bluuebunny/crossref_metadata_2025_split huggingface dataset:
Audit of the Missed Seizure Rate and Management at Northamptonshire Healthcare NHS Foundation Trust (NHFT) Electroconvulsive Therapy Clinic
Authors: Moledina Sanaa , Jani Jaiker 
Published: August 2024

AimsThe audit aimed to study missed seizure frequency, management, and restimulation rate at NHFT's ECT clinic.MethodsWe conducted a retrospective analysis of ECT treatments administered between October 1, 2021, and March 21, 2023, collecting data on stimulation frequency and doses, duration of motor seizures and EEG activity, and patients' demographics. The study compared current practice with the NHFT ECT protocol, which defines missed seizures as treatments failing to induce convulsions and EEG activity. Management entails restimulation at least once or twice according to the stimulus dosing protocol during the seizure-threshold (ST) determination phase or by increasing the dose by 10% (50 millicoulombs) during the treatment phase, alternatively recording reasons for not re-stimulating. The ratio of missed seizures to total stimulations was used to determine the missed seizure rate, and the ratio of total restimulations to missed seizures was used to calculate the restimulation rate.ResultsThe clinic provided 268 treatment sessions and 26 courses of bilateral ECT to 23 patients aged 17–84 years, primarily female (60%) and Caucasian (74%), with a 12.6% missed fit rate and a 67.5% restimulation rate. Thirty missed seizures occurred during the initial ST determination phase, with twenty-two restimulated. Four of these could not be restimulated due to the maximum limit of three stimulations per ECT session. Seven missed seizures occurred later in the treatment phase, with three restimulated. For restimulations during the seizure-threshold determination phase, only eight of the twenty-two restimulation doses matched the stimulus dosing chart, and over half of these patients were stimulated at a lower-than-recommended dose. Once a seizure was generated and the threshold was identified, suboptimal maintenance doses were chosen, with 47% of patients stimulated on the same dose and 37% on doses only marginally over the ST in consecutive sessions. During the treatment phase, two out of three restimulations were performed with a dose lower than the specified 10% increase. The reasons for deviating from the guidelines were not documented.ConclusionNational audits of ECT clinics in 1981 and 1992 showed 50% and 25% missed seizure rates, respectively. Bridgend ECT Clinic maintained a missed fit rate of ≤5% over a 6-year period, which is half that of NHFT. Missed seizures have been associated with treatment failure and post-ECT adverse effects; hence, to effectively manage them, we propose that all ECT administration personnel be familiar with the NHFT ECT protocol, including the stimulus-dosing protocol, and document any clinical grounds for deviations.
Interactions Between Lamotrigine and Contraceptives – Communication Practises
Authors: Monir Samina , Atwine Cissy , Hutchings Helen , Harris Michael 
Published: August 2024

AimsThis audit assesses communication practices regarding interactions between lamotrigine and oral contraceptives in North West Sussex (NWS) Specialist Perinatal Mental Health Services (SPMHS).The predicted outcome includes increasing awareness about potential interaction between lamotrigine and contraceptives with resulting impact on patient safety.BackgroundLamotrigine is used for epilepsy and mental health disorders but can interact with contraceptives, affecting efficacy and safety. NICE recommends it for bipolar depression, relapse prevention and recurrent depression. Interactions with hormonal contraceptives can influence effectiveness of either drug and increase the risk of side effects. Patients on lamotrigine should be counselled so they can make an informed decision about taking the medication.MethodsReviewed records of all patient on the caseload on 21st June 2023. Collected data for lamotrigine prescription, indication, contraceptive method, and documented counselling. Calculated percentage of patients counselled on lamotrigine-contraceptive interaction.ResultsIn 261 patient records, 11.9% were previously or currently on lamotrigine or had a discussion about starting lamotrigine. 6.1% currently and 3.1% previously on lamotrigine. Counselling on lamotrigine's interaction with oral contraceptives was documented with 3.1%, while 74.2% received none. Indications for lamotrigine use were epilepsy 9.7% and mood stabiliser 90.3%. Of 27 patients who weren't currently pregnant, 9 of them were informed of the interaction risk while 18 were not. Contraception methods were documented for 10 individuals.ConclusionFindings showed the need for increased awareness about the interaction and documentation of appropriate discussions to inform their choice.
Audit of the Management of High Clozapine Levels Within Solihull Community Mental Health Teams (CMHTs)
Authors: O'Connor Sarah , Hashmat Huma 
Published: August 2024

AimsTo review the practice of management of clozapine plasma levels in Solihull CMHTs between April and September 2023. Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) clozapine guidelines were issued in January 2023 and further ratified in December 2023. The standard set out in the January 2023 guideline was that service users with elevated clozapine levels >600mcg/L should be assessed for signs of toxicity and consideration given to a dose reduction. Those with levels above 1000mcg/L should be reviewed urgently.MethodsClozapine blood clinic diaries were reviewed in order to obtain a list of 48 service users who had attended for clozapine blood tests between April and September 2023. Blood results were reviewed for clozapine level results. For those service users whose clozapine level had been over 600mcg/L, clinical notes were reviewed to determine whether they had been screened for clozapine toxicity.ResultsOf the 48 service users prescribed clozapine, 24 had clozapine levels over 600mcg/L and 11 had levels over 1000mcg/L. Of the service users with clozapine levels over 600mcg/L, 16 (67%) were screened for toxicity. Of those with clozapine levels over 1000mcg/L, 9 (82%) were screened for toxicity.ConclusionBetween April and September 2023, Solihull CMHTs demonstrated an understanding of the need for actioning elevated plasma levels as a priority, however, this could be further improved. The risks of adverse effects and toxicity with clozapine increase with raised plasma levels, particularly with levels over 1000mcg/L. Therefore, it is important that raised plasma levels are actioned accordingly. Locally, we have implemented a flow chart which summarises the updated clozapine guidelines, to assist clinicians in interpreting and acting on high clozapine levels and to prompt clinicians to review service users for signs of toxicity. We hope to incorporate this visual aid into the updated BSMHFT guidelines.
Equity on the Mother and Baby Unit: An Audit of Detention Rates and Length of Stay According to Ethnicity and English Language Ability
Authors: Eiman Najla , Senior Morwenna , Jones Sarah 
Published: August 2024

AimsA large body of evidence suggests that experiences of, and access to mental healthcare in England varies according to ethnicity. Inequitable use of restrictive interventions is of particular concern, including within perinatal services: a national-level study of inpatients on Mother and Baby Units (MBU) in 2017 found that 28% of white patients were detained under the mental health act (MHA), compared with 61.5% of Black African, and 66 – 77% of Asian mothers. We carried out an audit with the aim of examining detention rates, length of stay, and time to first section 17 leave on an MBU in South Manchester according to ethnicity and English language ability, to compare with national averages.MethodsWe identified all patients discharged from Andersen Ward (an MBU) between March 2022 and March 2023. Using electronic medical records we extracted information on: ethnicity, language spoken (English vs other), mental health act status (detained under Section 2/3 vs informal), duration of admission, date of detention, date of first Section 17 leave. We calculated the percentage of patients who were detained according to ethnicity (White British, Mixed/other, Asian, Black), and the odds of detention according to ethnicity. Statistical significance was assessed using chi-squared testing. We also compared average length of stay and time to first section 17 leave by ethnicity.Results74 patients had been discharged from the MBU within the audit period. 88% of Black inpatients were admitted under the Mental Health act, compared with 72.7% of Asian mothers, 33.3% of Mixed ethnicity or other ethnicities and 28.3% of white mothers. Differences in detention rates according to ethnicity were statistically significant. Of 11 mothers documented as having a language other than English as their primary language, all had been detained. Length of admission and days to first section 17 leave were not significantly different between ethnicities.ConclusionMany factors may contribute to the observed higher detention rates among non-White patients: language barriers and a lack of intercultural competence could lead to risk-averse decision-making during MHA assessments, and different help-seeking patterns might mean White mothers seek help earlier, or for less severe mental health problems. Recommendations include expanding access to high-quality interpreters; investigating factors underlying MHA decision-making through qualitative research; and improving cultural competence among section 12 approved clinicians by incorporating feedback from ethnic minority patients into training and refresher courses.
An Audit of Junior Medical Seclusion Review Documentation in the Adult Psychiatric Intensive Care Unit (PICU) setting
Authors: Sharma Anju , Khawaja Afshan 
Published: August 2024

AimsSeclusion facilities are frequently used in adult psychiatric intensive care units (PICUs). Seclusion refers to the supervision of a service user in a secure area.Aim: To evaluate whether trust standards for seclusion review assessments at Park House Hospital were being met.ObjectivesTo measure the quality of junior medical review documentation to determine whether reviews of physical health, risk, medication, and mental state exams (MSEs) were included. The time frames in which reviews were being undertaken and the rationale for seclusion were considered.MethodsA retrospective audit of notes on the electronic patient information system was completed. Those included were patients secluded between May 2022–October 2022. The majority of seclusions occur on the male PICU, or 136 suite. Eligible patients were identified following consultation with the business intelligence team within Greater Manchester Mental Health (GMMH). For those who had multiple periods of seclusion, the first episode of seclusion was audited. Data were obtained from the last recorded junior review prior to the seclusion episode being terminated. Progress notes and the internal MDT review documents were searched. This was compared against the local trust seclusion policy.Results20 patients were included in the audit. The majority had a diagnosis of either paranoid schizophrenia (40%) or schizoaffective disorder (25%). 95% of seclusion reviews had a clearly documented initiation time and rationale for seclusion. Physical health considerations were documented in 75% of reviews. 50% of junior reviews documented an assessment of risk to others, compared with 5% of reviews with documented review of risk to self. Half of all reviews had evidence of a MSE and medication review, including the use of rapid tranquilisation (RT). Of the reviews eligible for initial medical review within 60 minutes, this was completed in 44% of cases.ConclusionJunior medical reviews have consistently documented the rationale for seclusion and physical health reviews. Areas for development include clear documentation of MSE however documentation may be limited due to time constraint, lack of engagement from the patient or if patients are asleep. The policy since time of audit has changed to reflect this, where consideration must now be given to “overall psychiatric health”. It was found that risk to self largely remains undocumented, despite trust policy. There is evidence to suggest risk to self may increase during a period of seclusion. Another area of development includes medical review documentation to specifically comment on use of RT.
Audit of Quality of General Practitioner (GP) Referrals to a Local Memory Service in South Sefton
Authors: Adegbohun Abosede , Sibanda Shelton , Zafar Salman , Sikdar Sudip 
Published: August 2024

AimsTo assess the quality of General Practitioner (GP) referrals to a Local Memory Service in South Sefton – a reaudit.MethodsThe quality of GP referrals received from primary care to the Memory Clinic at South Sefton Neighbourhood Centre (SSNC), Mersey Care NHS Foundation Trust, was assessed over three months. This reaudit was based on an initial similar audit conducted in 2019 of 106 GP referrals to SSNC.The GP’s documented history and duration of memory loss, collateral history, and the impact of the patient's memory loss on activities of daily living (ADLs) were analysed. Also explored were the cognitive tests, physical examination, and completeness of blood investigations.The expected standard for completeness was set at 100%. Achieved compliance for each parameter was graded 95% and above (green), 75% to 94% (yellow), and below 75% (red).Results106 GP referrals were received in the SSNC Memory Service between June and August 2022. About 86% of the referrals had a history of memory loss noted by the referring GPs, while only 46% commented on the duration of memory loss. We observed increased documentation regarding the patient's history of memory loss, physical health status and cognitive testing. On the other hand, there was an 8% reduction in the referrals regarding the impact of memory loss on activities of daily living in comparison to the initial audit done in 2019.About a quarter of all the GP referrals were accepted based on the information the GP provided on the first referral letter sent to the service. On the contrary, 70 referrals were either considered inappropriate or declined outright. Alternative diagnostic advice was given to the referring GPs in 12, and the GP asked to provide additional information in 9 of these 70 referrals. After the GP offered further details, 17 initially rejected referrals were accepted for assessment.ConclusionEven though there were some observed improvements in the information GPs provided on referrals made to the local memory service in 2022 compared with 2019, this still fell drastically below the expected standard. The finding from this re-audit process brings to the fore the need for improved partnerships between memory services professionals and GP colleagues.A new referral proforma has been designed in collaboration with the local Integrated Care Board (ICB), detailing essential information that needs to be documented by the GP before a referral is sent to memory services
Assessment of Admissions to Psychiatric Intensive Care Unit (PICU) at Farnham Road Hospital, Guildford: A Clinical Audit
Authors: Singh Hardeep , Sultan Waseem , Alame Karim , Tagoe Reuben 
Published: August 2024

AimsThe primary aim was to analyze three months of admissions to Rowan Ward PICU (February 22 to April 2022) according to NAPICU's 2014 criteria, followed by implementing recommendations and conducting a re-audit (November 2022 to January 2023) to assess their impact. Secondary objectives included examining the link between prior PICU admissions and higher readmission rates, even when not clinically necessary.MethodsMethods involved assessing each admission against NAPICU's criteria and reviewing the reason for admission (RFA) for appropriateness. Data collection utilized various sources, including SystmOne, Mental Health Act assessments, and referral documents. Collaborative analysis with the PICU consultant was conducted due to the subjective nature of RFA interpretation.ResultsResults from the initial audit revealed that 12 out of 36 patients (33%) were deemed unsuitable for PICU admission, with 8 having prior PICU admissions (67%). Only 22% had documented multidisciplinary team (MDT) discussions. In the subsequent audit, 9 out of 38 patients (24%) were deemed unsuitable for PICU admission, with 2 having prior admissions (22%). Only 3% had documented MDT discussions.ConclusionThere was a reduction in inappropriate admissions from 33% to 24% in the subsequent cycle. This improvement was linked to the implementation of recommendations from the first audit, such as introducing a standardized referral form, enhancing consultant-to-consultant communications, and forming a PICU outreach team. While the initial findings indicated higher readmission rates for patients with prior PICU admissions, this trend lessened in the subsequent evaluation. However, there is still insufficient documentation of Multidisciplinary Team (MDT) discussions, highlighting the need for a re-audit to accurately assess any changes.
Re-Evaluating Rapid Tranquillisation Practices in Elderly Patients (over 65 Years of Age) at a General Hospital: A Follow-Up Audit
Authors: Singh Hardeep , Wrench Harrison , Jenkinson Josie 
Published: August 2024

AimsThis re-audit of rapid tranquillisation (RT) practices in patients over the age of 65 at a district general hospital took place as part of a wider quality improvement project to assess whether practices had improved following previous audits.MethodsData was accessed using the hospital's electronic patient record system. Drug charts for patients over 65 admitted to six wards (total n = 172) were reviewed. The wards comprised three geriatric wards, two medical wards, and one surgical ward. Drug charts were reviewed using the audit tool developed in previous audits, which has been designed to collect relevant data according to the recognised standard (in this case the local mental health trust's RT guidance). Data was collected on RT type, RT frequency of RT, RT route, indication documentation, post-RT monitoring, nature of prescription (PRN, stat, or regular), underlying diagnosis of delirium or dementia, and involvement of specialist teams.Results•Of the 172 audited patients, 9 (5.2%) received RT, compared with 13 out of 297 (4.3%) in the previous 2022 audit.•PRN remained the most common prescription pattern, with two designated as stat and the remaining three mostly stat but occasionally incorporating PRN. Intramuscular administration continued to be the most common route in both cycles.•In the current cycle, the maximum frequency was indicated in 55.5% of cases, whereas it was not indicated in the previous cycle.•In the current cycle, indications were documented for 88.8% of prescriptions, a significant increase from 50% in the previous cycle. Furthermore, there was almost 100% compliance in nursing/medical documentation of RT administration in patient notes, which was lacking in the previous audit.•Psych liaison or dementia team involvement was observed in around 33% of cases in the current cycle, whereas it was not evident in the previous cycle.•Post-sedation monitoring in line with policy was not evident in either cycle.ConclusionOverall, both audits highlighted consistent challenges in prescription practices and post-administration monitoring, albeit with variations in compliance levels and team involvement. Since the completion of this re-audit, a new RT policy has been approved which has much clearer guidance for the general hospital. This RT policy will be launched with a programme of teaching and training for the hospital. We aim to track progress by conducting a re-audit within 6–12 months.
Completion Audit of Inpatient Glasgow Anti-Psychotic Side-Effect Scale (GASS) Forms
Authors: Tait Andrew , Wong Eugene 
Published: August 2024

AimsSide-effects are a recognised burden of all medications and are linked to poor compliance. In psychiatry, poor compliance can result in a relapse and significant deterioration in mental health. This has an impact on both the patient and the wider healthcare system. It has been speculated that if patients had more control/recognition of side-effects, compliance would increase.GASS is a self-rating scale for side-effects of antipsychotic medication. It has the added effect of being able to stratify side-effects by their severity and biological system involved (Central Nervous System (Sedating) effects, Neurological (Movement) disorders, Anticholinergic, Gastrointestinal and Endocrine). The form consists of 22 questions with a scoring sheet attached to the reverse. Symptoms are graded by frequency and patient's perceived burden.The British National Formulary has ‘minimum standards’ expected. These are designed to create a standardised approach to side-effect reviewing, encouraging a proactive reviewing process. These are meant to take place: After initiation and dose titration, at 3 months and annually thereafter. The National Institute for Clinical Excellence Guideline CG178 and the Scottish Intercollegiate Guidelines Network (Guideline-131) both advocate this standardised approach with the gold standard adding a review at 1 month.The aim for this project was to audit the current completion rate of GASS forms in inpatient wards. The secondary aim was to improve completion rates after intervention.Methods1.Search case notes and extrapolate data to Microsoft excel.2.Review data and identify challenges perceived from staff.3.Implement changes targeting highlighted challenges.
1.Present at ward QI meetings.2.Create & discuss Infographic for staff.3.Highlight role/importance of forms and usefulness to clinicians.4.Re-audit after 2 months.ResultsInitial results found a completion rate of 7% across both wards reviewed (n = 41). Within this, 1 form was actually valid. One of the wards had no completed forms. The post-intervention group had fewer patients involved (n = 35), but an increased number of completed forms. Completion rate had risen from 7% to 26% (3–9 patients). Within this, the valid forms had increased from 1 to 4.ConclusionThere was a clear impact on completion rate after initial interventions. The sub-optimal increase in completion highlighted the ongoing need for further input to improve completion rates.This was a small, local audit of patients in an acute inpatient psychiatric ward. There was a recognised limitation on the number of patients in the study and acuity of some patient's illness, preventing completion.