bluuebunny/crossref_metadata_2025 huggingface dataset:
Root causes of deaths by suicide amongst patients under the care of a mental health trust: a thematic analysis
Authors: Bagchi Dhruba , Webb Kerry , Odejimi Opeyemi
Published: June 2021

Aims

This study explores common themes emerging from root causes of Serious Incident (SI) reports of mental health service users who died by suicide under the care of a mental health trust.

Background

Suicide is a global health problem. It is estimated every year about 800,000 people die by suicide worldwide. Previously, the United Kingdom (UK) reported a significant reduction. However, the latest report in 2018 indicated a marked increase. Furthermore, 28% of people who died by suicide in the UK were under the care of mental health service 12 months prior to their death. The causes of suicide are not usually straightforward, but sometimes could be preventable. Thus exploring the root causes is a step in the right direction to preventing this global problem.

Method

Thematic analysis was carried to identify themes emerging from the Root Causes (RCs) within the Serious Incident (SI) reports of patients who died by suicide while under the care of the Trust between January 1st, 2017 and July 31st, 2018. Over the 18 month period, there were 71 deaths, of which 36 were ruled as suicide by the coroner. A further 16 were considered by the review team as possible suicide and were therefore included to increase the scope of learning. This review is therefore based on 48 cases.

Result

Three main themes emerged from this study. They are patient, professional and organisational factors. Majority of the death were patient related factors, particularly exacerbation of patient's mental health condition. Furthermore, the most frequently occurring professional and organisational factor were issues around patient risk assessment and management and inadequate psychiatric bed respectively.

Conclusion

The findings of this study have helped gained an understanding of the perceived causes of death of patient who died by suicide. It is hoped that this will in turn influence the manner in which, decisions, policies and resource allocation are carried out to further prevent and reduce the incidence of suicide, particularly amongst mental health patients.
Trends in referrals to liaison psychiatry teams from UK emergency departments for patients over 65
Authors: Bradbury Sarah , Crowther George , Chinnasamy Manimegalai , Shaw Laura , Ormerod Sara , Wilkinson Alison , Chubb Rebecca , Daher Mazen , Kumar Pramod , Gaskin Andrew , Williams Karen , Brown Angus , Stebbings Eleanor , Sahu Sunita , Smyth Roger , Kinsler Hilary , O'Connor Stephen , Wells Andrew , Overshott Ross , Junaid Kehinde , Mordekar Aparna , Humphries Jenny , James Karen , Mittal Shweta , Dasari Sarita , Grant-Peterkin Hugh , Campbell Niall , West Robert , Tadros Professor George , Sampson Elizabeth
Published: June 2021

Aims

The number of people over the age of 65 attending Emergency Departments (ED) in the United Kingdom (UK) is increasing. Those who attend with a mental health related problem may be referred to liaison psychiatry for assessment. Improving responsiveness and integration of liaison psychiatry in general hospital settings is a national priority. To do this psychiatry teams must be adequately resourced and organised. However, it is unknown how trends in the number of referrals of older people to liaison psychiatry teams by EDs are changing, making this difficult.

Method

We performed a national multi-centre retrospective service evaluation, analysing existing psychiatry referral data from EDs of people over 65. Sites were selected from a convenience sample of older peoples liaison psychiatry departments. Departments from all regions of the UK were invited to participate via the RCPsych liaison and older peoples faculty email distribution lists. From departments who returned data, we combined the date and described trends in the number and rate of referrals over a 7 year period.

Result

Referral data from up to 28 EDs across England and Scotland over a 7 year period were analysed (n = 18828 referrals). There is a general trend towards increasing numbers of older people referred to liaison psychiatry year on year. Rates rose year on year from 1.4 referrals per 1000 ED attenders (>65 years) in 2011 to 4.5 in 2019 . There is inter and intra site variability in referral numbers per 1000 ED attendances between different departments, ranging from 0.1 - 24.3.

Conclusion

To plan an effective healthcare system we need to understand the population it serves, and have appropriate structures and processes within it. The overarching message of this study is clear; older peoples mental health emergencies presenting in ED are common and appear to be increasingly so. Without appropriate investment either in EDs or community mental health services, this is unlikely to improve.

The data also suggest very variable inter-departmental referral rates. It is not possible to establish why rates from one department to another are so different, or whether outcomes for the population they serve are better or worse. The data does however highlight the importance of asking further questions about why the departments are different, and what impact that has on the patients they serve.
Reducing admission time to Broadmoor High Secure Hospital – a case review
Authors: Capanna Maria Vittoria , Ali Saima , Bates Robert
Published: June 2021

Aims

Prolonged waiting times for admission to psychiatric hospital settings are a common and widespread issue. Delayed admissions may result in poorer outcomes due to prolonged mental suffering and delays in initiating treatment. Long waiting times also have a negative impact at a service level, impeding patient flow.

National guidance has been recently updated, recommending that patient transfers to secure services take no longer than 28 days from referral. These transfers are frequently affected by delays in admission, possibly resulting in increased risk to patients, staff and the public.

The aim of this project was to audit all referrals to Broadmoor High Secure Hospital in England within a one year period with special focus taken on calculating the time taken from referral to admission. We aimed to assess if there were any rate limiting steps which could be targeted to reduce time from referral to admission.

Method

We collected data and conducted a retrospective cohort review for all admissions from September 2019-September 2020. Where available, information was obtained for each step of the referrals process. Individual patient records were reviewed where required.

Exclusion criteria: data withdrawn, transfers from other high secure services (HSS), incomplete data, “MOJ instruction” or urgent admission bypassing the process.

Result

18 cases were excluded as per exclusion criteria. 46 patients were included in the study. 16 referrals originated from medium secure psychiatric hospitals, and 30 from prison.

The average time from referral to admission was 44.3 days. Admission of patients from MSUs was quicker, taking an average of 40.3 days when compared to prison referrals, which took 45.9 days.

The breakdown of timings for each step in the referrals process was calculated to determine if a rate limiting step could be identified.On average it took 2.1 working days to allocate a case to a clinician, 7.6 days for an assessment, 9.2 days to complete a report and 3.5 days to submit this to the admissions panel. The mean time from referral to the date of the panel hearing was 22.5 working days, and admission took a further 21.8 days on average.

Conclusion

The current average time to admission exceeds the new 28 day recommendation. This could both be due to the COVID-19 pandemic, and miscommunication about time targets. We will review the process and aim to reduce the time from referral to admission in line with new guidance.
An audit on consent to treatment within forensic inpatient units at the Newsam Centre
Authors: Bond Elisabeth , Tial Stephanie Vel En , Stephenson Clare
Published: June 2021

Aims

We aimed to investigate the adherence to the Mental Health Act Code of Practice and the adequate documentation of consent to treatment across three forensic low secure inpatient units.

Method

Our sample included all inpatients detained on three forensic wards at The Newsam Centre. This included a total of 31 patients with an age range of 25 to 59 years. The Mental Health Act Code of Practice was used as criteria for audit standards. Data were collected using Microsoft Excel and analysed using descriptive methods.

Result

We found that 28 patients out of 31 had been admitted for over three months and of these patients 12 were subject to a T2 and 16 subject to a T3. A total of 24 patients had their CTT medication list documented on the online drug chart; with a remaining seven patients who did not. As per guidelines, 27 patients had the appropriate medications prescribed as per their CTT, however one patient did not. The audit revealed a total of two patients currently on a Section 62. Of the qualifying T3 forms, four patients had this reviewed every two years whilst there was one patient who had not.

Conclusion

We found that the adherence to Mental Health Act Code of Practice was overall positive with the majority of service users being reviewed appropriately and documented as per guidance. However, areas identified for improvement included the recording of CTT on online drug charts as well as reviewing T3 every two years. This audit highlights the need for easy access to guidance, appropriate documentation as well as frequent checking of adherence. A leaflet has been created outlining the guidelines and will be distributed to all staff working within the forensic settings and placed in easily accessible locations. As further recommendations from this audit we advise all wards to plan weekly checks during team meetings to ensure information is up to date and that all staff are aware of any discrepencies. A re-audit is planned in the coming months to re-assess adherance after implementation of the interventions.
The impact of COVID-19 on an inpatient mother and baby unit: a service evaluation
Authors: Cranshaw Joanna , Seneviratne Gertrude , Rao Ranga , Ogunmuyiwa Julia , McMillin Rebecca , Ntephe Chukwuma , Dain Victoria
Published: June 2021

Aims

Unique challenges have been faced by women in the perinatal period during the COVID-19 pandemic and the impact of this is compounded for women suffering from mental illness. This service evaluation looked at different aspects of the treatment pathway on a specialist inpatient psychiatric Mother and Baby Unit during the pandemic to identify what changes occurred.

Method

Data were collected for all admissions to the unit between January 2019 and October 2020, with the beginning of the pandemic being defined as on or after 1st March 2020. Information was collected retrospectively from electronic clinical notes on ethnicity, length of stay, diagnosis, mental health act use and restrictive practice, medication, psychology, occupational therapy and social services involvement.

Result

There were 114 admissions to the MBU during the study period. 4 were parenting assessments rather than acute psychiatric admissions and were excluded from the analysis, giving a sample of 110 women. 58% (62/110) were classed as “pre-pandemic” and 43.6% (48/110) were “during pandemic”. 95.45% (105/110) of women were postpartum 4.55% (5/110) were pregnant. Mean length of stay was shorter during the pandemic at 44 days, compared to 61 pre-pandemic. There was greater use of the mental health act during the pandemic: only 43.75% of patients were informal throughout admission, compared to 70.97% pre-pandemic. Mean duration of detention was shorter at 25 days (32 pre-pandemic). Psychotic illness made up a greater proportion of diagnoses during the pandemic: 56% (27/48) compared to 44% (27/62) pre-pandemic. The next most common diagnostic group was mood and anxiety disorders, which made up 29% (14/48) of diagnoses during the pandemic, but 43% (27/62) pre-pandemic. Outcomes as measured using the Health of the Nation Outcome Scale showed a mean improvement between admission and discharge of 6.65, compared to 5.15 pre-pandemic. HONOS scores were higher on admission during the pandemic (12.83, vs 10.88), suggesting a higher level of acuity.

Conclusion

During the COVID-19 pandemic on this Mother and Baby Unit, length of stay was shorter, a greater proportion of patients were detained under the mental health act (although length of detention was shorter) and psychotic illness was more prevalent. This study demonstrates that there were differences in this perinatal inpatient population during the pandemic and this may be a reflection on the wider impact of COVID-19 on perinatal mental health.
Audit of shared-care lithium monitoring in a large rural GP practice
Authors: Cranshaw Thomas
Published: June 2021

Aims

To compare monitoring of lithium treatment with shared care lithium monitoring agreements in a large rural GP practice.

Background

A ‘near miss’ event with a patient with drug induced long QT syndrome highlighted a need for an audit of lithium monitoring at a large rural GP practice.

The practice had entered into shared-care monitoring agreements with the local mental health care trust. Under these agreements, responsibility for physical monitoring of lithium treatment was assumed by the practice.

Method

Using audit functions built into the IT system, all patients at the practice who were currently prescribed lithium-containing medications were identified (n = 28). Individual monitoring standards were determined for each patient based on the shared care agreement. These varied depending on age and comorbidity. Monitoring data obtained from medical records was compared against the individualised monitoring requirement.

Result

The key finding was that 26% of patients for whom annual ECGs were indicated according to the shared care agreement had received an ECG in the past year. 78% of patients had a lithium level recorded in the previous 3 months. 81% of patients had a renal function test within their monitoring requirements. 52% of patients had lipid measurement in the previous year.

Conclusion

There is a great degree of heterogeneity in the extent to which shared care monitoring agreements are achieved. It is noted that those standards to which a Quality Outcome Framework incentive applied had a greater chance of being met. Worryingly, the QOF statements relating to lithium treatment have now been retired as of April 2019. It is suggested that psychiatrists are aware of the challenges primary care faces when monitoring lithium treatment.
Re-evaluating trainee experience of involvement in serious incidents – has anything changed?
Authors: de Bernier Glori-Louise , Debelle Alice , Calcia Marilia , Waterman Lauren
Published: June 2021

Aims

To complete an audit cycle to investigate: trainees’ experiences of SI involvement since 2017, perceptions of current support systems and trust facilitation of learning from SIs and the impact of the interventions implemented following the 2017 survey.

Background

In 2017, data were collected from trainees working in psychiatry within two London trusts to examine the nature of their involvement in serious incidents (SIs), their experience of the process following an SI and their knowledge of the support systems available to them. Due to concerning results from this, several interventions were put in place in accordance with trainees’ suggestions.

Method

Cross-sectional surveys were e-mailed to trainees of all grades in July 2019, including GP and foundation doctors, working within two mental health trusts. These built upon the 2017 surveys, additionally enquiring about demographic information and the personal and training consequences of SIs on trainees.

Result

61 (15% of all trainees) returned the survey with 41 (67%) respondents unable to recall any SI related teaching during induction and 47 (77%) not having received a written guidance document on SI procedures.

24 (39%) had been involved in an SI. Only half felt adequately supported by the trust at internal investigation. Knowledge of the available internal and external sources of support ranged from 38-71% however these sources were rarely utilised. 12 (60%) trainees did not feel that learning had been facilitated following an SI and almost none had been informed of internal investigation outcomes.

Respondents who gave a low (1-4/10) rating of support from their NHS Trust were more likely to have been informed about the incident in person, been invited to team-based support or been aware of the variety of sources of support available, when compared with respondents who scored their Trust support more highly. Suggestions for improvements made by trainees included opportunities to observe coroners’ inquests and a peer support scheme from colleagues with experience of SI involvement.

Conclusion

Unfortunately, trainees did not report much improvement in their experiences compared those in the 2017 survey, and a large proportion continued to feel unsupported. Interventions had not been as widely circulated as intended and only half of trainees had been invited to team-based support. Possible further interventions include increasing email communication to trainees following SIs and setting up a peer support scheme. We are in the process of organising a coroner's inquest observation programme for trainees.
An audit on admission clerkings across Lancashire and South Cumbria NHS Foundation Trust (LSCFT)
Authors: Edgell Sophie , Sultan Ahmed , Hussain Mohammed
Published: June 2021

Aims

Following a Care Quality Commission (CQC) outcome showing that capacity assessments were not routinely completed on admission of patients we decided to complete an audit on current practice. We planned to review admission clerkings at Chorley Mental Health Inpatient Unit to assess quality, with the overall aim of putting measures in place to improve standards. We planned to make the results reflective of all psychiatry wards within Lancashire and South Cumbria NHS Foundation Trust (LSCFT) with the addition of a qualitative survey.

Background

We are aware the standard of clerkings can vary and affect patient care. CQC outcome showed that that capacity assessment was not routinely documented and consultants have stated that clinical impressions are rarely documented in junior doctor clerkings. This audit allowed us to objectively assess these observations. We believed the results may show common themes throughout psychiatric practice more generally.

Method

The gold standard was a 20 item list of expected components of a clerking, based on trust guidelines. A snapshot of current inpatients (n = 30) on 31/10/19 was taken. An Excel sheet was used for information gathering. Data were analysed and graphs created. A qualitative questionnaire on current practice was sent to trainees (n = 8) on different sites for an overview of practice across LSCFT. Therefore, a mixed-methods model was employed.

Result

Items with the highest completion included clerking within 6 hours, face-to-face review with consultant completed within a week and current medication documentation. The items with the lowest completion included clinical impression documentation, bloods completed within 24 hours and documentation of capacity assessment and smoking/substances history. Common factors between clerkings with fewer completed items included poor patient engagement and patient transfer from another ward.

Qualitative survey (n = 8) showed that junior doctors across the health board are not using uniform methods for capacity documentation or an official checklist for clerking.

Conclusion

We concluded that the low rate of capacity assessment completion was an important finding due to legal implications, and that there should be a uniform place for documentation of this. Physical health consequences of other missing components were explored. We will introduce standardisation of capacity assessment documentation and use of a clerking checklist, before re-auditing. The results were presented at local teaching and recommendations sent to Site Tutors for inclusion in local inductions.
Service evaluation project: the effects of healthy weight commissioning for quality and innovation (CQUIN) interventions on metabolic parametrs of service users in a medium secure forensic ward
Authors: Fage Elena , Sharma Gaurav
Published: June 2021

Aims

Service users of secure forensic units can be prone to weight gain due to various reasons including medications, physical illnesses, sedentary habits and mental health difficulties. They in turn are at greater risk of obesity related health problems like Diabetes, Hypercholesterolaemia, Ischaemic Heart Disease, Depression among others.

Our project was aligned with government's plan to improve prevention and screening for the obesity and metabolic syndrome among the patients of medium secure facilities by 2020.

Our primary objective was to gather and analyse the data on current metabolic parameters such as weight, body mass index (BMI), blood pressure (BP) and biochemistry markers of the service users on a 18 bedded Male medium secure long term rehabilitation ward.

Our secondary objective was to suggest healthy weight interventions that would help patients to loose weight and to explore the effects of these interventions on biochemistry markers and vital signs parameters.

Method

We collected cross sectional data in given period of time (mid-March 2020). Seventeen service users were included in the final sample. Following initial data collection, we suggested various healthy weight interventions for the patients and repeated data collection after four months (July 2020).

Interventions offered:

Healthy eating group

1:1 sessions with doctors and pharmacists

Gym referrals

Dietician referrals

Relaxation group

Result

Baseline

Fourteen patients on the ward (n = 14) were found to be either overweight or obese. Two patients (n = 2) had high BP, twelve patients (n = 12) had deranged lipid profile, six (n = 6) had high blood glucose (existing Diabetes).

Following intervention

Fourteen patients (n = 14) remained either overweight or obese. Nine patients (n = 9) lost weight following the intervention. Eight patients (n = 8) gained weight over 4 months. In both of the patients (n = 2) with raised BP the readings came back to normal after the intervention. One (n = 1) patient with normal BP at the baseline had high blood pressure following intervention.

Conclusion

Our service evaluation projects revealed that majority of the patients on the ward had deranged metabolic parameters such as increased BMI, abnormal blood tests and high BP.

Following our intervention more than a half of the patients lost weight whilst other half gained weight during the period of observation, which we suspect is associated with significant physical activity restrictions during the coronavirus pandemic. In both patients with high BP at the baseline it has improved following the intervention.

We would continue implementing healthy weight interventions on the ward and across the unit.
Audit of physical health monitoring during initiation and ongoing treatment with antipsychotic medication in a tier 3 outpatient CAMHS service, Belfast
Authors: Hamlyn Pam , McMenamin Aaron , Boyd Hilary , Patton Lara
Published: June 2021

Aims

To evidence that physical health monitoring during antipsychotic initiation and continued treatment within the Child and Family Clinic is current, as per the agreed Antipsychotic Medication Monitoring Schedule for Belfast Trust CAMHS (2015), supporting Quality Network for Community CAMHS(QNCC) accreditation.

Background

The Antipsychotic Medication Monitoring Schedule CAMHS(2015) was agreed by a working group of consultant psychiatrists and pharmacists, based on evidence from The Canadian Alliance for Monitoring Effectiveness and Safety of Antipsychotics in Children (CAMSEA), NICE Guidelines CG 185(2014), CG155(2013) and Maudsley Guidelines, and was to be located on the electronic system (PARIS).

Method

In January 2019, a list of all children/young people on antipsychotic medication was collated (n = 12). Presence of the monitoring schedule in the clinical notes or PARIS was recorded. The Electronic Care Record was reviewed for blood results and PARIS letters for documentation of physical health parameters (heart rate, blood pressure, height, weight, BMI, extrapyramidal side effects, ECG) and to identify documentation of risk/benefit review where monitoring was declined. Re-audit January 2020 (n = 9). Criteria:

All patients commenced on antipsychotic medication will have baseline blood investigations and other physical health parameters documented as per the monitoring schedule. If monitoring was declined, the reason for this and indications for prescribing must be documented as a risk/benefit analysis.

All patients on antipsychotic medication will be current with their physical health Monitoring Schedule.

All patients will have their Monitoring Schedule completed in clinical notes or on PARIS.

Result

First cycle results (n = 12):

Baseline bloods (or documented declined) = 92%, Baseline ECG (or documented declined) = 75%

Complete monitoring bloods = 33%, Physical health monitoring parameters complete = 42%

Monitoring schedule present in the notes and current = 42% (0% on PARIS).

Initial Recommendations: Standardised recording of monitoring using PARIS clinic letters and the schedule in front of clinical notes; Baseline ECG mandatory

Second cycle results (n = 9):

Baseline bloods (or declined) = 89%, Baseline ECG (or declined) = 67%

Complete monitoring bloods = 44%, Physical health monitoring parameters complete = 56%

Monitoring schedule present in notes and current = 38%, Present, not current = 50% (0% on PARIS).

Conclusion

Lower numbers at re-audit limit interpretation.

Further recommendations: Antipsychotic initiation checklist; Central bloods diary for clinicians; Antipsychotic care-pathway booklet, co-produced with young people, incorporating the monitoring schedule.
Evaluating appropriate use of nictoine replacement therapy on acute adult psychiatric units and adverse events related to smoking bans on wards
Authors: Hasnaoui Sabrina , Ramachandran Virupa
Published: June 2021

Aims

To assess if patients are offered appropriate and adequate NRT (nicotine replacment therapy) upon admission to an acute adult inpatient ward.

To evaluate the number of adverse events occurring which are related to mandatory temporary abstinence from cigarette smoking on inpatient wards.

Background

Not all patients are able or willing to quit smoking when admitted to secondary care. In line with NICE Guidance, psychiatric inpatients should not be permitted to smoke inside the hospital building or outside on hospital grounds. NRT is the most widely used smoking cessation aid. It aims to temporarily replace the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms.. NRT should be offered to patients who need support with nicotine withdrawal during an inpatient stay. Trust guidelines state nursing staff are able to administer NRT to patients on admission without prescription, reducing cravings and withdrawal symptoms such as agitation and anxiety which can lead to adverse events such as aggressive behaviour. Cravings may result in the patients self-discharging or absconding from the ward to smoke.

Method

A retrospective review of electronic records was conducted of all inpatients admitted to two acute adult units over a three month period (65 patients). Patients were identified as smokers or non-smokers. Search words used included: ‘smoking’, ‘NRT’, ‘nicotine’, ‘cig’ to search for relevant entries. Data collected included whether NRT was offered and given by nursing staff on admission and adverse events related to smoking.

Result

Data from 65 patient admissions were reviewed (31 males, 34 females, mean age 37 years). 37 (57%) patients were identified as smokers. NRT was offered and accepted by 17% of patients on admission and not recorded in 77% of admissions. NRT was declined when offered by 3% of patients.

Adverse events related to smoking occurred in 38% of ‘smoking’ patients. 40% of these adverse events occurred in first 72 hours of admission. Adverse events include verbal conflicts, physical aggression towards nursing staff and smoking in patient areas.

Conclusion

The majority of patients were not offered NRT on admission or this was not accurately documented in clinical notes. When offered NRT, a large proportion of patients accepted it demonstrating its acceptability amongst this patient group. There is a high rate of adverse events related to smoking on wards. More accurate documentation is required to ensure NRT is being sufficiently offered to patients to reduce possible withdrawal symptoms and adverse events.
Has vitamin D had its day? An audit of vitamin D, prolactin and HBA1C monitoring over one year in an in-patient secure service
Authors: Lujanschi Oleg , Thomas Toral
Published: June 2021

Aims

To ensure that service users in in-patient secure services have prolactin, vitamin D and HbA1c monitoring as per current best practice guidance.

Background

Service users prescribed antipsychotic medication are at risk of developing raised prolactin levels and metabolic syndrome. In both sexes, long-standing hyperprolactinaemia can lead to low bone mineral density with an increased risk of developing osteoporosis.

In recent years there has been increasing controversy on the increase in Vitamin D monitoring despite the poor evidence for complications from vitamin D deficiency in adults. Not undertaking this test in the absence of symptoms will potentially reduce anxiety for service users could save £17 per test and £50 for a 12-week course of Vitamin D supplementation. Local and national guidance indicate Vitamin D monitoring should only be done in symptomatic people.

Method

Fifty-five service users in the five in-patient wards had their electronic records and pathology results reviewed over a one-year period. All service users were expected to have a minimum of an annual HbA1c and prolactin level but to only have vitamin D monitoring if symptomatic for deficiency.

Result

Although 100% of service users in MSU were tested, vitamin D testing was consistently undertaken without documented clinical evidence of deficiency. The ranges across all units were: prolactin (72- 1384mU/L), HbA1c (30–90 mmol/mol) and vitamin D (15–124 nmol/L). Local reference ranges are prolactin (53- 360mU/L), HbA1c (<48 mmol/mol) and Vitamin D (50–120 nmol/L).

Prolactin levels were highest on the male medium secure wards.

The other two units had significantly less testing with prolactin and HbA1c levels being the least measured (18% of service users on male LSU and 23% on the female ward respectively). Vitamin D testing on these two wards were 38% on the female ward and 18% on the male ward for both tests.

Conclusion

Northside House has a dedicated physical health team and this is likely to explain its 100% score. However, vitamin D testing was being undertaking automatically rather than based on symptoms.

The recommendation is to add prolactin and HbA1c to the physical screens done before CPA meetings for all service users prescribed an antipsychotic but to stop Vitamin D testing in the absence of clinical symptoms of vitamin D deficiency.
Service evaluation of long acting buprenorphine subcutaneous injection (BUVIDAL) in the west Lothian community addictions service
Authors: Martin Amy
Published: June 2021

Aims

1. To establish if long acting buprenorphine subcutaneous injection retains patients in treatment.

2. To obtain the patient opinion of long acting buprenorphine subcutaneous injection and ascertain if it improved other aspects of their life for example relationships and employment.

Method

Information was gathered from TRAK, the patient record recording system, and Illy, the prescribing system. This allowed data to be gathered on previous opiate substitute treatments and when the patient was commenced on the long acting buprenorphine injection. A patient questionnaire was used to obtain qualitative data on the patient's view of this treatment option.

Result

West Lothian Community Addictions Service starting offering long acting buprenorphine injection as a treatment option in March 2020. Since then there has been a consistent demand from patients to be commenced on this treatment. On 31st January 2021 39/53 (73.6%) of patients who had been commenced on long acting buprenorphine for 6 months had been retained on this treatment. Moreover, 3 patients were lost to treatment due to transfer to Her Majesty's Prison. Patients who were commenced on this treatment option were both new to treatment and those who had previously been difficult to retain on methadone or sublingual buprenorphine. The questionnaire supported the antidotal feedback that patients found this treatment option to be hugely beneficial.

Conclusion

Long acting buprenorphine injection has been well tolerated by patients and there has been a clear demand for this treatment option from patients accessing the service. It appears that the clarity of mind, that is associated with buprenorphine, has not been a barrier to retention in treatment. We have found the retention rate of the patients on this treatment option has been higher than the median 6 month retention for either methadone or buprenorphine, compared to a recent systematic review. In addition, it has helped patients consider employment, improve relationships and maintain a level of stability that they may not have previously achieved on either methadone or sublingual buprenorphine.
Electroconvulsive therapy (ECT) and schizophrenia
Authors: Masin Rhys , Kirov George
Published: June 2021

Aims

An evaluation of the benefits of ECT in patients with schizophrenia who received ECT in Cardiff & Vale UHB, in order to:

⋅

Investigate the effectiveness of ECT as a treatment for schizophrenia

⋅

Inform future clinical practice

⋅

Identify clear outcome measures for use in future research

Background

Schizophrenia is a severe and debilitating mental illness, for which pharmacological treatment is often ineffective. ECT is seldom used for schizophrenia, despite encouraging evidence for its efficacy. Current guidance in the UK is inconsistent, as RCPsych contemplates the use of ECT in schizophrenia in certain cases, while NICE does not. This confusion warrants the need for further evaluation of ECT as a treatment for schizophrenia.

Method

Eight suitable patients were identified, and a retrospective chart review was conducted in relation to the following outcomes:

•

What was the main indication for ECT, and was the issue resolved

•

Change in clinical rating scales

•

Concordance with medication before and after treatment

•

Length of hospital stay before and after treatment, over one year

•

Mental Health Act status after treatment for those treated on section

•

Was the level of observation reduced following treatment

Result

Initial indication for treatment was completely resolved in seven out of eight cases. All patients improved in overall symptomatic score (mean improvement = 59.5%). Five patients (62.5%) improved above the threshold of clinically significant response. At the commencement of treatment, three (37.5%) patients were refusing all medication, three (37.5%) had poor concordance and two (25%) were fully concordant. At treatment endpoint, all were fully concordant. Average length of hospital stay remained unchanged: 30 weeks during the year before ECT, and 33 weeks during the year after ECT. Of six patients treated under Section 3, four (66.7%) had their section lifted within six months. Observation level was reduced in all cases that had been placed under continuous observation.

Conclusion

ECT improved all outcomes except admission duration. These results provide support for the consideration of ECT as a meaningful treatment option for schizophrenia.
The improvement of the quality of medical reviews of patients in seclusion in Rampton Hospital
Authors: McPhail Emma , Yanson Ian
Published: June 2021

Aims

Improve and standardise the quality of medical seclusion reviews (MSRs).

Acknowledge existing good practise.

Highlight areas for improvement.

Improve the awareness of doctors performing MSRs of the requirements in the Mental Health Act Code of Practice (MHA CoP)

Background

MSRs are an essential clinical tool to ensure safe and consistent patient care. Patients detained in seclusion can be at heightened risk of poor mental and physical health, in addition to being a risk to themselves and others. There is clear guidance in the MHA CoP regarding what areas require to be covered in a MSR.

Method

A retrospective audit of all MSRs in September 2019 across all patients within all directorates within Rampton Hospital was undertaken. 281 inpatients were identified within Rampton Hospital, and 61 of these patients were found to have had seclusion in September 2019. A total of 439 MSRs were identified for these patients.

The standard applied was the MHA CoP guidance for MSRs:

1)

MSRs should be conducted in person, and should include:

2)

Review of physical health

3)

Review of psychiatric health

4)

Assessment of the adverse effects of medication

5)

Review of observations required

6)

Reassessment of medication prescribed

7)

Assessment of the patient's risk to others

8)

Assessment of the patient's risk of self-harm

9)

Assessment of the need for continuing seclusion

100% compliance with targets or a reason why it was not possible was expected to be documented.

Result

The results show there is a large variation in compliance with the MHA CoP. The area with the highest compliance was the completion of reviews in person-(99.3%). The criterion with the average worst compliance was whether the need for physical observations was reviewed-(4.3%). Physical health was reviewed in 86.1% of cases, in contrast to psychiatric health at 38.3%. The adverse effects of medication and reassessment of medication prescribed were recorded in only 8.9%. The risk from the patient to others was recorded in 25.3%, whereas risk to self was recorded in 10.7%. The need for continuing seclusion was recorded in 72.7%.

Conclusion

The quality of MSRs at Rampton Hospital is currently inadequate. Improvement in practice is required to meet accepted standards and ensure safe, consistent patient care. Ways to improve this are being considered, including improving the knowledge of the MHA CoP and providing a MSR template.
Epidemiology and current treatment patterns of treatment-resistant depression in Scotland: a CPRD study
Authors: Ming Timothy , Denee Tom , Scott Gemma , Morrens Joachim , Weatherburn Christopher
Published: June 2021

Aims

To assess the incidence and treatments currently used in clinical practice for the treatment of treatment-resistant depression (TRD) in Scotland.

Background

Patients with major depressive disorder (MDD) who have not responded to at least two successive antidepressant (AD) treatments in a single episode are described as having Treatment-Resistant Depression (TRD). Epidemiological data on TRD in Scotland is lacking. Furthermore, there is no data to our knowledge on therapies prescribed in Scottish clinical practice to treat TRD.

Method

A retrospective, longitudinal cohort study was conducted using Clinical Practice Research Datalink (CPRD) medical records. Adult patients were indexed on AD prescription, requiring MDD diagnosis within 90 days, from Jan 2011-May 2018 with 360-day baseline and 180-day minimum follow-up periods. Failure of ≥2 adequate oral AD regimens following indexing constituted TRD classification. Incidence rates of MDD and TRD (within the MDD cohort) and treatment lines following TRD classification were derived.

Result

The analysis included 20,059 patients with MDD (mean age 44 years, 63% female, median follow-up 59 months); 1,374 (6.8%) were classified as TRD. Median time-to-TRD classification was 25 months. The incidence rate of MDD was 15.9 per 1,000 patient-years and for TRD was 14.7 per 1,000 MDD-patient-years. For all first four post-TRD treatment lines, SSRI monotherapy was the most commonly prescribed therapy, followed by combination (dual/triple) therapy and augmentation therapy (at least one oral AD supplemented with lithium, an antipsychotic or an anticonvulsant therapy). At first-line of TRD treatment, 1,050 (76.4%) patients received monotherapy AD, 212 (15.4%) received combination AD therapy and 112 (8.2%) received augmentation therapy. The most common monotherapy treatments at first-line TRD were sertraline (15.6%), mirtazapine (13.8%), fluoxetine (12.2%) and venlafaxine (11.6%). Among combination therapies, mirtazapine, venlafaxine, sertraline and amitriptyline were frequently used. Among the TRD and MDD cohort, no somatic treatments were coded in CPRD, although the use of these treatments was likely underestimated.

Conclusion

Monotherapy AD treatment was the most common therapy type for all four post-TRD treatment lines. These data support the need for new treatments that can achieve and maintain therapeutic response, and avoid continuous cycling through similar AD therapies.

This study was sponsored by Janssen Cilag Ltd.
Preliminary investigation into the identification and management of catatonia in patients admitted to adult inpatient units
Authors: Moore Joanna , Kunicki Amy , Latcham Georgina , Perkins Eleanor , Vaccari Emma
Published: June 2021

Aims

The prevalence of catatonia is considered to be approximately 10% in psychiatric inpatients. Clinical experience suggests a lower documented prevalence. This could cause longer admissions and complications, such as Neuroleptic Malignant Syndrome (NMS). We carried out a service evaluation to investigate the recognition and management of catatonia on inpatient units in Southern Health Foundation Trust (SHFT). We reviewed the local documented prevalence of catatonia, treatment offered and prevalence of complications.

Method

We retrospectively reviewed the electronic records of 95 consecutive admissions to four adult inpatient units in SHFT, starting on 1st August 2020. We reviewed notes for the admission to establish whether catatonia was suspected and identified. We applied the screening questions from the Bush-Francis Catatonia Rating Scale (BFCRS) to the documented mental state examinations (MSE) prior to, and shortly after, admission. We also recorded the prescriptions issued during the first 72 hours of admission, and whether patients developed neuroleptic malignant syndrome (NMS), serotonin syndrome or required admission to a general hospital during admission.

Result

Catatonia was documented as a possibility for 2 patients (2.1%). One showed possible posturing and stupor, while there were no documented symptoms for the other. In both cases the possibility was discounted by the clinical team. Twelve patients (12.6%) showed one or more possible or confirmed signs of catatonia. Eleven of these were prescribed regular antipsychotic medication on admission, but only 3 were prescribed regular benzodiazepines. NMS was more likely to be suspected in patients with a BFCRS of 1 or more compared with those with a score of 0, with an odds ratio of 8.1 (95% CI [1.03-64.0], Fisher's exact test = 7.79, p = .076).

Conclusion

Catatonia is likely under-recognised and under-treated locally among psychiatric inpatients. Although only approaching statistical significance, the higher rate of suspected NMS in patients showing possible catatonia is noteworthy and needs further investigation. Regular benzodiazepines were not frequently prescribed in this group, while antipsychotics, prescribed in all of these patients, can precipitate NMS. Alternatively, this finding could reflect the overlap in clinical presentation between NMS and catatonia. Data collection was limited by the frequent use of “remote clerking”, in the context of the COVID-19 pandemic. Additionally, the quality of mental state examinations was often not sufficient to draw any conclusions on the possible presence or absence of catatonic symptoms. This project has highlighted practice in need of improvement, which will be further prospectively investigated and improved via a Quality Improvement Project.
Does the advice requested by carers of people who live with dementia reflect the level of commissioned post-diagnostic support? A retrospective evaluation of calls to the Me2U dementia day centre 24-hour advice line
Authors: Nathan Rajan , Callaghan Stephen , Walker Kelly , Mason Angela , Whittington Rosemarie
Published: June 2021

Aims

The aim was to examine the reasons for advice requests by carers of people who live with dementia (PLWD) that attend the Me2u dementia day centre in order to identify key explanatory themes. We hypothesised that requests were related mainly to coordinating care and clinical issues due to limited post-diagnostic support (PDS) in our area.

Background

The Me2u dementia day centre (Merseyside) cares for PLWD and also supports carers. As part of the service, a 24-hour advice line is included for PLWD and their carers who attend the centre. Locally, there is limited PDS and most carers navigate the health and social care system alone mirroring the findings by the National Collaborating Centre for Mental Health (NCCMH).

Method

We undertook a retrospective evaluation of 244 advice calls, from 64 carers, between 01/06/2019 and 31/12/2019. We analysed time of call, type of advice, type of dementia, age and whether the advice was for the PLWD or for the carer.

Result

Of the 244 calls, the most common time to call was between 09.00 - 14.00 (n = 168; (68.8%) peak 09.00 - 10.00 (n = 38). Average age of the person about whom the advice was sought was 79.08 years. 91.4% of the advice calls related to PLWD (most common dementia Alzheimer's) and 8.6% to the carer only. The mean number of calls per person was 3.8 (range 1–24).

Advice data were grouped into 9 broad themes namely, related to symptoms/behaviour (32.79%, n = 80), request for Me2u to coordinate care (20.08%, n = 49), general advice (14.75%, n = 36), personal care (9.42%, n = 23), carer only advice (8.60%, n = 21), social issues (6.14%, n = 15), social care (4.50%, n = 11), safeguarding (2.46%, n = 6), non-health and social care issue (1.23%, n = 3).

Conclusion

Reasons for limited/poor PDS given by the NCCMH are; absence of named coordinators of care, over-reliance on families and carers to manage and facilitate appointments, poor recognition and management of comorbidities. This data show that 52.87% of calls were for clinical advice and coordination of care reflecting NCCMH findings. The interventions post-call reduced the impact on providers of urgent care.

These findings provide support for the provision of a [24-hour] advice line as a routine part of post-diagnostic support services, especially in areas that have limited or poor PDS. Commissioners of PDS services in areas that have limited or poor PDS should make this a priority to prevent unplanned admissions to hospital and carer breakdown.