bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessing wellbeing in foundation doctors during the COVID-19 pandemic
Authors: Handa Nikhita , Pramanik Sanjeev
Published: June 2021

Aims

The COVID-19 pandemic has had a drastic effect on the mental health of the global population that is likely to be felt for years to come. One group particuarly likely to be affected by this in the immediate future are the healthcare professionals working on the frontline of the NHS pandemic response. As members of a foundation cohort of these junior doctors we aimed to create a way to quanitfy the wellbeing of ourselves and our colleagues at this challeging time. We aimed to use a combination of numerous tools to monitor foundation doctors in Blackburn during this crisis. This would inform which measures would be best suited to be put in place to protect this cohort from early burnout and poor mental health in the future.

Method

We designed a survey of 25 questions which we invited our foundation colleagues to fill in anonymously during the first and second waves of the pandemic in response to times when foundation doctors were redeployed to aid the frontline. The survey has been based on the PHQ9, GAD7, Epworth Sleepiness scale, Physician wellbeing index, Medical students wellbeing index, Maslach burnout inventory BMA burnout questionnaire and the QOL scale.

Result

From a cohort of around 140 foundation doctors we had 46 participants in our trial of this tool; 46% had been redeployed and 54% not redeployed. Over 50% of survey respondents reported high stress, poor motivation and depersonalisation over the two weeks at the peak of the pandemic, key early signs of burnout. Lack of interest in their work, poor sleep and anhedonia were increased across both groups (redeployed and non redeployed). The interventions after the first wave data which repondents found beneficial included; financial reassurances during redeployments, protected non clinical areas for rest, a named individual senior staff member for wellbeing support.

Conclusion

Key issues the survey raised were fed back to foundation programme leads in monthly meetings. This allowed us with our foundation leads to make targeted changes in order to support foundation doctors at this time. Without the data from this tool which we tailored to the foundation experience we believe these rapidly worsening issues during the pandemic would not have been addressed so swiftly. We then resurveyed the foundation cohort to assess which of these interventions have been most widely used and appreciated.
A quality improvement project to improve handover in the integrated assessment liaison team
Authors: Hazan Jemma , Vallabhaneni Kirtana
Published: June 2021

Background

Efficient handovers are integral to patient care. Challenges to handover for liaison psychiatry included high patient and staff turnover and varied handover approaches across the multidisciplinary team (MDT).

Method

MDT focus groups and questionnaires explored change ideas. PDSA cycles were used to design a structured handover.

We aimed to:

Reduce handover time to 30 minutes.

Improve communication using the SBAR tool.

Implement a multidisciplinary teaching schedule in the time saved.

Daily measures:

Handover timing

Team Satisfaction (Individuals ranked handover as ‘good’, ‘average’, or ‘poor’)

Weekly measures:

Semi-qualitative questionnaires triangulated areas for improvement.

Emails, posters and team meetings provided team feedback regarding QI progress.

Result

A structured twice-daily handover format incorporating SBAR, allocated handover coordinators and documentation was created. Weekly MDT teaching sessions were developed.

Over 4 weeks, ‘good’ handover ratings increased from 22% to 65%; ‘poor’ ratings decreased from 25% to 8%. Mean handover time decreased from 37 minutes to 28.5.

The team viewed SBAR as a positive efficiency-promoting tool. MDT teaching improved team communication and confidence. Documentation is an area to improve.

Conclusion

Structured handover has promoted efficiency and effective information-sharing amongst the liaison psychiatry team.

Interdisciplinary teaching can promote inclusive team feeling and encourage confidence across the MDT.
The physical healthcare of patients in secure hospitals: setting standards for medical equipment
Authors: Hood Abigail , Andersson Johanna , Jones Charlotte , Gardiner Lisa
Published: June 2021

Aims

The increased morbidity and mortality relating to the poor physical health of patients with severe mental illness has repeatedly been an area identified as requiring improvement. Despite this, no national minimum standard has been published around the minimum level of physical health equipment that should be available within an inpatient psychiatric setting.

The aim of this project was to improve and standardise availability of physical health equipment across the five clinical areas within a medium secure inpatient forensic setting, thus enabling optimal and timely medical care and physical examination of patients to occur.

Method

This project used a combination of audit and quality improvement practices. An audit standard was created and current practice was established within the 5 clinical areas of a Medium Secure Forensic Unit. Improvements were made in a systematic and measured way and two audit cycles were completed.

Result

At baseline, the attainment of audit standard ranged from 14-76%. Clinical areas were sharing equipment and there was an inconsistency as to where and how equipment was being stored. Changes implemented included redistribution and reorganisation of equipment which increased attainment to between 48% - 86%. Following this further equipment was ordered and the equipment was separated into that which was required on a daily basis to conduct physical observations and more specialist specific examination equipment. Re-audit found attainment across the five clinical areas being between 90-100%.

Conclusion

Monitoring of physical health within psychiatric inpatient settings is a key area of patient care, and is frequently identified as requiring improvement. Without access to equipment to monitor and assess physical health, this becomes challenging and potentially poorly completed. By standardizing available equipment and furthermore through practical steps such as separating the equipment required on a daily basis and that used less frequently the retention of equipment improved. This enables delivery of high quality, timely and thorough monitoring and assessment of physical health to be achievable.
Improving cardiometabolic screening on an inpatient psychiatric ward: a quality improvement project
Authors: Howarth Harrison , Pass Jonathan , Ahmed Fahel , Wiethoff Sarah
Published: June 2021

Aims

Primary aim: To increase the proportion of patients receiving a full cardiometabolic screen whilst on the ward to 75%.

Secondary aims: To improve communication with GPs regarding cardiometabolic health, to improve the rates of intervention when abnormalities are found to 75%.

Background

People with serious mental illness are known to have significantly increased risk of cardiometabolic syndrome than the general population. Estimates suggest there would be up to 12,000 fewer deaths from cardiovascular disease if people with serious mental illness had the same outcomes as the general population. People with serious mental illness die on average 20 years earlier than the general population due to preventable physical health problems.

Whilst on the ward, we have an excellent opportunity to screen and treat patients with cardiometabolic risk factors, yet screens are often incomplete, not acted upon, or simply not carried out.

Method

Using the Plan-Do-Study-Act (PDSA) methodology, we trialed interventions to improve the cardiometabolic screening process on out 16 bed inpatient ward. Across 8 cycles, we set up a protocol to ensure all new patients received a full cardiometabolic screen during their admission reviews, engaged nursing staff with the process and managed inconsistencies with blood transportation and delivery. We also started using British Heart Foundation information leaflets, and treating patients in accordance with the Lester Tool: Positive Cardiometabolic Health Resource. We made design changes to the discharge summary template allowing for clear communication with GPs on discharge.

Result

At the end of 8 cycles, we had achieved 100% compliance with the full cardiometabolic screen (as defined by the Lester Tool) from a baseline of just 25%. We also improved intervention with identified abnormalities from a baseline of 0% to 100%.

Conclusion

Improvements in cardiometabolic screening and treatment were possible using the PDSA methodology. Given the success of this quality improvement project, we plan to introduce our methodology onto other wards in the trust.
Improving attitudes towards the COVID-19 vaccine in forensic mental health workers: a quality improvement project
Authors: Howarth Harrison , Stevens Toby , Gostick Benjamin , Stock Lisanne , Stone David
Published: June 2021

Aims

The primary aim of the project was to improve attitudes towards the COVID-19 vaccine in forensic mental health staff at a large regional tertiary forensic psychiatry unit. The main variable examined was attitudes towards safety of the vaccine. Secondary aims included decreasing misinformation about the vaccine and improving vaccine uptake.

Method

Paper questionnaires were distributed to willing staff members across 6 forensic inpatient wards within the North London Forensic Service. Participants included a range of allied health professionals including nurses, health care assistants, ward managers, occupational therapists, assistant therapists and administrative staff. Questionnaires used a mixture of Likert scale for agreement/disagreement with statements and yes/no questions.

Plan-Do-Study-Act (PDSA) methodology was utilised in implementing changes, and repeat questionnaires used to measure changes in attitude and behaviour. Change ideas implemented included the creation of ‘mythbusters’ posters which target vaccine misinformation, the creation and distribution of posters of staff members who had already taken their vaccine, the creation of vaccine champions to aid engagement in conversation about the vaccine, vaccine information packs being distributed to all wards and the opportunity for staff to ‘drop-in’ to clinics for information about the vaccine.

Result

Vaccine uptake improved from 7% before interventions to 69% after interventions.

The proportion of people very unlikely or unlikely to get the vaccine reduced from 25% to just 9%. The proportion of those feeling neutral reduced from 32% to 6%. The proportion of those either likely or very likely to get the vaccine increased from 34% to 85%.

Before interventions only 20% felt that the vaccine was either safe or very safe. This improved to 63% after interventions

Before interventions, only 27% of respondents felt they had received enough information by the trust to make an informed decision. After interventions, 80% said they had received enough information.

The project was successful in reducing misinformation in every domain. Particularly reassuring was the reduction to zero of some of the most harmful misinformation claims, such as the presence of a tracking chip in the vaccine and the belief that COVID does not exist.

71% of respondents indicated the interventions we set out changed their view on the COVID-19 vaccine.

Conclusion

The changes implemented lead to clear improvements in all domains measured, suggesting targeted information is an effective strategy in improving uptake and attitudes around the vaccination program.
Assessement of a structured technological support intervention on uptake of video consultations
Authors: Kotwal Tejas , Thomas Kerushan , King Carlos Escudero , Gupta Avirup
Published: June 2021

Aims

The coronavirus pandemic has led to an increased reliance on remote patient-clinician interactions, mainly the use of telephone and video consultations. Video consultations are key in psychiatric care, as telephone appointments do not sufficiently allow clinicians to accurately ascertain a patient's mental status and perform a risk assessment. The aim of our quality improvement project was to increase the uptake of video consultations within a community mental health team, focusing on substituting telephone consultations for video.

Method

We accessed Electronic Patient Records to retrospectively quantify the method of contact for 130 consultations delivered over a 4-week period. After collecting baseline data, we conducted focused interviews with 10 care providers, identifying the specific clinician and patient barriers to video uptake that informed our intervention design.

Our intervention consisted of two 4-week Plan, Do, Study, Act (PDSA) cycles.

PDSA 1 involved delivering a focused PowerPoint presentation to the care team, highlighting the benefits of video consultation technology and encouraging clinicians to use it as their primary method of remote communication with patients. Additionally, we conducted qualitative interviews with members of the team to highlight the successes and challenges thus far.

PDSA 2 involved creating a video consultation instructional PDF which highlighted how to operate the technological aspects of both Microsoft Teams and WhatsApp Video Call. This included: how to set-up video calls, accept invitations, and overcome common troubleshooting issues.

The proportion of remote consultations was quantified retrospectively to compare trends in video consultation uptake from baseline to the conclusion of PDSA 2.

Result

Overall, we saw a 15% increase in video consultations with respect to baseline. The greatest change was attributable to PDSA cycle 1, which incurred an 8% increase in video consultation uptake, from 13.85% to 21.9%. PDSA cycle 2 further increased video consultation uptake by 6.97%, from 21.9% to 28.87%. Specifically focusing on remote consultations, the proportion conducted with video rather than telephone increased by 17.3%. Interviewed clinicians reported limited financial access, technological fluency, and issues with patient privacy as the most important barriers to the uptake of video consultations.

Conclusion

Our project successfully increased the proportion of consultations conducted by video. This was achieved by targeting interventions to address both patient and clinician barriers to video consultation uptake. Moreover, we understand that motivating and mobilising the care team was a key factor. Possible future work includes improving the sustainability of the interventions and assessing their efficacy in other care teams.
Innovating in CMHT's: mental health wellbeing group visits
Authors: Parkinson Samuel Mammolotti , Laher Ismail , Johnson Shola
Published: June 2021

Aims

‘Group consultations/visits’ are described as providing shared medical appointments delivering a range of care options and education by clinicians while providing elements of patient choice, empowerment and peer support.

This innovative and cost effective model of care delivery was first conceived in the US and has been gaining a strong foothold in the UK since 2016, mainly limited to GP settings.

The project goal was to attempt to transfer the model into a mental health setting by developing and delivering a novel intervention, to improve health and wellbeing options in a CMHT population.

Method

A four session course was developed focussing on stress, sleep and nutrition. These chosen topics covered common significant challenges to patient health in psychiatry. Sessions were delivered to proactively address these important health related issues in a group visit setting.

Baseline and post intervention feedback including telephone interviews were conducted to evaluate the effectiveness of the intervention.

Result

The qualitative data and the positive feedback obtained from participants indicate the intervention was highly valued and deemed effective in promoting positive health and lifestyle changes. Participants valued the educational and co-production aspects as well as the social and peer support elements of the groups. They appreciated the level of access they had with the clinicians involved, to explore their health and wellbeing in more detail without being limited by the usual 30 minute clinic follow-up sessions.

The clinicians involved found the sessions rewarding and more engaging than most of routine 1:1 clinic sessions as they were able to spend quality time exploring important issues and not just educate the patients but also be educated by their questions and feedback about their lived experiences.

Conclusion

The project aim was met and we believe this intervention can be successfully incorporated into the identified service provision gap within the CMH T model. There is potential to build on and embed this innovation with roll-out to a wide range of service users in different settings.

In line with existing literature from GP settings, the consensus was that the amalgamated group visits/consultations model could be successfully modified to meet the needs of patients in the Mental Health arena who have a range of physical health and lifestyle concerns.

We planned to obtain more information about improvement in patient self-management but this was affected by the pandemic. However, we believe it is a cost effective and helpful innovation which warrants further promotion and evaluation.
QI project: Improving the discharge advice from functional old age psychiatry wards for the monitoring of lithium and antipsychotic medication in the community
Authors: Mathews Amy , Needham Nicole
Published: June 2021

Aims

NICE guidelines and Maudsley prescribing guidelines both stipulate that patients over the age of 65 prescribed lithium or antipsychotic medication should have their bloods and physical parameters monitored regularly. There is currently no provision from the community mental health teams in Edinburgh to provide this monitoring, which falls to the patients GP. Following an initial data collection, it was found that there was no monitoring advice being provided on immediate discharge letters (IDLs) for patients discharged from two functional old age psychiatry inpatient wards at the Royal Edinburgh Hospital. This patient group often have comorbid medical conditions and therefore monitoring of their psychotropic medication is especially important. The aim of the QI project was for 100% of patients discharged from thesewards on lithium or antipsychotic medication to have appropriate advice documented on their immediate discharge letter (IDL) with regards to medication monitoring.

Method

Data were collected monthly by reviewing the notes of all discharged patients to determine the frequency at which medication monitoring advice was documented on IDLs from the two wards. A proposed new template for discharge letters which included advice on medication monitoring was discussed and agreed with the old age psychiatry team in Edinburgh. This was disseminated to the appropriate medical staff members and was included in induction packs for junior doctors. Following this a new “canned text” template was implemented to automatically populate the discharge letter with advice depending on whether they were antipsychotics/lithium/neither.

Result

IDLs for 91 patients discharged between May 2020 and February 2021 were reviewed. Baseline data showed that 0% of patients (n = 15) had appropriate monitoring advice documented on their IDL. Following initial introduction of monitoring advice to the induction pack for junior doctors, the mean frequency of completed advice on IDLs was 50.9% across 6 months. Following implementation of the canned text, the frequency of completed advice on discharge letters for February 2021 was 100% (n = 7).

Conclusion

This QI project has been successful in improving the rate of appropriate advice for antipsychotic and lithium monitoring being provided on immediate discharge letters. It is hoped that this will help reduce adverse effects associated with antipsychotics and lithium in older psychiatric patients. Further work could be done on determining the frequency that the advised monitoring is being carried out.
No time to die: improving response to emergency scenarios in the 136 suite
Authors: McKnight Rebecca , Combs Nicola
Published: June 2021

Aims

Improve confidence and experience of trainees performing preliminary medical reviews in the 136 suite.

Improve patient safety by increasing trainee's confidence in responding to emergency scenarios, including crash calls of patients in the 136 Suite.

To orientate trainees to the 136 suite and the emergency crash equipment, in order to better prepare trainees for emergency scenarios.

Background

The authors encountered a crash call in the 136 suite, in which a patient had concealed an opiate overdose. The patient was successfully resuscitated but concerns were raised by the junior doctors that they were unaware of what or where the emergency equipment was kept in the 136 suite. Following a debrief session, we established that junior doctors needed more orientation to the 136 suite and more teaching on performing preliminary medical reviews and responding to emergency situations.

Method

Trainees, were asked to complete an anonymous, qualitative questionnaire with 16 questions asking about their confidence to respond to emergency situations in the 136 suite.

Based on the feedback, an interactive teaching session was delivered two weeks later. The session covered a structured approach on how to perform a preliminary medical review and scenario-based teaching on emergency situations. Trainees were then shown the 136 facility, introduced to the lead nurse and shown the emergency crash equipment and drugs stores.

Trainees were then re-consulted, with the same questionnaire to ascertain whether confidence and knowledge had increased.

Result

Following initial induction, only 25% of trainees felt confident performing 136 Suite preliminary reviews. 50% of trainees had encountered crash calls at Park House Hospital, however 93% did not receive orientation of emergency equipment locations. Only 44% of trainees felt confident managing a crash call; reasons included feeling ‘rusty, little recent experience, not being familiar with the equipment’.

Post-interactive teaching session, 89% now felt confident performing 136 Suite preliminary reviews. 100% knew where the crash equipment was located in the 136 Suite.

Conclusion

Trainees should receive a robust induction on how to perform 136 preliminary reviews and have orientation of the facility, including crash equipment during induction

Trainees require refresher training in addition to their basic life support training on common emergency scenarios encountered in psychiatric hospitals.

A resuscitation skills training session is being organised for new trainees and hopefully incorporated into each forthcoming rotation.
Prevalence of pulmonary disease in alcohol and poly substance abuse
Authors: Sheikh Ghazanfar
Published: June 2021

Aims

The aim of this study is to identify the prevalence of pulmonary disease or progression of symptoms which can lead to respiratory disease in substance misuse. Identify risk: prescribe a safer substitute treatment (Methadone vs Buprenorphine). Identify combination of different drugs, causing toxicity and damage to lungs.

Background

Smoking and illicit substance misuse is recognized as a cause of pulmonary disease

Method

The study was conducted in 2015 at outpatient addictions service (CAPS/CDC 69 Warwick Road London SW5 9HB). All 50-participants gave consent and data were collected including demographic details, history of substance abuse, route of administration, medical history, Peak Expiratory Flow rate (PEFR). A questionnaire was designed to assess the severity of shortness of breath (SOB), with or without exertion to ascertain the extent of the disease.

Conclusion

14 males and 3 females achieved 31 to 48.9 % of predicted PEFR. 13 males and 7 females achieved 51.1 to 69.6% of predicted PEFR. 7 males and 2 females achieved 70.8 to 91.1% of predicted PEFR. 2 males and 2 females achieved 100 to 114.3% of predicted PEFR. From the questionnaire on SOB with or without exertion, 8 males and 2 females reported moderate to severe shortness of breath on minimum exertion. 33 males and 11 females reported variable degree of SOB. 4 males and 2 females did not report SOB on reasonable exertion. 23 males and 10 females reported variable degree of SOB at rest, 14 males and 3 females reported no SOB at rest. 34 participants were receiving OST with methadone, 16 were on Buprenorphine. 6 patient treatments were switched to Buprenorphine due to Exacerbated COPD. 47 patients reported using Tobacco from harmful to dependent use. 44 patients reported harmful to dependent use of crack cocaine. 34 patients fulfilled the criteria of harmful use of cannabinoids. 33 patients were diagnosed with harmful to dependent use of alcohol. 10 patients reported heavy use of solvents. 2 patients reported harmful use of Party drugs. Many patients reported a history of recurrent chest infections 3-6 times a year, Asthma, COPD, Emphysema, Pneumonia and 2 were treated for Tuberculosis. 1/3 patients have a diagnosis of hypertension and IHD, liver disease and portal hypertension
Improving experiences of transgender patients in inpatient services through a ward based staff training program
Authors: Stanton Noah , Lyons Phoebe , Barsby Dr Amy
Published: June 2021

Aims

The aim was to improve the experience of transgender patients in a general adult inpatient setting, through delivering practical 'bitesize' ward-based staff training. This training was to improve awareness of issues faced by transgender patients, knowledge around gender dysphoria, and increase confidence in discussing these issues appropiately with patients.

Method

Staff from a range of disciplines attended sessions held on the ward in small groups; these bite size sessions were delivered in under 20 minutes making them easy to fit around clinical commitments.

Result

All attendants rated increased confidence in their skills and ability to support transgender patients.

Conclusion

Improved staff training specifically focussing on transgender patients can contribute towards improved care for this patient group; this should form part of a wider strategy including clear operational policy and supportive environments.
Patient experience survey for community drug and alcohol service users in hospitals
Authors: Yahya Nurul , Watts Derrett
Published: June 2021

Aims

To explore and monitor experience of hospital care provided to patients of Stoke Community Drug and Alcohol Services (CDAS) and Edward Myers Unit (EMU; detox inpatient based unit).

Method

The sample was collected from patients who attended face-face clinics at CDAS and patients living in Stoke-On-Trent who were admitted to the Edward Myers Unit. The survey pertains to four locations, which include Royal Stoke Hospital, A + E, Harplands Hospital (Mental Health Unit), and EMU.

We collected data of over two months from September–November 2020. The cohort of patients from CDAS included new presentations or restart Opioid Substitution Treatment (OST) clinics and people known to the alcohol team at CDAS.

We delivered a survey pertaining to experience of hospital care in the last 12 months. This includes treatment at A&E Royal Stoke Hopital, any of the wards at Royal Stoke Hospital, Harplands Hospital and Edward Myers Unit.

Result

The uptake for the survey was 53/83 (64%) at CDAS clinic and 23/44 (52%) at Edward Myers Unit. The sample comprised more men than women. The majority were aged 31–40 years. Most common substances used were alcohol.

Majority of patients has been admitted to the general hospital, either in the ward or seen at A + E. Most people were very satisfied with their treatment in all four locations. This include withdrawal symptoms, pain, mental health, and discharge plan. There were diverse reasons given of the satisfactory scores. EMU seems to have the best overall scores comparatively to the other units, with Harplands Hospital seems to be doing worse.

The free text comments revealed that the staffs' courtesy, respect, careful listening and easy access of care was particularly the strongest driver of overall patient satisfaction. Patients look for supportive relationships, to be involved in treatment decisions, effective approaches to care, easy treatment access and a non-judgemental treatment environment. In some aspects, patients were dissatisfied with pain management, longer waiting times and inability to treat them as equal to non drug/alcohol users.

Conclusion

On objective measures, patients were satisfied with treatment received, however, some has point out their dissatisfaction, particularly in the mental health setting. This project calls for greater attention and support for addiction service provision in emergency departments and hospital wards. Although these findings do not represent the views of all patients in SUD treatment, findings give insight into the ways treatment providers, service managers and policy makers might enhance the patient experience to improve patient treatment prognosis and outcomes
The impact of COVID-19 restrictions on the presentation of self-injury: experience at a tertiary centre
Authors: Adams Tobias , Arnaout A , Bickerton S , Li L , Reid AWN , Leow SH
Published: June 2021

Aims

The national lockdowns due to the COVID-19 pandemic, have had a considerable effect on mental health, with reduced access to social interaction through work and leisure activities, and increased barriers to community mental health services.

This study aims to evaluate how the presentation of patients with self-injury has changed during the first national U.K. lockdown, at a Plastic Surgery Tertiary Referral Centre in the East of England.

Method

Retrospectively recorded data from 23 March 2020 to 31 December 2020, spanning the duration of the first two lockdowns in the UK, were compared to the same period in 2019. The demographics of patients, along with the nature, severity and outcomes of the self-injury were recorded and compared.

Result

The number of patients referred for self-injury reduced by 22.9% during lockdown (2020: N = 42/109, 2019: 67/109)

The most common attendance route was via ambulance during lockdown (2020:40.5% 2019: 31.3%) whilst the most common attendance route being via the front door in 2019 (2019: 35.8%, 2020: 26.2%)

The number of new presentations with no prior history of self-injury was higher in lockdown 38.1%) compared to 2019 26.9%.

The lockdown cohort had a smaller proportion of patients presenting with complications (2020: 9.5% vs 2019: 17.9%), less readmitted (2020: 11.9% vs 2019: 23.9%). Similar re-attendance rate (2020: 40.3% vs 2019: 38.1%) and re-intervention (2020: 13.4% vs 2019: 14.3%).

A greater proportion in 2020 met the threshold for inpatient psychiatry input (2020: 52.4% vs 2019: 41.8%).

During the lockdown, a higher percentage of flexor tendon injuries involved multiple tendons (60.0% vs 52.2%). A higher percentage of extensor tendon injuries (14.3% vs 7.4%), and a greater proportion of these also involved multiple tendons (66.7% vs 40.0%). More self-injuries were complicated by fractures (7.1% vs 4.5%) and more required soft tissue reconstruction (11.9% vs 3.0%).

Conclusion

Despite fewer patients presenting with self-injury during the 2020 lockdown, the injuries were more severe. Many of which had multiple structural injuries, and some with life-changing injuries, this is in line with our clinical observations.

During lockdown there was a higher proportion of first-time presentations without a history of self-injury and an increased need for inpatient psychiatry input. This may reflect the impact on mental health as a result of restricted social interactions.

These findings demonstrate the impact of lockdown on mental-health and may help inform medical services of potential changes in the presentations in future national social restrictions.
Mental wellbeing in doctors: the measure matters! development of a core outcome set for measuring wellbeing in doctors
Authors: Baldwin David , O'Neill Aimee , Sinclair Julia , Simons Gemma
Published: June 2021

Aims

To achieve a consensus Core Outcome Set for measuring mental wellbeing in doctors.

Hypothesis: A minimum set of valid, reliable and practical wellbeing measures is needed for doctors.

Background

The importance of doctors’ mental wellbeing to everyone using Health Care is highlighted by the levels of burnout reported in doctors around the world. In 2019 a number of UK policy documents made recommendations for the wellbeing of doctors, but how those wellbeing interventions are evaluated needs to be defined. Core Outcome Sets are increasingly being used in medicine to prevent waste in research, by recommending the inclusion of a minimum set of valid, reliable and practical measures. An operational definition and Core Outcome Set for wellbeing in doctors is needed to meaningfully progress the work in this field.

Method

The Centre for Workforce Wellbeing (C4WW), a collaboration between the University of Southampton and Health Education England, was created to support research into the nature, assessment and enhancement of wellbeing in physicians. A Systematic Review of wellbeing measures used in doctors and the robustness of those measures, along with surveys of 250 UK doctors of all grades and specialities and patient and public involvement is informing what a core outcome set could be. A Delphi Study among 37 UK experts has been initiated to establish the consensus Core Outcome Set.

Result

Publication of research into doctors’ wellbeing is growing internationally. In the UK alone data are being captured by multiple national organisations including: the Care Quality Commission, General Medical Council, British Medical Association and the Royal Colleges. Health and Social Care Organisations are, therefore, keen to “do something” and are spending money on wellbeing interventions with little, or no, evidence base and a lack of appropriate, comparable evaluation. A Core Outcome Set for measuring wellbeing in doctors is ethically required to reduce waste, to replace burnout measures and to refine wellbeing interventions.

Conclusion

Wellbeing measures that actually measure wellbeing, and not burnout, which are validated, reliable and practical, are needed to inform local organisational, national government and international research policy. An absence of burnout does not equate to wellbeing. The focus of measurement needs to shift to capture in what contexts we thrive, not just survive. If everyone used the same Core Outcome Set to measure mental wellbeing, direct comparisons could be made, and money invested, in creating infrastructure, processes and cultures that really work.

Health Education England funded PhD.
Methylation of the glucocorticoid receptor gene NR3C1: a summary for clinicians working with children and families
Authors: Brown Victoria
Published: June 2021

Aims

It has been shown that the glucocorticoid receptor NR3C1 gene can be methylated (“switched off”) in response to early adversity. Methylation has also been linked to physiological changes in the body's response to stress by changing the sensitivity of the hypothalamic-pituitary-adrenal (HPA) axis. In adults, associations have been made between NR3C1 methylation and borderline personality disorder, depression and post-traumatic stress disorder. Environmental and social co-variates increase with lifespan so establishing cause and effect is difficult. Studies in children, then, may illuminate patterns to inform current hypotheses.

This paper reviews the literature on children and adolescents linking glucocorticoid gene receptor NR3C1 to the psychopathology of mental illness. Findings are presented in an accessible manner to engage people less familiar with genetics and to inform frontline clinicians of this quickly growing area of research.

Method

MEDLINE and PsychINFO were searched for relevant peer-reviewed original research using the following keywords and associated mesh terms: NRC31, glucocorticoid receptor gene, methylation, epigenetics, child, adolescent, trauma, psychopathology, gene expression.

Result

14 studies were identified involving 5475 young people. Degree of NR3C1 methylation was associated with severity of early life adversity. Methylation was linked with psychopathology including borderline personality disorder, internalising symptoms and externalising symptoms with sex differences. The most consistent association was with depression. Methylation seems to modulate the interaction between environment and genetics with the suggestion that the effect may be protective in some cases. However, longitudinal genetic sampling was only conducted in one study.

Conclusion

Heterogeneity of studies in the epigenetics field are discussed but should not detract from future possibilities. The hope is to identify therapeutic targets or monitor response to treatment as we work to better understand the biology of developmental psychology, mental illness and resilience. There is a growing understanding that epigenetic modifications likely change over time and clinical significance is most likely dictated by changes at multiple gene locations. Thus future research may need to move away from single gene research typically employed in favour of longitudinal whole genome studies in larger population studies.

It is time that clinicians integrate the concepts of “epigenetic adaptation to environmental stress” with “nature vs. nurture” in their psychoeducation with families. To understand that one's problems might be the symptom of environmental mismatch, and potentially reversible too, can bring validation and hope to families.
Case series suggesting an association between sertraline and urinary side effects in a Sheffield child and adolescent mental health services (CAMHS) population
Authors: Chaudhry Sidra , Alex Nisha
Published: June 2021

Aims

To suggest a link between sertraline and urinary side effects in a Sheffield Child and Adolescent Mental Health Service population.

Background

Evidence suggests that Serotonin has an important role in bladder control through central and peripheral neurological pathways. Increased serotonergic activity leads to parasympathetic inhibition, which results in urine retention. It is through this mechanism of action and their effect on pre-synaptic serotonin 1A and peripheral 5-HT3 receptors that SSRIs were observed to have anti-enuretic effect. At low 5-HT concentrations, micturition is inhibited whereas at high levels, an excitatory effect is achieved. This may suggest a dose-dependent relationship between Sertraline and urinary side effects.

Method

Inclusion criteria:

Under 18 years of age

On Sertraline

Reported urinary side effects

Exclusion criteria:

Above 18 years

Not on Sertraline

Associated urinary problems

Did not report urinary side effects

Clinical records of eligible patients were accessed to gauge temporal relationship between initiation of sertraline and reported urinary side effects.

Result

Three cases were identified in the authors’ clinical practice at Sheffield CAMHS that were suggestive of a link between sertraline and urinary side effects.

Conclusion

It's important for clinicians to bear in mind the genitourinary side effects of SSRIs, which may be debilitating for patients in the CAMHS population. It's equally important for us as clinicians to educate young people and their parents about these potential side effects and how they can be managed. It has also been observed that higher doses of Sertraline have shown a possible link between onset of urinary side effects.
Impact of psychiatric comorbidities on emergency surgical patients’ outcomes
Authors: Chen Hongying , Devine Michael , Khan Waqar , Khan Iqbal Z , Waldron Ronan P , Barry Michael Kevin
Published: June 2021

Aims

Psychiatric disorders are increasingly prevalent and present as a comorbidity in many hospitalized patients. Studies have demonstrated that the presence of comorbid psychiatric conditions (CPC) is associated with worsened inpatient outcomes. Emergency surgical admissions and the impact of CPC on their outcomes has not been studied in Ireland to date. This study aims to provide a comprehensive analyses of the relationship between a wide range of psychiatric comorbidities and surgical presentations.

Method

The Hospital In-Patient Enquiry (HIPE) and prospectively maintained electronic patient records were used to identify all surgical emergency admissions between 31st August 2019 and 1st September 2020 to Mayo University Hospital, Ireland. Patient demographics, comorbidities, primary diagnoses, length of stay (LoS), discharge destination, and surgical interventions were recorded. Subgroup analyses were performed examining LoS variation in the type of surgical presentation. Physical comorbidities were scored using the Charlson Comorbidity Index (CCI). Statistical calculations were performed using SPSS.

Result

A total of 995 admissions were recorded. The presence of CPC increased the overall mean LoS by 1.9 days (p = .002). This trend was observed in both operative and conservative management. Significant increase in LoS was noted in patients with a comorbid depression (2.4 days, p = .003), dementia (2.8 days, p = .019), and intellectual disability (6.7 days, p = .007). Subgroup analysis revealed greater LoS in patients with CPC diagnosed with non-specific abdominal pain (1.4 days, p = .019), skin and soft tissue infections (2.5 days, p = .040), bowel obstruction (4.3 days, p = .047), and medical disorders (18.6 days, p = .010). The odds of nursing home or convalescence as a discharge destination was 2.44 (95% CI: 1.37–4.35, p = 0.002) in patients with CPC and the odds of self-discharge against medical advice in this population was 4.89 (95% CI: 1.43–16.70, p = 0.005). No significant difference was observed in mortality and readmission rates.

Conclusion

Psychiatric comorbidities significantly impact length of hospital stay and influence discharge planning in surgical inpatients. Greater vigilance is required in providing care for patients with psychiatric comorbidities, particularly those with depression, dementia and intellectual disability. Better optimisation of facilities and a more personalised approach to patients with CPC are required to improve inpatient outcomes and resource allocation.
Investigating the association between depressive disorders and cerebral haemodynamics
Authors: Chithiramohan Tamara , Parekh Jvalant , Beishon Lucy , Kronenberg Golo , Haunton Victoria , Minhas Jatinder , Robinson Thompson , Panerai Ronney
Published: June 2021

Aims

Alterations in cerebral blood flow (CBF) may contribute to the development of depression, and serve as a novel biomarker. The aim of this review is to summarise and synthesise the available evidence on alterations in cerebral haemodynamics in depressive disorders relative to healthy control populations.

Method

MEDLINE (1946- present), EMBASE (1947– present), Web of Science (1970–present), PsycINFO (1984–present), CINAHL (1976–present) and CENTRAL were searched using a predefined search strategy. Studies which compared the cerebral haemodynamics of adult patients (>18 years old) with depressive disorders against healthy controls (HC), by any imagining modality, were included. Studies with varying severity and chronicity of depressive disorder were included. A meta-analysis was conducted in four groups: 1) CBF (ml/min/100g) 2) Cerebral blood flow velocity (CBFv) (cm/s) 3) Combined CBF and CBFv 4) Ratio of uptake of radiotracer. A random effects model was used and heterogeneity and publication bias were assessed. Data are presented as mean difference (MD) or standardised mean difference (SMD) and 95% confidence interval (95% CI). A narrative synthesis of the remaining studies was performed.

Result

87 studies met the inclusion criteria. CBF (ml/min/100g) was significantly reduced in patients with depression compared to HC (15 studies, 538 patients, 416 HC, MD: −2.24 (95% CI −4.12, −0.36), p = 0.02, I2 = 64%). There were no statistically significant differences between patients and controls in the other three outcomes. CBFv (cm/s): 6 studies, 305 patients, 198 HC, MD: −1.23 (95% CI −6.10, 3.64, p = 0.62, I2 = 65%. Combined CBF and CBFv: 20 studies, 804 patients, 573 HC, SMD: −0.16 (95% CI −0.32, 0.01), p = 0.06 I2 = 51%. Ratio of uptake of radiotracer: 3 studies, 60 patients, 53 HC, MD: −0.11 (95% CI −0.11, 0.11), p = 1.00, I2 = 0%). The narrative synthesis revealed varying results, with many studies identifying a decrease in CBF in depressed patients compared to controls, but other studies identifying an increase, or mixed results. Multiple regions of impairment were identified, including the anterior cingulate cortex and prefrontal cortex.

Conclusion

There was a statistically significant reduction in CBF in depressed patients compared to controls. The narrative synthesis revealed varying results, however specific regions of interest have been identified. Further research is needed to explore the effect of antidepressant medication, utilising different imaging modalities, and at different levels of disease severity.
Length of stay in a home treatment team
Authors: Firdosi Mudasir , Gill Nicole , Hubbeling Dieneke
Published: June 2021

Aims

The aims were to establish the mean length of stay (LOS) in the Wandsworth home treatment team (HTT), and to identify which variables were associated with LOS. We hypothesised that the variables that are routinely collected via the electronic record system were associated with the LOS.

Background

Psychiatric HTT's have been set up in all NHS trusts in England. These 24-hour community health services exist to assess and manage patients during a crisis, who would otherwise be admitted to an acute psychiatric ward. HTT's also allow inpatients to be discharged sooner, as their treatment can continue in the community. Currently, research into predictors of LOS in HTT's is limited.

Researchers have been exploring whether LOS in psychiatric inpatients can be predicted, but no consistent pattern has emerged. This suggests that LOS is mainly determined by the local service organisation, and the individual circumstances of the patients.

Method

Routinely collected data about all patients under the care of the Wandsworth HTT during the financial year 2018/2019 were used. Only the first admission per individual was considered. Admissions lasting less than 2 days, or more than 42 days were excluded. This is on the basis that those with a very short LOS had not consented to being treated at home, and those with a very long LOS were due to administrative errors. This resulted in a total of 664 admissions being included in the study. The available data for analysis included age, gender, diagnosis, HoNOS cluster, ethnicity, nationality, religion, marital status, referral source, employment status, accommodation status, and accommodation type. The data were analysed in SPSS version 25 using ANOVA, independent samples T-test, and Pearson's correlation.

Result

The mean LOS in the Wandsworth HTT was 14.28 days (standard deviation: 8.57). LOS was positively skewed, with a median LOS of 13 days, but 46.5% of admissions had a LOS longer than this. None of the variables (age, gender, diagnosis, HoNOS cluster, ethnicity, nationality, religion, marital status, referral source, employment status, accommodation status, and accommodation type) had a significant association with LOS, but there was a trend for referral source and accommodation type.

Conclusion

The results from this study suggest that LOS cannot be consistently predicted in the Wandsworth HTT from the routinely collected variables, and that it is the specific circumstances of individual patients that determine their LOS.

There was no external funding for this study.