bluuebunny/crossref_metadata_2025 huggingface dataset:
An Audit of PPI Cover in Those Taking SSRIs Within an Older Adult Community Mental Health Team
Authors: Cooper Michael , Langan Clare , Haxton Christopher
Published: July 2023

Aims

Serotonin in platelets has a major role in promoting vasoconstriction and platelet aggregation. Selective serotonin reuptake inhibitors (SSRIs), which are widely used clinically, inhibit the serotonin transporter responsible for serotonin uptake into platelets. This serotonin depletion reduces clot formation, thus increasing bleeding risk. This risk is particularly elevated in older adults who are also more likely to have co-morbid physical health conditions. The Maudsley Guidelines recommend that if SSRIs cannot be avoided in those assessed as high bleeding risk, then gastro-protective proton pump inhibitors (PPIs) should be prescribed. The aim of this full cycle audit was to evaluate all patients in an older adult community health team (OACMHT) to assess how many were prescribed an SSRI and whether PPI cover had been considered in those deemed to be at higher risk of a GI bleed due to either age or concomitant medication use.

Methods

All patients open to the OACMHT prescribed an SSRI were identified. Their electronic notes were checked to see if they were either prescribed medications or had comorbidities which increased bleeding risk. Electronic notes were reviewed to assess if bleeding risk had been considered at the time of prescribing SSRI, in addition to whether a PPI had been prescribed.

This was repeated 6 months later following the results being presented to prescribers within the OACMHT.

Results

Patient age ranged from 60 – 101 years. 23% of patients were prescribed SSRI medication. There was an improvement in the proportion of patients on SSRIs prescribed PPIs in the second cycle compared to the first cycle of this audit (64.7% vs 56.5%). We also found that the majority of patients prescribed an SSRI and medications known to increase bleeding risk were prescribed a PPI in both audit cycles. We found only 1 patient in our cohort had bleeding risk explicitly documented in electronic notes.

Conclusion

SSRI use is common within the OACMHT. The majority of patients were prescribed a PPI alongside their SSRI. This improved in the second cycle of this audit. A significant number of those prescribed a PPI had their PPI prescription commenced prior to an SSRI being prescribed which may have artificially inflated our results.

However, a significant proportion of patients prescribed SSRIs were not prescribed PPI cover which is not in line with current Maudsley guidelines. Therefore there is still work to be done in minimising bleeding risk in patients taking an SSRI within the OACMHT.
Identifying and Advising on the Menopause in Secondary Mental Health
Authors: Dugard Rebecca
Published: July 2023

Aims

Women aged 45 to 55 years can suffer psychological symptoms during the menopause including low mood, increased anxiety and poor memory. NICE guidelines recommend that hormonal replacement therapy (HRT) is considered to alleviate low mood symptoms that arises as a result of the menopause. It is not currently routine for perimenopausal symptoms to be explored during consultations and physical health checks with female patients in the community. Additionally, in secondary mental health settings the option of HRT is not routinely discussed. The aims of my completed initial audit are to improve the psychological symptoms in women experiencing the menopause or perimenopause. I aim to encourage doctors and nurses to routinely screen for perimenopausal symptoms of women aged 45 to 55 years. I aim to encourage doctors and nurses to routinely ask if women in this age category have used HRT or would consider discussing HRT options with their GP.

Methods

I performed retrospective data collection of 30 women aged 45 to 55 years in an Outpatient Clinic setting. I referred to the clinic letters of these women over the past 12 months and recorded if there was any documentation of HRT or perimenopausal symptoms. I used the progress note search feature to screen for any further documentation of the discussion of HRT or perimenopausal symptoms. I referred to the most recent completed PHIT (physical health) questionnaire for these women. I recorded if the sexual health section of the PHIT questionnaire had been completed and if any discussion of HRT or perimenopausal symptoms had been documented.

Results

I found that 3 out of the 30 women had discussions regarding HRT and/or perimenopausal symptoms documented in their clinic letter or progress notes. I found that 17 out of the 30 women had the sexual health section of their PHIT questionnaire completed in full. I found that 0 out of the 30 women had documentation of the discussion of HRT or perimenopausal symptoms in their PHIT questionnaire.

Conclusion

My results displayed that only a small percentage of women aged 45 to 55 years are having discussions in secondary mental health setting regarding HRT and perimenopausal symptoms. Therefore, there is a clear need for the further education and training on the menopause for doctors and nurses working in these settings. This will encourage the routine screening of perimenopausal symptoms in women of this age category so that HRT can be considered.
Compliance Audit on Diagnosis and Treatment of Folate and Cobalamin (Vitamin B12) Levels in CAMHS Transition Service at Oldham, a Full Cycle Audit
Authors: Elisseou Antigoni , Darwin Genevieve , Ramkisson Roshelle
Published: July 2023

Aims

To investigate compliance with British Society of Haematology (BSH) guidelines and NICE clinical summarieson diagnosis and treatment of folate and cobalamin deficiencies in CAMHS Transition service, Oldham.

Methods

The standards used were based on BSH guidelines and Nice clinical summaries, with targets for all 100%:

1.

Haemoglobin concentration and mean corpuscular volume (MCV) checked at the same time as assay for serum cobalamin and folate.

2.

Cobalamin and folate assays should be assessed concurrently due to the close relationship in metabolism.

3.

Treatment of established cobalamin deficiency should follow the schedules in the BNF.

4.

All patients with anaemia, neuropathy or glossitis, and suspected of having pernicious anaemia, should be tested for anti-IFAB regardless of cobalamin levels.

5.

Patients found to have a low serum cobalamin level in the absence of anaemia and who do not have food malabsorption or other causes of deficiency, should be tested for IFAB to clarify whether they have an early/latent presentation of pernicious anaemia.

6.

Treatment of folate disorders should follow the schedule in the BNF.

7.

We reviewed all open cases to Transition service in Oldham. Their NHS number was checked through the pathology laboratory portal. In addition, notes on Paris electronic system and digital letters were checked to see if results were acknowledged. The initial audit period run from February 2021 to April 2021.The results were shared with the Multidisciplinary Team and an algorithm was created and shared in an attempt to improve the practice. The re-audit run from May 2022 to July 2022. A total of 80 patients were included in the audit and 25 patients in the re-audit. We entered and analysed our data using Microsoft excel.

Results

Compliance levels for the standards for the audit were as following: standard number 1, 2 and 5 were 100%, number 3 and 6 were 0%, and number 4 was not applicable.

Compliance levels for all the standards were 100% for the re-audit.

Conclusion

The results of the initial audit indicate that not all standards were met. However, results of the re-audit indicate all standards were met. It appears implemented changes may have affected the outcome of results. However, as the sample of patient was small might need to repeat this audit cycle in the future to see if the results remain the same.

The physical health protocols are relevant to psychiatric practice and the algorithm can be disseminated for further use.
An Audit to Assess the First Patient Follow-Up After Initiation of SSRIs in Primary Care
Authors: Elliott Rachael , Fleet Kelly
Published: July 2023

Aims

NICE guidelines recommend that patients started on antidepressants aged 18–25 years are reviewed 1 week after initiating treatment to check response. All other patients should be reviewed within 2 weeks. The audit aimed to evaluate if these guidelines are being met in Primary Care now that most mental health appointments have changed from face to face to telephone consultations post COVID-19.

Methods

Notes of 60 patients that had been started on an SSRI across the period of January 2022 – December 2022 at a North West based Primary Care practice were analysed. Time from initial consultation to medication review with a general practitioner (GP) and/or contact with a Mental Health Practitioner (MHP) within the practice were recorded. Consultation notes from MHPs were analysed for reference to tolerability of medication to assess if the patient's new treatment was discussed as part of support appointments.

Results

Median time for initial follow-up of patients aged 18–25 years was 3 weeks demonstrating 8% compliance with NICE guidelines. Median time for initial follow-up for those >25 was 4 weeks, demonstrating 19% compliance with NICE guidelines. Of those that did not receive a follow-up with a GP within the suggested time frame, 20% met with a MHP for support with their condition and had side effects of new medication referenced in the notes. Within 4 weeks, 58% of patients had an appointment with a MHP where medication was mentioned. Median follow-up for anxiety disorders was 4.5 weeks compared to disorders of depression at 4 weeks. Patients new to the SSRI were followed up at a median of 3 weeks compared to 4 weeks for those that had completed a course previously.

Conclusion

Current follow-up of patients at the practice is not compliant with NICE guidelines. A practice meeting will be held to identify improvements to the patient follow-up process and look at the barriers patients face when arranging follow-up appointments. More than half of audited patients met with a MHP for support within 4 weeks of SSRI initiation. This highlights an opportunity to assess patients that are already meeting with practice staff when GPs have been unable to review them within the time frame. A pro-forma will be developed for MHP to utilise to specifically ask about medication. A repeat audit of both GP and MHP appointments will be completed in 6 months.
Audit of Prescribing Practices & Medication Monitoring on Learning Disability Female Low Secure Unit
Authors: England Rosie , Rashid Ambreen
Published: July 2023

Aims

To ensure psychotropic medication is being prescribed and monitored as per Trust and national guidelines.

Methods

The audit included all patients admitted to the low secure female forensic unit at the time of data collection, giving a total of seven patients. Data were collected from medication charts, psychiatric report and clinical notes. The data collection tool looked at Mental Health Act (MHA) status, diagnoses, current psychotropic and physical health medication, documented indications, consent to treatment forms, completed capacity assessment forms, last medication review and recent physical health monitoring. For patients prescribed Clozapine, frequency of blood testing was checked. For patients prescribed Sodium Valproate, completion of annual risk acknowledgement forms was checked.

Results

The following audit standards were met with 100% compliance: "For patients on regular psychotropic medication, there should be clear indications for this on the drug chart." "All patients on combined antipsychotic therapy or High Dose Antipsychotic Therapy should have a care plan in place." "For patients detained under the MHA, appropriate Consent to Treatment forms should be present and up to date." "All patients should have a documented annual health check within the last 12 months." "All patients prescribed psychotropics should have psychotropic blood monitoring within last 12 months."

The compliance for the standard “For patients detained under the MHA, appropriate capacity assessment documented on MHA 58 Assessment of Capacity for Treatment form should be present and uploaded to Carenotes” was 71%.

The compliance for the standard “All female patients of childbearing age prescribed Valproate should have an annual Risk Acknowledgment form completed” was 0%.

Conclusion

There was a good standard of documentation of medication and indications on drug charts. Consent to Treatment forms were up to date for all patients. Semi-sodium Valproate and antipsychotic medication used out of license was within Trust guidance. Sodium Valproate was used off license in three patients. Monthly FBC blood monitoring occurred for patients on Clozapine, with the most recent Clozapine level within the last 12 months. Physical health checks and investigations were carried out annually for all patients. However, it was difficult to locate all results. Areas for improvement included: All investigation reports should be uploaded in the same folders with easily identifiable file names for ease of access. All patients on Valproate should have a completed annual risk acknowledgement form. The audit recommendation was to put in place care plans for all patients prescribed Valproate therapy, including review dates for risk acknowledgement forms.
Risk Factors Related to Driving: A Review of Clinical Practice Evaluating and Addressing Fitness to Drive Among Psychiatric Inpatients
Authors: Fraser Alistair , Chandra Pallavi , Sundhar Reka , Kar Nilamadhab
Published: July 2023

Aims

Mental illness is linked with a higher risk of dangerous driving; e.g. patients with neurotic disorders have 50% more accidents than controls and 10% of drivers involved in accidents have reported feeling suicidal. The Driver and Vehicle Licensing Agency (DVLA) have provided guidance related to fitness to drive for those with mental illness. In this context we intended to study the risk factors associated with psychiatric inpatients related to driving and whether concerns have been documented in clinical reviews.

Methods

Case notes of 100 randomly selected psychiatric inpatients in one calendar month were evaluated including: their driving status; concerns regarding driving based on their clinical status (Diagnosis, Medications, Side effects); any clinical advice given and communication with DVLA in the previous one year, were ascertained from electronic records. Missing values were not included in calculation.

Results

The sample consisted of 51 female and 49 male patients (mean age 39.7±13.5 and 39.1±12.7 respectively), with the majority 69% from Caucasian ethnicity; 64% were informal. There was no difference noted in driving status based on ethnicity or legal status on admission.

On admission 33% of patients reported that they were not driving, 12% were driving, 2% refused to answer and in more than half (53%) driving status was not documented. Considering some of the risk factors for driving, persistent alcohol use was noted in 39.8%, drug use in 34.4%, personality disorder 37%, attention deficit hyperactivity disorder or autistic spectrum disorder in 4%, being on medications with side effects that may impair driving 80.8%, having side effects that impair driving 10%, and suicidality 54.5%. Only in a minority of cases were fitness to drive related issues discussed in their last review (3%), in progress notes (1%), or in discharge notes (2%). There was no documentation related to communication with the DVLA for any patients.

Conclusion

The results suggest there is a need to record the driving status of psychiatric inpatients and to discuss driving related concerns when considering mental state, medications and side effects. Information related to driving should be given to patients, and DVLA should be notified as appropriate. This might help in improving safety related to driving by psychiatric patients.
A Clinical Audit on Adult ADHD From Community Mental Health Teams: Experience From the East of North Wales
Authors: Gajdhar Wamiqur Rehman , Loo Jiann Lin , Anyanwu Ugochukwu , Okachi Okachi , Habeeb Bassem
Published: July 2023

Aims

The Royal College of Psychiatrists (RCPsych) has formulated “Attention Deficit-Hyperactive Disorder (ADHD) in Adults: Good Practice Guidelines” to provide evidence-based guidance for clinicians, acknowledging there is an increasing burden on the services with the assessment and management of adult ADHD in the United Kingdom. As there is no trust-wide policy in North Wales and some practitioners perceive that it is challenging to perform an extensive assessment for ADHD in the adult secondary mental health services, there is a need to study the pre-referral workup and diagnostic approach for patients referred to the adult mental health services. This clinical audit is aimed at understanding the guideline adherence level of the assessment and management of adult ADHD by both primary and secondary mental health services in Betsi Cadwaladr University Health Board.

Methods

Convenient sampling was performed on 50 patients from three community mental health teams (CMHT) from East of North Wales for patients with a confirmed diagnosis of adult ADHD. The source of information included referrals from the primary care (including general practitioners and primary mental health service) and medical records from the secondary mental health care. Relevant clinical information was collected and coded as “present”, “absent”, or “unclear”. The data were compared to the standard derived from “ADHD in adults: Good practice guidelines”.

Results

Only 34% of the referrals documented the use of Adult ADHD Self-Report Scale, 18% documented the use of Autism Spectrum Quotient (AQ-10), and none documented the use of Weiss Functional Impairment Rating Scale (W-FIRS).

Only 46% of patients was diagnosed using a standardised instrument after more than one session of diagnostic assessment. The percentage of documentation of baseline blood pressure, pulse rate, weight, and height were 58%, 70%, 50%, and 44% respectively.

Most documentations fell below 50%, including comorbid and family history of physical health conditions, history of neurodevelopmental issues, and corroborative history. All teams performed well with the documentation of functional impairment, comorbid anxiety disorder, depressive disorder, and substance use disorder, i.e., >90% of patients.

Conclusion

This audit reflects the need for quality improvement in documentation in both primary and secondary care settings although the solution should not add to the existing burden of practitioners. Convenient sampling from East of North Wales limits the generalisability of findings. Also, the absence of data may be contributed by logistic issues around paper-based medical records, i.e., illegible handwriting and inability to locate the documentation.
Anaesthetic to ECT Time Interval (AETI): Is the Time Interval Between Administration of Propfol to the Time of Delivery of Stimulus in Electroconvulsive Therapy (ECT) Being Documented and Within the Limits Set by a New Departmental guideline
Authors: Gill Natalie , Dudley Bethany
Published: July 2023

Aims

To establish if new departmental guidelines regarding Anaesthetic to ECT Time Interval (AETI) documentation were being followed. The guideline states that the average time from end of Propofol administration to the time of stimulus delivery should be at least 120 seconds. AETI should be recorded at all ECT sessions including the initial titration sessions when the seizure threshold is being established. The aim of the guidance is to reduce the impact of the Propofol use on seizure threshold and quality. By improving seizure quality, the stimulus dose required to elicit an adequate seizure can be kept to a minimum which is associated with a lower risk of cognitive side effects during ECT.

Methods

Review of electronic RiO notes and ECT prescription documentation for patients who received ECT treatment using Propofol as the induction agent at Hopewood Park ECT Department over a 4 week period in August 2022. Analysis of data collected and presentation to department.

Results

6 patients met inclusion criteria, age range 35-78. The indication for ECT was severe depressive illness (4) or catatonia (2). In total there were 30 ECT treatment sessions included, of those, 23 (76%) had AETI times documented. There was no clear correlation between sessions for patients who did not have an AETI time recorded and those who did. Two were documented as unsuccessful seizures and needed further dose titration. The others happened to be the first treatment dose of ECT given following titration session. The treatments where AETI time was recorded were all equal to or more than 120s (mean AETI was 151.7s). Therefore, 100% of the AETI times that were recorded did meet this standard.

Conclusion

76% of patient treatments had AETI recorded and of those recorded 100% met the standard of being >120s. To improve documentation, a prompt box is to be added to the ECT documentation sheet. The AETI guidelines are to be uploaded to the Trust Intranet Page and displayed in the ECT department. The guideline is planned to be rolled out across the other two ECT departments in the Trust in the coming months. Further work is planned to gather data pre- and post- Trust wide roll out to observe any trends in dose escalation or other clinical factors.
Assessing Whether Physical Health Forms Are Completed for Every New Admission on a Mental Health Ward
Authors: Golchinheydari Sirous
Published: July 2023

Aims

The audit assessed whether physical health forms, which are separate from admission clerking notes, were being completed for new admissions on the ward. A physical exam has to be carried out for every new admission and the findings recorded on the form within 24 hours of the admission. After the first audit cycle, recommendations were to be made and interventions carried out. A re-audit was completed to assess the compliance.

Methods

The records of all patients admitted onto a ward at a mental health unit on the 1st of October 2022 were reviewed to determine whether the admitting doctors had completed the physical health form or not. This was recorded on an excel sheet as complete, recorded on clerking but form not complete, or patient was not seen. After data extraction, junior doctors were reminded about the form personally and a poster was made informing junior doctors about the form which was placed in the junior doctor's room. A re-audit was carried out four months later.

Results

The audit showed that the forms for 75% of patients were not completed by the duty doctor on admission. Out of the forms that were not completed, one patient was not clerked in on time and one patient did not want to see the doctor and refused examination. Therefore, 65% of patients were examined and examination recorded on admission clerking, but the form was not completed. On the second cycle, 35% of the forms were not completed with one patient refusing examination, thus, 30% of the forms were not completed despite examination being carried out.

Conclusion

The recommendations and interventions proved to be successful as the compliance in completed forms increased. Further interventions such as frequent reminders and mentioning the importance of the form on induction could be made. A third cycle to assess compliance among the new junior doctors rotating onto the unit could be completed to assess the effectiveness of these interventions.
Clinical Re-Audit of the Interface Between Community and Inpatient Management of Service Users
Authors: Hakeem Michel
Published: July 2023

Aims

•

The working interface between inpatient and community mental health teams can ensure a smooth and safe transition for service users following admission to the hospital.

•

It is the first opportunity to reassess this aspect of service after the pandemic as the original audit was done before the lockdown.

•

To follow up on amber results and to identify if the data captured from the previous audit has improved.

•

This clinical audit project also reviewed how often community mental health teams and service users met during a patient's inpatient stay.

Methods

•

The audit was conducted at West Park Hospital, Darlington. Information was collated from a consecutive group of female inpatients that were discharged from Elm Ward between 01/02/2021 and 23/03/2021. The audit data collection was performed between 01/05/2021 and 31/05/2021.

•

Data were collected retrospectively and was obtained from the inpatient medical records system (PARIS), and input into a designated audit tool.

•

Medical records were reviewed for the duration of each inpatient episode, and the criteria and standards above were applied.

Results

•

The data demonstrate that in the vast majority of cases, the ward invited the community team to the relevant meetings during the patient admission (96%) which indicates the improvement in compliance with virtual meetings

•

In 100% of cases, there were contacts between the community team through MS Teams or directly through phone or face to face (the number of contacts depends on the length of admission, shown in the figure below)

•

The percentage of patients that were offered a written copy of the care plan was observed to have increased when this is compared to the original Audit

•

The percentage of patients whose GP doctor was informed also increased to 20%, however, that is still at red remarks

Conclusion

•

An amber compliance rating was assigned to this clinical audit report. High compliance was achieved for evidence of the reason for admission, anticipated risks, and capacity communicated to the ward by the care coordinator/crisis team.

•

There is evidence of inviting the care coordinator/crisis team staff to the initial formulation meeting and review/MDT meetings. However, some elements of the Admission, Transfer, and Discharge policy required improvements, particularly in relation to information about expected length of stay communicated to the ward by care coordinators/crisis team staff

•

It should be clear who should be responsible to inform the patient's GP within 24 hours of admission

•

Still, compliance with offering patients a written copy of the care plan (care document/ intervention plan), is low.
Audit of On-Call Assessments (Acute and Urgent Care)
Authors: Javaid Sadia Tabassum , Watts Darret , Jorsh Mike , Usman Mehr Muhammad , Stevenson Laura , Popoola Oluwafemi , Bentley Corrina , Dawson Sam , Briacu A
Published: July 2023

Aims

BACKGROUND: Local algorithms are in place which outline the required process for arranging a Mental Health Act assessment. It requires one doctor from the patient's allocated care team or Trust on-call consultant during the working hours and one doctor from the on-call team (registrar/Consultant- if no registrar) during out of hours. Concerns were raised that on-call doctors were not always asked to participate in assessments in accordance with Trust protocol. AIMS: To improve the on-call assessment process at Northstaffs Combined Healthcare NHS Trust (NSCHT). OBJECTIVES: To determine: Whether NSCHT doctors from the on-call rota participate in Mental Health Act assessments, as appropriate. Any patterns relating to day, time of day or location of assessment which correlate with on-call doctors not participating in assessments appropriately. Any areas where the required standards relating to on-call assessments are not being met. As well to take this opportunity to note down how long was admission following mental health act assessment and if any role of substance misuse.

Methods

All assessments undertaken during November and December 2020 were identified by the Mental Health Law Team. This resulted in a total for analysis of n=141 cases. Data collection was undertaken by Working Group members using a form devised by the Clinical Audit Department and entered online for analysis. Analysis was subsequently undertaken using SPSS and validated according to departmental protocol.

Results

MHAA was done 35% inpatient, 30% Section 136 Suite, 14% community, 12% UHNM, 3% access, 2% police custody and 4% in other areas/ out of areas. Outcome were that 45% detained under section 2 MHA, 35% on section 3 MHA, 2% admitted informally and 18% neither detained nor admitted. 26% of the time substance misuse (acute / chronic) formed part of assessment.

Conclusion

•

Overall results showed that at least one NSCHT doctor was involved in 91% of assessments undertaken, with roughly two thirds of doctors being Consultants and one third Registrars.

•

Focusing on assessments undertaken in the Section 136 suite, at least one NSCHT doctor was involved in 92% of assessments undertaken, with roughly half of doctors being Consultants and half Registrars.

•

Focusing on out of hours assessments, at least one NSCHT doctor was involved in 89% of assessments undertaken, with roughly two thirds of doctors being Consultants and one third Registrars.

Recommendations:

•

To amend the Section 136 form to add the role of the doctor in the assessment.

•

Results to be presented and discussed at the Mental Health Law Governance Group-completed.

•

Results to be presented to the Acute and Urgent Care Directorate-completed.

•

Executive Summary to be presented to the Clinical Effectiveness Group-completed.
Is There a Role for Digital Psychiatry in Older Adults Mental Health Services in the Post Pandemic World?
Authors: Karanayil Gayathri , Altaan Sadir
Published: July 2023

Aims

1.

To evaluate the clinical practice and documentation of remote patient consultations in memory assessment service during COVID-19 pandemic

2.

To gather the views of clinicians and patients on the benefits and challenges of remote patient consultations 3.To understand the role of digital psychiatry in our services after the pandemic

Methods

An audit tool and feedback questionnaires for patients and clinicians were completed through discussions and consensus with multidisciplinary team. RCPsych guidance for cognitive assessments was also considered.

A random sample of 20 patients was identified who had virtual consultations. Rio clinical records were used for data collection using audit tool.

Patients and clinicians were sent questionnaires

Results

Evaluation of clinical practice

The audit demonstrated that all the relevant documentation was completed in vast majority of cases and the clinical practice was not significantly affected by the consultations being carried out virtually. Mental state examination was identified as one aspect which got partially completed in 4 out of 20 assessments during the remote consultations

Patient survey

Patient survey showed that the purpose of the consultation was mostly served by remote appointments. Almost 90% fedback that the communication was clear and they were able to engage freely and effectively with the clinicians. 55% reported preference for face to face meetings in future. 28% preferred remote consultations citing not having to travel as the main reason for their choice. Another benefit identified was relatives who don't live locally could also attend the virtual meetings to support the patients and to offer useful information

Clinicians’ survey

From clinicians’ perspective, the main advantages were reduced travel time, improved time efficiency, and reduced risk of infection. The main disadvantages were inability to get the full clinical picture compared to face-to-face appointments, technological challenges, and lack of personal touch.43% reported that the job satisfaction has improved from hybrid working

Conclusion

There are certainly benefits and advantages for remote consultations from the perspective of both patients and clinicians. While majority of clinicians prefer a combination of remote working and face-to-face consultations, more than half of patients expressed preference for face-to-face appointments. This audit demonstrates that, although remote consultation is not the gold standard method in assessing cognitive functions and dementia diagnosis, it was useful for obtaining most of the relevant information to enable diagnosis and initiating treatment in timely manner. We also found that approximately 437 miles of travelling was prevented because of the possibility of virtual meetings
Retrospective Analysis of a Single Centre Experience of the Pharmacological Management of Patients With Intellectual Disability & Challenging Behaviour Across Three Audit Cycles
Authors: Khodabux Nusra , Hamid Mohamed , Perry Rebecca , Cawley-Nash Bernadette , Savvopoulou Ioanna , Gumber Rohit , Barrett Mary
Published: July 2023

Aims

To investigate adherence to NICE and STOMP guidelines for the pharmacological management of patients with intellectual disability (ID) and challenging behaviour (CB) in a large acute mental health trust over three audit cycles

Methods

The electronic records of a purposive sample of patients with ID and CB under the care of the ID Team at a large acute mental health trust were retrospectively reviewed over three audit cycles (conducted in 2013, 2014 and 2021).

Results

The sample sizes were 31 (2013), 17 (2014) and 35 (2021). Over the three cycles, most patients had moderate (35%, 47%, 49%) or severe ID (42%, 35%, 31%). Common co-diagnoses included autistic spectrum disorder (45%, 47%, 69%), mood disorders (23%,18%,17%) and epilepsy (16%, 24%,31%).

Target behaviours for intervention were aggression (42%, 27%, 49%), agitation (10%, 40%, 40%) and self-injurious behaviour (28%, 20% and 20%).

Medications used for CB were antipsychotics (61%, 24%, 62%), benzodiazepines (20%, 29%, 42%), antidepressants (13%, 35%, 42%) and mood stabilizers (6%, 12%, 9%)

The number of patients on multiple medications to manage CB declined over the years, with an increasing number receiving singular drug therapy (19%, 35%, 34%).

Over the three audited years, there were improvements in risk assessment (68%, 94%, 100%), descriptions of the nature of targeted behaviours (74%, 100%, 100%), metabolic monitoring (0%, 0%, 95%), documentation of successful and unsuccessful interventions (48%, 65%, 86%).

Adherence to certain standards however declined over time or remained difficult to achieve: complete evaluation of mental (87%, 94%, 60%) and physical health (61%, 88%, 60%), documentation of consent (19%, 76%, 46%), documentation of discussions regarding potential side effects (32%, 47%, 50%) and 6 weeks’ review of medications’ efficacy (52%, 65%, 50%). A positive behaviour support care plan was available in 75% of cases in 2021 and had not been audited in previous cycles.

Conclusion

This retrospective analysis highlights a reduction in the use of polypharmacy to manage CB in patients with ID over time. Adherence to standards remains patchy across the years with improvements in risk assessments and metabolic monitoring. Standards necessitating outpatient intervention such as review of medication efficacy, evaluation of mental and physical well-being were hard to achieve, in part explained by service changes and pressures related to the COVID-19 pandemic. Future improvements may require increased pharmacy-led reviews.
Going somewhere…?
Authors: Kumar Praveen , Ashmore Robert , Bantwal Ashwin
Published: July 2023

Aims

Challenging behaviours often results in exclusion from communities and is associated with worse outcomes for patients with Intellectual Disability (ID). Due to substantial cut backs in local community service provisions across Highland for people with ID, placements have dwindled and recent trends indicate a high demand for “crisis” inpatient admission for PWID with co-morbid mental health and/or pervasive developmental disorders. This project aims to thematically analyse the admission trends to the Intellectual Disability Assessment and Treatment Unit (IDATU) in NHS Highland over a 5 year period (2018-2022).

Methods

All patients admitted to and discharged from the IDATU over a 5 year (2018-2022) period were identified. Their case notes were reviewed and details on the primary reason for admission were manually gleaned from the admission clerking document. Data were also gathered for demographics, diagnosed mental disorder, legal status and length of admission.

Results

Total 18 new admissions were identified. All had established ID and/or co-morbid mental illness, autism, & other organic conditions. The average age was 30.2 years. 81% of admissions were formal. Length of admission varied from 1 to 814 days.

Allowing for some overlap, admission themes mainly fell into 3 categories: challenging behaviour related- Aggression, Abscond, Self-Neglect, Suicidal (50%), Decline in mental/Physical health- Psychosis, Confusion, Weight Loss (16.7%) and manageability- Vulnerability, Breakdown of social situations (33.3%).

Several themes were identified amongst the stated reasons for admission in case notes. A pattern emerged whereby these fell into 3 different headings as shown by the table here.

Conclusion

The above three themes identified are not surprising. A combination of behaviours grouped as “challenging” and also felt to be “unmanageable” were cited as primary reasons for admission.

Notwithstanding the dwindling of community resources and workforce attrition within the ID Service in recent years, the actual numbers admitted to IDATU was roughly down by 50% comparing a 5 year analysis done from 2012-2017 (34 Vs 18).

Robust scrutiny/tightening of IDATU admission criteria, along with other new service initiatives may have helped mitigate against any inappropriate use of IDATU beds.

Given the established and well researched risk of institutionalisation, it is of interest to us that our findings suggest that the services employed by the State to reduce this risk were already involved in a large proportion of cases. It is our recommendation that future service development planning should focus, incentive, invest and expand robust community ID services and resources within Highland.
Audit and Re-Audit: Improving Standardised Admission Blood Tests Adherence for Psychiatric Intensive Care Unit (PICU) Patients
Authors: Lawson Joel , Zabrzycki Domenic , Satisha Shantala
Published: July 2023

Aims

1.

To evaluate current adherence with the Royal College of Psychiatrists guidance “Standards for Inpatient Mental Health Services”: Were the blood tests carried out within 24-hours of admission?

2.

We standardised the blood test parameters that are required following admission to our PICU ward and measured if all relevant blood tests* were completed during admission.

3.

Re-audit after implementation of a standardised policy.*(Full blood count, urea and electrolytes, liver function tests and lipid profile, CRP, thyroid function tests, vitamin B12, folate, prolactin, vitamin D, calcium and HbA1c%).

Methods

First cycle is an audit of electronic patient records for all admissions to the PICU ward in a two-month period by using an audit proforma to capture information to answer the questions above.

After implementing a standardised guideline for PICU, second cycle was conducted over a two-month period for the re-audit.

Results

In the first cycle, a total of 20 patient records were audited. 30% had bloods taken within 24 hours of admission to PICU. 10% of patients had bloods taken on their previous ward. 40% of patients declined/unsafe, and 20% were not done in the timeframe.

69% of patients directly admitted to PICU had all the relevant admission blood tests completed and 23% had some of the blood tests done. These numbers were lower for the patients transferred to PICU from other wards.

In the second cycle, a total of 16 patient records were audited. There was an improvement in number of patients having bloods done within 24 hours of admission with only 6% not done in the timeframe.

Of the patients directly admitted to PICU, all the consenting patients (89%) had all the standardised blood tests. These figures remained lower for those patients transferred from other wards without an indication to retest the bloods.

Conclusion

The standardised guideline for PICU that was implemented after the first cycle consisted of a pre-filled blood test request form which included all relevant parameters detailed above.

This had a positive impact with a significant percentage increase in the total number of patients directly admitted to PICU having all relevant admission blood tests completed at re-audit (77% to 100%).

There was also a significant percentage increase (80% to 94%) of bloods taken within 24 hours of admission to PICU.

The next step will be to implement these pre-filled forms across all wards in the KMPT trust.
Assessing Recording of Allergy Status on Rio Amongst Patients in Sandwell CAMHS
Authors: Akhator-Eneka Nwaife , Maanuwa Olufikunayo
Published: July 2023

Aims

To assess recording of allergy status for patients under the care of Sandwell CAMHS

Methods

This audit was performed at Sandwell CAMHS. The project was discussed and logged with the Trust's audit department.

Medical records of all patients (516 patients) seen between January and March 2022 by the medics in Sandwell CAMHS were examined for documentation of allergy status

For all patients the alert bar on Rio was examined to determine whether or not their allergy status was recorded.

A data collection tool was devised to collect information in accordance with the standard i.e, the drug allergy recorded or not and when recorded;

•

it is present

•

no known allergy

where present;

•

substance name

•

reaction

•

severity

•

date recorded

•

Evidence and Certainty

Results

For the Recording of Allergy Status on Rio, the audit revealed:

A.

60 out of the 516 patients had their allergy status recorded.

Out of these 60 patients;

18 had possible allergy

42 had no known allergies

B.

456 had no recordings of allergy status

C.

Those with possible Allergies;

The substance name was documented for all in Rio for those who had allergies indicated

12 of the 18 possible allergies had the allergic reaction documented

13 of the 18 possible allergies had the severity documented

3 of the 18 possible allergies had the date recorded

1 of the 18 possible allergies had evidence and certainty recorded

Conclusion

The audit revealed a poor recording of the allergy status

The following recommendations have been made:

Present audit at the Specialist mental health quality improvement group.

Clinicians should be made aware of the expected Nice Guidelines for documentation of allergy status.

Clinicians to update allergy status of patients every 6-12 months.

Develop an action plan and governance documentation with the specialist mental health quality improvement group.

The results of this audit have been shared with the Rio lead for them to consider making relevant changes in Rio i.e. The systems should include prompts for annual updates of allergy status.

A clear trust policy of documentation on how allergy status/adverse effects will be should be recorded Rio.

If possible, it should be included in the junior doctors' handbook and the eLearning.

To carry out a re- audit in 6 months to 1 year
Evaluating and Optimising the Self-Administration of Medication (SAM) in an Inpatient Psychiatric Rehabilitation Setting
Authors: Maguire Cormac
Published: July 2023

Aims

To analyse the process of self-administration of medication (SAM) in an inpatient psychiatric rehabilitation setting in order to improve the MDT awareness and engagement with the process. The project also aims to improve the level of completion of the relevant SAM documentation in the department.

Methods

The medication prescriptions and self-administration charts (where present) for the patients on the ward were reviewed to identify errors or omissions in completion of the documentation.

Thereafter a number of interventions were completed. This included informal education sessions and follow-up written correspondence to the relevant staff (via email and the ward handover book). The potential for SAM was additionally prompted at the weekly MDT meeting in order to identify additional suitable patients for the process.

Results

Three out of 18 inpatients were initially engaged to some degree with SAM at the start of the project. For the relevant patients involved, completion of attendance documentation and adherence to written instructions from 70% to 90%. Improvements in other aspects of the documentation were also observed. Following the prompted MDT discussions a further five patients were identified to commence SAM, who may otherwise have remained on traditional nurse-led medication administration.

Conclusion

Engagement with SAM was initially variable and therefore was improved by targeted discussions and more MDT involvement. Documentation was identified as a potential pitfall and completion improved due to the interventions above. During the project a number of medication errors were incidentally highlighted and were reported via the DATIX tool. This demonstrates the importance of risk awareness associated with the SAM process in order to improve patient safety. There should be an MDT approach when considering patients for SAM process as this can affect discharge decisions. SAM could also be considered outwith the inpatient rehabilitation setting (e.g in General Adult Psychiatry wards). SAM is important in order to promote patient autonomy and independence in a safe manner. In the future it would be useful to explore patient attitudes towards medication self-administration in order to identify barriers to concordance.
Secondary Service Communications to GPs-a Regional Audit
Authors: Mitu Tajnin , Zachariah Vinila , Ray Jason , Salmoiraghi Alberto , Singh Ramandeep , Williams Laura , Bhangu Vikram , Elsayed Asmaa , Ikuewumi Opeyemi , Gejdhar Wamiqur Rehman , Rezk Amin , Khan Mohammad , Rowley Christopher , Okhiai Lopez
Published: July 2023

Aims

The purpose of the audit was to assess the standard of communication to GPs from secondary mental health services and to ascertain whether the information included in letters to GPs was in accordance with the recommendations of RCPsych and PRSB. The audit cycle was completed by re auditing to identify how the recommendations from the first audit has improved the quality of communication to GPs.

Methods

The audit was conducted on three psychiatric units, in three sites across Betsi Cadwaladr University Health Board and clinic letters were studied to identify whether the information was as per recommendations from: RCPsych and PRSB.

The first audit used 121 letters in total from 3 sites, with the data being collected using audit proforma over a 2 week period from 04/04/22.

The re audit looked at 69 letters with data collection using audit proforma over one week period from 19/12/22.

Results

Majority of letters sent to GP were lacking key information like details of Care coordinators ,medical comorbidities ,non psychiatric diagnosis, and actions for GP with this data missing in 91.7%, 61.22 %,79.59% and 71.43% respectively. Fill rates for other information like patients' details was 100% , psychiatric diagnosis was 83.47%, psychiatric medications , follow-up plan were 80.17%.

The results of the re-audit most letters contained Psychiatric Diagnosis (97.1%, previous 83.5%), Psychiatric Medication (91.4%)previous 80.17%), and Follow Up Plan(98.6%, previous 80.2%). Many letters did not include information regarding Medical Comorbidity (28.6% vs 31.4% ), Non-Psychiatric Medication (65.7% vs 34.7%), Details of Care Co-ordinator (54.3% vs 8.3% ) and Action for GP (27.1%, vs 44.6%).

Conclusion

The recommendations from first audit were to create local guidelines and templates with recommended headings for clinical letters, provide formal teaching for junior doctors and to re audit to see if the implemented changes has led to an improvement.

The re-audit showed improvement since the introduction of the template in majority of headings in GP letters with decline in fill rate for 2 headings and these changes varied among three sites.

Barriers identified affecting the overall outcome of the re audit were :template not being used, lack of training to juniors, and psychiatrist workload.

In conclusion , we aim to re-distribute the template and increase awareness with informal teaching sessions, provide information on template during induction for doctors and organize training sessions on three sites.