bluuebunny/crossref_metadata_2025 huggingface dataset:
Simple Interventions Can Greatly Improve Clinical Documentation: A Quality Improvement Project of Record Keeping on the Legal Aspect of Dementia at Memory Service
Authors: Majid Sheth Shabinabegam Abdul , Wald Claudia
Published: June 2022

Aims

1. To ensure there is documented evidence of discussion about legal aspect of dementia with patients and relatives. 2. To Improve documentation of Financial management by 100% at the end of 3 months. 3.To Improve documentation of LPA and other related legal areas by 70% at the end of 3 months

Methods

In Kensington and Chelsea and Westminster Memory services, we are seeing patients with cognitive impairment which can be due to dementia. So, it is really important to discuss and help a person and/or relative with making decision about client's health, welfare or finances. Though each team member discusses about what they did for the same, we identified that it was not reflected in the documentation.

After finalising data collection form, we then performed a retrospective collection of number of documented assessment/discharge report/progress notes within an identified 3-month time period from March to May 2021. Our intervention was Email and MDT remainders, developing patient information video, and structured format to document about legal aspect of dementia like, financial management, Lasting power of Attorney, Court of protection, Advance will, etc. We run PDSA cycles and collected a data at the end of each month to see whether change ideas are helping to improve documentation and whether any modification will require with the plan.

Results

Out of 67 patients record which were reviewed as a baseline data, 39% of them has diagnosis of dementia or Mild Cognitive impairment. Discussion about LPA was recorded in only 16% of the documents. There is no mention of how a person is managing their finances in 30.7 percent of documents. After implementing change ideas, 29 patients who were seen during the month of December were reviewed using the same data collection form. Documentation of discussion about financial management was improved to 93.1%. Documentation of Discussion about how to set up LPA, if a person doesn't have one has been approved from 10.4% to 55.2%. The cycles will continue for month of January and February and data will be assessed and compared at the end February 2022.

Conclusion

Basis on the data available till date, a general improvement in the record keeping of notes was seen. Simple intervention like email reminders, reminder in MDT, structured format for documentation and patient information in visual format can improve the documentation of work. More detailed conclusion will be drawn at the end of 3 months.
Portugal and It's Drugs Policy - What Changed?
Authors: Vieira Mariana Macedo , Faria Ana Raquel
Published: June 2022

Aims

The authors intend to briefly review the literature regarding the progress of substance misuse rates and harms, the support available and reflect on the current national situation. We aim to better understand the changes in policies and services, and their impact to see what can be learned from the Portuguese experience.

Methods

A narrative literature review was carried out by the authors using the keywords “addiction” “drugs policy” “Portugal” “drug use”. The authors declare no conflicts of interest.

Results

The end of the dictatorship in 1974, the reopening of borders, and the return of white Portuguese from former colonies, were all associated with a dramatic increase in substance misuse in Portugal. In the 1990's it is estimated that 0.5%-1% of the population was using heroin at the time, with extremely high rates of HIV and Hepatitis in intravenous drug users.

At the start of this period, healthcare services were poorly organized, resources for substance misuse services were limited, legislation was punitive, and there was a general understanding that drug addiction was a consequence of a moral failing. A change in paradigm occurred in the late 1990's and new legislation introduced in 2001, which along with the growth in services to support substance misusers dramatically reduced the rates and negative outcomes of substance misuse.

Of note, new HIV diagnoses due to injecting and overdose rates dropped significantly in the XXI century and decriminalization did not lead to an overall increase in substance misuse.

Conclusion

The pivotal shift in the understanding of the nature of addiction as an illness lead to a profound change in interventions to mitigate this overwhelming problem that affected Portugal by the end of the XX century. We hope that by sharing this experience this will improve interventions around the world to support substance misusers and public health.
Homophobic Abuse & LGBTQ+ Well-being in the Acute Psychiatric Setting
Authors: Kane Edward , Lloyd Miranda , Malley Maeve , Fox Thomas
Published: June 2022

Aims

Homosexuality was declassified as a mental illness in 1973 however LGBTQ+ (lesbian, gay, bisexual, transgender, queer inclusive) service users still face discrimination within modern mental health services. This project assessed homophobia and LGBTQ+ abuse among service users on an acute male psychiatric ward. Our aims were to quantify the incidence of abuse, to explore staff attitudes toward LGBTQ+ abuse and to identify targets to improve LGBTQ+ service users’ experience. We hypothesised that incidents of abuse are common and not always challenged or escalated using appropriate channels.

Methods

Using a mixed methods approach we explored staff perceptions of LGBT+ abuse: quantitative data were generated from a questionnaire survey and qualitative data from a focus group.

Rates of homophobic incidents were assessed by analysing clinical documentation from two inpatient samples (n = 20), covering 2020–21 and 2021–22.

Results

Analysis of clinical documentation found three incidents from the 2020–21 sample and two from 2021–22; only one of these was reported via DATIX.

The survey captured the views of the ward team including nurses, healthcare assistants (HCAs), doctors and psychologists (response n = 13). Staff attitudes towards LGBTQ+ were rated as “positive” by 77% of responders and “neutral” by 23%; 100% stated it was their professional duty to respect and protect LGBTQ+ clients. Almost two-thirds (62%) had witnessed homophobia on the ward however a similar proportion (61%) had never directly challenged homophobia. Whilst all staff felt able to care for LGBTQ+ clients, and all were familiar with key LGBTQ+ terminology, only 50% felt they had received adequate training to fully support LGBTQ+ clients.

The focus group identified a nursing “lead” for LGBTQ+ issues and agreed to incorporate a “diversity statement” into ward admission rules. LGBTQ+ visibility measures were promoted including LGBTQ+ posters across the ward and staff uptake of the Rainbow Badge Initiative.

Conclusion

Our findings suggest homophobia is prevalent in the male inpatient psychiatric setting and management is suboptimal. Enhanced LGBTQ+ training is required to support staff to challenge every homophobic incident and escalate appropriately.

Simple steps to increase LGBTQ+ visibility are feasible and popular among staff. Future work should assess the impact of such interventions, however measuring change may be hampered by underreporting.

Further evaluations are needed to assess female wards and patient perspectives to build a full picture of inpatient LGBTQ+ abuse.
Identification and Management of Substance Misuse in Patients Referred for Psychodynamic Psychotherapy: A Service Evaluation Project
Authors: Lusby Joshua , Chu Kenny , Sathanandan Shivanthi , Hillen Thomas
Published: June 2022

Aims

To evaluate and improve upon collection of data pertaining to substance misuse in opt-in questionnaires sent to patients accepted by a psychodynamic psychotherapy service in an inner London Trust, and to explore options for improving care for the population of patients identified as potentially having a substance misuse issue who are accepted by the service.

Methods

An initial audit of all opt-in questionnaires was conducted between September 2019 and September 2020. In this analysis of 144 responses, 72 were found to have indicated that they had experience of a substance misuse disorder. Of these responses, 55% of answers made it possible to discern the substance of misuse, and 31% of answers allowed for differentiation between historic and current misuse. In response to these findings, the AUDIT-C was incorporated into the opt in questionnaire with data subsequently collected and analysed between December 2020 and February 2021. Subsequently, patients identified as having and AUDIT-C score indicating possible harmful or dependent drinking were offered interventions stratified by score with a clinician supervised by the substance misuse service

Results

In the re-audit period of opt-in questionnaires, there were 31 respondents, of whom 90% indicated that they or a contact had been concerned about their substance use. Inclusion of the AUDIT-C allowed for differentiation between alcohol and other substances in 100% of cases, and in 71% of cases it was possible to discern current vs historic substance misuse. In the period of December 2020- December 2021, four patients accepted the offer of a brief intervention.

Conclusion

It was felt that obtaining higher quality data pertaining to substance misuse in patients accepted for psychotherapy was beneficial in terms of being better able to understand needs of patients and also to guide clinical management. Furthermore, introduction of a pathway to guide interventions in cases identified as being potentially at risk appeared to be effective in addressing substance misuse within this population. It is hoped that this preliminary evaluation can guide further service model development within this psychotherapy department and within other services in order to better address the needs and improve access to services of patients with comorbid substance misuse disorders.
Audit on Availability, Quality and Frequency of Clinical Supervision
Authors: Askew Elizabeth , Gnanasekaram Gayathri , Hoar Amanda
Published: June 2022

Aims

We have completed a cycle of audit on the availability and quality of clinical supervision in Somerset NHS Foundation Trust. Last year we had highlighted the results of our first survey (run in 2020) in local teaching and audit meetings. We have now completed the cycle following the intervention. Both Severn deanery and Somerset NHS Foundation Trust both recommend psychiatry trainees have one hour of supervision per week, involving exploration of trainee clinical and educational needs. This audit is now part of a quality improvement project being run across Severn Deanery. This particular audit focuses on the results from Somerset NHS Foundation Trust.

Methods

Trainees working in Somerset NHS Foundation Trust were invited to participate in this survey. We used the original survey from last year but added further white spaces to invite feedback and to explore what was particularly good about the clinical supervision currently offered. Questions on accomplishing workplace based assessments (WPBA), managing e-portfolio requirements were asked, with Likert scale responses available. The survey was sent out in the form of Microsoft Forms disseminated via email to all junior doctors (n = 27).

Survey was run from May till June 2021 (nearing the end of placement). We sent out 3 reminders before closing the survey. The authors of the audit then reviewed the data.

Results

9 out of 27 doctors responded, response rate of 33%. Our last survey had a response rate of 63%. Supervision appears to be more regular now with only 11% stating that they were meeting their supervisor sometimes in comparison to 17% the last survey. Similar percentage of respondents were able to complete WBPAs as in the last survey (88% Vs 89%).

QI project/audits were being discussed at a similar rate (60% Vs 66%). 75% of psychiatry trainee respondents were discussing their psychotherapy competencies (42% were having some discussion in the last survey). There was a better response from GP and FY doctors for this survey.

Conclusion

Response rate appears to have fallen, however supervision appears to be more regular with more focus on competencies.

White space answers showed that most trainees were satisfied with supervision. However, supervision could be more consistent and serious attempts must be made to protect it from clinical work overshadowing it.

We will be comparing the results of our audit in Somerset NHS Foundation Trust to the results from other parts of the deanery.
Risk Assessments of Patients Admitted to Mixed Inpatient Psychiatric Wards: A Clinical Audit
Authors: Bennett Sharna , Delaffon Vijay
Published: June 2022

Aims

Following a Serious Incident (SI) on a mixed sex ward; it was important to investigate whether this is a widespread problem in Psychiatry. The acute care group standard is that patients with known risk to the opposite sex should not be admitted to mixed sex wards. A comprehensive risk assessment should take place when a patient is admitted to a mixed sex ward. Furthermore, if any risks are identified, these should be escalated to the multidisciplinary team (MDT), including the nurse-in-charge and on-call Consultant Psychiatrist.

Methods

We conducted a literature search to establish how different Trusts consider risk when arranging for admission, as well as to identify whether single-sex wards have helped to reduce the incidence of serious incidents. We then retrospectively collected data from 10 inpatients present on mixed sex wards throughout Kent and Medway in May 2021. This involved searching electronic notes at the point of admission, including progress notes and risk assessments to identify whether information is present to suggest that an admission to a mixed sex ward is unsuitable, and if so, whether this has been appropriately escalated.

Results

When patient notes were surveyed, only 50% of patients had a full risk assessment documented. Historical risks were documented in 40% of patients notes at admission. Junior doctors are required to complete an admission clerking for new patients, which should include a risk assessment; 70% of these contained a risk assessment, and 60% discussed risks towards others. 30% of patients had identifiable risks to the opposite sex but were admitted to a mixed sex ward. However, none of these cases were escalated to the MDT for discussion regarding the most suitable ward for the patient.

Conclusion

When patients are admitted to any inpatient psychiatric ward it is important to document a full risk assessment including historical risks. Unfortunately, full risk assessments were not always carried out at the point of admission, meaning that patients who had been admitted to mixed sex wards remained there despite previously documented risks. In general, junior doctors included risk assessments in their admission clerkings, but there is evidently room for improvement from all healthcare professionals. Recommendations for improvement are to generate specific guidance for documenting risk assessments and to offer teaching to healthcare professionals on ensuring they have completed a comprehensive risk assessment and when it is appropriate to escalate this to ensure further serious incidents do not occur. Re-audit is scheduled for March 2022.
Prescribing of Psychiatric Drugs in Pregnancy: A Review of Current Practice in a Community Mental Healthcare Setting
Authors: Hickling Lucy , Kar Nilamadhab
Published: June 2022

Aims

Prescribing of psychotropic medications in pregnancy is still considered a ‘grey area’ in clinical practice. National Institute for Health and Care Excellence (NICE) in the UK suggests that the decisions should be person-specific, considering the risks to both the mother and unborn child, and the patient is supported to make an informed decision. It is important to explore the use of psychotropic medications during pregnancy, or lack of it, and its subsequent impact on maternal mental health. It was intended to review the decisions expectant mothers are making regarding taking psychiatric medications during pregnancy, and the associated clinical outcomes. Their mental capacity for taking decisions was also checked.

Methods

A retrospective audit of case notes of patients (n = 16) known to community psychiatric team (CMHT) and specialist perinatal mental health (PNS) services in Wolverhampton, who notified their pregnancy between December 2020 and December 2021. Demographic and clinical data were collected from the electronic records.

Results

The sample had a mean age of 28.8 ± 6.3 years (range: 19 to 39 years), and 68.8% of them were Caucasian. A wide range of psychiatric diagnoses were present, most (62.5%) had comorbid diagnoses; and 25% had substance use, most commonly cannabis. Mean duration of gestation at the review following notification of pregnancy was 14.5 ± 7.7 (range: 6 to 29) weeks. It was observed that 25% were not taking psychiatric medications prior to pregnancy, 43.8% stopped taking their medication prior to the psychiatric review, most stopping abruptly, and 31.2% had continued their medication. The medications included aripiprazole, olanzapine, quetiapine, venlafaxine, sertraline and promethazine. Following the review, only 18.8% continued their medications. Of the 13 (81.3%) patients who were not taking medications, 9 (69.2%) had adverse mental health outcomes, with 2 (15.4%) patients requiring inpatient care. However, later 8 (61.5%) started taking medications whilst under the care of PNS. All of them had mental capacity to decide regarding their psychiatric treatment at the review.

Conclusion

Most psychiatric patients avoided taking psychotropic medications initially during pregnancy, however, a considerable proportion restarted their medications following review with the perinatal psychiatry team. The majority of patients who did not take medications had negative mental health consequences. It is important to develop an evidence base about the use of psychiatric medications in pregnancy and the associated short and long-term outcomes that may help the quality of information shared with patients.
Investigating the Influence of the Pandemic on the Wandsworth Home Treatment Team
Authors: Ali Ibrahim , Hubbeling Allerdiena , Saxena Saurabh
Published: June 2022

Aims

This study aimed to determine the impacts of the COVID-19 pandemic on the Wandsworth Home Treatment Team (HTT), South West London and St. George's Mental Health NHS Trust. We hypothesised that demographics and illness characteristics of patients would differ before and during the first wave of the COVID-19 pandemic and that concerns about possible infection with COVID-19 influenced the decision to be referred to the HTT. Additionally, we hypothesised that there would be fewer face-to-face contacts during the initial months of the pandemic.

Methods

Routinely collected data from the trust's electronic records (RiO) were compared from the 15th March – 15th May in both 2019 (control) and 2020 (early pandemic). Patients could have a maximum of 1 variable absent to be included in the study and should have been under the care of the WHTT for longer than 2 days. Overall, 301 patients were included in this study, 181 from 2019 and 122 from 2020. Variables compared were: marital status, age, sex, ethnicity, diagnosis, referral source, referral urgency, referral reason, referral weekday, count seen (number of contacts with a clinician), face-to-face contacts, and length of stay.

Results

The demographic variables: age, sex, marital status, and ethnicity were not significant. Likewise, the length of stay of patients, referral reason, and referral weekday were also not significant. However, during the early pandemic, there was an increase of 11% in the diagnosis of psychotic disorders/psychotic episodes (p = 0.039). Further, the referral urgency of patients within the 2020 period was significantly raised (p=>0.01). The referral source of patients was significantly different with an increased number of patients having been referred to the HTT from the ward (p = 0.017). The mean interactions (count seen) between patients and clinicians significantly lessened from 2019 to 2020, 12.8 Vs 10.2 (p = 0.008). Moreover, the percentage of face-to-face contact had also decreased from 2019 to 2020, 56.1 Vs 46.6 (p = 0.007).

Conclusion

Overall, less patients received care from the home treatment team during the first wave of the pandemic. Age, marital status, sex, ethnicity, length of stay, referral reason, and weekday were not significant. On the contrary, the diagnosis of patients, count seen, face-to-face contacts, referral urgency, and referral source were statistically significant. These findings reflect a different referral pattern to the Wandsworth HTT during the initial months of the pandemic accompanied with fewer face-to-face and other interactions overall.
Assessing the Anticholinergic Burden in the West Memory Assessment Service (MAS)
Authors: Lees Rebecca , Alderson John
Published: June 2022

Aims

Aim: Evaluate the recording of the Anti-Cholinergic Burden (ACB) score for patients referred to the West Leeds Memory Assessment Service (MAS). Objectives: 1) Calculate the Anti cholinergic Burden score of all patients referred to the West MAS in June 2021 where this has not already been done. 2) Determine if there is a need to review the process for assessing this component of the cognitive assessment in MAS.

Methods

All patients who were referred to the West MAS in June 2021 were included in this project. Data were collected from GP referral letters, the referral meeting documentation and patients’ GP prescriptions.

These records were checked for a documented ACB score. If ACB scores were not found, they were calculated based on a patient's GP prescription. Several ACB calculators were used to do this, as NICE does not recommend a specific scoring system.

Results

There were 60 referrals in June 2021. Within this data set, there were no documented ACB scores found at the point of referral.

The different scoring systems used led to considerably different ACB scores, with the lowest figure suggesting 20.4% of patients had a raised ACB score (n = 10).

In all three scoring systems used, the medication most frequently leading to a larger anticholinergic burden is Amitriptyline.

Conclusion

Within the service, during the referral process we are not routinely documenting anticholinergic burden. We are in the process of agreeing a standardised ACB tool to review all new referrals to the service and determine how we can communicate these findings with referrers. We are looking to improve local awareness of ACB scoring across the memory pathway and will undertake a re-audit of practice in 3 months to establish if the proposed changes improve our results
Audit on COVID-19 Vaccine Uptake and Hesitancy Amongst Pregnant or Postnatal Patients Under the Care of a Perinatal Mental Health Community Team
Authors: Nair Bosky , Oh Alex , Alsahaf Mahdi , Etteh Unwana
Published: June 2022

Aims

Women with perinatal mental illness are at increased risk for severe illness with COVID-19. Vaccination against COVID-19 is strongly recommended by JCVI (Joint Committee on Vaccination and Immunisation) and RCOG guidance. Mental health professionals should proactively inform their patients about COVID-19 vaccination and also address any concerns or misinformation, should they be raised. The aim of this audit was to evaluate the rate of uptake of the COVID-19 vaccine among patients under the West Kent community perinatal mental health team. In addition, we aimed to identify factors that deter patients from taking the COVID-19 vaccine. In patients who were hesitant to take the vaccine, we offered further information to aid their decision-making process.

Methods

We identified patients under the care of the West Kent perinatal mental health community team on 27/10/2021. We excluded patients who were discharged from the team in subsequent weeks during data collection. We collected patient demographics including highest level of education, ethnicity, religion and socio-economic status. Patients’ COVID-19 vaccine status was obtained via GP records or through telephone contact.

If patients had not had their COVID-19 vaccine, they were contacted to enquire whether they were planning to take the vaccine, if not, to ascertain reasons for refusal and whether they wanted additional information about the vaccine. Those women who requested additional information were offered the RCOG information sheet and decision aid.

Results

Amongst 86 patients included in the audit, 59% (n = 51) had taken both dose of the COVID-19 vaccine and 12% (n = 10) had taken a single dose. 29% (n = 25) were unvaccinated.

68% (n = 17) of unvaccinated patients were pregnant and 32% (n = 8) were postnatal. All women who did not accept COVID-19 vaccine were contacted to offer further information. Following this contact, 39% (n = 9) decided to accept the vaccine, 52% (n = 12) refused the vaccine and 26% (n = 6) were uncertain but were willing to consider taking the vaccine in the future.

The reasons for hesitancy in accepting the vaccine included a lack of trust in the vaccine, concerns around its development over a short period of time, concerns around close associates experiencing illness or side effects after taking the vaccine and scepticism over efficacy of the vaccine. Few women did not wish to take the vaccine during their pregnancy, but were willing to consider it after the birth of their baby.

Conclusion

We identified potential areas to optimise uptake of COVID-19 vaccines by discussing the importance, safety, efficacy and providing up-to-date information regarding COVID-19 vaccine in the perinatal period.
Clinical Audit of the Awareness of Safety Guidelines on Lithium Prescribing Within the Acute Hospital- James Cook University Hospital
Authors: Shakur Nayeema , Tahir Mubin , Badanapuram Ramanand , Nag Sagrika
Published: June 2022

Aims

Lithium is a useful drug and is of particular benefit in patients with chronic mood disorders like bipolar affective disorder and recurrent depression. Lithium requires careful monitoring and dose adjustment for safe use due to its narrow therapeutic index and high potential for toxicity. Monitoring must carry on even when mental health patients taking Lithium are admitted to acute hospital. Therefore, the main aim of this clinical audit was to evaluate the level of awareness of the lithium safety guidance amongst medical staff working within the Acute Hospital, James Cook University Hospital. Ideally 100% of staff should have the appropriate knowledge.

Methods

Questionnaire consisted of 6 items which were derived from key points within the Trust guidelines for Lithium. It was designed to highlight the key points in the document and check the level of awareness of the respondents. Respondents were drawn from James Cook University Hospital and South Tees Liaison Psychiatry team. A total of 25 respondents were included in the study.

Results

96% (24/25) of the respondents were aware that renal and thyroid function should be checked for patients on Lithium. 84% (21/25) were aware of the potential impact of Lithium on Kidney function (eGFR) and 68% (17/25) were aware of signs of Lithium toxicity.

60% (15/25) of acute staff were aware about referring patients with deranged Lithium levels to the Liaison Psychiatry team. 40% (10/25) were aware of the drugs that could potentially increase lithium levels like Diuretics, Non-steroidal anti-inflammatory drugs, ACE (angiotensin converting enzyme) inhibitors. Only 24% (6/25) of acute trust staff were aware about checking lithium levels on admission.

Conclusion

Ideally, a 100% compliance and positive response rate should be achieved as these relate to completion of expected safety checks. Lithium is a potentially high-risk drug with a narrow therapeutic index. Possibility of its acute and chronic side effects, including lithium toxicity, makes it essential to follow safety guidelines on lithium prescribing and hence ensure patient safety.

In view of this, the clinical audit results clearly show that there is significant room for improvement to achieve a 100% positive response rate for awareness of safety guidelines on Lithium prescribing.

Overall, there were an average of 57% positive responses and 42% negative responses for awareness of various aspects of the safety guidelines for Lithium.

A robust action plan which included teaching sessions on creating awareness about lithium monitoring was planned because of this audit.
The Impact of COVID-19 on the Quality of Admission Clerkings on an Old Age Psychiatry Ward – an Audit
Authors: Shanley Ivan , Faheem Jaweria , Bansal Sandeep , Khan Mahnur , Jeetun Hana
Published: June 2022

Aims

On 11th February 2020 a novel coronavirus was named SARS-CoV-2, with the World Health Organisation announcing that the associate disease would be known as COVID-19. As doctors providing an inpatient psychiatric service, there were various changes in our daily practice secondary to the pandemic. These included reduced staffing levels due to illness, the need to wear personal protective equipment during all patient contact and high levels of anxiety surrounding transmission. We hypothesised that the resultant pressure on our service might impact the quality of admission clerkings to our ward, (a 17 bed functional Old Age Psychiatry ward), and therefore resolved to audit the data. We determined that “quality” of the clerking should be equated to completeness, i.e. the degree to which all desired information is included.

Methods

Admission clerkings to the ward are to be completed on a pro forma built within the electronic patient record system (“Paris”). This pro forma is based on guidelines for the admission of patients to psychiatric inpatient units produced by the Royal College of Psychiatrists. The standard for the audit was set as 90% compliance with each individual section of the pro forma.

All admissions across three periods were extracted from the electronic record using the inbuilt reporting function. The periods were 1st April to 1st July in 2019 (pre-pandemic, n = 15), 2020 (early pandemic, n = 29) and 2021 (late pandemic, n = 22). Data were extracted manually from each admission clerking and recording anonymously on an excel spreadsheet, with either “yes” or “no” confirming or denying compliance with each domain (e.g. presenting complaint).

Results

All domains showed improved compliance from 2019 to 2021 other than recording of the mental state examination which saw a 9.09% decrease (which is not statistically significant). Comparing the pandemic years, performance was better in the early pandemic in 4 domains, better in the late pandemic in 10 domains and equal in 6 domains. 4 domains demonstrated a statistically significant improvement compared to pre-pandemic, however 9 domains still fell below the 90% standard set.

Conclusion

Despite the challenges posed by the COVID-19 pandemic the quality of inpatient admission clerkings has not only remained unharmed but in some domains significantly improved. Admission numbers increased during the pandemic periods, so it may represent greater familiarity with the clerking process, or perhaps a desire to make more comprehensive notes during a time of crisis. Repetition of the study post pandemic may be of value.
Using Qualitative-Electroencephalogram (Q-EEG) Mapping to Aid the Selection of Suitable Areas to Target Repetitive Transcranial Magnetic Stimulation (rTMS) Treatment in a Case of Depression With Comorbid Obsessive Compulsive Disorder (OCD)
Authors: Eltagy Louay , O'Neill-Kerr Alex , Hristova Nadia
Published: June 2022

Aims

We present the case of SN, a 25-year-old woman with diagnosis of anorexia nervosa, OCD, Generalized Anxiety Disorder (GAD) and depression. She has extensive history of contact with mental health services spanning more than 10 years. She has had 1 inpatient stay in an eating disorders unit lasting more than 6 months. Her treatment included various classes of medications, psychological therapy and social prescribing with little or no benefit. She has been referred to rTMS. The aims of the study are to determine the effect of rTMS in treatment of a patient with depression comorbid with OCD, understand the value of q-EEG in rTMS treatment and to treat OCD symptoms using rTMS guided by QEEG.

Methods

SN had a total of 56 rTMS sessions targeting standard depression and anxiety areas; F3 (left sided excitatory) and F4 (right sided inhibitory). Following this her depression and anxiety improved but her OCD worsened. She then underwent a Q-EEG to be able to understand the physiological cause of her symptoms and suggest meaningful further neuromodulation that is tailored to her. This indicated dysregulation within the default mode network. Spindling beta waves were detected over the posterior electrode suggesting a tendency towards ruminations. There was clear hyperactivity in the supplementary motor area. SN had further 30 rTMS sessions targeting the OCD circuit (FC1 and FC2).

Results

Rating scales showed a reduction in Patient Health Questionnaire-9 (PHQ-9) score from 22 to 14 (36%) in second course compared to an increase of PHQ-9 score from 9 to 15 (66.6%) in first course; indicating an overall 102% improvement in PHQ-9. It also showed reduction of Yale-Brown Obsessive Compulsive Scale (Y-BOCS) in second course from 34 to 8. It was not done in the first course but there was a clinical increase in OCD symptoms following the end of the first course. These results were corroborated clinically.

A repeat q-EEG showed that the areas previously highlighted in red at FC1 and FC2 had now all reverted to green, indicating normal neuronal connectivity.

Conclusion

rTMS can provide timely and adequate response to depression and anxiety especially one that has not responded adequately to medications and psychotherapy. Q-EEG is useful to direct the plan, create a personalized plan and achieve accurate results. The use of q-EEG, whilst useful, should be balanced with other considerations as financial constraints. It should be reserved to patients who have not responded favorably to standard rTMS treatment.
Natural Language Processing of Electronic Patient Records to Predict Psychiatric Inpatients at Risk of Early Readmission to Hospital Using Predictive Models Derived Through Machine Learning
Authors: Kapadi Tarif , Luz Saturnino
Published: June 2022

Aims

Psychiatric readmissions cause a burden on the healthcare system, incur a monetary cost and cause additional distress to acutely unwell patients. This project explores the use of the free-text of electronic patient records to predict inpatients in psychiatric hospitals at risk of readmission using predictive models generated by machine learning.

Methods

Free-text was extracted from the electronic patient records of patients admitted to hospitals in Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) during the five years 2015–2019 inclusive. The anonymised records were obtained via the CRIS (Clinical Record Interactive Search) database. A total of 17208 records were extracted.

The free-text entered by clinicians during an admission was extracted and processed using techniques of natural language processing to generate input vectors suitable to be used with machine learning algorithms. tf-idf (term frequency-inverse document frequency) vectors were used.

A selection of algorithms were used to train predictive models. Two-thirds of the records were used as training data with the remainder as test data. Baseline model performance was assessed and then best-performing candidates underwent hyperparameter optimisation using five-fold cross-validation to improve performance. Bayesian optimisation was used to automate hyperparameter tuning during cross-validation. Hyperparameters were optimised on the log loss function. As the dataset was imbalanced with negative instances outnumbering positive instances to a significant degree, various techniques such as random undersampling of negative instances in the training data were used to deal with class imbalance throughout this process. Following cross-validation, the best-performing models underwent performance analysis.

Models were used to make predictions on the test data. Performance was assessed using F1-measures, precision-recall curves and the average precision metric (equivalent to area under the precision-recall curve). These metrics were chosen due to their suitability in assessing models trained on imbalanced datasets.

Results

The best F1 score obtained was 0.233 using a Random Forest model trained using unigram tf-idf vectors of 500 token dimension.

The best average precision obtained was 0.157 using a Support Vector Machine trained using unigram tf-idf vectors of 2000 token dimension.

Both the above results required the use of random oversampling of positive instances to improve performance on the imbalanced dataset.

Conclusion

The performance indicates that the models generated are unlikely to have significant practical utility. Nevertheless, this exploratory project has produced a processed dataset with knowledge about its characteristics. This could be used for the further development of models using more complex techniques such as language modelling using neural networks.
Physical Health Screening in a Mental Health Setting
Authors: Middleton Laura , Ashcroft Katherine , Mather Alex , Gargan Georgina , Older Abby , Mitchell Andrew , Shaw Elizabeth
Published: June 2022

Aims

Research demonstrates greater mortality and physical health morbidity in those with mental illness, as compared to the general population. National Health Service (NHS) England has introduced policies to reflect this and promote improvements in physical healthcare for mental health patients. Inpatient admission provides a valuable opportunity to action such recommendations and offer a detailed health review, guided by local frameworks. A new annual audit commenced in Cheshire and Wirral Partnership NHS Foundation Trust (CWP) assesses admission physical health screening on its adult acute inpatient wards.

Methods

Audit standard was 100% compliance to CWP's admission pathway (Policy CP35). Parameters included doctor's review, medical history, physical examination, drug history, medication chart, allergy status, venous thromboembolic risk, blood tests, electrocardiogram (ECG), physiological observations, smoking history, body mass index (BMI) and falls risk. Data were collected retrospectively for all patients admitted or transferred to Juniper Ward, an acute adult inpatient unit in Bowmere Hospital in Chester, during October 2020 (cycle 1) and September 2021 (cycle 2). Different months were assessed due to senior staff changes in October 2021.

Results

30 patients were identified in 2020 and 37 in 2021. In 2020 the most consistently achieved parameters were, in order, medication chart/drug history, doctor's review and past medical history. In 2021 the most consistently achieved parameters were medication chart/drug history, smoking status and past medical history. Across both years completion of the cardiometabolic tool was lowest, although this improved from 6.7% to 16.2%. In 2020 there were 5 parameters achieving <50% compliance (cardiometabolic, physiological observations, smoking status, BMI and falls risk). In 2021 this reduced to 3 parameters (doctor's review, cardiometabolic tool, falls risk). Local policy was updated following the 2020 results, amending the criteria for doctor's review from commenced within 6 hours, to completed within 12 hours. Improvement was seen in all other areas in 2021, with medication chart/drug history documentation achieved in 100% of admissions.

Conclusion

Generalised improvement was seen following the 2020 audit, although only one parameter reached 100% compliance and most remained under 75%. The first cycle led to a policy change with respect to the doctor's review timeframe, although this limited direct comparison between years. A flow chart will be trialled on Juniper Ward, highlighting required tasks and assigning ownership to specific team members. The local Medical Education team were also made aware of the results to inform junior doctor induction. The audit will be repeated in Autumn 2022.
The Impact of COVID-19 Outbreak (2nd Wave) on Mental Health of the Healthcare Community in the NHS: A Web-Based Questionnaire Study
Authors: Nasim Omer , Hayat Muhammad Khizar , Hussain Zeinab , Afridi Malghalara , Khan Raza Ali
Published: June 2022

Aims

To determine the mental impact the second wave of COVID-19 has had on health care professionals working in the National Health Services (NHS), United Kingdom.

Methods

A cross-sectional descriptive web-based survey was conducted among the staff of National Health Services (NHS) in Poole, United Kingdom. Two tertiary care hospitals staff were part of this study. The study was spanned over a duration of 6 months, October 2020 to April 2021. A standard GAD-7 and PHQ-9 questionnaire along with demographic information was uploaded on google docs for data collection. All healthcare staff working in the hospitals were included. Any person that did not fill the questionnaire completely was excluded. Data collected were analysed using SPSS for descriptive statistics and the chi-squared test was done keeping p < 0.05 as significant.

Results

A total of 160 health care professionals took part in the survey, with a mean age of 37.36 (SD = 11.51) years, predominantly females (58.8%). The majority of participants were not depressed (78.1%, p = 0.004) nor were they anxious (85%, p = 0.008). A significant difference (p = 0.050) was seen in participant's anxiousness regarding the source of information. All other demographic parameters were not significant for differences in depression or anxiety (p > 0.05). 33.6% of the respondents agreed and 9.6% totally agreed to being terrified of contracting the coronavirus. 40.4% disagreed while 16% did not have an opinion. A similar trend was seen for the other statements. More than half (56.3% and 56.9%) of the participants answered in the affirmative that they were worried about contracting the disease and getting their living place contaminated, a staggering 91.3% were anxious about affecting their families.

Conclusion

The second wave of COVID-19 has had minimal effect on the mental health of health care workers in the NHS.
An Audit and Quality Improvement Project Regarding the Management of Patients With Eating Disorders Within the West Glasgow CAMHS Team
Authors: Singh Sukhmeet , Roberts Maryjane , Clark Alexandra , Boyle Christabel
Published: June 2022

Aims

There has been a significant increase in presentations of people with eating disorders (ED) within CAMHS in relation to the pandemic with a significant pressure on services to continue to provide evidence-based treatments for an expanding number of severely unwell patients. The first aim was to assess the quality of referrals received for patients with suspected ED and to then implement an intervention regarding the way that referrals are handled. The second aim was to establish a process for handling and monitoring patients already open to the service.

Methods

An initial and repeat survey was sent to staff within the team. The survey included the Mental Health Professional Stress Scale (MHPSS). An audit was conducted to establish the quality of referrals from GPs based on the Junior Marsipan guidelines. Data were collected on physical measures and the written content of referrals for March 2020–21 and March 2021–22.

Duty clinicians were asked to screen referrals and prompt GPs to submit recordings of physical parameters for the referrals to be triaged. In addition, a weekly meeting in a “board round” format was implemented to discuss new referrals and 40–50 existing patients each week depending on risk. We developed a physical health monitoring clinic once per week.

Results

MHPSS scores remained high between initial and follow-up surveys, with slightly increased mean scores for workload, organisational structure and processes, and lack of resources. Referrals from 2020–2021 (N = 26) and those from 2021–2022 (N = 39) were screened. The majority had a diagnosis of anorexia nervosa. Most referrals had records of height and weight (73.1 to 82.1%). 53.8% of referrals in the re-audit period required prompting for physical recordings to be submitted. There was no change in the written content of referrals at re-audit, with only 46.2% recording risk, 51.3% recording estimated onset and 56.4% documenting body image.

There was a slight reduction in the mean time between referral and diagnosis from 44.1 to 34.2 days. The weekly board round received positive feedback (N = 10) with 70–100% answering agree/strongly agree to statements such as manage patients’ care safely, obtaining urgent advice and physical monitoring.

Conclusion

The processes summarised above have been successful in improving the efficiency surrounding the management of patients with ED. Unfortunately, there has been no improvement in the stress levels of staff; we hope to conduct a focus group to better understand this. A referral proforma should be developed by the wider service for GPs to complete.
Morning Pseudoneutropenia in a Patient With Borderline Personality Disorder Treated With Clozapine
Authors: Tungaraza Tongeji
Published: June 2022

Aims

Neutropenia associated with clozapine affects up to 3% of patients. For the purpose of clozapine treatment, absolute neutrophil count (ANC) between 1.5–2.0 × 109/L is considered as amber result; requiring twice-weekly blood sampling until when it returns to normal. Interestingly, some patients on clozapine may develop transient neutropenia also known as Morning Pseudoneutropenia (MPN), or pseudoneutropenia. It is a phenomenon where normal diurnal variation of circulating white blood cells (WBC) and in particular ANC become more accentuated. In these patients, blood samples taken in the morning would tend to have amber results, while blood samples taken on the same day in the afternoon will have normal ANC. A case is reported where a patient with severe emotionally unstable personality disorder (EUPD) developed MPN 38 days after clozapine initiation.

Methods

AA is a 19-year-old white lady with a diagnosis of severe EUPD. Prior to starting clozapine, AA had tried several oral and depot antipsychotics, antidepressants and lithium without success. AA was started on clozapine. Her initial pre-clozapine blood count taken in the morning was WBC-5.8 x109/L and her ANC was 2.7 x109/L. AA improved quickly on clozapine. However, five weeks later, her first amber report was received. AA went on to have another six amber results before MPN was suspected. AA blood sampling was moved to the afternoon. There were no more amber results thereafter.

Results

To my knowledge, this is the first published case of a patient with EUPD treated with clozapine who went on to develop MPN. Recurrent amber results with samples taken before mid-day should alert clinicians of this phenomenon. Of course, other causes of neutropenia need to be excluded.

It is noteworthy that most reported cases in literature though few, involves patients with treatment resistant schizophrenia. Being aware of this phenomenon may raise our suspicion index and hopefully reduce the need for frequent repeated blood tests and the need to stop clozapine given the risk of relapse and its implications.

Few cases have also been reported in patients with physical health problems such as Grave's disease, systemic lupus erythematosus, and lymphangioleiomyomatosis. Medications that have been implicated to potentiate ANC diurnal variation including clozapine, risperidone, prednisolone, methimazole, and sirolimus.

Conclusion

Morning pseudoneutropenia is an accentuated normal diurnal variation of WBC. Early detection by collecting samples in the afternoon when there are recurring amber results can reduce unnecessary repeated blood tests and can prevent premature discontinuation of clozapine.