bluuebunny/crossref_metadata_2025 huggingface dataset:
“It's All in the Head” Well! Not Always: Mental Health Patients Are Not Immune to Physical Pain
Authors: Javed Asma , Sharma Rajasee
Published: July 2023

Aims

Emotionally unstable personality disorder (EUPD) patients are known to frequently present to acute hospitals with pain symptoms. Multiple pain syndromes like fibromyalgia, chronic fatigue syndrome etc. are also commonly diagnosed in this group of population. It can be difficult to differentiate psychosomatic pain from physical pain during these hospital presentations. Failure to exclude physical causes of pain can lead to inadequate pain relief and missed serious diagnosis.

Methods

We describe a 29-year-old lady known to have Type 1 Diabetes, chronic pancreatitis and past history of several overdoses. She was being supported by Home Treatment Team (HTT) before coming to the hospital. She presented to the Emergency Department (ED) after ingesting 40 tablets of Pregabalin. She was referred to mental health liaison service for ongoing suicidal thoughts. On assessment, she admitted taking multiple overdoses to relieve her of severe abdominal pain. Her pain symptoms had been attributed as attention seeking behaviour. She disclosed feelings of rejection and abandonment by hospital staff. Liaison team negotiated with emergency department staff to complete a physical health examination that revealed tenderness and guarding in the abdomen. She was booked for elective cholecystectomy after surgical review. However, she had to be admitted from ED for laparoscopic cholecystectomy because of worsening of pain and vomiting. She was referred to Pain Management Team after surgery. The team was cautious in providing her with pain medications considering past history of overdoses. She was unable to tolerate pain and voiced thoughts of overdose. We liaised with Pain Management Team to optimise her analgesics and arranged daily supervision of pain medications with HTT

Results

Our patient's physical symptoms of acute cholecystitis and frequent overdoses with pain medications were attributed to her personality disorder that resulted in dismissal of her real pain that “Its is all in the head”. This led to persistent pain affecting her mental health.

Conclusion

Patients diagnosed with EUPD should be carefully assessed to exclude organic causes of pain before attributing their symptoms to mental health disorders. A thorough assessment and treatment of physical symptoms can improve their mental health as well as reduce attendance in health facilities.
How Helpful Is the Label of ‘Emerging Personality Disorder’?: A Service Evaluation Exploring CAMHS Clinicians’ Experiences of Young People Being Labelled With a Diagnosis of ‘Emerging Personality Disorder’
Authors: Drozdova Zuzana , Bentham Charlotte , Collin Thea , Youakim Sherif
Published: July 2023

Aims

Use of the ‘emerging personality disorder’ label in young people has been a controversial topic amongst CAMHS clinicians. Following discussions in a CAMHS focus group, we formally explored the views and experience of CAMHS clinicians across teams in Humber Teaching NHS Foundation Trust with the view to gain more understanding of the different stances of the clinicians, the reasons behind them and to inform future care pathways.

Methods

The service evaluation was approved by Humber NHS FT CAMHS Clinical Network and Clinical Audit Team and conducted across the Humber CAMHS service, made up of multi-disciplinary professionals including medical, psychological, therapy, nursing and social work clinicians. Data were collected prospectively, using an anonymous online survey design, with Likert scale and open-ended questions, with the option of additional comments. Consent was gained form all participants. Qualitative data collected from the open-ended survey questions were analysed using thematic analysis as described by Braun and Clarke (2006). Researchers were blind to the demographic variables of respondents, in order to promote anonymity. Authentic anonymous citations were used to illustrate the findings.

Results

A total of 50 survey responses were received from CAMHS clinicians from 9 teams. Clinicians’ views of the helpfulness of the label of ‘emerging personality disorder’ within CAMHS (n = 49): 22.4% found it helpful (very or somewhat) to staff; 21.3% helpful to families; 65.4% found it unhelpful (somewhat or actively) to staff and 63.8% unhelpful to families. 47 responded to the optional open-ended questions eliciting experiences and views of the use of the label. Qualitative analysis revealed evidence of polarity of opinion, particularly in perceived consequences for the young people and families, and identified three major themes: a shared developmental and trauma-informed understanding; the perceived impacts associated with the label of ‘emerging personality disorder’ (9 subthemes); and clinicians’ proposed next steps. There was a shared understanding of the role of interpersonal trauma and invalidation, resulting impacts on the development of skills in emotion regulation and interpersonal relationships.

Conclusion

Our findings highlighted the polarity of the views, the lack of consensus in the use of this label amongst CAMHS clinicians and the importance of discussions around future pathways. There is a need to consider the view of experts by experience (young people and families who have been through this process) to consider the short and, more importantly, the long term impacts of living with a label of ‘emerging personality disorder’.
Suicidality in the Absence of Self-Harm: Trends in Presentation to a General Hospital's Liaison Psychiatry Service
Authors: Newton Nick , Lee William
Published: July 2023

Aims

Following the initial phase of the COVID-19 pandemic, and with the introduction of an off-site Crisis Hub, has there been a change in presentation to the Emergency Department (ED) with suicidality in the absence of self-harm?

Methods

Patients referred to the Liaison Psychiatry Service (LPS) from the ED at the Royal Cornwall Hospital with suicidal threat over a two-month period were identified in 2019 (pre-pandemic and the creation of the Crisis Hub), 2021 and 2022 (post pandemic and Crisis Hub implementation).

Demographic data for each attendance were recorded: age and gender, mode of arrival/route of referral and outcome of assessment.

Results

The number of attendances has decreased since 2019 (87 in 2019, 71 in 2021 and 53 in 2022). This is on the backdrop of decreasing total departmental attendances and a fall in the proportion referred to LPS: 541 in 2019, 3.84% of the total ED attendances, 510 in 2021, 4.32% of the total ED attendances and 400, 3.7% of the total ED attendances in 2022.

The proportion arriving under Section 136 of the Mental Health Act (MHA), is also increasing: 0% in 2019, but 15.5% in 2021, and 13.8% in 2022. This corresponds to an increasing proportion taken from the ED by the police to another Place of Safety.

A small proportion of those attending were considered suitable to be assessed at the Crisis Hub and were subsequently taken there (5% in 2021 and 3% in 2022). The most common reason to reject referral to the Crisis Hub was recent alcohol consumption.

The proportion requiring admission varied: 3.4% in 2019, 5.6% in 2021 and 1.7% in 2022.

Conclusion

The number of patients arriving with the police under s136 has increased. The numbers were too small to see a trend in transfers to the crisis hub and psychiatric admissions.

Future work might evaluate the vanguard street triage service, or be a repeat of this evaluation once there is medical cover in the hub, or look at the fraction of patients seen in the hub who are referred on to ED, or be qualitative studies of staff and patients’ views of the hub.
A Service Evaluation and Improvement Project: Outcomes of Referrals From Prison to the Male Psychiatric Intensive Care Unit (PICU) in Kent
Authors: Satisha Shantala , Dunn Jenny , Felix Francis , Delaffon Vijay
Published: July 2023

Aims

Aims: The project aims to evaluate the referrals from prison services for admission to our PICU from June 2020 to October 2021. Hypothesis: We expect referrals to come from multiple sources with variable timeframes for assessment. For those admitted to PICU, we expect delays in transfer out of PICU with increased PICU length of stay. We believe this to be secondary to lack of an established protocol for this pathway. Background: Our single 12 bedded male PICU in the trust has seen increased demands on its beds for prisoners requiring admission to mental health services. While PICU beds can meet the low secure requirements for prison transfers, they cannot function as forensic low secure beds due to their role within Acute services. With the increased number of referrals and the lack of a clearly defined pathway for these prison transfers, there was a risk of erosion of PICU philosophy aiming for discharge at the point when intensive care was not required, i.e increased length of stay.

Methods

Data were collected for all referrals from prison services to the male PICU between June 2020 and October 2021, recording the demographics, clinical information and timeframes for assessment. For those admitted to the PICU, percentage meeting the PICU criteria, admission-discharge pathways, serious untoward incidents and delays in transfer were recorded.

Results

There were 22 referrals from prisons, of which 11 (50%) were admitted to the male PICU. The referrals came from multiple sources with poor coordination between the PICU, forensic and prison services with delays in assessment. 100% of the admissions met criteria for PICU. There were 2 serious incidents related to security levels of the environment. The pathway out of PICU included prison, forensic services and acute wards. Over half the patients were downgraded to non-restricted detentions and stepped down to acute beds. There was a delay in transferring out of PICU in 36% of the patients leading to increased length of stay.

Conclusion

In conclusion, the data support our initial concerns that there is a need for a protocol guiding the transfer of prisoners to our PICU for treatment. This has led to discussions to develop such a protocol with close collaboration between prisons, forensic services and PICU. We hope this will lead to a much smoother process from having a single point of referral, timely assessments and decisions making, better defined exit pathways with less delays in transfer from PICU.
A Qualitative Evaluation of the Quality of Assessments for the Psychological Medicine in Primary Care Service: A Patient Perspective
Authors: Patel Zahra , Shaw Fiona , Aliu Oluwatoyin , Moffat Claire , Alachkar Mustafa
Published: July 2023

Aims. Background: Psychological Medicine in Primary Care, Stockport works with people with persistent physical symptoms and personality difficulties whose psychological needs cannot be met by existing services due to complexity. The service views the assessment process as a therapeutic intervention in its own right and utilises a relational, formulation-based approach over 2 to 5 sessions. A letter including this formulation is sent following assessment to both the patient and their GP.

Aims:

1.

To evaluate the quality of the assessments from a patient perspective.

2.

To improve the quality of the assessments in order to improve patient care and the support offered to patients.

Methods

A short questionnaire with open questions was created. Thirty-two patients assessed by the service took part in semi-structured interviews by means of a short telephone discussion after consent was taken. Three independent investigators reviewed their responses and performed thematic analysis, using an inductive and recursive approach.

Results

Theme 1: The understanding of the service and awareness of the referral affects the perception of the assessment.

Theme 2: There can be therapeutic gain in the assessment process, which appears to be mediated by the relationship with the assessors including:

•

Emotional catharsis

•

Having a wider perspective of personal issues

•

Developing new coping mechanisms

•

Regaining a sense of agency

•

Gaining a sense of hope

•

Developing a better understanding of emotions

•

Having a different experience to past encounters with mental health services

Theme 3: The relationship with the assessor plays an important role in the experience of the assessment process, and is mediated by skills of the assessor, including:

•

Active listening

•

A sense of thoroghness; not feeling rushed

•

Sensitive use of verbal and non-verbal communication

•

An empathic, non-judgmental approach

•

A warm, professional approach

•

Open, clear, collaborative communication

•

A consistent approach

•

Validation

•

Psychological containment

Patient perception of the degree of attunement in these areas appears to lend itself to a sense of psychological trust and safety in the process.

Theme 4: The outcome of the assessment can lead to various emotional responses which can play a role in how people perceive the assessment process

Theme 5: The assessment letter is considered an important part of the assessment by many, but not all, participants

Conclusion

Psychiatric assessment can be a therapeutic intervention in its own right and a collaborative, relational approach can help to facilitate this.
A Comparison of the Number of Referrals for Psychiatric Assessment and Prescribing Rates of Psychotropic Medication in the Year Leading Up to the COVID-19 Pandemic and the First Year of the Pandemic in a Child and Adolescent Mental Health Service (CAMHS) in South Edinburgh
Authors: Voy Steven , Robinson Clare , Blue Sarah
Published: July 2023

Aims

To establish if there were any significant changes in the number of referrals for psychiatric assessment or prescribing rates of psychotropic medication in the South Edinburgh tier 3 CAMHS team during the first year of the COVID-19 pandemic compared to the previous year. To explore factors that might be responsible for these changes.

Methods

Referrals to the Psychiatric Assessment Clinic were analysed between the periods of 23rd March 2019 and 22nd March 2020 and 23rd March 2020 to 22nd March 2021. Using the unique numeric patient identifier, data from these referrals was gathered retrospectively by looking at clinical documentation on the healthcare information system used across NHS Lothian. Data were gathered for 243 patients.

Data were collected on psychiatric diagnosis and, if medication was prescribed, what class of medication this was. Information on potential confounding factors was also gathered including sex, age, co-morbid psychiatric diagnoses, history of self-harming behaviours and suicide attempts, family set-up, schooling and other support services involved. Information was stored anonymously.

Data were coded. Statistical analysis was undertaken using SPSS (statistical package for the social sciences).

Results

Referrals for psychiatric assessment almost doubled from 83 pre-pandemic to 160 during the first year of the pandemic. Referral rates for most psychiatric disorders increased. The proportion of patients prescribed psychotropic medication increased significantly during the first year of the COVID-19 pandemic compared to the year preceding (P=0.031).

Analysis of possible confounding factors was completed. Anti-depressant prescribing rates for those from non-nuclear families increased significantly in the year during the pandemic (P=0.012). Other differences were observed but these were not statistically significant. The numbers of patients who self-harmed, attempted suicide or carried out both increased from 42 to 79.

Conclusion

Findings add to the existing body of literature highlighting an increase in referrals to mental health services and prescribing of psychotropic medications in the first year of the pandemic in comparison to those pre-pandemic. No clear conclusions could be drawn about factors responsible for change. Continuing to monitor referrals and confounding factors over time would be useful from a public health perspective. It would allow trends to be drawn so that planning can be carried out for future pandemics.
Audit of Clinic Letters Sent to GP Following CAMHS Outpatient Clinic Appointments at Black Country Partnership NHS Foundation Trust
Authors: Afinni-Adewunmi Nofisat , Eneka-Akhator Nwaife , Manuwa Olufikunayo
Published: July 2023

Aims

The aim was to evaluate the quality of clinic letters sent to GP following outpatient appointments by CAMHS Consultants. The audit was based on the guidance of the Royal College of psychiatrist on writing clinic letters .

Methods

Initial Audit was a retrospective audit of 40 randomly selected clinic letters sent to the GP following outpatient appointments in the previous 1 year between June 2021 and Janauary 2022. The Re-AUDIT was with 60 clinic letters sent to the GP following outpatient appointments between June 2022 and December 2022.

Information was then collected about whether the following were included in the letters;

inclusion of diagnosis with ICD code, current medication, indications for medications, allergies, physical measurements, mental state examination, risk assessment, care plan and useful links where relevant.

Results

Overall changes were seen in quality of the GP letter in some specific areas, while some areas showed a decline or no significant changes

In including ICD 10 diagnosis to the GP letters, 100% of letters as compared to 80% in initial audit

Indications for medications were discussed/noted in 56.6% of letters when compared to 32.5% initial audit. Physical measurements were also well documented in 80% of letters. This increased from the previous 55%. Mental state examination and risk assessment also increased from 88.3% from 60%, and 86.6% from 70% respectively.

There was a drop in figures in including Current medication in letters.(100% to 90%) and also in copying patients /carers into letters(from 100% in previous audit to 86.6% in re-audit)

Little of no changes were seen in the quality of letters when observing useful links and allergies. The numbers were very low: allergy status infact dropped from 27.5% to 3.3%. Including useful links and resources in the GP letters only showed a growth from 7.5% to 13.3%.

Conclusion

•

Significance of allergy status and continuous reminder that allergy can start at any age in any service user. Drug interaction also important

•

Clearly stating all treatment including pharmacotherapy and psychological therapies

•

Continuous emphasis of indications for medications and psychoeducation including about commencing, stopping medications and side effects

•

QI project to bring together all useful links and make accessible to clinicians and patients
Completing the Cycle: Re-Audit of Rotherham Specific Inpatient Physical Health Management and Documentation Following a 2021 Trust-Wide Audit
Authors: Bell Lydia , Jenkinson Joe , Allan Lewis
Published: July 2023

Aims

Rotherham Doncaster and South Humber (RDaSH) NHS Trust completed a Trust-wide audit in August 2021 to look at aspects of physical health management in their inpatient units. Good results were achieved in relation to new admissions having completed initial medical examination within 24 hours and consideration being given as to whether the patient had the capacity to make the decision to agree or refuse such an examination. However, inadequate results were achieved in relation to anything more than an examination of appearance, pulse or blood pressure being conducted with a chaperone, and the patient being given the opportunity to state their preferences in relation to the sex of the chaperone. This audit completed the audit cycle by re-auditing the above criteria in Rotherham inpatient units in order to assess ongoing progress against targets following recommendations.

Methods

A dip sample of five patients per ward (two Acute Adult, one Rehabilitation, one PICU and two Older Adult wards) was used. Patients who were admitted between 1st July and 30th September 2022 were picked randomly and their electronic records were studied.

Results

Nearly 90% of patients received a physical examination by a doctor within 24 hours of admission. But, whilst these patients undertook an examination that was more than just general observation, blood pressure or pulse, in only 14% of these was it documented that they had a chaperone present. In addition, not a single person was offered the choice to choose the gender of their chaperone.

Just one third of patients had their capacity to agree or decline examination documented. Perhaps unsurprisingly, the Older Adult wards performed better against this criteria.

Conclusion

Rotherham inpatient wards continue to perform well in terms of conducting timely initial physical health examinations. However, we identified there is a clear lack of documentation around documenting whether someone has capacity to consent to their physical examination or not and what gender someone would prefer to chaperone them. Unfortunately, this is a continuing issue.

We have identified an opportunity at the RDaSH Junior Doctor's induction, where the clerking is explained, to intervene and educate around what the Trust expects as standard.

We plan to implement this change and re-audit the above criteria again to see if we can make an improvement.
Physical Health Monitoring of Patients on Antipsychotic Medication at a Medium Secure Unit
Authors: Deol Harlene , Gibbon Simon , Fullerton Christine , Wokekoro Oronne
Published: July 2023

Aims

People who have a serious mental illness have a higher prevalence of physical health problems as compared to the general population; with a 2–3 times greater risk of cardiovascular morbidity and mortality, double the risk of obesity and diabetes, three times the risk of hypertension and metabolic syndrome and five times the risk of dyslipidaemia than the general population. There is a concern that some antipsychotic drugs have metabolic consequences that contribute to the risk. As such, it is imperative that patients treated with antipsychotics receive appropriate health monitoring. Physical health monitoring of antipsychotic medications is an essential aspect of our practice, and despite assurance in previous audits, we agreed to monitor biannually to ensure we were maintaining standards. Additionally, this audit aimed to look more closely at special monitoring requirements for drugs such as Olanzapine, Chlorpromazine, Clozapine and Quetiapine which had not been measured in previous audits and would likely highlight some areas for improvement.

Methods

Audit standards were drawn from the Maudsley Prescribing Guidelines in Psychiatry 14th edition, in addition to NICE Guidance CG178 - Psychosis and schizophrenia in adults: prevention and management.

A random number generator was used to select patients from each of the 7 wards, giving a sample size of 21 patients. Data were collected on Weight, BP, ECG and various blood tests conducted from February 2021 – February 2022. Data was collected from a combination of patient electronic record, CPA reports, and online blood results system. Data were inputted to MS Excel which created percentage compliance in each domain.

Results

1.

Blood Pressure: General compliance in the taking of BP met our standard of 100%

2.

Weight: Annual monitoring compliance was 93% however compliance fell short for special recommendations for Clozapine, Olanzapine and Chlorpromazine.

3.

ECG: Our compliance fell short in the recording of an ECG on admission, or at reaching target medication dose. Annual monitoring compliance was 93%.

4.

Bloods: Annual compliance for FBC, LFT, U&Es, Lipids, Prolactin and

5.

Glucose were 100%, however our compliance fell short for baseline recording and interim 3-6 monthly monitoring for various blood tests.

Conclusion

Overall results demonstrate good, safe practice, particularly during a challenging period for clinical teams. Shortfalls particularly at baseline were related to risk issues making investigations impractical. It was agreed that there should be an increased frequency of regular glucose monitoring and that HbA1c monitoring was a reasonable measure for this.
An Audit of Clinicians Completing Independent Seclusion Reviews (Trust-Wide Audit Within Cumbria, Northumberland, Tyne and Wear, NHS Foundation Trust)
Authors: Edwards Nicole , Fearnley Edward
Published: July 2023

Aims

The Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust (CNTW) seclusion policy states that if a patient has been nursed in seclusion for 8 consecutive hours (or 12 hours intermittently over a 48 hour period), then an independent seclusion review (ISR) is mandated. One member of this ISR team must include an Approved Clinician (AC). Our aim was to establish whether an AC (including non-medical) was present at ISRs. If the doctor was not an AC, we established whether a discussion with an AC was documented.

Methods

The method included reviewing all episodes of seclusion that took place in CNTW between the 01.10.2021 and the 31.12.2021 (i.e. Q4 for 2021). All electronic (RiO) seclusion records and progress notes were examined to determine who was present at each ISR occurring within each episode of seclusion.

Results

260 episodes of seclusion occurred in Q4 2021 within CNTW. 96 episodes continued long enough to trigger an ISR.

Of the 96 episodes, a total of 221 ISRs were examined.

Of those senior clinicians present at ISR, 83% were medical members of staff, 11% were non-medical ACs and 6% were neither.

Of the medical clinicians present at ISR, 68% were not AC grade.

Of the different grades of non-AC doctors present at ISRs, 72% were "SHO grade".

The overall breakdown of non AC medical staff included 6% F2 Doctors, 16% Higher Trainees, 19% Speciality Doctors, 4% Associate Specialists, 5% were International Fellows and 1% Senior Trust Fellows.

29% of ISRs occurred outside of normal working hours.

71% occurred 9:00-17:00 Monday to Friday (excluding Bank Holidays).

0% of non-AC medical ISRs had a documented discussion with the AC.

Conclusion

Nearly a third of IRSs occurred outside of standard (contracted) working hours for doctors.

In addition, the majority of ISRs were completed by non AC doctors. The majority of these doctors were "SHO" level Doctors (including Core Trainees, GP Trainees and Foundation Trainees).

The audit was presented at the CNTW Seclusion Steering Group, with actions including a change to the seclusion policy. This now explicitly states that ISRs must be conducted by an AC “unless in the case of extreme circumstances, and in such cases the review should be discussed with an AC”.

There are additional plans to develop consistent approaches for organising ISRs (to ensure the vast majority happen within normal working hours and with an AC present).
A Re-Audit of ECG Monitoring in Patients Admitted to the General Adult Inpatient Wards at Clock View Hospital, Liverpool, Mersey Care NHS Foundation Trust
Authors: Elagamy Yasmine , John Cherian , Dacosta Adetokunbo , Hyland Declan , Hassan Nesma , Nankoo Ryaz
Published: July 2023

Aims

The aim of this re-audit was to analyse current practice following a previous audit of ECG monitoring in patients admitted to the general adult wards at Clock View Hospital in 2020 and determine whether recommendations made from the original audit have improved performance.The objectives of this re-audit were: screen for recording of the admission ECG; ensure clear documentation of the ECG report; identify any reason why the ECG was not performed within 24 hours of admission and identify whether inpatients with an abnormal ECG on admission had any further investigation(s) done.

Methods

92 inpatients discharged from the three general adult wards at Clock View Hospital between 1st of January 2022 and 31st of March 2022 was obtained. The same audit tool designed and used in the original audit in 2020 was used for this re-audit. Each inpatient's electronic record was reviewed to determine whether an ECG was performed within 24 hours of admission. In those patients who didn't have an ECG done, the reason why was recorded (if documented) and whether those patients who had an abnormal ECG were referred for further investigation. The quality of documentation of ECG reports was analysed.

Results

Of the 92 inpatients, 57 (62%) had an ECG within 24 hours of admission and 16 (17%) had one done more than 24 hours after admission. 19 (21%) inpatients never had an ECG done at any point during their admission. The reason for not performing an ECG was documented for 32 (91%) of affected inpatients. Of the 73 inpatients who had an ECG done, 16 (22%) had an abnormal ECG, but only nine had further investigation (56% vs 23% in the original audit).

Conclusion

The findings from this re-audit showed that completion of an ECG within 24 hours of admission to the general adult inpatient wards at Clock View Hospital has improved from 52% to 62%. There has been improvement in quality of documentation of ECG reports. There was no documentation of the ECG report in 13% of cases compared to 35% in the original audit. In almost all affected cases, the reason for not performing an ECG was documented. The authors recommend creating an alert on the electronic record system if an ECG is not performed within 24 hours of admission and asking the ECG reporting service to copy the ECG report to the ward clerk and / or Consultant PA to ensure the report is reviewed promptly.
An Audit of Planned Follow-Up Following Discharge From Four Black Country CRHT's
Authors: Horton Gemma , Pegg Joanna , Undre Suhail , Bridgewater Peter , Odogwu Nwamaka
Published: July 2023

Aims

It is well established in the evidence base that mortality and suicide risk increases following discharge from an inpatient admission, leading to the national implementation of ‘72 hour follow-up’. However, there is little data examining outcomes following discharge from an admission to a Crisis Resolution & Home Treatment Team. Following a number of noted Serious Untoward Incidents at a trust level, we sought to examine the standard of follow up post discharge from all four Black Country CRHT's (Dudley, Walsall, Sandwell and Wolverhampton) in order to improve policy and thus patient outcomes.

Methods

The caseloads for all four CRHT's for the period of 1st-31st December 2021 were obtained. The clinical notes system RIO was searched and scrutinised for each patient to determine when the patient's next planned follow-up following discharge from that particular spell in CRHT took place. This was compared to the audits standard: all patients discharged from CRHT should receive some form of planned follow-up in the 3 month period post discharge.

Results

All of the patients discharged from Wolverhampton CRHT received 72 hour follow-up as conducted by members of their own team, however despite this 12% of the total caseload were either lost to long term follow-up or went into crisis before planned follow-up could take place. With regard to Dudley and Sandwell, only 51% and 47% of patients respectively were routinely followed-up within 3 months. A total of 30 patients across all 4 CRHT's went into crisis before planned follow-up took place. One patient ended their life 4 months following discharge from the CRHT; no planned follow-up took place. All of Walsall CRHT's patients were followed up on discharge unless they were discharged directly back to their GP.

Conclusion

Timely, regular and robust follow-up embedded in the community mental health team is paramount to the provision of safe psychiatric care. This audit has also uncovered the need for follow-up for patients discharged from CRHT to their GP, as this cohort of patients is sizeable. However we argue that a one off ’72 hour/7 day follow-up’ is insufficient when reducing morbidity and mortality, and robust long term care plans and regular follow-up should instead be a feature of longer term community mental health care.
How Satisfied Are Local General Practitioners, Who Are Part of the Brompton and South Kensington Primary Care Networks, With Communications About Patients Referred to the Mental Health Triage and Assessment Team?
Authors: Hussain Parisah , Marriott Sarah
Published: July 2023

Aims

The Triage and Assessment Team (T&AT) at South Kensington and Chelsea Mental Health Centre have conducted a research project to assess our written communication with General Practitioners (GPs) in primary care. We are responsible for screening and assessing new patients referred by GPs to the South Kensington and Chelsea Mental Health Centre community mental health team (CMHT) department.The aim is to ensure all patients referred from primary care, receive care from the most appropriate health professional(s) in the timeliest way and that we communicate with their referrer in a timely and helpful manner. We aim to deliver a service that is safe, effective and helpful to patients, carers and their referrers. The purpose of this study is to understand the referrers’ experience of our communications with them when they refer to the T&AT.

Methods

A pre-intervention survey was sent out in November 2022 to GPs who work and are part of the Brompton and South Kensington primary care networks (PCNs).

We received an equal number of responses from Brompton and South Kensington GPs respectively. Quantitative and qualitative data were both collected. We had a cross section of respondents including trainees, salaried GPs and partners.

Results

From the quantitative data, the majority of respondents reported they were reasonably satisfied with our communication with respect to timeliness, clarity and clinical relevance of our communication.

Respondents were less satisfied with the balance struck between clinical detail on the one hand and recommendations for the mental health shared care plan.

A qualitative analysis of respondents all free text comments and identified three main themes: the local referral pathway, the use of SystmOne computer software programme, and recommendations for improving communications between GPs and the T&AT at CMHT.

Conclusion

We have acknowledged concerns about the complex mental health referral pathway together with suggestions about improving the functionality of SystmOne across the GP and CMHT interface into the regular discussions we have with our respective PCNs.

The Triage and Assessment Team are designing improvements to the consistency, timeliness and relevance of our GP communications.

Once these improvements have been implemented, we will send out a post-intervention survey to GPs and reassess their satisfaction levels with our new mode of communication.
Pathways to Care at Early Intervention in Psychosis Liverpool: A Cross-Sectional Retrospective Audit Cycle
Authors: Koetsier Benjamin , Stevens John , Uffendell Chloe
Published: July 2023

Aims

Early Intervention in Psychosis (EIP) services provide an evidence-based approach to the identification and treatment of patients experiencing a first episode of psychosis (FEP). The NICE access and waiting time standard is that 60% of people experiencing FEP are treated with an approved care package within two weeks of referral. This is defined by allocation of an EIP care coordinator, though the offer of antipsychotics is also important. The aims of this audit were to (1) Collect data on EIP referral to treatment pathways and explore delays (2) Explore the origin of EIP referrals (3) Explore timings of referrals to review with a prescriber (4) Compare two audit periods to assess recommendation efficacy and provide future recommendations to reduce delays.

Methods

Two retrospective audits were carried out on patients accepted onto the FEP pathway at EIP Liverpool in May & June 2020 (34 patients) and December 2021 (11 patients).

Data were collected for each patient on time spent at stages of the referral pathway from initial referral to mental health services to first medical review with an EIP clinician. Further data included each patient's first point of contact with mental health services, the referral origin and first contact with a prescriber.

Data were collected using electronic health records. Duplicate referrals and extended inpatient admissions were excluded from prescriber analysis. Initial audit results from 2020 were compared with the re-audit in 2021, assessing for changes in pathway provision and compliance with the NICE standard.

Results

The results found that there was a 43.5% increase in wait time on the EIP referral pathway between the periods audited in 2020 and 2021, from an average of 9.8 to 22.5 days, related to the COVID-19 pandemic. The primary delays for both periods were referral assessment, care coordinator allocation and prescriber review.

The type of prescriber reviewing remained consistent, with reviews being conducted by a consultant for >50% of patients in both periods.

Conclusion

Between the two audited periods, the average pathway to care time increased to over the NICE standard despite implemented recommendations from the initial audit.

Stages of the referral pathway facing significant delays came from within the service, due to an increase in referrals, an increase in patients experiencing FEP by 50% and a change in the origin of referrals. A framework for improvement is recommended to improve pathways to care and outcomes for patients experiencing FEP within the EIP service.
Intensive Home Treatment Team (IHTT) Antipsychotic Initiation Baseline Physical Health Investigations Audit
Authors: Okonji Deborah , Walishetty Phalaksh
Published: July 2023

Aims

The aim of the audit is to measure performance against Bradford District Care Foundation Trusts (BDCFT's) ‘Antipsychotic Physical Health Monitoring Shared Care Guidelines’.

Methods

In September 2022, the audit project lead retrospectively reviewed the patient's electronic care record to establish their compliance to the standards.

The sample was drawn from the caseload of patients managed by the Intensive Home Treatment Team (IHTT) Bradford in September 2022. All patients who were initiated on antipsychotics by the IHTT were included in the audit. Patients who were initiated on antipsychotics by other teams such as Community mental health team (CMHT), Inpatient teams, etc, were excluded. A total sample size of 25 was used

All relevant areas of the record were checked, and data were collected on a data collection tool designed in Microsoft Excel and once collected these data were passed to the Clinical Audit team who completed the analysis using the same programme.

Results

Demographics: 15 patients (60%) were male and 10 (40%) were female. Their ages ranged from 18 years to 55 years with a mean age of 37 years.

The results of the audit highlight that only 32% of patients had a full physical health check prior to the initiation of antipsychotics. A further 56% had an incomplete physical health check. None of the individual investigations were fully compliant, as identified in the table above. BMI/weight was the investigation completed the least even though all antipsychotics are known to carry a risk of weight gain. HbA1c was the least completed blood test. Only 40% of all patients had their physical health checks reviewed by a relevant professional after they had been completed.

Conclusion

It is important that all patients prescribed antipsychotic medication have the necessary baseline investigations completed to ensure that the medication is safely prescribed, and the results of this audit was shared within the team for their consideration and review.

In cases where antipsychotics was started without the baseline monitoring, It is assumed that this decision was taken on a balance of risks. General lifestyle factors such as diet and physical activity can have a significant impact on the patient's physical health, yet this investigation was completed less frequently than determining any illicit drug use and identifying the patient's smoking status.

Following physical health checks, results of these need to be reviewed by relevant clinicians with documented evidence to this.
An Audit Looking at the Monitoring for Long-Term Antipsychotic Use on an Adult Inpatient Psychiatry Ward
Authors: Olagunju Oluwatomilola , McCarron Rionach
Published: July 2023

Aims

Patients with psychiatric disorders have been well documented to have an increased risk of cardiovascular disease and consequently a higher incidence of premature mortality. Literature has shown that many psychiatric disorders, particularly major depressive disorder, bipolar affective disorder, attention deficit hyperactivity disorder, post-traumatic stress disorder, anxiety disorders, and schizophrenia have an increased risk of metabolic syndrome. This increased prevalence of metabolic syndrome, and as a result cardiovascular disease, has been linked to factors that clinicians are involved in, such as the prescription of antipsychotic medication. it is therefore important for clinicians to be able to appropriately monitor patients on antipsychotic medications.

Aim: To improve the physical health aspects of care for patients with psychiatric illnesses admitted as inpatients.

Objectives:

1.

To ensure appropriate monitoring of the metabolic parameters of patients on admission.

2.

To ensure appropriate ongoing monitoring of the metabolic parameters of patients during their hospital stay.

Methods

Data were collected independently by two people. The data were collected using PARIS, an online documentation program used by the Greater Manchester Mental Health (GMMH) trust, as well as the patients’ paper prescribing charts. A total of 20 patients were audited. Standards were set according to NICE guidelines on patients on long-term antipsychotics admitted to adult inpatient wards. A total of 14 standards were set. The areas audited were measurements of BMI, ECG, blood pressure, lipids, prolactin and urea and electrolytes at baseline, at prescribed time points, and at dose changes as required by guidance.

Results

Overall, five of the standards were attained, seven of the standards were not attained, one standard could only be partially analysed, and one standard (monitoring at 12 months) could not be analysed due inadequate patient length of stay

Conclusion

Patients on long-term antipsychotics have an increased risk of cardiovascular disease and it is important that we are monitoring them frequently to avoid deterioration of their physical health and a further increase in their disease burden. This audit suggests three recommendations to ensure adequate monitoring.

1.

Consideration of a comprehensive admission proforma to help standardise the admissions process.

2.

The development of a tool to remind clinicians to recheck metabolic parameters for ongoing monitoring at 3 months, 6 months, and 12 months.

3.

Regular maintenance of the ECG machines to ensure no omissions in monitoring.
Audit of Antimanic Agents Monitoring in a High Secure Hospital
Authors: Oluwaranti Oluwaseun , Wahid Nazurah , Whitehouse-Lowe Henry , Yanson Ian
Published: July 2023

Aims

Antimanic agents are effective in the management of mood disorders and other neuropsychiatric conditions such as epilepsy and aggression. These medications may cause serious side-effects and affect vital organs; hence, specific checks are recommended before initiation and for continuous use of these medications. The aim of the audit was to check compliance with monitoring of antimanic agents (lithium, valproate, and carbamazepine) and to compare with the 2018 audit.

Methods

Preliminary data of all patients on the antimanic agents at Rampton Hospital from 01 December 2020 to 30 November 2021 were obtained from records.

Retrospective data were collected using a modified version of the 2018 audit tool. This includes patient hospital number, ward, medication initiation date, pre-initiation and monitoring tests. The tests were, depending on the medication; full blood count (FBC), thyroid function test (TFT), liver function test (LFT), electrolytes and urea (E&U), and electrocardiograph (ECG).

The audit criteria were based on the recommendation of the Maudsley Prescribing Guidelines (14th edition). A total of 16 standards were assessed overall.

Results

A total of 98 patients were prescribed antimanic medications through the review period with valproate-59, lithium -32 and carbamazepine -7. Three patients on valproate and 3 on lithium had incomplete data and were excluded. Therefore, a total of 92 patients were included in the final audit (valproate-56, lithium-29 and carbamazepine-7).

Pre-initiation compliance for LFT and FBC for valproate were 35.8% and 41.5% respectively, while the monitoring compliance within 6 months were 85.7% and 87.5% respectively.

For lithium, pre -initiation compliance for ECG was 73.1%; TFT and U&E had 88.5% and 96.2% pre-initiation compliance respectively. There was 100% compliance with monitoring of lithium level at 3 months, and both U&E and TFT within 6 months.

For carbamazepine, the pre-initiation and monitoring compliance was 50% and 100% respectively for three tests (LFT, FBC and U&E).

There was improvement in all the standards when compared with the 2018 audit compliance except FBC monitoring for valproate within 6 months which dropped from 92% to 87.5%.

Conclusion

Only 6 standards had 100% compliance with the guidelines. Lithium monitoring was generally higher than for other mood stabilizers; pre-initiation monitoring was poor for both carbamazepine and valproate. There was general improvement in the standards compared with the 2018 audit.

The guidelines for monitoring mood stabilizers apart from lithium needs to be made popular especially pre-initiation monitoring for valproate and carbamazepine.
Audit of DNA & Disengagement of Patients in West Essex Community MH Teams
Authors: Purakayastha Rosy
Published: July 2023

Aims

Non-attendances (DNAs) and cancellations are a very costly waste of resource within the NHS and so it is important to have a focused plan of action to proactively manage them. The Trust recognises that people may choose not to attend appointments, or discontinue contact with the services we provide for them. There will be occasions where a person's non-attendance is an indicator that :

•

they may be at risk to themselves or others through deterioration in their mental health, or other issues preventing them from attending.

•

Therefore, any failure of planned contact should be regarded as a potentially serious matter and should lead to an assessment of potential risk. Hence we aimed this study to see if trust policy of DNA and disengagement is being followed.

Methods

Data were collected for 51 patients who missed their scheduled appointment between February and August 2021, using a predesigned questionnaire tool.

Results

Out of the 51 patients, 37 of them Did not attend the initial assessment whereas 14 of them did not attend follow-up appointments.

18 patients had the diagnosis of depression, 9 of then had anxiety as the diagnosis and 8 had the diagnosis of personality disorder. Please see figure above for distribution of Mental Health diagnosis.

98.1% patients were notified adequately and for all the patients, letter was sent to the patient and the GP.

In 50.9% cases Risk Assessment was completed (although 37 patient did not attend, they were already known to our services). In 25% of cases, risk assessment was updated.

Review of the Contingency plan was done in case of 26 patients.

Out of the 51 patients, family was contacted for only 3 patients. Remaining 48 patients other known contacts were contacted in 4 cases.

Out of the remaining 44 patients, 3 patients were referred for home visits or AHMP.

Out of the remaining 41 patients, police/welfare check was done for 4 of them.

The remaining 31 patients were discharged from the services after they did not respond to our multiple correspondences including phone calls and letters.

Conclusion

Though trust policy is being followed to a good extent in regards to adequately notifying and contacting service user, offer another appointment and informing GP, we are failing to adhere to trust policy in regards to updating risk assessments, review crisis plans or doing welfare checks.