bluuebunny/crossref_metadata_2025_split huggingface dataset:
North West London New Model of Care Project (NMOC) – improving inpatient mental health care for children and young people
Authors: Tolmac Jovanka , Lewis Alun , Mohammed Azer , Fellow-Smith Elizabeth , Redelinghuys Johan , Girelas Braulio 
Published: June 2021

AimsSpecialised inpatient mental health services for children and young people are commissioned and managed by NHS England (NHSE) and provided by NHS as well as independent sector. The access to beds has been managed nationally with young people admitted far from home. There were capacity issues identified in London. To address these concerns, NHSE invited organisations to work in partnership to co-design and establish new models of care. This is one of the first of such projects, set up to manage the budget for children and young people's beds on behalf of NHSE and change the way of managing and monitoring admissions.Our aims:To reduce length of inpatient stayTo enable admission of young people as close to home as possibleTo improve resource efficiency, capacity and capability of managing young people in crisis in the community.MethodA number of changes were introduced, including engagement of community and inpatient clinical staff, repatriation to units closer to home and introduction of CRAFT meetings (early review meetings in inpatient units to enable timely and effective discharge planning and support back to local services). The implementation has been closely monitored by the project manager and clinical group, which included representatives from all organisations involved.ResultAfter four years, young people are admitted to hospitals closer to home and the length of inpatient stay has decreased by 18%. The number of admissions has decreased by 28%. Out of area occupied beds days have been decreased by 66%.Significant recurrent budget savings have been achieved. Over the past three years, these savings have been reinvested in developing crisis community support and more specialist community services within CNWL and West London Trust.ConclusionThere have been considerable benefits of multiple organisations working in partnership to improve patients care. The success of the project has created further opportunities for the development of services which provide safe and effective alternatives to admission (such as crisis services, home treatment teams and specialized community services). In summary, this collaborative model has improved the quality of care and experience for young people and reduced the need for psychiatric admission.
Use of clonidine in the management of opiate withdrawal in community patients
Authors: Kelsey David , Hoezoo Pierre , Grewal Pardeep 
Published: June 2021

AimsClonidine has been used to alleviate symptoms of opiate withdrawal. No validated prescribing schedules exist for the use of Clonidine in opiate detoxification in community patients. We have devised a Clonidine prescribing schedule for adult outpatients seeking opiate detoxification.BackgroundOpiate cessation following prolonged use produces a central noradrenergic (NA) response in the locus coeruleus (LC), causing symptoms that can result in reinstatement of use. Pharmacotherapies for withdrawal are thought to work through decreased NA release in the LC by agonising pre-synaptic alpha-2 adrenoceptors. Clonidine has been used since the 1970s. However, it is off-license in the UK, and superseded by Lofexidine. Though both cause hypotension, this is less marked with Lofexidine, which may be anxiolytic and considered better tolerated. Lofexidine is no longer available in the UK. Specialists may need to resort to Clonidine for those seeking opiate detoxification.MethodWe performed a feasibility study with the primary outcome being tolerability of an outpatient clonidine schedule. Patients (n = 7) were aged between 18 and 65 years (mean 32). Six were prescribed buprenorphine as opiate substitution (OST), and one methadone.Exclusion criteria were in keeping with BNF contraindications.An ECG was obtained for each patient before treatment. A urine drug screen and Clinical Opiate Withdrawal Scale were taken to confirm opiate dependence and withdrawal. Patients self-monitored withdrawal using the Subjective Opiate Withdrawal Scale and daily blood pressure measurements. Standard adjuvants for withdrawal were prescribed.A test dose of 100mcg Clonidine was given to assess for hypotension. If tolerant they received 100mcg QDS, reducing over eight days.Patients were contacted by their recovery worker twice during the period.ResultFive of the seven completed the course, two dropped out due to hypotension. No other adverse effects warranting discontinuation were encountered. Patients reported fatigue and light-headedness as their most troublesome side-effects. Of 3 patients who returned SOWS scores, 2 reported decline by 21/64 and 14/64 respectively. One reported an increase of 49/64 over 8 days. 3 of the 5 subjects who completed the course were not abstinent at completion, citing opiate withdrawal symptoms as causative.ConclusionThere is scope for the safe use of clonidine in the community for motivated individuals. Adequate monitoring of heart rate and blood pressure is required. Starting doses at 100mcg QDS appear well tolerated. Prescribers may wish to reduce this over a longer period to encourage completion and improve tolerability. Further research is needed.
Staff's perspectives on physical activity in acute mental health general adult wards
Authors: Lekka Nikoletta , Nunns Samantha , Verity Robert 
Published: June 2021

AimsPhysical activity (PA) has multiple health benefits for people with severe mental illness (SMI). Nevertheless, people with SMI engage in less exercise and more sedentary behaviour than the general population. Additionally, inpatient settings can exacerbate barriers to PA and facilitate sedentary behaviour. Staff's attitudes towards PA promotion may influence patient engagement. The aim of this study was to explore staff's views on PA for acute psychiatric inpatients, including enablers and barriers.MethodAn online anonymous survey with free text was sent to all 85 multidisciplinary team (MDT) members of two acute general adult wards, including nurses, doctors and allied health professionals. A qualitative approach was used to gain deeper understanding of the participants' perspectives. Manual thematic analysis was completed to identify discrete themes.ResultResponse rate was 64%, with 54 professionals responding. Notably, 100% agreed or strongly agreed that exercise is beneficial to physical and mental health. Nevertheless, 72% felt it was not easy to do PA with patients during their shift, while many reported they were able to encourage exercise but were unable to accompany patients to sessions. Specifically, participants reported lack of time (40%), high level of clinical activity (32%), lack of staff (30%), lack of PA resources inside the wards (20%) and conflicting priorities (18%), stopping them from helping patients to do more exercise. However, they felt more staff (28%), time dedicated to PA (26%), on-ward resources (18%), access to the gym and gardens (18%), staff dedicated to PA (16%) and staff trained in facilitating PA (10%), would help participants promote PA on the ward. Other suggestions to enable PA included a change in ward culture, valuing and promoting PA, daily patient encouragement by all MDT members instead of only occupational therapists, and PA promotion as part of mental health treatment and as physical health strategy. Finally, 70% of participants said they exercised regularly, although some reported lack of time or motivation, work commitments and workload-related exhaustion reducing their ability to exercise.ConclusionParticipants acknowledged the importance of PA for physical and mental health. Furthermore, they described multiple enablers and barriers. Prioritising PA during admission, providing on-ward activities, educating/training staff, reiterating that PA promotion is within all MDT members' job roles, and offering organisational support can contribute to improved PA provision and regular involvement of patients.An integrative approach to mental health and wellbeing, promoting PA in inpatient psychiatric settings is required.
A community service review of the quality of inpatient discharge summaries from six inpatient wards at St Charles Hospital: an initial audit and quality improvement recommendations
Authors: Mahmoud Omar , Munjiza Jasna , King Jacob 
Published: June 2021

AimsTo discuss whether Discharge summaries include important information to community mental health teams .To identify patterns and produce recommendations for change by Quality improvement methods .MethodA convenience sample was selected of the first 5 patient discharges from each of the 6 adult inpatient wards at St Charles Hospital. This represented a total of 30 reviewed summaries. Outcome items were generated following discussion with community psychiatric colleagues based on those aspects of an admission thought to be of most use to a community mental health team. These were; reason for admission, diagnosis, circumstances of admission, progress on the ward, risk assessment, physical health, legal status on discharge, discharge medication, discharge management plan, contact details. Basic identification was also recorded as was the ward and date of dischargeResult•Only 3.3% (1/30) of discharge summaries were complete of all items.•However 23.3% (7/30) were almost complete, failing to record only a single item, and a further 2 missing only 2 of 10 items. There was a bimodal distribution (Graph 1).•Seven (7/30) discharge summaries provided no information. Of these, four (4/7) discharge summaries were written in the progress notes directly, rather than using the discharge summary proforma.•The ‘reason for admission’ item was a clear low outlier with only 2/30 reporting this piece of information. For a number of cases, this was recorded unhelpfully as “in crisis”.ConclusionThere was limited evidence of systemic patterns,however some wards showed internal stark differences with some summaries complete or almost complete and others empty.The key findings from this report are the high number of discharge summaries which have either no responses to them (7/30). This may indicate that the writer did not know how to use the current discharge template, and therefore support with using this is indicated. For those with a very low (7/30) number of item responses, we might conclude that these discharge summaries were written by someone with knowledge of using the system, but for another reason did not complete the majority of the items asked, and for this reasons are not immediately clear. Similarly, as highlighted above the main low outlying result relates to the apparent widespread practise of writing “in crisis” as the ‘reason for admission’, unfortunately to community teams this is an unhelpful and self-evident response.
Microsoft teams virtual handover system
Authors: Mohan Mohit , Scally Ruth , Reed James , Cavaropol Calin 
Published: June 2021

AimsAccurate and timely handover of clinical information is of great importance to continuity and safety of care. Psychiatry doctors typically cover a number of sites across a catchment when they are on-call. Consequently, handover between on-call teams and day teams in psychiatric hospitals is reliant on using the nursing staff as an intermediary to flag concerns or relying on the day teams proactively checking the notes on daily basis for outstanding tasks.The key objective of this project was to use Microsoft teams to establish a handover system that is efficient, safe, reliable, easy to use and replicable.MethodA microsoft teams group was created comprising of all the medical staff members working at inpatient units across three sites that are part of Birmingham and Solihull Mental Health Trust. These members were divided into two groups - the ‘on-call team’ and the ‘day team’. Within the ‘day team’, every consultant was grouped with their junior doctors to form multiple subgroups.A system was established wherein the two teams could communicate with each other by posting a message and tagging the appropriate team. A provision was made to create a channel for every ward to allow for easy segregation and monitoring of tasks.Qualitative information about the use of the tool was monitored by monthly focus group meetings. A formal review of the messages was conducted after 8 weeks to assess the following parameters:Number of messages postedNumber of messages acknowledgedNumber of safety-related incidentsResultInitial evaluation of the results suggests that the new handover system was perceived to be safe, accurate and efficient while being intuitive and hassle-free. This increased the quantity and enhanced the quality of communication between the ‘on-call’ and the ‘day teams’ and allowed for early completion of tasks while reducing the number of safety-related incidents.ConclusionThe Microsoft teams proved to be a viable alternate tool to create a virtual handover process that is efficient, safe, reliable and user-friendly. It also has the potential to enhance the communication between inpatient and community teams.
Reducing the use of oral psychotropic PRN medication in acute mental health inpatients
Authors: Moore Zoe , Morrow Rachel , McGee Meta 
Published: June 2021

AimsProject aim:To reduce the use of oral psychotropic PRN* medication on Ward 3 AMHIC (Acute Mental Health Inpatient Centre) by 20% by May 2020(*PRN = Pro re nata/As required)On Ward 3, we identified a number of unintended negative consequences of PRN medication to both patients and staff.These included issues with over-use, dependence and side effects; as well as loss of staff ownership and challenging interactions with patients, (including escalation to aggression).Following the success of our Child and Adolescent Mental Health Inpatient colleagues in this area, we decided to embark on a project to change practice within our ward.MethodIn order to quantify the problem, we first collected baseline data on current use of psychotropic PRN medication.As a multidisciplinary project team, we then brainstormed potential contributory factors and displayed these visually as a driver diagram.This divided our project into 3 main areas:
1)Safe prescribing2)Safe administration,3)Safety culture.Project measures were also agreed as follows:Outcome: Number of doses of oral psychotropic PRN medication administered per weekBalancing: Violent incidents; IM administrations of psychotropic medicationProcess: Time taken to complete interventions; Patient and staff satisfaction. Change ideas were selected and implemented sequentially, using Plan-Do-Study- Act methodology.These included:
1)Weekly review of PRN prescribing2)Nursing administration sheetData were collected weekly and plotted on our run chart.ResultBy the end of May 2020, we had exceeded our initial goal, reducing the weekly median number of doses of oral psychotropic PRN medication administered by over 30%.Our balancing measures remained stable and we gained useful insights and development ideas from a staff survey.Further change ideas were planned for implementation over the months that followed, however, the impact of the COVID-19 pandemic meant that the project lost some momentum.ConclusionDespite running into some difficulty over recent months, the team remain motivated to maintain and build upon our previous success.In the past few weeks, “Calm Cards”, (a patient-centred intervention promoting use of individualised alternative coping strategies), have been introduced.We hope that the outcomes of this intervention will be positive, both in terms of further reducing use of PRN medication and encouraging development of skills which can be utilised beyond the hospital environment.We also intend to share our learning with colleagues and explore the possibility of introducing the project to other wards within the hospital.
A quality improvement project on nicotine replacement therapy in Shannon Clinic (Northern Ireland)
Authors: Moss Eileen 
Published: June 2021

AimsThe aims of this quality improvement project were to determine if Nicotine Replacement Therapy was being prescribed correctly in Shannon Clinic in Northern Ireland and also to improve the rates of correct prescribing of Nicotine Replacement Therapy in the aforementioned unit.BackgroundThere are several different types of Nicotine Replacement Therapy currently available. Shannon Clinic is a smoke-free clinical environment therefore patients who smoke are offered Nicotine Replacement Therapy on admission. When I was working at Shannon Clinic I became aware that there was no clear guidance available to medical staff on the wards regarding prescribing Nicotine Replacement Therapy and therefore I decided to carry out this quality improvement project.MethodAn audit of drug charts was done on the patients who were under the care of the consultant that I worked with. In total nine drug charts were included in the audit. After the audit was complete, I produced a poster to show how to correctly prescribe Nicotine Replacement Therapy. A copy of this poster was placed on each ward in Shannon Clinic. After a period of time the drug charts were re-audited to see if there had been an improvement in the rates of correct prescribing of Nicotine Replacement Therapy.ResultIn total, 22% of the drug charts which were included in the audit had Nicotine Replacement Therapy prescribed incorrectly on them. After the inclusion of a poster outlining how to prescribe Nicotine correctly on each ward in Shannon Clinic, 0% of drug charts had Nicotine Replacement Therapy prescribed incorrectly on them. This was an improvement of 22%.ConclusionThis quality improvement project was successful at reducing the rates of incorrect Nicotine Replacement Therapy in Shannon Clinic. In the future it is my hope that this quality improvement project should lead to the correct prescribing of Nicotine Replacement Therapy for all patients in Shannon Clinic. It should also lead to an increased awareness regarding the different types of Nicotine Replacement Therapy for medical staff working in this clinical unit.
Bridging the gap: improving liaison psychiatry documentation quality to meet the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) treat as one recommendations at newcastle hospitals
Authors: Ou David , Ibrahem Sara , Basirat Sahar , Brown Sarah 
Published: June 2021

AimsThis project aimed to assess and improve the quality and frequency of documentation from Psychiatric Liaison Team (PLT) to ward-based medical colleagues against the Treat as One recommendations. From experience, we hypothesised that written documentation of information crucial to patient care is not consistently meeting standards. This communication breakdown directly affects patient safety, potentially introducing additional risks to our already vulnerable patient group.Effective communication between PLT and our medical colleagues bridges the gap in providing continuity of care and ensures patients’ mental and physical health needs are met in acute trusts. The NCEPOD found that there remains many barriers to high quality mental healthcare provided to patients in general hospitals and recommended 7 elements that PLT documentations should encompass.MethodWe audited initial PLT assessments and the resulting documentation to determine if these met the 7 standards set by NCEPOD. Baseline audit undertaken from 21-27/09/2020 encompassing 130 patient referrals to PLT.A period of time was allotted to implement robust changes to improve the service. This included a streamlined e-template that automatically populates in the acute hospital eRecord system which prompts clinicians to document according to the NCEPOD standards, structured clinician training and education, and the nomination of “Treat as One Guardians” in the team to ensure that acute trust documentations are present during daily multidisciplinary meetings.The cycle was then completed on 22-28/02/2021 with a re-audit capturing 55 referrals.ResultImplementation of our recommended changes saw an increase from 58% of documentations with ≥50% NCEPOD elements to 98% in the re-audit.We also saw an increase in number of the NCEPOD 7 elements included following intervention: formulation (0% to 8%), legal status and capacity (47% to 79%), risk assessment (2% to 28%), risk management (18% to 53%), and discharge plan (2% to 29%).Completion rate of acute trust documentation increased from 74% to 96%.Our interventions also led to more contemporaneous communication, significantly reducing mean time from assessment to documentation in both acute trust and mental health records from 6.02 to 3.53 hours, (p = 0.04) and 6.12 to 3.50 hours, (p = 0.05) respectively.ConclusionFollowing our interventions, the results showed improving trends in the frequency and quality of our documentation with secondary outcomes showing increased documenting efficiency. Our current practice is not yet optimal and retains potential to adversely affect our patients. We propose further investigating barriers to change using the quality improvement PDSA (Plan, Do, Study, Act) methodology to continue innovating.
Improving cardiometabolic health assessments and interventions at St Charles Hospital, London
Authors: Rahman Mehtab , Julien Vernanda 
Published: June 2021

AimsSt Charles is one of the largest inpatient mental health units in London with 8 wards and covers the boroughs of Kensington & Chelsea and Westminster. This project aimed was set up so that 95% of patients in St Charles Mental Health Centre would have a complete cardiometabolic health assessment by December 2020. This would include Weight, Smoking, Alcohol, Substance Use, Hypertension, Cholesterol and Diabetes assessments with necessary interventions recorded. The outcome of the intervention would improve overall physical health and life expectancy.MethodPeople with serious mental illness experience significantly worse physical health and shorter life expectancy of up to 10 to 15 years than the general population. CNWL is making Physical Health of patients in Mental Health Services a priority. Performance in this area has been challenging across the Trust because of:
–Buy in from clinicians.–Staff did not feel empowered to discuss interventions with patients.–High sickness and absence as a result of COVID was found to directly correlate with reduced physical health monitoring/recording.–Lack of training in completing the SystmOne physical health templateThe following cardiometabolic risk monitoring interventions were recorded on SystemOne (electronic documentation platform) and performance reviewed using Tableau : Weight, Smoking, Alcohol, Substance Use, Hypertension, Cholesterol and Diabetes assessments with necessary interventions recorded.ResultPrior to the commencement of this project, the wards in St Charles Mental Health Centre completed physical health assessments on roughly 8% of the patients in February 2020. The QI project was implemented in June 2020. By September 2020, physical health recording across 8 wards across St Charles had increased to 89% following successful implementation of the interventions.ConclusionThe following interventions resulted in a significant improvement in physical health cardiometabolic risk monitoring at a busy inpatient mental health setting:
–Monthly physical heath meetings to enable shared learning with ward doctors, nurses and healthcare assistants.–Ongoing one-to-one and group support to train staff with completing and recording physical health assessments.–Tableau Physical Health Report regularly reviewed with MDT during ward round meetings.–Physical health leads given supernumerary days to run physical health clinics on the wards.–Fortnightly Physical health monitoring meetings with the Director of Nursing and Head of Governance.