bluuebunny/crossref_metadata_2025 huggingface dataset:
Out of Hours Work: A Trainee-Led Review
Authors: Hall Charlotte , Garnham-McEwan Drew
Published: August 2024

Aims

The 2016 Junior Doctor’s contract offers guidance as to the rest periods needed during non-resident on-calls (NROCs). The Rotherham, Doncaster and South Humber (RDaSH) NHS Foundation Trust currently works on a NROC trainee rota. NROC work undertaken is monitored via a log form, returned by the trainee after their shift. A retrospective audit was completed with only a 28% return rate of log forms. Though anecdotal evidence suggested inadequate rest and high workloads during on-calls, due to low engagement in monitoring formal data was lacking. Therefore, a trainee-led prospective audit was designed to formally monitor on-call workload over a period of 4 weeks.

The main aim of this project was to review the average amount of hours worked during an NROC shift and compare achieved rest periods against agreed standards (derived from 2016 contract). These standards indicate that 90% of shifts should achieve 8 hours rest in 24 hours and 5 hours continuous rest between 22:00–07:00. In order to accomplish this we first aimed to increase the return of completed on-call log forms to 75%.

Methods

Work was predominantly concentrated around increasing return rate of the log forms including: running teaching sessions, regional promotion, and sending daily reminder emails to return the forms. These forms were then reviewed and analysed.

Results

Across the 4 week audit period, the return rate of log forms was 95%, compared with the previous return rate of 28%. Average hours worked across all three localities exceeded the expected hours by RDaSH. When compared with the standards outlined, 1 in 3 shifts in Rotherham, 1 in 5 in Doncaster and 1 in 4 in South Humber did not achieve contractual rest periods. Out of these, not reaching 5 hours continuous rest was the most common reason for not meeting contractual rest periods.

Conclusion

RDaSH worked collaboratively with trainees to generate a number of interventions to mitigate the breaches in rest periods including: creation of a new clinical role to filter calls, reviewing the suitability of the NROC rota and increasing pay to reflect the increased workload. There is currently work underway to redesign the rota.

This audit highlights the importance of prioritising regular reviews of NROC work to ensure the safety of both staff and patients through achieving adequate rest periods.
Rapid Tranquillisation Practice and Debriefing; an Observational Study in Adult Psychiatric Inpatients
Authors: James Georgina , Mir Asif
Published: August 2024

Aims

Rapid Tranquillisation (RT) is the administration of parenteral sedation to de-escalate situations where patients may harm themselves and/or others. RT is a restrictive intervention potentially breaching patients’ human rights and is reserved for situations where other measures have failed. NICE guidelines (NG10) state that once immediate risks are managed, post-RT incident debriefing of patients and staff should be conducted. This study examines concordance with NG10 at an adult inpatient psychiatric unit and explores ways to improve compliance and patient/staff experience.

Methods

Adult psychiatric inpatients (aged 18–65) who received single or multiple RT therapy during the admission study period (October 2023) were included. Data collected from Electronic Patient Records and chart review included gender, age, ward type, date of RT and drug(s) administered. Following RT, anonymised data was collected on the presence, nature and details of debriefing.

Results

49 adult psychiatry patients were admitted during the study period and there were 32 episodes of RT use in 9 patients (18.4% of inpatients). 56.7% of these occurred on general wards and 43.8% on psychiatry intensive care, with 6 patients (66.7%) >1 episode. Intramuscular drugs used included one or more of lorazepam (78.1% of patients), haloperidol (25%), promethazine (21.9%) and aripiprazole (9.4%). After 46.9% (15/32) of RT episodes debrief was offered, and occurred in 28.1% (9/32); 40% (6/15) of those offered debrief did not participate. 52.4% (11/21) of female patients were offered debrief with 81.8% (9/11) uptake, compared with 36.3% (4/11) of male patients offered with 25% (1/4) uptake. No accounts were taken from patients’ advocate, carer or witnesses. Details of debriefs conducted were documented in 33.3% (3/9). Reasons for not conducting debriefing were documented in 43.5% (10/23). The most common reason given was “not clinically appropriate”. During debriefs, no patients were offered information leaflets about the RT medication used. Finally, staff debriefing occurred in 31.3% (10/32) of episodes.

Conclusion

Compliance with NG10 guidelines for debriefing inpatients following RT was low and was worse in male than female patients. Staff debriefing was poor and no witness or advocate accounts were utilised. These findings may be due to the stressful ward environment or disrupted patient-professional relationship immediately following RT administration. Understanding the reasons for the gender differences in uptake, patient, staff or environmental factors contributing to lack of debriefing will allow interventions and improve holistic patient care following RT. Information and awareness of RT therapy should be available for patients more readily on ward admission and following RT.
Transition of Care in Young People With Attention-Deficit/Hyperactivity Disorder (ADHD) From Child to Adult Services
Authors: Jung Sangwoo Richard , Saunders Catherine , Cardinal Rudolf , Ford Tamsin
Published: August 2024

Aims

This retrospective cohort study using routinely collected administrative clinical data from the Cambridgeshire and Peterborough Foundation Trust (CPFT) Research Database, aims to understand how many children and young people (CYP) with attention-deficit/hyperactivity disorder (ADHD) undergo successful transition from child and adolescent mental health services (CAMHS) and community paediatric services, to adult mental health services and investigate the factors that are associated with the successful transition of care in young people with ADHD to adult services.

Many young people with ADHD, in need of service transition from child to adult services, experience serious barriers in receiving the care they need, constrained by scarce resources, low capacity in specialist services and variable awareness or training across various levels of care.

Methods

We explored the numbers and clinical and socio-demographic characteristics of CYP with ADHD who undergo successful transition from CAMHS and paediatric services, to adult mental health services. We will explore whether children with certain sociodemographic factors/treatment/service attended are more likely than others to successfully transition using multivariable logistic regression.

Results

Note results are rounded for statistical disclosure control. We identified 24,240 unique CYP for whom a referral (age < 18) exists to CPFT between 1 Sep 2007 and 31 Aug 2019 (with follow up until 2020). Of this cohort, 2300 were referred at any time to any ADHD service, 1760 CYP had a record of ADHD medication in their clinical notes at any time of whom 1590 CYP had a record of ADHD medication under the age of 18. Of these 1590 CYP, 330 had at least 1 year follow up in the database before and after their 18th birthday and a record of ADHD prescribing during the year before they turn 18. This is a cohort of CYP who should have transitioned from child to adult services. Of these 330, 160 (48%) had been referred to any ADHD service between their 17th and 19th birthday and 190 (58%) had any record of ADHD medication in the year after they turn 18. Further analyses will explore the characteristics of CYP who successfully transition, and we will carry out a series of sensitivity analyses.

Conclusion

With an increase in the number of children with ADHD who are prescribed medication, we can expect an increasing cohort of emerging adults who need continued care. This study will provide evidence on the current state of care to help identify areas for improvement.
Self-Perceived Competence in Providing Eating Disorder Interventions for Young People: A Service Evaluation Project
Authors: Rogers Emily , Lusby Joshua , Oginni Olakunle
Published: August 2024

Aims

Despite the rising prevalence of eating disorders among young people and their associated morbidity and mortality, the level of self-perceived competence of professionals in providing health interventions is unknown. It could be expected that those with low self-perceived competence would be reluctant to initiate therapeutic interventions, which may increase the burden of unmet need for this population. Consequently, a service evaluation project was carried out in Cardiff and Vale Health Board Trust to assess the confidence of healthcare providers in working with young people with eating disorders, and to identify interventions acceptable to clinicians in order to meet this service need.

Methods

Fifty-two healthcare workers who worked with young people below 18 years responded to a brief survey. The survey was advertised via email through the medical education department between December 7 2023 and January 5 2024 to healthcare workers based at Adult and Paediatric Emergency departments, in-patient units of General Adult Medical and Paediatric departments and the Community-based Child and Adolescent Mental Health Services (CAMHS). The survey elicited participants’ specialty, location of practice, self-assessed confidence in managing eating disorders in young people, aspect of management participants require support in, and preferred interventions which might support greater literacy in this topic.

Results

Fifty-two participants responded to our survey of whom 48% (25) were doctors, 17% (9) were psychologists, and 13% (7) were nurses. The larger proportion of participants worked in CAMHS (42%) and Paediatric wards/emergency department (37%). About 43% reported having a role in managing young people with eating disorders. Half of the participants reported having “average” to “good” confidence in managing young people with eating disorders while none reported “very good” confidence. Discussion with colleagues was reported as the most common means of getting information about managing young people with eating disorders (79%), while the least cited was local teaching (13%). Most participants wanted support with recognising high risk presentations (60%) and providing psychological interventions (58%). The most highly requested interventions were written resources (65%), and teaching events – virtual (63%) and face-to-face (54%).

Conclusion

Considering the rising prevalence of eating disorders, self-rated confidence of participants in working with young people with eating disorders was relatively low. Interventions can include providing summarised policy documents, simple reference resources, and targeted teaching. These interventions will be implemented and the survey repeated to assess impact of the intervention, with a view to repeating this cycle in order to further drive improvement.
Dementia and Driving
Authors: Al-Dabbagh Mohammed , Muhammad Faquiha , Odegbaro Dolapo
Published: August 2024

Aims

This audit focuses on assessing the compliance of health professionals with the UK law by informing the drivers with dementia about their legal requirement to report their condition to the DVLA and their insurance companies. The aim of this audit is to ensure public safety by adhering to the General Medical Council (GMC) guidance; “Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA”, as well as the Driving with Dementia or Mild Cognitive Impairment Consensus Guidelines for Clinicians; endorsed by RCPsych and Alzheimer's Society. This will help ensure public safety and prevent potential accidents or incidents caused by impaired driving.

Methods

The audit reviewed retrospective data of 40 patients selected randomly (17 males, 23 females and mean age 78 years old), referred to the memory clinic at Watermill Resource Centre in Berrywood Hospital, Northampton. The inclusion criteria was patients referred between 1st January and 31st December 2022 that were diagnosed with dementia. We set a compliance target of 100%.

Results

The results showed that out of the 40 patients diagnosed with dementia, 23 had a recorded risk assessment. 11 patients were driving at the time of assessment. 7 patients were referred to occupational therapy for a driving assessment. The compliance in informing patients about reporting to the DVLA and their insurance companies was low. 8 out of 11 (73%) patients were informed about reporting to the DVLA, and 5 out of 11 (45%) were informed about contacting their insurance company. Additionally, only 4 out of 11 (36%) patients were informed about the consequences of not reporting to the DVLA and their insurer. There was also a lack of systematic documentation regarding driving risk assessment. There was no record of medics contacting the DVLA.

Conclusion

Overall, the audit revealed a need for improvement in compliance and documentation. It is recommended that health professionals strictly adhere to their responsibilities in risk assessment and informing drivers with dementia about their legal requirements regarding informing DVLA and insurance companies. Clear documentation should be made using a standard template available.
Audit of Annual Blood Tests for Patients on Antipsychotic Medications in the Recovery Team
Authors: Apantaku Omolayo , Mohamudbucus Mohamed Yaasir , Somashekar Bettahalasoor , Kumar Ashok , Borges Daniela
Published: August 2024

Aims

All patients who are prescribed antipsychotic medications require annual blood tests which must include Full Blood Count (FBC), Urea and Electrolytes (U&E), eGFR, Lipids (Cholesterol & Triglycerides), Liver Function Test (LFT), HbA1c/Plasma glucose. Some patients also require prolactin blood test depending on their prescribed antipsychotic medication.

NICE and Maudsley guidelines recommend an annual check of the blood tests mentioned above.

This audit ascertained compliance in terms of annual blood test monitoring for patients who take antipsychotic medications and provided recommendations to improve where necessary.

Methods

Half of the caseload from two General Adult psychiatry Community Mental Health Teams (CMHT) were recruited from a sample population of 228 patients. Odd number randomisation was applied to select our sample (e.g., 1, 3, 5…). Sample size was of 114 patients, 8 of whom were not prescribed antipsychotic medications and excluded. Hence, 106 patients were identified as representative for inclusion in this audit.

Retrospective data collection was from clinical entries, clinic letters and blood test results.

Data obtained from these patients was collated and analysed using MS Excel spreadsheet.

Results

The audit revealed that compliance was suboptimal for all required blood tests (Compliance 80% or above is recommended). The kidney function test of Urea & Electrolytes was the closest to recommended standards and best performance overall (77%), eGFR, was subpar at 60%. 74% of patients had the glucose monitoring tests (Plasma glucose/HbA1c) done while Full Blood Count and Liver Function Test were both completed in 76 patients (~72%). The worst performing category was Prolactin monitoring, of which only 9 of patients who required this had it done, recording a mere 31%.

Majority (66%) of the blood tests were done at General Practice (GP) surgeries, 25% by Mental Health Services, while the rest were contributed to by Accident & Emergency and Acute Hospital visits.

Conclusion

Following completion of this audit, recommendations were made to advise existing antipsychotic blood monitoring services (GP surgeries and private clinic affiliated with the Trust) of the recommended blood parameters for monitoring, and the need to update current systems. Also, Liaison with service managers and service leads to set up a dedicated physical health clinic for this purpose. The latter has been particularly successful as the Trust is now in the process of recruitment for the new physical health clinic team. A re-audit is planned in the near future.
An Audit on Telephone Referrals to Beechcroft, a Step 5 Regional Child and Adolescent Mental Health Inpatient Unit
Authors: Breakwell Andrew , Kelly Claire , Brakspear Lucy , McMurray Owen , Szczygiel Karolina
Published: August 2024

Aims

To audit telephone referrals to Beechcroft inpatient unit.

Beechcroft inpatient unit is a step 5 regional child and adolescent mental health inpatient unit in Belfast. It receives a large volume of referrals from across all five health and social care trusts in Northern Ireland. The process of referral to Beechcroft can vary between trusts and clinicians; the majority of admissions are emergency. The demand for beds has risen by 30% since 2019. Emergency admissions are commonly telephone referrals whilst others submit written referrals. The referrals process is managed by the ward sisters, as there is no bed manager post. Referrals are discussed with a consultant psychiatrist.

Referrals received often lack key clinical information, which makes decisions around appropriateness of admission or prioritising multiple referrals difficult. Furthermore, as the admitting doctor relies on this information, missing clinical information could result in patient safety issues.

Methods

24 telephone referrals were recorded between August to December 2023. 5 referrals were excluded for either no request for a bed (3) or telephone update following previous written referral (2). 19 telephone referrals were analysed across 7 different criteria as below, based on necessary information.

Criteria 1 Patient identifiable information

Criteria 2 Source of referral/referrer details

Criteria 3 Current location of patient

Criteria 4 Legal status

Criteria 5 Presenting symptoms

Criteria 6 Working diagnosis

Criteria 7 Risks warranting admission

Results

Yes    No   %Yes

Criteria 1   19    0   100

Criteria 2    19    0   100

Criteria 3   13    6   68

Criteria 4    14   5   74

Criteria 5   18   1    95

Criteria 6    2   17   11

Criteria 7   15   4   79

Total     100   33   75.2

Patient identifiable information and source was documented in all referrals. Only 10% of referrals included a working diagnosis. Location of patient, legal status and risks warranting admission were documented between 68 and 78%.

Conclusion

Crucial information such as working diagnosis was missing in 90%. Risks or legal status missing in up to a quarter of referrals. This has an impact on timely access, bed flow and potentially patient safety.

A need for improvement in receiving and documenting telephone referrals has been identified. To aid improvement in patient safety and flow, a bed manager for in hours has now been appointed. A standardised proforma for recording data will be developed by inpatient staff in collaboration with community staff to include the above criteria. A re-audit will be carried out following these service improvements.
Applying the CORE20PLUS5 to Address Health Inequalities for Patients Under the Rehabilitation and Recovery Service in the London Borough of Hackney
Authors: Brennan Ailbhe
Published: August 2024

Aims

The NHS England Core20PLUS5 aims to reduce national healthcare inequalities by identifying five clinical areas requiring accelerated improvement for the most deprived 20% of the population. Three of these clinical areas are: Severe Mental Illness (SMI), Early Cancer Diagnosis and Maternity Care.

Hackney has the highest proportion of areas within the most deprived 10% nationally. The Hackney Rehabilitation and Recovery Team is a specialist service for those with SMI. While the service does not provide maternity care it is uniquely placed for women's health outreach work in this population. Research has shown that lower participation by those with SMI in screening may make them 2.5 times more likely to die prematurely from cancer. Bearing this in mind, this project aimed to improve early cancer diagnosis and management of women's health to improve health inequalities for females with SMI in Hackney.

Methods

I audited cancer screening compliance from the medical records of the 19 female patients under the Hackney Rehabilitation and Recovery Team and obtained patient feedback to explore barriers to access screening. I used a pool of possible keywords to perform a search for any discussion of women's health issues during contact with mental health professionals. Encouraging a culture of ‘Making Every Contact Count’, I presented the results of this audit at a Team Education Session, after which attendees received a personalised list detailing their caseload's outstanding health needs as identified from the audit. I led a weekly physical health clinic which addressed women's health issues. I designed a referral pathway for patients with complex psychiatric needs with the local cervical screening service which allows for longer appointments.

Results

16% of the female patients under the care of the Hackney Rehabilitation and Recovery Service had never had a discussion covering women's health issues. 73% of mammograms and 53% of smear tests were outstanding. Barriers to access include a lack of knowledge of cancer screening programmes and practical issues in booking appointments. Some cited a lack of confidence in travelling to appointments and communication issues (access to a mobile phone, email address or post) as an issue.

Conclusion

Designing interventions to boost the uptake of cancer screening appointments for female patients with SMI is a practical application of the CORE20PLUS5 approach. An MDT approach including patient participation and feedback is key when developing effective outreach initiatives.
Audit on Discharge Summaries From General Adult Inpatient Units to Primary Care at Black Country Healthcare NHS Foundation Trust
Authors: Chandra Pallavi , Ahmed Omair , Vajawat Bhavika , Ojuawo Olutobi , Varshney Prateek
Published: August 2024

Aims

Discharge summaries act as a key source of condensed information of inpatient stay as well as follow-up plan. Its timely availability to primary care and other multi-disciplinary teams involved in patient care is vital, especially when patients are being managed out of locality by different teams.

The project aimed at assessing if discharge summaries for General Adult inpatients across all four localities of the Trust was made available and in a timely fashion on patient electronic records as well as to primary care using national guidelines as the standard. Using the same guidelines, it also evaluated the quality of the summaries based on the information contained.

Methods

Data was retrospectively collected in October 2023 for general adult inpatient discharges for the month of January 2023 across all four localities of Black Country Healthcare NHS Foundation Trust. Records for 148 out of the 152 discharges were assessed. Data was collected from electronic patient records Rio and evaluated on Microsoft Excel. The evaluation checked whether discharge summaries were available, duration between discharge and its availability on electronic records as well as contents of summary. Professional Record Standards Body and the RCPsych guidelines were used as standards.

Results

28 of the 148 (18.9%) patients did not have a completed discharge summary. Of these, 14 (9.4%) were out of locality patients. The average duration from discharge to summary being made available was 12.7 days. Most of the summaries contained all relevant information as per guidelines.

Conclusion

The findings were presented to the Trust’s QI committee. It was concluded that while majority patients had a summary made available, there is a need for additional strategies to ensure summaries are available soon after discharge to ensure safe post-discharge care.

It was identified that the bed management team should notify parent teams of admissions and discharges promptly.

The medical secretary is to monitor the admissions register and ensure the junior doctors in the team complete discharge summaries in a timely manner.

Business intelligence team to use clinical coding to identify any missing discharge summaries and provide medical teams with a monthly report in case any are missed by the secretaries.

Once above recommendations are implemented, a re-audit would help to analyse the improvements in practice. The results would also help guide the Trust in developing a policy to harmonise processes across the Trust and thereby ensure safe patient care post-discharge.
Antibiotic Prescribing in Acute Wound Management
Authors: Al-khatib Hani Dourado , Corn Emma , Ozidu Victoria
Published: August 2024

Aims

The primary aim is to ensure patients receive recommended acute wound care. Specific objectives include improving wound management, enhancing antimicrobial stewardship, and aligning practices with national guidelines.

Methods

A retrospective audit spanning May to October 2023 assessed prescriptions for in-patients receiving antibiotics for wound management. Detailed patient records were scrutinized to evaluate compliance with standards, including wound assessment documentation, antibiotic indication adherence, tetanus status recording, and wound swab collection.

Results

A total of 21 patients/encounters met the criteria for inclusion. Documentation deficiencies were prevalent, with only 61.9% of prescriptions featuring complete wound assessments. Additionally, antibiotic indications met NICE criteria in only 42.8% of cases, while tetanus status documentation was absent across all records. Despite 76% receiving first-line antibiotics, only 19% had wound swabs collected.

Conclusion

Self-harm rates in the United Kingdom, particularly among those with mental health disorders, are alarming. Hospitalizations are often required to address acute self-inflicted wounds, yet in-patient settings present unique challenges exacerbating self-harming tendencies.

This audit underscores the imperative of optimizing acute wound management in in-patient settings. By implementing evidence-based practices and addressing identified deficiencies, healthcare providers can enhance patient outcomes and ensure optimal care delivery.
A Re-Audit of Physical Health Monitoring of Day-Care Patients in the Adult Eating Disorder Service at Surrey and Borders Partnership NHS Foundation Trust
Authors: Fulmali Amit , Pathan Tayeem
Published: August 2024

Aims

To determine if the physical health monitoring of day-care patients in the Adult Eating disorder service (AEDS) is done in line with the recommendations of NICE guidelines and relevant Medical Emergencies in Eating Disorders (MEED) Guidance on Recognition and Management.

Methods

1. For every attendance of patients to the day-care Clinic it is expected that the physical health monitoring to be offered would include:

•

Weight

•

Height (if first attendance)

•

BMI

•

HR (Pulse rate)

•

Sitting/Standing BP

•

Temperature

2. Relevant blood tests and ECGs on a schedule based on patient's BMI or as needed based on clinical indication.

23 patients were identified as having been seen in AEDS day-care centre between April 2021 till the point of discharge. 9 were deemed inappropriate due to incomplete information. Of the remaining 14, 9 patients were randomly selected, their documentation were looked from admission to day-care to the point of discharge. The monitoring was audited at 3 points of contact over the course of their first clinic appointment, the middle and point of discharge.

Results

1.

Comparing data from previous audit, the average admission in day-care decreased from 5.5 to 3.5 months.

2.

There was overall improvement in the ECG and blood test monitoring.

3.

At the admission and the last assessment there was 100% monitoring of BMI, weight, blood pressure and pulse.

4.

There was a drop in temperature monitoring by 11.1% in the first and last assessment due to faulty equipment.

5.

The ECG and bloods percentage dropped by 11.1% at all the monitoring points.

6.

At the midpoint there was no documentation of BMI, Blood Pressure, and pulse for 1 patient.

Conclusion

1.

Investigations were delayed from the patient's side.

2.

Due to COVID there was difficulty in accessing the primary care appointments for investigations.

3.

The temperature equipment was not working properly.

Recommendations:

1.

Keeping a fixed format for documenting day-care visits on the SystmOne software. A Sample format made available for documentation.

2.

Document all the parameters checked in the patients’ electronic records on the same day.

3.

Day-care clinical team to upskill on ECG via training.

4.

Team Resources to be allocated to have in-house ECG in day-care.

5.

SUSS test to be done for all RED (High risk) patients as clinically indicated and clearly document in the notes, e.g. SUSS: done/not done and reason with date SUSS conducted on.
Evaluating Adherence to Rapid Tranquilization Protocols in Psychiatric Emergencies: An Audit of a Tertiary Care Facility in Pakistan
Authors: Gul Naima , Nizami Asad
Published: August 2024

Aims

This audit assesses the adherence to and effectiveness of rapid tranquilization protocols in a tertiary care psychiatric facility in Pakistan, particularly focusing on the use of intramuscular (IM) haloperidol and promethazine. The evaluation also includes an analysis of how these practices align with the prescribed guidelines for managing psychiatric emergencies.

Methods

A comprehensive retrospective analysis of patient records from January to December 2023 was conducted. The focus was on assessing the sequence of interventions (de-escalation techniques, oral medication, IM administration), medication choices, adherence to protocol steps, and documentation of patient monitoring post-administration. Descriptive and inferential statistical methods were applied to analyze the data.

Results

Among 482 patient records:

The primary diagnoses included schizophrenia (44%), bipolar disorder (29%), and severe depression with psychotic features (27%). IM haloperidol and promethazine were predominantly used, with 68% of cases bypassing oral medication or de-escalation attempts. Only 60% of cases showed adherence to the recommended protocol steps, including assessment for medical causes and optimization of regular prescriptions. In 12% of cases, a second injection was necessary, with the interval between injections undocumented in 15% of these cases. Vital monitoring post-administration was not recorded in 30% of cases. Medication unavailability was an issue in 8% of aggressive cases. Protocol deviations included the omission of recommended pre-treatments, such as ECG for haloperidol and the lack of alternative options like buccal midazolam or inhaled loxapine.

Conclusion

The audit reveals significant deviations from established guidelines in the rapid tranquilization process. The frequent omission of non-invasive interventions and the lack of consistent monitoring and documentation practices highlight areas needing immediate improvement. Training in de-escalation techniques, adherence to step-wise intervention protocols, and ensuring the availability of a range of medications are crucial. This study underscores the importance of aligning psychiatric emergency practices with established guidelines to ensure patient safety and effective treatment outcomes.
An Audit of Baseline Physical Health Monitoring in Patients Under the Care of Mersey Care NHS Foundation Trust Who Are Commenced on Lithium
Authors: Hyland Declan , Chinnari Gopal , Elhaj-Houssen Tawfik , Orrell Rose-Anne
Published: August 2024

Aims

Lithium is clinically indicated for use in the UK for treatment and prophylaxis of mania, treatment and prophylaxis of bipolar disorder, treatment and prophylaxis of recurrent depressive disorder and treatment and prophylaxis of aggressive or self-harming behaviour. Prior to commencing lithium, there is a need for several physical health checks and blood tests to be completed to ensure that lithium remains appropriate to prescribe.

This audit aimed to establish whether Mersey Care NHS Foundation Trust’s prescribing practices of lithium are in keeping with national guidance prior to initiation and how the Trust’s performance compared with national performance as identified by the Prescribing Observatory for Mental Health (POMH) lithium audit.

Methods

A total of 127 patients under the care of the Trust who were prescribed lithium (lithium carbonate and lithium citrate, tablet and liquid formulations) were identified using the Trust's electronic record system and electronic prescription chart system. The POMH lithium audit tool was used to capture data for each lithium patient as Mersey Care NHS Foundation Trust was participating in the national POMH lithium audit. Each patient's electronic record was scrutinised to determine whether the following were measured prior to lithium being initiated – weight/body mass index (BMI)/waist circumference, Thyroid Function Tests (TFTs), serum calcium level and estimated Glomerular Filtration Rate (eGFR).

Results

Of the sample of lithium patients included in the audit, 78% of patients had a weight/BMI/waist circumference done prior to initiation of lithium; 80% of patients had a serum calcium level; 93% had TFTs done; and 100% of patients had an eGFR completed prior to initiation of lithium.

Conclusion

The results of this audit indicate that the Trust is performing well with the required physical health monitoring prior to initiation of lithium. Trust performance for all four parameters that were included and assessed in this audit were above the national compliance level reported in the POMH lithium audit. There is clearly a need, however, to improve performance and to ensure that both medical and nursing staff across the Trust are aware of the physical health monitoring required before initiating any patient on lithium. A Quality Performance Alert will be sent to all medical and nursing staff to raise awareness and lithium monitoring will be included in the induction for junior doctors working in the Trust. Future auditing of Trust performance on required physical health monitoring prior to commencing lithium will be conducted.
An Audit of Whether Patients on the General Adult Inpatient Wards and the PICU in Mersey Care NHS Foundation Trust Who Are Prescribed High Dose Antipsychotic Therapy Are Being Monitored as per Trust Policy
Authors: Hyland Declan , Singh Roopa , Dainton Kerry
Published: August 2024

Aims

High Dose Antipsychotic Therapy (HDAT) should only be used in exceptional circumstances, as there is little evidence to suggest that higher than recommended doses of antipsychotics are more clinically effective than standard doses, with potential side effects being greater. In practice, there are several clinical scenarios where HDAT may be prescribed and the potential benefits must outweigh the potential risks. NICE guidelines for psychosis and schizophrenia advise that dosages outside the range given in the British National Formulary should be justified and recorded.

This audit aimed to determine whether patients on the 16 general adult inpatient wards and Psychiatric Intensive Care Unit (PICU) in Mersey Care NHS Foundation Trust who are prescribed HDAT are managed as recommended by the Trust's HDAT policy.

Methods

A list of all inpatients admitted to the 16 general adult inpatient wards and the PICU in the Trust between 17th and 20th of July 2023 was obtained. The electronic prescription record for each patient was scrutinised to determine whether the patient was prescribed HDAT. For each HDAT patient, the patient's electronic psychiatric record was analysed to determine whether baseline physical health assessments – ECG, BMI, waist circumference, BP, pulse rate, FBC, U and Es, LFTs, serum prolactin level, HbA1c level and random serum total cholesterol level and lipid profile were completed before commencing HDAT. Each HDAT patient was reviewed to determine whether a cardiovascular assessment was completed prior to commencing HDAT.

Results

29 inpatients on the 16 general adult wards and the PICU were prescribed HDAT. The Trust's HDAT policy states 13 baseline physical health assessments should be completed prior to commencing HDAT. For the 29 patients, 13 baseline physical health assessments should have been completed on 378 occasions. On 98 occasions, the patient refused and these were excluded from the compliance. There were 226 (81%) occasions they were completed and 54 (19%) when they weren't completed. 12 (41%) of the 29 HDAT patients had a cardiovascular assessment done prior to commencing HDAT.

Conclusion

There are a significant number of inpatients in whom not all the required baseline physical health assessments prior to commencing HDAT are completed. A cardiovascular assessment is an important aspect of deciding whether to prescribe a patient HDAT and yet commonly not completed. There is a need to ensure that nursing and medical staff on the inpatient wards are aware of the Trust's HDAT policy and need to refer to and to adhere to it.
Is ADHD Medication Monitoring Being Completed in CAMHS?
Authors: Johnston Benjamin , McFerran Helen
Published: August 2024

Aims

•

To determine the demographics of the patients prescribed medications for ADHD under the CAMHS teams within Southern Trust (NI).

•

To assess whether the physical health monitoring guidelines (as outlined by NICE – nice.org.uk/guidance/ng87) have been followed.

•

If monitoring is not up to date, to determine why not.

Methods

We reviewed records from clinical notes and NIECR (Northern Ireland Electronic Care Record) to collect demographic details.

Following NICE guidelines, we used the clinical notes to determine which patients had physical health monitoring up to date, including heart rate (HR), blood pressure (BP), weight and height.

For any patient with monitoring not up to date, we reviewed the notes or contacted the practitioners to determine why this was the case.

Results

96 patients were found to be prescribed ADHD medications. Full demographic details were obtained and collated for these patients, including age, sex, diagnosis, co-morbidities, and medication information (e.g. preparation, dose, polypharmacy).

Of the 96 patients, 1 was excluded as their monitoring was carried out by paediatrics.

71 out of the remaining 95 had their monitoring up to date, leaving 24 patients with monitoring not up to date. Of these 24:

•

8 were due to non-attendance

•

4 were due to equipment issues (e.g. faulty/unavailable)

•

3 only had partially completed monitoring (e.g. BP, weight, height but no HR recorded)

•

1 was only reviewed virtually

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1 had documented completion of monitoring, but no figures documented

•

7 unknown – no reason given.

Conclusion

After 1 patient was excluded, 71/95 patients had monitoring up to date (~75%).

Of the remaining 24, some were due to systemic issues affecting all services, e.g. non-attendance or faulty equipment. However, some were due to issues more easily addressed.

This led to a discussion at a trust-wide patient safety meeting, with the following outcomes:

1.

Staff were given a presentation on NICE guidelines for ADHD medication monitoring to ensure knowledge is up to date.

2.

The importance of completing all aspects of monitoring and documenting these each time was highlighted.

3.

If monitoring could not be completed, the reason must be documented, to avoid further “unknowns”.

4.

An agreed plan to schedule monitoring appointments following virtual reviews.

5.

Annual re-audit using the same data template, with the aim of improving each year.
Prescribing Practice of Citalopram and Escitalopram in Older Adults Following the 2014 MHRA Guidance of Associated QTc Prolongation: A Clinical Audit
Authors: Kar Shreyan , Prasanna Aparna
Published: August 2024

Aims

Citalopram and escitalopram are commonly used serotonin-specific reuptake inhibitors (SSRIs) for the treatment of depression and anxiety. These medications are known to cause corrected QT interval (QTc) prolongation, with risks of further arrhythmias. In 2014, the Medicines Healthcare Regulatory Agency (MHRA) published guidance outlining this risk and advised decreased maximum daily doses of citalopram 20mg and escitalopram 10mg in the elderly population. The aim of this audit was to explore the prescribing patterns of citalopram and escitalopram in a community sample of older adults with psychiatric disorders, against MHRA guidance.

Methods

Older adults (aged >65 years) in the community mental health services in Wolverhampton, who were prescribed citalopram or escitalopram, were identified through a search of clinic letters in June 2023. We checked the medications, doses, history of QTc prolongation, concurrent medications that may prolong QTc, electrocardiogram (ECG) reviews, and any discussion about the risk. The data was collected by accessing the electronic patient record and related health records. In total 17 patients were included, with no exclusions.

Results

Most of the patients (94.1%, n = 16) were on citalopram and only one patient was on escitalopram. The most common dose of citalopram was 20 mg (62.5%, 10/16), with one patient having a higher than the recommended dose (30 mg). Escitalopram was within the recommended dose. There was no history of QTc prolongation in any patient. Concurrent medications that could prolong QTc were identified in 35.3% (n = 6) of the patient population; all of these were antipsychotics. A small proportion (11.8%, n = 2) of the patients had documentation stating about QTc prolongation and arrhythmia risks for citalopram or escitalopram. A review of ECG when initiating or adjusting treatment was noted in only one patient.

Conclusion

Most of the older adults had citalopram and escitalopram within recommended limits. A considerable proportion of patients had concurrent medications with an additional risk of prolonging QTc and subsequent arrhythmia. It is essential to consider ECG in all elderly patients before starting medications with a risk of QTc prolongation. There is a need to discuss the cardiac risk associated with citalopram and escitalopram with the patients and improve documentation. It may be better to provide written information to the patients and caregivers regarding this.
A Clinical Audit on the Monitoring and Management of Antipsychotic-Induced Hyper Prolactinaemia
Authors: Khan Noman
Published: August 2024

Aims

Antipsychotic medications are one of the major iatrogenic causes of hyperprolactinaemia with the attendant short- and long-term effects and risks associated with it.

•

The audit sought to answer the question: Are we monitoring and managing hyper prolactinemia caused by anti psychotic medications appropriately?

Methods

•

A literature search for relevant data and standards with regards to monitoring and management of hyperprolactinaemia was conducted.

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The audit was based on the standards derived from South West Yorkshire NHS Partnership Foundation Trust’s (SWYPFT) standards, NICE guidelines, and the Maudsley Prescribing Guidelines in Psychiatry (14th edition), focusing on the Trust's standards.

•

The total population under consideration included every patient under the care of the North Kirklees, Community mental health team (CMHT), Old age psychiatry services (OPS) that was using antipsychotic medication in the time period between 16 June 2022 and 15th July 2023.

Results

•

Total patients 61

•

Female 30

•

Male 31

•

Age: 65 and above

•

Already on antipsychotic: 49

•

Started on antipsychotic: 12

•

Two or more antipsychotic: 2

•

Switch from one antipsychotic to other: 4

•

Prolactin monitoring not required: 27 because were already using olanzapine, quetiapine and aripiprazole

Monitoring required: 34

•

Initiation: 12

•

Prolactin level done 2/12

•

Prolactin level not done 10/12

•

LAI (long acting antipsychotic) 11

Prolactin level done 7/11

Prolactin level not done 4/12

Not done: 75% were with Care coordinator

25% Wellbeing team

•

On oral antipsychotic that require prolactin level monitoring: 11

•

Prolactin level done 5/11

•

Prolactin level not done 6/11

Conclusion

Patients who were on antipsychotics in community required prolactin monitoring. In more than 50% of patients prolactin were not monitored regularly because of communication gap between Psychiatrist and GPs as no clear instructions were mentioned from Psychiatrist to GPs, patients and care coordinators.

A small number of patients in whom prolactin was raised were highlighted to their respective medics and managed accordingly.
Audit of Non-Pharmacological and Rapid Tranquilisation Practices in Managing Distress Among Older Adults: A Comparative Study in Inverness Hospitals
Authors: Kumar Praveen , Wild Adam , Howells Fiona , Kumar Tharini , Williams Phoebe
Published: August 2024

Aims

This audit evaluates the adherence of nursing and medical staff to local protocols for managing distress in older adults (aged >65 years) using non-pharmacological approaches and rapid tranquilisation (RT) in a psychiatric hospital's dementia ward, an acute medical unit, and a geriatric ward in a general hospital. We hypothesize that operational differences between these wards significantly influence the management of older adult patients.

Methods

Conducted from September 17 to October 8, 2022, in hospitals in Inverness, Scotland, this study reviewed 322 case notes and drug charts from patients who underwent RT in three wards: the Old Age Psychiatric Ward, Acute Medical Unit (AMU), and Geriatric Ward. Focus groups and informal discussions with ward nurses and junior doctors were organized to understand their perspectives on handling distress in dementia patients, with an emphasis on de-escalation techniques.

Data focused on key parameters:

•

Patient Diagnosis and Legal Status.

•

Administration Details: including initiation time, de-escalation techniques, consultation with senior doctors, and details of drugs administered (route, drug, and dosage).

Results

Staff nurses in all wards prioritized non-pharmacological de-escalation techniques, such as recognizing early signs of agitation, employing distraction and calming tactics, and acknowledging the importance of personal space, even in the face of staffing challenges and high patient loads. These measures were consistently employed prior to considering RT, adhering to the local protocol. Physical restraint was employed only in scenarios where there was a risk to the patient or others, executed by personnel trained in managing violence and aggression.

Conversations with junior doctors, particularly in the AMU, revealed a limited understanding of the RT protocol, suggesting a need for enhanced training and awareness. Overall, the study indicates that while RT is regarded as a last resort after the failure of psychological and behavioral approaches, there is a clear necessity for further education and training to ensure the safe and effective administration of RT.

Conclusion

This audit demonstrates that despite the varying environments and pressures in the three wards, adherence to the local protocol for managing distress in older adults is largely effective, with a strong preference for non-pharmacological methods. The findings highlight the need for ongoing education and reinforcement of RT protocols, particularly among junior doctors, to ensure patient safety and adherence to best practices. The results suggest that with proper support and training, the use of RT can be a carefully controlled and beneficial tool in managing distress in older adult patients.