bluuebunny/crossref_metadata_2025 huggingface dataset:
Prescribing in First Episode Psychosis
Authors: Searle Edita , Patel Raeema , Macpherson Robertson
Published: August 2024

Aims

This audit aimed to review prescribing in First Episode Psychosis (FEP) in Gloucestershire Health and Care NHS Trust, against NICE guidelines (CG 178) we hoped to develop prescribing guidelines for the Trust and to compare our results with Avon and Wiltshire Partnership (AWP) Trust's results of similar audit (AWP-235 Audit of Prescribing in FEP).

Methods

The sample was the Trust Early intervention (EI) caseload of patients with diagnosis FEP. We developed the audit tool based on AWP's audit methodology.

We gathered information about

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The role of initial prescribers.

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The prescribing of up to three antipsychotics.

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Choices of antipsychotic medication, whether the patient was given choice and information about the antipsychotic.

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Recorded reviews of side effects.

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Duration of treatment.

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Reasons for switching antipsychotic.

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Whether clozapine was offered to patients where indicated.

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Whether a recommended antipsychotic free period allowing for investigations and assessments was adhered to.

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Other medications prescribed alongside the antipsychotics.

Results

77 patients were identified.

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Adherence to the NICE guideline criterion of initial prescriber being in secondary care was good.

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Olanzapine was the preferred first antipsychotic choice for 50% of patients, aripiprazole was the most common choice as 2nd and 3rd antipsychotic (around 30% patients).

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Recording of Information about antipsychotic treatment was lower than expected, about 30% of the sample at first choice, this increased to 50% for second choice and 40% at the third choice of antipsychotic.

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Around 90% of the sample had recorded review of medication and its side effects.

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17% of the sample had duration of treatment less than 6 weeks at first antipsychotic, this dropped to 9% and 6% at second and third respectively.

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Reasons for switching were mostly due to side effects and lack of efficacy. Refusal to take the antipsychotic was a common reason for switching to the third antipsychotic.

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Only about 20% of patients who were eligible were offered clozapine.

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An antipsychotic free period up to 7 days was adhered to in almost 70%.

Conclusion

As a result of the audit findings we have developed Trust prescribing guidelines for adults presenting with FEP, which include recommendation for 7-day antipsychotic free assessment period, need to involve patients and family/carers when making decisions about choice of medication and recorded discussion about clozapine for eligible patients.
DNACPR: Utilising Poster Interventions to Improve Compliance With Scottish Government Guidance
Authors: Shahbaz Aized Raza , Herron James
Published: August 2024

Aims

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Study current practices in Old Age Psychiatry (OAP) wards regarding Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) documentation.

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Create an intervention to improve compliance with Scottish Government guidance.

Hypothesis:

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An intervention could improve likely inconsistencies in current DNACPR practices.

Background: DNACPR forms are a contentious issue in the media, impacting patients and families’ views. The Scottish Government's ‘Cardiopulmonary resuscitation decisions – integrated adult policy: guidance’ from 2016 seeks to prevent inappropriate attempts at CPR and subsequent distress to patients and families. It makes various recommendations for clinicians when making these decisions and completing DNACPR forms.

Methods

This was a two-cycle retrospective audit utilising physical and electronic notes for all patients across two OAP wards at the Vale of Leven Hospital, Alexandria. Data were collected on demographics, presence and adequacy of DNACPR forms based on Scottish Government guidance. Between the first (12/09/22) and second (25/11/22) cycle, a poster to aid DNACPR decisions and documentation was created and displayed in the ward office.

Results

There were a total of 13 patients in cycle 1 and 14 patients in cycle 2. The number of patients with forms increased from 3 to 8 between cycles (including all those with organic diagnoses in cycle 2). Between cycle 1 and 2, there were improvements in the proportion of forms: completed at admission (66.7% to 87.5%, respectively), correctly filed (66.7% to 100%), with review timeframes specified (0% to 62.5%) and consultant signatures (33.3% to 100%). The mean age of patients with DNACPR forms was higher than those without forms in both cycles (86.7 and 85.7 in cycle 1 respectively versus 77.9 and 77.7 in cycle 2). The mean number of comorbidities did not vary significantly between those with and without forms or between cycles.

Conclusion

The project revealed various shortcomings in DNACPR practices across both wards. The creation of a poster intervention helped to improve DNACPR practices and compliance with Scottish Government guidance. Despite this, notable areas for improvement still remain. Incorporating these new practices into hospital policy alongside more audit cycles could aid further progress in outstanding areas for improvement.
Improving Women's Sexual and Reproductive Health in Acute Inpatient Psychiatric Services – A Quality Improvement Project
Authors: Tulip Sally , Godsell Sarah , Roche Sophie , Okay Alara Acunas , Hartshorn Kirsty
Published: August 2024

Aims

Women with severe mental illness are at higher risk of sexually transmitted infections (STIs), unplanned pregnancies and poor engagement with cervical and breast screening. Despite current national guidance, these issues are poorly addressed during psychiatric admissions.

We aimed to improve the provision of women's sexual and reproductive healthcare on psychiatric wards using a quality improvement framework.

Methods

Female psychiatric inpatients aged over 18 were included. A baseline audit was performed in October 2022 on a female psychiatric ward, followed by six PDSA cycles from August 2022–January 2024 (n = 108).

We introduced women's health assessments (WHAs), offering counselling on: (1) contraception, (2) cervical and breast screening, and (3) STI screening. We arranged treatment and follow-up.

Changes were made at each PDSA cycle: ensuring provision of emergency contraception and STI swabs; establishing a protocol for referring to the sexual health clinic; creating dedicated clinic time to offer counselling; developing a poster and educational leaflet; and creating a proforma to record outcomes. The interventions were then extended to a neighbouring ward.

We reviewed electronic notes and recorded the percentage of patients offered counselling at baseline and after each cycle, later also recording the percentage of patients accepting interventions.

Results

At baseline, 12.5% of inpatients had been offered at least one of: contraceptive counselling, cervical and breast screening or STI screening. This improved to 87.7% offered a leaflet and 63.1% offered counselling by the final cycle. Of these patients, 48.8% accepted at least one intervention. On the neighbouring ward, offers of counselling increased from 28.6% to 63.6%.

Introduction of dedicated clinic time increased offers of interventions the most, to 94.1% (cycle 3). Compliance was lowest in cycle 4 (54.2% offered any intervention) which coincided with junior doctor changeover. Provision of an educational leaflet did not increase acceptance of interventions (cycle 5).

Introduction of WHAs led to detection and treatment of STIs in seven patients. Absent contraception was identified and started for a patient taking sodium valproate. Five patients were administered emergency contraception and two commenced long-term contraceptives. A case of female genital mutilation was identified, and a case of cervical neoplasia (CIN 3) was detected.

Conclusion

Provision of WHAs improved women's healthcare in inpatient psychiatric settings, with clinician contact being the most valuable resource in achieving this. There were several barriers, importantly clinician availability and awareness during junior doctor changeover. We will establish our interventions trust-wide, protocolising WHAs in the junior doctors’ handbook, and collect patient feedback.

Additional authors: Dr Terteel Elawad, Dr Judith Stellman.
Evaluating the Effectiveness of Skills Training in Affective and Interpersonal Regulation (STAIR) Therapy for Complex Post Traumatic Stress Disorder Delivered by Core Psychiatry Trainees
Authors: Abayaratne Dasal
Published: August 2024

Aims

This project aims to evaluate the effectiveness of Skills Training in Affective and Interpersonal Regulation (STAIR) psychotherapy delivered by Core Psychiatry Trainees (CPTs) within the Sheffield Specialist Psychotherapy Service; a regional tertiary psychotherapy service for people with complex trauma and personality difficulties.

STAIR is a manualised evidence-based skills-based psychotherapy for people with Complex Post Traumatic Stress Disorder (cPTSD) awaiting trauma processing that is deliverable by a range of qualified and non-qualified staff. It was introduced to address two key difficulties the service faces: a long waiting list for trauma processing potentially contributes to patient deterioration, and a difficulty in identifying suitable cases for CPT short psychotherapy case requirements given the majority of potential patients awaited longer term psychotherapy.

Methods

A modified STAIR protocol was developed to meet the requirements of CPTs.

A 1-year prospective evaluation was used to compare pre and post patient reported outcome measures. These include the Nine item Patient Health Questionnaire (PHQ9) for depression symptoms, Impacts of Events Scale Revised (IES-R) for trauma symptoms, Recovering Quality of Life – 10 question (ReQoL-10) for quality of life, and the Short form Inventory of Interpersonal Problems (IIP-32) for relational symptoms. Descriptive statistics were used and data analysed using repeated measure t-tests.

Results

17 patients completed STAIR delivered by CPTs. There was statistically significant mean improvement in Quality of Life (p = 0.001), trauma symptoms (p = 0.009) and depression symptoms (p = 0.019). Mean ReQoL-10 and IES-R improvements additionally met criteria for reliable change. There was non-significant (p = 0.0146) improvement in relational symptoms measured by IIP-32.

Conclusion

This evaluation demonstrates promising patient outcomes from STAIR delivered by CPTs for people with Complex PTSD awaiting trauma processing. This may help both negate any potential deteriorations whilst awaiting therapy, as well as prepare patients. Further evaluations could focus on acceptability and outcomes for CPTs.

Whilst the nature of this small evaluation limits further interpretation and generalisability, this pathway offers a promising means of meeting CPT psychotherapy competencies whilst also improving outcomes for patients.
Evaluating Multiprofessional Caseload Review in the Community Mental Health Team One Year On: Improving Patient Flow and Creating a More Responsive Service
Authors: Anwar Zarina , McClure Olivia
Published: August 2024

Aims

To evaluate the effectiveness and sustainability of multidisciplinary outpatient caseload reviews in the community mental health team (CMHT).

Methods

Caseload review for all patients under the outpatient clinics within South Leicestershire CMHT commenced in August 2022. A consultant psychiatrist and senior nurse spent 2–4 hours weekly reviewing each patient's electronic record chronologically from those waiting the longest for an appointment guided by a template including variables such as stability, risk and medication. Based on clinical need, the patient may be offered an outpatient appointment for ongoing treatment or review for discharge, nurse discharge clinic or transfer to another service.

This process is now embedded into routine clinical work, and momentum sustained by clinical and operational leadership roles within the team. The cycle is iterative and ongoing to ensure patients new to the service are included and flow from referral to discharge maintained.

Results

Between August 2022 to January 2024, 1460 out of a total of 1699 caseload reviews were completed. 622 (42%) of these are identified as suitable to be reviewed for discharge.

Of those, 256 (41%) were suitable for nurse discharge clinic, and 366 (59%) by a medic.

110 patients received an outpatient appointment following nurse discharge clinic, clinically indicated in 25.

Average additional wait time for an outpatient appointment has reduced from 34 weeks (September 2022) to 22 weeks (January 2024).

Conclusion

Consultant Psychiatrists in the CMHT frequently hold high outpatient caseloads with associated delays to care and treatment, and limited capacity and flexibility to respond dynamically to patient need contributing to reduced job satisfaction and burnout. Embedding multiprofessional caseload review into routine work creates greater capacity and responsiveness, reducing outpatient wait times and improving quality of care by earlier identification of those needing more expeditious review. Continuing this in an iterative cycle aligns with key principles of community transformation in the NHS Long Term Plan ensuring effective caseload management and fostering a more dynamic and responsive approach to meet patient need. Engaging senior clinicians and administrative staff is critical to successful implementation and close joint working has a positive ripple effect on team cohesion, morale and shared clinical decision making. The benefits are recognised at Trust board level with funding secured from the local Integrated Care Board to implement caseload reviews across all CMHTs within Leicestershire Partnership NHS Trust.
Impact of rTMS Treatment on Utilisation of Mental Health Services
Authors: Dua Devakshi , Gresswell-Thompson Hannah , Nisa Zaib , Matabdin Ihaab , Mohdesham Zaim
Published: August 2024

Aims

Repetitive Transcranial Magnetic Stimulation (rTMS) is a non-invasive brain stimulation recommended by NICE for treatment of depression. Our aim was to study the impact of real world rTMS treatment on service utilisation.

Methods

Data was collected for all patients who received rTMS treatment at the Centre for Neuromodulation Services (CNS) and followed up for 6 months. Sociodemographic data was collected for all patients. To understand service utilisation, data was collected to record involvement of mental health services including Community Mental Health Team, inpatient admission, Crisis and Home Treatment, Psychiatry Liaison and Talking Therapies.

Results

Fifteen patients completed treatment in the year 2023 since inception of the service. All patients received 25 daily treatment sessions over a period of 5 weeks.

67% of the patients were female (N = 10). 93% of the patients were White-British (N = 14) with one patient with British-Indian ethnicity. The mean age of patients was 50.8 years.

One-third of the patients were involved with more than two services within the Trust in the 6 months before referral for rTMS. Historically, most patients were involved with Talking Therapies (N = 13; 86%), Crisis and Liaison Teams (N = 10; 67%) and inpatient services (N = 9; 60%). Two (13%) patients were not on any medications at the time of starting treatment. In the 6 months after completion of treatment, only 3 (20%) patients were involved with more than one service while 3 (20%) patients were discharged from services.

Conclusion

The referral pattern along with involvement of services revealed that complex patients requiring multiple services were referred for TMS treatment. The drop in number of services involved post completion of treatment suggests that TMS was effective in reducing service utilisation. The study sample was limited to a small group and the same would have to be repeated with a larger sample.
Adverse Event Reporting in Older Adult Mental Health: A Theme Analysis
Authors: Herbert Kim , Fergie Ashley
Published: August 2024

Aims

We carried out a theme analysis of SAER (Significant Adverse Event) reports completed in Older Adults Mental Health Services in Greater Glasgow & Clyde. We wanted to identify common themes to bring about shared learning.

Methods

We analysed 19 SAERs from 2017 to 2023, using deductive coding. The ‘Human & Contributory Factors’ included within the SAER toolkit formed the coding system. Coding was then discussed between authors to explore the themes.

Results

Considering the demographics of the group, patients who died by suicide demonstrated gender distribution and methods in keeping with recognised statistics. However there was an over-representation of anxiety disorders and grief reaction (64%). This may prompt clinicians to hold a lower threshold for risk management strategies in this group.

Theme #1: ‘Management & Organisation’. In the period covering the pandemic, reports reflected the need for rapid changes in practice and how in some cases this had an impact on patient care e.g. restricting the possibility for review in the patient's home.

Challenges in liaising with external agencies such as Police Scotland were also highlighted

Many reports reflected that practice could have been updated, encouraging willingness to scrutinize long-standing practice.

Theme #2: ‘Communication & Team factors’. Communication failures between staff were more common than with patients. It was more common for communication failures to occur between teams than within.

This theme also covered issues with availability of information, such as the hybrid model of working with electronic systems but also with some paper records, and the opportunity for information to be missed as a result.

Theme #3: Quality of Care. This theme referred to recommendations for more robust or formalized methods of working, or for care to be more clearly patient-centred.

Delays accessing care were also highlighted. This might refer to a delay accessing other treatments within the inpatient setting, or to missed opportunities or delays in outpatient assessment.

Factors around specific tasks were frequently identified. Most often this referred to guidelines not being followed (updating formal risk assessments, referral to Tissue Viability, etc.). In a smaller number of reports it was identified that guidance was insufficient with recommendations for these to be reviewed.

The importance of patient factors was acknowledged in all reports without this apportioning blame to them or absolving the team from identifying areas for improvement.

Conclusion

This theme analysis identified a number of key themes for older adult psychiatry teams to consider. Results have been disseminated locally.
A Service Evaluation of Clinicians Writing Clinic Letters to Patients
Authors: Junaid Elizabeth , Eyeoyibo Mogbeyiteren
Published: August 2024

Aims

Writing clinic letters addressed and directed to the patient could be considered part of a strategy to implement a person-centred approach by giving patients more autonomy and understanding of their assessment and care plan. We carried out an audit of current practices and a survey of clinician attitudes within two community mental health teams to determine who clinic letters were being addressed to, whether they are being written in a suitable language and exploring the barriers to improving clinic letter writing.

Methods

We reviewed the first 100 initial and first 50 follow up clinic appointment encounters in two community mental health teams over a one-month period. We used a Microsoft Excel proforma to collect information on who the clinic letter was written to (patient or GP), whether the patient had been copied into the letter, and if not, if there was a recorded reason for why the patient had not been copied in. We also calculated the Flesch Readability score of each of the clinic letters to determine their reading ease using the Microsoft Word add-on tool. Following the initial audit, we carried out a survey to gain insight into clinician attitudes towards writing clinic letters directed to patients. The survey was sent out to all clinicians in the two community mental health teams where the audit was carried out.

Results

The audit revealed that 53% of clinicians wrote their clinic letters addressed to the patient and 47% wrote them addressed to the GP. 69% of letters were classified as, according the Flesch Readability Score: fairly difficult to read, difficult to read or very difficult to read. The reading ease varied amongst different clinician types. The clinician survey had 16 respondents and revealed various reasons that clinicians did not to write to the patient – including the clinician's own opinion that letters should be addressed to the GP, current practice in their team to write to the GP, long-standing style of writing addressed to the GP and lack of training in writing to the patient.

Conclusion

There has been variable practice amongst clinicians for whom their clinic letters are directed to. The majority of letters in our sample were not easy to read and this could be considered suboptimal for the target population. Training in clinic letter writing directed to the patient and the development of purposefully designed clinic letter templates are ways that we could help facilitate improvement in this practice.
Pills, Potions and Psychosocial Support in Pregnancy and the Post-Partum: Evaluating Interventions in a Specialist Perinatal Clinic
Authors: McWilliam Sheridan , Gupta Neeti , Kar Nilamadhab
Published: August 2024

Aims

Psychiatric illnesses are common in the perinatal period and many women are treated with psychotropic medications. Prescribing psychotropic medications often raises concern among patients and clinicians, because of a lack of information and no license to prescribe during pregnancy. This project aimed to evaluate the interventions offered in a perinatal clinic against the Perinatal College Centre for Quality Improvement standards. This included evaluating medications prescribed in the antenatal and postnatal periods; counselling regarding medication risks and benefits, provision of verbal and written information and psychosocial interventions.

Methods

Data of 60 patients (30 antenatal and 30 postnatal) attending perinatal outpatient clinics covering two cities in Midlands, England, consecutively from November 1st 2023 were collected from electronic clinical notes and clinic letters. Patients who did not attend their appointment were excluded.

Results

The mean age of the sample was 30.3 ± 5.2 (range 19–41). Average gestational age was 6.5 ± 2.1 months (range 2.0–9.5) for antenatal women, and average postnatal duration was 6.5 ± 5.0 months (range 0.1–22.0) at the time of review. All women had psychiatric diagnosis, except one who was discharged back to primary care. The most common diagnoses were mixed anxiety and depression (38.3%), emotionally unstable personality disorder (38.3%), and postnatal depression (20%). The majority (75.0%) were prescribed psychotropic drugs. Antidepressants were prescribed in 66.7% of antenatal and 76.7% postnatal patients; most commonly prescribed overall were sertraline (33.3%) and citalopram (23.3%). Antipsychotics were prescribed in 30.0% of antenatal and 46.7% of postnatal patients. Aripiprazole and quetiapine were most commonly prescribed in the antenatal (both 13.3%) and postnatal (both 20%) periods. A larger proportion (40.0%) of women had as required medications; promethazine (20.0% vs 30.0%), diazepam (6.7% vs 13.3%) and zopiclone (3.3% vs 13.3%) were most frequently prescribed, with figures indicating prescription rates in the ante- versus postnatal period. None of the medications were prescribed above licensed limits nor met criteria for high dose antipsychotic monitoring. Verbal and written information about medications was provided in 78.3% and 35.0% of all cases respectively. Most (65.0%) women were offered psychological therapies, and of these, 69.2% received it.

Conclusion

Most women in the perinatal period were prescribed psychotropic drugs, with higher proportions in the postnatal period. The findings suggested areas of improvement, such as offering written information, documenting the discussion of medication counselling, and to increase the psychotherapeutic support. It also suggests developing manualised educational interventions to improve information sharing with patients, and perinatal care.
Exploring the Experiences of the NCL CAMHS Co-Production Experts by Experience in Barnet, Enfield and Haringey Mental Health Trust: A Thematic Analysis
Authors: Nijabat Kiran
Published: August 2024

Aims

This study focuses on the North Central London Child and Adolescent Mental Health Services (NCL CAMHS) Co-production workstream, initiated to establish co-production as a foundational method for service planning and delivery in the NCL region.

To understand what the CAMHS experts by experience members found useful and did not find useful in co-production projects within Barnet Enfield and Haringey Mental Health NHS Trust and NCL wide co-production.

Methods

Semi-structured interviews conducted with experts by experience within the Barnet Enfield and Haringey (BEH) NHS Trust aimed to explore their co-production experiences, identifying facilitators and barriers. The study employed an inductive thematic analysis, grounded in a constructionist epistemological position, to analyse qualitative responses from semi-structured interviews. Braun and Clarke's (2006) methodology guided the analysis, consisting of six phases. The researchers emphasized reflexivity, reflection, and maintaining coherence, consistency, and flexibility throughout the recursive process. The voices of the lived experience co-production members played a central role in the research, influencing the entire report.

Two members of the NCL CAMHS lived experience group served as “Lived Experience Researchers” and received training on coding reliability based on Braun and Clarke's (2006) guidance.

Results

Thematic analysis revealed several key findings. Recognition of co-production values within the group highlighted the importance of giving voice to service users, valuing their individual experiences, and promoting power-sharing. Facilitators included good team working, valuing diversity, accessible online sessions, and promoting equality through interactions. Conversely, barriers included inconsistent meeting timings, power imbalances, and a consultation-style dominance. Participants expressed the need for more involved projects and recommended a transformation of BEH's co-production strategy.

Conclusion

Recommendations for BEH include a comprehensive evaluation of their co-production projects on the ladder of participation, emphasizing the importance of higher-level collaborations. Training for staff on co-production principles is crucial for fostering a mindset shift, and the establishment of a dedicated co-production team, including a co-production lead, is advised by service-users who co-produce. These roles can drive co-production projects, provide organizational structure, and facilitate stakeholder engagement.
Service Evaluation: Yoga Class Benefits for Mental and Physical Health in Mother and Baby Unit
Authors: Nikitina Akvile , Green-Thompson Zeyn
Published: August 2024

Aims

During the perinatal period women are at increased risk for mental health illness. It is estimated that around 0.5 in 1000 deliveries will result in admission to the mother and baby unit (MBU). Recovery is achieved by combining pharmacological treatment with holistic approaches. The majority of MBU settings will offer a variety of sessions that aid relaxation, reflection, and bonding. We have chosen to trial an additional service – Yoga class. It is known that Yoga is beneficial not only for strength, flexibility, and chronic pain but also for improved concentration, relaxation, and anxiety reduction.

Methods

Service evaluation took place in 8 bed, inpatient MBU. Selection criteria included non-pregnant women who had 4–6 weeks postnatal health check, were interested in trialling the class and were willing to complete pre- and post-class selected questions from the Dialog scale. The total number of Yoga classes conducted was 9 but there was no set number of classes for patients to commit to. Sessions were run between October 2023 and February 2024. Dialog scale was selected as a well-established outcome measure within the ward. We measured 3 areas by a Dialog scale (physical health, mental health, and leisure). The rating range was 1–7 with 1 being totally dissatisfied and 7 totally satisfied. Questions were completed before and after the class.

Results

In total 7 patients attended at least 1 Yoga class. We have calculated pre- and post-class average scores to measure change in selected outcomes. Physical health self-reported evaluation improved from 4.09 (SD = 0.79) to 4.48 (SD = 0.71). Mental health score improved from 3.61 (SD = 0.96) to 4.29 (SD = 0.99). Leisure score rose from 3.67 (SD = 1.3) to 4.34 (SD = 0.55). From the class record it was noted that overall, the uptake of the class was encouraging with 85% of patients returning to the Yoga with on average completion of 3 classes. 6 out of 7 patients did not attend further classes due to discharge or other commitments rather than withdrawing from classes.

Conclusion

From the collected data we can see that Yoga classes appear to be associated with moderate improvements in mothers’ mental and physical health, at least immediately post-class. Whether this translates into long-term benefits remains unknown. Our service evaluation indicates that Yoga can be a beneficial part of holistic management for mothers in the MBU setting. In the future, this study could also involve pregnant mothers, who are an important population within the MBU setting.
Staying Too Long – A Review of Delayed Discharges From Paediatric Wards
Authors: Pearson Harriette , Strachan Hilary
Published: August 2024

Aims

Since 2020, there has been an increase in children with mental health presentations ending up on general paediatric wards. Hospitals are identified as a place of safety for young people in crisis, though admission to a paediatric ward is not without risk for the child and staff involved in their care. Stays are often prolonged and classed as delayed discharges. This evaluation looks at 22 admissions to general paediatric wards within an acute health trust in Greater Manchester.

Methods

Local CAMHS teams identified 22 patients with a mental health presentation who had been admitted to paediatric wards and had delayed discharges between September 2021 and December 2023. Their electronic notes were analysed to identify number of bed days and CAMHS contacts, legal status, and discharge destination. Incident reports of each admission were analysed, and categorised into ‘Restraint/Rapid Tranquilisation’, ‘Assault on staff’ ‘Self harm’ ‘Abscondence’ and ‘Other’.

Results

Of the 22 cases analyses, total bed days were 1469. The average number of bed days was 66.7. 6 admissions were over 100 days with the longest being 186 days. The majority (19) of the presenting complaints were categorised as ‘self-harm’ and /or ‘suicidal ideation’. The average number of core CAMHS contacts was 23 per admission, with an average of 9 consultant contacts, 5 Junior doctor out of hour contacts, and 32 meetings (e.g. discharge meeting, strategy meeting) requiring CAMHS attendance. 11 admissions involved assault on staff, with the highest number of assaults 48 during a single admission. 18 of the admissions required additional staffing (clinical support worker, security). Three patients required police to be called to the ward due to assault on staff. 9 of the patients were discharged to a social care placement, 8 were discharged home. The remaining were discharged to inpatient unit, day unit or to a family member.

Conclusion

Mental health admissions to paediatric wards are associated with a high level of CAMHS contacts provided by Tier 3 staff, which creates a previously unseen burden on the service. Admissions can be prolonged. Patients are cared for in an environment which is not designed to meet their needs. This is demonstrated by high level of patients absconding from the ward and increased restrictive measures such as restraint and 1:1 observation. Admissions are also associated with high levels or assault on staff. Further work is needed to evaluate the economic impact of additional staffing on paediatric wards, as well as the impact on paediatric nursing and security staff.
Assessing Physical Health Risk in People With Intellectual Disability Using the Decision Support Tool for Physical Health [DST-PH]
Authors: Melrose Zoe , Rothon Catherine , Siddiqi Daanish , Peters Ayodele
Published: August 2024

Aims

Accurately and comprehensively assessing physical health risk for people with intellectual disability (ID) is paramount in improving health outcomes, reducing the need for acute hospital admissions and preventing mortality. We aimed to compare the existing approach to assessing physical health risk with the use of a novel standardised risk stratification tool, the Decision Support Tool for Physical Health [DST-PH]. We hypothesise that DST-PH will be useful in improving and streamlining the assessment of physical health risk factors in people with ID.

People with ID are more likely to have poorer physical health outcomes and are at increased risk of premature and preventable death. Annual data from LeDeR (Learning from lives and deaths – People with a learning disability and autistic people) consistently underlines the need for developing strategies that reduce the risk of people with ID developing conditions associated with high causes of morbidity and mortality.

The DST-PH is an online tool that helps clinicians to identify people with ID who are at increased risk of early and preventable death. The tool captures key patient data about underlying health issues and risk factors that can contribute to poor health outcomes. Patients are then stratified according to their overall level of risk using a ‘RAG’ (red, green, amber) system. This allows targeted intervention and monitoring for those patients in need.

Methods

All patient-facing staff in the Wandsworth Learning Disability Service were surveyed about their confidence levels in assessing physical health risk factors independently. We then asked each member of staff to assess physical health risk and assign a RAG rating for 2 randomly selected patients using their usual methods (clinical judgement). We then assessed the same patients using the DST-PH tool. Results were then compared to determine the degree of correlation between clinicians' existing risk assessment methods and the risk ratings assigned using the DST-PH.

Results

Survey results showed that staff would welcome the introduction of a risk stratification tool. Comparison of risk assessment data showed a significant correlation between clinicians’ assessment and the results from the tool.

Conclusion

Results evidenced the drive for ID clinicians to be observant of the physical health care needs of their patients. Introduction of the DST-PH may help to streamline the risk assessment process and increase confidence levels of clinicians.
A Service Evaluation and Improvement Project: Reducing Delays in Transfer of Patients From Psychiatric Intensive Care Unit (PICU) to Prison After Completion of Treatment
Authors: Satisha Shantala , Pettifor Emily
Published: August 2024

Aims

The project aims to reduce the delays in transferring prisoners back to prison after they have completed the treatment of their mental health disorder in our male PICU.

Hypothesis:

When prisoners are admitted to our PICU for treatment of their mental health condition, there is a delay in transfer to prison after completion of their treatment due to lack of clear protocol between the services. We expect this project to significantly reduce these delays by agreeing treatment goals and exit pathways prior to admission.

Background

Our 12 bed male PICU accepts admissions from prison for patients meeting our admission criteria. With increased number of admissions from prison since 2020, we were experiencing delays in transferring the patients back to prison after completing their hospital treatment.

Methods

Data was collected for all admissions from prison services to the male PICU ward since June 2020 to April 2023. We introduced a PICU-Prison Transfer Agreement form in October 2021 which had to be signed by the mental health team and the governor of the prison before the admission. The form asked for details of any pending court appearances, solicitors’ details, release date, list of staff to be invited for CPA and agreement to accept the patient back to their prison after completion of treatment.

Results

There were 44 referrals in this time period of which 24 were admitted to PICU. Prior to introducing the PICU-Prison Transfer Agreement, there was an average of 22.5 days (range 19–30 days) delay in patients being transferred to prison after being deemed ready for transfer. After the intervention, the delay in transfer reduced to an average of 10 days (range 5–11 days). The number of patients experiencing delay in transfer to prison of more than 2 weeks decreased from 100% to 0%.

Conclusion

In conclusion, the project shows that a simple intervention of introducing an agreement form prior to admission has reduced the delays in patients being discharged from PICU to prison. It has also improved the quality of care with additional information provided in the form. When we accepted an admission from prison outside our county, prior to admission, the out of area prison arranged for a local prison to sign the agreement to accept the patient on discharge from PICU. This has led to a closer working and effective communication between the PICU and the prison services.
Audit Review of GP Referrals to Perinatal Mental Health Team – Emphasis on Medication
Authors: Roy Shirley , Chima Paul
Published: August 2024

Aims

Audit had been completed with aim to review GP referrals to Perinatal Mental Health Services over a 6/12 month period.

Focus on medication, and information provided on referral proforma; prescribing via letters sent to Perinatal Mental Health Services.

The reason for undertaking this project is due to evidence of variance in practice in prescribing and documenting medications.

Methods

The project team retrospectively took 6 months of data each for the four localities and looked at the list from the weekly MDT during that period.

The team identified the GP referrals and then looked in detail at the referral in Carenotes System.

The data was collected on a proforma designed in Microsoft Word and was then sent to the Improvement Team for collation and analysis using Microsoft Excel.

Results

66% used the referral proforma and 20% used the referral letter.

The majority (106) of referrals were for a routine review/nonspecific.

The majority (78) of referrals were post-natal. 25% of referrals did not indicate whether the patient was post-natal or antenatal and hence no Expected Date of Delivery [MS(CPT1] entered.

10% of referrals medication had been stopped. 24% of patients were to review to start medication.

Results show that sertraline had been initiated the most frequently. 65% unspecified. In 26%, sertraline had been most frequently prescribed.

Where medication had been stopped, the majority of proformas (64%) were incomplete. 9% of patients had Selective Serotonin Reuptake Inhibitors suspended such as sertraline and citalopram.

Conclusion

In most cases, the reason for referral was unclear.

Medication was often stopped unnecessarily – for most medications, it was not indicated whether medication was started/stopped.

If patients were started on medication, sertraline and citalopram were either started or stopped most frequently.

We also found that some of the referrals were illegible.

We presented the findings within our perinatal mental health team meeting.

We found the following to be actioned, including discussions with local GP practices and/or local GP educational forums.

We hope to re audit following the above action.
A Study to Determine How Frequently Patients Are Admitted to Acute General Hospitals With Psychiatric Presentations and Whether Acute Medics Feel Confident in Managing Such Cases
Authors: Viney Ruby , Umla-Runge Katja , Vrigkou Eleni
Published: August 2024

Aims

Mental Health Trusts have seen significant funding cuts in recent years resulting in higher admissions to acute medical hospitals due to psychiatric disorders. Little information is available on the quantity of such presentations and no studies have explored how confident acute medical doctors feel in managing patients with mental health disorders.

Primary objective: To evaluate whether acute medical doctors feel confident in the common psychiatry topics required to manage patients presenting to medical hospitals with mental health disturbances.

Secondary objective: To determine how frequently patients with mental health disorders are admitted to medical beds, either primarily due to their psychiatric disorder or due to another medical problem.

Methods

Acute medical doctors working in Merseyside, UK completed a self-report survey in which they rated their confidence level in relation to common psychiatric topics. Admission data for 4 large hospitals in Merseyside were analysed to determine the proportion of all patients admitted to medicine in a 1-year period who had a mental health disorder. Results were further broken down into primary diagnosis by ICD–11 code to determine which mental health conditions presented most frequently to general medical hospitals.

Results

10 acute medical registrars and 33 acute medical consultants completed the survey. Most acute medical doctors felt at least partly confident in their psychiatry knowledge. However, around a quarter of doctors lacked confidence in managing psychotropic medications and performing risk assessments, with a third of acute doctors unsure how to access specialist psychiatric advice.

43.8% of all medical admissions had a mental health disorder. This was comprised of 3.1% who presented primarily due to a mental health illness, and 40.7% who had a mental health disorder but attended for a different reason. Substance misuse accounted for a significant proportion of these admissions.

Conclusion

Despite almost half of patients admitted to medical beds experiencing mental illness, many acute medical doctors lack confidence managing psychiatric ailments and half of the respondents felt their medical training has not prepared them sufficiently.

In addition, many doctors are unsure how to access specialist advice when needed. This leaves both doctors and patients at risk of harm and suggests a need for additional psychiatric training for acute medical doctors and improved access to support.
Developing and Testing a Patient Feedback Survey for Patients Referred to the Bromsgrove Memory Clinic for Memory Assessment
Authors: Yousef Mohammed , Wooster Richard , Weerasena Lathika
Published: August 2024

Aims

A patient feedback survey was designed based on Memory Service National Accreditation standards. The aim was to measure if the Bromsgrove Memory Clinic was meeting these standards and to show if a patient survey could be obtained in a group with cognitive issues.

Methods

The 18-question survey was offered to patients referred by General Practitioners for memory assessment. The survey was designed with cognitive difficulties in mind and could be filled out jointly by patients and their accompanying person. Answers were collected using Likert scale format. 23 completed surveys were collected. Large font and facial expression diagrams were used to aid the participants. Surveys were collected during outpatient/home visits by clinicians (doctors/nurses) trained in memory assessment.

Results

From the first question, 12/23 strongly agreed they received enough information prior to the appointment to feel well prepared about what to expect, 9 chose agreed and 2 gave neutral answers. The second question asked how long they waited to receive an appointment, 13 were seen within 6 weeks or less from point of referral, 7 waited between 6-weeks and 3-months. 16 participants strongly agreed to feeling happy with appointment date/time. 17 strongly agreed the clinic was easy to locate.

Next, 13/23 strongly agreed, 8 agreed, 1 was neutral that they felt confident the clinic would be able to meet their needs and 1 disagreed. Question seven asked “did staff explain the assessment process to you?” and 20/23 strongly agreed. Question eight asked if participants were given opportunity to ask questions, 22/23 strongly agreed. 21/23 strongly agreed enough time was given to discussing important information. 17/23 strongly agreed they knew they could stop the assessment at any point. 22/23 strongly agreed their privacy was respected.

Questions 12–14 looked at information given, and they could class it as “Not enough, Right amount, Too much or Not applicable”. 19/23 indicated “right amount” for information given about diagnosis. 21/23 felt information about investigations or tests was the right amount. Regarding information about medications, 20 selected “the right amount”.

18 strongly agreed the information, advice and support was helpful and sufficient. 19 strongly agreed they were treated with respect and dignity. 20 strongly agreed they wouldn't hesitate to recommend the service to others.

Conclusion

The results showed an overwhelmingly positive memory service experience in Bromsgrove and it is possible to meaningfully survey this patient group with some adjustments. The survey could be repeated to monitor standards over time.
Venous Thromboembolism (VTE) Risk Assessment in an Older Adult Mental Health Inpatient Ward
Authors: Ajewole Oluwatobi , Ogbeide-Ihama Margaret
Published: August 2024

Aims

This audit aimed to investigate how VTE risk assessments on one of our older adult inpatient units meet to the recommended standard by:

1.

Assessing the compliance of admissions to the trust VTE policy, which is based on the corresponding National Institute for Health and Care Excellence (NICE) guideline.

2.

Determining if VTE assessments were performed using appropriate clinical tools, as recommended in the policy, and correctly recorded in patient notes.

Methods

All admissions to the ward (n = 77) within the one year from 01.06.2021 to 31.05.2022 were retrospectively reviewed for VTE assessments based on the abovementioned standards. Data was extracted from progress notes and ward round entries for completion of the VTE assessment during admission, documentation of the assessment tool, documentation of the VTE prophylaxis prescription if indicated, and reassessment of risks during admission.

Results

This audit showed that only 3% of patients had a VTE assessment documented within the first 24 hours of admission. Overall, over a 10th of all patients never had an assessment, and of those who did, no one had the assessment tool used documented or uploaded on their clinical records. Also, of those who had a VTE assessment done, 5% were assessed to be at risk, and of these, only half had VTE prophylaxis prescribed.

Conclusion

This audit showed the ward is essentially not meeting the standard for VTE risk assessment, with recommendations to incorporate VTE assessment as part of the clerking proforma and the medication charts, similar to the usual practice on physical health wards.