bluuebunny/crossref_metadata_2025 huggingface dataset:
A Qualitative Study Exploring the Role of Hindsight Bias in the Process of Reviewing Clinical Practice Prior to Adverse Incidents
Authors: Hadjioannou Irene , Lewis Emily , Scott Leo , Thomas Catrin , Salmoiraghi Alberto , Nathan Rajan
Published: June 2022

Aims

To explore the effect of hindsight bias on retrospective reviews of clinical decision making prior to adverse incidents to inform future approaches to incident investigations.

Methods

We have undertaken focus groups with doctors of varying grades across the North West of England and North Wales. A vignette based on a real-life case from the publicly available NHS England Homicide Independent Investigation report database was presented to each group in one of three versions which differed in terms of the ending of the vignettes (i.e. suicide, homicide, no adverse incident). Using a semi-structured interview approach, the group participants were encouraged by the facilitators to reflect on issues relating to risk and risk management. All groups were provided with the same vignette which initially made no reference to the outcome and asked to comment on matters of risk and risk management. Halfway through the discussion, one of the three outcomes was disclosed, and further group discussion was held. The recorded interviews were transcribed and thematic analysis was undertaken using an adapted Framework Method.

Results

Preliminary results (n = 10) indicate that participants identified the potential for significant harm, particularly to others, and identified evidence of key psychopathological and historical correlates to support assertive management of risk and admission to hospital.

Whilst knowledge of the outcome did not lead to participants changing their favoured management plans, it did alter how they appraised the case and led to participants constructing “narrative” explanations for the outcome given. The level of conviction participants held for their management plan reduced when their expectations about the outcome were confounded.

Participants presented with the suicide outcome vignette described their difficulties appraising risk to others and their over-sensitivity to that risk. Participants faced with the ‘no adverse outcome’ vignette perceived the original management plan far more favourably in hindsight. The groups that were presented with the homicide outcome vignette initially focused on both risks to self and others as well as the perceived need for further information. Following knowledge of the outcome, there was a tendency to highlight parts of the letter pertaining to risk to others which they previously had not given as much attention.

Conclusion

The initial analysis of our data confirms the findings from previous studies that hindsight colours the appraisal of adverse events. However, this study is novel in that it describes the nature of the thought processes underpinning the influence of hindsight on appraisals of risk.
Psychiatric, Neurophysical and Neurocognitive Sequelae of Post-Acute COVID-19 Syndrome: A Systematic Review
Authors: Vincent Arun , Ofovwe Oghenefejiro , Gschwandtner Manfred , Shergill Sukhi , Faruqui Rafey
Published: June 2022

Aims

COVID-19 causes cognitive, neurophysical and psychiatric sequalae that persist beyond the acute illness. These appear to be independent of the direct impact on respiratory function although the impact of multiorgan, especially brain pathology, may be a contributory factor – as may psycho-social effects of the disease. We performed a systematic review of literature to assess the sequelae of post-acute COVID-19 syndrome to better understand the need for dedicated interventions to improve functioning.

Methods

We conducted a systematic review of reports included in MEDLINE, PsycINFO, and EMBASE. We searched for cohort studies exploring psychiatric and neuro-cognitive sequelae of post-acute COVID-19 in adults with a sample size of at least 100. The search was conducted on 4 February 2022. Findings are reported in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two authors independently assessed the included studies’ methodological quality using The National Institute of Health (NIH) quality assessment tool for observational cohort and cross-sectional studies and all records were rated as good or fair.

Results

Our search identified 66 records and 14 met protocol requirements. The studies varied in sample size ranging from 100 to 3762 participants. Time to follow-up ranged from 1–12 months. Main symptoms identified by a majority of the studies were; Fatigue (25% to 85%) and Sleep problems (20% to 79%). Psychiatric symptoms; Anxiety (19% to 56%), Depression (11% to 47%), PTSD (6% to 43%) and altered sense of reality (3% to 15%). Neuro-cognitive symptoms; Cognitive dysfunction (25% to 85%), brain fog (12% to 81%), memory problems (24% to 73%), concentration difficulties (25% to 54%), and attention deficit (27%).

Female sex, advanced age, pre-morbid asthma or COPD, increased disease severity, high BMI and new neurological complications during hospitalisation were some of the identified risk factors for persistent symptoms in post-acute COVID-19. One study identified male sex as a risk factor for moderate to severe PTSD. Current evidence suggests that symptoms decrease over time.

Conclusion

There is clear evidence of neuro-physical, psychiatric and neurocognitive sequelae in post-acute COVID-19 syndrome. Differences in assessing and reporting findings makes it difficult to synthesize meaningful information. Identifying and formulating standardised assessments for outcome measures and reporting systems would be useful in future research. Further research into symptoms of post-acute COVID-19, to understand the pathophysiology will better enable us to raise public awareness, introduce preventative measures and incorporate appropriate treatment strategies for rehabilitation.
Frequency of Diagnostic Classification Systems’ Usage by Mental Health Professionals in Day-to-Day Clinical Practice
Authors: Vrigkou Eleni , Stamatakis Robert , Umla-Runge Katja
Published: June 2022

Aims

Diagnostic classification systems (DCSs) are medical models constructed by experts with the purpose of facilitating diagnostic processes. Specifically in psychiatry, DCSs serve as mental health professionals’ major diagnostic tool. Several studies, however, suggest that mental health professionals may not systematically apply the DCSs in day-to-day practice. The primary aim of this secondary research was to assess the actual frequency of DCSs’ application in psychiatric practice. All DCSs were considered. The secondary aims were to investigate the mode of DCSs’ application (e.g., assign diagnosis, inform treatment, administrative/billing or teaching purposes), and to assess if DCSs’ usage patterns vary depending on the clinicians’ specific occupation (e.g., psychiatrists, psychologists) and country of employment.

Methods

The bibliographic databases of MEDLINE Via Ovid, PsycInfo, Web of Science and Global Health were searched from 1/2000–12/2020. All primary studies assessing DCSs’ frequency of application by mental health professionals were eligible for inclusion. The search yielded nine eligible articles. The total number of participants from all included studies was 10,388. The study samples were diverse, including practitioners from a wide variety of geographical locations, languages, and income-level countries.

Results

The results of the study showed that 69% (95%CI = 58–80%) of the responders use DCSs “often, almost always or always” in day-to-day practice. Regarding the mode of DCSs’ application, responders stated that they use DCSs most frequently for administrative/billing purposes and assigning a diagnosis. The study's results also showed that 68% (95%CI = 45–90%) of psychiatrists and 74% (95%CI = 43–100%) of psychologists use the DCSs “often, almost always or always”. Subgroup analysis based on responders’ country of employment suggest that the frequency of “often, almost always or always” DCSs’ usage (according to World Health Organization regions) were: for the Region of the Americas 75.3%, for the African Region 73.5%, for the Western Pacific Region 71.6%, for the European Region 69.4%, for the South-East Asia Region 66.8%, and for the Eastern Mediterranean Region 57.1%.

Conclusion

The study's outcomes indicate that DCSs are integrated into the daily practices of mental health professionals worldwide. Further research is needed, however, in order to assess in more depth DCSs’ application practices (e.g., comparative usage of different DCSs, types of mental disorders, patients and settings where DCSs are more frequently applied). Such findings could be valuable, since they can be used to help appraise the quality of DCSs’ actual use, the impact of DCSs on clinical care and public health, and also to aid design more effective mechanisms for DCSs’ further implementation.
A Scoping Review on Barriers to Mental Healthcare in Canada as Identified by Healthcare Providers
Authors: Wang Jeffrey , Pasyk Stanislav , Slavin-Stewart Claire , Olagunju Andrew
Published: June 2022

Aims

Mental illness is among the leading causes of disability globally, however the treatment gap is wide even for developed countries. The perspectives of patients and mental healthcare providers are critical to understanding barriers to adequate mental healthcare and developing scalable solutions that improve access and quality of services. However, the views of providers are relatively understudied, precipitating our review to collate and synthesize their perspectives on the barriers to mental healthcare in Canada.

Methods

We searched MEDLINE/PubMed and PsychINFO for studies with findings in Canada published in English from 2000–2021 with terms for mental health, psychiatry, barriers, and referrals. Included studies were evaluated with the National Institutes of Health Study Quality Assessment Tools and Critical Appraisal Skills Programme.

Results

631 papers were screened, finding 20 eligible studies, including 13 qualitative, one cross-sectional, one retrospective, and five mixed-methods studies. Through inductive content analysis, five themes of barriers emerged: (1) patient accessibility (19% of studies), (2) health systems availability and complexity (31%), (3) training/education (25%), (4) work conditions (21%), and (5) cultural sensitivity (4%). Among barriers discussed, common challenges included a lack of resources for both patients and providers, gaps in continuing education for primary care providers, and health systems challenges such as difficulty securing referrals, unclear intake criteria, and confusion due to overload of contacts.

Conclusion

Health systems face a multi-faceted set of challenges to improving access to mental healthcare that will require solutions from various stakeholders. Understanding these barriers is critical in focusing initiatives to improve mental health care, both in Canada and in countries facing similar challenges.
Introduction of ECT Discharge Summary- a Quality Improvement Project to Improve Communication Between Treating and Referring Clinicians and Aiming Better Patient Care
Authors: Ahmad Ayesha , Khan Adnan , Abiodun Yetunde
Published: June 2022

Aims

There was an initial QIP done in 2019 highlighting the deviation and deficits from ECTAS Guidelines. We tried to make positive change by introducing checklists and assessments. We were able to reach our goal but noted that collating information was a time taking task. More ever, documents were not always accessible as patients come to Mid Essex ECT clinic from other parts of Trust as well as from Private inpatient settings which meant that we did not have records for those patients. We noticed clear lack of communication between out of area referring and treating clinician regarding treating team's view about patient progress, assessment results and recommendations for future ECT need, which we thought could be improved by generating discharge summary of each patient as end of treatment.

Methods

We conducted retrospective audit for all treated patients in ECT clinic in 2020(n = 18,re-audited in 2021 and 2022(n = 13) to see documentation, including Consent documents; Form 5(consent) in case of capacity, T4/T6/S62, Documentation of Memory assessment, as well as MADRS assessment before and during the procedure. We started generating ECT discharge summaries in November 2021 and collected data for all patients (13) till 6th February 2022.

Results

Documentation of Legal Status: 5% in 2020 vs.100% in 2021* and 2022

Written consent /form 5: 95% in 2020 vs. 100% in 2021* and 2022

Documented Mini-ACE: 5% in 2020 vs. 100% in 2021* and 2022

Doc. MADRS assessment; 0% in 2020 vs. 100% in 2021* and 2022

*(excluding patients who did not complete the treatment)

Conclusion

The audit results of 2020 showed improvement however assessments done during treatment were not accessible to referring clinicians or to patients. Introduction of discharge summary helped to give snapshot of patient's weekly progress, weekly objective assessment scores which helped the referring clinicians to get idea about patient's improvement and resulted in improved communication as well as patient and carer satisfaction.

Small actions can have big impact on the way patient care is delivered. We believe that going through process of auditing helped us to improve our practice and make a positive change in terms of delivering better care.
Improving Awareness and Accessibility of Well-being Resources Among Core Psychiatric Trainees in the West Midlands Deanery- a Quality Improvement Project
Authors: Asiodu Nneamaka , Williams Ellen , Narula Amitav
Published: June 2022

Aims

Supporting the mental health and well-being of psychiatrists impacts on the quality of patient care delivered, and crucially for trainees, on retention to the profession. Our aim was to survey core trainees to gauge their awareness, access and use of well-being resources.

Methods

111 core trainees in the West Midlands deanery were invited to complete an anonymous online survey during November 2020. Quantitative data were analysed using Google Forms and Microsoft Excel. Qualitative data were reviewed by all team members to identify relevant themes.

Results

Only 14% of trainees felt well informed about the well-being resources available to them, 57% who attended local trust induction and 82% who attended deanery induction did not think nor recall if the topic had been covered. Despite this, trainees were aware of a range of resources, with the most known being BMA Wellbeing (58.3%), Psychiatrists’ Support Service (44.4%) and the local Peer Support Unit (30.6%). Just 14% of trainees reported using a well-being resource during their training.

Conclusion

Our results suggest that more work needs to be done at local trust and deanery level to make well-being a priority during induction and improve awareness of available resources. At least one trainee reported they would not seek help, due to concerns about the impact on their training progression, and stigma may be an under-reported barrier to accessing these resources.

We hope to use our results to improve signposting, and to collate a resource easily accessible and applicable to all trainees in the deanery.
QIP: Liaison Psychiatry Outcome Measures at University College Hospital in London
Authors: Auyeung Ariana , Patel Lisa
Published: June 2022

Aims

The purpose of this quality improvement project was to improve the collection of outcomes in the Liaison Psychiatry (LP) department at the University College Hospital in London (UCLH). To achieve this, the Framework for Routine Outcome Measurement in Liaison Psychiatry (FROM-LP) was used to gather data and evidence on clinical and other patient-related outcomes provided by the department. The FROM-LP was created to provide a consistent way to compare the quality and performance of Liaison Psychiatry services across the NHS. It was developed in 2015 and is based on the most widely used measurement frameworks for assessing quality and performance of services.

Methods

This project implemented the FROM-LP, using the Identify and Rate the Aim of the Contact (IRAC) tool and the Clinical Global Impression – Improvement scale (CGI-I) from September to November 2021 in the UCLH Liaison Psychiatry department. The PDSA (plan, do, study, and act) cycle was used to carry out this quality improvement project and the data were collected by two foundation year doctors.

The IRAC scale identified ten categories for the aim of contact by LP and a rating on whether the aim was fully achieved, partially achieved, or not achieved after patient contact. The CGI-I scale was used to rate whether a patient had improved upon discharge by LP. Data were also collected on the demographics of patients, the specialty teams that referred to LP, whether legal frameworks were used, and where patients were discharged to.

Results

This project improved the collection of outcome data in the department from 0% to 98.16%, indicating an improvement of outcomes measurement by >98%. Other outcomes collected showed that patients were predominantly 21–30 years of age and referred to community mental health teams when discharged. The IRAC tool showed most patients were referred for assessment and diagnosis, with the majority of these aims marked as ‘fully achieved’. The CGI-I tool showed most patients were ‘much improved’ upon discharge.

Conclusion

The collection of these outcomes led to the creation of an outcomes measure form on the primary electronic software system (Carenotes) utilized by the department and local trust. This electronic form is now currently being used by the Liaison Psychiatry department at UCLH for their patients and makes this improvement sustainable while providing an easier means to continue collecting data. Ultimately, the collection of these outcomes will guide future changes and improvements for both the liaison psychiatry department and its patients.
Improving the Referral Process Between Acute Wards and the Psychiatry Department at Tameside General Hospital
Authors: Bann Claudia , Yeung Sharon , Fish Emmalene
Published: June 2022

Aims

The project aims to address the barriers faced by the acute hospital and the psychiatry department in the referral process for a psychiatric opinion, at Tameside General Hospital (TGH). The Care Quality Commission (CQC) undertook a review of how people's mental health needs were met in acute hospitals in 2017 and concluded that there were barriers to this, for multifactorial reasons. Examples included: acute hospital staff not feeling adequately prepared to treat mental health conditions and lack of mental health care services 24/7. The current referral process at TGH for the acute hospital doctors requesting a psychiatric opinion presents a challenge for the referring doctor and psychiatry doctor in receipt of the referral. Many at the acute hospital have found the process of referral unclear, and many in the psychiatric department have found that referrals seldom contain sufficient information to determine whether a psychiatric review is required and whether it needs to be prioritised.

Methods

To understand the specific difficulties encountered during the referral process, two questionnaires were created. One for TGH acute trust doctors and one for the psychiatry doctors, asking what the perceived barriers were and how these could be overcome. Data were collected between September and October 2021.

Results

We obtained results from 17 acute trust doctors. The results revealed that most referring doctors found the referral process unclear. 100% agreed that they would benefit from guidance with the referral process e.g., a psychiatry specific referral form and/or a flow chart outlining the referral process. All responders wanted guidance around the roles and responsibilities of the psychiatric team in relation to the hospital setting.

We obtained results from 7 psychiatry doctors. Most were not satisfied with the referrals received. 100% would like to see a specific psychiatry referral form implemented in the acute hospital.

Conclusion

Key findings were: the referral process is unclear, acute trust doctors don't feel well enough equipped to manage mental health concerns, referrals don't contain sufficient patient information, and that the acute trust doctors don't know where to ask for help. The project reflected earlier CQC findings.

After discussion with the acute trust, our action plan includes creating a psychiatry-specific referral form, to be distributed together with a flow chart which directs acute trust doctors to the appropriate source for psychiatric opinions. We also aim to join departmental and junior doctor teachings regularly to distribute and educate on the process.
Improving Access and Confidence in Learning Lessons From Serious Incidents: A Quality Improvement Project Aimed at Junior Doctors
Authors: Beyers Cornelia , Parkinson Eleanor , Harsh Rajendra , Nardeosingh Sameer , Oseji Dolapo , Packham Alice , Conway Nick , Rowe Renarta , Scally Ruth , Rochelle-Bates Joshua , Awais Onaiza , Surti Farhaana
Published: June 2022

Aims

Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) previously developed some methods of learning lessons following serious incidents. However, despite various systems available, frontline junior doctors were not regularly exposed to important learning opportunities. This potentially resulted in doctors not being aware of learning from serious incidents, and not feeling embedded within the organisation, with potential effects on their training experience. As we identified an unmet need within the Trust in learning lessons from serious incidents amongst junior doctors, we aimed to improve access and confidence in learning from serious incidents by starting a Quality Improvement project on this theme.

Methods

The current approach involved a comprehensive quarterly bulletin circulated by email to staff. An initial survey confirmed that this was not very effective in delivering learning lessons information to junior doctors.

Using a QI driver diagram, we identified potential areas for change. Selected change ideas were sequentially trialled including shortened email bulletins, supervision templates and remote learning lessons sessions. Initial PDSAs highlighted difficulties with communication via email, with many trainees failing to read/engage with this format.

Results

The use of remote interactive learning sessions yielded positive results, with improvement in the confidence in learning from Serious incidents. We therefore continued to refine this method to wider groups.

During the COVID-19 pandemic we experienced multiple setbacks and created a timeline tosupport team morale, maintain team energy, visualise progress and motivate the team. We therefore managed to persevere and strengthened the group by recruiting members to the team and complete the project.

Conclusion

The team have been able to create a sustainable, effective and interactive short teaching session which has shown to be effective in engaging trainees in this vital area and help us meet our aim. This format further has the potential to be refined and implemented locally and nationally.
Restructuring Patient Review and Allocation in a South London Home Treatment Team
Authors: Boardman-Pretty Theo , Tweed John , Day Camilla , Stephenson Lucy , Quinn Jalon , Rifkin Larry
Published: June 2022

Aims

Lambeth Home Treatment Team (LHTT) provides short-term intensive community psychiatric care to a diverse South London population. The high turnover of patients requires a streamlined process to review and discuss their progress. We aimed to discuss patients in more frequent, targeted and shorter meetings, and to improve continuity of medical care using a ‘named doctor’ system. We assessed impact on length of stay with LHTT, on staff time as well as on both patient and staff satisfaction.

Methods

The system of once-weekly day-long discussions of entire caseload was replaced by twice-weekly discussions of new and concerning patients only. The system of medical reviews was changed from ad hoc to MDT-agreed allocation to a specific doctor for the duration of LHTT stay.

Data on duration of treatment and caseload size were taken from regular LHTT statistical reports. Staff and patient questionnaires assessed impact on satisfaction and time spent in review discussions.

Results

Qualitative reports of staff experience revealed that the new system was felt to provide better continuity of care, better time efficiency (less time spent learning about new patients) and improved learning experiences for doctors in training. Downsides included lack of ‘automatic second opinion’ when a patient was reviewed by a different doctor, felt to be mitigated by more frequent discussions in MDT reviews when needed.

Patient feedback showed no significant change was noted in overall experience of LHTT, although patients were more likely to feel involved in their care (88% said ‘definitely’ compared to 68% before the change).

Time spent discussing patients in clinical review meetings reduced from an average of 38.5 to 28.5 person-hours per week.

Average caseload reduced from 57 to 42. However, duration of treatment increased from 18.8 days to 20.4 days.

Conclusion

The reduction in staff time in reviews suggests that the system had been appropriately streamlined. While caseload size reduced, duration of stay slightly increased, so the new system was not found to have had a significant impact on objective measures of patient care.

Staff feedback was generally favourable, highlighting continuity of care and time efficiency. Patient feedback, while good both before and after our change, suggested a greater feeling of involvement in their care, possibly due to clearer communication and discussion of plan from the start of LHTT care.
Lithium Monitoring Within NHS Forth Valley 2020
Authors: Carbarns Amy
Published: June 2022

Aims

The aim of this audit is to improve the monitoring of appropriate parameters in patients within the health board who are prescribed lithium, including lithium level, urea and electrolytes, thyroid function tests, calcium. It will also look at whether the same patients are appropriately referred to renal services.

Methods

A retrospective review of electronic patient records of 100% of the patients in Forth Valley Health Board who have collected a lithium prescription in the 6 months between March and August 2020.

Results

69% of patients had a lithium level checked within the time period set out in the NICE guideline. Only 43% complied with the guideline on renal referral and 63% on calcium. Compliance with assessment of urea and electrolytes was better at 90%, and thyroid function tests at 85%.

Conclusion

Part of the decline in compliance with guidelines is likely in relation to the availability of face-to-face appointments during the pandemic, and reduction in outpatient appointments. As a result of this there is a planned further audit looking at how lithium monitoring is reviewed in outpatient psychiatry. This is intended to increase the involvement of psychiatry and the patient in ensuring appropriate monitoring is completed rather than relying solely on the GP.
Establishing a Diagnostic Autism Assessment Clinic in a Primary Healthcare Setting to Reduce Waiting Times, Increase Efficiencies and to Improve the Patient Journey and Clinical Outcomes
Authors: Dabbagh Nadia , Dhuhair Baraa
Published: June 2022

Aims

To establish a multidisciplinary diagnostic autism assessment clinic in primary healthcare so as to reduce lengthening waiting lists for specialist hospital based services, to increase efficiencies and improve the patient journey and clinical outcome. Timely diagnosis and early access to community based early intervention services optimizes outcomes.

Methods

Waiting time for specialist hospital based services were increasing in number. Analysis of the data revealed that 42.9% of all referrals were autism related and 75.5% of these referrals were for autism assessments in under six-year-olds. Bottlenecks were found in the current system. In collaboration with primary healthcare colleagues, a new pathway was developed with paediatricians, social workers and primary healthcare physicians completing a comprehensive initial assessment including conducting a Childhood Autism Rating Scale (CARS). Each of the three hospital based child psychiatrists then ran a diagnostic autism clinic in the primary healthcare setting once a month (so three clinics in total) to review the initial assessment, meet the child and family/carers and then to confirm the diagnosis and write a medical report for community based services as appropriate. Follow-up care remained in primary healthcare unless there was diagnostic uncertainty, significant behavioural difficulties or comorbidities requiring medication. The project timeline started with one and gradually increased to four diagnostic assessments in each clinic, that is, twelve per month.

Results

57 diagnostic assessments were completed in first eight month period. Waiting times for diagnostic assessments in under six-year-olds were reduced from two to four months to only one to two weeks. Medical reports were issued within five working days. Under six-year-olds and their parents no longer had to attend busy, less child friendly hospital settings but rather were able to attend a purpose build early intervention centre within the primary healthcare setting.

Conclusion

In conclusion, this is an example of a successful quality improvement project embracing the efficiencies of integrated models of care between primary, secondary and tertiary services. Critical success factors included strong leadership support, compelling rationale and purpose, clear clinical pathways and clear roles and responsibilities. It was presented as part of the hospital wide quality meetings in November 2021.
Implementing a Physical Health Clinic on an Acute Adult Inpatient Psychiatric Ward
Authors: De Souza Rowan , Patel Alisha
Published: June 2022

Aims

Acute Inpatient Psychiatric Wards present the challenge of a high turnover of patients who have multiple physical health comorbidities that both contribute to patients’ overall morbidity and may exacerbate any mental illness. Furthermore, there are a number of physical health parameters which must be checked and monitored in the initiation of psychiatric treatments. It is therefore important that patients receive physical examination, blood tests and Electrocardiograms (ECGs). The busy environment of inpatient units and the acute presentation of patients, who often decline interventions, lack capacity or cannot communicate their physical health problems, mean these assessments are often missed when offered in an ad hoc fashion. This Quality Improvement Project looked at implementing a Physical Health Clinic to look at whether this structured environment would provide better coverage of these physical health assessments.

Methods

The number of physical examinations, blood tests and ECGs both offered but declined and successfully obtained was measured on an Inpatient Ward with 20 patients and 2 junior doctors over 2 weeks with assessments being offered in an ad hoc fashion. Following this, a structured clinic run by a doctor and nurse with three 20 minute appointments three times a week was implemented and the same data collected over 2 weeks. A paired T-test was used to evaluate the results.

Results

There was a statistically significant increase in the number of successfully obtained physical examinations, bloods tests and ECGs when the Physical Health Clinic was implemented (Mean difference = 7.33, Two tailed P value = 0.0480,95% confidence interval 0.16–14.50, t = 4.4, df = 2, standard error of difference = 1.667). However, there was no difference between the number of bloods, examinations and ECGs offered but declined (Mean difference = 4.83, Two tailed P value = 0.2495, 95% confidence interval −3.92–8.58, t = 1.6059, df = 2, standard error of difference = 1.453).

Conclusion

The clinic led to a statistically significant increase in the number of examinations, blood tests and ECGs successfully obtained. The reasons for this are hypothesized that having a structured clinic prepares the patient to have a physical assessment and ensures their availability, provides motivation for staff and increases the efficiency of assessments with appropriate teamwork between doctors and nurses. Issues with the Clinic are limited availability of junior doctor and nursing staff and emergencies disrupting the functioning of the clinic. Implementing the clinic on a wider scale is required to assess its effectiveness.
Missing Person Protocol: Rapid Risk Assessment Re-Audit 2021
Authors: Fowler Juliette
Published: June 2022

Aims

The Rapid Risk Assessment (RRA) has been a part of the Missing Person's Protocol since 2017 following a ward level intervention to try and provide as much information in as succinct a way as possible to the Police when a patient goes missing from the ward. This tool allows for rapid evaluation of a person's risk level on admission to hospital allowing consistent decisions to be made around risk to self and others, including physical risk and states why the risk level has been so set. In line with the National Framework for Missing Persons, a Return to Ward Interview is undertaken when a patient returns to the ward. The document is reviewed on a weekly basis at MDTs. The aim is to re-audit the extent to which the RRA within all wards at Royal Cornhill Hospital has been completed within the patients’ notes.

Methods

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All General Adult (GAP), Older Adult (OAP) and Learning Disability Wards were audited for the level of completion of the RRA proforma.

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10 sets of notes were audited in each ward (where possible).

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Data were gathered on a proforma for consistency looking at each area of the RRA: Patient Details, Brief Admission Details, Risk Level, Police Contact.

Results

58 sets of patient notes were checked. 100% of notes contained the RRA proforma.

The average completion of all sections was 87.5%.

There has been a 21% improvement in completion of the RRA since the first audit in 2017. There was variability across the wards, but there has been a 14.5% improvement in completion of sections compared to the previous audit.

The Patient Details section of the RRA was the most fully completed area, The Brief Admission Details section was poorly completed and it is important to be able to give this information to the Police when they are contacted about a missing person.

Conclusion

Across the wards, the data were less well completed by General Adult Psychiatry and best within Learning Disabilities. This is perhaps because of the higher turnover of patients but it would be interesting to consider the reasons for the disparity in data.

Improvement seems to have been driven by the teaching around the RRA and weekly review of the RRA at MDT

None of the wards audited had completed the Return to Ward Questionnaire. The ward staff made comment that the questions within this document are asked but more informally.
Alcohol Screening on Admission to an Acute Mental Health Ward
Authors: Gesell Sutapa , Tsitsiou Yvonne , Prochazka Josef
Published: June 2022

Aims

Alcohol misuse is estimated to cost the NHS £3.5 billion/year. Only 6% of people suffering from alcohol dependence in England, receive treatment per year, highlighting that alcohol misuse is under-identified. During the COVID-19 pandemic, people have significantly changed their drinking habits, evidenced by government tax receipt data, suggesting alcohol sales increased by 3% to 5% in the UK compared to 2019. Problems associated with harmful alcohol consumption were intensified by the crisis, even though the long-term impacts of COVID-19 on alcohol consumption are uncertain. There was a notable increase of patients with dual diagnosis of mental illness and alcohol misuse on our ward, which is a general adult inpatient psychiatric ward. As such, the aim was to assess and improve alcohol screening on admission to an acute mental health ward.

Methods

Through a System One review, we assessed whether alcohol consumption is documented on admission (within 72 hours) in units, and a validated screening tool is used (AUDIT-C), which was expected in all patients. Their notes were initially retrospectively analysed and subsequently reviewed approximately six weeks following the implementation of interventions.

Interventions included presenting the findings of the primary survey to our colleagues during a multidisciplinary team meeting on the ward and a trust-wide audit meeting attended by both junior and senior doctors. Additional interventions included posters outlining the importance of alcohol screening in the interview rooms of the acute wards (including a QR code link to our presentation and findings).

Results

Out of the 17 patients on the ward, 47% (8/17) were not appropriately screened for alcohol misuse during their first 72 hours of admission. 47% (8/17) had no documented alcohol history on admission clerking. Only 12% (2/17) had partially quantifiable alcohol intake, both drinking above the recommended weekly amount. None of the ‘Current Drinker’ patients had AUDIT-C screening. Improvement was noted following the interventions during the secondary survey.

Conclusion

Although alcohol screening in acute psychiatric admissions is often vague or incomplete, simple reminders and education can improve screening. If the alcohol history cannot be obtained from the patient on admission, which is often the case, the clinician should clearly document review of notes for historical alcohol use, to avoid potential complications, such as alcohol withdrawal, delirium tremens or seizures.

This project raises further questions on how effective brief interventions for excessive alcohol consumption in acutely unwell/psychotic patients are, encouraging a further area of research.
Outcomes of a Quality Improvement Project to Reduce Unnecessary Blood Tests in Beechcroft Regional Child & Adolescent Mental Health Unit, Belfast Trust
Authors: Gillanders Catherine , Doherty Francess , Fitzsimmons Sarah
Published: June 2022

Aims

An estimated 25% of blood tests are unnecessary with an annual cost to the trust of approx. £26.5 million. Aside from the huge financial impact, patients are undergoing unnecessary invasive procedures with detrimental impact on lab flow processes and inappropriate use of Doctor and Nursing Staff time. Some young people have multiple admissions to Beechcroft in a short space of time or bloods checked in A + E prior to transfer are missed and replicated. Longstanding use of blood template terms “Admission bloods” or “Eating Disorder Bloods” has added to the problem. Initial scoping exercise found one young person had 40 blood tests during their admission. AIM STATEMENT: Reduce baseline blood testing of Glucose, Lipids and TFTs by 10% by June 2021

Methods

QI project commenced December 2019 using the IHI Model for Improvement Methodology was promoted by the project team through conversations with staff, unit meetings, email and posters.

Outcome Measure: Total glucose, lipid and TFT blood tests recorded fortnightly for the unit over 18 months

Process Measures: Training as part of new nursing staff induction, reminders in daily nursing handover, number of staff attending Biochemistry liaison meetings

Balance Measures: Reduced blood test costs, reduced unnecessary staff workload

Change Ideas

6 PDSA cycles were implemented

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Separate Bloods Diary for each ward – January 2020

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Blood diary brought into weekly care planning meetings – July 2020

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Education Posters displayed in ward clinical rooms – September 2020

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MDT meeting with Clinical Biochemistry – April 2021

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Junior Doctor to update bloods diary post weekly care-planning – May 2021

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Bloods diary brought to daily nursing handover & dissemination of new monitoring guidelines – June 2021

Results

Glucose tests reduced by 68% with new median of 2.2 instead of 7. Lipids and TFTs median of 10 remains unchanged.

Conclusion

COVID-19 has disrupted monitoring. Fundamental changes made within our service by stopping blood glucose monitoring and using BMs instead has led to significant improvements. We will continue to monitor results following 2 recent change ideas. We hope to include patient feedback moving forward.
QI: Improving Physical Healthcare Recording in a Mental Health Service for Homeless People – Working With KPI's
Authors: Hall Hugh , Ward Michael , Wicks Georgina , Sulej Katarzyna , Agyapongmaa Abena
Published: June 2022

Aims

As a mental health team for homeless people, we are aware of poor health outcomes for our patients. They face the double-hit of chronic serious mental illness (SMI) and homelessness, reducing life expectancy. As outlined in guidance, “secondary care team should maintain… monitoring service user's physical health”. We aimed to improve recorded annual physical health checks according to Trust Key Performance Indicators (KPI) for weight; hypertension; diabetes; cholesterol; and screening for smoking, drugs and alcohol on SystmOne (e-patient record) in Westminster's Joint Homelessness Team's (JHT) caseload, with target of 90% by December 2021 set by Central and North West London (CNWL) NHS Trust.

Methods

Using monthly physical health KPI reports to target uncompleted annual health checks for JHT's 135 patients. PDSA cycles were used over a six-month period from July 2021 – January 2022.

Intervention 1: Using available GP data to pull across into our records, making use of existing information.

Intervention 2: Dedicated clinical session from FY2 doctor to assess patients with missing physical health checks.

Intervention 3: Specific teaching to whole MDT to increase awareness and uptake.

Intervention 4: Designed our own reporting to give real-time rather than monthly reporting.

Outcomes were measured from monthly Physical Health reports for the active caseload.

Results

At baseline only 26.67% of patients had completed recorded health checks. Intervention 1 more than doubled our recordings to 54.17% over a 2-month period. Our second intervention further improved recorded physical health checks.

The third intervention increased our recorded physical health checks to 82.35% over a 2-month period. Notably, at the beginning of our project 7 out of 135 patients, had no engagement in physical health check monitoring, this reduced to 1 after intervention 3.

At the end of our fourth cycle, we had increased our recorded physical health checks to 83.93%.

Overall, results show an improvement of 57.26%, or a relative increase of 3.15 times the amount of recorded physical health checks over 6 months.

Conclusion

As a result of incorporating dedicated clinical time, teaching and real-time use of data, we have improved our recorded physical health checks. There is room for improvement with 16% of patients still with incomplete health checks and approximately 10% of patients without blood tests. Some of this is due to accessibility and engagement difficulties for people with SMI and entrenched rough-sleeping, with ongoing work being done.
Junior Doctors' Enjoyment of Mental Health Placements in Derbyshire
Authors: Shahid Erum , Harlock Abigail , Ramji Abbas , Gupta Ritu , Gopal Vishnu
Published: June 2022

Aims

To assess the job and training satisfaction of junior doctors working in Mental Health placements in Derbyshire; to highlight areas of good practice and identify areas that need improvement to enhance their working experience.

Methods

This is an ongoing Cycle of Quality Improvement to address Juniors Doctors enjoyment of work and job satisfaction. On a 25 point questionnaire we sought feedback as open response, graded response and free text. Questions were formulated using suggestions from Royal College of Psychiatrists Supported and Valued Review and BMA Fatigue and Facilities Charter. Advised areas of improvement from the previous 2017 Quality Improvement project were also reviewed and incorporated into the questionnaire design.

All junior trainees (including Core Psychiatry trainees, Foundation trainees, GP trainees and junior trust grade doctors) working between December 2020 to April 2021 in Derbyshire Healthcare NHS Foundation Trust were sent the questionnaire.

Official end of placement feedback from January-December 2020 was also compared to our findings.

Results

15 doctors completed the questionnaire.

Areas of trainee-reported satisfaction included training on management of common psychiatric conditions (73%), weekly teaching sessions (100%), ability to organise leave (100%).

Areas of dissatisfaction included training on management of psychiatric emergencies (40%), poor regularity of supervision (53%), inadequate access to phlebotomy services (66%), ability to take adequate breaks (66%) and ability to fulfil training requirements (40%).

Discrepancies were noted in responses to similar questions in our questionnaire compared to the official end of placement feedback, with greater trainees answering with negative responses in this project.

Conclusion

This project highlighted areas of high satisfaction for trainees and showed specific areas for improvement. Trainees responses have been reviewed with Educators and Trust Management for collaborative solutions, pilot schemes and future QI projects identified.

Observer bias was noted, with greater numbers of doctors answering similar questions negatively when feedback was anonymous, suggesting that they may be giving more honest answers when their identity is concealed.