80.0% of patients were Caucasian. 67.0% lived in areas classed within the top 30% most deprived in the country, whilst 2.0% had no fixed abode. The majority (79.0%) of patients self-presented; outside of normal working hours (70.0%). The most common reasons for attendance were thoughts/intent of self-harm/suicide (50.0%), overdose (29.0%) and self-harm by laceration (7.0%).

The majority (73.0%) of patients had a known psychiatric diagnosis, with the most frequent being depressive disorder (36.0%) and emotionally unstable personality disorder (15.0%). Almost half (48.0%) had a history of self-harm, and 40.0% were under the influence of alcohol/illicit substances upon presentation to ED. The most common psychosocial triggers were conflict with partner (26.0%) and stress due to the COVID-19 pandemic (19.0%).

Following assessment, 24.0% of patients were discharged to their General Practitioner, 18.0% to the community mental health team; and 17.0% to the Crisis & Home Treatment Team. A minority (13.0%) were admitted to a psychiatric hospital (10.0% informally, 3.0% under the Mental Health Act 1983).

Approximately one in five (21.0%) patients re-attended to MHLS within 3 months. Out of 37 patients that had previously been assessed by MHLS in the preceding 12 months; 37.8% were reassessed within 3 months (p < 0.01).

Conclusion

In the studied sample, most (90%) of psychiatric patients attended ED for self-harm or suicide, and a significant proportion had repeat attendance. Socioeconomic deprivation, substance misuse, relationship difficulties and stress due to the COVID-19 pandemic were major issues, alongside diagnosed depression and personality disorder. Focussed support for these issues may decrease ED attendance due to self-harm/suicidality.
Service evaluation of primary care mental health support services in north Wales
Authors: Raja Jawad , Salmoiraghi Alberto , Azhar Zeenish
Published: June 2021

Aims

Bringing specialist psychiatrist into PCMHT

Undertaking initial assessments for people Referred by G.P's

Working According to the principle of “Prescribing Interventions”

Decrease number of assessments carried out within secondary Care

Method

County of Wrexham is situated between the lower Dee Valley and the Welsh mountains. It is the largest town in North Wales (140,000)

Since 2013, the total new patient referrals to be seen by Wrexham county consultant psychiatrists has consistently risen

This issue has been dealt with in different ways across North Wales and indeed the whole of Wales

Following a review of services in Wrexham during 2017, it was identified that there was an opportunity to pilot a new model which would allocate a designated Consultant to the local Primary Care Mental Health Team (PCMHT)

The Consultant would work entirely within Part 1 of the Mental Health Measure and would offer specialist opinions to Tier 1 Services

Result

PCMHT team members are maintaining open cases for a significant amount of time rather than the 8–10 sessions that was originally predicted during the implementation of the Mental Health Measures

In order to sustain the service, the minimum number of direct clinical patient contact sessions to be offered by the psychiatrist was up to 4 a week.

During the review period, total number of clinics offered were 51 and a total of 139 patients were offered appointments

Consultants in secondary care covering the same area received exactly 100 less referrals in the first 6 months of the pilot

Main source of referrals to the Tier 1 Consultant came from G.P.'s and the local PCMHT itself

Conclusion

Pilot demonstrated that bringing specialist consultant psychiatrist dedicated to the PCMHT improved the care offered to patients referred by G.P's

Scope of PCMHT needs to extend in order to absorb mild to moderate mental illness and thus avoid patients going into secondary care

This model should be supported, and further resources should be inputted into PCMHT

We should move from a categorical diagnostic referral system to a needs-based intervention where only the most complex cases requiring lengthy interventions shall progress to secondary care

Risk should not be classed as criteria to move patients into secondary care and PCMHT should be able to absorb moderately risky cases
Suicide: can we identify and manage those at risk more effectively?
Authors: Roberts Emily , Grew Anne-Marie , Julyan T Everett
Published: June 2021

Aims

This study aimed to conduct longitudinal analysis of suicide reviews for mental health service users in Ayrshire to improve local practice and outcomes. Traditional risk factors – middle-age, male and alcohol misuse – were hypothesised to convey greater risk of completing suicide.

Background

Suicide is an important public health issue in Scotland, with potentially devastating impacts. Practice and policy may lag behind emerging evidence. Mental health problems are associated with an increased suicide risk, and care provided to those who take their own lives is reviewed to identify recommendations and learning points to improve practice and outcomes. However, these reviews and their conclusions are often considered individually, when studying them collectively over time it is necessary to characterise common themes and highlight factors that could be addressed to reduce suicide. Moreover, national averages can obscure local patterns.

Method

Access to reviews of suicides for mental health service users in Ayrshire was granted by the Adverse Event Review Group. Relevant data were extracted for the 35 General Adult service users completing suicide between 2013 and 2015, including details of the act, demographics and clinical factors, and analysed for trends. Those with and without emotional instability as a primary diagnosis or significant problem were dichotomised to facilitate identification of statistically significant factors specific to these symptoms.

Result

There were 35 completed suicides including three inpatients. Suicide was most common in the 25-29 and 45-54 age ranges, and over 68.6% were male. Hanging accounted for 60.0% of deaths, and self-poisoning for 8.6%. Up to 62.9% of patients did not appear to have ongoing scheduled appointments on a regular basis. Diagnoses were difficult to identify – 48.6% had no clear primary diagnosis specified in the reviews, and features of depressive, anxiety, psychotic, substance misuse and personality disorders frequently overlapped and co-occurred. 22.9% had problems with emotional instability; their median age was 14 years younger, and 87.5% were female.

Conclusion

Small sample size precluded detailed analysis. The traditional risk profile remains relevant. However, almost 25% of those completing suicide were younger females with emotional instability, despite frequent contact with services. Given the challenges in predicting suicide, we should continue to consider how best to prevent this tragic outcome in all service users, especially in younger females with emotional instability; middle-aged males who misuse alcohol, and those with ill-defined diffuse psychological difficulties who do not fit into discrete categories or are reviewed infrequently.
Priority clinic access or outreach to provide Sexual and Reproductive healthcare for people with mental illness?
Authors: Rose Elizabeth , Covshoff Elana , Pittrof Rudiger , Kumar Usha , Rose Elizabeth
Published: June 2021

Aims

To compare two sexual and reproductive health (SRH) clinical pathways (a priority appointment at a mainstream SRH clinic versus assertive community outreach), and to explore how each improves access to care for people with psychotic mental illness, severe addictions and/or learning disability.

Method

Observational, descriptive study of two clinical access pathways within SHRINE (Sexual and Reproductive Health Rights, Inclusion and Empowerment), a specialist SRH programme to improve SRH care for severely marginalised people.

The SHRINE programme delivers effective, ethical, accessible and user-centred SRH care for people with severe addiction, serious mental illness and/or learning disability in the deprived inner London boroughs of Lambeth and Southwark. These individuals often find accessing conventional SRH clinics very difficult. SHRINE clients can self-refer but most of them are referred by their health or social worker.

Clients or referrers indicate their preferred pathway: priority appointment at the mainstream clinic or assertive community outreach. The priority appointment pathway at Camberwell Sexual Health Centre (CSHC) is as flexible as possible, with minimal waiting times, reminders, invitation to bring a friend or care worker and active follow-up of non-attenders via key workers. Assertive community outreach can be in an addiction clinic, postnatal ward, mental health centre, psychiatric ward, outpatient clinic, homeless hostel or the client's home.

Time allocation for outreach and priority appointment-based care was 8 and 4 hours per week respectively. Care in both pathways was provided by senior doctors. Content of care was similar but facility for provision of gynaecological care including cervical smears and investigations for abnormal uterine bleeding e.g. pelvic ultrasound scans and endometrial biopsies were only available in the mainstream clinic setting at CSHC.

Result

From May 2016 to December 2020 SHRINE received 1367 referrals from 125+ teams. We offered 1591 first or follow-up appointments of which 1369 (86%) were attended. A total of 1153 (84%) of our patient contacts occurred in the outreach setting where 93% the appointments were attended. Of the 358 appointments at CSHC 316 (60%) were attended.

Conclusion

Making clinic access as simple and convenient as possible is not a sufficient strategy to meet the SRH needs of marginalised people. To enable them to realise their human right to sexual and reproductive health we need to leave our clinics and meet our clients where they are. A combined model of outreach and priority access clinic pathways is essential for provision of SRH care for people with mental illness.