bluuebunny/crossref_metadata_2025 huggingface dataset:
Are patients self-referring to Lewisham Community Wellbeing (LCW) when advised to do so by the assessment and liaison psychiatry team?
Authors: Bhatia Gautam , Thevarajan Thileepan , Manivannan Jadesh , Majidian Danny
Published: June 2021

Aims

It is well-recognised by the RCPsych that mental illness is both a cause and consequence of social exclusion, and thus social inclusion is an important part of recovery and leads to better outcomes for patients.

The Lewisham Assessment and Liaison team Neighbourhood 4 (A&L N4) is a CMHT service that acts as an intake team for all referrals into secondary care mental health services, with the purpose of assessment and brief intervention. Currently, if a patient is assessed to potentially benefit from our local social inclusion service, Lewisham Community Wellbeing (LCW), they are advised to self-refer. However, there is no follow-up as to whether patients go on to do this.

Therefore, this audit aimed to calculate:

How many patients are advised to self-refer to LCW (advised referral)

How many of these patients make the self-referral to LCW (completed referral)

Method

The electronic notes for patients who were accepted by the A&L N4 team from July to September 2020 were retrospectively analysed to see if an LCW self-referral was advised. A list of these patients was then given to LCW to check whether they had self-referred.

Result

A&L N4 worked with 82 patients during the study period. 16 patients were advised to self-refer to LCW- an advised referral rate of 19.5%. There was notable month-to-month variation in the advised referral rate- 29.6% in July vs. 9.4% in September.

Of the 16 patients advised to self-refer to LCW, 5 did so- a completed referral rate of 31.3%.

Conclusion

The completed referral rate of 31.3% is difficult to interpret given there are no standards in this area. On one hand, the self-referral process as it currently exists is functioning; on the other, some two-thirds of patients are not making the most of a service deemed to be of benefit to their recovery.

To improve completed referral rates, efforts should be made to better ‘sell’ LCW to the patient. Potential ways of doing this would be through closer working with LCW- for example, LCW could join the clinical meetings more regularly to discuss new services they offer and feedback any patients A&L has referred. There should also be emphasis on making the self-referral process as straightforward as possible.

A secondary finding was the notable monthly variation in advised referral rates. It is important to ensure the A&L team are consistently identifying the right patients for LCW, and again, closer liaison with LCW would help achieve this.
Oppurtunistic completion of the 9 diabetic care processes during inpatient admission to a mental health hospital: an audit of local practice
Authors: Brooker-Thompson Chad , Sultana Yasmin , Ashraf Adeela
Published: June 2021

Aims

Diabetes is more prevalent in people with mental illness than in the general population. Those with both mental illness and diabetes are more likely to have poor glycaemic control. Clients with mental illness and diabetes are less likely to receive the 9 NICE recommended annual diabetic care processes than the general population. In 2017, the Joint British Diabetes Societies for Inpatient Care (JBDS-IP) and the Royal College of Psychiatrists released guidance recommending that inpatient psychiatric admissions should be used as an opportunity to complete diabetic care processes, and a named staff member should be responsible for this.

We aimed to review local compliance with this JBDS-IP guidance, increase knowledge and improve local care for clients living with both mental illness and diabetes.

Method

We reviewed the notes of all current inpatients to general, forensic or learning disability wards at our centre and identified all patients with a known diagnosis of Diabetes. We identified which of the 9 care processes had been completed (or had the most recent result documented, or had a plan made for completion) during this admission. We identified if a named staff member was responsible for completing processes on each ward, and whether the care processes were documented in the patients’ notes.

Result

We identified 18 current diabetic inpatients at our centre (14% of inpatients). We found that none of these patients had a diabetic care processes review documented and none of these patients had had a foot check and urinary albumin performed during admission, or had the last community result identified and documented. We found that less than 15% of patients had a documented plan concerning the completion of retinal screening. One ward had a named staff member responsible for reviewing their diabetic patients’ screening. However, 6/9 care processes had been completed in the significant majority of patients (>75%).

Conclusion

Our centre is not compliant with the guideline audited. We have implemented a plan to increase awareness of care processes through posters, teaching (at junior and consultant level), creating documentation templates and ensuring wards nominate a staff member to review care processes. We have organised a re-audit. Organising foot examination, renal function testing and retinal screening during admission for clients who may have complicated social situations and may not be aware of (or be non adherent with) the long term management of their diabetes has the potential to significantly reduce morbidity in this client subgroup.
An audit into the use of psychotropic medications in patients with autism spectrum disorder in a high security psychiatric hospital
Authors: Carthy Elliott , Murphy David
Published: June 2021

Aims

Autism Spectrum Disorder (ASD) is a common neurodevelopmental disorder associated with difficulties in social communication and language development, preoccupations, a need for routine, sensory sensitivities and emotional dysregulation. People with autism who have violently offended may be prescribed psychotropic medications to treat comorbidities, or off-license to manage aggressive or challenging behaviours. However, the evidence base for their use remains scarce.

Method

This was a retrospective audit at Broadmoor Hospital, a high security psychiatric hospital in the United Kingdom, into the safe and appropriate prescribing of psychotropic medicines in those with an ASD compared to guidance from the National Institute for Health and Care Excellence (CG142): “Autism spectrum disorder in adults: diagnosis and management”. This first cycle was undertaken during May and June 2020 and included all patients with a confirmed or equivocal diagnosis of ASD in the preceding five years.

Result

A total of 22 participants were included in this study. Of these, 17 participants had a confirmed diagnosis of ASD and five participants had a suspected diagnosis of ASD, but without formal confirmation with neurocognitive testing. A total of 13 (76.5%) participants with confirmed ASD were prescribed antipsychotic medication, nine of whom had an established comorbid mental disorder with psychotic symptoms. Of the remaining four, three had a diagnosis of a personality disorder. Three participants in this study had a confirmed diagnosis of ASD without any additional comorbid mental health diagnoses. No patients were prescribed psychotropic medicines for the core symptoms of ASD. The specific documentation of off-license use of antipsychotic medicines in those without a diagnosis of a psychotic disorder was poor. This was not recorded in any such participant in the preceding 12 months.

Conclusion

This audit highlighted that dual diagnoses of ASD alongside non-affective psychosis and personality disorder are over-represented in this high security setting. The NICE clinical guidelines CG142 guidelines state that “antipsychotic medications should only be used for behaviour that challenges if …. the risk to the person or others is very severe”. By definition, all patients admitted to high security are deemed to be a grave and imminent risk to the public. Psychotropic medicines may therefore be clinically indicated at a much earlier stage than in community patients, instigated alongside appropriate psychosocial interventions and treatment of comorbid conditions. It may be that catered guidelines need to be formulated to support the safe and appropriate prescribing of psychotropic medicine in forensic settings.
An audit into the management of diabetes mellitus at Broadmoor Hospital
Authors: Carthy Elliott , Ross Callum
Published: June 2021

Aims

Diabetes mellitus confers a twofold excess risk of cardiovascular disease - the leading cause of premature mortality in those with severe mental illness. Inpatients in forensic settings often have more severe, enduring and treatment-resistance forms of mental illness, sometimes necessitating combinations of prescribed antipsychotics. This audit aimed to assess adherence to National Institute for Health and Care Excellence (NICE) guidelines NG28 titled “type 2 diabetes in adults: management” and summarise the metabolic parameters of those with diabetes mellitus at Broadmoor hospital.

Method

This was a retrospective audit in a high secure forensic psychiatry hospital in the United Kingdom, into the management of patients with diabetes mellitus compared to guidance from NICE (NG28).

Result

We report data from over 30 inpatients (out of approximately 200) at a high secure forensic psychiatry hospital with a diagnosis of type 2 diabetes mellitus across two audit cycles. This audit identified improved adherence to national guidance regarding six monthly monitoring of HbA1c but with less than 50% of such patients having an HbA1c at or below the recommended target. This is in addition to high rates of other metabolic disorders such as obesity, dyslipidaemia and hypertension and a mean QRISK3 score that was markedly higher than a healthy person with the same age, sex, and ethnicity. There was a prevalence of background diabetic retinopathy of 8%, diabetic nephropathy of 5.4%, no recorded cases of diabetic neuropathy and a macrovascular disease prevalence of 5.4%. There were no new diagnoses of microvascular or macrovascular disease between audit cycles. One of the key changes between audit cycles was the recruitment of a dietician to the hospital. By the time of undertaking the second audit cycle, 23 patients had documented evidence of having been offered a referral to the dietician.

Conclusion

This audit highlighted the marked cardiovascular risk in patients with type 2 diabetes mellitus at a high secure forensic psychiatry hospital. This includes suboptimal control of blood pressure, lipid profiles and HbA1c that increases the risk of premature mortality in these patients with severe mental illness. Wider, cultural changes in practice need to be implemented to improve the metabolic health of patients in the long-term inpatient setting of Broadmoor Hospital. This includes prescribers avoiding the most diabetogenic antipsychotics where possible, increasing the provision of sugar-free options at the on-site shop, examining the proportion of carbohydrate-rich foodstuffs in the shop and understanding the characteristics of its heaviest purchasers, and continued coordination between primary care and ward teams to support patients in making sustained changes to improve their metabolic health.
Junior doctor daytime bleep audit
Authors: Dhandapani Asha , Soundararajan Sathyan , Sambhi Rajvinder
Published: June 2021

Aims

There had been ongoing concerns with regard to covering daytime duty bleeps across the three sites in the Mental health Department, BCUHB, North Wales.

Frequent empty on-call slots meant some doctors being asked to hold the bleep between 9-5 in-order to cover the vacancy.

Some felt this added to the existing workload and that it was unfair and unsafe.

This issue was raised during a supervision session with the Educational supervisor, North Wales and an initial data collection was suggested.

Method

Data were collected over 2 week period to look at the Daytime bleep duties between 9 am to 5 pm

We hoped the data would demonstrate certain patterns of the task being asked to perform.

Result

The total number of bleeps were noted to be 249

Discharge notification and prescription writing was noted to be the commonest reason for bleep in East and Central while Routine review and Discharge notification was the reason to be bleeped major number of times in the West

Nearly 70% and 90% of the bleeps were found to be appropriate by the East and West respectively, while only a mere 15% were reported so in Central.

While 30% of these bleeps in the West were considered to be deferred, 70% bleeps were deferrable in the East and almost 95% in Central.

The general trend in all 3 centres was as follows:

All three centres have high numbers of bleeps for discharge, prescribing tasks and routine patient reviews

Most think planned discharge paperwork could be done in advance and jobs can be deferred if there is a ward/team doctor available

Conclusion

A simple solution could be some jobs being planned ahead (e.g TTO/Discharge Summaries, Re-write charts) and done by the team/ward doctor. ECG could be arranged to be done by nurses/ECG technicians. Some nurses/HCAs are trained in phlebotomy, however, they have not been utilising the skills. That needed to be reinforced in safety huddles meeting.

Apart from these suggestions, we were also wondering about the impact of the service models and how the juniors placed in the community mental health unit could stay involved in their team inpatients
Dementia screening: an audit of screening for reversible causes of dementia
Authors: Herbert Kim , Richardson Elspeth , Daly Adam , Carswell Christine
Published: June 2021

Aims

This audit aimed to assess to what extent patients being referred for assessment of memory problems were receiving appropriate screening for reversible causes. We considered the blood tests recommended by the National Institute for Clinical Excellence (NICE).

Background

Research into ‘reversible dementias’ identified numerous common underlying causes. As a result of this NICE complied comprehensive guidance on investigations which should be performed in the initial stages of assessing patients with memory problems, ideally at a primary care level. These investigations are also crucial at the point of secondary care assessment in order to make a confident diagnosis.

Method

Details of patients referred by their GP to the Older Adult CMHT with memory problems over a one month period were collected. We then used the local laboratory database to note whether each of the eight recommended blood tests had been performed in the preceding 6 months. We measured this against an agreed standard of 95%.

After the first cycle of data collection we prepared business-card sized ‘aide memoirs’ for GPs that could serve as a quick reminder. These were sent out to all GPs in the area along with a letter outlining the audit findings.

Result

Overall 31 patients were included in the first cycle. 15 patients had all 8 dementia blood screens (48%), 13 (42%) had some of the recommended tests and 3 patients had no screening tests at all (10%). On average patients had 76.6% of the recommended bloods completed. The most commonly completed tests were Full Blood Count (FBC) and Urea & Electrolytes (U&Es), with blood Glucose being the most frequently omitted.

In cycle 2, 20 patients were included. Of these patients, 10 had the full complement of screening bloods (50%); 8 had some tests completed (40%) and 2 patients had no screening tests complete (10%). On average 76% of tests were completed. There was an improvement in the rate of completion of both Glucose and Liver Function Tests from cycle1.

Conclusion

This audit demonstrated that current practice does not meet the national standard in general. Our intervention produced a modest improvement in the proportion of patients who received a full complement of dementia screening tests, as well as increasing the rate of patients receiving a blood glucose as part of their screening. It would likely be beneficial to consider further intervention and a 3rd audit cycle in due course.
An evaluation of the prevalence of physical health comorbidities in patients with severe and enduring mental illness following admission to the general adult psychiatric inpatient wards in Mersey Care NHS Foundation Trust
Authors: Hyland Declan , Prime Millie , Carter Ellen
Published: June 2021

Aims

This evaluation aimed to establish the prevalence of physical health comorbidities in SMI patients admitted to the general adult wards in Mersey Care NHS Foundation Trust.

Background

Mean life expectancy in individuals with severe and enduring mental illness (SMI) is 15-20 years shorter than that of the general population. A significant proportion of excess mortality in patients with SMI is due to natural causes, e.g. cardiovascular disease and type II diabetes mellitus. Although SMI patients are at greater risk of developing chronic physical health problems, they often receive worse health care than the general population. SMI patients more likely to engage in unhealthy lifestyle behaviours, such as poor dietary choices, smoking and physical inactivity; Antipsychotic medication prescribed to these patients can cause adverse metabolic side effects.

Method

A list of all inpatients on the eight general adult wards in the Trust was obtained in September 2020, producing a sample of 135 inpatients.

An audit tool was designed, capturing demographic data – gender, age, ethnicity, and also recording whether the patient had a diagnosis of an SMI (e.g. schizophrenia, bipolar affective disorder). The presence of any physical health comorbidities and whether the inpatient was a smoker was also recorded.

Result

Of the 135 inpatients, 10 didn't have any physical health monitoring completed and were excluded from the sample, making the final sample 125 inpatients. 68 of the inpatients were male, 57 were female. 98 had a diagnosis of an SMI, 27 did not. Most inpatients were of “white British” ethnicity. Of the 98 SMI patients, 14 had type II diabetes mellitus, 11 had essential hypertension, 12 had chronic obstructive pulmonary disease and 22 were obese (i.e. a BMI > 30 kg/m2). 70 of the 98 patients with an SMI were smokers.

Conclusion

As expected, a significant proportion of patients with SMI admitted to the general adult inpatient wards are smokers. Whilst admission to hospital may not be considered an ideal time to get patients to consider quitting smoking, admission does at least provide an opportunity to educate patients on the negative effects on physical health that smoking has. This evaluation has highlighted that physical health comorbidities are common in this patient group. Admission to the psychiatric ward provides a golden opportunity to provide education to patients on the importance of making healthy lifestyle choices and also to assess any physical health comorbidities and ensure the management of any such comorbidities is optimised prior to discharge.
Evaluation of physical health assessments for new admissions to the Oleaster during the first wave of COVID-19
Authors: Lawson-Smith Erin , Sutherland Danielle , Brookes Eleanor , Zhang Alex , George Joji
Published: June 2021

Aims

Physical health of psychiatric inpatients is worse than the general population. Physical health monitoring of these patients can have positive effects on outcomes. Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) states that a physical health assessment (PHA) should be completed within 72 hours of admission. This comprises a physical health form (PHF) and minimum data set (MDS): BP, BMI, TB and BBV status, alcohol and drug screen, smoking status, Hba1c and lipids. In a 2017 audit, compliance was shown to need improvement, with 28.3% of admissions not having a PHF documented.

Objectives

To assess whether PHAs for new admissions to the Oleaster, Birmingham during the first wave of COVID-19 were completed in line with trust policy

To compare findings with a previous audit

To make recommendations to improve inpatient physical health and compliance with trust policy

Method

A retrospective audit was conducted, with PHA details accessed via the electronic medical records system RiO. Admissions from 16/03/2020-30/06/2020 were accessed and 158 admissions (155 patients) were included. 21 admissions were excluded as they were internal transfers; only data from the initial admission were included. Data were collected by 2 medical students and a psychiatry trainee using a data collection tool. Data were recorded and analysed on Excel.

Result

Of 158 admissions, 81 had PHFs (51.3%). 59 were completed within 72 hours of admission (34.3%); 39 were completed fully (24.7%). Of incomplete PHFs, 2 explicitly stated incompletion due to COVID-19. 22 PHFs were created but not completed within 72 hours. 15 gave a deferral reason e.g., refusal to consent or agitation. For 77 admissions (47.3%), no assessment was documented, with no reason given.

2 admissions (1.3%) recorded the full MDS within 72 hours of admission.

2 admissions (1.3%) had fully complete PHAs (PHF and MDS) within 72 hours of admission, fulfilling trust policy.

Conclusion

51.3% of admissions had a PHF, with 34.3% documented within 72 hours of admission. However, only 1.3% of admissions fulfilled trust policy of both a completed PHF and MDS within 72 hours of admission. There were more admissions without a PHF than in the previous 2017 audit; 47.33% compared to 28.3% previously. Given trust targets that a PHA should be fully completed for 100% of admissions, it was found that the Oleaster did not meet these guidelines during this period and improvements must be made to maintain integrity of patient care.
Impact of COVID-19 on referrals for physical and mental health care
Authors: Lekkos Petros , Thorpe Joanna , Obeney-Williams Janet , Xing Fiona
Published: June 2021

Aims

To determine the effect of the COVID-19 pandemic on referrals to mental health and physical health services.

Method

We analysed referral data from three psychiatric services in the boroughs of Camden and Islington across 2018-2020: Early Intervention Services (for patients with a 1st episode of psychosis), Crisis Resolution Teams and inpatient admissions. We also analysed GP referral data to Cancer Services (two-week wait referrals) to Whittington Hospital, Royal Free Hospital and University College Hospital (all of North Central London). We examined the impact of the COVID-19 pandemic on these referrals and compared the findings between physical and mental health. We chose to use EIS and Cancer services as comparable services since they both operate with the two-week target of achieving diagnosis of psychosis and cancer respectively.

Result

The number of referrals to EIS and CRT both decreased to 61% in April 2020 with respect to their baseline; EIS referrals continued to decrease to 48% in May before starting to recover. Inpatient admissions saw a smaller reduction to 87% in April 2020. The number of cancer two-week wait referrals similarly decreased and reached a trough of 37% in April 2020. The rate of recovery back to the baseline number of referrals and admissions relative to previous years differed between services, with acute care recovering faster. Referrals to CRT and inpatient admissions recovered by 98% and 115% respectively by June 2020; comparatively, referrals to EIS recovered to 102% by December 2020. In contrast, cancer two-week wait referrals returned to 106% by September 2020, a rate faster than EIS, but slower than CRT and inpatient admissions.

Conclusion

The reduction in the number of referrals across all examined services correlated with the first wave of the COVID-19 pandemic. The rate of decrease was similar across all services, coinciding with the peak of COVID-19 infections. However, the ultimate degree of decrease and following rate of recovery in numbers differed across both psychiatric and non-psychiatric services. These differences likely have multifactorial origins. The authors discuss contributing factors, such as changes in health seeking behaviours observed during the pandemic, potential impact of reduction in face to face consultations in primary care, as well as temporary changes in the population demographic of Camden and Islington resulting in absent target groups (i.e. students who make up a large proportion of referrals to EIS opting to return home). It remains important to not neglect mental health and face a hidden epidemic once COVID-19 pandemic settles.
You have to acknowledge the problem before you can address the problem: Audit looking at identification of co-existing substance misuse in a Liaison Psychiatry patient population
Authors: McLean Emma , Kadiwar Akash , Alexander Mariam
Published: June 2021

Aims

To evaluate if patients referred to Ealing Liaison Psychiatry Service (ELPS) with co-existing substance use are being appropriately identified as per NICE guidelines.

Patients with co-existing substance misuse have greater morbidity and mortality and it is therefore important to identify these patients to optimise their management. NICE recommends that all patients are asked about their substance use.

Anecdotally, our team felt we were doing a good job of identifying and managing such patients but we had no objective evidence of this.

Method

Completed a retrospective audit looking at a sample of patients referred to ELPS over two weeks in December 2019.

A training session for ELPS was then held to highlight the initial audit results and NICE guideline recommendations.

We then repeated the audit over two weeks in March 2020.

Result

Initial audit (100 patients):

Only 69% of patients asked about substance use. From those asked, 50-65.2% were using a substance, most commonly alcohol.

None of the patients over the age of 80 were asked about substance use vs 79.5% of patients aged 20–40 years.

55% of females vs 81% of males were asked about illicit substances.

33.3% of ward referrals vs 74.2% of Emergency Department referrals asked about substance use

Re-audit (53 patients):

Significant improvement across all areas

93% now asked about substance use

60% of over 80s, 96% of females and 85% of ward referrals were now being correctly asked about substance use

Conclusion

We were surprised to find that we were initially not meeting NICE standards regarding asking patients about their substance use.

Acknowledging this problem during our training session proved to be effective.

This knowledge will help us develop our care pathways with our Acute colleagues and the Drug and Alcohol Liaison Service.
The monitoring and use of Pro re nata (PRN) psychotropic medication for people with learning disabilities on an inpatient ward
Authors: Mistry Heena
Published: June 2021

Aims

This project was designed to evaluate the use of PRN medication and PRN monitoring charts on an adult learning disability ward. These charts had been designed by the trust to provide us with a way of monitoring the use of psychotropic PRN medication to ensure monitoring of treatment response, physical health and side effects.

Method

The data were collected from PRN monitoring charts, electronic case notes and electronic prescribing chart records for all patients on an adult learning disability inpatient unit. The sample consisted of 7 patients who had been prescribed and/or received PRN psychotropic medication over a five week period. Quantitative data were derived by simple calculation for the total amount of PRN medication used and number of PRN monitoring charts completed. Qualitative data were collected of prescription charts and PRN protocols which is supposed to guide treatment.

Result

Out of all the incidences where PRN medication was administered, only 64% of monitoring charts were completed. Out of the 7 patients on the ward, 6 had PRN protocol charts and for only 5 patients these were followed.

Conclusion

Clinical practice must be improved. The results were presented to ward staff and doctors to discuss the implications for patient care and ways to improve clinical practice by ensuring full monitoring of the use of PRN medication to help reduce the overmedication of people with learning disability by improving the use of the PRN charts. NICE guidelines and The Royal College of Psychiatrists have published guidelines on the prescription of psychotropic drugs for people with learning disabilities. NHS England have also published an article to discourage over-medication of people with learning disabilities. There is a risk that doctors are prescribing medication to treat behaviour that is an expression of distress or a mode of communication rather than a mental disorder. Doctors have a responsibility to ensure they have fully assessed the person's potential to benefit from medication before they prescribe. The audit would serve to provide a baseline for this team prior to any audits in the future.
The effectiveness of community treatment orders (CTOS) across Birmingham and Solihull Mental Health Foundation Trust (BSMHFT)
Authors: Navaratnarajah Sambavi , Basu Riya , Rashid Syed
Published: June 2021

Aims

To ascertain if CTOs ensure that patients are effectively treated in the community and maintain stability in their mental health.

If a patient requires recall(+/- revocation) that this is done in a timely fashion in according to the 1983 Mental Health Act.

Background

A number of studies have been inconclusive in determining the benefits of CTOs in reducing the re-admissions of “revolving door” patients In Assertive Outreach (AO). It is felt that CTOs have reduced readmission of patients due to the intensive input from community teams, decreased recall and subsequent revocation. Those admitted are thought to require fewer inpatient days. It is clear that many patients who require recall following non-engagement, non-compliance, will accept medication following RC review. However at present in BSMHFT patients can only be recalled if they are allocated a bed. Due to the national bed shortage, this has resulted in delays following decision to recall and thus early and effective treatment for patients. In this aspect it defeats the role of the CTO as per the 2007 MHA.

Method

CTO data from 1st April 2018 to 31st March 2019 was obtained from all 6 AOT's in BSMHFT. The following factors were considered;

1.

Time between decision to recall by RC and recall to inpatient facility

2.

Number of recalls converted to revocations

3.

Number of inpatient bed days if revoked

4.

Number of admissions on CTO

5.

Patient/family agreement of CTO

Result

98 CTO patients were recorded over this period. 19 out of 26 recalls had recall dates documented. 10 recalls were revoked due to relapse of mental illness. Average days from RC recall decision to actual recall or cancellation was 63.89 days. Main reasons for delay were bed unavailability and execution of warrant.

Following revocation, average inpatient bed days was 103.71. 41% of families agreed with CTOs, 36% of patients contested their CTO.

Conclusion

Over a quarter of patients on CTO were recalled to hospital however, less than half of these had their CTO revoked. The remainder accepted treatment following urgent community review whilst on the bed list. Evidently the majority of patients didn't need admission. With the ongoing bed crisis, alternative avenues need to be sought to ensure prompt treatment and prevent relapse.

A CTO suite designed for recall could be the solution for the future.
Neuroimaging in an older adult inpatient psychiatric unit
Authors: Nechowska Aoife
Published: June 2021

Aims

This audit aimed to analyse the use of neuroimaging and its effect on treatment in an older adult inpatient psychiatry unit over the period of one year.

Background

Brain imaging can be used as a diagnostic tool in psychiatry. According to NICE guidelines, structural imaging, such as magnetic resonance imaging (MRI) or computed topography (CT), can be used in the workup for dementia diagnosis in order to exclude non-dementia pathology and identify dementia subtype. This is important in the geriatric population where evidence of small vessel disease has an impact on treatment options and management of polypharmacy.

Method

A list of patients from the past year (January to December 2019) was accessed. Patient records were then analysed to see if neuroimaging had been accessed during their admission at The Meadows Hospital, Surrey and Borders Partnership. This included imaging from prior to admission. Analysis was divided into type of imaging, comments and impact on diagnosis.

Result

Overall numbers for the audit were small. A total of 74 patients were admitted onto the unit, of which 3 were readmissions. There was missing information for 8 patients, giving a total of 63 patients. CT scans were accessed for 35 patients (56% of total); 3 of these were done during the admission. MRI scans were completed for 21 patients (33%), with one requested during admission. A total of 9 patients (14%) had both CT and MRI scans. Neuroimaging results led to a change in diagnosis for 6 patients (10%). In all cases this reflected the finding of small vessel disease and a change of diagnosis to either vascular dementia or mixed dementia.

Diagnoses were also analysed. The Meadows Hospital has 2 dementia wards (male and female) and 1 functional ward (for females). A total of 36 patients (57%) were diagnosed with dementia, of which the biggest groups were: Alzheimer's dementia (13 patients, 36%) and Vascular dementia (11 patients, 31%).

Conclusion

The majority of the patients were admitted with established diagnoses and so only a small number had changes made following review of imaging. Good imaging results and reports help to differentiate types of dementia. Although neuroimaging is not gold standard in diagnosing dementia syndromes, it is now an important aspect in the diagnostic pathway. Getting the diagnosis correct will help with treating individuals appropriately and avoid unnecessary prescribing.
Compliance to completion of sodium valproate annual risk acknowledgement form among women of child-bearing age prescribed sodium valproate in the intellectual disability (ID) services of an NHS trust
Authors: Ohize Victor , Bagalkote Deval
Published: June 2021

Aims

To determine the proportion of women of child-bearing age prescribed SV who have the SV ARF filled.

Background

In 2018, the Medicines and Healthcare products Regulatory Agency (MHRA) gave guidance regarding Sodium Valproate (SV) prescription. It acknowledged the significant risk of birth defects and developmental disorders in women of child-bearing age prescribed SV.

Consequently, the MHRA recommendation is that SV must not be used in females of child-bearing age unless: conditions of pregnancy prevention programme are met; other treatments are ineffective or not tolerated; and evidence of discussion of risks with patient or carer and annual review of the risks are documented. The evidences of the above criteria are expected to be documented in an Annual Risk Acknowledgement Form (ARF).

Method

Retrospective study involving systematic search of Trust database to identify women with ID, aged 16–50 years prescribed SV from 2018 to 2019.

Result

18 of 28 patients had ARF filled, a 64% compliance.

The main indications for SV prescription were epilepsy; challenging behaviour; and mood stabilization.

The distribution showed neurology and psychiatrist led prescription initiation equally distributed at 50%.

The ARF compliance was higher in the neurology group (93%) compared to 36% in psychiatrist group.

A review across the 5 ID teams (A,B,C,D and E) of the trust shows variable compliance to ARF compliance (17%,81%,100%,60%,0% respectively) with teams having higher proportion of neurology led SV prescription initiation also having higher proportion of ARF completion compliance (0%,55%,80%,80%,0% respectively).

Conclusion

Conclusion / Recommendation

ARF compliance is below standard at 64%.

Despite the SV prescription being equally distributed between neurology led and psychiatry led, patients whose prescription of SV is neurology led (prescription indication as epilepsy) had better ARF compliance outcome (93%) compared with patients whose prescription is psychiatry led (prescription indication as challenging behaviour or mood stabilization) with 36% ARF compliance.

Organizational difference with dedicated epilepsy nurse in the ID service means patients with epilepsy had reviews of medication and compliance to MHRA guidance in completing the ARF.

There is need to increase doctors’ awareness to review ARF status during patients’ appointment. Information Technology design to flag up out of date ARF may be helpful.

The review of ARF may also flag up consideration of other alternatives: behavioural, psychological, functional and environmental interventions as well as alternative medications like Risperidone for challenging behaviours and other mood stabilizing options. This will minimize SV prescription, which is the original goal of the MHRA guidance.
A clinical audit to investigate polypharmacy and interactions in inpatients in an old age psychiatric ward
Authors: Rathnaiah Mohan , Brailsford Beth , Mokashi Nisha
Published: June 2021

Aims

To identify any problematic polypharmacy in the patient records of those staying in Cherry Ward, an old age psychiatric unit at Highbury Hospital, Nottingham in the calendar year 2018.

Background

Multi-morbidity is defined as more than one long-term medical condition in a single individual and is a factor that is closely associated with polypharmacy, the use of multiple medications concurrently. Appropriate and Problematic are the two classifications of polypharmacy outlined by the King's Fund report, the first describing optimised evidenced-based pharmacological management of comorbidities and the latter to label prescribed medications whose use is not in the best interests of the patient. The risk of drug interactions and adverse drug reactions is increased with polypharmacy, and frail elderly patients are particularly at risk of the side-effects of psychotropic medications used in the management of mental health disorders. Guidelines highlight this group as a key party to be identified when searching for at-risk people.

Method

The electronic records of those admitted and discharged from Cherry Ward in 2018 were reviewed in the period spanning January to May 2019, and the first forty-three patients were analysed in Microsoft Excel using criteria based on the King's fund report and the Medscape and BNF (British National Formulary) drug interaction tools. The Medscape drug interaction checker was used for initial screening; the complete medication list for each patient was entered into it and the number of interactions was displayed with advice on severity. If necessary, the individual interactions for each specific medication could also be cross-referenced in the BNF using the extensive lists provided for each drug. These are also graded from mild to severe.

Result

On discharge, 69.7% (thirty patients) met the criteria for being at higher risk of polypharmacy. One patient became at higher risk of polypharmacy during admission, and another two stepped down from meeting the criteria on admission but not on discharge. Thirty-one of the forty-three patients had at least one interaction recorded; 18.6% (eight patients) had at least one potentially severe interaction.

Conclusion

A substantial proportion of patients in Cherry ward in 2018 were at a higher risk of polypharmacy, reflecting current practice as outlined in the King's Fund report. Problematic polypharmacy is common among older patients hospitalised with psychiatric illness. Recommendations include use of an automated electronic system to investigate and flag up problematic polypharmacy and severe medication interactions.
Cervical screening in assertive outreach team patients
Authors: Reynolds Hannah , Bello Samaila , Leech Hanna
Published: June 2021

Aims

To assess the uptake of cervical screening in patients under Birmingham and Solihull Assertive Outreach Teams; this included a re-audit of patients under the Central Birmingham Assertive Outreach Team.

Background

Patients with severe and enduring mental illness are known to have poorer physical health outcomes. In Birmingham and Solihull there are 6 Assertive Outreach Teams. These teams manage patients with a diagnosis of psychosis who have complex needs requiring intensive multidisciplinary input and often struggle to engage with health services. The national cervical screening programme aims to prevent cervical cancer by detecting and treating cervical abnormalities. Acceptable coverage is defined as screening at least 80% of people aged 25–49 years within the last 3.5 years and 80% of people aged 50–64 years within the last 5.5 years. In 2018 71.4% of women in England and 70.9% in the West Midlands were screened adequately. An audit of 15 patients under the Central Birmingham Assertive Outreach Team in 2014 showed 46.2% had taken up screening, measured in the last 5 years for those aged 50–64 years and the last 3 years for those aged 25–49 years.

Method

A list was obtained of all female patients under the Assertive Outreach Teams with patients excluded if they were under 25 years or over 64 years or if they were known to have undergone a total hysterectomy. All GP practices with eligible patients registered to them were written to requesting the date of the patient's most recent smear test. Cervical screening was classed as in date if carried out in the last 3.5 years for patients aged 25–49 years or 5.5 years for patients aged 50–64 years.

Result

Out of 127 eligible patients, 110 had correct GP details on their record. Responses were received regarding 101 patients, 48 of whom had in date cervical screening (47.5%). Of 58 patients aged 25–49 years, 26 had in date cervical screening (44.8%). Of 43 patients aged 50–64 years, 22 had in date cervical screening (51.2%).

Conclusion

13.4% patients did not have a known GP practice, increasing the risk of multiple poor physical health outcomes. The rates of cervical screening among Assertive Outreach Team patients are similar to the original audit in 2014 and fall significantly below the national standards and averages. These findings, along with the importance of working together to address the need for physical health monitoring in this population, will be communicated with the local Assertive Outreach Teams and GP practices.
Implementation of physical examination pro forma – a complete audit cycle
Authors: Singh Sidhu Deshwinder , Molyneux Guy
Published: June 2021

Aims

Aim of this audit is to achieve and maintain 100% compliance in physical examination on admission.

Background

Conducting physical examination on admission is a mandatory requirement and is monitored by the Mental Health Commission during yearly inspections. A report published by Inspectorate of the Mental Health Commission recently in 2019 identifies a gap in physical health monitoring. We conducted a complete audit cycle in an inner city hospital psychiatric ward to monitor compliance with physical examination on admission.

Method

We based the audit on Judgment Support Framework (JSF) version 5 standards. A retrospective review of all of the patient's medical records was carried out. 13 medical records were reviewed in the first cycle. The results of the first cycle were presented to the Multi Disciplinary Team (MDT) members, including the Non-Consultant Hospital Doctors (NCHD). Physical health policy was reviewed, in consultation with the committee and Clinical Director, a Physical Examination pro-forma (colour coded) was developed and implemented. It was based on the National Guidelines and the JSF ver.5. All members of the MDT and NCHDs were briefed on the pro forma introduced. A repeat audit cycle was conducted of all patients admitted after first audit cycle. Data were collected using a simple audit tool indicating if physical examination was conducted or refused.

Result

A total of 22 medical records were audited. 13 medical records in the first cycle indicted only 3 patients had physical examination on admission. However, prior to admission a total of six patients had physical exam in the Emergency Department (ED). Upon implementation of the pro forma, 9 medical records of all patients admitted post-first cycle were audited. A total of 7 patients had physical examination on admission to the ward. Two patients refused physical examination and this was clearly documented. One patient had physical examination completed in ED. All newly admitted patients had physical examination completed or the reason why it wasn't completed documented clearly.

Conclusion

Physical examination pro forma was successfully implemented, raising current compliance to a 100%, with a significant improvement from 23% compliance in the first cycle. Existing pro forma is helpful as a reminder to NCHDs. Colour coding of pro forma improves accessibility and distinguishability during the process of admission and auditing. Physical examination pro forma will be audited every 6 monthly.
Audit on monitoring physical health of patients on mood stabilisers following NICE guidelines
Authors: Soundararajan Sathyan , Dhandapani Asha , Jones Claire
Published: June 2021

Aims

The aim is to find out if the physical health monitoring is adhered to in accordance with NICE guidelines in individuals with Intellectual disability who are on mood stabilisers and known to LD services.

Method

We sought to explore if the physical health monitoring for prescribing mood stabilisers in a sample of people with ID was consistent with good practice guidelines.

We collected the data by reviewing the clinical records of individuals with LD who were under the care of mental health services in the CLDT- Wrexham and prescribed a mood stabiliser drug. We also contacted the patient's carers who came to outpatients and by calling the GP surgery and enquiring about the details. We also assessed the Welsh clinical portal in order to assess the blood tests.

Data were collected by trainee doctors in Psychiatry. This was a retrospective audit, looking at data from Learning Disability psychiatry caseload. We identified about 16 patients on mood stabilisers.

Result

Physical health monitoring for prescribing mood stabilisers was almost consistent with good practice guidelines. This has shown that the majority of the monitoring has complied. There are few lacunae, such as Thyroid function not being monitored every 6 months for patients on Lithium, Serum Carbamazepine levels not being monitored as per guidelines with 1 patient not having blood done at all whilst on Carbamazepine. Moreover, the details are not readily available for the Consultant/ team when needed, thus making it very tedious for them to search/ contact the GP, etc.

Conclusion

Medications such as mood stabilisers can increase the risk further if the patient's physical health is not monitored regularly. This can lead to compromised quality of life for the patient and in some cases increased morbidity. Hence we have come up with a proforma that can be attached to patient case notes. This will serve as a record for us and prompt for physical monitoring. We will keep a database online with reminders set. This is to ensure a continuity of care for the patients.