bluuebunny/crossref_metadata_2025 huggingface dataset:
Neurodiversity Within an Adult Home Treatment Team in Newham, London
Authors: Iyiola Johnny , Lewis Fergus , Glavin Stephanie , Shukla Richa
Published: June 2022

Aims

An increasing proportion of patients presenting in crisis to Newham Home Treatment Team (NHTT) had been noted to exhibit clinical signs and symptoms of neurodiversity. The aim of our project was to identify the number of confirmed and suspected autism and ADHD cases over a 12 month period. We also collated data on gender, age, presenting complaint, medication, and use of screening tools.

Methods

The project involved a retrospective case note review of the NHTT (South) caseload from November 1st 2020-October 31st 2021. This involved searching caseload and electronic patient records on RiO for keywords: “autism”, “ADHD”, “ASD”, “Asperger”, “Attention Deficit Hyperactivity Disorder”, “AQ10”. Patients were included if neurodiversity was suspected or already diagnosed. Data were collected on age at presentation, gender, presenting complaint, NHTT diagnosis, other diagnoses, Autism Spectrum Quotient (AQ-10) score, whether screening for attention deficit hyperactivity disorder (ADHD) was completed, age at first presentation to services, and medications at discharge.

Results

Over a 12 month period 49 patients (out of 258) presenting to NHTT South raised clinical suspicion of neurodiversity, representing 19% of the caseload and on average one new patient per week. The majority of these (47) related to autism, 13 of which had confirmed diagnosis (M = 26, F = 23). Of the 36 for whom there was clinical suspicion of autism, an AQ10 score was recorded for 18. 14 patients were suspected to have ADHD, 6 of which were confirmed (M = 5, F = 9). There was not a significant impact of gender. The majority of patients included (33) presented with a mood disorder (M = 15, F = 18), and a minority (13) with psychotic disorders (M = 7, F = 6). Over half of patients included presented with suicidality (M = 11, F = 14), and just under half had received a diagnosis of personality disorder (M = 7, F = 16). 21 patients were prescribed anti-psychotic medication (M = 13, F = 8), and 24 were prescribed an antidepressant (M = 9, F = 15).

Conclusion

Our findings demonstrate that neurodiversity may currently be under-diagnosed and is often mis-diagnosed, with suspicion frequently raised in previously undiagnosed adult psychiatric patients presenting in crisis. There is need for increased awareness of presenting features of neurodiversity within secondary mental health care services, and particular screening for patients experiencing suicidality may be beneficial. The AQ10 is under-utilised as an independent screening tool, and should be promoted to aid in identifying neurodiversity. Patients who may be neurodiverse are frequently prescribed antipsychotic and antidepressant medication, and further studies exploring prescribing practices in this patient sub-set may be useful.
High Risk Care Plans in Liaison Psychiatry
Authors: Abbasi Yasmin , Jones Claire , Clark Marina , Chaudhry Mohammad Meher Ali , Akass Kit
Published: June 2022

Aims

To audit completed liaison service high risk care plans against local and national guidelines.

Methods

Sample comprised of a snapshot of all liaison patients currently on the case load on 14th December 2021. Electronic notes were reviewed to identify High Risk Care Plans (HRCPs) and audit completion against local guidance. Currently there is no national guidelines.

In addition staff from the liaison team were surveyed to consider their confidence in completing HRCPs in order to direct staff training. Acute hospital staff were also surveyed to ascertain positive and negative aspects of the current HRCPs, in order to suggest quality improvements ahead of the upcoming integration of new Digital notes system.

Results

Sample size 284. High Risk Care Plans completed 11, with an additional 2 required but not found in the notes.

Non pharmacological deescalation advice was specified in only 2/11.

Regular medication was documented in 5/11.

Specialist rapid tranquillisation medication advice in 8/11.

8/11 made reference to the local rapid tranquillisation policy, which was not made available in the notes.

Absconsion risk is documented in 8/11 and advised level of observation 10/11.

Conclusion

According to local guidelines High Risk Care Plans were appropriate for 4.6% of the liaison case load, but record was included in the notes for 3.9%. Of those completed mandatory fields including non pharmacological deescalation and rapid tranquillisation advice were not always complete. Reference to rapid tranquillisation policy not immediately available in the notes is largely unhelpful in an emergency.

Our local target is for 100% completion of appropriate high risk care plans and full documentation for each of the mandatory fields in the high risk care plan. Improved training and record keeping is required.

Staff survey suggested unfamiliarity with document and unclear boundaries between standard and patient specific information impaired utility of high risk care plans. We recommend familiarising staff with the document and encourage highlighted font for key information.
Adherence to the Admission Policy in a Local Old Age Psychiatric Unit in Wrexham: A Clinical Audit
Authors: Mitu Tajnin , Seddiq Nehad , Loo Jian , Perera Mark
Published: June 2022

Aims

Elderly patients are more vulnerable due to the higher prevalence of underlying physical health problems. Hence, it is prudent to have a baseline and regular update on the physical health assessment for all old age mental health inpatients. This paper is aimed to discuss the clinical audit findings on the physical health assessment are done in accordance to the trust policy.

Methods

The clinical audit was conducted in a local elderly inpatient mental health unit over a period of a week. The standard used was based on the local Health Board Policy on acute inpatient admission, which includes an admission clerking with details on physical health need and physical examination should be done within 12 hours of admission, blood investigations and medication chart should be completed within two hours of admission, and an ECG (electrocardiography) should be done at the point of admission.

Results

A total of 21 elderly inpatients admission clerking were analysed. It is noted that over 95 cases admission did not adhere to the prescribed standard. Only 67% of the admission clerking was completed within 12 hours, while only 52% of the admission had physical examination done. Only 24% of the admission completed their blood investigations within two hours and 14% of them had ECG done at the point of admission. Although 90% of medication chart was completed within two hours of admission, there is still room for improvement. Feedback from the junior doctors revealed a multifactorial contribution to the failure of meeting the standards: patient being agitated during admission, lack of communication among different teams, lacking an online documentation system on handover, and the heavy workload on junior doctors on venepuncture and ECG.

Conclusion

The clinical audit has shown a huge area of improvement is needed in terms of the physical health assessment and documentation for elderly inpatient psychiatry unit.

We recommend having a good handover system, training more nurses and HCWs in phlebotomy and ECGs, having ward based doctor cover to improve the adherence for future.

We will be presenting this audit in post grad teaching and junior doctor forum with a plan to conduct a regional audit to compare the adherence on the three different hospital under the same health board.
Re-Audit of Benzodiazepine and Z-Drug Prescribing in Two Community Treatment Teams in the Cumbria, Northumberland, Tyne and Wear Trust
Authors: Obayi Michelle , Hargreaves Helen , Ahuja Niraj
Published: June 2022

Aims

This is a re-audit of Benzodiazepine and Z-hypnotic drugs prescriptions in two community treatment teams (CTTs) in the Cumbria Northumberland Tyne and Wear (CNTW) Trust, comparing with previous audits in 2009, 2017 and 2018 to check whether areas of good practice were maintained, and progress was made.

Methods

We reviewed caseloads of four CNTW consultants in the two CTTs which included 554 patient encounters with 60 encounters where benzodiazepines or z-drugs were prescribed. Nine missing data sets brought the total audit sample to 51. For these 51, prescribing information was gathered from RiO and assessed against standards derived from CNTW Trust Policy and BNF prescribing guidance. To be compliant, 90–100% of prescriptions needed to meet the standard.

Results

Overall, the rate of prescribing of benzodiazepines and Z- drugs increased from previous audit (7% in 2018, now 10.8%). Good areas of practice maintained were as follows (all 100%): all teams were compliant in prescribing within BNF limits, refrained from prescribing diazepam in 10 mg formulation, and no pregnant/post-partum women were prescribed these medications.

Although non-compliant, there were clear improvements in documenting indicated use (2018: 61.65%, 2021: 80.8%), and providing prescriptions of <4 weeks in duration (2018: 58.2%, 2021: 79.2%)

Key areas of concern were as follows: poor documentation of indication, duration of treatment and plans for review/discontinuation (compliance ranged from 31.5% - 81.2% in these areas). There was poor documentation of what verbal advice was given (0–16.9%), and lack of clearly documented tapering/discontinuation plans for those on long-term prescriptions (16.1%). The provision of written advice reduced from previous audit (2018: 10.7%, 2021: 5.8%). As 41/51 encounters were via telephone or video due to COVID-19 pandemic, this may have impacted on results.

Conclusion

Despite improvement in some areas, there remains scope for ongoing improvement in other areas. To improve these, we plan to produce and distribute an educational email to all prescribers, including the following: information on this audit and its findings, prescribing guidelines, relevant e-links to patient information leaflets as well as the audit proforma used for this audit, to encourage prescribers to undertake self-directed practice. A poster will be distributed, highlighting prescribing guidelines and standards, to be printed and displayed in clinical areas as reminder of prescribing responsibilities and the importance of documentation. Prescribers will be encouraged to participate in a small quiz to test learning. Efficacy of these measures will be assessed with a re-audit in one years’ time.
Driving Risk Assessment and Advice Provision for Inpatients Based on Features of Illness, Treatment and Driver and Vehicle Licensing Agency (DVLA) Guidelines
Authors: Ofovwe Oghenefejiro , Nzekwue Nduka
Published: June 2022

Aims

The aim of the project was to improve the routine incorporation of driving advice based on Driver and Vehicle Licensing Agency (DVLA) guidance into discharge planning by responsible inpatient teams. This would optimize patient safety, demonstrate good clinical practice (trust and professional body values) and minimize/prevent the emergence of accidents/unfair loss of licenses/unfair attribution of driving accidents caused by people who have been under recent or ongoing inpatient care.

Methods

The following questions: “Do you have a valid license”, “Do you own/have access to a vehicle”, “Do you currently drive” were developed as a standard template for gathering patients’ driving information.

These questions were embedded within:

1.

Barriers to ward discharge discussions

2.

Trust-wide communications via screensaver and circular

Answers to these questions were to be clearly documented on patient's records to serve as prompts for the responsible discharging team to take up providing the appropriate advice.

After a specified period, the electronic discharge notification (EDN) database was searched for patients with relevant diagnosis who were discharged from all the general adult/older adult acute inpatient wards within a specified period. The patients’ records were then checked for documentation of relevant driving information evidenced by documentation of answers to the screening questions as well as recorded evidence of DVLA discussion/advice held since date of diagnosis or admission.

The standards audited against were all patients:

1.

should have their driving licence status recorded during their admission

2.

should have their access to a vehicle recorded during their admission

3.

with a relevant mental health diagnosis should have a record of advice regarding driving given in bespoke and DVLA informed manner during ward discharge planning by the responsible discharging team

4.

should have documentation of the outcome of the driving advice given by the responsible team in their records

Results

28 patients with relevant DVLA notifiable mental health conditions were audited. 11% (n = 3) had driving licence status recorded. 14% (n = 4) had access to a vehicle recorded. 7% (n = 2) had driving advice given. Only one patient had outcome of driving advice recorded. No best practice was identified.

Conclusion

Documentation of driving information, DVLA signposting advice and outcome for patients with relevant mental health diagnosis is a crucial part of patient risk assessment and management as these patients are not free from posing a driving risk on discharge. The trust is implementing actions to improve the routine incorporation of driving advice based on DVLA guidance into discharge planning.
Medical Assessment and Management of Self-Inflicted Head Injury in an Inpatient Child and Adolescent Mental Health Services (CAMHS) Setting
Authors: Patrick Georgie , Smallwood John , Webb Cara
Published: June 2022

Aims

To ascertain whether current medical assessment and management of self-inflicted head injuries in an inpatient CAMHS setting conforms with current NICE guidance.

Methods

Incidents of self-inflicted head injury were identified on the incident logging system Ulysses. Incidents were matched to entries on Paris, the online clinical notes system. Data were collected from Paris on whether the incident was reviewed by a doctor, time until doctor review and which components of the NICE guidance were completed during the review. The data were collated into an Excel spreadsheet and analysed.

Inclusion criteria were CAMHS inpatients at 1 Greater Manchester hospital during November 2021 who had an incident of ‘head banging’ recorded on Ulysses. Exclusion criteria were patients on ward A as the ward was found to have its own care plans for managing head banging rather than escalating to doctors.

Results

There were 52 incidents of head banging logged. 56% (n = 29) of incidents received a doctor review and 32% (n = 17) did not. For 10% (n = 5) of incidents a doctor review was declined and for 2% (n = 1) a review was conducted for another indication. The mean time taken until review was 4.3 hours with a range of 1 to 16 hours.

NICE guidance lists 9 components of the history that should be covered. 1 component met the 100% target and 1 component was documented in > 50% of incidents. The remaining 7 components were documented in < 50% of incidents.

NICE guidance lists 16 components of physical examination that should be completed. No components of the physical examination met the 100% target. 5 components were documented in > 50% of incidents. The remaining 11 components were documented in <50% of incidents.

NICE guidance recommends verbal and written safety netting advice is given. Advice was given in 16% (n = 5) of incidents. NICE recommends a responsible adult remains with the patient for 24 hours, this was documented in 77% (n = 22) of incidents. NICE recommends ongoing doctor concerns necessitate patient transfer to A&E. Concerns/lack of concerns were documented in 6.6% (n = 2) of incidents.

Conclusion

This audit has demonstrated inconsistencies between doctor's documentation of self-inflicted head injuries in an inpatient CAMHS setting. The reviews do not meet the standards outlined by NICE. There is a good emphasis on gross neurology but less awareness of the need to document more subtle pathology and ongoing monitoring requirements.
An Audit on Patient Safety and Prescribing in Patients With a Learning Disability, Autism, or Both at a Scottish GP Practice
Authors: Sardar Amina , Somasundara Dhruvashree , Carter Clare , Weatherburn Christopher
Published: June 2022

Aims

The aim was to investigate the proportion of patients with a previous diagnosis of learning disability or autism who later successfully underwent an annual review of their prescribed anti-psychotic or anti-depressant. This audit was prompted after Public Health England announced that a significant number of adults with a learning disability, autism or both take a prescribed antipsychotic, an antidepressant or both without appropriate clinical indications (psychosis or affective/anxiety disorder).

Methods

The sample included 23 patients from the practice who had received a diagnosis of learning disabilities, autism, or both by 12th October 2020. Of these, 12 patients had a record of at least 5 prescriptions of an anti-psychotic in the last 12 months and 20 patients had a record of at least 5 prescriptions of an anti-depressant within the last 12 months. The notes for these patients were reviewed in May 2021 in an effort to ascertain whether a medication review had been completed for these patients since May 2020. The review process included a phone call between the patient and the prescribing doctor to determine whether there any side effects were being experienced and to assess the need for the continuation of the prescription. The resulting data were recorded and analysed on Microsoft Excel.

Results

Out of the 12 patients who had been prescribed an anti-psychotic, 10 had received a medication review within the last 12 months. From the 20 patients who had been prescribed an anti-depressant, 19 had undergone a review of their medication within the last 12 months.

Conclusion

Review of anti-psychotics and anti-depressants prescribed to patients with a diagnosis of learning disability, autism, or both was overall positive with the majority of these patients receiving a medication review within 12 months. As a further recommendation, another audit can be done to explore whether these patients had an annual blood test done as increased cholesterol is a known side-effect of psychotropic drugs.
Presenting Symptoms of Undiagnosed Autism Spectrum Disorder Among Young Boys and Girls in Community CAMHS Between 2018–2019
Authors: Setlhare Kesegofetse , Rafi Sobia
Published: June 2022

Aims

Though Autism Spectrum Disorder (ASD) is a common childhood neurodevelopmental disorders, the literature on presentation of undiagnosed ASD in Consultant Child and Adolescent Mental Health Services, (CAMHS) is scarce. The aim of the study was to look at symptoms at presentation among boys and girls in CAMHS, compare the symptom profile between the two genders, establish the main referral and assessment pathways and interventions employed after diagnosis

Methods

This was a retrospective review of patients’ files referred to ASD Walsall CAHMS Clinic conducted in February 2021. A random sample size of 44 boys and girls equally distributed from the ASD database was selected randomly from the completed ASD assessment list, the equal distribution between genders was intentional. We looked at presenting symptoms reported on the referral letters, assessments in CAMHS, and interventions outlined from ASD outcome letters of all subjects with completed ASD assessment, in age groups 7–18 years.

Results

Across genders, most patients presented in the teenage years with common age of presentation seen at ages 15 and 17, both at 15.9% and mean age being 13 years. Ninety-five percent of patients were in school at the time of referral. Only 4.5% of patient were referred through crisis and the rest through local GP. A variety of presenting symptoms were seen, with the majority of the patients presenting with social and communication difficulties (77.3%), under /overreaction to sensory stimuli (63.6%) and anxiety (61.4%). 9.1% of patients had a family history of ASD. 100% of assessments included ADOS, SALT and neurodevelopmental assessment. 77.3% of patients were referred to support groups like living with ASD parent support groups. Along with CAMHS, education (97.7%) was the main agency involved in the care of these patients. In 44.2% of patients, EHCP was requested or already in place. The in between gender comparison also showed that although most symptoms were similar in both groups, some such as self-harm were higher among girls (27.3%) as compared to boys (13.6%) as well as obsessional symptoms which were more common in boys (63.3%) as compared to girls (27.3%).

Conclusion

Undiagnosed ASD presents with a wide variety of symptoms amongst boys and girls. Previous UK studies have shown an earlier presentation of ASD and which is contrary to our findings demonstrating a much later presentation. Therefore, we recommend referrers to be aware of the varied presentations and have a lower threshold for referral to secondary services to aid quicker ASD diagnosis and management.
Are We Following MHRA Guidance Regarding Valproate Prescription in Women of Child-Bearing Potential?
Authors: Shetty Adarsh , Polson Joseph
Published: June 2022

Aims

To clarify if MHRA guidance regarding valproate prescription in women of childbearing potential is being followed by psychiatrists in Cwm Taf Morgannwg University Health Board.

Methods

Women of childbearing potential who were prescribed valproate for mental health conditions were identified by contacting GP practice pharmacists. The notes of these patients were reviewed to see if the ARAF (Annual Risk Acknowledgement Form) had been completed. The GP records were cross-checked to see if highly effective contraception was prescribed for women who were on valproate. The first audit was done in November 2018, while the second audit was completed in December 2020. The main intervention after the first audit was general awareness raising amongst psychiatrists in secondary care about the MHRA guidance and the need for annual reviews, through email reminders and posters. The 2020 audit gathered detailed clinical information, including the reasons for prescribing valproate and the doses prescribed.

Results

2018 – out of 53 women on valproate, 1 had a completed ARAF, and 15 were on highly effective contraception.

2020 – out of 48 women on valproate, none had a completed ARAF, and 13 were on highly effective contraception.

Concerningly, only half (46%) of these women were prescribed valproate for bipolar disorder. The rest were prescribed valproate for a variety of diagnoses including schizophrenia, cyclothymia, emotionally unstable personality disorder, and complex PTSD.

Conclusion

Raising general awareness about MHRA guidance failed as an intervention in this audit. Hence, after the second audit, specific targeted emails are being sent to each sector's consultant psychiatrists, with a list of female patients of childbearing potential in their sector who are prescribed valproate. A valproate register was created for the Merthyr/Cynon and Rhondda/Taff Ely localities – to our knowledge, this is the first time this has been developed in Wales. The impact of these interventions is being evaluated with a third audit which is being done in March 2022. This audit cycle highlighted significant challenges in sharing information across primary and secondary care. Detailed information about patients on valproate, with information on prescribed contraception, was available only for the 2020 audit, due to the appointment of a pharmacist working across primary and secondary care.
An Audit Cycle Highlighting the Rate of Chlamydia Screening in a Forensic Child and Adolescent Mental Health Unit in Birmingham
Authors: Ugalahi Theresa , Hassan Hamid , O'Brien John
Published: June 2022

Aims

Chlamydia, a sexually transmitted bacterial infection caused by Chlamydia Trachomatis can result in long-term complications for affected individuals. The National chlamydia screening programme recommends screening at-risk young persons, however for the vulnerable patients at the Forensic Child and Adolescent Mental Health Service (FCAMHS), there has been no audit to determine the completion rate. This audit aim to (1) Determine the demographics of young persons on admission (2) To determine the rate of chlamydia screening as well as the percentage of patients who qualified for a Chlamydia screening(3) To determine the rate of documentation for completed tests.

Methods

This was a retrospective study. The medical electronic records of patients who met the inclusion criteria was searched. All the three mixed-sex adolescent forensic wards (2 medium secure units and one low secure unit) at FCAMHS Ardenleigh, Birmingham were sampled.

All patients that were on admission aged above 15 years of age were recruited.

A total sample size of 19 was obtained for the initial audit and 12 for the re-audit.

Data collection

Data were collected by the author for the initial-audit and re-audit by searching the clinical progress notes, the investigation results and the physical health rethink forms. An excel software was used for analysis.

Results

Demographics

There were 11 males (57.9%) and 8 females (42.1%) in the initial audit

In the re-audit, there were 7 males (58.3) and 5 females (41.7). Some of the patients were still on admission at the time of the re-audit, hence the percentages were calculated differently. The mean age and average length of admission was also calculated.

Chlamydia screening

In the initial audit, the percentage of patients tested for Chlamydia was 11.5%, even though 36.8% of patients met the criteria for Chlamydia screening. In the re-audit, 25.0% were tested, and 41.7% met the criteria for Chlamydia screening.

Physical health (Rethink) forms

The physical health form was completed for majority of patients 73.7% in the initial audit although, this was not compatible with screening rates. Before the re-audit was concluded, the physical health forms were no longer in use.

Conclusion

The audit highlighted an overall improvement in the rate of screening following recommendations from initial audit. The inclusion of Chlamydia screening in admission processes could be useful in improving sexual health.
What Is the Evidence for Using Anti-Epileptic Drugs to Treat Agitation and Irritability in Huntington's Disease?
Authors: Leong Kok Keong , Paramlall Mark
Published: June 2022

Aims

Background: Huntington's disease (HD), due to the pathological expansion of CAG trinucleotide repeats within the Huntington's gene on chromosome 4p (1), is an autosomal dominant progressive neurodegenerative disease with motor, cognitive and neuropsychiatric symptoms that includes irritability and agitation in an estimated 38–73% of HD patients (2) which is characterized by impatience and a tendency to become angry in response to minimal provocation. Expert consensus recommends implementation of environmental and behavioural strategies then commencing treatment with SSRI's, Neuroleptics or Anti-Epileptic Drugs (AED) (3). No previous papers, to our knowledge, have examined the newest antiepileptic agents or have identified the most efficacious antiepileptics for this use. Aim: We present a review of the literature describing antiepileptic treatments for agitation and irritability in HD focusing on identification of the most efficacious antiepileptics and the role of newer antiepileptic agents for this use.

Methods

A search in the main database sources (EMBASE, MEDLINE, Allied and Complementary medicine) was performed in order to obtain a comprehensive evaluation of available antiepileptic psychopharmacological treatments in HD for agitation and irritability.

Results

Antiepileptic (AED) agents described in consensus statements and case studies have included sodium valproate, carbamazepine and lamotrigine, which work by inhibition of voltage gated Na and Ca channels, and are often combined with antipsychotic agents for improvement of pathological mood swings and irritability. However, none of the papers identified were Level III or better.

Conclusion

No specific mood stabilizing antiepileptic psychopharmacological treatment of the Psychiatric symptoms of irritability and agitation in HD was identified. Overall, the use of AED have weak evidence base with no quantifiable outcome measures, such as such as the Disruptive or Aggressive Behavior behavioural subscale of the Unified Huntington's Disease Rating Scale or the Neuropsychiatric Inventory, indicating improvement of symptoms identified. Surveys and expert opinions were based on their personal knowledge of the HD populations and the selection of the experts surveyed was not systematic which could influence the practice pattern results. The review indicates a pressing need for treatment studies to determine which psychopharmacological and behavioral treatments are most efficacious.
Haematological Monitoring in Clozapine Use: Blood Best Sampled in the Afternoon?
Authors: Ade-Dosumu Adedoyin , O'Connell Henry
Published: June 2022

Aims

Clozapine is an atypical antipsychotic used in the management of Treatment-Resistant Schizophrenia (TRS). Despite its efficacy, Clozapine is associated with rare but clinically important haematological side effects of neutropenia and agranulocytosis, thus warranting regular monitoring of full blood count (FBC) white blood count (WBC) and neutrophil count (NC).

Clozaril Patient Monitoring service (CPMS) supervises the prescribing of Clozapine and haematological testing for patients. Amber and Red alerts are issued by the CPMS when WBC and NC values fall below specified levels, Clozapine treatment is either suspended or discontinued completely.

Methods

We present a case of 35-year-old Caucasian lady with a history of schizophrenia who was maintained on Clozapine treatment for 10 years and whose Clozapine was necessarily stopped because of red alerts. This lead to a significant deterioration in her mental state and level of functioning necessitating a prolonged hospital admission.

Results

•

Detailed retrospective review of this patient's CPMS results over a 2-year period identified consistently higher levels of WBC and NC, when the blood tests were conducted in the afternoon compared to mornings.

•

Literature review supported the phenomenon of a diurnal variation of WBC and NC levels in a proportion of patients prescribed Clozapine.

•

With clear knowledge of this patient's diurnal trends in WBC and NC count, it was possible to liaise with CPMS and restart her Clozapine treatment, leading to a significant improvement in her mental state and level of functioning.

Conclusion

•

We recommend that clinicians consider this phenomenon of diurnal variation in blood parameters in patients with frequent amber and red alert results who are at risk of having their Clozapine medication discontinued.

•

Close collaboration with CPMS and haematological advice may lead to a more nuanced approach to blood sampling, whereby afternoon samples are used in certain at-risk patients.
Clinical Audit of Clozapine Prescribing Practice and Monitoring Process in an Australian Community Mental Health Service
Authors: Fernando Tharushi , Bhandarkar Ritesh , Meadows Graham
Published: June 2022

Aims

Clozapine, a well-established treatment of choice for treatment-resistant schizophrenia is known to reduce suicidality, lessen the risk of tardive dyskinesia and reduce relapse risk. It contributes to a higher quality of life by reducing cognitive clouding. Patients taking Clozapine have improved social and work functioning. But Clozapine's significant side effects require regular, intense monitoring to minimize mortality and morbidity. To improve current practice of clozapine prescribing and monitoring, a systematic audit of service practices against guidelines of local hospital / Monash Health Clozapine patient management guidelines and the Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines will identify any deficits and inform measures to overcome them.

Methods

An audit was conducted to compare the current clozapine prescribing practice and monitoring process compared with local hospital / Monash Health Clozapine patient management guidelines and RANZCP clinical practice guidelines among clozapine prescribed patients in an Australian community mental health service.

Results

Medical records of thirty-three eligible adult patients on clozapine were audited. All the patients were prescribed dosages within the recommended daily clozapine range. Clozapine was used for appropriate indications (treatment of treatment resistant-schizophrenia or schizoaffective disorder). Of the 33 patients, clozapine level was subtherapeutic on 54.5% of patients. 54.5% of patients were on an adjunct psychotropic with clozapine. Aripiprazole and sodium valproate were used by eight patients each, and nine patients were identified using selective serotonin reuptake inhibitors. The most common side effect was hypersalivation (57.6%), followed by weight gain (39.4%), sedation (21.2%) and constipation (12.1%). Monthly weight monitoring, physical examination, medical officer monthly review and full blood examination, at 97% compliance met these standards. However, monitoring of Body Mass Index (BMI) (66.7%) and six-monthly consultant reviews (42.4%) showed poor compliance (<70%) with the standards. Most metabolic blood investigations were in moderate compliance (70–90%) except for relatively high compliance for lipid profile (90.1%). Monitoring cardiac functions by echocardiogram were only 75.8% met the standard.

Conclusion

Most patients in this clinic receive recommended monthly monitoring practice but for BMI monitoring, six-monthly consultant review, most blood investigations and annual or 2 yearly echocardiogram findings indicated need for improvement. Polypharmacy of psychotropics increases the side effect burden and further increases the need to closely monitor the physical health and prescriptions of this cohort of patients. The next stage of this project will involve a codesign approach to developing a response to these findings that will be outlined here.
Primary Care Referrals of Suspected Eating Disorders in Children and Young People in Greater Manchester Audit
Authors: Geers Benjamin , Ochando David
Published: June 2022

Aims

Current NICE guidance states that Children and Young People (CYP) with suspected Eating Disorders (EDs) should be immediately referred to specialist services on their first presentation to primary care. This audit assessed whether these standards were being met across Greater Manchester and what general practitioners felt would be helpful in supporting them to correctly refer patients. Aim 1: Analyse information from referral forms on all patients referred to Manchester Foundation Trust Community Eating Disorders Service (MFT-CEDS) from primary care between 17th December 2020 – 17th June 2021. Aim 2: Gain insight into how confident GPs in Greater Manchester feel identifying suspected EDs in CYP, their knowledge of guidelines regarding referral, and how they would like to be supported to improve referrals of suspected CYP-ED.

Methods

Quantitative data on all primary care referrals made between 17th December 2020–17th June 2021 were analysed. Referrals were classified as correct if they were made both immediately and directly to the correct service. Subgroup analysis of data by geographic region of Greater Manchester was also undertaken. Qualitative data were collected through a survey which was sent to General Practitioners across Greater Manchester. The survey assessed knowledge of current guidelines and views on what training materials could be helpful to improve the referral process.

Results

A total of 69 patients were referred to MFT-CEDS by their GP between 17th December 2020 and 17th June 2021. 35% of GP referrals to MFT-CEDS were documented as being made correctly as per current guidelines. 43.5% of all referrals were not initially made to MFT-CEDS. 58% of referrals were documented as being made immediately. North and South Manchester had the lowest rates of correct referrals of 10% and 8% respectively. There were 10 survey respondents, of which the majority did not know current referral guidelines and did not feel confident in identifying suspected Eating Disorders in CYP.

Conclusion

The majority of primary care referrals of CYP with suspected eating disorders to MFT-CEDS were not made in line with current NICE guidance.

The following recommendations were made based on the findings of this audit:

1) Create an information document and video regarding identification and referral guidelines for suspected EDs in CYP, 2) Design an easy-to-use referral template for GPs, 3) Conduct interviews with GPs working in North and South Manchester to help identify what additional support they need, 4) Re-audit referral data once quality improvement measures have been in place for 6 months.
Training Non-Medical Staff for SARS-CoV-2 Swab Collection on a Psychiatric Old Age Ward
Authors: Legg Joanna , Ouabbou Sophie , Hay Susan
Published: June 2022

Aims

In the second half of 2020 patients admitted to Highgate Mental Health Centre had to isolate in their rooms until a negative SARS-CoV-2 test result was obtained. This was stressful for both patients, who were unwell in their mental state, and staff. Swabs for PCR testing were only being collected by junior doctors which meant that out of hours, this responsibility would fall exclusively upon the duty doctor. There were often significant delays to obtain a sample. We decided to train non-medical staff on an old age ward so that the responsibility of collecting samples could be shared with nurses and healthcare assistants.

Methods

In November 2020 we held one training session with several members of staff from our ward. In the following days we did one to one training sessions with the members of staff who, due to their shifts, were not available for the original training session. We excluded admissions that happened prior to SARS-CoV-2 being mandatory, those where the patient refused to be swabbed, and those patients who were transferred from another institution already with a pre-admission swab.

Results

There were 37 admissions, of which we included 30 based on the exclusion criteria. 17 admissions occurred prior to training and 13 after the training sessions. Prior to training, it took 1.059 days to obtain a sample and it took 0.846 days after the training sessions.

Conclusion

Providing a training session to enable nurses and healthcare assistants to take samples for SARS-CoV-2 testing reduced the amount of time between admission and obtaining a swab sample. We therefore shortened the first step of the process that leads to obtaining a negative result and enable a patient to come out of isolation.
A Quality Improvement Project (QI) on Screening for Rapid Eye Movement Sleep Behaviour Disorder (RBD) in Patients Referred to Trafford Memory Assessment and Treatment Service (MATS), Part of Greater Manchester Mental Health Trust (GMMH)
Authors: Moir Rachel , Pye-Jones Ruth , Sindhi Amit , Benjamin Boben
Published: June 2022

Aims

Lewy Body Dementia (LBD) is predicted to be under-diagnosed in the general population. RBD is one of the four core clinical criteria for the diagnosis of LBD. Longitudinal studies of RBD show strong association with LBD, so there is potential for early identification of LBD and subsequent management. We aimed to screen 100% of patients referred to Trafford MATS for RBD.

Methods

We performed three Plan-Do-Study-Act (PDSA) cycles; in the first cycle we introduced a validated RBD screening question, from the DIAMOND-Lewy study, to the initial memory assessment proforma. This asked ‘Have you ever been told that you “act out your dreams” while sleeping (punched or flailed arms in the air, shouted or screamed)?’

In the second PDSA cycle, we delivered a RBD and LBD educational package to the specialist memory nurses who undertake the initial assessments. In the third PDSA cycle reminders were sent to the team to use the new assessment proforma.

We collated data from patients who had undergone an initial memory assessment between 06/04/21- 22/06/21 from the trusts electronic database.

Results

Initial baseline data showed that 0% of initial assessments screened for RBD; at the end of PDSA one this was 100% and 75% at the end of PDSA two. This increased to 100% at the end of the last PDSA cycle. The main reason for non-completion of the screening question was use of the old proforma.

4/152 patients screened positive; patients were diagnosed with Alzheimer's disease, delirium, vascular dementia and mixed Alzheimer‘s disease and vascular dementia, respectively.

Conclusion

The introduction of a RBD screening question into the MATS initial assessment proforma improved screening for RBD. We think the variation in screening compliance rates was likely due to practitioners using old assessment proformas, hence sending reminders of the new proforma.

A limitation of the project was that some patients did not have a bed partner, which makes identification of the disorder more difficult.

Since the completion of the project, we have circulated a news bulletin through the Dementia United charity to raise awareness of our QI project nationally and also discussed the project with the Lewy Body society. Whilst our project has not yet identified a patient with LBD, we feel that introducing this screening question is a very easy and reproducible change to implement and RBD should be screened for in all memory patients.
Improving the Appropriateness of Referrals From Primary to Secondary Care Confounded by the COVID Era: Student Status and Quality of Referral Evaluation in Oxford City Team (SQUARE-OCT)
Authors: Quadros Wesley , Ahmad Mohamed , Patkee Wishwanath , Katsanouli Theodora , Hyams Katy , Watkins Nicola , Krayem Amani , Bilip Maja , Zghoul Tarek , Tarfarosh Shah , Holm-Mercer Leah , Toparlak Sureyya , Tian Adam , Masood Khadija , Quested Digby
Published: June 2022

Aims

The Oxford City and NE Oxon Adult Mental Health Team (AMHT) is an adult mental health team receiving referrals from GPs for most cases suspected to have a mental health illness requiring secondary mental health services’ input in Oxford city. In January 2020, the team was remodelled with care coordinators working in separate functions based on the duration AMHT support was required for, i.e. an assessment team and a treatment team, but with medics covering both functions of the team. This quality improvement project examines AMHT referrals over 2020/21, hypothesising a reduction in the proportion of inappropriate referrals following the remodelling compared to a 2018/19 pre-remodelling audit.

Methods

The project covers a total of 2803 referrals the team has received from 13/01/2020 to 12/01/2021. The outcomes measured included the number of inappropriate referrals returned to the GP, referrals only requiring a single assessment, the proportion of these referrals as university students in Oxford, and the diagnostic groupings of the referrals in students vs non-students. These outcomes were measured pre- and during the COVID-19 pandemic over 2020/21.

Results

A reduction in the total number of referrals to the team was noted over 2020/21 but this was compared to an 11 month audit in 2018/2019. During the study period, 19.5% (546/2803) of referrals were deemed inappropriate compared to 21% of referrals received in 2018/2019. Of 2803 referrals, 14.7% (97/658) were inappropriate pre-COVID-19 vs 20.9% (449/2145) during the pandemic. Of the total number of referrals, 32.9% were returned to the GP following a single assessment.

The top 3 diagnostic categories in ‘non-students’ were mood/affective disorders (33.7%), anxiety/stress related disorders (17.2%), and neurodevelopmental disorders (7.8% total - ADHD was 3%). A significant increase in ADHD referrals and mood disorders amongst students compared to non-students is notable with the top 3 diagnostic categories for students being mood/affective (24.7%), neurodevelopmental disorders (19.5% - ADHD 17.7%), and anxiety/stress related disorders (13.4%). Students constituted 26% of the total number of referrals.

It was notable that during the pandemic there was a higher proportion of inappropriate referrals.

Conclusion

Our project demonstrates a reduction in the proportion of inappropriate referrals sent to the AMHT following remodelling as compared to 2018/19. Further work is necessary to elucidate the contributing factors and reduce inappropriate referrals even further. An innovation is planned to automate the logging of referral outcomes to expedite a re-audit.
The extra-embryonic area opaca plays a role in positioning the primitive streak of the early chick embryo
Authors: Lee Hyung Chul , Hastings Cato , Stern Claudio D.
Published: June 2022

Classical studies have established that the marginal zone, a ring of extra-embryonic epiblast immediately surrounding the embryonic epiblast (area pellucida) of the chick embryo, is important in setting embryonic polarity by positioning the primitive streak, the site of gastrulation. The more external extra-embryonic region (area opaca) was thought to have only nutritive and support functions. Using experimental embryology approaches, this study reveals three separable functions for this outer region. First, juxtaposition of the area opaca directly onto the area pellucida induces a new marginal zone from the latter; this induced domain is entirely posterior in character. Second, ablation and grafting experiments using an isolated anterior half of the blastoderm and pieces of area opaca suggest that the area opaca can influence the polarity of the adjacent marginal zone. Finally, we show that the loss of the ability of such isolated anterior half-embryos to regulate (re-establish polarity spontaneously) at the early primitive streak stage can be rescued by replacing the area opaca by one from a younger stage. These results uncover new roles of chick extra-embryonic tissues in early development.
Hearing without a tympanic ear
Authors: Capshaw Grace , Christensen-Dalsgaard Jakob , Carr Catherine E.
Published: June 2022

The ability to sense and localize sound is so advantageous for survival that it is difficult to understand the almost 100 million year gap separating the appearance of early tetrapods and the emergence of an impedance-matching tympanic middle ear – which we normally regard as a prerequisite for sensitive hearing on land – in their descendants. Recent studies of hearing in extant atympanate vertebrates have provided significant insights into the ancestral state(s) and the early evolution of the terrestrial tetrapod auditory system. These reveal a mechanism for sound pressure detection and directional hearing in ‘earless’ atympanate vertebrates that may be generalizable to all tetrapods, including the earliest terrestrial species. Here, we review the structure and function of vertebrate tympanic middle ears and highlight the multiple acquisition and loss events that characterize the complex evolutionary history of this important sensory structure. We describe extratympanic pathways for sound transmission to the inner ear and synthesize findings from recent studies to propose a general mechanism for hearing in ‘earless’ atympanate vertebrates. Finally, we integrate these studies with research on tympanate species that may also rely on extratympanic mechanisms for acoustic reception of infrasound (<20 Hz) and with studies on human bone conduction mechanisms of hearing.