bluuebunny/crossref_metadata_2025 huggingface dataset:
Reflections on a person's experience of mental illness: an innovative teaching pilot for second-year medical students
Authors: Blanchard George , Quail Louis , Yang Grace , Terence Katherine , Kalra Amisha , Sarkar Neil , Spector Aimee , Abraham Seri , Reeves Suzanne
Published: June 2021

Aims

We sought to develop a teaching pilot to help year 2 medical students meet the following learning outcomes: Develop a better understanding of patient and carer experiences of mental illness; Recognise and challenge unhelpful attitudes towards people with mental illness; Promote a broader understanding of cultural issues surrounding mental illness, including stigma and discrimination.

Method

337 medical students were invited to attend a lecture by author LQ, a documentary photographer who presented a narrative of his brother Justin's lived experience of schizophrenia (louisquail.com/big-brother-introduction). 197 students attended the session, which was recorded and made available online. Students were invited to enter a competition to win a signed copy of LQ's book, ‘Big Brother’ and asked to submit either a 500-word written reflective piece, or a creative work accompanied by a 200-word statement. 13 submissions were received, including paintings, drawings, collage, photography, and poetry, all of which were blind rated by authors SR and GB, based on originality and quality of reflection. Of the six shortlisted, three winning entries were chosen by author LQ.

Result

All reflections moved away from a technical understanding of schizophrenia, towards person-centred interpretations, with dominant themes of ‘stigma’, ‘disempowerment’, ‘understanding people as individuals’, ‘subjective experience of mental illness’, ‘inclusion’ and ‘healing power of nature’.

The three prize winners (authors GY, AK and KT) used different mediums: GY painted an osprey over a chaotic collage of disordered and stigmatizing words (the osprey representing empowerment and the “reservoir for wellbeing in nature”); AK's sonnet began as an ode to the chaos of Justin's experience, but the concluding lines reframed this struggle, conveying feelings of hope and beauty; and KT's self-portrait, produced with a slow shutter-speed photograph, powerfully conveyed a sense of disorientation and disturbance. She reflected on how the stigma of mental illness affects self-perception. The talk was well-attended, and reflections were of high quality. A limitation of this pilot was that only a small proportion of students completed the reflective assignment.

Conclusion

Innovative teaching strategies are needed to address negative attitudes towards mental illness and psychiatry, which are prevalent amongst the medical profession. This pilot provides a model for combining carer-led, reflective, and creative elements in undergraduate psychiatry teaching, with the aim of challenging stigma. This model will be evaluated in a further study involving fifth year medical students, which will use a validated scale to measure change in students’ attitudes towards mental illness and psychiatry.
Audit of therapeutic drug monitoring of ‘clozapine plasma levels’
Authors: Bellam Shakina , Khundakar Martina , Khanna Priya
Published: June 2021

Aims

To re audit the monitoring of Plasma Clozapine levels in Rehabilitation setting in CNTW Trust as per Trust Guidelines PGN on “Safe prescribing of Clozapine”.

Objectives:

To determine if

1. The reason for a clozapine plasma level request is recorded.

2. Results are recorded correctly.

3. Appropriate action is taken and recorded when results are significant.

Background

Clozapine plasma level monitoring is useful when assessing adherence, adjusting the dose, monitoring the effects of changes in smoking habit, investigating clozapine side effects and when toxicity is suspected.

An initial audit was carried out within the Trust in 2015 and the following recommendations were made:

Check and record clozapine plasma level

At baseline (a level should be taken once the patient has been on the target dose for at least a week)

Annually.

When clinically relevant to optimise therapy.

An entry must be made in the patient's progress notes recording the reason of requesting the test.

On receipt of results, the paper copy must be scanned & an entry made in progress notes.

The clinician should comment on the significance of the results and propose an action plan.

We re-audited compliance with the guidance in Rehabilitation (inpatients and community) by reviewing patient notes for a 2 year period of 2017–2018.

Method

The audit work involved a review of 31 case records of patients prescribed Clozapine whose last plasma level was taken between 2017–2018. Patient's details were identified from a randomly generated list by the Trust pharmacy.

Result

<50% compliance was seen with baseline, annual monitoring, reason for recording and proposed action plan by clinician.

>50% compliance was seen with scanned results and levels checked when clinically relevant.

No significant improvement from the previous audit except improvement in compliance with documentation of levels.

Conclusion

Dissemination of Clozapine Key cards within teams.
The use of antipsychotic polypharmacy at Ravenswood House Medium Secure Unit: the extent of use and reporting of outcomes
Authors: Cherrington Laura , Patel Hari
Published: June 2021

Aims

To evaluate the use of antipsychotic polypharmacy in Ravenswood House Medium Secure Hospital. We also aimed to review the reporting of the outcomes of their use.

Background

The use of antipsychotic polypharmacy (APP) continues to be practised within forensic psychiatric inpatient settings yet there is a lack of robust evidence for the benefits of doing so. The practice is also associated with the use of higher total antipsychotic doses beyond the recommended BNF maximum. Such prescribing is associated with an increased side effect burden. Doctors have a duty to justify the ongoing use of antipsychotic polypharmacy and to avoid potentially ineffective and/or harmful use.

Method

A cross-sectional review of the medication cards for 51 in-patients at Ravenswood House Hospital was completed. Demographic data and data pertaining to diagnoses and medication was also gathered from the electronic patient records.

Result

23 patients (45%) in Ravenswood House Hospital were prescribed antipsychotic polypharmacy. 87% of those prescribed antipsychotic polypharmacy had a primary diagnosis of either schizophrenia or schizoaffective disorder. 19 patients (37%) had two regular antipsychotics prescribed. 74% of these prescriptions were above the recommended BNF maximum. 62% were also prescribed a regular benzodiazepine. The vast majority of indications documented for APP were chronic behavioural disturbance and treatment resistant schizophrenia. The majority of these patients were on a T3. There was a significant under reporting of the rationale of prescribing APP. It could be surmised that at least 11 combinations were in part to mitigate side effects, but only 3 had this documented. There was also a lack of documentation or use of rating scales regarding the clinical outcomes and side effects of APP.

Conclusion

Prescription of antipsychotic polypharmacy is an important issue in secure forensic hospital settings. The lack of clear documentation of clinical effectiveness and side effect burden remains a concern. Wider study is required to establish the benefits of such prescribing to justify its ongoing use.
Capacity and consent to treatment – how well did we do?
Authors: Wee Khui Chiang , Anandan Nithya , Angahar Nguemo , Mannam Abhilash
Published: June 2021

Aims

An audit on capacity assessment and consent to treatment on inpatient visits to Atherleigh Park Hospital was performed using the Mental Health Act Code of Practice as a framework. Six standards were evaluated:

1) documentation of capacity assessment in patient care records

2) documentation of patients who display a lack of capacity

3) completion of a Section 58 and/or 62 for detained patients

4) documentation of medicines on T2/T3 form and if they match with the patient's prescription chart

5) evidence of medication concordance and monitoring of adverse side effects

6) patient education on medicines prescribed for them

Method

Inclusion criteria included patients who were detained under Sections 2, 3 and informal admissions, who were admitted for 72 hours or more, between October and December 2019. This gave a total sample size of 75. Data were collected by looking at patients’ care records and if applicable, their Section paperwork to identify any documentations related to the standards evaluated as above. Data collected were transcribed to a web link, downloaded and analysed.

Result

In standard 1), it was found that 77% of the capacity assessment and consent to treatment forms were recorded in patient care records. Of these, 100% of were completed by a medic and 99% of all sections in the form were completed. However, only 57% of patients were re-assessed when their capacity and consent changed during admission. In standards 2), 3) and 4), documentation of patients who lacked capacity, completion of a Section 58 or 62 form and charting of medications on the T2/T3 forms were fully compliant. In standards 5) and 6), 76% of medication concordance were documented in patients’ records. Only 39% of adverse effects from medications were documented but monitoring compliance was 100%. Medication counselling was done infrequently, with 47% of patients given a leaflet and 28% educated on their side effects.

Conclusion

Action plans were identified. Firstly, to link the capacity assessment form with patient electronic ward round notes to ensure clinicians complete it at the end of a review. In order to monitor adverse effects from medications, physical examination, blood tests and ECG are to be done following a new prescription, and to be repeated if indicated. Information leaflets on common psychiatric medications are to be made readily available for patients. The findings from this service evaluation and the actions plans were shared with doctors. A re-audit is vital to re-evaluate the hospital's compliance.
Experiences of psychiatrists assessing under 18s on an “all age” rota. An evaluation of the current service
Authors: Turtoi Nicoleta Clarisa , Ansell Martin , Govender Trinisha , Bould Helen
Published: June 2021

Aims

Gloucestershire Health Care Trust operates an “all age” out of hours on-call rota, staffed by Registrars and Consultants who cross-cover all psychiatric sub-specialities. Our aim was to understand the challenges faced by psychiatrists of different professional backgrounds when assessing under 18 year olds in a health-based Place of Safety (POS).

Method

We circulated a survey to all psychiatrists on the on-call rota, to gather quantitative and qualitative information on the challenges posed by assessments of under-18s in a POS and assess whether an under-18 specific policy was needed.

Result

Out of the 50 psychiatrists invited, 27 completed this survey (during February 2021). 33.3% of respondents reported that they had completed a POS assessment of an under 18-year-old when a Consultant Child and Adolescent Psychiatrist/Registrar was not available to join. 33.3% of respondents had been asked to complete such an assessment as the sole psychiatrist joining the AMHP, with 24% of those respondents reporting feeling uncomfortable doing these assessments without a second doctor present, and an additional 24% feeling comfortable only sometimes. 48.1% of the doctors surveyed did not invite parents or carers to take part in the assessment, despite this being considered best practice, citing reasons such as: being unaware that this was a possibility, assessments conducted at unsociable hours, safeguarding concerns involving the parents, and social distancing in the context of COVID-19. 41% of respondents had assessed vulnerable young people (children looked after or with a diagnosis of an autism spectrum condition) in the POS and reported that these assessments posed significant challenges to safe discharge planning and identifying appropriate placements. 81.5% felt that a tailored policy for young people was needed. Qualitative findings suggest psychiatrists think such a policy should include clear procedures (flowcharts), potential outcome scenarios/options for safe discharge, referral criteria for CAMHS, contact details for key staff members, a handover protocol. Respondents felt a shared policy with all stakeholders (AMHP service, Mental Health Services, police) was required.

Conclusion

Our survey highlights the challenges for non-CAMHS specialists assessing under 18s in a health-based POS and the need for an under-18 policy to support safe practice. Major themes will be further explored in a focus group to guide policy development.
Assessing DNA rates within first time psychiatric referrals and the extent to which DNA rates are reduced by an SMS reminder service
Authors: Coates Henry
Published: June 2021

Aims

1) To assess the average wait time for patients to be offered an appointment and to establish any correlations between longer waiting times and 'Did not attend (DNA)' rates 2) To assess the number of patients who have opted into the text message appointment reminder service and whether this had an effect on DNA rates.

Background

Research has indicated that the Did Not Attend (DNA) rate in Psychiatry is estimated at 20%, twice that of other medical specialties (1). With NHS Digital estimating that DNAs cost the NHS £1 Billion per annum, there has been much interest in reducing the rate of DNAs within Psychiatry (2). Findings have shown that short waiting times are associated with higher rates of attendance (3). In addition, poor appointment attendance within Psychiatry is also associated with increased disease severity and higher rates of hospital admission (4).

Method

We conducted retrospective data collection on 99 patients referred to Professor Oyebode between January 2018 and August 2019. Our data collection involved assessing time the referral was received, time to first appointment and the patient's communication preference (e.g. whether they opted in to the SMS alert service). All data collection was conducted through use of RIO and coded/ammonized into a Excel spreadsheet. No sampling methods were employed and our population only consisted of first-time referrals to Professor Oyebodes clinic.

Result

1) We found no correlation between a longer waiting time to first appointment and an increased DNA rate.

2) All patient waiting times between 1st January - 31st August were within the maximum limit set by national guidelines

3) Opting into the text messaging service remains severely low. Of the patients audited, 95% had not completed a communication preference form. Overall, it is still unclear whether the text messaging service has a positive impact on DNA rates.

Conclusion

Our data have shown no significant correlation between a longer waiting time and an increased DNA rate for first time Psychiatry appointments. Secondly, we have concluded that between the audited period, waiting times were still within the maximum 18 week wait set by the Mental Health Standards. Finally, we can conclude that uptake of the text messaging service remains very low at 4%. Due to a limited sample size of only 4 patients, it is still unclear from this audit whether opting into the text messaging services will have a positive decrease on the number of DNA's.
‘Foreseeing well-being’: developing a physical health strategic vision across a large mental health trust ‘foreseeing well-being’: developing a physical health strategic vision across a large mental health trust
Authors: Cole Bethany , Kamalu Nwaorima , Neubauer Kyra
Published: June 2021

Aims

Statistically, suicide is less than half as deadly as poor physical health for people with severe mental illnesses (SMI). For every 1000 SMI patients, diseases such as diabetes cause 10-20,000 ‘years of life lost’ compared to 4,000 ‘years of life lost’ to suicide. National charity Rethink dubbed the failure of the NHS to act on this as tantamount to “lethal discrimination”.

We aim to reform the physical health care provision for service users under the care of Avon and Wiltshire Mental Health Partnership NHS Trust (AWP).

Method

To evaluate the current service within AWP, we combined data from a comprehensive audit of 106 inpatients, local Quality Improvement (QI) Projects, and qualitative feedback from a pilot Medical-Psychiatric Liaison Service (MPLS).

Result

Key findings included:

High rates of physical comorbidities among psychiatric inpatients of all ages

Novel illnesses occurring during admissions

Evidence that patients are not receiving adequate physical healthcare from wider NHS

Junior doctors receiving inadequate support from Seniors and acute Hospital services when managing physical illnesses

Poor recording of cardiometabolic monitoring with few interventions delivered (even when indicated) and challenges finding relevant data in records.

During the MPLS pilot, a Consultant Physician provided virtual ward rounds and advisory sessions. 100% of staff involved reported the service was beneficial for their clinical practice and patient outcomes.

Conclusion

Taking these findings and input from colleagues within AWP and nationally, we created a comprehensive strategic overview on how AWP can deliver high quality physical health care, detailing improvements to make across 5 key domains: Inpatient, Community, Workforce, Education and Information Technology (IT).

Presently, we are working with Clinical Commissioning Groups developing protocols clarifying roles and responsibilities across primary and secondary providers. We are standardising communication between AWP and primary care and expanding links with specialist secondary services (e.g. endocrinology and cardiology). We formed the BRIGHT (Better Recording of Information for Governance and Healthcare in the Trust) project workgroup alongside IT to build safer and more effective records systems.

Medium term recommendations include employing a full-time MPLS Consultant Physician, in addition to ‘Physical Health and Wellbeing Workers’ in all localities, Advanced Nurse Practitioners (working within structured physical care systems) and more allied health professionals (dieticians, speech therapists and physiotherapists).

In the long term, the new Physical Health, IT and QI working groups will maintain development of these proposals, improve training and supervision for clinicians, and achieve healthcare parity for patients across localities.
A service evaluation and improvement project: outcomes of older adult functional referrals to the North Derbyshire Liaison Team
Authors: Ejaz Maha , Atkins Joseph , Azam Bushra , Laverack Stuart
Published: June 2021

Aims

This project aims to examine a group of service users over the age of 65 with functional presentations, who were assessed by the Liaison Psychiatry team between June 2018 and 2019.

Hypotheis: We believe that there is a need for a community crisis service for the older adult North Derbyshire population with functional presentations.

Background

Due to the lack of community crisis services for patients over 70, it was felt that a significant number of these patients were admitted to inpatient psychiatric units from medical wards who would benefit from crisis intervention instead. We wanted to see the clinical outcomes of this population, referred to the liaison team, determining whether this was significant concern. If this need is established, based on the data collected, this will enable the trust to look into starting a service for this age group to provide care in their own home. In turn, it will help to reduce unnecessary admissions to acute mental health wards and reduce stays in the general hospital – preventing consequences associated with long term hospital stays.

Method

Retrospective analysis using PARIS notes of 366 patients referred to the liaison team were scrutinised to determine the assessment diagnosis and outcome of patients with functional conditions. The inclusion criteria were patients over the age of 65 referred with functional psychiatric illnesses between June 2018 and 2019. We excluded 84 patients assessed to have delirium or organic presentations from our analysis. Data were collected and analysed using Excel.

Result

Among the referrals to the liaison team, the majority of patients were referred with mood disorders followed by self-harm, psychosis and anxiety. Although the majority of patients were referred back to either the community mental health team or primary care, 11% of the sample were admitted to inpatient psychiatric units. This number may have been lower and admission may have been avoided if a community crisis service was in place for this population.

Conclusion

In conclusion, the data support our initial concerns that there is a need for crisis services for this age group with functional presentations. There is ongoing discussions around a need to develop this service and therefore our results will contribute to the development of an older adult functional service in Derbyshire.
Has the COVID-19 pandemic affected out-of-hours presentations in CAMHS?
Authors: Evans Sacha
Published: June 2021

Aims

The aim of this project was to look at whether the COVID-19 pandemic, specifically lockdown, has impacted out-of-hours presentations to Child and Adolescent Mental Health Services (CAMHS) in North Central and East London.

Method

Specialist Registrars (SpRs) on the Royal London/Great Ormond Street CAMHS Higher Training Scheme are contacted for advice regarding all CAMHS presentations in the North Central and East London area. Responsibilities includes provision of advice to 6 hospitals (including 4 emergency departments) and 4 child and adolescent inpatient units. A record of all phone calls and call-outs, including Mental Health Act and Section 136 (S136) assessments are maintained and this study compares pre- and post-COVID-19 data to see if there are any differences in number of presentations, on-site assessments (including Mental Health Act and S136 assessments over 2019 and 2020.

Result

Numbers of CAMHS presentations were lower in 2020 (mean 74 patients per month) compared with 2019 (60 patients per month). This was consistent across all months except October and December. The largest difference was seen in March: 109 patients presented in March 2019, compared with 55 in March 2020. This is also reflected in the number of assessments conducted on site. However, there do not appear to be differences in the numbers of Mental Health Act or S136 assessments undertaken over 2020, compared with 2019.

Conclusion

CAMHS out-of-hours presentations dropped off significantly at the start of the COVID-19 pandemic in the UK, and in particular, with the first lockdown (March to July 2020). Specialist Registrars provided advice via telephone less frequently in 2020 compared with 2019, and were required to do fewer on-site assessments of children and young people presenting with mental health difficulties.

There were no significant differences in Mental Health Act or S136 assessments between the two years, however, these numbers are too small to make any meaningful conclusions.

It is likely that children and adolescents were less likely to present to emergency departments for assessment of their mental health difficulties during the COVID-19 pandemic, rather than this reflecting a true reduction in mental health difficulties.

Recommendations:

It is helpful to continue to monitor CAMHS out-of-hour presentations.

Trusts may want to consider alternative settings for providing emergency CAMHS assessments, for example, mental health hubs.

Limitations:

This provision of data is subject to recall bias.
A service evaluation of the use and outcomes of inpatient detoxification for the treatment of alcohol and opiate dependence within a community addictions service
Authors: Griffin Harry , Rishi Natasha , Kelleher Mike
Published: June 2021

Aims

The 2012 Health and Social Care Act transferred Addictions commissioning from the NHS to local authorities, leading to cuts of up to 30-50% of budgets and having the greatest impact on inpatient detox services. In a system with such limited capacity, effectively triaging access to detox services and optimising the efficacy of each detox has become increasingly important. NICE offers limited guidelines to assist with making these decisions, focused on assessing the severity of dependence and risk, but provides little detail on specific predictors of success. Our aim is to evaluate the nature of cases referred for inpatient alcohol or opiate detox and their treatment outcomes. This will help develop our understanding of the factors which influence achieving abstinence, and inform future decision-making regarding suitability for inpatient detox and post-detox planning. Conclusions will form part of a review of the local alcohol care pathway guidelines.

Method

A retrospective case note review of all inpatient detox admissions between April 2019-March 2020 (n = 113 patients) is being undertaken. Our data collection tool extracts quantitative and qualitative data based on criteria from Alcohol use disorders (NICE, 2017), Opiate detoxification (NICE, 2019) and local pathway guidelines.

Result

Preliminary analysis of data from November 2019–March 2020 (43 patients) showed that a clearly documented rationale for inpatient detox was recorded in 95% of cases. 100% of cases had a recorded AUDIT score, whilst SADQ scores were recorded in 50% of cases. 33% of cases were admitted to rehab post detox, and 19% were prescribed anti-craving medication. Abstinence at one year was confirmed in 21% of cases. 28% of clients received a second detox within one year. The rationale for inpatient detoxes in this population is to be reported.

Conclusion

Preliminary data may highlight an opportunity to improve pre detox decision-making and post detox care, with confirmed abstinence in only 21% of clients at one year after detox. The low proportion of completed SADQ scores before accessing detox could offer an opportunity to improve client assessment, and the small proportion of clients prescribed anti-craving medication highlights an area of post detox care which could also be improved. The main limitation of this study is the lack of linked analysis of outcome to specific predictors, which is something that could be explored in future. It would also be valuable to gain survey data on the experience of accessing detox from a service user perspective.
Management of emotionally unstable personality disorder in an urban Irish setting
Authors: Yee Calvin Har Siu
Published: June 2021

Aims

To determine the prevalence of emotionally unstable personality disorder (EUPD) attending a community mental health team (CMHT) in a major Irish city

To describe the current psychiatric care afforded to this cohort of service user

Method

Clinical chart review of all 328 patients attending a CMHT outpatient in an urban setting was carried out. Patients diagnosed with EUPD or displayed features of EUPD were identified. Data on the various interventions offered to this cohort of service users were collected and compared against current guidelines.

Result

Out of the 328 patients actively attending the service, almost 17% (n = 55) were diagnosed with EUPD and further 6% (n = 19) were found to display features of EUPD such as emotional dysregulation, self-harming behaviour and cognitive distortions. Comorbid psychiatric disorder such as mood or anxiety spectrum disorder was diagnosed in 23% (n = 17) of this cohort. Meanwhile, 8% (n = 6) was diagnosed with addiction disorders and 5% (n = 4) was diagnosed with a comorbid personality disorder. A significant proportion of 77% (n = 57) were prescribed psychotropic medication with 51% (n = 29) being on more than one psychotropic medication. Antidepressants, antipsychotics and hypnotics were the three most common medications prescribed at the rate of 89% (n = 51), 30% (n = 17) and 28% (n = 16) respectively. A majority of 66% (n = 49) were offered intervention from a multi-disciplinary team (MDT) member with 47% (n = 23) being offered more than one type of intervention. Referrals to community mental health nurses and psychology service were the two most common interventions offered with a referral rate of 59% (n = 29) and 55% (n = 27) respectively. 28% (n = 21) of service users with EUPD or EUPD traits has had at least one hospital admission while attending the CMHT and 46% (n = 34) have been admitted to the day hospital at least once.

Conclusion

The prevalence of EUPD in our outpatient sample corresponds with findings in previous studies. Standard psychiatric care is the most common option available to the majority of general adult patients with EUPD in Ireland due to the lack of any national treatment programme and scarce availability of specialised therapeutic approaches such as dialectical behavioural therapy within community mental health teams. Our CMHT will attempt to integrate mentalization-based treatment into our outpatient management of EUPD patients taking into account current clinical guidelines for management of EUPD and resources needed for training and delivering the intervention.
A question of information mismatch in the SPC and PIL on the effect of ADHD stimulant medications on tourette's syndrome
Authors: Hisham Idura , Shabbir Shazia
Published: June 2021

Aims

To assess the quality of information provided by pharmaceutical companies to patients and doctors regarding the impact of stimulant medications indicated for the treatment of Attention Deficit Hyperactive Disorder (ADHD) on Tourette's syndrome(TS) and tics in children and its implication on treatment.

Background

It is estimated that between 35% to 90% of TS patients also have ADHD. However, there remains a pervasive belief that the use of stimulants to treat ADHD symptoms in children with comorbid tic disorders is contraindicated because of concerns about possible tic exacerbation. Recent studies has disproved this, which is reflected in United Kingdom(UK) and European ADHD and TS guidelines. Pharmaceutical companies are legally required to provide a Summary of Product Characteristic (SPC) and Patient Information Leaflet (PIL) for each medicine as it is an integral part of the marketing authorisation approval. The SPC contains vital information for the usage and prescription of a drug for use by healthcare professionals. The PIL included in the medication packaging is a patient-friendly version of the SPC.

Method

The available stimulant medications licenced for use in paediatric patients with ADHD in the UK were identified through the Medicines & Healthcare products regulatory Agency (MHRA) website. The SPC and PIL were then accessed from the Electronic Medicines Compendium (EMC) website. Those not on the site were obtained directly from the marketing authorisation holder. Any direct mention of tics or Tourette's in the contraindication, warning and caution, or side effect section were documented. The information was then tabulated and compared.

Result

Of the three stimulant drug types, 17 variations are currently available for use in the UK. There were inconsistencies found between the SPC and PIC in reference to the impact of these drugs on tics and TS in all 17 licensed medication. Most discrepancy was found in regard to TS as a side effect (16/17) and also tics (15/17). TS is also listed as a contraindication in the SPC and PIL for all available variety of Dexamphetamine class drugs. This is inconsistent with current clinical evidence and guidelines.

Conclusion

The disparities in information regarding the impact of stimulant medications on tics and TS can have wide ranging effects. Outcomes could include poor patient adherence, or prevention of initiation of potentially beneficial treatment. It would benefit to standardize the information between these two documents to minimize inconsistencies in understanding between doctor and patient.
Striving for better comunication - an audit
Authors: Breen Eleanor
Published: June 2021

Aims

The aim of this audit is to assess communication between the general and psychiatric hospital. This audit was prompted after a number of patients were transferred to Udston Hospital, a community hospital with two older adult acute mental health wards, with no written communication. This led to several significant issues including medication errors, ambiguity regarding patient escalation plans and uncertainty regarding what had been discussed with families.

Method

Over the course of one month eight patients were identified who had been transferred from the acute site to Udston Hospital. Three were new admissions to Udston, four were returning after treatment for physical illness, and one returned following assessment in ED. Data were collected by examining paper and electronic notes, and analysed using Excel. The results of this audit were discussed at the local clinical governance meeting. A 2nd cycle was performed. Eight transfers were identified. Four were returning after an assessment in ED, two were new admissions to Udston and two were returning after treatment for physical illness.

Result

Initial audit found that 38% of patients were transferred with their medical notes, 50% were transferred with no written documentation whatsoever, and none of the patients were transferred with a transfer letter. The second cycle found that 88% of patients had a transfer or discharge letter. 12% of patients came with no written documentation.

Conclusion

The initial audit found significant deficiencies in communication. Highlighting the need for all patients to have a transfer letter at a local management meeting seems to have led to an improvement. However, differences between the samples in the 1st and 2nd audit cycle could be distorting the results. Further audits would be useful given the small sample size and due to the differences between the sample populations.
Are acute psychiatric units providing adequate inpatient services for borderline personality disorder patients?
Authors: Ling Siew , George Joji
Published: June 2021

Aims

To assess the adherence to NICE guidelines CG78 (1.4) regarding the inpatient services provided for BPD patients at an acute psychiatric unit (The Oleaster).

Borderline personality disorder (BPD) patients are frequent users of psychiatric inpatient services. However, evidence suggests that inpatient treatment is ineffective in the long-term recovery of such patients. The inpatient services at the Oleaster will be audited against NICE guidelines for BPD. We hope to improve the care of patients with BPD and ensure effective use of psychiatric resources.

Method

Retrospective case notes review of 35 patients admitted into the Oleaster from 1/11/2018–31/10/2019. This was taken from an initial sample of 72. Patients were excluded if they were admitted for other concomitant mental or behavioural problems (except problem use of tobacco, drugs or alcohol).

Result

69% of patients were referred to other mental health services (e.g CRHT/HTT, other local alternatives, liaison team) prior to admission. There was no evidence of referrals in 31% of the sample population.

The reasons for admission include significant risks to themselves/others (n = 14) and detention under MHA (n = 14). Reasons were not noted in 7 patients.

Advance agreement on the length and purpose of admission took place in 19 and 27 patients respectively. Discussion of potential harms and benefits of admission only took place in 4 patients. Discussion was not applicable in 2 patients who lacked capacity.

Of the patients admitted ≥2 times in the previous 6 months, only 38% had a CPA review arranged. It was not arranged in the remaining 62%.

Conclusion

There is room for improvement in the appropriate admission and documentation of BPD patients. Referral prior to admission was well adhered but documentation was unclear. Implementing a set checklist before admission could be recommended. Active involvement of patients was inadequate. It is especially lacking in regard to informing patients of the potential harms of admission. This can be improved by educating patients and staff on this matter.CPA reviews were not arranged in a timely manner. Placing an alert on patients’ records when they are admitted again within the last 6 months would help to reduce this issue. Overall, greater effort is required to ensure patient's most current needs are met and that limited psychiatric resources are used effectively.
Compliance with nice guidelines for management of depression in a community mental health team
Authors: Mellor Sophie , Pantall Shay-Anne , Brownell Lisa
Published: June 2021

Aims

To evaluate compliance within a Community Mental Health Team (CMHT) to the NICE guidelines for the management of depression.

Background

Reducing the prevalence of depression continues to be a major public health challenge.

Given the complexity and recurrent nature of the condition, the NICE guideline CG90 is an invaluable resource to aid the effective management of depression. Here we present an audit of adherence to this guideline within a CMHT.

Method

A retrospective electronic casenote review of all patients diagnosed with depression between January 2016 and October 2019 under the care of a Birmingham CMHT (n = 35), assessing key performance areas including: quality of assessment and coordinated care, risk assessment, choice of pharmacological and psychological treatment using the stepped care model and appropriate crisis resolution planning.

Result

Key results include:

The majority of patients were Caucasian (63%). Ages ranged from 27 to 69 (mean age 48 years old).

Severity of disorder was typically moderate (46%) or severe (48%). Of those with a diagnosis of severe depression, 41% had associated psychotic symptoms.

Psychiatric comorbidity was high (49%), of which generalised anxiety disorder was the most common (59%).

Referrals were typically from primary care (77%). Approximately half (51%) had reported suicidal thoughts according to the referral.

A quarter of patients (26%) were seen by CMHT within 8 weeks of referral; 20% of referrals however waited over 12 months before being assessed.

Risk assessments were out of date for 71% of patients.

100% of patients had a crisis plan noted within their most recent clinic letter; however, none of these met the required standards.

Polypharmacy was common (60%), with 34% prescribed two antidepressants. Use of lithium augmentation was uncommon, with only one patient prescribed this. 43% were prescribed an antipsychotic; of which, 29% had appropriate physical health monitoring completed.

Over half of patients (60%) had been referred to psychology services; of these, 38% had either completed or were in ongoing treatment at the time of review.

Conclusion

CMHTs manage the care of individuals with depression who have high levels of active symptoms and disability, psychiatric comorbidity, care requirements, and complex treatment plans. Pharmacological management was broadly in line with guidelines, and rates of referral to psychology were satisfactory. Risk assessment and crisis planning are clear areas in need of urgent attention in order to comply with guidelines and ensure patient safety.
Physical health monitoring of patients prescribed depot antipsychotic medication in north west Edinburgh community mental health team
Authors: Murdie Douglas , Wojtowicz Jakub , Thompson Alexandra , MacLeod Anne , Mallis Adam , Evans Hamsi , Haggart Joshua , Choi Hae , Argent Vikki
Published: June 2021

Aims

To monitor the quality of physical health monitoring of patients prescribed depot antipsychotic medication in the North West Edinburgh Community Mental Health Team (CMHT). We also evaluated the completeness of prescriptions and Mental Health Act (Scotland) (Act) 2003 paperwork where relevant.

Background

Antipsychotic medications are medicines for treating conditions such as Schizophrenia, but some may be associated with an increased risk of Metabolic Syndrome. Moreover, evidence indicates that patients with major mental disorder have a reduced life expectancy in comparison to those without such diagnoses. These two factors illustrate the importance of the physical health of this patient cohort being monitored on a regular basis. This project will evaluate how a local CMHT is performing, with the possibility of enacting service improvements if required.

Method

The records of the 60 patients prescribed depot antipsychotic medication administered by this CMHT were reviewed. A check-list was created consisting of 14 categories analysing the quality of physical health monitoring, as well as compliance with prescription standards and, where relevant, Mental Health Act (Scotland) (Act) 2003 paperwork. We compared patient records against our checklist for the calendar year of 2019. The Scottish Intercollegiate Guidelines Network (SIGN) 131 (Management of Schizophrenia) section 5.2 was used as the gold standard for physical health monitoring against which the data we collected was compared.

Result

We identified a wide range of flaws with the current system and implementation of monitoring, and difficulty in locating the required information. There was no consistent monitoring of physical observations on electronic record, nor an accepted alternative way in which this was documented. Furthermore, blood tests were not consistently obtained either by the service or GP practices in a reproducible manner. This led to discussions within the CMHT regarding creation of a new pathway for the monitoring of this patient cohort using a Quality Improvement model, with the ultimate goal to establish a regular physical health clinic.

Conclusion

There is significant evidence that patients with major mental disorder do not access healthcare as consistently as those without, leading to a disparity in life expectancy. In light of the fact that antipsychotic medications can be associated with Metabolic Syndrome, we have an even greater responsibility to tackle this marked health inequality by appropriately monitoring our patients. This was not done well in this particular CMHT, but this project will lead to improvements in the service and ultimately patient care.
Clozapine clinics in north Wales - service evaluation audit
Authors: Raja Jawad , Azhar Zeenish , Malik Masood
Published: June 2021

Aims

1.

Quality of clozapine clinic appointment

2.

Effectiveness of clozapine clinic servive

3.

Compliance with BCUHB guidelines for physical health monitoring in clozapine clinics

4.

We retrospectively audited 40 case notes 10 each from 4 differtent CMHT clozapine clinics

My role in the Project & How does this represent my practice?

1.

I was the audit and overall lead for this project

2.

I formulated the audit tool and registered my project with Audit Registration Team

3.

I lead data collection and compilation of results

Background

1.

This audit followed up from a Coroner's investigation for a clozapine clinic patient

2.

Clozapine is used for Treatment Resistant Schizophrenia but needs close monitoring due to potentially fatal side effects

3.

NICE recommends annual monitoring of weight, blood pressure, waist measurement, blood glucose and plasma lipid levels

Method

1.

Has the patient been seen in the past year by clinician to monitor response to clozapine treatment?

2.

Has the clozapine plasma level been measured during the last year of treatment?

3.

Is brief MSE & Risk assessment documented during review?

4.

Has Life style modification advice been provided?

5.

Has annual physical health been completed?

6.

Has Annual CTP/CPA been completed and documented?

7.

Has the patient been allocated a named care coordinator?

8.

Has clozapine side effects monitoring been documented?

Conclusion

1.

Clozapine is a superior medication for the treatment of refractory schizophrenia and is also be effective for other conditions

2.

Clozapine is underused due to a variety of barriers related to the drug and its properties, the health care system & regulatory requirements

3.

This service evaluation/quality improvement project provides the framework for clozapine clinics evaluation and recommends strategies for improvement
Urine drug screening in women's forensic mental health services: is current practice meeting guidelines?
Authors: Rampling Jeremy , Pantall Shay-Anne , Mann Ravinder
Published: June 2021

Aims

To investigate adherence to Trust guidelines for urine drug screening amongst female forensic psychiatric inpatients.

Background

The use of illicit substances is an important risk factor which needs to be considered in the management and treatment of forensic psychiatric patients. Research has demonstrated that a high proportion of women admitted within secure services in the UK have a history of substance use. Substance misuse amongst this population can lead to an increased risk of violence, re-offending and mental health relapse; which can pose a significant threat to the safety of other patients, staff and the public. It is therefore important that regular drug screening is carried out to minimise such risks. Ardenleigh is a blended female secure unit in Birmingham. The service has established specific substance use guidelines, outlining the need for each patient to have a personalised drug screen care plan in place. Here we present the findings of an audit completed in 2019.

Method

A six month retrospective electronic case note audit for female inpatients admitted to Ardenleigh as of 1st September 2019 (n = 27). We compared drug screen care plans and frequency of urine drug screens over 6 months with the recommendations of the current service-specific Trust guidelines. Care plans should include: information regarding random drug screening; frequency of random drug screening; triggers for increased risk of substance misuse; and consequences for a positive test result to be contained within inpatient care plans.

Result

Patient aged between 20 and 56 years old (median age 31). Fewer than half of inpatients (41%) had a documented random drug screen completed within the review period. In terms of care-planning, only 52% of patients had random drug screening mentioned in their care plan. 22% of patient care plans reported the actions/consequences for a positive test result. Not a single care plan mentioned how frequently patients should be being tested or potential triggers for increased risk of drug misuse amongst inpatients.

Conclusion

Current practice and recording of drug screening amongst female forensic psychiatric patients is poor compared to expected standards. The lack of consistency in drug screening raises concerns regarding whether potential substance misuse amongst inpatients may be going undetected, and therefore impacting the recovery of patients. Improvements to drug screening practice should be considered in order to ensure optimal recovery and safety to patients and others.