bluuebunny/crossref_metadata_2025_split huggingface dataset:
Improving Handover Between Psychiatric and Acute Wards
Authors: James-Thomson Hilary 
Published: August 2024

Aims1.To develop an understanding of transfers in both directions between Psychiatry and the other Acute wards within FVRH.2.To improve compliance with National standards of handover as laid out by NICE and GMC.MethodsData was taken from a combination of the care partner, trakcare, and HepMA systems looking at the quality, content and professionals involved in handover. This was done for all transfers in and out of 2 old age psychiatry wards over a 2 week period. The auditing of transfers into MHU and transfers out of MHU initially started as 2 separate projects with staggered data collection; these were combined after baseline data was collected, and the intervention and re-audit phases treated the two as a single project. Data was compared with the standards collated from GMC and NICE guidance.ResultsTransfer handovers in neither direction met audit standards at baseline assessment.Interventions focusing on behavioural change in the mental health unit did achieve behavioural change but failed to solve issues with handover between departments.It is worth noting that there was significant delay in some transfers out of mental health being escalated, considering the reduced facilities in mental health wards versus acute wards.ConclusionTransfer handover between Psychiatry and Acute Wards is a multi-system issue and as such will require a multi-system approach to achieve meaningful change. New local guidance for handover between mental health and acute wards is being drafted in response to the findings of this audit.
Monitoring of Blood Clozapine Levels After a Change in Smoking Status for Patients Treated With Clozapine: A Clinical Audit From Hull Community Mental Health Team
Authors: Mahmood Kamran , Anakebe Odira , Theobalds-Ward Keshia , Gulati Madhu 
Published: August 2024

AimsAccording to The Medicines and Healthcare products Regulatory Agency (MHRA) Drug safety update in August 2020 regarding clozapine, monitoring blood clozapine levels for toxicity is now advised in certain clinical situations such as when a patient stops smoking or changes to e-cigarette.Aim of this audit was to determine whether blood clozapine levels are being performed in patients on clozapine when there has been a change in patient’s smoking status from two localities, East and West Hull community mental health team.Because there is a risk of significant blood clozapine change within 3–5 days post starting or stopping smoking which consequently increases the risk of toxicity, we also looked at whether a medical review was undertaken post change in smoking status in order to review if any adjustment was required in current clozapine dose.MethodsA list of Hull CMHT patients on clozapine was obtained from local clozapine clinic. The data comprised patients who were on clozapine from both localities of CMHT between October 2022 to October 2023.Data was obtained retrospectively from Trust's patient electronic record system.Eligibility criteria was set for the patient on clozapine to be a current smoker, or have been a smoker over last 12 months. Non-smokers and the ones on clozapine without a change in smoking status over the duration period were excluded.58 patients were identified to be smokers and taking clozapine. Change in smoking status was documented in 21 instances, and therefore included in final analysis of results.Results42.86% patients had a clozapine blood level check post smoking status change.19% of patients from our sample had a medical review after change in smoking status within the duration time of audit.ConclusionWe concluded that compliance with current MHRA guidelines in relation to blood clozapine levels and change in smoking status is quite poor in Hull CMHT and measures are needed for improvement.We recommend that every patient with a change in smoking status must have blood clozapine level checked within a week of any change in smoking status and a medical review in two weeks. We identified some scope of improving current clozapine monitoring form on electronic system and recommend changes by adding a section where change in smoking status is recorded.
Lithium Prescribing on an Older Adult Inpatient Ward and Trialling Improvements to Communication on Discharge
Authors: Patkee Wishwanath , Barclay James 
Published: August 2024

AimsLithium is the recommended first-line pharmacological treatment for bipolar disorder and as an augmentation of the treatment for depression. Both NICE and local guidelines stipulate the need for patient counselling regarding side effects, interactions and toxicity, alongside strict monitoring requirements for initiation and maintenance.We aimed to assess compliance with these guidelines for patients prescribed lithium on a functional older adult inpatient ward in Hertfordshire Partnership NHS Foundation Trust (HPFT). Additionally, following feedback from the local crisis and community colleagues, concerns were emphasised around inconsistent communication on discharge. We therefore also aimed to evaluate the introduction of a small-scale intervention to the method of discharge communication.MethodsA retrospective analysis of electronic patient records was undertaken for the 43 patients within HPFT prescribed lithium during their inpatient stay on a functional older adult ward over a five-year period (2019–2023).Lithium monitoring on drug initiation was assessed for compliance with the standards set by NICE guidelines for the management of bipolar disorder. For all patients prescribed lithium, we also noted demographics, diagnosis, rate of side effects and toxicity, discontinuation, and documentation of discharge communication to the community. A standardised template for communication with community and crisis colleagues was introduced, and its impact was assessed.Results58% (n = 25) of patients were initiated on lithium, with 80% (n = 20) of them having documentation of counselling. Baseline blood tests were consistently recorded for all newly prescribed lithium patients (n = 25), and regular serum monitoring was present in all patients. Common side effects included tremors (26%; n = 11) and polyuria (7%; n = 3), while in 63% of patients (n = 27), no side effects were noted. Toxicity occurred in four cases, leading to discontinuation in 50% of them.Prior to concerns being highlighted around handovers to community colleagues, there was specific documentation of a handover in 19% (n = 6) of cases. Following consultation with stakeholders and consensus regarding the trial of a template for communication to the patient's community consultant, documentation improved to 75% (n = 6).ConclusionAll patients in this study who were initiated or maintained on lithium received serum monitoring as inpatients in accordance with NICE guidelines. The introduction of small-scale improvements with a standardised template has been effective, significantly improving discharge communication with community colleagues for patients on lithium. Further research is necessary to elucidate the impact of these changes on patient care in the community by gathering feedback from a diverse group of community colleagues.
An Audit: Compliance of Controlled Drug Prescriptions With Legal Requirements and Approved Home Office Wording
Authors: Saeger Ivan , Sandhu Callum , Kelleher Michael 
Published: August 2024

AimsThe completion of methadone and buprenorphine prescriptions, together: opioid substitution therapy (OST), must conform to legal requirements for the prescription of controlled drugs (CDs) as well as Home Office approved wording when writing instalment prescriptions.Our service uses a part automated printing system for individual prescriptions and uses a manual record to track prescriptions issued for individual clients over time, a “script record”.We aimed to audit the terms used on the internal script record as well to audit compliance of OST prescriptions with the legal requirements for CD prescriptions and Home Office Approved wording for instalments.MethodsAll prescriptions for methadone or buprenorphine over the course of a week that were prepared for signing were audited.The prescriptions were audited against the legal requirements for writing CD prescriptions and against Home Office approved wording for instalment prescriptions.The script record was audited against internal standards for variation of terms used to describe frequency of collection of instalments.ResultsA total of 64 prescriptions were audited.100% of prescriptions complied with the legal requirements for the prescription of CDs.7 prescriptions (11%) omitted Home Office approved wording to instruct what should be done on days when the dispensing pharmacist was closed, i.e. that instalments should be dispensed on the prior open day.46 prescriptions (72%) had additional Home Office approved wording that was not applicable to the script. For example additional wording to allow for pickup of part of an instalment following a missed day, when the prescription was only for daily supervised consumption to begin with.Audit of the internal script record found a total of 13 different terms used to describe frequency of collection of instalments; there are 6 standardised terms used within the internal script record. On 2 occasions the frequency of collection of instalments was left blank.ConclusionIt is essential that prescriptions for controlled drugs follow the legal requirements laid out for them; within the scope of our audit these were entirely adhered to.There was however more variability in the use of the Home Office approved wording for instalments of OST. Scripts here tended to error for including additional wording not relevant to the specific script. Additionally, the service's own internal script record showed variability in the terms used to describe frequency of collection.It is evidently important that the wording on prescriptions is clear and concise and the terms used internally are standardised.
Audit of Admissions to Acute Psychiatric Inpatient Unit of Patients With Eating Disorders/Disordered Eating
Authors: Sanglikar Roopa , Martyn Gabriela 
Published: August 2024

AimsThe aim of this study was to understand current clinical practice, adherence to evidence-based guidelines, and the perceptions, knowledge and attitudes of the multidisciplinary team caring for inpatients with eating disorder/disordered eating on general adult psychiatric ward.MethodsThe audit was undertaken at inpatient general adult psychiatry ward between 1st July 2022 to 30th April 2023. A retrospective method was used to collect data on admissions of patients with eating disorder/disordered eating alongside qualitative data retrieved for perceptions, knowledge and attitudes of the multidisciplinary team (MDT) and use of and adherence to national guidelines. The data was collected from everyday bed state and MDT handover, admission summary, electronic notes which included physical health charts and discharge summaries. The MDT staff involved were nurses, doctors, health care assistants, dieticians, psychologist, and occupational therapist.Patients were included if eating disorder management was indicated and undertaken at some stage during the admission, even if the eating disorder was not the primary reason for admission. The age group was above 18 years and included male and female patients. Eight discrete admissions (6 females, 1 male and 1 transgender patient) were included in the audit. Adverse events like refeeding syndrome, electrolyte derangement needing Intravenous/Nasogastric tube feeding, self-harm, level of cooperation between medical and community eating disorders team, community mental health teams and outcomes were recorded. Data analysis was done through Microsoft Excel. Percentages of patients who had met each of the standards were calculated. Documented practices were compared in line with standards of NICE (National Institute for Health and Care Excellence) guidelines and MEED (Medical Emergencies in Eating Disorders) guidelines.ResultsThe audit concluded that gaps exist between evidence-based practice and patient care. Despite being admitted due to concern about eating difficulties, a substantial number of patients were not given an eating disorder diagnosis on discharge. And the patients who had eating disorder as primary diagnosis had limited inreach support from specialist team.ConclusionThere is major challenge in management of disordered eating presentations within inpatient general adult psychiatry units and inreach specialist support for those admitted with eating disorders as primary diagnosis. These findings emphasize for targeted implementation strategies to improve patient care and uptake of research into practice.
Audit of Shared Care Guideline Compliance for ADHD Patients: Monitoring Physical Observations by General Practitioners
Authors: Utomi Chinwe 
Published: August 2024

AimsTo evaluate the adherence to shared care guidelines for ADHD patients by assessing if their Blood Pressure, Pulse Rate, and Weight have been monitored at least twice within the last year by their GP, as recommended by NICE guidelines.Following initiation and stabilization on an ADHD medication, shared care with the GP is initiated whereby the GP is responsible for prescribing the medication, and monitoring physical observations every 6 months.MethodsData Collection:
a. Collate the list of patients that were due for annual structured review in August and September 2023 from the team's shared drive.b. Randomly select 50 patients from this list.Inclusion criteria:
1. Patient must have been on ADHD medication in the past 12 months.Data Assessment:
a. Access the GP records (Patient Practice Management system) for the selected 50 patients.b. Review the patient records for each of these 50 patients to identify when Blood Pressure, Pulse Rate, and Weight measurements were recorded within the last 12 months.c. Record the date and results of the Blood Pressure, Pulse Rate, and Weight measurements for each patient.d. Determine if each patient had these measurements done at least twice within the last year as per NICE guidelines.e. Calculate the percentage of patients who met this guideline.ResultsSample size: 22 patients patients met the inclusion criteria.
•Blood pressure checked within the last 6 months – 22/22 (100%)Blood pressure checked within the last 1 year – 19/22 (86%)•Pulse rate checked within the last 6 months – 20/22 (90%)Pulse rate checked within the last 1 year – 18/22 (81%)•Weight checked within the last 6 months – 21/22 (95%)Weight checked within the last 1 year – 20/22 (90%)8 out of 22 had a “significant” change in their BP reading.This significance is in keeping with NICE Guidelines that is, an increase of 2–4 mmHg for patients on ADHD medication, but this is generally not significant in terms of risk.How was the project outcome disseminated?A letter was sent out to GP practices commending the positive outcome of the audit. Recommendations for further improvement were suggested flagging up a review if there is a reduction of 10% or more in body weight within 12 months of treatment.ConclusionThe positive outcome of the audit shows the effectiveness of current practices. However, it's important to maintain a commitment to ongoing improvement. Regular evaluations and audits remain essential to adapt to evolving guidelines, address emerging challenges, and sustain a culture of excellence in healthcare delivery.
Community Clozapine Initiation Practice
Authors: Yisa Kabir , Ghaly Adel , Cumming Louise , Adenusi Taiwo 
Published: August 2024

AimsTo establish the proportion of CMHT Preston service users with schizophrenia who met the NICE standard (CG 178) of being offered clozapine after inadequate response to treatment with at least two antipsychotic drugs.MethodsInclusions – Service users on the CMHT Preston caseload with schizophrenia who attended outpatient clinic between January and June 2023.Exclusions – Organic psychosis and non-schizophrenic/unspecified psychosis.Sample size – 50.Sampling – First 50 service users with established diagnosis of schizophrenia.Data collection – Retrospective case-note audit from electronic patient records.Data analysis – Quantitative.Results45 service users (90%) met the clozapine eligibility criteria of not responding adequately to or tolerating at least 2 other antipsychotic medications while 5 service users (10%), did not meet the criteria. The proportion of eligible service users who were offered clozapine, and therefore met the standard, was approximately 64%, representing 29 out of the 45 eligible service users. Approximately 36%, representing 16 eligible service users, were not offered clozapine. In one isolated case, a service user who had only 1 previous antipsychotic trial and therefore did not meet the eligibility criteria, was offered clozapine. No reason was given in 13 out of the 16 service users who were not offered clozapine despite meeting the eligibility criteria. In the remaining 3 service users in this group, 2 were not offered clozapine because of cardiac problems and 1 was not offered because of significant history of poor compliance with antipsychotic medications. Furthermore, 25 eligible service users (86%) of those who were offered clozapine went on to initiate it with only 4 service users (14%) in this group not going ahead to initiate clozapine. In all 4 service users who did not initiate clozapine after being offered, the reason given was that the service users declined it.ConclusionThe findings from this audit indicate that a considerable proportion (64%) of CMHT Preston service users with schizophrenia are being offered clozapine in line with the NICE standard, and 86% of those offered went on to initiate clozapine. However, there is room for improvement in terms of offering and ultimately initiating clozapine in a timely manner as evident from the findings which highlighted an average of three antipsychotic trials before eligible service users were offered clozapine. The existing established local clozapine community initiation pathway can potentially be optimised to improve clozapine access and ultimately enhance clinical outcomes for this subset of service users.
Monitoring the Conformance of Patients Undergoing Electroconvulsive Therapy (ECT) Treatment to Electroconvulsive Therapy Accreditation Services (ECTAS) Standards at Worcestershire Specialist Mental Health Services
Authors: Youssef Nancy 
Published: August 2024

AimsTo confirm that 100% of patients treated by Electroconvulsive Therapy (ECT) have weekly assessment of mental state via Montgomery–Åsberg Depression Scale (MADRS).To confirm that 100% of patients treated with Electroconvulsive Therapy (ECT) have regular assessment of their cognition before treatment and every 4 treatment sessions via the Montreal Cognitive Assessment Scale (MOCA).MethodsThis Audit included all service users attended ECT suite regularly at Worcestershire Specialist Mental health services over a period of 12 months between April 2022 and April 2023.Twenty patients were included in this audit for whom data was collected from both electronic and paper records to analyse the percentage of compliance with the Electroconvulsive Therapy Accreditation service (ECTAS) standards with regards to the recommended weekly assessment of mental state via MADRS and the recommended regular assessment of cognition before treatment and every 4 treatment sessions via the MOCA Scale.ResultsThe Audit included 20 patients having ECT treatment done regularly over a year.Overall, 87.32% of the patients were found to have MOCA assessment done before their first ECT session and every 4 treatment sessions as per guidelines. While 96.29% of the patients had MADRAS assessment done weekly or every two treatment sessions as per guidelines.Regarding MOCA assessment, it has been found that 80% of the patients had MOCA done before their first treatment session. 94.73% of the patients had MOCA done after their 4th treatment session. 89.47% of the patients had MOCA done after their 8th treatment session. And 84.61% of the patients had MOCA done after their 12th treatment session.With regards to MADRAS, 100% of the patients had MADRAS done before the start of the treatment. 90% of the patients had MADRAS done after the second treatment (1st week). 100% of the patients had MADRAS done after 4th treatment (second week). 100% of the patients had MADRAS done after 6th treatment (third week). 93.33% of the patients had MADRAS done after 8th treatment (4th week). 92.85% of the patients had MADRAS done after the 10th treatment (5th week).ConclusionOverall, ECT practice at Worcestershire Specialist Mental health services has been found to be in compliance with the ECTAS guidelines.The majority of patients had MOCA assessments done regularly every 4 weeks with the highest compliance found to be after the first 4 treatment sessions and the lowest compliance was for the MOCA assessment done before the start of the ECT treatment.In terms of MADRAS assessment, there was an overall adherence with the guidelines with very few patients missing MADRAS assessment only once over their course of treatment.
Cognitive Decline With Low-Dose Procyclidine and Improvement Following Removal of Anticholinergic Burden
Authors: Aboelenien Shaimaa , Cherian Vinu , Philip Joel 
Published: August 2024

AimsA recent Cochrane review published in December 2023 concluded that “no trials found that interventions to reduce anticholinergic burden led to any other improvements in cognition compared to usual care”. We describe the case of a 62-year-old lady who developed significant cognitive decline following the initiation of a low dose of procyclidine, which was rapidly reversed upon stopping the medication.MethodsWe present the case of a 62-year-old lady with a diagnosis of schizo-affective disorder, whose symptoms had been stabilized on a regime of lithium carbonate 500mg nocte, sulpiride 400mg BD and fluoxetine 20mg OD. When the patient presented to the outpatient clinic, she was noted to have bilateral coarse tremors and slight cogwheel rigidity. Procyclidine was started at a dose of 5mg OD to manage these extrapyramidal side-effects.Following this, family members reported that the patient had difficulty initiating and following conversations. Short-term memory was affected and she was observed to have reduced attention span. These problems were reportedly getting worse with time, with a simultaneous decline in functional abilities. She was no longer able to carry out her daily shop, and family members ensured that she was no longer driving as they had concerns about her road safety. She stopped taking procyclidine after 1 month and notably, these problems ceased within one week of stopping the medication.Cognitive testing confirmed that the patient was cognitively intact after procyclidine was stopped. The patient scored 96 on the ‘Addenbrooke's Cognitive Examination’ scale, which falls within the normal range. The ‘Instrumental Activities of Daily Living’ scale was administered to assess functioning at the time of the cognitive impairment. This returned a score of 1/8, indicating that there was significant functional impairment secondary to cognitive impairment when prescribed procyclidine. The ‘Informant Questionnaire on Cognitive Decline in the Elderly’ was administered to objectively quantify the extent of cognitive decline as noted by family. This returned a score of 4.3, confirming that the patient's cognition had indeed been worse when compared with her baseline.ResultsOur case report highlights the rapid improvement in cognition with the removal of anticholinergic burden in a 62-year-old female. Our report can, therefore, be a harbinger for more robust trials to determine the efficacy of interventions to reduce anticholinergic burden in preserving or improving cognition.ConclusionIt is important to monitor for any change in cognition when prescribing anticholinergic medication in at-risk individuals.