bluuebunny/crossref_metadata_2025 huggingface dataset:
Atomoxetine as an Alternative Therapy for Adolescent Adhd With Comorbid Cerebral Palsy: A Case Report
Authors: Calilung Dominique , Yaman Busra
Published: July 2023

Aims

The prevalence of Attention Deficit Hyperactivity Disorder (ADHD) in children with Cerebral Palsy (CP) is 19%. Whilst there is evidence that methylphenidate is an efficacious first line therapy for patients with ADHD, there is a lack of literature describing atomoxetine use in ADHD with comorbid CP.

Methods

Here we report the case of a 17-year old Caucasian female with ADHD and CP. The patient was referred to Child and Adolescent Mental Health Services (CAMHS) for ongoing anxiety following extensive orthopaedic surgery, which was managed with sertraline and concurrent Cognitive Behavioural Therapy.

A CAMHS assessment led to her subsequent diagnosis of ADHD resulting in an initial treatment of low-dose methylphenidate (Ritalin). This was discontinued after four days due to progressive headache, tachycardia, and unilateral leg restlessness. The patient was hesitant to commence lisdexamfetamine, a second line stimulant medication, due to the possibility of similar adverse side effects.

Atomoxetine (20mg/day) was commenced for a month then increased to 30mg/day. After five months, it was discontinued. The patient reported no significant improvements to attention or concentration, but reported a later onset of escalating anxiety prior to discontinuation. Consultation revealed that the patient's anxiety may be attributed to biopsychosocial factors unrelated to pharmacotherapy, but could not discount the possibility that this was a side effect of atomoxetine. Following the discontinuation of atomoxetine, the patient and her carer were amenable to trialling lisdexamfetamine.

Results

Previous data have demonstrated that patients with CP have lower tolerance to particular pharmacological agents, therefore atomoxetine was started at a low dose (20mg/day) to permit a gradual titration up to the recommended therapeutic dose. Worsening anxiety whilst on atomoxetine (30mg/day) may be a result of one or a combination of the following: (1) long-term side effect, (2) subtherapeutic dose response, (3) identified precipitating and perpetuating psychosocial factors, particularly in the school setting.

Conclusion

The case report demonstrated an acceptable safety profile for the use of atomoxetine in a young person with ADHD and comorbid CP. The expected therapeutic benefits of atomoxetine for ADHD may have been offset by extenuating biopsychosocial factors. Further research is needed to determine whether there exists a causal relationship between atomoxetine therapy and worsened anxiety within this patient group. Furthermore, this case highlights the importance of understanding the complexities of ADHD treatment in patients with confounding environmental factors and comorbid neurological disorders.
Improving the Admission Process to Inpatient Wards for Gender Diverse Service Users at Oxleas NHS Foundation Trust: Service Evaluation
Authors: Abdelsamie Ahmed , Pontes Diogo , Absi Musa , Aboelsoud Sarah
Published: July 2023

Aims

1.

To evaluate the knowledge and experience of staff members working in inpatient units at Oxleas NHS trust on the topic of healthcare of gender diverse service users.

2.

To improve the admission process for gender diverse service users by creating an admission checklist, increase awareness and provide training when possible.

Methods

A questionnaire with 11 questions was sent to different staff member groups. The questions assessed their knowledge of the policies for gender diverse service users and their clinical experience in dealing with this group of service users when being admitted to inpatient wards.

Results

25 members of staff completed the questionnaire. Of those, 52% were not aware of the existence of a specific policy for admitting and treating gender diverse service users at Oxleas. From the respondents who knew about the policy, 60% did not know where to find it. 44% of all respondents do not ask service users for their preferred name, gender and pronouns when they are admitted to an inpatient ward. From those who ask service users, 45% do not document service users’ chosen name, pronouns and gender identity on RiO (the digital record system used at Oxleas). 68% of participants do not know how to change the demographics information on RiO for service users. When asked about the allocation criteria for inpatient beds, 24% replied that it should be done according to the service user's assigned gender at birth, while 8% responded that they should be allocated to any available bed. 40% of staff members reported that trans service users can not easily access daily personal products on the ward that are related to their trans-specific health needs. 72% of those who responded do not know what specific services or organisations to direct this group of service users to in case they need any further support. 56% of staff do not feel confident in dealing with trans specific needs and 88% have not received any training on the area from the Trust.

Conclusion

Although the Trust has created a specific policy for gender diverse service users, staff members’ knowledge of such policy is sub-optimal. Moreover, there is a lack of training available to staff on inpatient wards, which is reflected in their lack of confidence in working with this group and the lack of knowledge around external services to refer these service users to. In response to this, we have implemented some changes. Pronoun preference has been added to RiO and we have encouraged staff members to use it when completing demographics. An admission checklist specific to gender diverse service users was created and shared within the organisation. We scheduled teaching sessions on this topic, however, these did not go forward due to lack of attendance.
Awareness of Fitness to Drive Guidance Amongst Doctors in Black Country Healthcare NHS Foundation Trust : A Survey
Authors: Sundhar Reka Ajay , Chandra Pallavi , Fraser Alistair , Kar Nilamadhab
Published: July 2023

Aims

Psychiatric patients have a higher risk of road traffic accidents than others. The Driver and Vehicle Licensing Agency (DVLA) has provided guidance on different psychiatric conditions and medication that would impact driving. The General Medical Council and Royal College of Psychiatrists advice doctors to notify the DVLA when patients unfit to drive fail to inform the DVLA themselves. In this context, it was aimed to study the awareness of doctors regarding DVLA guidance and its use in their clinical practice.

Methods

We conducted a survey about doctors’ awareness of guidance on Fitness to Drive via an online questionnaire. Likert type scoring ranging from strongly agree to strongly disagree was used to assess the (i) awareness of DVLA guidance for psychiatric patients, (ii) confidence in advising patients, (iii) feeling it is a job requirement to advise patients on driving; and (iv) checking the driving status and if patients have informed DVLA where necessary. This included questions on years of experience in medicine, current grade and subspecialty of Psychiatry.

Results

The sample consisted of 78 doctors, from various grades from Foundation Year 1 trainees to Consultants; working in different Subspecialties in Psychiatry. There were 36 trainees, 12 middle grades, 28 consultants and 2 ‘other’ doctors. The average year of experience of the responding doctors was 14.2±11.0 years with a range of 1-38 years.

Majority (62.8%) of doctors responded that they are aware of the DVLA guidance for psychiatric patients; however 47.5% reported having confidence to advise patients on DVLA guidelines. Considerable proportions (79.5%) of doctors felt that as psychiatrists, it was their job to give advice on driving; but only 50% said they check the driving status and whether patients have informed the DVLA when necessary as part of routine practice.

When using the Likert scale, comparing to other subspecialties, General Adult Psychiatrists responded that they check driving status less routinely (p<0.05), however there was no difference in other areas evaluated. Trainees’ responses indicated less awareness (p<0.001), confidence (p<0.001), and checking of driving related issues routinely in clinical practice (p<0.005).

Conclusion

The survey results suggest variation in awareness of Fitness to drive guidance for psychiatric patients and their use in routine clinical practice amongst doctors. While trainees would need more information and training to increase their confidence, there is a need for all psychiatrists to use the guidelines in regular clinical practice.
Understanding the Length of Stay (LOS) in Mental Health Acute Wards for Patients of the Joint Homelessness Team vs Other Westminster Patients
Authors: Gesell Sutapa , Hall Hugh
Published: July 2023

Aims

The Joint Homelessness Team (JHT) is a specialist mental health service for rough sleepers in Westminster. Patients have many years of declining mental health, leading to a downward social decline, resulting in homelessness.There is a concern that mental health patients are discharged prematurely due to bed pressures. This means treatment may not be optimised, with social issues and risks remaining. Serious mental illness (SMI) is associated with reduced life expectancy and high morbidity. Thus, homelessness and SMI are a double-hit of risks for people. For JHT patients, there are many barriers to admission, including coordinating complex street or S135(1) assessments and police availability; some cases have taken months or years to plan. If patients remain sub-optimally treated at discharge, there's a high risk they abandon accommodation and return to rough-sleeping; leading to further lost years of illness and homelessness.

Methods

This was a retrospective analysis. Via SystmOne, we identified all JHT admissions in 2021 and their LOS. Data were collected, including demographics, mode of admission, discharge destination and whereabouts at three months (as a secondary endpoint). LOS figures were gathered for other Westminster patients from general adult wards for 2021.

Results

There were 57 JHT admissions in 2021. 1 patient was excluded as still admitted. 22 patients were already care-coordinated by JHT and admitted for relapses; for the remainder it was a first admission.

For Westminster patients, there was a low variation throughout the year in number of monthly admissions and LOS; monthly average LOS range was 30-38 days. For JHT, there was higher variability for number of admissions and LOS with no seasonal pattern; monthly average LOS ranged from 4-95 days.

At three months, 22 (39%) patients were not housed in the community. Of these: 3 were discharged to the streets; 9 became street homeless; 3 were discharged to ‘Stepdown’ and went AWOL soon after; 5 patients were readmitted; 2 patients their location was unknown. 28 (50%) were housed in homeless hostels.

The data were presented at a borough-wide academic meeting.

Conclusion

While the dataset is small, the LOS for JHT was inconsistent, reflecting the variability of the cohort. This may need further exploration.

With 39% of admissions having unsatisfactory endpoints, this suggests that many patients were not well enough to work collaboratively out in the community. There was a consistent pattern of shorter admissions leading to poorer endpoints at three months.
Ethnic Differences in Dose and Levels of Clozapine: Exploring Need for Any Specific Monitoring Needs
Authors: Jiwanmall Stephen , Kar Nilamadhab , Obuobie Akua , Maiti Tanay , Lester Deborah , Mclaughlin Kerry , Hanson Thomas
Published: July 2023

Aims

Clinical research shows that compared to Caucasian patients, Asian patients appear to have a lower clozapine dose requirement for clinical efficacy. Hence, appropriate dose adjustment should be considered in Asian patients receiving maintenance clozapine therapy. Secondly, studies in the UK report that Asian patients with treatment-resistant schizophrenia were less likely to receive clozapine than Caucasian patients. The objectives of this study were to find out the ethnic difference in dose and levels of clozapine in ethnic minority patient (BME (Black and minority ethnic) populations and to explore if there is a need for any specific monitoring.

Methods

Demographic (age, gender, and ethnicity) and clinical variables (diagnosis, clozapine dose, plasma level of clozapine and nor-clozapine, smoking status, side effect profile, and physical comorbidities) were collected from the electronic patient records and analysed.

Results

The sample consisted of 66 (56.4%) Caucasians, 22 (18.8%) Asians, 21 (17.9%) African-Caribbean, and 8 (6.8%) mixed ethnicity patients. Their age range was 19-80, with an average of 46.9 ±11.9 years.

Among the ethnic groups, age, clozapine, nor-clozapine level and QTc were comparable, except for the dose of clozapine; Caucasian had the highest dose (414.8±140.0 mg), followed by African-Caribbean (373.8±163.7 mg), Asian (333.8±121.2 mg) and mixed (260.7±110.7 mg) (F3.68, p<0.05). The difference remained significant when all the BME groups were combined as well.

Side effects such as hypersalivation, drowsiness, blurred vision, polyuria, sore throat, headache, vomiting (none), dizziness, difficulty passing urine, urine incontinence, flu-like symptoms, nausea, were comparable among ethnic groups.

There was no difference in smoking among the groups. Considering comorbidities compared to BME, Caucasians had significantly lower rate of hypertension (27.1% vs 9.1%, p<0.01); diabetes (18.6% vs 4.5%, p<0.05), however dyslipidemia (5.1% vs 3.0%) was comparable.

In addition to the above, the dose of clozapine was positively correlated with clozapine and norclozapine levels (p<0.05). Clozapine and norclozapine levels correlated significantly (p<0.001). Age was negatively correlated with norclozapine assay (p<0.05) and positively with the number of cigarettes. It appears as the age increases, the number of cigarettes goes up, and norclozapine levels come down.

Conclusion

There are a few variations of clozapine prescribing in different ethnic groups. Although the Caucasians had higher doses, they had comparable blood levels. A higher proportion of BME patients on clozapine had hypertension and diabetes, emphasizing metabolic risk. Our study findings suggest clozapine monitoring should look into ethnicity related risk factors.
Demographic Characteristics of Adolescents Referred for Psychoanalytic Psychotherapy – Who Is Being Left Out?
Authors: Pietrogrande Erica , Strzelczak Agnieszka
Published: July 2023

Aims

In response to the growing awareness of health inequalities in the UK, institutions are called to take responsibility in tackling obstacles to equality, diversity and inclusion to mental health services access. This study aims to evaluate the demographic profile of referrals from London borough of Camden residents (aged 18 to 25 years) to the Tavistock Adolescents and Young Adults Service (AYAS) for psychodynamic psychotherapy. We aim to evaluate whether the demographic characteristics of referrals were a good representation of the local population.

Methods

Age, gender, and ethnicity of Camden AYAS referrals received between 12th April and 14th December 2021 (n=38, age range 17 to 24 years) were collected retrospectively using the electronic patient record system and compared with the following age groups of the latest Camden Census data (2011): 16-17, 18-19 and 20-24 years.

The two sets of data were analysed using Chi-Square goodness of fit test.

Results

Females were significantly overrepresented among AYAS referrals compared to Camden population (86.5% vs 52.8%, X2=16.83, p=.001).

No conclusion could be reached regarding transgender individuals due to lack of data about transgender population in 2011 Census data.

Ethnicity was recorded in n=33 referrals and evaluated at group and subgroup level, utilising standardised categorisation.

We found that the proportions of five main ethnic categories differed significantly between the AYAS and Census groups, (X2=13.07, p=.05). In the AYAS referrals Mixed ethnicity group was over 3 times higher than expected based on Census data, while the Asian group was markedly underrepresented.

Significant disproportions were also identified at ethnic subcategory level (X2=39.98, p=.01).

No one of Asian-Bangladeshi or Asian-Chinese ethnicity was referred to AYAS in the timeframe considered.

People of Black ethnicity were represented as expected overall with all referrals (n=3) identifying as Black-African.

Although overall White ethnicity was represented as expected, White-British were underrepresented (18.2% vs 39.2%) with majority of referrals identifying as other White ethnic subcategories (36.4% vs 15.5%).

Conclusion

Limitations of this study include sample size, outdated Census data and limitations of statistical tests used. Our findings indicate males are under-referred to the AYAS psychotherapy service together with some ethnic minorities (Asian overall, and in particular Asian-Chinese and Asian-Bangladeshi).

This may be due to unconscious bias in the referral process. Further exploration is needed to understand underlying causes so that effective strategies to promote equality in access to services can be implemented.
Are We Executing Our Vision?
Authors: Raju Sri , Chouhan Priyanka , Balan Nisha
Published: July 2023

Aims/Background

Safety plan and Goal setting are standard interventions offered by CAMHS Crisis Resolution and Home Treatment team. The Department of Health Best Practice Principles and NICE guidelines recommend collaborative production of risk management plans and recovery orientated input. We wanted to ensure compliance and understand patient's views on usefulness of these.Aims:- Did all patients complete safety plan and goal setting? Was this done collaboratively?Did these strategies help?Were documents easy to access?

Methods

There were two arms to the project.

1.

Review of 40 electronic case notes out of 715 patients seen from Jan to April 2021. We looked at completion of safety plan, goal setting, goals achieved, HONOSCA scores, risk ratings and mood scores.

2.

Between April and July 2022, willing patients were requested to complete anonymised electronic questionnaire through a QR code. The questionnaire asked if patients felt included when completing the safety plan and goal setting, whether these interventions helped recovery and if the documents were easy to access. A free text option for feedback was also given.

This proposal was approved by the Improvement and Knowledge Hub within the LPT NHS trust who confirmed that ethical approval was not required.

Results are reported in percentages.

Results

Case notes review (n=40):

•

99% had safety plans completed, done collaboratively.

•

90% had goal setting completed, done collaboratively

•

Rationales documented within the notes for not completing.

•

85% reported Improved mood scores

•

90% reported improved risk ratings

•

65% achieved 2 or more of 3 goals set.

•

67.5% had HONOSCA at admission (average score 13.6) and discharge (average score10.5) – improvement documented.

Questionnaires: 18 questionnaires returned.

•

100% completed safety plan and goal setting

•

83% reported they felt included when doing safety plan and goal setting.

•

83% said goal setting was helpful in recovery.

•

94% said safety plan helped.

•

82% reported easy access to documents.

Conclusion

Results suggest compliance with guidelines and strategies are useful. There is consistency in relevant information from the case note review and questionnaire feedback. Case note review included objective and subjective perspectives. Questionnaires gathered patient perspective; in confidence/anonymously.

Recommendations:

1.

Repeat survey ensuring case review and patient feedback for same period.

2.

Use children and young people friendly version, offer paper version, advertise widely - to improve questionnaire response rate.

3.

Complete HONOSCA on admission and discharge.

4.

Research to explore usefulness of interventions in CYP
Satisfaction Survey of Patients and Carers for Telephone vs Face-to-Face Reviews - a Service Evaluation Project
Authors: Sevim Busra Acar , Randhawa Tani , Haworth Katherine , Khan Kehkashan
Published: July 2023

Aims

The COVID-19 pandemic necessitated major changes in clinical care, including remote patient contact. Havering Older Adults Mental Health Team and Memory Service (HOAMHT&MS) patients often fell within the vulnerable category for poorer outcomes with the SARS-CoV-2 virus, so remote contact was preferable during the pandemic. Telephone assessments were offered to replace face-to-face reviews for some patients. Feedback from patients and carers was collected to compare these modes of patient contact. Remote assessment has positive impacts including; improving access to care in remote areas/when local services cannot meet demand and for disabled patients. Understanding the patient experience about remote assessments helps navigate decisions about future modes of consultation.

Methods

This evaluation was organised in HOAMHT&MS. A Rio* diary search was conducted for practitioners from 15/07/2020 to 15/10/2020. 75 questionnaires were sent from each clinic (OAMHT and Memory Service). We sent an equal number of questionnaires for telephone appointments and face-to-face reviews. Questionnaires were posted to patients with pre-paid envelopes to return responses.

*Rio is our Electronic Patient Record System

Results

We had a total return of 23 questionnaires from the Memory Service and 24 from the OAMHT clinic. Most questions were a likert scale from Poor (1) to Excellent (5). The overall satisfaction score out of 5 (average of all the responses):

OAMHT:

Patient/telephone: 3.7 (n=13)

Patient/face-to-face: 4.1 (n=7)

Memory Service:

Carer/telephone: 4.4 (n=8)

Carer/face-to-face: 4.2 (n=9)

Some of the open ended feedback:

OAMHT:

•

Carer/telephone:

“The telephone was rushed and at the end of the meeting the person wanted to sign my husband off.”

•

Patient/face-to-face:

“Help was always there for me.”

“The clinic deserves a medal.”

Memory Service:

•

Carer/telephone:

“Very helpful - I am now contacting them for further advice. They understand my stress and give me full support.“

•

Patient/face-to-face:

“Very happy with the care and attention from the consultant, doctor and nurses at the memory service.”

Conclusion

OAMHT Responses:

•

Face-to-face feedback more positive

•

Patients experienced more distress - nature of illness (distress/crisis) compared to memory (usually gradual decline)

•

Telephone appointments seem less satisfactory - less likely to meet the emotional need of patient/carer

Memory Service:

•

Generally positive feedback from carers and patients in all areas - able to take a meaningful history over telephone
Optimising and Future-Proofing Dementia Care With Amnestic Mild Cognitive Impairment (aMCI) Clinics
Authors: Raninga Smit Kishorbhai , Wasunna-Smith Brenda , Millward Alice , Rees Kerry , Kuruvilla Tarun
Published: July 2023

Aims

Amnestic Mild Cognitive Impairment (aMCI) is considered a pre-dementia (prodromal) phase of Alzheimer's disease (AD), with a higher probability in patients with positive biomarkers (temporo-parietal region, atrophy on CT/MRI imaging and hypometabolism on FDG-PET scan).We developed a pilot service development project in the North Sector of Gloucestershire Health and Care (GHC) Trust. Its’ main aim was to ease some of the pressures on the Memory Assessment Service (MAS) nurses and the medical memory clinics. The main objectives were: 1. To develop and run an aMCI Clinic service for eight months between March and November 2022 at GHC with North Sector patients to reduce waiting times compared to the preceding years. 2. In patients with aMCI and a positive biomarker, continue annual cognitive testing with early identification of conversion to dementia, thereby starting anti-dementia medication, and continue through the post-diagnosis pathway. Future plans include creating a business case for the Care Commission Group to consider commissioning a countywide aMCI service.

Methods

Patients (n=23) with the diagnosis of aMCI and a positive biomarker were selected. Data included the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) to assess patients’ daily functioning, clinical history and service satisfaction questionnaires. Different initial objective tests, including Addenbrookes Cognitive Examination (ACE-III), Repeatable Battery for the Assessment of Neuropsychological Status (R-BANS), Telephone Interview for Cognitive Status (TICS), and Rowland Universal Dementia Assessment Scale (RUDAS) were used. Data for waiting times from referral to first assessment were collected and statistically analysed using a repeated measures design across years 2020,2021,2022(March-November) and a one-way repeated measure ANOVA was performed.

Results

Analysis of waiting time indicated a non-significant decrease in waiting times from referral to first assessment. A decrease in the waiting times from September 2022-November 2022 was noted, pointing towards a possible time lag effect. Within six to twelve months of repeat testing, 62% of patients remained with an aMCI diagnosis whereas 32% of patients progressed to dementia (Alzheimer's or Vascular). From the post-appointment patient feedback received (65%), all patients reported to be very satisfied (57%) or satisfied (9%).

Conclusion

It is prudent to assess the time lag effect on the results produced in subsequent months. A repeat review with a larger sample size to increase the sensitivity and specificity of the results obtained is recommended.
Exploring the Trend in the Use of Electroconvulsive Therapy (ECT), Modified ECT and Transcranial Magnetic Stimulation (TMS) in Northamptonshire Healthcare Trust
Authors: Tariq Safyan , Alwetayan Salem , O'Neill-Kerr Alex
Published: July 2023

Aims

Our aim was to analyse the trend in the use of new courses of ECT in Northamptonshire Healthcare Trust from 2007 to 2022 and to compare the use of ECT, Modified ECT (MECT), TMS, Ketamine and combined TMS + Ketamine in the Treatment Centre and The Centre for Neuromodulation in Northamptonshire Healthcare Trust from 2013 to 2022.

Methods

Data for new ECT courses were collected from the Treatment Centre in Northamptonshire Healthcare Trust from 2007 to 2022. These data were then compared with new courses for TMS, MECT, ketamine and combined TMS + Ketamine from various sites across the trust from 2013 to 2022. These data have been represented as two separate graphs the first showing trend of ECT and the second comparison of the trend of ECT, MECT, TMS, Ketamine & combined TMS + Ketamine.

Results

The data show that there has been a significant decrease in the number of ECT and MECT procedures performed in recent years, with a decrease of over 50% to 70% in new courses of ECT & MECT among various units in the trust. Regarding the data for TMS treatment vs ECT there is a gradual decrease in ECT and increase in TMS over the years, of particular note is the recent period of 2019 to 2022 during which there were 10 times more referrals for TMS compared to ECT at Northamptonshire Healthcare Trust. During this period TMS accounted for 87% of the total new treatments, while ECT accounted for 9% and Ketamine 4%.

Conclusion

Our findings suggest that TMS is becoming an increasingly popular treatment option for depression and may eventually replace ECT and Modified ECT as the primary treatment in the Northamptonshire Healthcare Trust. This poster provides an overview of the current state of ECT, Modified ECT, TMS, and ketamine as treatments for depression, and highlights the need for further research to better understand the relative effectiveness and safety of these treatments, especially in treatment-resistant depression cases.
Enhancing Medical Governance of Care Within an EIP Service
Authors: Veldmeijer Claire , Perera Samantha , Fuller Martin , Kavanagh Gail , Whale Richard
Published: July 2023

Aims

We aimed to enhance the clinical governance of medical input to patients within Brighton Early Intervention in Psychosis (EIP) service. The Service Standard Operational Policy indicates that patients should be medically reviewed every 6 months as part of the Care Programme Approach (CPA) and include review of: diagnosis, service eligibility, medication positive and negative effect, clinical improvement, risk assessment and physical health.

Methods

The EIP caseload on a specific date was reviewed to explore if a medical CPA review had taken place. A detailed medical letter evidenced this. A meeting was convened between team doctors to identify from electronic records when the last medical CPA had taken place. General characteristics of the delayed review group were identified. An excel spreadsheet was used to create a system to autogenerate when a next review is required.

Results

142 patients were identified on the EIP caseload. 21 patients had been discharged so were excluded. 121 patients were eligible for this audit, including 8 inpatients. 46 (38%) patients were identified as having an overdue CPA review.

Those with overdue CPA reviews were found to be overall clinically stable, on the caseload for over a year and those who had had a recent change in Lead Practitioner (LP) who were not aware of service operational policy due to high staff turnover linked with the COVID-19 pandemic. Some duplications of routine medical reviews were identified between team doctors within the 6 months.

Conclusion

This service was not achieving CPA standards of the operational policy. A spreadsheet was set up to proactively alert the LP when patients required a 6 month review. Policy information sessions were set up for the team and will be specifically included in new worker induction training. A full audit cycle will be completed by implementing the change made and re-auditing to see if there is an improvement. Duplications of routine medical reviews will be explored in more detail.
The Patient's Guide to Buvidal: A Service Improvement of a Digital Repository of Patient Information for Patients Taking Buvidal in Wales
Authors: Ward Devon
Published: July 2023

Aims

Buvidal is being used with patients with opioid dependence. Only 35% of patients read the paper patient information leaflet, which could be improved by condensing the information, making it accessible and relevant. Therefore, the aim was to create a series of informative videos answering important questions for patients taking Buvidal and then evaluate their perceived efficacy.

Methods

Data were collected from a questionnaire taken by patients taking Buvidal and healthcare professionals (HCPs) working in Substance Misuse Psychiatry in Wales. The results and preferences were analysed and the information was used to create 5 videos addressing the questions the participants thought were the most important. A second questionnaire was sent out alongside the videos to the original participants to gauge their utility. The Patient's Guide to Buvidal can be accessed on YouTube: shorturl.at/afjl3.

Results

All participants reported that the videos would be useful in answering their questions about Buvidal. Participants ranked the use of Buvidal, the effect of comorbidities and other substances on taking Buvidal and side effects as the most important topics to be covered in the videos. Understanding and confidence increased in a mean of 80% of the topic areas discussed. HCPs reported an increase in 9 out of the 12 topic areas, whereas patients reported an increase in 7. There was no statistically significant difference between prescriber and patient confidence (t(22) = 0.197, p=0.05). 100% of the participants stated they enjoyed the videos and preferred them to the patient information leaflet.

Conclusion

The digital repository could be a valuable addition to the holistic care of patients taking Buvidal to improve their understanding of important questions and topic areas. The use of one long video using YouTube's bookmark feature may be preferred by patients to easily navigate the videos. In the future, new medications and routes may benefit from videos like this targeted at HCPs as well.
An Audit of Documentation Relating to a Decision-Making Capacity to Consent to Admission to the Peter Bruff Mental Health Assessment Unit
Authors: Zinchenko Oksana , Sivakanthan Sujeeththa , Rai Yugesh , Shoka Ahmed
Published: July 2023

Aims

Assessment of the capacity to consent to admission is an important legal and ethical issue in daily medical practice. Mental Capacity Assessment (MCA) should be carried out thoroughly based on all the domains mentioned in the Mental Capacity Act (2005) and be recorded in the patient's notes or admission. This audit evaluated the documentation available on the electronic database (Paris) in order to ascertain what information was and wasn't documented. The standard used: “Decision–making and mental capacity”. NICE guideline NH108 (2018) recommendations 1.4 Assessment of mental capacity were used as a standard for this audit. 100% of all admitted patients should have MCA completed during the admission clerking.

Methods

The data were examined retrospectively from the MCA on admission, available on the electronic health record database (Paris). The audit tool focuses on quantitative data collection on Mental capacity documentation.

A random sample was selected of 15 patients admitted in May, June, September, and October 2022 to the Peter Bruff MH Assessment Unit (male and female). Total 60 patients.

All data were anonymised. Results were tabulated and presented in statistical form back to the clinical teams.

Results

All patients who were admitted to the assessment unit were subjected to capacity assessment, consenting to informal admission and acceptance of treatment.

MCA was completed and patients had capacity both on clerking and during the ward review in 85% of cases, (n=61). MCA was completed and 3 % of all patients were found to lack capacity on clerking (n=2). MCA was completed, and patients had the capacity on admission, however, they had no capacity during the review in 5% of cases (n=3). MCA was not completed, or the information was unavailable, for 7% of the cohort (n=4).

Capacity to consent is specific to a decision and can vary over time; a patient is therefore competent or not with respect to a specific decision and for a given moment in time.

We found that after the clerking assessment, when patients were reviewed by the unit doctor and the consultant, whether on the day of admission or shortly after (in a matter of hours), on several occasions some patients were lacking the capacity to consent to the admission.

Conclusion

The missing link to be identified between the MCA capacity assessment that was carried out by the clerking doctor, compared to the MCA that was conducted by the unit doctor and consultant. This could be a restrictive environment on the unit or less attention paid to the quality of capacity assessment and further training is needed for professionals.
A Review of Unmet Needs – Making a Case for a High Dependency Rehabilitation Service
Authors: Fuller Amanda , Abdelkader Moustafa , McGill Meenaxi , Robinson Denzil , Smith Joanne , Sigfid Alice , Eyeoyibo Mo
Published: July 2023

Aims

The Kent and Medway Partnership Trust (KMPT) Rehabilitation service strategy 2020-2025 in line with NICE guidance for Complex Psychosis 2020, sets out to deliver a complete mental health rehabilitation pathway with local provision of high dependency rehabilitation units (HDRU), open rehabilitation units and community rehabilitation provision across the county. There is a lack of HDRU provision in Kent and Medway in its rehabilitation pathway. All HDRU provision is by external providers, often out of area, dislocating people from family support and local resources essential for their recovery and integration. Kent has a relatively high number of out of area (OAT) placements based on national benchmark data (GIRFT). The proposal to develop a HDRU locally led to a review of local population needs for HDRU. The review with the existing OAT data provided information on the number of HDRU beds required in Kent and Medway.

Methods

We identified 564 patients who had had 5 or more Mental Health Act assessments, in cluster 16 and 17, more than 3 admissions to psychiatric inpatient units and with CTO recalls. Two senior clinicians reviewed these patients against the HDRU eligibility criteria. Demographics, diagnosis and comorbidities were also recorded.

Results

119/564 patients met the threshold for HDRU assessment. Using our conversation rate from referral to admission in our open rehab, it means about 20% (24) of this cohort would require treatment in a HDRU. Demographics, diagnosis and comorbidities were reviewed which gave important information about service provision requirements. This was compared with NICE guidance recommendations of 1 high dependency unit per 600,000 - 1,000,000. Therefore, based on this, we would be expected to have between 23 and 38 patients requiring HDRU treatment.

Conclusion

A high level of unmet need for HDRU exists in Kent and there is a need for further recognition of the relevance within the rehabilitation pathway. Lack of local provision of HDRUs means the use of longer, expensive and variable quality out of area or private placements. These can be not only detrimental for patients due to a loss of connection to an area and social network but a drain on resources. These results support the case for x2 12 bedded HDRUs. The lack of provision of HDRU impacts on the wider system and patient's timely access to appropriate treatment pathways.
Metabolic Syndrome Monitoring in Patients on Depot Antipsychotics
Authors: Ateem Salah
Published: July 2023

Aims

We conducted this audit in patients attending the Community Mental Health Team (CMHT) at St Davnet's hospital in Monaghan, County Monaghan, Ireland. The British Association for Psychopharmacology (BAP) guidelines were used for this audit to assess our service compliance with standard guidelines and to consider implementing measures to enhance the service's compliance with guidelines and maintain improvement. Metabolic syndrome (MetS) is common in patients who are prescribed depot antipsychotics. Worldwide the prevalence of MetS in Schizophrenia patients is between 30 and 40%, and MetS increases the risk of CVD and mortality. Research showed that patients with severe mental illness die 10–30 years earlier due to physical illness.

Methods

The audit cycle was from the 15th of February to the 15th of June 2022. Demographic and therapeutic variables were collected from participants within the CMHT. The action plan which included psychoeducation for nursing staff regarding guidelines for monitoring and documentation was implemented following completion of the initial audit, and then re-audited.

Results

During initial audit the sample size was 48 patients; 77% were females and 23% were males. The mean age was 54.3 years, ranging from 24 to 90 years. 39.6% of patients had MetS monitoring charts in their files, and 29.2% had completed documentation of their MetS charts. Blood pressure, lipids, and glucose were documented in 31.3%, while BMI/girth was documented in 29.2%. Paliperidone was the most common used antipsychotic (43.8%), followed by Flupentixol (31.3%), and Aripiprazole (14.6%). In re-audit the sample size was 46 patients; 76% were females and 24% were males. The mean age was 53.7 years, with the same age range as in the audit sample. MetS monitoring charts were 100% completed in all files. Glucose documentation was 95.7%, blood pressure was documented in 91.3%, BMI/girth, and lipids were documented in 87% of files. Paliperidone, Flupenthixol, and Aripiprazole were the commonly prescribed antipsychotics.

Conclusion

The implementation of the action plan resulted in recognizable improvement in MetS monitoring and documentation. To maintain this level of improvement it is essential for the CMHT to continue educating the nursing staff and other team members about the importance of MetS monitoring and documentation. Defining documentation roles and responsibilities among team members will facilitate monitoring. Identification of files that require MetS monitoring can be improved by placing colour code stickers. A MetS Clinic can be considered as a long-term plan.
Consent on Information Sharing
Authors: Jeje Jide , Ogungbayi Modupe , Binmohdzaki Mohdhafizudin , Prabhu Aishwarya
Published: July 2023

Aims

This clinical audit is aimed at assessing the knowledge, attitude and practices of team members towards compliance regarding information sharing and consenting service users and to create awareness about existing Trust policies and national guidelines, importance of gaining consent for Information Sharing. Consent to share information should be recorded on the appropriate clinical record keeping system and/or paper. Service users also have the right to request that information is not shared – and staff must record these decisions in the clinical record. Team members work with other agencies and at times need to share patient information. Hence, there should be discussion about who information is going to be shared with, and why. A recorded consent is useful in instances when patient data may need to be shared in court.

Methods

The 1st cycle of the audit was conducted from 15th of December 2022 to 4th of January 2023. Clients that met the inclusion criteria were checked to see if the form was filled in by the relevant practitioner/ ever filled in. This was done for both the Community Mental Health Team (CMHT) and Memory assessment Services (MAS). A survey with 7 questions was sent out to team members to assess their knowledge of the Trust policy as well as national guidelines on consent on information sharing.

Results

A total of 238 service user records were assessed. 119 each under CMHT and MAS. Combined results of 37% of the 238 services users had consent documented while 63% did not have consent documented. 27% of services users under MAS had consent obtained and documented. 56% of service users under CMHT had consent obtained. 100% of team members that responded to the survey knew to discuss personal and confidential information sharing with patients. 91% of staff knew that the discussion on consent and information sharing should be documented. 23.5% of staff were not aware of trainings on information sharing and 35.3% of staff were unaware of where to document the consent.

Conclusion

Although rare, unrecorded discussion/consent on Information sharing can cause serious implications. This audit highlights the need to create awareness about the importance of recording Information Sharing consent. Possible reasons for results include team members not being aware of where to document in client records, Trust has not properly educated staff on Information sharing and the way to record it in electronic health records and the Concept of implied consent.
Audit of Physical Health Monitoring in Long-Stay Psychiatric Inpatients on Clozapine in NHS Ayrshire & Arran
Authors: Carson Chris
Published: July 2023

Aims

There is a body of evidence showing the health inequalities faced by people with schizophrenia, with some studies indicating that their life expectancy is approximately 20 years less than that of the general population. The vast majority of patients with schizophrenia require long-term treatment with antipsychotic medications, such as Clozapine. These can lessen disease burden significantly however can be accompanied by adverse effects, including metabolic syndrome. This audit aimed to determine whether the local physical health monitoring guidelines for those on Clozapine are being carried out for long-stay patients in inpatient forensic and rehabilitation psychiatry services in NHS Ayrshire & Arran.

Methods

The guideline “National Standard for Monitoring the Physical Health of People Being Treated with Clozapine” was issued by the Scottish Government in 2017. This guideline advises on physical health parameters which benefit from monitoring during Clozapine titration and on-going therapy. This audit reviewed whether the parameters with specified frequencies, such as annual LFT monitoring, were being monitored within the recommended timeframes.

Results

In our group of 18 patients on long-term Clozapine therapy, 10 had undergone a serum fasting blood glucose and 12 had a lipid profile checked in the preceding 6 months. Meanwhile, all 18 had liver function tests done within the last year prior to data collection. All patients had a BMI, heart rate and blood pressure reading documented in the last year, while 12 out of 18 had an ECG carried out in the same time period.

Conclusion

This audit has revealed a mixed picture in terms of the adherence to guidelines for physical health monitoring for our long-stay forensic and rehabilitation patients on Clozapine therapy. A need for more fastidious blood test monitoring within the forensic service has been identified, with a particular focus on the measuring of serum fasting blood glucose and lipid panels. It was noted that a physical health monitoring checklist incorporating the above guidelines had previously been introduced into the rehabilitation ward, and the benefit of this was demonstrated in the 100% adherence they achieved. We have therefore decided to introduce a similar checklist to the forensic wards as our intervention, with a plan to re-audit in 6 months' time.
An Audit on Physical Health Assessment and Medical Review for Service Users Under the South Cambridgeshire Crisis Resolution and Home Treatment Team
Authors: Chougule Amitkumar , Balasubramanian Saravanan
Published: July 2023

Aims

According to the Home Treatment Accreditation Scheme (HTAS) Standards for Home Treatment and Crisis Resolution Teams, the physical health assessment and medical review are type-1 criteria. These standards must be met for all service users since failure to meet them would constitute a significant threat to patient safety, rights, or dignity. This audit aimed to measure the compliance of the south Cambridgeshire crisis resolution and home treatment team (CRHTT) with the HTAS standards for physical health assessment and medical reviews.

Methods

This audit was registered with Audit & Service Evaluation Registration services at the Cambridgeshire and Peterborough NHS foundation trust (CPFT). The necessary permissions to access patient records on the trust's electronic patient record (EPR) system were obtained from appropriate authorities in the CPFT IT department. From August 2021 to July 2022, all referrals to South Cambridgeshire CRHTT were screened for inclusion and exclusion criteria, and clinical records of 77 service users who met these criteria were analysed. The required data were collected on an excel sheet and analysed using descriptive statistics to measure the percentage of service users who satisfied the audit criteria. The audit was conducted between May 2022 and July 2022.

Results

A total of 1232 referrals were screened, and 77 (6.25 %) service users (n=77) satisfied the inclusion criteria. The average age of service users was 37, with 54.55% of the subjects being females and 45.45% being males. 70.12% of the CRHTT reviews met the Physical health assessment criteria as set by HTAS while 94.80% of the CRHTT reviews met the medical review criteria set by HTAS. The expectations were 100% of the CRHTT reviews should meet the HTAS standards for physical health assessment and medical review. The HTAS standards were not met in 30 percent of service users for the physical health assessment criteria and in 5% of service users for the medical review criteria for the CRHTT assessments done by the south Cambridgeshire CRHTT team for the period between August 2021 and July 2022.

Conclusion

This audit suggests that the south Cambridgeshire CRHTT is currently not meeting the standards laid down by HTAS and there is room for improvement in the physical health assessment and medical review process. The recommendations were made and additional audits may be necessary to ensure that all service users receive HTAS-compliant care.