bluuebunny/crossref_metadata_2025_split huggingface dataset:
Antipsychotic prescribing in dementia
Authors: McLoughlin James , Roemmele Emma , Cryan Marguerite , Dolan Catherine , McCarthy Geraldine 
Published: June 2021

AimsThe majority of people with dementia will develop one or more behavioural or psychological symptoms of dementia (BPSD) as the illness progresses. Treating these symptoms in diverse residential environments is a challenge, with frequent prescribing of antipsychotic medications. The risks and limited benefits of antipsychotic use in this context are well recognised, prompting national guidelines in Ireland to improve prescribing patterns.1) Assess the frequency and appropriateness of prescribing of antipsychotic medication in older adults with BPSD referred to Psychiatry of Old Age service in the West of Ireland (Sligo) by comparing with best practice guidelines.2) Address identified deficits via quality improvement initiatives within department.MethodAudit standards were set using draft National Clinical Guidelines and NICE guidelines for prescribing in dementia to develop a study specific audit tool.Items assessed included: the frequency of review of antipsychotic use, whether or not non-pharmacological methods were trialled, if there was an assessment of benefit of the antipsychotic and discussion or risks, if a reduction/discontinuation of antipsychotic was considered, if metabolic monitoring was achieved.Clinical records for all patients actively under the care of the clinical team with a diagnosis of BPSD were assessed using this tool at the time of the study.Result49 patients with BPSD were attending the service in this time period. 58% (n = 29) of the entire cohort were prescribed an antipsychotic, most commonly quetiapine. Patients cared for at home showed the lowest levels of antipsychotic use at 50% (n = 18), while those who were in nursing home (80%, n = 8) and hospital care (100%, n = 3) showed higher rates, though this sample size was too small to demonstrate statistical significance, χ2 = 5.12 p = 0.077.Exploration of non pharmacological management of BPSD, documentation of discussion of risks of AP medication (metabolic, cardiovascular, falls, sedation, extrapyramidal), attempt at dose reduction or antipsychotic withdrawal were all achieved in less than 45% of cases (range 33–45%).ConclusionThis audit revealed higher than expected rates of antipsychotic prescribing in our BPSD cohort. It also revealed suboptimal documentation around the use of antipsychotics in this population during clinical interactions.A subsequent intervention to the proforma assessment tool to prompt these discussions improved these behaviours, there was no impact on the rates of antipsychotic prescribing.Despite increased attention regarding the limited benefits of antipsychotic medication in BPSD their use remains widespread. Due attention must be given to changing this practice in order to protect this vulnerable patient group.
An audit to review the extent to which appropriate preconception advice is given to women being discharged from mental health wards on psychotropic medication, in line with NICE guidelines
Authors: Muskett Helen , Bradley Kirsty , Stott Lauren , Moreton William , Jones Sarah 
Published: June 2021

AimsThe release of the Cumberlege Report in 2020 served as a reminder of the importance of informed consent for women when they are started on treatment that may affect their fertility or future pregnancies.Our aim was to evaluate current performance with regards to advice given to women of childbearing age around contraception, impacts of psychotropic medication on fertility and future pregnancies, and availability of preconception counselling.MethodStandard identified as NICE Guideline 192 (Antenatal and Postnatal Mental Health), sections 1.2 and 1.4.60 female inpatients were selected by looking at the most recent discharges prior to 03/11/2020 from 3 local acute adult wards. All females aged between 18 and 48 years were included.Electronic notes were reviewed for each patient. The discharge summary and last four ward round entries were reviewed, then key-word search of the patients’ records was performed using the terms “pregnan*”, “conception”, “contraception”, and “fertility”.The following information for each patient was documented in a spreadsheet:Discharge medicationIs there any discussion or advice around contraception?Have women taking antipsychotic medication been given advice regarding the possible impact on fertility?Has the potential impact of psychotropic medication on a future pregnancy been discussed?Has advice been given about the availability of preconception counselling should they plan a pregnancy in future?ResultOn discharge, a total of 33 women were taking one or more antipsychotics and 14 were prescribed a benzodiazepine. 24 women were discharged with antidepressants and 10 women were using a mood stabilising agent. 8 women were discharged without any psychotropic medication.Overall, 4 women received advice about contraception, and a further 8 women were already using contraception. The impact of taking an antipsychotic on fertility was not discussed with any patient. No women were advised about pre-conception counselling. The impact of taking psychotropic medication on a future pregnancy was discussed with one woman.ConclusionCurrent practice falls well below the standard set by NICE. Opportunities to inform women are being missed, and this has implications for the wellbeing of the patient and, potentially, future children.Action plan;Present findings at teaching.Deliver local teaching covering preconception counselling and the role of adult mental health teams when managing women of childbearing age.Produce a poster for inpatients wards and an information leaflet for women of childbearing age to aid with discussions.Create a poster for doctors’ offices to remind about NICE standards and documentation.Re-audit in 6 months.
GASS-tly side effects: antipsychotic monitoring for inpatients across NHS Lanarkshire
Authors: Paton Cristina , Hammond Siggi , Hills James , Jones Leah , Wong Eugene 
Published: June 2021

AimsBest practice in the prescribing of antipsychotic therapy includes monitoring for medication side effects. National guideline SIGN 131 advises the use of a validated side effect scale, for example the Glasgow Antipsychotic Side-effect Scale (GASS). Local recommendation in NHS Lanarkshire advises that patients prescribed antipsychotic therapy should be offered GASS at each contact and after initiation or titration. We aimed to improve compliance with antipsychotic side effect monitoring for inpatients in general adult psychiatry across two hospital sites in NHS Lanarkshire.MethodWe conducted a full-cycle audit. In October 2020, we took a cross-sectional sample of inpatients in general adult psychiatry in University Hospital Hairmyres and University Hospital Wishaw who were prescribed antipsychotic therapy for a functional psychotic disorder. For these inpatients, if applicable, we identified whether GASS had been completed on admission (OA), whether GASS had been completed after initiation or titration of antipsychotic therapy (I/T), and whether GASS had been acknowledged and discussed at consultant-led multi-disciplinary team meeting (MDT). Thereafter, we implemented several targeted interventions in order to improve compliance. In January 2021, we completed the cycle by taking a new cross-sectional sample of inpatients fulfilling identical parameters.ResultFirst cycle in October 2020 (n = 27) showed compliance OA of 4.2%, I/T of 9.5%, and MDT of 3.7%. Our interventions included a presentation at trust-wide clinical governance meeting; a presentation at one of the weekly departmental teaching sessions in psychiatry; an email summarising the audit to consultants in general adult psychiatry; meetings with senior charge nurses for each ward; and inclusion of GASS as part of routine admission paperwork. Re-audit in January 2021 (n = 23) showed compliance OA of 11.1%, I/T of 40.0%, and MDT of 21.7%.ConclusionOur full-cycle audit led to modest improvement in documented monitoring for antipsychotic side effects. There was relatively greater improvement in prescriber-led outcomes I/T and MDT, suggesting increased prescriber awareness. However, rather than reliance on individual prescribers to ensure compliance, consideration of GASS alongside monitoring of other physical health parameters would likely result in greater and more sustained improvement. In NHS Lanarkshire there is ongoing work to this end, ultimately with the intention to set up a defined antipsychotic physical health monitoring schedule, integrated across inpatient and community care.
Investigation and management of vitamin D insufficiency and deficiency in acute adult psychiatric admissions: a clinical audit
Authors: Sood Rhiya , Hughes Richard , Romeu Daniel , Mahmood Tariq , Cardno Alastair 
Published: June 2021

AimsGrowing evidence suggests vitamin D as a contributing factor in psychiatric illness, particularly depression. Leeds and York Partnership NHS Foundation Trust (LYPFT) has a policy recommending that vitamin D levels are checked in all inpatients. The principal aims of this audit were to establish whether vitamin D levels were checked in inpatients and whether oral supplementation was commenced where appropriate, with a pre-determined target of 90% for both. The secondary aims were to assess whether rates of checking and replacing vitamin D, and mean vitamin D levels, differed between Caucasian and non-Caucasian populations.MethodWe investigated adults aged 18–65 years newly admitted to the Becklin Centre, an acute psychiatric inpatient unit of four wards, between 1st December 2019 and 29th February 2020. 140 patients met eligibility criteria and were included in this study, of which 86 (61.4%) were Caucasian. Data were collected between 25th and 28th February 2021 by retrospectively reviewing two electronic patient record systems, Care Director and PPM, and the electronic prescribing platform EPMA. Results were compiled on a pre-determined data collection tool and analysed using Microsoft Excel. We defined insufficiency as serum 25-hydroxyvitamin D levels below 75nmol/l and deficiency as below 30nmol/l.ResultVitamin D levels were checked in 79 (56.4%) inpatients, and the proportion checked differed significantly according to ethnicity (Caucasian = 64.0%, non-Caucasian = 44.4%; χ2 = 4.59, p = 0.032). Of these, 1 (1.3%) had an insufficient sample, 5 (6.3%) had normal levels, 41 (51.9%) had insufficient levels and 32 (40.5%) were deficient. Colecalciferol was commenced for 61 (83.6%) of those with insufficient or deficient vitamin D levels. Rates of colecalciferol prescribing did not differ between ethnic groups (Caucasian = 82.0%, non-Caucasian = 85.0%; χ2 = 0.091, p = 0.76). Mean vitamin D levels did not significantly differ (p = 0.77) between Caucasians (38.3nmol/l) and non-Caucasians (36.2nmol/l).ConclusionLYPFT did not meet the target for testing for and treating vitamin D insufficiency and deficiency in psychiatric inpatients. Other blood results were often available when vitamin D levels were not, suggesting a lack of awareness of the guidance. Ethnicity influenced rates of vitamin D analysis but not replacement or mean serum levels. We aim to present our findings to the Trust's medical workforce to raise awareness of the relevant guidance. Given the paucity of psychiatric inpatients with normal vitamin D levels, further research into the role of vitamin D in psychopathology is warranted.
Audit on the documentation of ethnicity within CAMHS
Authors: Scott Charlotte , Lakin Roger 
Published: June 2021

AimsEvidence suggests children from minority ethnic groups have lower rates of referrals from primary care to CAMHS, are more likely to be referred via involuntary or compulsory routes and less likely to have access to therapies than children from white backgrounds. In order to understand how ethnicity influences individuals and ensure service innovation meet these needs data collected have to be accurate. The Mental Health Services Data Set outlines all children and families receiving NHS care should have ethnicity included as a mandatory data submission and services are performance managed on this.The aim of this audit to review the documentation of ethnicity for service users in CAMHS. We agreed that 100% of patients within York and North Yorkshire (Y&NY) CAMHS should have their ethnicity documented.MethodIntegrated Information Centre (IIC) was used to collect data on the documentation of ethnicity for patients under Y&NY CAMHS on 27th August 2020.ResultThe total caseload was 4109 patients.823 (20%) had their ethnicity documented as ‘unknown’ (the clinician had entered ‘unknown’ or the patient has ‘declined to disclose’).49 (1.2%) patients had no entry regarding ethnicity (missing).ConclusionWe recommend further exploration to consider why 1 in 5 patients have ‘unknown ethnicity’ documented. We recommend: conducting a refined search considering the percentage of ‘declined to disclose’ and ‘not stated’ within the ‘unknown ethnicity’ section emailing care coordinators for patients with ‘unknown ethnicity’ or ‘missing ethnicity’ conducting a questionnaire to gather the opinions and experiences of clinicians, patients and families when talking about ethnicityreviewing the process for documenting ethnicity to improve accuracy developing staff training, to promote a culture of confidence and curiosity when discussing ethnicity Following this intervention we will aim to re-audit and consider if this has improved the rates of documentation of ethnicity.
High dose antipsychotic therapy (HDAT) prescibing practice within the south trafford community mental health team
Authors: Sparasci Oli , Rojo Luis 
Published: June 2021

AimsHigh Dose Antipsychotic Therapy (HDAT) is defined by the Royal College of Psychiatrists as either: “A total daily dose of a single antipsychotic which exceeds the upper limit stated in the BNF” or “A total daily dose of two or more antipsychotics which exceeds the BNF maximum as calculated by percentage.”The use of HDAT is associated with significant risks to physical health and as such requires regular monitoring of various physiological parameters such as ECG, bloods and an assessment of cardiometabolic risk.Following previous audits of HDAT prescribing practice in the inpatient setting within Greater Manchester Mental Health (GMMH) NHS FT, an audit of HDAT prescription in a general adult CMHT was conducted in Summer 2020, with the following aims:To identify patients in the South Trafford CMHT who are prescribed HDAT.To assess the prescription of HDAT against local guidance on the use of unlicensed medications.To highlight good practice and areas for improvement in the prescription of HDAT.MethodAll patients under the South Trafford CMHT in Summer 2020 were identified. Current prescriptions for antipsychotic medication were ascertained through review of electronic patient records. Those noted to be on HDAT were assessed against audit criteria derived from the GMMH Unlicensed Medicines Policy, previous audits of HDAT use and the RCPsych consensus report on HDAT prescription.Result11 of 252 patients (4%) were identified as being on HDAT, of which eight were due to polypharmacy and three to high dose of a single antipsychotic. For 1/11 patients target symptoms and a risk/benefit rationale were documented. The mean length of time on HDAT was 6 years. 7/11 patients had either tried or considered clozapine in the past. 8/11 patients had not had an ECG within the last year, 4/11 had not had yearly U&E. 8/11 had regular mental health reviews.ConclusionCompliance with the audit standards was found to be highly variable. This may reflect many factors, including the length of time since commencing HDAT and the complex shared care arrangements currently in place in Trafford. Thus, the following recommendations have been made:To start a register of all patients prescribed HDAT.To review local guidelines and documentation to ensure they are up to date and can be effectively implemented in routine clinical practice.To ensure that the responsibility for conducting yearly physical health checks for patients prescribed HDAT is communicated to the relevant parties.
Improving risk assessments for CAMHS admissions at Great Ormond Street Hospital
Authors: Stock Lisanne , Evans Sacha 
Published: June 2021

AimsDuring the COVID-19 pandemic, admissions to the Mildred Creek Unit (MCU), an Inpatient CAMHS Ward at Great Ormond Street Hospital (GOSH) changed.The MCU is a 7–10 bed unit for children aged 7–15 years based on therapeutic milieu principles. The ward accepts patients via a planned national referral pathway, however, during the COVID-19 pandemic, patients were admitted as emergencies and consequently risk assessments were missed. Risk assessment is important in all admissions and as the MCU is not a locked unit, early risk assessment is particularly important.We aimed to review whether risk assessment occurred within one working day of admission, as suggested by the ward risk assessment policy, and if this was not the case, our aim was to ensure that all risk assessments took place within this period via our audit interventions.MethodWe collated data looking at the time between admission to GOSH and the date at which first risk assessments took place. We then put in place three interventions.
1)Posters prompting doctors who were providing on-call liaison input to perform a risk assessment within one working day of admission.2)New junior doctors were provided with written and verbal information to emphasise the importance of early risk assessment.3)Guidelines also highlight that assessment of risk may need to be on-going. We therefore added a prompt section in the weekly ward round proforma with the aim of reducing the interval between risk assessments during admission.The first audit cycle was conducted on the 3/8/2020 and the second on the 28/11/21 to allow for a comparative number of inpatients between the first and second audit cycle.ResultWe found these interventions significantly reduced delays in risk assessments. Prior to the audit's first cycle the average delay between admission to GOSH/MCU and a risk assessment was 2 weeks. After the interventions there were no patients whose risk assessment was delayed outside the next working day parameters.ConclusionThis full cycle audit demonstrates the impact that prompts to clinical practice can make on patient care. It is important to recognise the need for flexible risk assessment with regular review, especially at times of clinical change. We hope that this continued trend for early risk assessment leads to improved clinical care and timely discussion of risk for all new CAMHS inpatients at GOSH.
Service evaluation of weight gain in patients prescribed antipsychotics within the early intervention service
Authors: Ward Louisa , Marriott Charlotte , Tong Godwin 
Published: June 2021

AimsTo assess physical health in patients under the Early Intervention Service, whom are prescribed antipsychotics.To consider whether further intervention needs to be provided or promoted to improve physical health in this group.MethodAssessment of carenotes database for all 63 patients on EIS caseload prescribed antipsychotics.ResultOut of 47 patients studied, 20 were non-smokers at baseline. 25% of them ended up becoming smokers by the end of the study time.Out of 47 patients studied 28 were non-drinkers at baseline. 32% of them ended up engaging in alcohol by the end of the study time.Out of 47 patients studied, 38 patients had data available to record weight changes per year. Out of the 38 patients, 27 of them had positive weight change; average weight change was + 6.38 kg per year. The highest weight gain was 38.4 kg, the highest weight lost was 47.3 kg.Out of 47 patients studied, 35 patients had data available to record BMI changes. Out of the 35 patients, 27 of them had positive BMI increases, average BMI change was + 2.68. The highest BMI increase was 12.84. The highest BMI decrease was 8.24.Out of 47 patients studied, 11 patients had data available to record random glucose level changes. Out of the 11 patients, 7 of them had increased glucose levels, average glucose change were + 0.5mmol/l. The highest increase in glucose was 3.9mmol/l and the highest drop in glucose was 2.6mmol/l.Out of 47 patients studied, 19 patients had data available to record HbA1c levels. Out of the 19 patients, 10 of them had increased HbA1c levels, with the average change being + 0.31 mmol/mol. The highest increase in HbA1c levels was 5 mmol/mol and the highest drop in HbA1c levels was 3 mmol/mol.Out of 47 patients studied, 30 patients had data available to record cholesterol changes. Out of the 30 patients, 21 of them had increased cholesterol levels, with the average change being + 0.09mmol/l. The highest increase in cholesterol was 1.7mmol/l and the highest drop in cholesterol levels was 2.6.Taken together, we show that anti-psychotic use has a negative effect on physical health parameters such as weight gain, BMI increase, HbA1c levels and cholesterol levels. This increases the patient's risk of developing diabetes/metabolic syndrome in the future.ConclusionRe-audit.
An audit of waiting times in the outpatient clinic in Inverness Sector A NHS Highland during the COVID-19 pandemic
Authors: Zinchenko Oksana , Hyland Jennifer 
Published: June 2021

AimsThis audit was to assess and improve the organizational efficiency of referrals to Inverness Sector A Outpatient Service. The referrals were audited to measure the average waiting time from referral to first offered outpatient appointment and to assess the proportion of patients waiting longer than 12 weeks.MethodThe audit included routine referrals to the CMHT Inverness Sector A, NHS Highland from GP practices: Kingsmills, Burnfield, Riverside, Fairfield, Foyers and Drumnadrochit Medical Practices. The number of referrals and the number and proportion of clients given appointments for assessments were calculated. Referrals were received directly from primary care and the Mental Health Liaison Team or following Out of Hours contacts at the Mental Health Assessment Team.Data were collected retrospectively: referrals from 1 Jan 2020–31 Aug 2020. Sample size came to 160 patients aged 16–65 years. Data were collected via review of recorded documentation on the NHSH electronic patient record systems (SCIstore), from 5th–25th January 2021.Result160 patients (male 82, female 78) were referred from 1 Jan to 1 Sept 2020. Of these, 140 (87.5%) were given an appointment for an assessment. The mean waiting time was 12 weeks for 103 patients (64%), with 57 patients (36%) waiting longer than 13 weeks. The bimodal distribution of waiting times prompted an analysis of those with longer waiting times. In some instances, appointments were delayed because patients either did not attend (DNA) or cancelled their appointments. Reasons for delays included: postponement until further information was available; cancellation of meetings or patients DNA. In 20 cases (12.5%), the referrals deemed inadequate, prompting further liaison with the referrer for clarification about the nature of the problem and previous psychological interventions.ConclusionThe number of transactions (any amendment to a patient record) was higher than the number of patients affected, as several transactions can relate to one patients’ record.Most referrals are vetted in advance via the daily Inverness triage huddle. Ways of improving the quality of information provided by referrers would be explored.On receipt of each referral, the date of the 12 week deadline would be calculated and highlighted in a database.The cross-sector (Highland wide) standardisation will add clarity about medical capacity, that does not involve use of excessive clinician time.