bluuebunny/crossref_metadata_2025 huggingface dataset:
Communication in COVID: a quality improvement project into staff communication with family/carers at New Haven Older Adult Mental Health Inpatient Unit
Authors: Jones Felicity , Khanna Bhavna , Almoosawi Batool , Humm Alex , Mahon Upjeet , Edwards Rosie
Published: June 2021

Aims

In the psychiatric care of patients, family involvement is key to recovery. At the New Haven Unit, there have been a number of complaints regarding poor communication and lack of updates given to families during COVID-19.

The aim is to:

To increase the overall satisfaction of the family with the service received for their loved ones

Ensure effective and timely communication of updates to the families, to prevent further complaints, by assigning a member of staff per patient to be the primary individual responsible for family contact

Create an addition to the weekly ward round MDT proforma on ‘Carenotes’ where communication can be documented

Method

A standardised questionnaire has been sent to the relatives of inpatients at the New Haven Unit. Qualitative data are being collated, which will lead to quantitative statistical analysis of the satisfaction ratings.

Based on the current bed state on the ward at the time of the project all 32 relatives of current inpatients were contacted and 23 agreed to complete the survey which was sent out either by email or post.

The new MDT proforma will be added, which will be used to record actions needed to be taken involving communication and updating family members on a weekly basis. This opportunity to record communication will improve continuity of care and satisfaction amongst family members.

There will be follow-up via a second questionnaire to identify improvement.

Result

The average results of selected categories so far are shown below (still awaiting further responses):

Frequency of updates regarding loved ones = 4.33/10 (10-excellent)

To what degree were your concerns listened to? 7.33/10

Quality of content discussed with staff members = 3.33/4 (4- excellent)

Other categories scoring below the expected standard, included awareness of visiting guidelines and questions regarding lasting power of attorney, in which 33.3% of participants responded either ‘no’ or ‘not sure’ respectively.

Questions addressing formalities of introduction and confidentiality through identity confirmation, scored highly.

Conclusion

We are awaiting more survey responses in order to identify additional areas of improvement; however, it is already clear to see that there are areas that would be advanced through structured, assigned reminders via an MDT amendment.

We will also be introducing set dates for conference calls with the families now involving the whole MDT; one within the first week of admission, one after six weeks and one at the point of discharge as a minimum.
Improving physical health assessment of old age inpatients on the Oaks Acute Admission Ward
Authors: Aus Dr Karen , Gougoulaki Marilia , Elia Maja , Wall Emily
Published: June 2021

Aims

Old age psychiatry patients are subject to increased frailty, comorbid load and medication adverse events than equivalent older age populations without psychiatric illness. Timely physical health assessment and monitoring is therefore an essential part of treatment provision. The Oaks is a 20-bed old age acute admissions ward in Barnet, Enfield and Haringey Mental Health Trust. With this quality improvement project, we aimed to deliver high-quality assessment and treatment of physical health for our patients.

Method

Using NICE guidelines as a blueprint, we devised a list of parameters essential to the management of old age inpatients. This included blood tests (full blood count, urea and electrolytes, liver function, thyroid function, cholesterol, lipids, iron studies, vitamin D, glycated haemoglobin, prolactin), investigations (imaging, ECG, physical examination, cognitive testing) and assessments (body mass index [BMI], functional review, mobility, Rockwood Frailty Score). The implementation goal was to ensure all parameters were acted on within 24 hours of admission (or 48 hours for patients admitted on weekends).

We initially audited these parameters in patients admitted to the Oaks in October and November 2020 (n = 24). We subsequently collated all parameters into an online spreadsheet, which was distributed to ward medical staff. For each new admission, parameters could be marked as pending or complete. The spreadsheet was reviewed in daily ward handover. Following implementation, we collected data on the parameters for patients admitted in December 2020 and January 2021 (n = 16).

Result

Prior to implementation of the spreadsheet, 42.0% of all parameters had been actioned within 24 hours of admission. Following the implementation of the spreadsheet, 86.2% of parameters had been actioned within 24 hours (mean difference 44.2%, 95% CI 13.5% to 64%, p = 0.006).

In detail, there were significant increases in timely actioning of magnesium (increased by 61.7%, p < 0.001), cholesterol (61.7%, p < 0.001), glycated haemoglobin (65.8%, p < 0.001), vitamin D (65.8%. p < 0.001), prolactin (61.7% p < 0.001), lipids (61.7%, p < 0.001), thyroid function (51.7%, p < 0.01), iron studies (80.9%, p < 0.001), imaging (42.5%, p = 0.01), frailty scores (60.0%, p < 0.01), BMI measurement (55.9%, p < 0.001), and functional review (42.5%, p = 0.01).

Conclusion

Implementation of a monitoring spreadsheet with relevant parameters linked to daily ward handover resulted in widespread and significant improvement in the assessment of physical health among old age psychiatry inpatients.
Improving physical health care for inpatients with eating disorders
Authors: Knights Edward , Schelhase Monique , Jones Rhys , Burke Lou
Published: June 2021

Aims

Primary aim – To improve how physical health issues are addressed for inpatients with eating disorders

Secondary aim – To improve efficiency within the MDT

Background

The Yorkshire Centre for Eating Disorders (YCED) is an inpatient unit for the treatment of patients with anorexia and bulimia nervosa. Anorexia nervosa has the highest mortality of all psychiatric disorders with an extensive list of physical manifestations. This project was designed to help better address the physical health concerns of our patients by introducing a primary care style, once weekly clinic that patients could self-refer to.

Method

Questionnaires were designed to assess whether a once weekly physical health clinic would benefit the service.

The clinic was run on a weekly basis from 26th April to 24th June 2019. Follow-up questionnaires were designed and distributed to both patients and staff following this period. Data were analysed with Microsoft Excel to determine if improvement had been made.

Result

N = 12 inpatients responded to the initial questionnaires, n = 2 were discharged during the 8 week period so were included in the analysis but did not complete the follow-up questionnaire.

100% of the staff (n = 8) felt a once weekly clinic would benefit their patients. 62% (n = 5) stated they felt distracted from their other duties with physical health requests.

33% (n = 4) of the inpatient group felt the clinic would benefit them with 67% (n = 8) stating indifference to the idea.

26 appointments were conducted in the physical health clinic with 80% (n = 8) of the service users accessing at least once. 70% (n = 7) stated their physical health concerns had been better addressed since the clinic had been started.

90% (n = 9) of inpatients and 90% (n = 9) of staff responded that the physical health clinic should remain permanent. 90% (n = 9) of staff stated they had more time for their other duties since the introduction of the clinic.

Prior to the clinic 63% (n = 5) of staff responded that in a typical day they were approached between 2-5 times for physical health requests with the other 37% (n = 3) being approached once.

Following the clinic 80% (n = 8) of staff responded that they were approached once in a typical working day.

Conclusion

The qualitative data from the questionnaires indicated success in both improving patient care and reducing nursing workload.

The physical health clinic has been made a permanent feature on the ward and has been continued by the incoming foundation doctor and ward ANP.
Monitoring and investigation of tachycardia in patients receiving clozapine therapy; a quality improvement project
Authors: Kurkar Michael , Blair Joshua , Graham Poppy
Published: June 2021

Aims

Clozapine is an antipsychotic agent with a number of significant physical health risks which necessitate monitoring, including cardiac complications such as myocarditis and cardiomyopathy. Reliable detection of cardiac complications requires active vigilance, with consideration for investigations if serious cardiac side effects are suspected (including electrocardiograms, echocardiograms and blood tests). There was dissatisfaction in the outpatient department about delays to taking action on abnormal physical observations, such as tachycardia. This raised safety concerns about how these delays would limit our ability to investigate and diagnose cardiac complications in a timely manner. We set a project aim to reduce the rate of retrospective action on abnormal physical observations, by half in the 4-month project timespan.

Method

All correspondence sent to the outpatient department from the local clozapine clinic was monitored and assessed for the need for further action or investigation, and the proportion of retrospective action needed was recorded. This was then monitored during implementation of project interventions, to detect any change in performance.

Result

Baseline monitoring showed retrospective action had to be taken on 41.2% of patients attending the clinic with abnormal physical observations, with significant delays up to 51 days later. Our initial intervention was the design of a clinical protocol to guide and signpost clinical staff at the time of the patient's attendance. Unfortunately, due to wider organisational barriers, this was not able to be implemented during the timescale of this project; however increased staff awareness during the protocol implementation process led to a reduction of retrospective action to 26.7%. A follow-up intervention to increase staff awareness and education was carried out, with development of a poster for the clinical room. This approach maintained the improvement, with a further slight reduction to 26.3%, representing a decrease of 37.5% from the baseline rate. A total of 106 patient letters were assessed during the project.

Conclusion

We believe that developing a clinical policy to use at the time of the patient's clinic attendance still remains the optimal intervention; a view backed up by this project's identified drivers for change. However, wider organisational barriers prevented the implementation of this policy, and overcoming these barriers are outside the scope and timescales of this project. This project demonstrated maintained, but sub-target, success with measures that increase staff education and awareness. However, it remains to be seen if this improvement will persist, and this would be a potential target for further QIP or monitoring.
Physical health assessment quality improvement project
Authors: Lambert Maggie
Published: June 2021

Aims

My aim was to ensure at least 60% of clients in the Acute Day Unit have a ‘physical screening tool’ entry.

Background

As a GP starting training in psychiatry I am very aware of the importance of physical health and the overlap between physical health and mental health. It has been found that there is a 20 year mortality gap for men and 15 year mortality gap for women in people with mental health problems. Thorncroft described this as ‘the scandal of premature mortality’.

Nice Guidelines state: ‘Reducing premature mortality by improving physical healthcare for people with severe mental illness remains an NHS England priority. Funding has been made available to ensure that at least 60% of people who have severe mental illness receive NICE-recommended physical assessments and follow up from 2018/19 onwards.’

The Acute Day Unit seemed to be the ideal situation to try to address this problem as clients are with us for 6-8 weeks during which time their physical health as well as their mental health can be optimised.

Method

I emailed the whole team to invite ideas and questions regarding the QI project and discussed it further at the MDT meeting. It was important at the start to get the whole team on board. Having discussed it we decided to put six blocks of thirty minute slots weekly into the timetable for physical assessments. These were to be booked in by the client's care coordinator. I also added a column onto our team spreadsheet to input whether or not the physical assessment had been done. Frequent encouragements and reminders were sent round the team of which clients still needed a physical assessment.

Result

Before the changes were made 25% of clients were having their physical assessments done. After the changes were made 63% of clients had their physical assessment done, three of the twenty seven clients having only started at the day unit that week.

Conclusion

Having made a change to the system of scheduling six regular slots for physical assessments there has been a dramatic rise in the number of clients having their physical assessment done. As this change has been to the system and will be continued automatically on the team calendar the improvement has been more easily sustained. We are keen to keep improving on this change with an ideal level of over 75% of clients having a physical health assessment.
Improving safety-planning in patients admitted with self-harm
Authors: Mishra Vatsala , Hughes Kathryn , Sunderland Alexander , Calcia Marilia , Parsons Martin
Published: June 2021

Aims

Self-harm is a common presentation to acute hospitals, associated with increased risk of completed suicide. Safety plans are increasingly recommended to help patients recognise and prevent escalation of self-harm behaviours.

This project aimed to improve quality and documentation of safety planning for patients admitted at an acute general hospital due to self-harm, who were assessed by Liaison Psychiatry. We aimed to increase the number of patients given written safety plans on discharge by 50%.

Method

The PDSA cycle model of quality improvement was used. A retrospective audit of clinical records was conducted over 3 months to establish baseline documentation of safety planning (n = 51). A template for a self-harm crisis plan, used in other areas of the Trust, was adopted, to be adapted to each patient. A leaflet for sources of crisis support and patient feedback form were developed and distributed to clinicians in the team. Data collection was repeated one month later (n = 48). The second set of interventions involved a training session for clinicians on developing safety plans in collaboration with patients, and a poster highlighting the process to be undertaken when discharging a patient admitted with self-harm.

Result

Following initial interventions, 20% of patients had completed safety plans and 50% received advice, an increase of 20% and 40% respectively. The second PDSA cycle showed increase in numbers to 38% and 67% respectively.

Conclusion

Creating a crisis plan with a hospital-specific leaflet for the Liaison Psychiatry team increased the number of patients discharged with safety plans in place. 86% of patients who participated in safety-planning found the process helpful and felt likely to use the plan in future crises. This is an area of ongoing quality improvement which can be implemented in other hospitals to better equip patients with skills and support to reduce self-harm/suicide attempts.
A quality improvement project on the discharge summary completion process in an addictions service
Authors: Mohamed Lily
Published: June 2021

Aims

Discharge summaries are vital documents that communicate information from hospital to primary care providers. The documents contain description of the patient's diagnostic findings, hospital management, laboratory results, medications list and arrangements for post-discharge follow-up. Ineffective communications between healthcare providers in the form of delayed or poor quality discharge summary may adversely affect patient care and safety.

The setting of this project is Gwent Specialist Substance Misuse Service (GSSMS) which is the statutory specialist addictions service within Aneurin Bevan University Health Board (ABUHB). GSSMS has been arranging and managing inpatient alcohol detoxes for many years. One of the issues highlighted by an inpatient alcohol detox audit in 2017 was discharge summaries were not being completed for every patient who was admitted with a compliance rate of only 57.7%. A quality improvement project was initiated following the presentation of the audit on a Staff Education Day.

The aim of the project is to increase the discharge summary completion rate from 57.7% to 80% by June 2019.

Method

A discharge summary process map was developed to understand the possible causes of delay then Plan, Do, Study, Act (PDSA) methodology was utilised. The result of the original audit was taken as the baseline measurement and benchmarking activities and PDSA cycle were performed. Interventions included root cause analysis by way of brainstorming, education, communication and constructing a checklist.

Result

There has been significant improvement with the compliance rate following the PDSA cycle. It went up to 100% before tapering off to 85% by the end of the project.

Conclusion

Awareness building, continuous monitoring and engagement of teams alongside regular feedback were shown to be the important factors to achieve and sustain the improvement.
A quality improvement (QI) project on improving trainee confidence in conducting remote psychiatric consultations at Pennine Care National Health Service (NHS) Foundation Trust in the United Kingdom (UK)
Authors: Moir Rachel , Ramkisson Roshelle , Abraham Seri , Matheiken Shevonne
Published: June 2021

Aims

When the coronavirus disease 2019 pandemic hit the UK, clinicians within Pennine Care NHS Foundation Trust (a five-borough mental health trust) were faced with the challenge of rapidly switching to a novel way of assessing patients remotely.

The idea for a QI project on trainees’ experience with remote consultations was conceived in April 2020. We present our February 2021 results here.

We aimed to improve trainee confidence in conducting remote psychiatric assessments by at least 40%, to ensure effective and safe patient care during their 6 months placement.

Method

Our discovery process included surveying trainees in April 2020 to explore experiences with remote psychiatric consultations, a literature search of current UK guidance and a local audit. The audit reviewed documentation of consent to remote consultations, with reference to standards as per NHS England remote consultation guidance. Key change ideas included publication of an article, ‘Remote consultations – top tips for clinical practitioners’, video-simulated remote consultations and a session on remote consultations in the trainee induction.

In the first ‘plan-do-study-act’ (PDSA) cycle, we presented key findings from the article in a video presentation, which was sent trust-wide. We measured confidence in conducting remote assessments pre- and post-presentation via a feedback survey. Unfortunately, response rates were low and in the second PDSA cycle we targeted a smaller cohort of trainees at the August 2020 induction, although encountered similar difficulties. In the third PDSA cycle, we collected real-time data using an interactive app at the February 2021 trainee induction, and measured pre- and post- confidence following a presentation and a video-simulated remote consultation.

Result

2/34 respondents had accessed previous remote psychiatric consultation training and12/35 had some telepsychiatry experience. Pre-induction trainee confidence results revealed: extremely uncomfortable (16%), not confident (31%), neutral (47%), confident (6%) and very confident (0%) and post-induction confidence was 0%, 22%, 52%, 26% and 0%, respectively.

Conclusion

Our project started during the first peak of the pandemic, which may be a reason for initial limited response rates. Our results suggest that the remote psychiatric consultation trainee induction session has shown some improvement in trainee confidence; the ‘confident’ cohort improved from 6% to 26%.

Our next steps include collecting similar real-time data, mid-rotation and uploading video-simulated remote consultations to the Trust Intranet. We plan to complete the local audit cycle. We also plan to incorporate patient experience (from an ongoing systematic review) to inform a potential triage process post-pandemic, choosing between face-to-face versus remote consultations.
Reducing levels of Violence in the Psychiatric Intensive Care Unit (PICU) - a multidisciplinary quality improvement project
Authors: Moore Zoe , Pritchard Lynne , Hamilton llana
Published: June 2021

Aims

Our aim: To reduce the number of Level 1* violent incidents in Ward 4 by 30% by April 2020

*Level 1 is defined as “Behaviour involving force, which causes or is intended to cause physical harm to others; but excludes assault on objects, threats or verbal abuse”

Ward 4 is Belfast Health and Social Care Trust's only PICU, with a total of 6 beds. Our project took place on the background of a recent move to a new purpose-built inpatient unit, as well as a trust-wide initiative to address levels of violence across inpatient psychiatry services.

Method

We divided our project into 3 main areas:

Patient factors

Staff factors

Environmental factors

We identified and implemented a number of change ideas, using Plan-Do-Study- Act methodology, regularly meeting to review progress and plotting our data on a run chart.

Key patient interventions included a “Mutual Respect” exercise and regular “Community Meetings”.

Staff interventions included use of Safety Crosses, Daily Safety Briefings and the Broset Violence Checklist (BVC).

Environmental factors were continually assessed and escalated as appropriate.

We raised awareness of our project and gained feedback by creating a dedicated notice board, providing a staff information session and including it as an agenda item at ward meetings.

Our project measures were identified as:

Outcome: Number of level 1 violent incidents occurring per week

Balancing: Number of incidents in other categories; Patient satisfaction

Process: Staff safety rating; Engagement with interventions

Result

Unfortunately, we were unable to meet our initial goal and there continued to be considerable variation in the number of weekly incidents.

We believe this was attributable to several factors, including the level of acuity within the ward during the project timeframe. It was noted that a relatively small number of patients contributed to a large proportion of the total incidents. Our results, therefore, did not reflect the success of interventions with other patients on the ward.

Despite this, we noted improvements in terms of patient and staff engagement with the project, including subjective reports of staff safety during shifts.

Conclusion

The unpredictable and complex nature of the PICU setting cannot be under-estimated and this ultimately impacted on achieving our intended outcome.

We do feel, however, that the project has had a positive impact and we hope we can build on this progress over the coming months.

Further interventions are being explored, including personalised daily activity schedules and attempts to reduce levels of continuous observations.
A study to improve the quality of writing clinic letters to patients attending the outpatient clinic
Authors: Mudiyanselage Irangani , Belgamwar Madhvi
Published: June 2021

Aims

In many countries (including the UK and Australia) it is still common practice for hospital doctors to write letters to patients’ general practitioners (GPs) following outpatient consultations, and for patients to receive copies of these letters. However, experience suggests that hospital doctors who have changed their practice to include writing letters directly to patients have more patient centred consultations and experience smoother handovers with other members of their multidisciplinary teams. (Rayner et al, BMJ 2020)

The aim of the study was to obtain patient's views to improve the quality of clinical letters sent to them, hence the level of communication and standards of care.

Method

An anonymous questionnaire was designed and posted to collect information from patients attending one of the South County Mental Health outpatient clinic in Derbyshire. 50 random patients were selected between March to November 2020. Patients were asked to provide suggestions to improve the quality of their clinic letters written directly to them and copies sent to their GPs.

Result

Out of 50 patients 48% (n = 24) responded. Majority of patients (92%) expressed their wish to receive their clinic letters written directly to them and 79% preferred to be addressed as a second person in the letters. More than half (54%, N = 13) of them would like to have letter by post. Majority of them (92%, N = 22) wished to have their letter within a week of their consultations.

Patients attending clinics felt that the communication could be better improved through writing clearly: a) reflection of what was discussed during the consultation b) updated diagnosis c) a clear follow-up plan d) current level of support e) medication change f) emergency contact numbers g) actions to be carried out by their GP and further referrals should there be any.

Conclusion

Patients in community prefer to have their clinic letters directly addressing them in second person. It was noted that the letters needed to reflect accurately on what was discussed during the consultation in order to have patient centered consultations. This in turn would improve communication and thus rapport, trust and overall therapeutic relationship.
A pilot to assess the feasibility and potential clinical utility of enhanced sleep management on inpatient wards in a mental health trust
Authors: Roshi Ambrina , McGowan Rose , Roberts Lauren , Watson Stuart , Anderson Kirstie , Keown Patrick , Bowles Rod , Weddle Ron , Connolly Sophie
Published: June 2021

Aims

To assess the feasibility and utility of introducing the following changes on to in-patient units:

Structural and cultural adaptation to create a sleep friendly ward environment

A “Protected Sleep Time” between midnight and 6am

Routine screening for sleep disorders, including obstructive sleep apnoea and restless leg syndrome

Background

Insomnia and other sleep disturbances are cause, correlate and consequence of psychiatric disorders. Routine hourly night time observations, ward noise, bright lights at night time, sleep disorders, insufficient exercise, insufficient day light exposure, too much caffeine and inappropriate psychotropic use are all causes of disturbed sleep (Horne 2018).

Method

Seven wards participated in a pilot (SleepWell). These consisted of one male and two female Acute Wards (General Adult), a High Dependency Unit, a Neurorehabilitation ward, an in-patient dementia service and one rehabilitation ward. These wards were supported via an existing trust management structure and the pilot was specifically supported by two trust managers (RW and RB) and by a clinical director (PK). The expectation was that each ward would identify a sleep champion from existing staff to facilitate the changes. A “product” was developed which identified core sleep management features but, in addition, wards were not confined to these. The existing policy that all inpatients should be checked each hour over night was suspended for the pilot wards and the patients had protected sleep time (PST) if the MDT agreed that it was clinically appropriate.

Quantitative and qualitative techniques were used to identify facilitators of change, impact on sleep and, outcome.

Result

Protected sleep was viewed positively by all staff and approximately 50% of patients on the pilot wards were able to have PST at some point in their admission. Routine sleep disorder assessments were harder to implement and 33% of patients were screened. There were no deaths or significant events on patients due to PST. Hypnotic use on the pilot wards reduced. It is anticipated that PST where it is safe will be rolled out across all adult and old age wards in the trust.

Conclusion

With support, it has been feasible to change many aspects of sleep management across a breadth of inpatient units in a large NHS trust.
Survey to evaluate care of complex clients in residential setting
Authors: Sadraei Rosa , Pathy Puru , Collins Michael
Published: June 2021

Aims

Delivering a new efficient assessment and shorter term secondary mental Health intervention service for individual sectors

Background

In November 2015, there was a transition to services with the focus on delivering more efficient service to clients

Previously we had been a combined sector Service. This transition, a reduction in resources and a move away from delivering care Through specialist mental health teams created from the national service framework - such as Assertive outreach, early intervention in psychosis and community rehabilitation - to a more Streamlined generic service, catering for these differing groups of people using a “Pathways Model” approach

Result

Across the two sectors we had 47 clients on CPA Pathway living in 24 hour residential Settings who all had a current care coordinator.

These 47 clients represented the workload currently of 2.8 FTE Band 6 care coordinators.

There were at Origin, 13 Residential/Nursing/Secure 24 Hour care providers, where clients were residing.

However of these 90% of residents lived in one of 5 settings, 3 settings in Ashfield and 2 in Mansfield.

Over 50% of individuals residing did not have existing connections with Mansfield or Ashfield before being placed into the area.

18 Clients (%38) were under section of the mental health act and 1client (%2) was on a life-Licence from criminal justice.

Conclusion

Transfer of CPA Care Coordination Protocol

To send paper referral to our Single Point of Access Meeting at the listed address at the earliest point relocation/placement is confirmed.Formal handover meeting for care will be coordinated, not sooner than 3 months after the placement commences. It will be expected that services currently involved in provision of service continue to hold care responsibility in the interim period.

As we move to a paperless environment, provision of electronic documentation such has previous CPA documents, Risk assessments, social circumstance reports & Discharge summaries, would be greatly appreciated
The introduction of electronic prescribing in the Orchard clinic-a QI project
Authors: Sayeed Hannah , Lenihan Fionnbar
Published: June 2021

Aims

Hospital Electronic Prescribing and Medicines Administration (HEPMA) system successfully rolled out in July, 2020 at the Orchard clinic as the first site in NHS Lothian. The initial aim was to collect some “pre-HEPMA” and “post-HEPMA” data to look at “staff's attitudes to a new IT system, and does that change with successful implementation of it?” in the form of a survey. In the light of the findings of the pre-HEPMA staff survey, it became the QI project (as above).

This aimed to look at both qualitative data; in the form of a staff attitudes survey towards a new IT system and quantitative data; to measure benefits of its implementation and to address issues raised by staff in the survey in the form of an audit in both pre and post HEPMA cycles.

Method

Two cycles were completed as follows:

1. Pre-HEPMA cycle in March, 2020:

Survey: Questionnaires asking question re- own IT skills, preparation and expectations of outcome of its implementation.

Audit: Measured time taken to write and re-write paper prescriptions. Proforma filled by staff to measure time taken to log on and other IT related issues.

2. Post-HEPMA cycle in October, 2020:

Survey: Replicated above questions re-own IT skills, support during and after launch, disaster recovery and views about actual outcome of its implementation.

Audit: Replicated to measure time taken to complete electronic prescriptions.

Result

24 staff questionnaires returned in both cycles. Staff felt more confident in their own IT skills, training and hence competence to use HEPMA; more supported, more confident about contingency plans and HEPMA to be more beneficial than initially anticipated. Overall, actual perceived success of (91%) compared to anticipated success (71%).

The majority issues raised via the first survey were felt to be addressed. Time to log was on average

The audit showed a clear benefit in terms of clinical time saving, e.g. daily clinical time spent writing prescription reduced from an average 45 to 6 minutes with HEPMA.

The quality of documentation on the prescriptions remained unchanged.

Conclusion

Staff's attitude towards IT does change after successful implementation of a new IT system. But IT issues make the whole process laborious.

There was evident benefits realization with an electronic prescribing system compared to paper prescriptions.

I was awarded “Employee of the month” for this project which I also presented at the NHS Lothian grand round (>150 attendees) for dissemination and future replication.
Improving access to mental health services for homeless people in Torbay
Authors: Scott-Gatty Tom , Cant Tom
Published: June 2021

Aims

Devon continues to see increasing numbers of rough sleepers despite the “Everyone In” initiative and the South West region is now behind only London and the South East nationally. The interaction of homelessness and Mental Health is complex. Mental health problems and trauma contribute to people becoming homeless as well as homelessness itself causing or exacerbating existing problems, all complicated by high rates of substance use and poor physical health. Despite the desperate need in this population they often struggle to access mental health services which are not designed with their needs in mind. Their pattern of service use is primarily that of acute services when in crisis and disengagement in the community which results in high costs and poor outcomes.

Method

In July 2019 an outreach service was set up consisting of a psychiatry core trainee (Dr Tom Scott-Gatty) for half a day per week supervised by the Torbay North CMHT consultant (Dr Tom Cant) to seek opportunities to engage individuals in assessment and treatment and improve outcomes in this population. The service is primarily based at the homeless hostel in Torquay (Leonard Stocks Centre) for ease of access but is flexible about where patients are seen. Patients have been seen in various locations including medical wards, prison, on the street etc. The role includes close work and liaison with other professionals such as GPs, probation, charity sector, drug and alcohol etc. and this is integral to supporting the level of complexity seen in this population. Engagement, building relationships and trust are central to serving this vulnerable and marginalised population.

Result

In January 2021 feedback forms were completed by 13 patients and 18 professionals who had used the service. Feedback was overwhelmingly positive with average overall score 9/10 from both patients and professionals. All patients reported feeling comfortable using the service and that mental health services are now easier to access. All respondents would like to see the service continue. A significant number of patients and professionals identified increasing the hours offered by the service as an area for improvement.

Conclusion

This service has succeeded in improving access to mental health services for homeless people in Torbay. The service is valued by both the people it serves and the professionals supporting them. Further improvement to the service could be achieved by expanding capacity. Funding has been identified from existing local authority budgets to add a CPN to the team to achieve this.
Audit for prescription and administration of PRN buccal midazolam for people with learning disabilities and epilepsy in the Hertfordshire & Essex
Authors: Sharma Anu , Sawhney Indermeet
Published: June 2021

Aims

The current audit aims to identify the gaps in the practice of administering prn buccal midazolam, for management of epilepsy in people with intellectual disability and to review training needs, with a view to improve patient care.

Background

Convulsive status epilepticus is a medical emergency requiring admission to hospital and has a mortality as high as 20% (SUDEP -Sudden Unexpected Death in Epilepsy). It is imperative that the carers are fully aware of the risks associated with the epileptic attacks, are able to recognize the attacks and offer rescue medication to the patient in a timely and effective manner. National guidelines have been drafted jointly by ESNA (Epilepsy Specialist Nurses Association) and ILAE (International League Against Epilepsy) for prn administration of buccal midazolam. The use of rescue medication by trained carers can significantly improve the outcome and reducing the risk of hospital administration and chances of SUDEP. Buccal midazolam is widely used to manage prolonged seizures. Administration should be undertaken only by people who have received both epilepsy awareness and buccal midazolam training.

Method

All patients with intellectual disability with epilepsy were studied and patients who were prescribed prn midazolam have been shortlisted shortlisted for data analysis. A template was designed and data are being collected from the carers, community nurses and the prescribing clinicians. Data are categorized under headings of background information about epilepsy, recognizing complications during a seizure and the ability to administer buccal midazolam. Further information about the type and the frequency of training courses (including the refresher courses) being offered to the carers for administration of buccal midazolam would also be documented. There is also data collection pertaining to the timely review of the care plan by the prescribing clinicians and the about the licenced or unlicensed used of midazolam. The quality of epilepsy awareness training is being explored in depth and also the competency of the county council nurses offering the training to the carers shall be analysed under different headings.

Result

Data are currently being collected in Hertfordshire and Essex mental health services.

Conclusion

After the data analysis, the short comings shall be addressed and effective measures shall be put in place to improve the quality of training being provided to the carers and to standardise the practice for prn midazolam prescription.
A survey of the use of seclusion and physical restraint at school and at home for children under the care of the NHS Lanarkshire CAMHS – learning disability team
Authors: Singh Sukhmeet , McKie Judith
Published: June 2021

Aims

To attempt to quantify the use of seclusion and restraint for young people managed by the NHS Lanarkshire CAMHS Learning Disability team.

Background

There has been increasing interest in the use of seclusion and restraint in children with learning disabilities, reflected by various news reports in the UK and USA. A survey of parents conducted by the Challenging Behaviour Foundation (2019) found that 35% of disabled children (n = 204) had been regularly physically restrained and a further 21% had been regularly secluded. The use of restrictive practice in children is contradictory to the UN Convention on the Rights of the Child as well as the conclusion of a recent report conducted by the Scottish Children's Commissioner titled “No Safe Place” which called on schools to stop using restraint and seclusion until national guidelines and standards were in place. No data were submitted to the Children's Commissioner from Lanarkshire. Anecdotally there was an impression in the team that restrictive practices were widely used at school and home.

Method

The NHS Lanarkshire CAMHS-LD team is a small team caring for children aged 5–18 years with moderate to severe/profound learning disability with mental disorder and/or severe challenging behaviour. The methodology for this retrospective audit relied on reviewing patient case notes and speaking with involved clinicians. We discussed each individual patient on their respective caseload as to whether the child had been restrained or secluded at home or at school.

Result

All 108 children from the caseload were included in the audit of whom 52.8% had been either restrained or secluded. 24.1% of children were both restrained and secluded at school, while 15.8% were restrained and secluded at home. These patients were complex. 86.1% had Autistic Spectrum Disorder and 55.6% had another comorbidity, such as ADHD.

Conclusion

The figures are broadly similar to those in the Challenging Behaviour Foundation report. The team knew all of the individual patients very well and review them across a variety of settings such as school and home with instances of seclusion and restraint being directly witnessed by clinicians. Nevertheless, there is the issue of recall bias. These findings will be shared with NHS Lanarkshire management for further discussion and dissemination. .
Improving access to the physical health clinic in a community first-episode psychosis service
Authors: Tansley-Ahmed Zena , Lim Wei Han
Published: June 2021

Aims

Physical health outcomes are poor for patients with severe mental illness as demonstrated by the significant mortality gap present globally.[1] Access to and engagement with care is a key factor underpinning this disparity.[2] The Early Intervention in Psychosis service works with young people from 14-35 experiencing a first episode of psychosis in the community. Within the service, difficulties in engagement have been reflected in the high ‘no-show’ rates observed in the Foundation Year 2 trainee doctor-led physical health clinic. This quality improvement project aimed to reduce the ‘did not attend’ (DNA) rate in the physical health clinic by 20% in order to improve patient outcomes, particularly in the context of their physical health.

Method

The project took place between September and November 2020, over the course of 10 weeks. A driver diagram was constructed to identify key influencing factors and subsequent change ideas. In order to implement each of these changes, three cycles within the Plan, Do, Study, Act (PDSA) ramp framework were completed. These consisted of phone reminders within 48 hours of appointments, a teaching session for staff alongside the distribution of an accompanying information leaflet and increased flexibility in clinic times with opportunistic appointments. The change ideas were cumulative with each cycle lasting a duration of seventeen days.

Result

The baseline DNA rate was calculated based on the preceding month and found to be 55%. Following cycle one of the project, there was a significant reduction in DNA rates to 30% although this remained relatively stable at 33% after cycle two. By the end of cycle three when all interventions had been introduced, the DNA rate had dropped to 22%. As such, a total drop in DNA rate of over 30% was achieved which surpassed the initial aim of the project.

Conclusion

The outcomes of this project demonstrate that the introduction of even simple measures can lead to positive change. Successful implementation of these changes requires teamwork and a culture of openness and flexibility. Feedback from team members, particularly care coordinators, also indicated better resulting engagement of clients with the service overall, suggesting potential for both improved mental and physical health outcomes. Next steps for this project may involve not only continued implementation of established changes but also service user input and scope for virtual consultations particularly in light of current COVID-19 restrictions.
Improving patient access to medication information: a quality improvement project on patient-centred prescribing
Authors: Todd Anna , Blunstone Rosy
Published: June 2021

Aims

Ward rounds are sometimes the only opportunity for patients to discuss medication. Patient and professional feedback on an acute male inpatient ward in South London highlighted a demand for more medication information outside the formal ward round setting. We aimed to have 100% of patients meet our criteria for “Patient-Centred Prescribing” on the ward by March 2021. To fulfil criteria, all patients are offered: (1) ward round discussion, (2) written patient information leaflets (PILs), (3) informal discussion groups, all regarding medication.

The principles of this quality improvement project (QIP) were drawn from definitions of patient-centred care and standards of good practice; patients should have access to a variety of information formats, relevant to the individual, and the knowledge gained empowers patients.

Patient experience data revealed that 30% of clients answered passively to the question, “Do you feel involved in your care?” We hypothesized that medication discussion groups positively impact patients’ wellbeing, by providing a safe space that facilitates conversation surrounding medication issues.

Method

We conducted weekly audits on patients whose admission duration was >7 days, and recorded fulfilment of the above criteria. At week 1, we introduced a program of weekly medication discussion groups led by members of the wider multi-disciplinary team covering a broad topic range. At week 6, we developed a rolling rota of the discussion groups and posters were displayed in advance. At week 14, all patients were offered PILs through a 1:1 interaction and this continued as routine practice. Medication discussion group feedback was obtained via questionnaires and “The Blob Tree”, a psycho-emotional assessment tool commonly used in healthcare settings.

Result

In 19 weeks, the median percentage of patients who fulfilled our criteria for Patient-Centred Prescribing was 92.86%. After 11 medication discussion groups, 79.3% of questionnaire responders wanted further sessions. 88% of “The Blob Tree” responses collected inferred a positive emotional response after the group discussions and half of those noticed an improvement in their emotional state.

Conclusion

This QIP was overall a success; it fulfilled a requirement to meet good standards in information sharing and became embedded in the fabric of the ward, continuing to run as part of the activities program. It demonstrated the impact of education on patients’ mental wellbeing through empowerment and peer support. As a by-product it established multidisciplinary connections and improved therapeutic relationships. Challenges included patient engagement secondary to acute mental illness or negative symptoms and maintaining project momentum following a COVID-19 outbreak.