bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment resistant depression in the UK: sub-analysis of a European real-world evidence study
Authors: Talbot Jordan , MacIntyre Donald J , Rathod Shanaya , Morrens Joachim , Young Allan H
Published: June 2021

Aims

Treatment resistant depression (TRD) affects ≤20% of patients with major depressive disorder and is defined as failure to respond to ≥2 different antidepressants in the same major depressive episode (MDE). TRD patients’ outcomes are poor and real-world data from the UK are limited. The Treatment Resistant Depression in Europe Cohort was established to study patients being treated in local, routine clinical practice. The analysis presented here aimed to compare UK-specific data with data from other European countries included in the study.

Method

A prospective, multicentre, observational cohort study of TRD patients in Italy, Germany, Spain, Portugal, the Netherlands, the UK and Belgium was conducted. Patients aged 18–74 years with current TRD, Montgomery-Åsberg Depression Rating Scale (MADRS) score ≥20, and initiating a new treatment for depression, were eligible. Data from medical records, clinician assessments and patient-reported questionnaires were collected over time, with follow-up of ≥6 months.

Result

Data from 411 patients were analysed. At baseline, UK patients (n = 49) had similar depression severity to the whole European cohort (34.7% vs 32.6% of patients categorised as severe based on MADRS score, respectively). Patients had experienced the current MDE for a mean (standard deviation [SD]) of 6.1 (7.9) years vs 2.6 (3.9) years and 14.3% vs 4.9% had experienced ≥5 treatment failures during this time in the UK and whole cohort, respectively. Total mean (SD) Sheehan Disability Scale (SDS) scores of 24.5 (5.1) and 22.4 (5.5) were reported for the UK and whole cohort, respectively. Unemployment and long-term sick leave rates were 38.8% and 20.4% in the UK and 30.2% and 19.0% in the whole cohort, respectively. At 6 months, 8.9% of UK patients were in remission, and 82.2% had not responded to treatment, representing the lowest remission and highest non-response rates across all countries.

Conclusion

UK patients had been ill for longer and had more prior treatment failures than other countries in the study. They had high work and functional impairment, and the worst treatment outcomes of all the countries studied. UK TRD patients experience high disease burden; there is an unmet need for treatment strategies with better response rates.

Acknowledgements

We thank all participating patients. Study, and medical writing (Costello Medical, UK), funded by Janssen. AHY's independent research is funded by the National Institute for Health Research. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.
CAMHS Emergency Assessment Service (EAS): development & implementation during the COVID-19 crisis
Authors: Saour Tania , Tolmac Jovanka , Girelas Braulio , Turton William , Branney Lauren
Published: June 2021

Aims

•

To provide emergency psychiatric assessment throughout the COVID-19 pandemic.

•

To maintain patient and staff safety by minimising exposure to infection risk by reducing A&E contact.

•

To alleviate pressures on the A&E department by enabling CAMHS patients be seen in an alternative setting.

•

To provide a more appropriate environment for the assessment of young people in acute distress.

Method

•

Service live 8th April 2020 to 8th June 2020.

•

Exclusion criteria: 1) confirmed/suspected overdose; 2) self-harm with injuries requiring medical attention; 3) acute psychotic episode; 4) drug/alcohol intoxication; 5) high risk of absconding (ASD/LD/LAC), 6) severe agitation/aggression; 7) eating disorders requiring medical intervention; 8) section 136 of the MHA; 9) break down of a social care placement; 10)medically unexplained symptoms.

Data reviewed of all young people who were referred to A&E during March–April 2020. Each case was assessed as to whether they were then seen within the EAS Service.

These cases were reviewed demographically looking at ethnicity, gender, while also reviewing the reason for referral.

Result

•

A total of 90 cases referred to Urgent Care Team

•

Nineteen (21%) met criteria for assessment at EAS

•

80% of presentations between 12am and 9am.

•

Commonest reasons for referral : low mood with suicidal ideation (42%), anxiety (26%)

→

50% service users not previously known to CAMHS

•

Majority of service users were female

•

Mean age 15 years

•

All but one of the young people assessed at the EAS, were discharged home with community follow-up

Conclusion

•

Average total no. monthly referrals to CAMHS Urgent Care Team (UCT) fell from approx. 90 to 45.

•

Only a small proportion of referrals (21%) could be safely seen by the EAS, suggesting that the majority of young people required a joint assessment by A&E and CAMHS Urgent Care Team.

•

When need arises, very rapid reconfiguration and implementation of CAMHS emergency services is achievable.

•

EAS diverted a small number of young people from exposure to COVID-19 in A & E.

•

The service was set up speedily without evaluation of parent/carer/young people views or evaluation of cost-effectiveness.

•

If similar services are to be set up permanently, the balance between safety and the risk of division between mental & physical health services and potential to increase stigmatisation of mental illness should be considered.

•

Adaptation to future outbreaks should be informed by this initiative.
Triple chronotherapy for the rapid treatment and maintenance of response in depressed outpatients: a feasibility and pilot randomised controlled trial
Authors: Veale David , Serfaty Marc , Humpston Clara , Papageorgiou Andriani , Markham Sarah , Hodsoll John , Young Allan H
Published: June 2021

Aims

Triple chronotherapy (defined as sleep deprivation for 36 hours, followed by 4 days of advancing the time of sleep, together with daily morning bright light therapy for 6 months) has demonstrated benefits for the rapid treatment of depressive symptoms in 4 small, controlled trials of in-patients. Our aims were to test the feasibility of recruitment and delivery of triple chronotherapy for out-patients with depression.

Method

In a single blind trial, 82 participants were randomised to either triple chronotherapy or a control intervention. The primary outcome was Hamilton Depression Rating Scale 6 item (HAM-D6) at 1 week. Timings of observer ratings were baseline; 1 week; 2 weeks; 4 weeks; 8 weeks and 26 weeks after randomisation. Triple chronotherapy consisted of (a) Total sleep deprivation for 36 hours. On Day 1 patients were supported in a small group to stay awake at night with an occupational therapist, (b) Phase Advance of Sleep over 4 days. Phase Advance began after the first night of sleep deprivation, when they left the hospital at about 8am and were asked to go to bed earlier at about 5pm and rise at about 1am. Their sleep and wake up times were then shifted 2 hours later on each of the following three days until they attained their usual bedtime again at about 11pm.As a control for the triple chronotherapy, participants were given psychoeducation and written information on sleep hygiene. They were also given SomniLight amber light daily for 1 week in the morning.

Result

Participants in the triple chronotherapy group were able to stay awake for the planned thirty-six hours and 89.9% adhered to the plan of phase advance of their sleep over the following 4 days. We achieved our recruitment target with 60 participants having completed the trial within 13 months. There were no reported adverse side effects. We explored outcomes and found a significant difference between the groups for the HAM-D6 at week 1, 8 and 26. Response (> 50% reduction in symptoms) was achieved by 52% in the triple chronotherapy group compared to 18% in the control group at week 1. This gradually increased to 70% achieving response in the triple chronotherapy group at week 26 compared to 22% in the control group.

Conclusion

Triple chronotherapy produced a significant and rapid benefit after 1 week in out-patients with depression that was sustained at 26 weeks. Further cost-effective trials with a larger clinical sample size are required.
A retrospective case-control service evaluation of CAARMS scores of patients with autism in York EIP, compared to age matched controls
Authors: Whitney Daniel , Wright Stephen
Published: June 2021

Aims

Studies show the prevalence of Autism Spectrum Conditions in Early Intervention in Psychosis (EIP) populations is 3.6-3.7%, compared to approximately 1-1.5% in the general population. The CAARMS (Comprehensive Assessment of At Risk Mental States) is a national tool used by EIP services as a screening tool to bring patients into services and stratify their symptoms to determine what pathway may be most appropriate (First Episode Psychosis pathway (FEP) or At Risk Mental State pathway (ARMS)). As far as we are aware the CAARMS has not been validated in an autistic population. It is our view that several of the questions in the CAARMS may be interpreted differently by people with autism, thus affecting the scores. The aim of this evaluation was to identify whether CAARMS scores differ between patients diagnosed with autism and matched controls in York EIP.

Method

From their mental health records, we identified all patients in the service with a diagnosis of autism. We then compared the CAARMS scores, at the time of referral, to those of age matched controls (matched by being in the age range 16-30) without an autism diagnosis, using continuous sampling by date of referral.

Result

14 patients in the service had a diagnosis of autism and had completed a CAARMS. CAARMS domains are all scored between 0 and 6 (indicating increasing severity or frequency). Compared to the age matched controls, autistic patients had a higher mean difference in their scores for ‘Non-Bizarre Ideas’ (mean difference of 0.86 for severity and 0.57 for frequency) and ‘Disorganised Speech’ (mean difference of 0.28 for severity and 0.57 for frequency). These results did not reach statistical significance which was unsurprising given the sample size. The gender split between groups was similar.

Conclusion

Our evaluation suggests a difference in CAARMS scores between patients in our service with a diagnosis of autism and those without. A larger study would be needed to confirm a statistically significant difference and multicentre results would be needed as evidence of generalisability. However, if such a difference were confirmed it might question the validity of CAARMS in autistic patients or suggest that modifications, perhaps in the form of reasonable adjustments to the questions or scoring, were needed to increase the validity in this population. We would suggest that spending extra time checking the patient has understood the intended meaning of the questions in the CAARMS may increase validity, particularly in the ‘Non-Bizarre Ideas’ domain.
Quetiapine: off-label prescribing in a community mental health team
Authors: Abdelgadir Ala , Walsh Richard , Walsh Elizabeth , Patel Sonn
Published: June 2021

Aims

Quetiapine is an atypical anti-psychotic medication licensed for the treatment of schizophrenia, bipolar disorder and adjunctive use in major depressive disorder. It's off-label use in low doses is increasing, possibly due to its sedative qualities, tolerability, low risk of extrapyramidal symptoms and to limit the unnecessary use of benzodiazepines. However, previous research highlights the risk of metabolic consequences even in low doses. Our aim is to establish the prescribing patterns and off-label use of quetiapine within a complete comminity mental health team population (CMHT).

Method

The GR1 CMHT provides care to a population of 25,000 people in a mixed urban and rural area. Multi-disciplinary case notes for all registered patients were reviewed for a one-year period. A database was created to include sociodemographic details, diagnosis, and medication. The proportion of patients prescribed quetiapine was identified and the dosage divided into multiple increments. The team's consultant reviewed and verified all ICD-10 diagnoses. Quetiapine dose by diagnosis was examined using descriptive statistics.

Result

Of 246 registered patients, 62 (25% of CMHT caseload) were prescribed Quetiapine. Quetiapine was prescribed across a range of disorders including psychotic 17 (27%), mood 18 (29%), anxiety 14 (22 %), personality disorders 11 (18%) and others 2 (3%). Doses spanned between 25 mg – 800 mg daily. 19 patients (31%) were prescribed less than 25 mg, 20 patients (32%) between 25 mg and 100 mg and 23 patients (37%) above 100 mg. In psychotic and mood disorders, dosage varied widely between the low and high range. Furthermore, of the psychotic disorders, 11 (65%) were prescribed a second antipsychotic medication. For diagnoses in which the prescribing indication was clearly off-label, the dosages were predominantly low (100 mg or less).

Conclusion

Quetiapine was commonly prescribed in our patient population. Its frequent off-label use in low doses suggests that its prescription was for its additional qualities. Our findings highlight the importance of assessing the risk-benefit profile for every patient given the potential side effects, involving patients in the consultation of its off-label use and appropriate monitoring.
Audit of compliance with WHO surgical safety checklist (modified for electroconvulsive therapy including NPSA advice)
Authors: Alam Faisal , Ashraf Rizwan , Sein Kyaw , Feeney Terri
Published: June 2021

Aims

This audit aims to evaluate the compliance with the WHO surgical safety checklist during the electroconvulsive therapy treatment in ECT clinic at Greater Manchester Mental Health Bolton Directorate. The audit is based on WHO surgical safety checklist modified for ECT including National Patient Safety Agency advice. The goal is to improve the compliance and in turn improve clinical outcomes.

Background

The WHO surgical safety checklist (modified for Electroconvulsive therapy including NPSA advice) is devised to promote patient safety, improve teamwork, reduce errors/adverse events and improve overall quality of care. An audit was completed regarding the compliance with the safety checklist at the Bolton ECT clinic and to assess how this could be improved.

Method

Following approval from the clinical audit department, GMMH NHS Foundation Trust, 20 checklists from randomly selected patient ECT files were included in this audit. We looked at whether the checklists were completed, signed and dated. Our current WHO surgical safety checklist is as per the Electroconvulsive therapy accreditation service standards.

Result

A total of 20 WHO surgical safety checklists were reviewed. 95% of the checklists (19/20) were completed by the duty Psychiatrist. 1 form was not completed. 25% (5/20) were not signed rendering them invalid. A total of 75% checklists were complete and valid. Checklists were present in all the case notes.

Conclusion

Compliance with the WHO surgical safety checklist during the electroconvulsive therapy treatment can be challenging due to various reasons ranging from time pressure to difficult clinical situation. This audit has highlighted that the overall compliance with the set standards (100% completion) was not achieved. A repeat audit will be important to further improve the compliance and overall clinical outcome.
The hidden cost of not having a dual diagnosis team (an audit looking at inpatient admissions for Redbridge Community Recovery Team West)
Authors: Bandukda Madeeha , Bhenick Muhammad Aadil , Chaudry Najam , Getachew Henok
Published: June 2021

Aims

Co-existing mental illness and substance misuse is highly prevalent within the UK, with approximately 40% of people diagnosed with psychosis having a history of substance misuse. However, in Redbridge we currently do not have access to a dual diagnosis team or integrated care.

This audit aims to assess the health and social implications of fragmented care, plus the effectiveness of mental health services in assessing patients with dual diagnosis and referring to specialist misuse teams. We used the NICE guidelines on co-existing severe mental illness and substance misuse [CG120] to help guide our recommendations.

Method

We identified 50 out of 359 patients within our service who were admitted to psychiatric hospital over a one year period (between 01/11/2019- 01/11/2020).

We looked at medication compliance, use of the Mental Health Act and accommodation status to compare between those with and without known dual diagnosis. We used frequency and length of admission as indicators of how successfully patients were being managed in the community and the cost to the hospital trust. Urine drug screening and referral to substance misuse services were chosen as markers of whether patients were being appropriately managed on admission.

Result

A higher percentage of patients with dual diagnosis were detained under the Mental Health Act compared to those without substance misuse (89% versus 72%). They were more likely to have no fixed abode (28% versus 13%) and be non-compliant with treatment pre-admission (83% versus 56%). Patients with dual diagnosis also had a higher number of hospital admissions, with a greater proportion having 3 admissions that year (11% versus 3%).

Only 50% of patients with known dual diagnosis had a urine drug screen performed on admission and just 25% of patients who were currently misusing substances were referred to specialist services by the inpatient team.

Conclusion

Our audit found that there are overall poorer outcomes for patients with dual diagnosis versus a psychiatric illness only. It is evident that integration of services will improve the care we are able to provide and reduce costs associated with multiple admissions to hospital.

We identified three key areas for improvement. Firstly, we advised on the need to improve documentation. Additionally, we recommend ensuring assessment of current drug misuse is done on admission, including performing simple tests such as urine drug screening. Finally, we highlighted the need to improve discussions about substance misuse with patients, within teams and between services, aiming for integrated and holistic care.
An audit of admission clerking of patients in Heddfan, Adult Mental Health Unit in BCUHB - north Wales
Authors: Dhandapani Asha , Soundararajan Sathyan , Simiyon Manjula , Zachariah Vinila , Sambhi Rajvinder
Published: June 2021

Aims

To ensure admission clerking includes salient features needed for the management of both physical and mental health of the patient and also to aid in administrative purposes.

Method

The audit included a team of doctors reviewing the admission clerking notes for 50 patients in the General Adult Psychiatric unit in-patient ward.

We created a standard questionnaire-based on Intended learning outcome of core training in psychiatry CT1-CT3 from Royal College of Psychiatry and standard textbooks.

Our aim is to achieve 100 % compliance in clerking

Result

It was noted that only 30% wrote their GMC number, 4% added route of admission of the patient and a mere 8% filled the Consultants name. Though almost everyone had written the presenting complaints, the other aspects such as history of presenting illness, medical and family history, Allergy status and substance misuse history were missing in many clerking notes. None of them had filled in details of personal history and very few did a risk assessment.

Further lacuna was noted with Mental state examination. Physical examination was also noted to be incomplete. While more than 50% had completed the Blood investigations and ECG, half of them had not documented it and that meant searching in the entire file. A mere 20% filled the nursing observation level whilst none had completed the formulation in the notes.

Conclusion

Admission clerking is a vital source of information that would be needed for the formulation of patients diagnosis and future management.

Apart from this, it also is needed for further continuity of care.

Hence this vital source of information will need to be shared with the junior doctors who will be clerking the patient and seeing them in the first instance.

We, therefore, intend to create a complete clerking proforma along with physical health proforma to aid us in this respect.

We will audit initially in the first round and then plan to introduce a proforma for Clerking and physical examination based on the findings.

We will re-audit to see if the standards are achieved after using the proforma and will consider a Quality improvement project based on this topic
Sodium valproate prescribing safety in women of childbearing potential
Authors: Donnelly Shane , Alex Rajesh
Published: June 2021

Aims

The purpose of this audit was to identify all women being prescribed Sodium Valproate under the Bassetlaw Local Mental Health Team (LMHT) caseload to see how well latest prescribing guidelines are being met, and help set up a system allowing efficient monitoring of Sodium Valproate prescribing in the future.

Background

Despite early concerns regarding potential teratogenicity, Sodium Valproate became a widely used anticonvulsant and mood stabiliser and is licensed for use in Epilepsy, Migraine prophylaxis and Bipolar affective disorder. Research evidence now shows its use in pregnancy increases risk of neurodevelopmental disorders to 40%, and serious birth defects to 10%. Despite research finding these risks prescribing practice did not significantly change. To better reflect these findings in clinical practice in 2018 the Pharmacovigilance Risk Assessment Committee recommended Sodium Valproate should not be used in pregnancy unless they have a form of epilepsy unresponsive to other anti-epileptic drugs, and all with childbearing potential should be enrolled in a pregnancy prevention programme (PPP). This was endorsed by UK Medicines and Healthcare Devices Regulatory Agency in April 2018 with launch of the PPP.

Standards:

Must be offered counselling about risks of valproate to unborn child and importance of effective contraception.

Annual specialist Review by a specialist now mandatory

Risk acknowledgement form must be updated at least annually.

Method

The electronic RiO records for all female patients on the Bassetlaw LMHT caseload in the year 2019 were checked to identify those prescribed Valproate. For those prescribed Valproate, evidence of annual risk acknowledgement form, date of last appointment, underlying diagnosis and contraceptive method was checked. This data was stored together on an excel file and used to create a patient list to help allow future monitoring.

Result

From 594 female patients identified, 27 (4.5%) were prescribed Sodium Valproate. Of these, 14 (52%) had PPP documentation uploaded, 24 (89%) had been reviewed within the last 12 months, and 13 (48%) had no documentation of contraceptive method.

Conclusion

This audit helped highlight there is likely a large population of patients not yet on the Pregnancy Prevention Programme. Creating a monitoring system in excel for female patients being prescribed Valproate can help improve adherence to latest guidelines, with a colour coding system to highlight those needing risk acknowledgement forms/appointments within the next three or six months. Educating patients and other healthcare professionals about risks will also help improve prescribing practice and avoid use in pregnancy.
To assess implementation of trust policy (smoke free policy) on an acute mixed mental health ward setting
Authors: Elisseou Antigoni , Rahuja Saika
Published: June 2021

Aims

To assess implementation of Trust Policy (Smoke Free Policy) on the acute adult mental health unit To evaluate barriers to implementation of local standards and NICE guidelines To evaluate if Q-Risk score is being calculated and noted.

Background

There are about 34,000 people residents in mental health facilities in England and Wales on any one day (Commission for Healthcare Audit and Inspection 2005) and many of them smoke.

Smoke free policy implemented in the GMMH since 1st of July 2018.

Smoking is single largest preventable cause of ill health & premature mortality in England.

Smoking prevalence is significantly higher among people admitted to hospital due to the mental illness i.e. 70%

According to WHO SHS (second hand smoking), is a human carcinogen to which there is no safe level.

Method

An audit tool questionnaire was used to collect the data on the Acute Mixed mental health ward setting i.e. Bronte Ward, Laureate House, Wythenshawe Hospital

Identified method: interview with each patient, PARIS documentation review and Patient's Kardex review.

Sample size: 23 and on re-audit 12.

Method of data input: Microsoft Excel

Data were analyzed by calculating percentage

Result

The majority of the patients that took part in the Audit were smokers (91%), a high percentage overall. This indicate how important it is for a plan to be in place regarding smoking on the ward since there is a smoke free policy now in the GMMH. Our results showed that not everyone was asked regarding their smoking status (87%).

An important figure that came out from the results was that only 50% of the patients asked about their smoking status were told that there is a smoke free policy.

For a smoke free policy ward only 33% of the smokers that took part in the audit were provided with brief advice regarding smoking cessation which shows that there might be a need of a more precise implementation regarding support to receive brief intervention for smoking cessation, NRT and specialist advice.

The results also showed that the QRisk is not calculated, a useful marker of cardiovascular risk.

Conclusion

Give leaflets regarding smoking cessation on admission, offer support and advice to all the patients being on the ward. And re-audit in due course to see the effect of this intervention.
Audit of the impact of the integrated psychological medicine service (IPMS) on service utilisation
Authors: Harvey Sarah , Bromley Joanna , Edwards Miles , Hooper Megan , McAndrew Hannah , Timms Joanne
Published: June 2021

Aims

An audit to assess the impact of an Integrated Psychological Medicine Service (IPMS) on healthcare utilization pre & post intervention. We hypothesized that an IPMS approach would reduce healthcare utilization.

Background

The IPMS focusses on integrating biopsychosocial assessments into physical healthcare pathways. It has developed in stages as opportunities presented in different specialities leading to a heterogeneous non-standardised service. The key aim is involvement of mental health practitioners, psychologists & psychiatrists in complex patients with comorbidity or functional presentations in combination with the specialty MDT. This audit is the first attempt to gather data across all involved specialities and complete a randomised deep dive into cases.

Method

Referrals into IMPS from July 2019 to June 2020 pulled 129 referrals, of which a 10% randomised sample of 13 patients was selected to analyse. 5 patients had one year of data either side of the duration of the IPMS intervention (excluding 8 patients with incomplete data sets).

We analysed; the duration & nature of the IPMS intervention, the number, duration & speciality of inpatient admissions & short stays, outpatient attendances, non-attendances & patient cancellations. Psychosocial information was also gathered. One non-randomised patient was analysed as a comparative case illustration.

Result

Randomised patients; patient 78's utilisation remained static, patient 71 post-referral engaged with health psychology & reduced healthcare utilisation. Patient 7 increased healthcare utilisation post-referral secondary to health complications. Patient 54 did not attend & increased healthcare utilisation post-referral. Patient 106 had increased healthcare utilisation post-referral from a new health condition. The randomised sample identified limitations of using healthcare utilisation as an outcome measure when contrasted to the non-randomised case (which significantly reduced healthcare utilisation post-referral).

Conclusion

Correlation only can be inferred from the data due to sample size, limitations & confounding factors e.g. psycho-social life events, acquired illness. Alternative outcome measurements documented (e.g PHQ9/GAD7) were not reliably recorded across pathways.

The results evidenced that single cases can demonstrate highly desirable effects of a biopsychosocial approach but they can also skew data sets if results are pooled due to the small sample size & heterogeneous interventions. With some patients an increase in healthcare utilisation was appropriate for an improved clinical outcome. This audit identified that utilising healthcare utilisation as an outcome measure is a crude tool with significant limitations & the need to agree tailored outcome measures based on the type of intervention to assess the impact of IPMS.
An audit during COVID-19: monitoring of CMHT-patient contact and physical health assessments in a rural Welsh setting
Authors: Jauhari Shreya , Foster Fran
Published: June 2021

Aims

The enforcement of lockdowns and restrictions on non-essential contact have changed Community Mental Health Team (CMHT) practice. Therefore, this audit carried out its 4th cycle of physical health monitoring for patients on antipsychotics with severe mental illness (SMI) under the CMHT during the period of the COVID-19 pandemic in order to observe its impact on physical health monitoring. In addition, with the increased use of telepsychiatry substituting routine face-to-face appointments during the pandemic, this audit also reviews the effect of lockdown on maintenance of contact between CMHT and people with SMI.

Primary Objective: to compare the current clinical practice with the standards derived from NICE guidelines which include parameters like weight, body-mass index, blood pressure, ECG and blood tests, then compare with the previous three audit cycles, which collected identical data.

Secondary Objective: to monitor amount of contact between healthcare staff and people with SMI on antipsychotics during the three months of Welsh lockdown and compare current clinical practice with the clinical practice achieved in the identical period in 2019.

Method

Method for Primary Objective: Clinical practice on physical health checks were split into 10 standards derived from the NICE guidelines (NICEQS80, Quality Standard 6). Data collection surrounding physical health checks of patients on antipsychotics from 26th June 2019 to 26th June 2020 were collected and compared with the previous three audit cycles, which collected identical data.

Method for Secondary Objective: Retrospective data surrounding amount and type of contact between CMHT and people with SMI was collected from 26th March 2020 to 26th June 2020, a period of enforced lockdown in Wales, and compared with the identical period in 2019.

Result

The audit iterates trends over the last 4 cycles (2016/2017, 2017/2018, 2018/2019 and 2019/2020). The current audit cycle increased in 2/10 standards and decreased in 8/10 standards, compared with the average compliance in the 3 previous audit cycles. Out of the 10 derived standards, certain standards fared worse than others.

There was a 79% increase in the number of staff-patient contact during the lockdown period. The majority of the contact in 2019 was face-to-face (84.31%), however, as expected, in 2020 the majority of the contact was non face-to-face (61.75%). However, this was accompanied by an 85.79%

Conclusion

Despite being in a pandemic, patient contact was maintained. Physical health monitoring has decreased in the majority of standards, therefore greater attention is needed to address this. Recommendations are provided in the audit.
Clinical audit of cardio-metabolic monitoring in people with intellectual disability (PWID) taking antipsychotic medication
Authors: Kyaw Sandar , Bintizahari Fadzlien , Speight Peter
Published: June 2021

Aims

To ensure close monitoring of physical health parameters when antipsychotics are prescribed and to liaise with primary care to ensure appropriate interventions are implemented.

Background

Antipsychotics are the most frequently prescribed psychotropic medication for PwID. Treatment with antipsychotic agent is associated with cardio-metabolic risks such as obesity, diabetes, and dyslipidemia. A strong association is well documented between antipsychotic use and the risk of stroke in schizophrenia although the magnitude of this association has yet to be studied in PwID.

PwID have an increased risk of premature death. Cardio-metabolic monitoring and appropriate intervention to this vulnerable cohort will improve the preventable cardio-metabolic multi-morbidity. The NICE guideline (CG11) recommends antipsychotic medication should only be initially prescribed and monitored by the secondary care professionals for at least 12 months. They also should work together with primary care to ensure appropriate interventions are arranged where necessary.

Method

A retrospective audit was performed for 40 service users, taking antipsychotic medication. Quota sampling was used to identify 10 cases each from the caseload of 4 consultant psychiatrists, within the Intellectual Disability community setting, between September 2019 and October 2019.

An audit tool was designed, in accordance with cardio-metabolic measures (smoking status, height, weight, Blood Pressure, HbA1c, Lipid profile), based on physical health CQUIN targets and the Lester adaptation tool. Collection of data was performed from electronic case records and electronic blood results service. The work was performed with the approval of local clinical audit team and analysed by using Microsoft Excel.

Result

Baseline cardio-metabolic assessment was observed in over a half of the sample population (50–65%) whilst only less than 15% was noted at 3–6 months. Documentation Evaluation of physical health assessments for new admissions to the Oleaster during the first wave of COVID-19 on body weight and blood pressure was seen only in 15% and 2.5% of population respectively at 3–6 months. Collaboration with GP for annual health check was observed in 78–100% of population.

Intriguingly, our finding indicates a significant improvement in all required compliance when nursing team is involved.

Conclusion

Improving physical healthcare is essential to reduce the cardio metabolic outcome in PwID taking antipsychotic medication. Better involvement of community nurses as well as availability of Sphygmomanometers at every outpatient clinic will determine the successful implementation of cardio metabolic monitoring and effective collaboration with primary care clinicians.

Once the action plan is disseminated to the teams, the impact of change will be reassessed by a re-audit in one year's time.
Improving baseline and follow-up physical health monitoring when commencing oral antipsychotics
Authors: Mitchell Nathan , Sajjad Aamer , Grocholewska-Mhamdi Anna , McMain Catherine
Published: June 2021

Aims

NICE guidelines suggest baseline physical health monitoring be performed prior to commencing antipsychotics, in addition to follow-up monitoring for adverse effects for at least 12 months. ‘Shared Care Guidelines’ were adapted from NICE guidance for local use in North East Lincolnshire. Nevertheless, a local audit published in 2018 reported low compliance with baseline monitoring in community mental health teams (CMHTs) compared to inpatient teams. The parameter most infrequently performed overall was the Glasgow Antipsychotic Side Effect Scale (GASS) questionnaire.

This study aimed to assess whether compliance with baseline physical health monitoring had improved in line with the previous audit's recommendations. Additionally, it aimed to expand on previous findings by adding compliance data for follow-up physical health checks and produce further recommendations to optimise performance.

Method

A retrospective re-audit was performed in NAViGO Health and Social Care to assess compliance with the guidelines for physical health monitoring when commencing antipsychotics in previously antipsychotic-naïve patients. Patient records were examined for which recommended physical health checks were performed at baseline, and at 1-, 3- and 6- months from commencing antipsychotics.

Result

15 eligible patients were identified to have been commenced on antipsychotics, 8 patients under a CMHT and 7 under an inpatient team. The average overall compliance at baseline for checking 16 parameters was 50%. For the CMHT, compliance was 60%, compared to 38% for the inpatient team. Across both teams, baseline compliance was highest for renal function tests, liver function tests, and blood pressure and pulse (80%). For 1-, 3-, and 6- month checks, overall compliance for checking recommended parameters were 33%, 29% and 29% respectively. GASS monitoring compliance was 7% at baseline, 0% at 1- and 3-months, 7% at 6-months.

Conclusion

The CMHT performed better than the inpatient team at baseline monitoring. This may reflect action on the previous audit's recommendations to increase provision of community ‘Wellbeing Health Improvement Service’ (WHISe) clinics. However, performance of the GASS questionnaire at baseline was consistent with the previous audit, with similar performance at follow-up extending these findings.

In response, the first recommendation is for Quality Improvement Activities to help improve compliance with the ‘Shared Care Guidelines’. This may include CQUINs and further provision of community clinics to improve compliance with both baseline and follow-up checks. Secondly, it is proposed that GASS questionnaires be sent to patients prior to appointments to be completed in advance to avoid further risk of GASS being incomplete.
Perinatal mental health outcome measures in a mother and baby unit
Authors: O'Connor Johanna , Katyal Raunica
Published: June 2021

Aims

To Audit Perinatal outcome measures and understand better the population served in order to improve care and understand risks. Our audit standards inculded: paired HoNOS and PBQ recorded on admission and discharge as well as ASQ scores prior to admission.

Method

Health of the Nation Outcome Scales (HoNOS), Postpartum Bonding Questionnaire (PBQ) and Ages and Stages Questionnaires (ASQ) were recorded on Lorenzo and SystmOne. Scores were collected over 20 months within the same MBU and these were analyzed.

Result

Our audit standards had an overall audit compliancy of 73% with paired HoNOS better than PBQ. Mental health severity mitigated and maternal bonding improved to a significant degree. Depression was the principal presentation as were patients from deprived areas. Only 55% of babies had ASQ scores completed appropriately pre- admission.

Conclusion

As the newest MBU in the country, this an initial foray of perinatal outcomes. Gratifyingly, benefits of MBU admission for mother and baby is evidenced in this snapshot.
Counting ECGs in acute psychiatry – The patients' price for junior doctors' rotations
Authors: Rogowska Marianna , Montgomery Adam , Dratcu Luiz
Published: June 2021

Aims

On 05/08/20, when a new cohort of doctors rotated onto an acute ward, (John Dickson Ward, Maudsley Hospital, London) a new handover tool on MS Teams was introduced, which replaced previously used MS Word document. The new handover tool can be accessed and edited by any of the users in the team. We hypothesised that the introduction of an interactive, live-updated tool would help improve physical health monitoring for patients, especially compliance with ECG taking. The aim of this project was to test this hypothesis.

Method

Authors have reviewed electronic documentation of patients admitted to and discharged from John Dickson Ward between 01/04/2020 and 24/12/2020. Evidence of whether an ECG was performed, was offered but declined by the patient, or was not offered were noted in the final audit. Patients were divided into 3 groups: (1) Patients admitted and discharged from 01/04/20 – 05/08/2020; (2) Patients admitted and discharged from 05/08/2020 – 24/12/20, and (3) Patients admitted before the intervention date, but discharged after the date (i.e., the period when new junior doctors had rotated onto the ward). Fifty patient records were identified in Group 1, fifty in Group 2, and 18 in Group 3.

Result

Surprisingly, the percentage of patients who had a documented ECG did not improve after the intervention, with 37/50 (74%) of patients having an ECG in Group 1, and 37/50 (74%) of patients having an ECG in Group 2. However, an incidental finding was made that significantly fewer patients received ECGs during the changeover period (Group 3), with only 6/18 (33%) of patients receiving ECGs. The percentage of patients who were not offered ECGs also increased during the changeover period, with 2/50 (4%) in Group 1, and 3/18 (17%) in Group 3 not being offered.

Conclusion

This incidental finding highlights the challenges associated with the junior doctor changeover period. Much time is needed for doctors to adjust to their new surroundings and methods of working, and this may result in basic elements of patient care being overlooked. We surmise that other elements, such as ensuring all patients having regular blood tests and physical examinations, may also be of a lower standard during this period. There is scope for future audits to address this, and for future quality improvement projects to implement changes ensuring medical care remains at a high standard during junior doctor changeover periods.
Clinical audit investigating the recognition of tardive dyskinesia in an acute inpatient setting
Authors: Romeu Daniel , Elisha-Aboh Christiana , Abid Hamza , Merry Lauren , Mahmood Tariq , Lacey Fiona
Published: June 2021

Aims

Tardive dyskinesia (TD) is a disabling extra-pyramidal side effect (EPSE) associated with long-term antipsychotic medication, with an incidence rate of 5% per year of typical antipsychotic exposure. The Abnormal Involuntary Movement Scale (AIMS) is a validated tool for screening for TD and its use is recommended every 3–6 months in those taking antipsychotics. Atypical antipsychotics present a lower risk and have contributed to complacency in monitoring and treatment. The primary aim of this audit was to establish whether AIMS was completed for all patients taking regular antipsychotic medication for three months or more. Secondary aims were to investigate whether patients were informed about EPSEs on initiation, titration and change of antipsychotics, and whether they were assessed for the emergence of side effects during subsequent clinical reviews.

Method

This single-site audit examined the care of inpatients on Ward 4 of the Becklin Centre, a male working-age acute psychiatric ward, between 1st November 2020 and 31st January 2021. Patients aged 18–65 years who were prescribed regular antipsychotics were eligible for inclusion. Exclusion criteria included the presence of other neurological movement disorders. 50 patients were included. Data collection took place between 8th February and 6th March 2021; this involved reviewing patient records throughout their inpatient stay on Care Director, an electronic patient record system. Results were compiled using a pre-determined data collection tool and analysed using Microsoft Excel.

Result

For 14 (28.0%) patients there was documented evidence of the provision of verbal information surrounding EPSEs during initiation or change of antipsychotics, and 12 (24.0%) received written or verbal information about wider side effects. For 19 (38.0%) there was a documented assessment of side effects during clinical review following the initiation or change of antipsychotic medication. Of the 33 patients who took antipsychotics for over three months, 3 (9.1%) received an AIMS assessment.

Conclusion

An inadequate proportion of inpatients prescribed long-term antipsychotics were assessed for TD, likely due to a lack of awareness of the relevant guidance. A substantial number of patients were not informed about side effects, suggesting an element of medical paternalism. This study provides opportunity to improve practice by educating the medical workforce and raising awareness of TD symptoms amongst the wider team. Valbenazine is a new FDA-approved treatment for adults with tardive dyskinesia, representing a further avenue for management. Greater focus on patient involvement, and communication surrounding anticipated side effects, is likely to benefit compliance with treatment and improve the doctor-patient relationship.
COVID-19 antibody seroprevalence in residential psychiatric inpatients
Authors: Shah Sheena , Hussain Arshad , Qadri Sabreena , Roub Fazle , Rauf Insha , Kumar Praveen
Published: June 2021

Aims

While other mental health care outpatient facilities were moved to COVID-centers in March 2020 during the COVID-19 pandemic, the Institute of Mental Health and Neurosciences in Kashmir remained the only functional outpatient facility in the region. It is the only mental health care hospital in the country with a residential facility for psychiatric inpatients catering to the whole population of Jammu and Kashmir, India. The Mental Health Care Act 2017 that neccesitated “halfway homes” is yet to be implemented in the state leaving it's inpatients entirely under the institution's care. This study is to investigate the seroprevalence of antibodies to SARS-COVID-19 virus in the 34 residential inpatients in separate male (23 patients) and female (11 patients) wards. This was done as an audit to strategies and measures taken by the institute in protecting it's inpatients.

Method

3 to 5 ml of peripheral venous blood samples were collected and plasma extracted and analysed using the CE-IVD Roche Cobas Elecsys AntiSARS-CoV-2, Electrochemiluminescence Immunoassay (ECLIA) for the qualitative detection of total Immunoglobulins (IgG, IgM and IgA; Pan Ig) generated against SARS-CoV-2 (Roche Diagnostics, Indianapolis, IN, USA). The test was performed according to the manufacturer's instructions.

Result

Out of the 34 inpatients, 2 male inpatients tested positive for antibodies against SARS-CoV-2 (seroprevalence of 5.88%). In comparison, based on a report conducted by the government's Department of Community Medicine and Biochemistry on the 28th of October 2020, out of 2,361 participants in the community, 959 tested positive (seroprevalence of 40.6%).

One of the inpatients that tested positive was re-admitted after testing negative via RT-PCR. The second patient was admitted after being found homeless. He was tested negative on day 1 via RAT and on day 5 via RT-PCR. We believe both of them aquired the infection in the community.

Conclusion

This audit shows that the strategies implemented by the institute were effective in the prevention of the spread of COVID-19. Practical implementations of what works and improvisations are the proven methods of decreasing the mortality and morbidity in vulnerable populations while continuously providing vital mental health services.