bluuebunny/crossref_metadata_2025 huggingface dataset:
Physical health monitoring before commencing regular antipsychotics in a Psychiatric Intensive Care Unit (PICU) - A Quality Improvement project
Authors: Divyanish Divyanish , Channa Afshan
Published: June 2021

Aims

To compare the practice in a PICU setting against the standard practicing guidelines before commencing antipsychotics with regards to:

1.

Physical examination

2.

ECG

3.

Baseline blood investigations

4.

Physical health conditions

5.

Family history of medical conditions.

Method

Data were collected from the PICU, Black Country Healthcare NHS Foundation Trust which covers four different hospital sites. 37 patients were admitted in PICU from 1st March 2020 to 30th September 2020, out of which 30 were included. 6 case notes were not available and one patient was admitted twice, thus case notes for only one admission was included in data collection.

The standard guidelines for PICU outline that each admitted patient should have physical examination, vitals monitoring and baseline investigations including routine blood tests and ECG within first 24 hours. The data were collected as per standards retrospectively within two weeks from case notes in health records. Investigations were accessed through electronic information system for current inpatient admission and 12 months prior to the admission to the PICU.

Result

Mean age of the sample (n = 30) was 34.26 years. 37% of patients had physical comorbidities and a family history of medical conditions was documented for only 3% of cases. A large proportion of inpatients (53%) refused to have blood investigations before treatment and only 13% of blood investigations were completed before commencing treatment. Only 7% of patients consented to an ECG prior to commencing treatment. 27% of patients had a physical examination, including vitals, before starting treatment, a further 37% had just their vitals taken within 24 hours of admission and 20% refused any form of physical examination during their inpatient admission. 7% of cases had complications due to a lack of investigation.

Conclusion

Although there are standard guidelines for the PICU setting, it has been noted that these guidelines aren't always implemented. Multiple factors have a role to play such as: non-consenting patients, inaccessibility of previous records, initial assessment forms being incomplete including assessment of mental capacity and lack of follow-up with physical investigations by both primary care and secondary mental health services. As per findings, a few recommendations were proposed to meet the standards.
A quality improvement (QI) project to ensure females on valproate in a CMHT outpatient clinic, eput are registered on the valproate pregnancy prevention programme
Authors: Emmanuel Adebayo , Pillay Parvathy , Immadisetty Vyasa
Published: June 2021

Aims

Recent MHRA guidelines, state that Valproate medicines must no longer be used in women or girls of childbearing potential due to its highly teratogenic effects unless a Pregnancy Prevention Programme is in place. We carried out a service evaluation to determine if there was any way of identifying such patients with the aim of setting one up if required.

Background

Valproate is highly teratogenic and evidence supports that use in pregnancy leads to physical birth defects in 10 in every 100 babies (compared with a background rate of 2 to 3 in 100) and neurodevelopmental disorders in approximately 30 to 40 in every 100 children born to mothers taking Valproate. Data from a previous inpatient audit identified 35 females of childbearing age and none was on a pregnancy prevention plan. Audits done thereafter confirmed there was no system available for identifying such patients. Availability and accessibility to a synchronised IT system, which alerts when the yearly review is due is consistently identified as a contributory factor.

Method

A request via the Medicines management team was sent to the GP surgeries within the catchment area to assist in identifying female patients on their records on Valproate registered on the Pregnancy Prevention Programme.

The Plan-Do-Study-Act (PDSA) Quality Improvement (QI) model was used to bring about change. The target set to achieve was a 50% reduction in the prescriptions of Valproate in such patient groups.

Result

We had 10 out of the 50 GP surgeries contacted responded with a list of female patients on Valproate, a total of 25 patients’ altogether. In total, 4 patients out of the 25 were registered on the Pregnancy Prevention Programme and the overall non-compliance rate was 86%. . Factors believed to contribute to the low numbers include a lack of a system for registering women of childbearing age on the pregnancy protection plan and the recent introduction of GDPR regulation.

Conclusion

There are ongoing discussions with various stakeholders like the Medicines management team, Pharmacists, electronic records team (IT) and other clinicians regarding inserting an alert in the electronic system that reminds clinicians to register all such women on the Pregnancy Prevention Programme, while automatically creating a yearly reminder for completion of the annual risk acknowledgement form.
The power of reflective practice: evaluating the impact of a psychoeducation and reflective practice group for surgical nursing staff and health care assistants in a trauma centre
Authors: Harrison R
Published: June 2021

Aims

To offer a psychoeducation and reflective practice group for nursing staff (NS) and health care assistants (HCAs) working on a Trauma and Orthopaedics Ward in Southmead Hospital, Bristol. To explore the staff experience of having a reflective space, and how this impacted on their attitudes and knowledge and confidence in psychiatric presentations.

Background

Reflective practice can raise the quality and consistency of nursing care, but it is not part of everyday culture and practice. Southmead Hospital is a trauma centre and the surgical NS and HCAs care for multiple patients following self-harm or suicide attempts. They report at times not having the mental health knowledge and confidence to appropriately manage patients on the ward and are at high risk of occupational stress and burnout. Our mental health liaison team (MHLT) identified this need and offered to provide a space to address these concerns and evaluate the impact of this intervention.

Method

After liaising with the ward manager, I developed and provided a fortnightly forty-minute psychoeducation and reflective practice group for NS and HCAs on one Trauma and Orthopaedic ward in Southmead Hospital. Topics were rotated and included suicidal ideation, self-harming behaviour, mind and body link, the stress -vulnerability model and verbal aggression.

The staff were asked to complete anonymous paired pre-and post-course questionnaires about their attitudes and confidence regarding mental health difficulties. This questionnaire included both quantitative components (e.g. 1–5 Likert scales) and qualitative components (free text boxes) which were analysed and coded accordingly.

Result

Quantitative results showed that staff felt it was important to learn about mental health conditions and have a reflective space. Their confidence and knowledge improved in understanding and managing psychiatric presentations. Qualitative results revealed several common themes – (i) Space; staff valued a protected, structured, safe space, (ii) Relationships: staff valued sharing with colleagues and supporting each other, (iii) Sharing and learning; staff valued a space to think about patient's formulations, discuss common experiences, express their own emotions and learn from each other and (iv) Psychoeducation; the staff welcomed ideas of ways to communicate with patients and specific skills to use on the wards.

Conclusion

Trauma and Orthopaedic NS and HCAs perceived a range of benefits from participating in a psychoeducation and reflective practice group. Further research is required to evaluate whether reflective practice groups help to reduce staff burnout and can change the ward ethos to improve the patient experience.
A quality improvement project to improve the number of section 136 GP discharge summaries from the place of safety
Authors: Hazan Jemma , Ozer Mikail , Ramesh Yathooshan , Westmoreland Richard
Published: June 2021

Aims

A Quality Improvement project with the aim to increase the number of patients discharged with a GP discharge summary from the Chase Farm Place of Safety over a 12 month time period by 50%.

Background

An initial audit was conducted at Chase Farm Place of Safety (POS) to see if patients held under Section 136 of the Mental Health Act (S136) and then discharged home had a GP discharge letter completed and sent. The audit revealed that 0.02% of patients who were under S136 and discharged home did have a discharge letter sent to the GP.

As a result of the initial audit, key stakeholders were contacted, and involved in the intervention design and implementation. The intervention was introduced and all doctors working in the trust were emailed the new protocol

Method

We implemented the following intervention:

If a patient was registered at a GP Practice then the nursing staff in the POS copied the entry of the discharging doctor from the electronic progress notes and pasted this in to the S136 discharge template on the electronic progress notes and this was emailed to the GP.

We informed Doctors to be aware that their entry would go out to the GP and should contain the following: Impression, Outcome/Plan, Specific Risk /Safeguarding concerns and specific management plans.

Result

In the initial audit the notes of all patients discharged from the POS under S136 were reviewed over a 3 month period between November and January 2018. We found that 2 out of 89 patients (0.02%) had a completed GP summary which was emailed to the GP Practice.

After the intervention was introduced the notes were audited between July and September 2019. We found 33 out of 60 patients (55%) had a completed GP summary which was emailed to the GP Practice.

Conclusion

There was an improvement of 54.8% in the number of discharge summaries. Further consideration needs to be given to improving this percentage and understanding what remaining barriers there are.
Using SBAR in psychiatry: findings from two london hospitals
Authors: Janaway Benjamin , Zinchenko Ruslan , Anwar Lubna , Wadlow Clare , Soda Edwin , Cove Karen
Published: June 2021

Aims

We aimed to evaluate the use of the Situation, Background, Assessment and Recommendation communication tool (SBAR) at two large psychiatric hospitals, in order to design new approaches to teach and reinforce its sustained use. In doing so we hope to improve communication, staff experience and outcomes for patients.

We hypothesised that use prior to intervention would be low and attitudes inconsistent between teams and objective data.

Background

SBAR is a communication tool developed to accurately refer information with improved outcomes within the NHS. Within psychiatry there is evidence of relatively poor care of medical problems leading to adverse outcomes in a group more susceptible to multiple physical illnesses. The reasons for this include a cultural ethos of learned helplessness in staff and lack of medical knowledge.

The use of SBAR is likely to overcome these issues.

Method

Surveys were presented to doctors and nurses staff at two Psychiatric Hospitals, Chase Farm and Edgeware. Inclusion in the survey was voluntary and anonymous. Questions elucidated topics ranging from awareness of SBAR through to its use and benefits.

Objective data were also collected, looking at handover gathered during the survey period. This was collected via phone from the duty physician over a five-day period, twice-daily. Qualitative data on handover content was collected at CFH.

Audit standards around knowledge, use and outcomes were set. Data were collected and analysed in house.

Result

The data (n23) showed that most nurses reported awareness (86.96%) ease of use (86.96%) actual use (60.87%) efficacy in communication (78.26%) value in understanding patients (78.26%) and agreement with mandatory use (78.26%.)

Doctor reports (n14) showed that although 100% were aware of SBAR, no respondents thought nurse-led communication was adequate, or that SBAR was used. The majority thought that mandatory SBAR use would improve communication (92.86%) and patient care (100%)

Objective data (pooled) of referrals showed that on 6.52% used SBAR. Qualitative data showed that handover was often inaccurate, lacking in information and unsafe. Suggestions for teaching included written or video media, or taught classes.

All audit standards were failed.

Conclusion

SBAR is an effective tool for improving communication and patient outcomes, and is well perceived by the MDT. However, it is poorly used with psychiatry leading to adverse outcomes. Reported use is undermined by objective data. Its mandatory use is well supported and new teaching initiatives are thus being designed to remedy this and improve client experience.
Perception of junior doctors about local induction in Birmingham and Solihull Mental Health Foundation Trust - A quality improvement project
Authors: Jehanzeb Saima , Nader Kozara , Scally Ruth
Published: June 2021

Aims

A quality improvement project was undertaken to understand the perception of trainees about the quality of the local induction delivered by Birmingham and Solihull Mental Health Foundation Trust (BSMHFT). The primary aim was to evaluate the current local induction programme, following concerns raised by previous trainees in National Training Survey (General Medical Council) and local inspection. Our secondary aim was to devise a revised induction programme based on the trainees’ identified needs.

Method

Two anonymised questionnaire surveys were emailed to all Foundation Year Trainees, Core Psychiatry Trainees and General Practice Speciality Trainees working in BSMHFT, in December 2019 and March 2020, using trust survey monkey.

Result

The overall response to survey was 60 percent. 44.44 percent of the responses came from Core Psychiatry Trainees, with 27.78 percent responses each from Foundation Year Trainees and GP Speciality Trainees. Local induction was defined as induction specific to place of work (47.06%), trust based induction (41.18%) or all of the above options (11.76%) by trainees. 83.33% of all trainees had received local induction, whereas 16.67% did not have any local induction at the start of their post. 11.12% trainees were very satisfied and 44.44% were satisfied with local induction. 72.22 percent of the trainees were informed about of the local induction, prior to starting the post.

33.3% trainees had a paper version, 22.22% had an electronic version of local induction pack, whereas 44.44% had no induction pack. 55.55% of those trainees who had an induction pack, 43.75% found it very helpful and 56.25% did not find it helpful.88.89% thought having a local induction would be helpful, whereas 11.11 percent did not feel it would help. 94.44% of the trainees completed a local orientation checklist with their consultants. Some of the trainees experienced difficulty in gaining access to electronic prescribing, electronic patient record system (RIO), and identity badges (ID) at the beginning of their post.

Conclusion

11.12% trainees were very satisfied, 44.44% were satisfied, 22.22 % were neither satisfied nor dissatisfied and 22 % were dissatisfied, with local induction. 88.89% of the trainees thought having a local induction pack would be helpful. Based on the trainees identified needs we developed a template for local induction pack for each post. Clinical supervisors have agreed to take the lead in preparing the local induction pack specific to their post with trainees.We aim to repeat the survey after implementing the changes identified by trainees based on their training needs.
Child parent psychotherapy in the treatment of severe trauma in a 4-year-old child with co-occurring autism spectrum disorder
Authors: Lamb Clare , O'Sullivan Barry
Published: June 2021

Aims

This poster describes Child Parent Psychotherapy (CPP) in the treatment of severe trauma in a 4-year-old child with co-occurring Autism Spectrum Disorder (ASD).

Background

The London Infant and Family Team (LIFT) implements the New Orleans Intervention Model. It targets the mental health needs of under 5 year olds, providing evidence based assessments and interventions for infants, their parents and foster carers within the framework of the Family Court in England. The majority of children seen by LIFT have suffered severe trauma. LIFT delivers a range of interventions including CPP - a relational treatment for young children who have experienced trauma.

CPP seeks to intervene in a number of ways: provides developmental guidance, demonstrates that the child's behaviour has meaning and can be linked to past traumas, enables the child to have space to play and talk about what has happened, helps to name and contain emotions - supporting emotional regulation, and helps the dyad to understand each other. The dyadic relationship is key to the intervention - helping to establish safety for the child and strengthen the caregiver-child relationship, enabling the child to make sense of past experiences and learn new ways to express feelings. Exploration of trauma takes place through a combination of play and interpretations made by the clinician, who supports and holds in mind the experiences and history of both child and carer. There is evidence that CPP helps young traumatised children to become less anxious, more secure in their attachment relationships and more able to cue their needs. There is less evidence of the efficacy of CPP in the context of young children with a co-occurring diagnosis of ASD.

Method

The poster describes the assessment of a 4-year-old child of normal intelligence with a two year history of severe neglect, and physical and emotional abuse, who presented significant behavioural and emotional disturbance. Tools used to assess the child's behaviour, trauma symptoms and ASD are outlined. The process of CPP with the child and foster carer dyad is described. Outcome measures and symptom resolution are reported.

Conclusion

Co-occurrence of ASD did not prevent this child accessing trauma therapy. He engaged in symbolic play, made use of CPP interpretations, and achieved significant improvement in his symptoms. The differential diagnoses of trauma symptoms and ASD presenting in young children are discussed, alongside the importance of understanding and treating trauma in this context.
Improving the quality of GP referrals to the Croydon Assessment & Liaison Team
Authors: Lewis Gabriella , Chaplin Lucia , Knott Gareth , Coull Alexandra , Sobamowo Lamide
Published: June 2021

Aims

To increase the percentage of GP referrals to the Croydon Assessment & Liaison (A&L) Team deemed to be of ‘good quality’. The A&L Team receives a large number of referrals daily from GPs, and it was identified that many of these referrals did not include important and relevant information, leading to delays in patient assessments.

Method

A questionnaire was distributed to A&L MDT members to collect information about what information they consider important in a GP referral. The project team reviewed the results of the questionnaire, along with current policies and guidelines, to create a set of criteria by which to assess the quality of GP referrals, as there was no pre-existing gold standard available. A random sample of 6 GP referrals per week stratified by locality was collected and assessed against these criteria.

Using Plan-Do-Study-Act (PDSA) methodology change ideas were generated, and a GP referral form was identified as an important intervention to adopt. A previously-developed draft form was updated after a round of consultations with various stakeholders including Assessment & Liaison staff, GPs and the CCG. The new GP referral form was uploaded to the GP DSX electronic referrals platform and GP practices were also emailed directly to encourage them to use the new form.

The proportion of GP referrals deemed to be of good quality was compared pre and post-intervention. Uptake of the new GP referral form was recorded as a process measure, and the length of time taken to discuss referrals at A&L daily referrals meetings as a counterbalance measure.

Result

At baseline 33% of GP referrals were deemed to be of good quality using the developed criteria. This improved to 58% after implementation of the new referral form in January 2021. There was poor overall uptake of the form, with only 32.5% of GP referrals utilising the new form so far, however of the referrals received on the new form 69% fulfilled the criteria for good quality. Comparison of length of discussion required for referrals with and without the new form showed no significant difference (7.7 and 7.6 minutes respectively).

Conclusion

Implementation of a standardised GP referral form was effective at increasing the proportion of referrals deemed to be of good quality. However, further PDSA cycles focused on improving uptake of the form will be required.
Exploring the views of young people with autism spectrum disorder (ASD) on how to improve medical consultations
Authors: Mayor Alexander
Published: June 2021

Aims

The aim of this study was to explore experiences of consultations with non-specialist health professionals in a group of young people with ASD and their parents and what they considered would help to improve these interactions.

Background

Research has shown that general awareness around autism is poor among the general medical community and this can result in poor communication during medical consultations.

Method

An opportunistic group of 4 young people with ASD and 8 parents from a local support group in Exeter were interviewed in an informal environment about their experiences of healthcare consultations after seeking verbal consent.

Result

Among the 8 parents interviewed the themes emerging were a deep lack of understanding and awareness among medical staff of the challenges faced by individuals with autism, the importance of the doctor-patient relationship to allow children to open up to healthcare professionals, and the need for all children to be respected as individuals.

Among the 4 young people (13 to 19 years) with ASD interviewed they identified significant anxiety around waiting for appointments and expressed a desire for a distractor to relieve stress, questions posed by clinicians were often vague and should be clearer, 3D models/mannequins could be useful to support understanding of anatomy and physiology, patience and a calm demeanour were vital with a quiet clinical environment to avoid distraction, time for mental preparation is important and efforts should be made to avoid delays or cancellation of appointments where possible.

An interactive website was generated in the light of feedback from the client group and their parents, aiming to educate clinicians regarding the challenges faced by this client group and provide a guide suggesting how to facilitate effective consultation through the use of simple techniques to promote engagement/reduce anxiety in the clinical environment.

Conclusion

Simple changes to the approach to consultation with clients with ASD - a quiet consultation space, no delays and better communication - could reduce stress and promote positive interactions with a beneficial effect on healthcare delivery for this client group.
Dublin's homeless crisis – is this reflected in emergency department psychiatry referrals?
Authors: McLoughlin Aoibheann , Feeney Anna , Cooney John
Published: June 2021

Aims

This study seeks to explore the prevalence and impact of homelessness in an adult sample of psychiatry referrals over a one-month period via the Emergency Department at St. James's Hospital.

Background

Homelessness has now reached a crisis point in Ireland. In July 2019, there were 10,275 people documented as homeless nationwide, with the number of homeless families increasing by 178% since June 2015. The majority of individuals registered as homeless are located in Dublin. St. James's Hospital (SJH) provides psychiatric care to a population of 136,704 people across Dublin South-City within areas of significant deprivation according to the most recent social deprivation index.

Method

All Emergency Department psychiatry referrals over a one-month period were recorded. Month of study was randomly generated. Data were collected from electronic records. Socio-demographic information was analysed. Data were anonymised and recorded using Microsoft Excel. Current homelessness statistics were accessed from the Department of Housing, Planning, and Local Government and compared to the data collected.

Result

During the month of the Study (March 2019), 4315 adults accessed emergency homeless accommodation in Dublin. Of the 109 psychiatry referrals received through the Emergency Department at SJH during this time, over a quarter (28%) of those referred reported themselves to be homeless or living in temporary accommodation. An additional 5% were documented as living in residential or sheltered care at time of assessment. All of the referred homeless patients were unemployed (n = 30). 50% of homeless patients were referred to psychiatry following expressed thoughts or acts of self-harm. Illicit drug abuse was associated with 73% of referrals. Alcohol abuse was associated with 47%. Of those who were referred, under a quarter (23%) were assessed as having a major mental illness, and in the majority of these cases, illicit drug and alcohol abuse were compounding factors in exacerbating symptomatology. Of those referred, 66% had previously been reviewed by psychiatry during prior ED presentations and 60% of homeless presenters reported that they had previously been, or were currently linked in with community mental health teams.

Conclusion

Frequently, vulnerable patients most in need of social and psychiatric care, such as homeless people with addiction issues, are eclipsed from accessing supports. The high proportion of patients reporting to be homeless is cause for concern and suggests the need for tailored and integrated multi-disciplinary assessments and interventions at an Emergency Department level.
Quality improvement by introduction of 72-hour admission pathway in Forest House Adolescent Unit (FHAU) for young people in crisis
Authors: Mufti Sadaf , Zirinsky Linda
Published: June 2021

Aims

Short admissions for crisis management among young people suffering with Emotionally Unstable Personality Disorder (EUPD) as recommended in National Institute for Health and Care Excellence (NICE) 2009 guidelines are not routinely offered in the United Kingdom (UK). Our aim was to introduce crisis admissions lasting for 72 hours. During this brief admission the families of young people presenting with suicidal behaviour are offered an assessment and diagnosis of young person's difficulties, psychoeducation, and safety plan for future risky behaviour, in addition to respite.

Background

Three-day Crisis admission was set up with the aim of reducing inappropriate long admissions in people who may have more negative effects from admission than positive ones. A need was felt for a brief admission pathway in order to be able to provide treatment for patients suffering from EUPD traits in keeping with NICE guidelines. NICE guidelines suggest that people with borderline personality disorder should be considered for acute psychiatric inpatient admission only for the management of crises involving significant risk to self or others that cannot be managed by other services. The guidelines also recommend ensuring that the decision is based on an explicit and joint understanding of the potential benefits and likely harm that may result from admission and agreeing to the length and purpose of the admission in advance.

Method

A retrospective study comparing length of hospital stay in the 2018 (when this model was introduced) with previous years, the number of serious incidents was carried out to assess the impact of this new admission model. The rate of readmissions in the same year was also assessed. For qualitative feedback regarding the effectiveness of the crisis admission as an intervention, a survey was carried out to assess parent satisfaction and the nursing staff was asked for their views.

Result

There was a marked reduction in the number of serious incidents linked to suicide and length of hospital stay was reduced to half in the year when the crisis admissions were introduced as compared to the previous year. Only about 10-15% of patients required re-admission in the same year. About 90% of parents gave a positive feedback confirming the effectiveness of this intervention.

Conclusion

72-hour crisis admissions for adolescents are effective, appropriate, clinically indicated alternative to routine admissions with a high parent satisfaction.
An audit into the monitoring of off-label antipsychotics in primary care
Authors: Rafi Damir , Ferreiro-Pisos Javier , Hargrave John Millwood , Pérez Cristina Losada
Published: June 2021

Aims

To ascertain whether patients prescribed second generation antipsychotics for off-label indications are being monitored and screened adequately for physical health side-effects.

Background

The prevalence of off-label antipsychotic use has increased significantly over recent decades. Common off-licence uses include dementia, post-traumatic stress disorder, adjunctive treatment for unipolar depression and personality disorders. Recent studies have demonstrated that up to 65% of antipsychotic prescriptions are now off-label. Since the metabolic side-effects of second-generation antipsychotics are well-established, guidelines have emphasised the need for active, routine physical health screening of all individuals taking these drugs. However, there have been few studies or reviews which have specifically investigated screening rates of individuals receiving antipsychotic medications for off-licence indications.

Method

An audit of patients taking second-generation antipsychotics for off-label indications, under the caseload of Neighbourhoods 1, 3 and 4 of Lewisham Assessment & Liaison team, was conducted. After isolating individual patients fulfilling inclusion criteria, patient investigation documents were requested from relevant GP practices. 40 patients were isolated in total, and data were successfully collected in 60% (n = 24). Data were collected via a proforma. This consisted of patient information, indications for antipsychotic use, and each variable to be monitored. The audit standard used was the recommendations of the 12th Maudsley guidelines. Data were then entered into SPSS and analysed.

Result

The most common reasons for off-label antipsychotic prescribing were Emotionally Unstable Personality disorder (42%, n = 10) and depression (29%, n = 7). Findings demonstrated that 54% (n = 13) of patients audited had ‘basic’ blood screening (FBC, U&E, LFTs), however glucose (38%, n = 9), Prolactin (13%, n = 3), and Creatine Kinase (0%, n = 0), and monitoring was less frequent. 0% (n = 0) were completely monitored as per audit standard.

Conclusion

Primary care monitoring of off-label antipsychotics is unsatisfactory, with no patients having a complete set of investigations. Reasons for this are unclear at this stage, however based on initial discussion with GP surgeries, may be due to lack of education regarding screening investigations, patients lost between primary and secondary care services, and a lack of clarity regarding responsibility and designated roles. This audit will be expanded to also include patients from Neighbourhood 2 of the Lewisham Assessment & Liaison team. A more detailed investigation will be conducted into the barriers to physical health screening, such that a targeted intervention can be implanted.
Manualising the induction of higher trainees in psychiatry for North Wales: The CiSGC Guide (“Croeso i Seiciatreg Gogledd Cymru”)
Authors: Raja Jawad , Loo Jiann Lin , Sambhi Rajvinder , Shivashankar Somashekara
Published: June 2021

Aims

There is a significant period of adjustment for new higher trainees in psychiatry given the presence of inter-trust differences in the National Health Services (NHS). It may take some time for a trainee to become familiar with the new administrative system and workflow of the new environment, which may be even longer for an international medical graduate (IMG). Although there is an existing induction system, having a written structured manual will assist the trainees to get through this process more easily. Hence, this Quality Improvement Project (QIP) outlined the creation of an induction manual that serves as a starter pack to facilitate the settling-in process of new North Wales higher trainees in psychiatry, i.e. the “Croeso i Seiciatreg Gogledd Cymru” (CiSGC) guide (means Welcome to North Wales Psychiatry in Welsh).

Method

The induction manual was initially drafted by the authors based on the available printed policies and information online. Further input and from different stakeholders were obtained to triangulate and enrich the manual. Specific links and further references were included in the manual for the reference of prospective manual users. Authors’ contact details were included for any further clarification, suggestions or input.

Result

The manual consisted of four sections: A) General Process before, during and after Reporting Duty, B) Trainees’ Duty, 3) Speciality-specific Guidance, and 4) Health Board-related Information. The General Process section covered the visa-related information, post-acceptance paperwork process, access to email and hospital informative system, medical practice-related issues (including section 12(2) approval and medical indemnity). The Trainees’ Duty section briefed on time-tabling and clinical duty. The Specialty-specific Guide provided important information related to training. Lastly, the section of Health Board-related Information highlighted the administrative structure of the NHS Health Board, important contact numbers, link to information. Specialty specific sections were created for general adult psychiatry and old age psychiatry as there is no other higher training of psychiatry in North Wales at the moment. Further sections in the pipeline include substance misuse and liaison psychiatry.

Conclusion

This induction manual is neither prescriptive nor exhaustive. It serves as a generic reference to facilitate new trainees in their adjustment process. Further review and revision will be conducted before every induction process to ensure the information is up-to-date and incorporating new input from the trainees.
Let's get moving! Improving physical activity amongst rehabilitation patients; a quality improvement project
Authors: Rowland Ruth , Somerville Laura , Dorman Sarah , Finnerty Mark
Published: June 2021

Aims

This Quality Improvement Project aimed to improve physical activity amongst patients in a 16-bedded, low secure unit in the Downshire Hospital, Northern Ireland. We introduced an exercise programme with the aim of increasing minutes of physical activity per week. Secondary outcome measures were weight, mood and energy levels.

This project took place in the context of COVID-19 restrictions having reduced opportunities for off-ward activity and staff noting subsequent deconditioning and weight gain amongst the patient cohort. Cohort consisted largely of patients with a severe mental illness, many of whom had physical health co-mobridities.

Method

This project included all patients in the 16-bedded unit.

Baseline data were collected prior to programme introduction, including weekly activity levels and weights. A questionnaire explored patient confidence and attitude towards physical activity.

Focus groups were held with patients and staff in order to identify how best to introduce the programme, discuss content, and identify potential barriers.

We introduced an eight-week programme of weekly, thirty-minute, mixed ability exercise sessions. These were led collectively by the multi-disciplinary team. Patients actively participated in programme design; choosing session soundtracks and contributing to content planning.

Likert scales were used to measure self-report mood and energy levels pre- and post-session. Staff engaged in a weekly post session de-brief, where challenges were identified and solutions suggested. Weekly qualitative feedback was sought from participants. The sessions were thus developed and adapted according to patient and staff feedback over the programme's course.

Following the 8-week programme, activity levels and weight were re-measured and compared to baseline. Pre-programme questionnaires were also repeated.

Result

Patients reported increased enjoyment and confidence engaging in physical activity, as well as improved overall self- confidence and a sense of pride and ownership of the sessions.

Staff reported a more cohesive team environment, greater sense of work-place fulfilment and improved therapeutic relationships.

Comparing pre and post session ten-point-Likert scales showed a 153% mean increase in self-rated energy levels and a 98% mean increase in self-rated mood. This reflected a mean score increase of 3.8 in both.

Minutes of physical activity per week increased for all session participants, although remained below national guidance.

Weight reduction did not occur.

Conclusion

Exercise benefits not only physical health, but also emotional and psychological well-being. This project demonstrates how introduction of a weekly ward-based exercise class can offer this as well as improving working environment, team cohesion and therapeutic relationships. Weight reduction may be observed in the longer term.
Quality of seclusion medical review according to trust guidelines
Authors: Shahbaz Shumaila , Ward Richard
Published: June 2021

Aims

We accessed whether medics are following Trust Policy while conducting seclusion medical review and identify the strengths in quality of seclusion medical review and identify the areas which need improvements to improve our quality and standards of patient's care and safety and to reduce risks.

Background

The Mental Health Act Code of Practice sets an expectation for mental health services for restrictive interventions (use of restraint, seclusion and rapid tranquilisation) by following good standards. Medical reviews provide an opportunity to evaluate and amend seclusion management plan. This clinical audit was undertaken by looking at quality of record keeping about seclusion review by junior doctors, staff grades and consultants at different times (day, night, and weekend).

Method

Data analysis was carried out by using Microsoft Excel. The audit had Humber Teaching NHSFT approval. We assessed electronic healthcare records. Data collection was carried out or retrospectively in 2019(n = 40) using following parameters:

1)

A review of patient's physical and psychiatric health.

2)

An assessment medication prescribed and adverse effects of medication.

3)

A review of observations required.

4)

An assessment of the risk posed by the patient to others.

5)

An assessment of any risk to the patient from deliberate or accidental self-harm.

6)

An assessment of need for continuing seclusion, and whether it is possible for seclusion measures to be applied more flexibly, or in a less restrictive manner.

7)

Time of Seclusion Review: Within first hour after seclusion and then every 4 hours until internal MDT. After MDT twice a day.

8)

Record Keeping.

Result

Key Successes (above 80%)

Time of seclusion review (with in first hour or when required)

Record keeping (accurate time and place for clinical notes).

Plan for continuing need for seclusion.

Good documentation of Risk to self and risk to others.

Good documentation of mental state examination.

Comments on physical health although it can be improved.

Key Concerns(Less than 60%):

Prescribed Medications.

Medication side effects.

Physical Observations

Conclusion

Medics are missing some important parts in seclusion medical review. We developed a template for seclusion medical review according to trust guidelines which are based on Code of Practice and to incorporate in already existing seclusion review form. We also delivered teaching and training to doctors and also showed junior doctor's an example of documentation. We will re-audit in 1 years’ time to see improvement.
Pilot project: easy read psychiatry clinic appointment outcome letters
Authors: Sharma Anu , Sawhney Indermeet
Published: June 2021

Aims

To improve communication with patients and carers by sharing information in an easily comprehensible manner.

Background

According to the department of health guidelines, there is legal requirement to provide copies all clinical correspondence to the patients. Therefore, after any clinic review, letters summarizing the consultation are sent out to GP and patients are copied in. However, these are not very meaningful for patients with special needs, as they struggle to comprehend information. Previous studies have shown that patients with learning disability would prefer letters in a simple language and would also like to participate in the decision making process. According to Accessible Information Standard, we have a legal obligation to deliver information to our service users in an easily understandable manner. We undertook a quality improvement pilot project of easy read templates to improve the understanding of patients and their carers/families.

Method

A standard easy read template was co-produced after collecting feedback from different service users and clinicians. Pictures were incorporated into the questionnaire to facilitate understanding. We collected reviews over a period of 2 months from Nov 2019- Dec 2019. This proforma did not replace the routine clinic letter send out to the GP and the patients. This easy read template began with the introduction of the doctor (with photograph) and it encompassed mental health, physical health, current medication (and the benefits and side effects if any) and changes of medication. It also included epilepsy and the risks (risks to self and to others), vulnerability, behaviours of concern and the day-to-day activities that a service user engages in and finally about the plan formulated at the end of the consultation. At the same time, there was a separate form (with self-explanatory pictures), which collected feedback about the above mentioned appointment outcome review form.

Result

Templates were handed out to 65 patients and carers, and 60 completed the form. All patients found the template useful and helpful, mainly because it was easily comprehensible, with pictures, and also “provided instant updates”.

Conclusion

This easy read template improves patients’ understanding and participation in the clinic review. This contributes to greater patient satisfaction. As Specialist Learning Disability services, we need to ensure that information is imparted to the patients and the carers in an easily understandable manner and this easy read template should be incorporated in the routine clinic practice.
Testing a computerised tool to improve physical health monitoring in a medium secure forensic setting
Authors: Smith Mike , Abbas Mustafa
Published: June 2021

Aims

This project aimed to improve adherence to regular monitoring of the physical health of inpatients within a medium secure forensic psychiatric unit. A computerised tool to remind doctors to do checks was created, which was proposed would improve adherence.

Background

The physical health of people with mental health problems is of some concern, with higher rates of physical comorbidity and mortality compared to the general population.

The forensic inpatient population has a high burden of both severe mental illness and physical ill health, and a high medication burden with potential adverse effects on physical health.

To support the health of patients in our medium secure unit, each should routinely have three physical health checks done at least every six months. These are 1) an electrocardiogram (ECG), 2) a set of blood tests and 3) a full physical examination.

Method

Patient records for 26 patients across two medium secure psychiatric wards were checked for 1) an ECG, 2) a full set of blood tests and 3) a full general physical examination within the past 6 months.

A tool was created that automatically calculated the next due date for each check and colour coded which were overdue (red) or within 30 days of the due date (yellow). This tool was given to the core trainees working on these wards to help them keep track of which checks needed to be done.

The records for patients on the same two wards were rechecked four months later and the adherence rates compared.

Result

On both wards, for each of the three physical health checks, a substantial improvement was seen in the proportion completed within the past 6 months.

Conclusion

The tool created was a useful means of presenting, in one place, relevant information needed by doctors working in medium secure forensic wards regarding physical health checks, and drawing their attention to tasks that needed to be done. This led to an improvement in the adherence to physical health monitoring in these wards. An area for future improvement was identified regarding the unit's capacity to perform ECGs in a timely manner.
A quality improvement project: documentation of liaison psychiatry patient reviews in the John Radcliffe Hospital, Oxford
Authors: Talks Alice , Shaw Susan , Bajorek Tomasz , Carpenter Lindsay , Topiwala Anya
Published: June 2021

Aims

Assess how current practice reflects recommendations from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Treat as One: bridging the gap between mental and physical healthcare report (January 2017).

Develop template for electronic documentation of liaison psychiatry reviews and implement for trial period.

Re-audit after trial period to assess for change in quality of documentation.

Background

The John Radcliffe Hospital (JR) is a tertiary centre and has a large liaison psychiatry department with 14 consultants. Patient reviews by the liaison team are documented using a blank note type, on an electronic system used by all specialties within the hospital trust. The NCEPOD Treat as One report makes recommendations for the content of documentation of liaison psychiatry reviews which aim to improve communication between specialties.

Method

86 patients referred to liaison psychiatry at the JR in September 2018 were randomly selected. Four liaison psychiatry consultants appraised the quality of documentation of anonymized reviews by consultant colleagues. The audit tool was a questionnaire containing 12 questions developed by the four consultants based on the NCEPOD Treat as One report. Data were collated from these questionnaires. The template for electronic documentation was developed to reflect the report recommendations and after discussion with the liaison psychiatry team. The template has been implemented and is used for all initial patient reviews.

Result

The 12 questions of the audit tool can be divided into two groups: assessment and management. As part of the assessment, the majority of reviews included a primary diagnosis (77.9%) and reason for referral (66.3%). Other aspects of the assessment were documented in the minority of reviews: mental capacity (19.8%), need for DOLS (2.3%), risks (27.9%) and risk management (7%). Regarding the management, the majority of reviews included: clear plan with numbered/bullet points (61.6%), medication changes (51.4%), useful plan (73%) and answered the reason for referral (69.8%). Other aspects of the management were documented in the minority of reviews: each action point assigned (47.7%) and non-medical MDT advice (18.6%).

Conclusion

The main area for improvement in documentation of assessment agreed by the liaison team is risk. The main areas agreed for improvement in documentation of management are medication changes, assigning action points to individuals, and including advice for non-medical MDT members. The next step is re-audit, planned for March 2020.