bluuebunny/crossref_metadata_2025_split huggingface dataset:
A question of information mismatch in the SPC and PIL on the effect of ADHD stimulant medications on tourette's syndrome
Authors: Hisham Idura , Shabbir Shazia 
Published: June 2021

AimsTo assess the quality of information provided by pharmaceutical companies to patients and doctors regarding the impact of stimulant medications indicated for the treatment of Attention Deficit Hyperactive Disorder (ADHD) on Tourette's syndrome(TS) and tics in children and its implication on treatment.BackgroundIt is estimated that between 35% to 90% of TS patients also have ADHD. However, there remains a pervasive belief that the use of stimulants to treat ADHD symptoms in children with comorbid tic disorders is contraindicated because of concerns about possible tic exacerbation. Recent studies has disproved this, which is reflected in United Kingdom(UK) and European ADHD and TS guidelines. Pharmaceutical companies are legally required to provide a Summary of Product Characteristic (SPC) and Patient Information Leaflet (PIL) for each medicine as it is an integral part of the marketing authorisation approval. The SPC contains vital information for the usage and prescription of a drug for use by healthcare professionals. The PIL included in the medication packaging is a patient-friendly version of the SPC.MethodThe available stimulant medications licenced for use in paediatric patients with ADHD in the UK were identified through the Medicines & Healthcare products regulatory Agency (MHRA) website. The SPC and PIL were then accessed from the Electronic Medicines Compendium (EMC) website. Those not on the site were obtained directly from the marketing authorisation holder. Any direct mention of tics or Tourette's in the contraindication, warning and caution, or side effect section were documented. The information was then tabulated and compared.ResultOf the three stimulant drug types, 17 variations are currently available for use in the UK. There were inconsistencies found between the SPC and PIC in reference to the impact of these drugs on tics and TS in all 17 licensed medication. Most discrepancy was found in regard to TS as a side effect (16/17) and also tics (15/17). TS is also listed as a contraindication in the SPC and PIL for all available variety of Dexamphetamine class drugs. This is inconsistent with current clinical evidence and guidelines.ConclusionThe disparities in information regarding the impact of stimulant medications on tics and TS can have wide ranging effects. Outcomes could include poor patient adherence, or prevention of initiation of potentially beneficial treatment. It would benefit to standardize the information between these two documents to minimize inconsistencies in understanding between doctor and patient.
Striving for better comunication - an audit
Authors: Breen Eleanor 
Published: June 2021

AimsThe aim of this audit is to assess communication between the general and psychiatric hospital. This audit was prompted after a number of patients were transferred to Udston Hospital, a community hospital with two older adult acute mental health wards, with no written communication. This led to several significant issues including medication errors, ambiguity regarding patient escalation plans and uncertainty regarding what had been discussed with families.MethodOver the course of one month eight patients were identified who had been transferred from the acute site to Udston Hospital. Three were new admissions to Udston, four were returning after treatment for physical illness, and one returned following assessment in ED. Data were collected by examining paper and electronic notes, and analysed using Excel. The results of this audit were discussed at the local clinical governance meeting. A 2nd cycle was performed. Eight transfers were identified. Four were returning after an assessment in ED, two were new admissions to Udston and two were returning after treatment for physical illness.ResultInitial audit found that 38% of patients were transferred with their medical notes, 50% were transferred with no written documentation whatsoever, and none of the patients were transferred with a transfer letter. The second cycle found that 88% of patients had a transfer or discharge letter. 12% of patients came with no written documentation.ConclusionThe initial audit found significant deficiencies in communication. Highlighting the need for all patients to have a transfer letter at a local management meeting seems to have led to an improvement. However, differences between the samples in the 1st and 2nd audit cycle could be distorting the results. Further audits would be useful given the small sample size and due to the differences between the sample populations.
Are acute psychiatric units providing adequate inpatient services for borderline personality disorder patients?
Authors: Ling Siew , George Joji 
Published: June 2021

AimsTo assess the adherence to NICE guidelines CG78 (1.4) regarding the inpatient services provided for BPD patients at an acute psychiatric unit (The Oleaster).Borderline personality disorder (BPD) patients are frequent users of psychiatric inpatient services. However, evidence suggests that inpatient treatment is ineffective in the long-term recovery of such patients. The inpatient services at the Oleaster will be audited against NICE guidelines for BPD. We hope to improve the care of patients with BPD and ensure effective use of psychiatric resources.MethodRetrospective case notes review of 35 patients admitted into the Oleaster from 1/11/2018–31/10/2019. This was taken from an initial sample of 72. Patients were excluded if they were admitted for other concomitant mental or behavioural problems (except problem use of tobacco, drugs or alcohol).Result69% of patients were referred to other mental health services (e.g CRHT/HTT, other local alternatives, liaison team) prior to admission. There was no evidence of referrals in 31% of the sample population.The reasons for admission include significant risks to themselves/others (n = 14) and detention under MHA (n = 14). Reasons were not noted in 7 patients.Advance agreement on the length and purpose of admission took place in 19 and 27 patients respectively. Discussion of potential harms and benefits of admission only took place in 4 patients. Discussion was not applicable in 2 patients who lacked capacity.Of the patients admitted ≥2 times in the previous 6 months, only 38% had a CPA review arranged. It was not arranged in the remaining 62%.ConclusionThere is room for improvement in the appropriate admission and documentation of BPD patients. Referral prior to admission was well adhered but documentation was unclear. Implementing a set checklist before admission could be recommended. Active involvement of patients was inadequate. It is especially lacking in regard to informing patients of the potential harms of admission. This can be improved by educating patients and staff on this matter.CPA reviews were not arranged in a timely manner. Placing an alert on patients’ records when they are admitted again within the last 6 months would help to reduce this issue. Overall, greater effort is required to ensure patient's most current needs are met and that limited psychiatric resources are used effectively.
Compliance with nice guidelines for management of depression in a community mental health team
Authors: Mellor Sophie , Pantall Shay-Anne , Brownell Lisa 
Published: June 2021

AimsTo evaluate compliance within a Community Mental Health Team (CMHT) to the NICE guidelines for the management of depression.BackgroundReducing the prevalence of depression continues to be a major public health challenge.Given the complexity and recurrent nature of the condition, the NICE guideline CG90 is an invaluable resource to aid the effective management of depression. Here we present an audit of adherence to this guideline within a CMHT.MethodA retrospective electronic casenote review of all patients diagnosed with depression between January 2016 and October 2019 under the care of a Birmingham CMHT (n = 35), assessing key performance areas including: quality of assessment and coordinated care, risk assessment, choice of pharmacological and psychological treatment using the stepped care model and appropriate crisis resolution planning.ResultKey results include:
The majority of patients were Caucasian (63%). Ages ranged from 27 to 69 (mean age 48 years old).Severity of disorder was typically moderate (46%) or severe (48%). Of those with a diagnosis of severe depression, 41% had associated psychotic symptoms.Psychiatric comorbidity was high (49%), of which generalised anxiety disorder was the most common (59%).Referrals were typically from primary care (77%). Approximately half (51%) had reported suicidal thoughts according to the referral.A quarter of patients (26%) were seen by CMHT within 8 weeks of referral; 20% of referrals however waited over 12 months before being assessed.Risk assessments were out of date for 71% of patients.100% of patients had a crisis plan noted within their most recent clinic letter; however, none of these met the required standards.Polypharmacy was common (60%), with 34% prescribed two antidepressants. Use of lithium augmentation was uncommon, with only one patient prescribed this. 43% were prescribed an antipsychotic; of which, 29% had appropriate physical health monitoring completed.Over half of patients (60%) had been referred to psychology services; of these, 38% had either completed or were in ongoing treatment at the time of review.ConclusionCMHTs manage the care of individuals with depression who have high levels of active symptoms and disability, psychiatric comorbidity, care requirements, and complex treatment plans. Pharmacological management was broadly in line with guidelines, and rates of referral to psychology were satisfactory. Risk assessment and crisis planning are clear areas in need of urgent attention in order to comply with guidelines and ensure patient safety.
Physical health monitoring of patients prescribed depot antipsychotic medication in north west Edinburgh community mental health team
Authors: Murdie Douglas , Wojtowicz Jakub , Thompson Alexandra , MacLeod Anne , Mallis Adam , Evans Hamsi , Haggart Joshua , Choi Hae , Argent Vikki 
Published: June 2021

AimsTo monitor the quality of physical health monitoring of patients prescribed depot antipsychotic medication in the North West Edinburgh Community Mental Health Team (CMHT). We also evaluated the completeness of prescriptions and Mental Health Act (Scotland) (Act) 2003 paperwork where relevant.BackgroundAntipsychotic medications are medicines for treating conditions such as Schizophrenia, but some may be associated with an increased risk of Metabolic Syndrome. Moreover, evidence indicates that patients with major mental disorder have a reduced life expectancy in comparison to those without such diagnoses. These two factors illustrate the importance of the physical health of this patient cohort being monitored on a regular basis. This project will evaluate how a local CMHT is performing, with the possibility of enacting service improvements if required.MethodThe records of the 60 patients prescribed depot antipsychotic medication administered by this CMHT were reviewed. A check-list was created consisting of 14 categories analysing the quality of physical health monitoring, as well as compliance with prescription standards and, where relevant, Mental Health Act (Scotland) (Act) 2003 paperwork. We compared patient records against our checklist for the calendar year of 2019. The Scottish Intercollegiate Guidelines Network (SIGN) 131 (Management of Schizophrenia) section 5.2 was used as the gold standard for physical health monitoring against which the data we collected was compared.ResultWe identified a wide range of flaws with the current system and implementation of monitoring, and difficulty in locating the required information. There was no consistent monitoring of physical observations on electronic record, nor an accepted alternative way in which this was documented. Furthermore, blood tests were not consistently obtained either by the service or GP practices in a reproducible manner. This led to discussions within the CMHT regarding creation of a new pathway for the monitoring of this patient cohort using a Quality Improvement model, with the ultimate goal to establish a regular physical health clinic.ConclusionThere is significant evidence that patients with major mental disorder do not access healthcare as consistently as those without, leading to a disparity in life expectancy. In light of the fact that antipsychotic medications can be associated with Metabolic Syndrome, we have an even greater responsibility to tackle this marked health inequality by appropriately monitoring our patients. This was not done well in this particular CMHT, but this project will lead to improvements in the service and ultimately patient care.
Clozapine clinics in north Wales - service evaluation audit
Authors: Raja Jawad , Azhar Zeenish , Malik Masood 
Published: June 2021

Aims1.Quality of clozapine clinic appointment2.Effectiveness of clozapine clinic servive3.Compliance with BCUHB guidelines for physical health monitoring in clozapine clinics4.We retrospectively audited 40 case notes 10 each from 4 differtent CMHT clozapine clinicsMy role in the Project & How does this represent my practice?
1.I was the audit and overall lead for this project2.I formulated the audit tool and registered my project with Audit Registration Team3.I lead data collection and compilation of resultsBackground1.This audit followed up from a Coroner's investigation for a clozapine clinic patient2.Clozapine is used for Treatment Resistant Schizophrenia but needs close monitoring due to potentially fatal side effects3.NICE recommends annual monitoring of weight, blood pressure, waist measurement, blood glucose and plasma lipid levelsMethod1.Has the patient been seen in the past year by clinician to monitor response to clozapine treatment?2.Has the clozapine plasma level been measured during the last year of treatment?3.Is brief MSE & Risk assessment documented during review?4.Has Life style modification advice been provided?5.Has annual physical health been completed?6.Has Annual CTP/CPA been completed and documented?7.Has the patient been allocated a named care coordinator?8.Has clozapine side effects monitoring been documented?Conclusion1.Clozapine is a superior medication for the treatment of refractory schizophrenia and is also be effective for other conditions2.Clozapine is underused due to a variety of barriers related to the drug and its properties, the health care system & regulatory requirements3.This service evaluation/quality improvement project provides the framework for clozapine clinics evaluation and recommends strategies for improvement
Urine drug screening in women's forensic mental health services: is current practice meeting guidelines?
Authors: Rampling Jeremy , Pantall Shay-Anne , Mann Ravinder 
Published: June 2021

AimsTo investigate adherence to Trust guidelines for urine drug screening amongst female forensic psychiatric inpatients.BackgroundThe use of illicit substances is an important risk factor which needs to be considered in the management and treatment of forensic psychiatric patients. Research has demonstrated that a high proportion of women admitted within secure services in the UK have a history of substance use. Substance misuse amongst this population can lead to an increased risk of violence, re-offending and mental health relapse; which can pose a significant threat to the safety of other patients, staff and the public. It is therefore important that regular drug screening is carried out to minimise such risks. Ardenleigh is a blended female secure unit in Birmingham. The service has established specific substance use guidelines, outlining the need for each patient to have a personalised drug screen care plan in place. Here we present the findings of an audit completed in 2019.MethodA six month retrospective electronic case note audit for female inpatients admitted to Ardenleigh as of 1st September 2019 (n = 27). We compared drug screen care plans and frequency of urine drug screens over 6 months with the recommendations of the current service-specific Trust guidelines. Care plans should include: information regarding random drug screening; frequency of random drug screening; triggers for increased risk of substance misuse; and consequences for a positive test result to be contained within inpatient care plans.ResultPatient aged between 20 and 56 years old (median age 31). Fewer than half of inpatients (41%) had a documented random drug screen completed within the review period. In terms of care-planning, only 52% of patients had random drug screening mentioned in their care plan. 22% of patient care plans reported the actions/consequences for a positive test result. Not a single care plan mentioned how frequently patients should be being tested or potential triggers for increased risk of drug misuse amongst inpatients.ConclusionCurrent practice and recording of drug screening amongst female forensic psychiatric patients is poor compared to expected standards. The lack of consistency in drug screening raises concerns regarding whether potential substance misuse amongst inpatients may be going undetected, and therefore impacting the recovery of patients. Improvements to drug screening practice should be considered in order to ensure optimal recovery and safety to patients and others.
High dose antipsychotic treatment monitoring audit
Authors: Scott Jake , Belda Jose 
Published: June 2021

AimsTo quantify how many patients were prescribed high dose antipsychotic treatment (HDAT) and establish whether guidance for monitoring HDAT was being followed in an Assertive Outreach Team.BackgroundSevere mental health disorders are associated with significant premature mortality, predominantly due to physical health conditions. Antipsychotic medications are associated with side effects, including metabolic syndrome and QT prolongation, which increase the risk of serious physical illness. HDAT is defined as when the total dose of antipsychotics prescribed exceeds 100% of the maximum BNF dose, if each dose is expressed a percentage of its maximum dose. There is limited evidence of clinical benefit with HDAT but an increased risk of side effects. Patients prescribed HDAT should therefore be monitored for side effects and clinical benefit. Sussex Partnership NHS Foundation Trust developed a form specifically for this purpose, to be completed in addition to a physical health assessment.MethodAll patients on caseload were audited using the electronic notes. Current inpatients were excluded, as inpatient HDAT monitoring forms are attached to paper drug charts and therefore were not available for review.ResultA total of 61 patients were audited. Nine were excluded due to being inpatients. 16 were on community treatment orders and 26 were prescribed a long-acting antipsychotic injection. 10 were prescribed clozapine. The median number of medications prescribed was one. Four patients were prescribed HDAT ranging from 117-150% of the maximum BNF dose. Of these four, one had a HDAT form but this was out of date. 39 of 52 (75%) patients audited had had a physical health assessment in the past 12 months. Two of the 13 missing a physical health assessment were on HDAT.ConclusionPhysical health monitoring should be carried out for all patients on antipsychotics, but is particularly important for patients on HDAT. This audit identified a problem in both general physical health checks and HDAT monitoring. On discussion with the multi-disciplinary team a number of barriers to appropriate physical health monitoring were identified. There was a lack of awareness within the multi-disciplinary team that patients were receiving HDAT and regarding the implications for side effects. A reliable system to highlight the need for physical health checks was also missing and the team did not have sufficient equipment to perform the necessary checks. Identifying these barriers should enable improvements in physical health and HDAT monitoring which can be re-audited.
A new handover protocol between old age admission and rehab wards
Authors: Carmen Aileen , Mahenthran Thanurshan , Hazan Jemma , Popescu Ioana 
Published: June 2021

AimsEfficient handovers are integral to patient care. Challenges to handover for wards include high patient turnover and varied handover approaches between wards, as well as admissions out of hours. Patients on Old Age Wards often have multiple comorbidities and can deteriorate rapidly without coordinated care. Our focus was on improving handover of patients transferred between the Old Age Admissions Ward and Rehabilitation Ward. We aimed to create a ward handover protocol to improve compliance with documenting a pretransfer plan and ensure there was an 80% compliance with completing this plan within 3 months.MethodAn MDT discussion took place in order to explore change ideas. Questionnaires were filled out post implementation of protocol. A handover proforma was designed to capture important patient data and continuing plans. A PDSA cycle was designed to deliver a structured handover.Per patient measures were collected including: whether a handover took place, recording of current medical and psychiatric issues, documentation of plan and was the plan put into action or reviewed.MDT feedback was collected on satisfaction with the protocol and handover process using open questions and Likert scale.ResultPrior to the establishment of the proforma there was no verbal or written handover between wards. In 28% of cases prior to the intervention, blood results were checked and medication reviews took place within the timeframe written in the patient's notes. A proforma was initiated and used for 93% of patient handovers between wards. Blood results were checked according to the planned timeframe in 86% of cases. Where the handover proforma took place, 100% of patients had a medications review. Qualitative detail revealed that key patient appointments such as MRI Brain scans and important plans such as fluid restriction limits were missed before implementing the protocol. Aftewards complex patient plans were recorded and implemented accordingly.Questionnaire feedback was positive and MDT found the proforma to be helpful and to improve patient safety.ConclusionThe team viewed the new handover pathway as a positive patient safety tool. Compliance with completing the protocol in the longer term and maintaining change is an area for ongoing improvement.