bluuebunny/crossref_metadata_2025 huggingface dataset:
Reverse-mentorship of the core concepts in philosophy and mental health: a medical education case report
Authors: Jewell Michael , Kamal Manzar , Bayney Richard , Hales Heidi
Published: June 2021

Aims

The aim of this medical education case report was to outline the development and outcomes of a reverse-mentorship project that enabled cross-generational collaborative learning. The project took the shape of a philosophy of psychiatry journal club facilitated by a psychiatry core trainee in west London, UK.

Background

Reverse-mentorship reverses traditional roles of mentor and mentee. It is an increasingly fashionable concept in medical education. The junior mentors the senior clinician. The implicit learning outcomes include provision of a two-way learning process, development of mentoring skills for the more junior clinician and collaboration that builds social capital within the workplace. Reverse-mentorship is effective when the junior mentor is recognised for their expertise in a particular area. In this instance, the junior mentor has a special interest in the philosophy of psychiatry.

Method

Junior mentor and senior mentees formed a monthly journal club. The club tracked arguments from anti- and biological psychiatry on the meaning of mental illness. The debate offered insight into a semantic analysis of mental illness and a deeper conceptual understanding of medicine. The learning material derived from the core concepts of philosophy and mental health (Fulford et al.). The role of the mentor was to facilitate group discussion around arguments from relevant papers. A survey, adapted from a recent reverse-mentorship review article, measured the quality of educational experience for mentor and mentees.

Result

Overall, mentees (senior clinicians) agreed that the mentor (junior clinician) displayed attributes and behaviours for effective mentoring across most domains, including enthusiasm, effective communication, respect for mentee expertise and active listening to the needs of the mentee. The mentor was particularly impressed with the mentees’ openness to learn new concepts and respect shown. General reflections on the experience of reverse-mentorship were positive overall. A thematic review highlighted particular aspects, including: a good way to learn a new skill and great opportunity to develop professional skills of mentoring.

Conclusion

The importance of mentoring in medical education is well established. Reverse-mentorship is a new concept that looks to harness the unique qualities of millennials, including their aptitudes for empowerment, innovation and collaboration. This medical education case report shows that an enthusiastic junior clinician can successfully pilot an educational-mentoring scheme aimed at senior clinicians. To make more explicit the intuitive benefits of reverse-mentorship, longitudinal reviews are needed. However, this case report contributes important insights into this burgeoning field of medical education.
Digital frontiers in international psychiatric recruitment: the lessons of the Northwest School of Psychiatry careers event November 2020
Authors: Kazmi Nosheen , Rodrigues dos Santos Catarina , Lewis Emily , Olety Sahana
Published: June 2021

Aims

A low level of psychiatric recruitment is a global issue[1]. The RCPsych & UK Mental Health Trusts jointly run School Events as part of a recruitment strategy. The North West has been running such events for the past years. After our first virtual event, we compare the quality, effectiveness and experience of a face-to-face (F2F) recruitment programme in 2018 with our first remote recruitment programme in 2020. In a world of fast paced technology, we reflect on what lies in the horizon for international psychiatric recruitment.

Method

The recruitment programme was organised by 4 psychiatric trainees affiliated to each mental health trust. A two-day remote programme on the Zoom platform comprising of 45-minute slots was created. Through their own experiences of inspirational speakers, trainees contacted speakers representing different specialities, teaching styles and philosophical outlooks.

Pre and Post Programme questionnaires and certificates of attendance were shared with speakers and attendees. These were compared with Pre and Post Programme questionnaires from the F2F event in 2018.

Result

When compared to the 2018 F2F programme, the 2020 virtual recruitment programme attracted a higher number and wider variety of applicants, in gender (62% female/38%male), nationality (UK 79%/Non-UK 22%), as well as wider distribution in age, UK deanery and training position. Despite the elimination of cost, the quality of teaching was rated higher than F2F due to the availability of high quality speakers (100% would recommend to a friend; 72% rated excellent). Whilst the programme was effective in changing minds, this did not exceed F2F recruitment rates. F2F recruitment feedback focussed on inclusion of sub-specialities, whereas virtual programme feedback focussed on ways to enhance interaction. Feedback focussed on technological applications such as interactive quizzes, breakout rooms, play-acting, and having the benefit of clinical vignettes or speakers’ personal stories to bring talks to life.

Conclusion

The use of remote technology transcended geographical and demographic frontiers. A variety of high-quality speakers, directly appealing to an international cohort were sourced, at no monetary cost. In future, the budget will be used in interactive applications, and time-limited session recordings. As the participants hungered for personal connections, we recommend a blended programme, with links to taster sessions, retaining the advantages of both strategies.
The Malaysian Northern Stars (supervision, training, and reflective system) project: a multi-facet ecosystem of producing local talents
Authors: Hadi Noor Melissa Nor , Loo Jiann Lin
Published: June 2021

Aims

The MRCPsych (Membership of the Royal College of Psychiatrists, United Kingdom) parallel training pathway has been introduced in Malaysia to produce competent psychiatrists to deliver evidence-based psychiatric care. Certain training centres faced specific challenges during the process of implementation, including the lacking of supervisors with experience in the MRCPsych examination, over-reliance on self-study and existing continuous medical education (CME), logistic difficulty in accessing specific training courses, the sustainability of local training, and loss of manpower due to frequent mobilisation of trainees. This article is aimed to illustrate the Northern STARS (Supervision, Training, and Reflective System) project, i.e. a project implemented as a solution for those challenges and an effort to develop a sustainable model of training for the local talents in Perlis, a northern state in Malaysia.

Method

The Northern STARS initiatives included: setting up a library with more MRCPsych-related materials; introducing trainees to virtual MRCPsych support groups; organizing both physical and virtual training locally, collaborating with local and international experts for consultation and teaching, and the introduction of protected study time. Virtual platforms were used innovatively to minimise cost. Ongoing data were collected for programme evaluation and quality improvement. Trainees were actively involved in the process to facilitate the development of leadership and administrative skills.

Result

A total of seven courses covering both skill and theory training had been organised: Ultra-brief Psychological Intervention Workshop, Dialectic Behavioural Therapy workshop, Personality Disorder Workshop, Critical Appraisal Workshop, MRCPsych Lecture Series, Addiction Psychiatry Lecture, and Basic Revision Course on Electroconvulsive Therapy. An estimated amount of twenty thousand Malaysian Ringgit had been generated and channelled into the community mental health centre, accounting for the indirect cost of a subscription to ZoomTM and the intangible cost of labour effort. Overall feedback revealed a high level of satisfaction together with some specific suggestions on areas of improvement, including the timing of course and coverage of the curriculum. To date, six medical officers are pursuing this pathway with three of them passing one paper and another two pursuing the final part.

Conclusion

The Northern STARS project is an ecosystem of training solutions while generating income and producing more local talents to expand this project further. More long-term evaluation from the perspective of human resource and health economics can be considered to understand the efficiency of the current initiative.
Survey of junior doctors' perspective of serious incident reviews
Authors: Popoola Olusegun , Naidoo Kuben , Shetty Amrith
Published: June 2021

Aims

Serious incidents according to NHS England (2015) are incidents where the consequences to patients, families and carers, staff or organisations are so significant or potential for learning are so great that a heightened response is justified. There is anectoctal evidence that this process is potentially difficult for junior doctors and the primary purpose of learning may be lost due to the stress involved.

Our aim was to evaluate junior doctors perspective of serious incident reviews. A secondary aim was to organise local and regional workshops based on the outcome of our findings to address misconceptions around serious incident investigations.

Method

A survey was developed using survey monkey and distributed to all trainees across the Mersey region through the Medical Education teams.

The junior doctors range from core trainees to higher trainees. The survey encouraged the use of free texting if necessary.

Results from the survey were then analysed

Result

18 junior doctors across the 3 mental health Trusts in the Mersey region responded.

12 respondents have been involved in a serious incident investigation in the past and 9 of the respondents stated that they did not recieve any support during the process. Out of the 3 that were supported, one rated the support as poor and frightening.

55.56% af all respondents found the process of serious incident reviews hard to understand.

66% of all respondents admitted that they are aware that the purpose of the review is for learning purposes.

100% of respondents agreed that a workshop to discuss the purpose and process of serious incidents investigation to aid their understanding would be useful.

Conclusion

From the survey, we concluded that junior doctors do have some understanding of incident reviews process but they still do not feel comfortable with the idea of being under ‘investigation'.

It is also important that formal support is made available during the process.

We organised a workshop in one of the 3 Trusts which was well attended and junior doctors asked if they could sit on review panels for experiential learning. This is to be presented to govenance teams across the mental health trusts in the region.

Further workshop across the 2 remaining Trusts could not be organised due to COVID-19 pandemic.
Does attending psychiatry teaching lectures change attitude of medical students towards people with mental illness? A longitudinal survey from nepal
Authors: Thapaliya Suresh , Singh Shizu , Goit Bharat , Sawant Sandesh , Gupta Anoop Krishna
Published: June 2021

Aims

The study aims to compare the attitude of early clinical year medical students towards people with mental illness at the beginning and the end of their psychiatry teaching schedule. It hypothesizes that long exposure to psychiatry lectures can help to reduce the negative attitude.

Background

Health professionals are also known to harbour negative attitude towards people with mental illness. Reducing stigma among medical students is crucial to shape the attitude of future health professionals towards people with mental illness. However, the effect of Psychiatry training on the attitude of the medical students shows mixed results.

Method

It was a prospective longitudinal study conducted among fourth year medical students affiliated with a teaching hospital in Southern Nepal as an initiative to improve quality of Psychiatry training for medical students. The students who gave their consent for participation were assessed for their attitude at the beginning, after the first two introductory lectures and at the end of the Psychiatry lecture-based teaching schedule (36 two weekly lectures in 5 month period), using self-administered 16-item Mental Illness Clinician's Attitudes Scale (MICA-2) ‘medical students version’ questionnaire in English language. Permission was taken from the author of the study to use the scale. IRB approval was taken prior to the study.

Result

A total of 95 (approx. 67%) students participated in the study. At the first follow-up i.e. second week, (n = 85), there was no significant difference in negative attitude as assessed by MICA score (p = 0.47). However, at six months follow-up (n = 82), the negative attitude significantly differed compared to the baseline (p < 0.001).

Conclusion

While brief lectures about mental illness can provide some knowledge about mental illness, long term exposure to psychiatry lectures can reduce attitude of medical students on people with mental illness. Hence, it is also crucial to incorporate academic contents that reduce negative attitude about people with mental illness.

Financial declaration: The study was self-funded by the department of Psychiatry at National Medical College and Teaching Hospital, Parsa, Nepal.
Attitude and knowledge about electroconvulsive therapy (ECT) among medical students in Nepal: a pilot survey
Authors: Thapaliya Suresh , Singh Shizu , Shrestha Shuva , Gupta Anoop Krishna
Published: June 2021

Aims

Electroconvulsive Therapy (ECT) is an important modality of treatment for treatment resistant psychiatric disorders. Young medical students like general public might harbor several misconceptions about ECT. In this pilot survey, we explored the knowledge and attitude about ECT amongst young medical students training in a medical college affiliated to a teaching hospital in Southern Nepal.

Method

A 23-item questionnaire in English language with either ‘True’ or ‘False’ response as outcome was developed by reviewing findings from previous studies. Brief information was also taken to record familiarity of medical students with ECT as a treatment procedure. The study was conducted as a departmental pilot survey for quality improvement of Psychiatry Undergraduate Training. A total of 128 medical students in early clinical year enrolled in MBBS curriculum at a teaching hospital in Southern Nepal participated in the survey. The students were not exposed to any specific teaching regarding ECT while participating in the study.

Result

The students were aged between 21 and 28 years with almost equal gender distribution. Among them, 89.1% had heard about ECT before whereas 15.6% knew someone who has received ECT. Although 90.6 % of students believed ECT can be lifesaving many times, a substantial number of students had misconception about ECT such as assuming it as a painful procedure (71.9%). Almost half of them believed ECT can have severe consequences like death or permanent brain damage. Around one fourth to one third believed ECT is inhumane, without scientific proof or a form of punishment for violent angry patients. Surprisingly, a significant higher percentage of male students believed that ‘ECT leads to permanent loss of memory’ (11/34 vs. 3/30, p = 0.04) and ‘ECT is given as a punishment to violent/angry patients’ (15/34 vs. 4/30, p = 0.01).

Conclusion

Several misconceptions about ECT are prevalent in medical students that need to be adequately addressed during their training to develop a positive attitude and basic knowledge about the treatment.
Research into psychiatry trainees views around the impact COVID-19 has had on the provision of electroconvulsive therapy training
Authors: Webb Cara
Published: June 2021

Aims

The current COVID-19 outbreak has changed the way electroconvulsive therapy (ECT) is provided. In many areas it has been moved from the more traditional ECT suites to general surgical theatres for a number of reasons, most notably being the need to ensure adequate ventilation. The introduction of the need for PPE to be worn throughout ECT and for general hospital operating procedures to be adhered to has also been a big change. The change in the required infection control procedures has had an impact on treatment capacity and has led many areas to reduce, relocate or centralise their ECT provisions which has had a knock on effect on training.

This study assesses the perceived impact COVID-19 has had on the provision of training and learning in ECT for core and higher psychiatry trainees in the North West as well as their perceived competence levels.

Method

Views were sought through surveys and focus groups from September to December 2020, participants were core and higher psychiatry trainees in the North West. Participants were recruited via email, the total population size was 87, 21 Core trainees responded and 14 higher trainees. From the survey respondents, 5 participants agreed to attend a focus group.

Result

Results show that the provision of ECT training has been poor during the COVID-19 outbreak. Almost 81% of core trainees surveyed and 92.86% of higher trainees had participated in no ECT sessions from the start of the COVID-19 outbreak to the time of data collection eight to ten months later.

81% of core trainees and 85.71% of higher trainees had received no teaching in any form about ECT over the period studied.

When considering the competencies required in ECT for a core trainee, one (4.76%) felt they were fully competent, 3 (14.29%) nearly competent, 7(33.33%) needs some improvement, 10 (47.62%) not yet competent. Only one higher trainee felt they met the RCPsych competencies, 5 (35.71%) were nearly competent, 6 (42.86%) need some improvement and 2 (14.29%) were not yet competent.

Conclusion

This study indicates a clear lack of provision of training which is very concerning ,and possibly pre dates the COVID outbreak, particularly in the case of specialty trainees who may well be consultants in a number of months and will not have the time to make up for the lost training. In order for ECT provision to continue it is crucial that we are able to adequately train the future workforce.
Peripheral cortisol administration blunts reward arousal but heightens anxiety-like arousal in marmosets
Authors: Alexander Laith , Gaskin Philip , McIver Lauren , Roberts Angela
Published: June 2021

Aims

Excess hypothalamic-pituitary-adrenal (HPA) axis activation is common in people with major depression and generalised anxiety disorder. We sought to determine whether higher circulating levels of the glucocorticoid cortisol are causally related to the expression of anhedonia-like and anxiety-like behaviours in marmosets.

Method

Four marmosets (two male, two female) took part in the study. Cortisol and saline control injections were administered intramuscularly and salivary cortisol samples were taken before and after injections to determine if circulating cortisol levels changed from pre- to post-injection. To measure anhedonia-like behaviours, we trained marmosets on an appetitive Pavlovian conditioning paradigm, where animals learn to associate two anticipatory auditory cues (conditioned stimulus + or conditioned sitmulus -, CS+ or CS-) with the presence or absence of food reward (unconditioned stimulus + or unconditioned stimulus -, US+ or US-). Using cardiovascular telemetry probes and video cameras, we recorded animals' cardiovascular and behavioural arousal in freely moving conditions, comparing the injection of saline control versus 5mg/kg, 10mg/kg or 20mg/kg intramuscular cortisol. To measure anxiety-like behaviours, we used a human intruder (HI) paradigm, where marmosets are confronted with an unfamiliar human in their home cage. We recorded their behaviour on video cameras after saline control or 20mg/kg intramuscular cortisol. We used an exploratory-factor analysis (EFA) to determine how marmosets' behaviours towards the intruder loaded onto an 'anxiety-like' score. We then compared these scores under saline control versus cortisol conditions. Significance was set at p < 0.05.

Result

Unlike saline control, we found that subcutaneous injections of 20 mg/kg cortisol successfully elevated peripheral cortisol concentrations to levels equivalent to peak circadian concentrations (p = 0.023). In the appetitive setting, 5 mg/kg, 10 mg/kg and 20 mg/kg cortisol injections blunted anticipatory (CS+ induced) increases in behavioural arousal (p = 0.004) but did not alter anticipatory cardiovascular arousal. Consummatory behavioural and cardiovascular arousal also remained intact. In the HI test, 20 mg/kg cortisol injections moderately increased anxiety towards the intruder as measured by an increase in marmosets' EFA-derived anxiety-like scores (p = 0.035).

Conclusion

In marmosets, elevated peripheral cortisol levels are causally related to the behavioural features of blunted reward anticipation together with elevated anxiety-like behaviours characteristic of mood and anxiety disorders. Future work will characterise the neuroimaging changes induced by elevated peripheral cortisol levels and identify the regions of the prefrontal cortex contributing to HPA axis regulation and dysregulation.
Multicentre evaluation of the pharmacological management of women with bipolar disorder in the perinatal period
Authors: Dias Marisa Casanova , Jones Ian , Wieck Angelika
Published: June 2021

Aims

The pharmacological management of women with bipolar disorder in the perinatal period is challenging. This population has a high recurrence rate, but some medications can be a concern in pregnancy and breastfeeding. Little is known about prescribing practices in perinatal services, and the impact of medication on recurrence rates.

The aims of this study are: 1) to describe the use of medication in women with bipolar disorder in the perinatal period and 2) to evaluate the impact of medication on the rate of postpartum recurrence.

Method

Clinical data were collected from pregnant women with a diagnosis of bipolar disorder in the nine participating centres in the UK and who were not experiencing an episode of illness entering the postpartum period. Using a proforma, data were collected for the period between conception and three months postpartum: sociodemographic, reproductive, the severity of illness, medication and recurrence.

Data were analysed for association using χ2 tests and logistic regression.

Result

In this sample of 167 women, 91 (55%) were taking medication at delivery: 62 (37%) antipsychotics, 41 (25%) antidepressants, and 25 (15%) mood stabilisers. In 12 cases medication was reduced before delivery. Of those who were taking medication at delivery six decreased of stopped after delivery and one increased the dose. 42% of women in this sample experienced a recurrence, with 30% of the sample experiencing a manic/psychotic episode. There was no significant association between taking medication and recurrence χ 2(1) = 0.07, p = 0.79. There continued to be no association in a multivariable analysis when adjusted for parity, severity (previous admissions, age at first treatment, bipolar subtype), type of medication during pregnancy and immediate postpartum changes aOR 0.33 95%CI [0.03; 3.40], p = 0.35.

Conclusion

A high number of women with bipolar disorder are taking medication before delivery and in the majority, antipsychotics are prescribed. The postnatal recurrence rate in both medicated and unmedicated women is high. These results are in line with existing literature. Further work is needed in larger samples to provide clinical guidance for women and their clinicians.
Buspirone in obsessive-compulsive disorder: a potential dark horse?
Authors: Garg Kabir , Tyagi Himanshu
Published: June 2021

Aims

Pharmacological management of Obsessive-Compulsive Disorder (OCD) presents a challenge in modern psychiatry. While most patients respond preferably to serotonin re-uptake inhibitors (SRI), the response is usually delayed by several weeks leading to an insufficient short term management of anxiety. It is also frequently inadequate and needs higher doses and augmentation in many instances. Investigating newer pharmacological strategies to address such treatment gaps has always been of interest. Buspirone is a novel anxiolytic medication with additional weak antidepressant and poor anti-psychotic effects. It is the only medication in its category, i.e. azapriones. It has comparable anti-anxiety efficacy to that of benzodiazepines without their sedating or habit forming effects, and has been demonstrated to moderate serotonin and other monoamine neurotransmission with a favourable safety profile.

Method

We reviewed the literature pertaining to the use of Buspirone in OCD for both as a primary anti-obsessive agent and for a potential secondary role in management of chronic anxiety and/or anxiety disorders comorbid to OCD.

Result

The results of a number of case reports and open trials have been positive while controlled trials have shown contradictory results. In a double blind RCT comparing clomipramine and buspirone, significant improvement was found in both groups with no differences between the two. Further two trials observing buspirone augmentation of clomipramine and fluoxetine treatment respectively, in a double-blind placebo controlled design reported significant improvement in the treatment as opposed to the placebo arm. Another double-blind placebo controlled study of buspirone augmentation of fluvoxamine resistant patients did not show significant benefits as an anti-obsessional agent, but notable anxiolytic effects were reported. In all the trials buspirone was largely well tolerated and did not pose any significant interactions with other psychotropic agents or dependence potential.

Conclusion

Buspirone is a pharmacologically unique agent with a good safety profile. Given the robust anxiolytic effects of this Peron along with complex neurotransmission modulatory effects coupled with a favourable tolerance and dependents profile might make buspirone an attractive novel pharmacological agent for augmentation in OCD . Further controlled studies to better establish effectiveness and deciphering if certain patients may respond to its use over others, are warranted
Different onset patterns of monthly paliperidone palmitate in hospitalised patient diagnosed with schizophrenia
Authors: Herrera-Sánchez Javier , Aznar Julia , Izaguirre Leire , Ovejero Santiago
Published: June 2021

Aims

Paliperidone palmitate long-acting injectable (PPLAI) initially requires two loading doses of 150 and 100 mg on days 1 and 8 (± 4 days) intramuscularly. In clinical practice, different PPLAI initiation patterns have been observed. The aim of this study is to describe different PPLAI onset patterns in hospitalised patients diagnosed with schizophrenia.

Method

A naturalistic, transversal, retrospective, descriptive study was carried out. Patients were recruited in the adult inpatient unit of Hospital Universitario Jiménez Díaz (Madrid, Spain) from November 2012 to February 2021. During this period, a total of 357 patients were treated with PPLAI, 172 of them were diagnosed with schizophrenia and, among these, 24 received an atypical onset pattern during hospitalization. Different PPLAI onset patterns, PPLAI dose at discharge and number of days hospitalised were analysed. This study followed the Declaration of Helsinki principles and was approved by the Local Ethics Committee. All participants gave written informed consent.

Result

The sample presents 24 patients (17 men, 7 women) that represents 6.72% of a global sample, with an average age of 40.21 years (men 35.59 years vs. women 51.43 years). In this study, different PPLAI onset patterns were described: those receiving 150-150 mg represent 25% of the sample (n = 6), as do those receiving 100-75 mg, also representing 25% of the sample (n = 6). The rest of the onset patterns were: 150-75 mg (20.83%, n = 5), 100-100 mg (12.5%, n = 3), 150-75 mg (4.16%, n = 1), 100-50 mg (4.16%, n = 1), 75-100 mg (4.16%, n = 1), and 75-75 mg (4.16%, n = 1). The average hospital stay is 17.88 days. The PPLAI maintenance dose at discharge was 104.17 mg/month. The group of patients who received two doses of 150 mg (150-150 mg) had an average length of stay of 27.67 days compared to the rest of the patients who had an average length of stay of 15.12 days, this difference being statistically significant (p = 0.010). The 150-150 mg group was discharged with a mean maintenance dose of 141.67 mg versus the other patients who needed a mean maintenance dose of 91.18 mg, which was also statistically significant (p = 0.001).

Conclusion

The most used pattern of atypical onset of PPLAI in this sample is 150-150 mg and 100-75 mg. Patients treated with 150-150 mg loading pattern are hospitalized for a longer period and needed higher maintenance dose at discharge. Further studies are needed.
Royal Australian and New Zealand College of Psychiatrists mood disorders clinical practice guidelines update
Authors: Allan John
Published: June 2021

Aims

To provide guidance for the management of mood disorders, both depressive and bipolar disorders, based on scientific evidence supplemented by expert clinical consensus.

Background

It is the EIT responsibility to monitor a patient's physical health and the effects of anti-psychotic medication for at least the first 12 months.

Method

The update has been developed in a consistent manner to the 2015 guideline. The composition of the working group has remained largely the same as has the process to evaluate the evidence and synthesise the findings. To approach the update, the working group identified areas within the 2015 guideline where significant changes had occurred, for example the development of new therapies or where thinking and practice have changed and new ideas have emerged. Recommendations were reviewed in light of any new findings and evidence. As only some sections of the 2015 guideline have been updated/revised, the time taken to develop the update has been considerably shorter. Public consultation and peer review informed the final version.

Result

This led us to review the mechanism in the team for arranging and reviewing these investigations.

Conclusion

The mood disorders clinical practice guideline update addresses both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework supplemented by expert clinical consensus.
Standards for lithium monitoring. “Are we good at adhering to these standards in Lanarkshire”?
Authors: Ansari Saba , Nawab Khalid , Killeen Niall , Spence Elizabeth , Fotedar Monika
Published: June 2021

Aims

The National Institute for Health and Clinical Excellence (NICE) recommend that renal and thyroid function must be checked before lithium is prescribed and for all patients who are prescribed lithium should have their renal and thyroid function checked every six months, and their serum lithium checked every three months. The aim of this audit is to ascertain whether or not routine blood monitoring for bipolar disorder patients, taking lithium is in keeping with the guidelines.

Background

Lithium has been a mainstay in the management of bipolar disorder since the 1970's; indeed, lithium carbonate was first used in the early 1880's for the treatment of mania. Despite its usefulness however, the drawback of lithium treatment remains its very narrow therapeutic index, toxic side effects and as such its need for close therapeutic monitoring.

Method

A list of patients with a diagnosis of bipolar disorder being treated with lithium was collated from an electronic database of psychiatry patients in Cumbernauld Community and inpatients at Glencairn unit Coathill Hospital and Cleland Hospital. A retrospective analysis using Clinical Portal was conducted looking at blood results; Lithium levels checked 3 times a year and Kidney functions and Thyroid function checked twice a year, over the previous year. Our results were then compared to the NICE Guidelines for lithium monitoring to see if they complied with the expected routine monitoring schedule. We may have missed patients open to Community Psychiatric Nurses (CPN) but not open to Consultant psychiatrists. Other group that might have been missed could be open to General Practitioners but not to secondary care. We attempted to contact them but this was unsuccessful.

Result

Total of 690 patients were studied. Of 690 patients 51 patients had the diagnosis of Bipolar Affective Disorder. 49 percent of them were prescribed Lithium. 48percent had their Lithium bloods checked and 60 percent had their Kidney function and thyroid functions checked according to the guidelines. There were no data available for around 7 percent of patients but their Lithium levels were indicated only in Clinical notes.

Conclusion

This audit has demonstrated that Lithium monitoring falls short of conforming to accepted standards. Data obtained by this audit have prompted an electronic alert system for patients on Lithium endorsing primary care, mental health and laboratory staff to work together to ensure supporting recommended Lithium monitoring.
Dr QI - A quality improvement (QI) approach to designing and delivering QI training
Authors: Krishnan Deepa Bagepalli , Ohize Victor , Baumber Luke
Published: June 2021

Aims

To develop and implement a QI training programme for trainees, Trust grade doctors and Consultants in Nottinghamshire Healthcare NHS Trust (NHFT) to enable them to deliver change in practice through acquisition of new knowledge and practical application of skills in QI projects using Model for Improvement.

Background

QI is crucial to improve patient care. Doctors are uniquely placed to input into patient safety and service delivery of healthcare. The skills required to be future clinical leaders and undertake improvement work are not innate and formal teaching and support is required.

What is DrQI?

DrQI is a trainee-led QI teaching programme developed in collaboration with Trainees improving patient safety through QI (TIPSQI) in North West deanery.

Method

A pre-implementation survey amongst doctors in NHFT in February 2019 (33 responses) suggested that 90% of doctors were interested in learning QI and about 48% preferred face-face workshops with support from the QI team.

A list of change ideas were created using a driver diagram with QI education and project support identified as key primary drivers.

PDSA cycles

Nine interactive workshops teaching key QI concepts (based on model for improvement) in NHFT, training more than 100 doctors. A workshop in Derbyshire Healthcare NHS Foundation Trust (70 doctors) and Nottingham University Hospital (20 doctors). Workshops were continually adapted based on qualitative and quantitative feedback. Different formats were tried including virtual sessions, game-based and problem-based learning approaches using small group activities.

Result

Pre-course and post-course questionnaires were used to assess change in understanding of individual components of QI methodology (SMART Aim, Driver diagram, PDSA cycles, outcome and process measures and run charts). Mean pre-course self-assessment score collated from seven QI workshops in NHFT (2019-2020) was 3.3 and mean post-course score was 7.68, showing an improvement in understanding of QI methodology.

Participants were asked to score the relevance (8.4) and quality of teaching (8.4) and the support from the QI team (7.4) on a scale of 1-10 (1 = poor and 10 = excellent). Additional free text feedback was obtained to help us improve the teaching programme.

Conclusion

Collaborative leadership trainee-led initiative to increase the QI capacity. A bottom up approach to complement the top down approach from the Trust QI team. Future steps include further collaboration and expansion of the scheme to other Trusts, Train the trainer sessions and building a network of QI champions.
On-call handover ‘– if it isn't documented then it didn't happen’
Authors: Campling Hannah , Aubrey-Jones Dominic
Published: June 2021

Aims

1. To standardise the doctor handovers for on-call duties

2. To ensure there is documented evidence of handover taking place at the end of each shift

Background

Since the introduction of the European working time directive the amount of hours that doctors are allowed to work has been reduced, resulting in increased handovers between teams. The National Patient Safety Committee and General Medical Council have recognised that this means we need to ensure handovers are as safe and robust as possible to ensure that patient safety is not compromised. A recent serious investigation report carried out at Chase Farm Hospital, London identified a lack of formalised handover between doctors as a contributing factor leading to patient harm. One of the recommendations of the report was for a Quality Improvement Project to be carried out in order to formalise handover.

The handover procedure at Chase Farm Hospital for core trainee doctors 'on-call' prior to this QIP was not standardised and consisted of an informal, verbal handover. Frustrations had been raised by doctors and other staff members that this current method of handover was unreliable and unsafe.

Method

We sent out a questionnaire about handover to all doctors on the on-call rota to help establish what intervention would be appropriate.

We then performed a retrospective collection of documented handovers within a two month time period.

Our intervention was to introduce an email handover procedure.

Following a two month trial of this intervention, we resent the questionnaire and performed a second retrospective collection of handover documentation.

Result

Prior to this QIP we found that 0% of on call handovers were being formally documented. After the introduction of our handover email 88% of handovers were being formally documented using the handover email.

Satisfaction with the handover procedure went from 0% being very satisfied and only 33% being satisfied to 50% being satisfied and 50% being very satisfied.

Conclusion

A standardised and documented handover procedure is crucial for patient safety and to allow doctors to communicate jobs effectively with each other.

A secure email for handover is a successful way of formalising the handover process.

Limitations include:

Access to the handover email for new staff or locum staff.

Ensuring that doctors who aren't on the on-call rota know how to use it to handover their ward jobs.
Improving quality of remote mental health consultations during COVID-19
Authors: Collins Phoebe , krall Karin
Published: June 2021

Aims

During the first wave of coronavirus pandemic, many Psychiatry outpatient appointments moved rapidly to remote or ‘virtual’ to protect patients and staff from infection. Telephone consultations do not allow assessment of appearance or other visual aspects of behaviour/affect, yet these are core components of Mental State Examination. Videoconsultation software was unfamiliar to many mental health clinicians, with obstacles including hardware availability, software provision and skills, data security as well as lack of clinican motivation and confidence preventing rapid uptake. I wanted to take advantage of excellent IT support, and NHS England funding of software licence, to drive introduction of Attend Anywhere patient videoconsultation (‘telepsychiatry’) software within my local ADAPT (Anxiety, Depression and Personality Disorder,Trauma) Community Mental Health Team from April 2020 onwards.

Method

I assembled a small group of clinicans to take part in a local pilot of Attend Anywhere software. One Care Coordinator, a Consultant Psychologist, two Consultant Psychiatrists and myself completed satisfaction and confidience scores throughout an 8 week period. Number of videoconsultation outpatient appointments offered to and accepted by patients were also recorded. Weekly group meetings were deemed impossible to schedule given pandemic workloads, so we used 1:1 quick remote catchups, identifying and troubleshooting obstacles, working with IT implement a work-around when the team hit a technical brick wall.

Result

Clinician confidence and satisfaction increased significantly during this period, as did number of offered & completed video consultations.

Attend Anywhere consultations were used for up to 25% of clinician weekly workload.

Clinicians who manage their own diaries started quickly

It was difficult to successfully engage Administration team to organise Attend Anywhere test calls, leading to slow uptake for Consultant Psychiatrists who do not manage their own diaries.

Conclusion

Patient obstacles to use of Attend Anywhere appeared to be idiosyncratic and multifactorial, including poverty, digital exclusion, lack of privacy at home, and clinical history of online grooming. However, some patients already used Attend Anyhwere software with their physical health teams, while others prefer videocall to phone. Age was not an obstacle.

Once this small group of clinicians began to use software successfully, it had a snowball effect within the team and other clinicians asked to sign up for the service. Full support from Administration teams will be crucial to increasing videocalls within the service. Clinicians suggested offering videoconsultation as an opt-out service and requested additional functionality from the software to widen use.
A quality improvement project to improve the physical health of people with intellectual disability & severe mental illness in a forensic inpatient ward
Authors: Dave Rupal , Miller Rachael , Bermange Lucy , Humphries Laura
Published: June 2021

Aims

Review physical health risk factors of service users Co-produce personalised care plans for service users Improve health knowledge and confidence in self-management of health problems Support reduction in risk by improving physical activity levels and supporting healthy dietary choices.

Background

People with intellectual disability have poorer physical health outcomes than those without intellectual disability; there is higher prevalence of obesity, constipation and diabetes in this group of the population, and consistent evidence of premature mortality. Excess mortality in persons with severe mental illness has also been established.

Empowering patients to take an active role in their care, is good practice and encouraged as part of the NHS Long Term Plan.

Quality Improvement methodology was used to design and deliver a multi-disciplinary team (MDT) intervention, on a forensic mental health ward for persons with intellectual disability, to improve physical health in this patient group.

Method

Cardiovascular risk was assessed for 13 patients on a low secure forensic mental health ward. Measures of weight, BMI, blood pressure, resting heart rate, smoking status & status regarding prescription of psychotropic medications were collected.

Together with individual comorbidities and activity levels, a personalised care plan was co-produced by MDT members and patients. Motivational interviewing techniques were adapted to support patients to set personal goals.

Education sessions were designed in 'easy-read' format and delivered by MDT members in a group format. Focus groups were held with service users and with staff members to explore barriers to change. Based on these, specific ideas to increase physical activity and support healthy dietary changes were introduced.

The Patient Activation Measure (PAM) questionnaire was modified and used to assess confidence and knowledge in preventing or reducing health problems, and maintaining changes.

Result

Cardiovascular risk and activity levels were assessed for 13 inpatients. 85% of patients had a BMI in the overweight or obese range. 62% were regular cigarette smokers. 92% were prescribed psychotropic medications. On review of 2 months of opportunities for activity, all patients were categorised as 'inactive'. Patients engaged to varying degrees to co-produce personalised care plans and to engage in group education and physical activity. Of these patients, all showed improvement in measures of Patient Activation and activity level.

Conclusion

An individualised approach is required in exploring physical health problems, considering modifiable risk factors and addressing barriers to change. Co-production, and active participation of MDT members in role-modelling 'healthy habits' was positively reported by patients to facilitate self-management.
The quality of handover on an inpatient psychiatric unit - information is key!
Authors: Davies Emma , Enemo-Okonkwo Ijeoma
Published: June 2021

Aims

To study the quality of handover, between nursing staff and doctors, on an inpatient psychiatric unit.

Effective handover between professionals is vital to ensure the accurate transfer of useful information to enable quality care and patient safety.

Implementation of a handover tool has been shown to improve patient safety, especially when used to structure communication over the phone.

Feedback at trainee doctor forums highlighted insufficient handover from nursing staff whilst on-call, a problem which prompted further exploration.

Method

Standards were developed for the expected quality of handover, consisting of a set of criteria for the minimum information required to ensure a safe and effective handover, stemming from the SBAR (Situation, Background, Assessment, Recommendation) approach, with adequate identification of patients, clear communication of the current situation and relevant details.

In an inpatient psychiatric setting, telephone calls to the on-call doctor were recorded for a two-week period, documenting whether key information was communicated.

Result

Total number of calls to on-call doctor recorded: 68. The patients name was given in 49% and the ID number in just 10%. Both relevant diagnosis/history and NEWS score was provided in 18%. However, the current issue and recommendation was given in 90% and 95% respectively.

Conclusion

The results thus far demonstrate a lack of structure and often limited information delivered in handover from nursing staff to the on-call doctor. This leads to difficulties in prioritisation, identifying the urgency of the situation and inefficiencies, as time is spent requesting further information which is not readily available.

After nursing colleagues were made aware, results from a further two-week period, from 65 total calls, demonstrated some improvement. Patient name given in 51%, ID number in 18%, relevant diagnosis/history in 12%, NEWS score in 17%, current issue in 92% and recommendation in 51%. It is clear that with marginal improvement, there remains a problem which we aim to address by collaborating further with senior nursing leads whilst implementing a succinct handover proforma. It is likely that with COVID-19 as the priority on the agenda this past year, quality improvement projects such as this has not been the main focus. We hope that we will be able to implement these changes in the coming months.