bluuebunny/crossref_metadata_2025_split huggingface dataset:
An Initial Audit of Delirium Detection and Management in an Intensive Care Setting
Authors: Barcelos Yzobelle , Mohanathass Kirthika 
Published: August 2024

AimsIn the intensive care unit (ICU), delirium occurs in up to 80% of patients on mechanical ventilation. Delirium is associated with an increased risk of morbidity and mortality, long-term cognitive decline, and risk of reintubation. This initial audit aims to identify areas of improvement in the early detection, prevention, and management of delirium in the ICU of the general hospital following trust guidelines.MethodsIn this baseline audit, data was collected about all inpatients on admission over a 7-week period (81 patients in total). The parameters audited were in accordance with trust guidance on the management of delirium and compliance to this was recorded. Parameters included: the correct use and documentation of screening tools, type and cause of delirium, pharmacological and non-pharmacological management, and other demographics such as sensory impairment and length of stay. Confused patients handed over verbally during ward rounds were also assessed again at the time, with documentation and parameters reviewed.ResultsOf the 81 inpatients in the ICU, 20 were observed with delirium during their stay. The documentation of delirium via the CAM-ICU screening tool was incorrect in 25% of patients with delirium (PWDs). Furthermore, behaviour (including sleep) was only monitored for 15% of PWDs and 0% had a complete “This is me” document (support tool for patient-centred care).Sensory aids were not available for 50% of PWDs and 25% of this group had drug/alcohol dependence. A diagnosis of delirium was only formally documented in 40% of PWDs and of these, 15% had the type of delirium documented. Only 8 PWDs received a specific management plan, with 6 PWDs receiving haloperidol or lorazepam for agitation. Non-pharmacological managements were not documented.The average length of stay in the hospital was 20% longer in PWDs compared with non-delirium patients, with 10 deaths in the ICU; 50% of these being PWDs.ConclusionThere is a lack of accurate documentation and a lack of medical optimisation for PWDs, which may lead to missed delirium diagnosis, greater risk of mortality and longer hospital stays. The results highlight a need for further education about delirium in the ICU, to increase awareness for better detection, prevention and promotion of appropriate delirium management and formal documentation as per trust guidelines. Furthermore, a need to consider alternative pharmacological management for delirium, specifically in the ICU where lorazepam and haloperidol may not be suitable in consideration of anaesthetic drug interactions and respiratory support requirements.
Use of Treatment Escalation Plans to Guide Care Planning on a Specialist Dementia Unit
Authors: Russell Charlotte , Calvert Lucy 
Published: August 2024

AimsThis audit reviewed the use of Treatment Escalation Plans (TEPs) on the Borders Specialist Dementia Unit (BSDU). We aimed to use data on completion rates and quality to adapt the TEP form to both improve practice and develop a more specialised form for use in inpatient old age psychiatry.TEPs improve clinical decision-making in frail and elderly patient populations, and are commonly used on medical wards. However, these forms are primarily orientated towards acute medical environments and may not be appropriate for use in psychiatric inpatient settings, despite the clear benefits they could provide in this patient group.MethodsThis retrospective audit reviewed completion rates and quality of completed TEP forms for 10 BSDU inpatients in December 2023. Data was gathered by reviewing TEPs and using a data collection form to collate information on completion rates and quality of information provided. Both the TEP form and the ReSPECT form were used to review what information would be relevant to include when completing TEP forms for new admissions to BSDU.ResultsSome sections of TEP forms were consistently well-completed – typically those that were quick to complete e.g. tick boxes. However, limitations of the existing TEP form reduced these sections’ usefulness in practice. Most significantly, the form does not indicate whether “ward level care” refers to care on the old age psychiatry ward, or transfer to a medical ward. The “Additional Information” section, which could be used to clarify the patient's ceiling of care and transfer status, was only completed in 40% of cases, despite being particularly relevant to the BSDU patient population. In addition, this audit highlighted that there is no process for reviewing TEPs to ensure they remain appropriate for the patient, which is particularly relevant for old age psychiatry inpatient populations due to their advancing frailty and quickly changing clinical picture.ConclusionThis audit showed that the current TEP form is not ideally suited to old age psychiatry settings. However, this could be improved with simple adaptations such as distinguishing between psychiatric ward care and medical ward care, and adding a review date to ensure these forms are regularly updated in light of the advancing frailty of old age psychiatry inpatient populations. I would also recommend implementing an initial review of TEP forms shortly after patients are admitted, to ensure the information contained on them is accurate and that they are countersigned by the responsible consultant.
Autistic Spectrum Disorder in Young People Presenting to a Paediatric Specialist Fatigue Service
Authors: Chute Rachel , Barona Manuela 
Published: August 2024

AimsTo investigate whether young people referred to a paediatric specialist fatigue service present with higher levels of autistic traits or have higher prevalence of Autistic Spectrum Disorders (ASD), than those found in the general population.Methods143 initial assessment reports of young people presenting to a paediatric specialist fatigue service were audited over a 5-month period to identify cases where a previous diagnosis of ASD has been documented, or the assessing clinician has recommended referral for an ASD assessment, or autistic traits have been documented in neurodevelopmental screening. Comparative data on age, gender, age of symptom onset, duration of symptoms, reported symptoms, comorbidity, family history, and sleep difficulties was then explored to help us identify/understand the profile of the young people who present to our service. Routine mental health screening questionnaire data from the Revised Children's Anxiety and Depression Scale (RCADS) was analysed in addition to clinical reports regarding mental health comorbidities.ResultsOf the 143 young people presenting to the specialist fatigue service over the 5-month period, 16 had a diagnosis of ASD, and 41 were suspected as having ASD. In total, 39% of service users had, or were suspected of having, ASD. The prevalence was higher in female service users than males with a total of 48% of female service users having, or being suspecting of having ASD, compared with 22% of males. Comparative data demonstrated that autistic/suspected autistic young people presenting to the service were more likely than their neurotypical counterparts to be: over 13 years old, have a longer symptom duration before presentation, have an Educational Health Care Plan, report friendship difficulties, have a family history of neurodiversity, report sensory difficulties, and have sleep difficulties. RCADS scores found that the ASD group were more likely than the neurotypical group to have clinical levels of anxiety (58.3% vs 15.3%) and depression (80.6% vs 58.3%).ConclusionOur audit suggests that there is a higher prevalence of young people with ASD/ASD traits presenting to a paediatric fatigue service than found in the general population. Reasons for this may relate to undiagnosed ASD presenting as severe fatigue due to the energy draining nature of camouflaging, as well as sensory overload, known as autistic burnout. Do we need to develop a specialist treatment pathway which is better adapted to these young people's needs? We are planning a follow up study and focus groups to explore this complexity further.
Improving the Assessment and Management of Sleep Problems in a Specialist NHS Gambling Treatment Service
Authors: Fagan Harry , Austin Holly , King Mat , Chamberlain Samuel , Ioannidis Konstantinos 
Published: August 2024

AimsSleep disorders, such as insomnia, are common in the general population and in patients with psychiatric conditions including the behavioural addiction Gambling Disorder (GD). The NHS Southern Gambling Service (SGS) is a tertiary centre providing evidence-based assessment and treatment for people affected by GD across the South-East of England. We aimed to assess the prevalence of sleep problems in help-seeking adults with gambling difficulties, including the association with gambling severity and other measures of psychopathology, and determine if 1) sleep is appropriately assessed and 2) whether sleep disorders are appropriately diagnosed and managed, in line with NICE guidelines, in this particular cohort.MethodsAll patients referred from September 2022–October 2023 who completed an initial clinician assessment were included. Gathered data included age, gender, pre-existing physical health conditions, and scores from the following questionnaires: Gambling Symptoms Assessment Scale (GSAS), Pathological Gambling Yale-Brown Obsessive Compulsive Scale (PG-YBOCS), Brief Pittsburgh Sleep Quality Index (B-PSQI), Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder 7 (GAD-7). Data analysis was performed under ethical approval (23/HRA/0279). Relationships between gambling severity and sleep quality, and depressive/anxiety symptoms were explored (using Pearson correlation coefficient). In patients with a B-PSQI score > 5 (suggestive of underlying sleep disorder), we determined whether sleep problems were appropriately assessed and managed.Results83 patients completed an initial clinician assessment (81% male, average age 38 years). Baseline B-PSQI scores were weekly positively correlated with gambling severity on the GSAS (r = 0.18) and the PG-YBOCS (r = 0.10) and anxiety symptoms severity on the GAD-7 (r = 0.26). Baseline B-PSQI scores were moderately positively correlated with depressive symptom severity on the PHQ-9 (r = 0.39) and higher B-PSQI scores were noted in patients reporting suicidality.54/83 (65%) patients had a baseline B-PSQI score > 5, of these, seven (13%) had a clearly documented management plan for insomnia in line with NICE guidelines.ConclusionMost patients referred to SGS had baseline B-PSQI scores suggestive of current sleep problems. B-PSQI scores were positively correlated with gambling severity and severity of anxiety and depression. Findings highlight that sleep problems are common in people presenting to the NHS gambling service, but also that there is scope to improve and extend signposting for affected individuals to receive sleep-specific support. The audit findings have been presented to the SGS team; resources for the assessment and management of sleep problems have been shared and a re-audit is planned for Summer 2024.Additional authors: Dr. Jodi Pitt, Esther Gladstone, Dr. Peter Hellyer.
Monitoring Initiation and Administration of Covert Medication(s) for Service Users in Amber Ward of Millbrook Mental Health Unit, Nottinghamshire Healthcare NHS Foundation Trust: A Re-Audit of Compliance With Maudsley Prescribing Guidelines in Psychiatry
Authors: Hammed Silvester , Kinch Adam , Rajamani Anto 
Published: August 2024

Aims1.To evaluate standards of practice regarding initiation and administration of covert medication(s), with comparison to the previous audit completed in January 2021.2.To highlight improvements and weaknesses requiring further recommendations for effective future practice.MethodsThis clinical audit assessed the current practice in Amber Ward (Old Age Ward for Dementia patients) against the same standards of practise used in the previous audit.The Audit Checklist included 10 standards from Maudsley prescribing guidelines for Covert Medication Pathway.A retrospective review of the paper and electronic records of 21 service users initiated on a covert medication plan between January 2021 and June 2022 was carried out.A descriptive statistic on the data and presented results in tables comparing frequencies and percentages with the data from previous audit was then performed.Results1.An increase in percentage of documented evidence of covert medication plan being discussed with a relative with Lasting Power of Attorney or in a Best Interest Meeting to 95% (n = 20) from 85% (n = 12) in the previous audit.2.An increase in percentage of documented evidence of pharmacy input on covert medication administration plan to 100% (n = 21) from 47% (n = 7) in the previous audit.3.An increase in percentage of documented evidence of covert medication administration in the drug charts to 100% (n = 21) from 53% (n = 8) in the previous audit.4.An increase in percentage of documented evidence of covert medication review date on the covert medication initiation forms to 85% (n = 18) from 67% (n = 10) in previous audit.5.A decrease in percentage of documented evidence of MDT discussion prior to starting covert medication plan to 90% (n = 19) from 100% (n = 15) in previous audit.ConclusionThis re-audit showed some improvement with 100% compliance in 4 out of 10 standards, however, there's still room for improvement to get the compliance to 100% across all the standards.We therefore recommended strict adherence to existing covert medication initiation plan form, with particular attention to be paid to the standard of proper documentation of the details of MDT discussions around covert medication plan initiation, as there was surprisingly a reduction noted in this standard.Finally, we recommended that another re-audit be considered within 2 years of completion of this re-audit.
Identification and Management of Hyperprolactinaemia in Patients With Intellectual Disabilities Who Are Prescribed Antipsychotic Medication: A Retrospective Audit
Authors: Healy Soracha , Patel Rupal 
Published: August 2024

AimsHyperprolactinaemia has long-term complications including reduced bone mineral density (BMD). People with an intellectual disability (ID) have a greater burden of disease and reduced life expectancy compared with the general population, including an increased risk of osteoporosis and fractures. There is a higher prevalence of antipsychotic prescriptions in people with ID which increases the risk of hyperprolactinaemia. Therefore, regular serum prolactin monitoring is important in this group. The aims of this audit were:
1.To identify how many patients with ID are prescribed antipsychotic medication and of these, how many have had prolactin levels measured in the last 12 months.2.To identify how many patients had elevated prolactin levels (>530 mIU/L).3.To identify if results had been managed as per current guidelines.MethodsData was reviewed from the Richmond and Kingston psychiatry caseloads using the electronic patient record, Care Notes. Each patient was reviewed against the inclusion criteria of diagnosis of ID and currently prescribed antipsychotic medication.125 patient records were reviewed on Care Notes. 50 patients were excluded as they were not prescribed an antipsychotic medication. The remaining 75 patients met the inclusion criteria.Results75 patients were prescribed an antipsychotic. Of the 10 different antipsychotics prescribed, the most common were risperidone (50.7%) and olanzapine (30.7%). Of those prescribed an antipsychotic, 39 (52.0%) had their prolactin levels measured in the last 12 months.The prolactin levels measured ranged from 82 mIU/L to 4890 mIU/L. 16 (41.0%) patients had elevated prolactin levels. In those with elevated prolactin, 68.8% were prescribed risperidone.Of the patients with elevated levels, 81.3% had their results discussed with them and treatment options considered. The majority of patients were monitored and screened for symptoms. In some cases, psychotropic medication was reduced with a view to stopping and others continued to be monitored. Two patients were prescribed aripiprazole 2.5mg as an adjunct.Those who had not had their prolactin levels discussed were all awaiting appointments as the blood tests had been taken recently.ConclusionA key area identified is how to increase uptake of blood tests in this patient group. Closer liaison with GP surgeries and proactive discussions with patients about the importance of screening for hyperprolactinaemia may help to improve outcomes. Referral to our in-house needle desensitisation service may also be helpful.There is also scope for future research regarding the management of hyperprolactinaemia in the ID population due to the increased risk of reduced BMD.
Driving in Home Treatment Teams: Are We Talking About It Enough? An Audit Covering Kingston and Richmond Boroughs in South West London and St George's NHS Trust
Authors: Healy Soracha , Lakhani Radhika , Ahmad Zulkarnain , Francis Sasha 
Published: August 2024

AimsLegality of driving and serious mental illness is often poorly understood by service users and staff. The risk of rare but serious consequences indicate the value in including driving risk in initial assessments. The Driving and Vehicle Licensing Authority (DVLA) advises not to drive and notify them of changes in condition or concerns around an individual's ability to drive. Crisis periods can represent changes in condition for individuals with chronic mental health conditions including psychotic disorders, manic episodes, severe anxiety and depression, and personality disorders. It therefore is pertinent for home treatment team (HTT) clinicians to consider driving safety, in patients requiring crisis intervention. The aim of our audit was to identify what proportion of patients on the Kingston and Richmond HTT caseloads are asked about driving and implement changes to facilitate discussion thereby improving safety.MethodsRetrospective data was collected from Rio clinical record software from the entire Richmond HTT and Kingston HTT caseloads at baseline, two and four months post-intervention. Clinical records were reviewed to establish if driving was being discussed. Data was inputted anonymously into Excel and simple statistical analyses conducted.Inclusion criteria were patients on the Richmond Kingston HTT caseloads on the date of data extraction for cycles 1, 2 and 3. Patients were excluded who had not yet had their initial assessment.Following initial data collection we joined stakeholders at Trust-Wide HTT Governance meeting covering five boroughs and presented findings. We agreed changes to implement including incorporating a driving prompt in the initial assessment proforma and providing a DVLA leaflet in the welcome pack.ResultsFrom baseline data of combined caseloads, 17.7% of patients had documented evidence of driving discussion. At two months, re-audit showed that 33.3% of patients were asked about driving. With consideration of delays in change implementation with large teams and shift work, a third data collection cycle was completed 4 months post intervention. This showed that 56.0% of patients were asked about driving.ConclusionThe changes implemented have been effective in sustaining increased awareness on this important topic and facilitating discussion with patients. There is potential to increase awareness further by expanding this as a trust-wide, regional or national initiative whilst enhancing stakeholder engagement.
A Re-Audit of the Assessment of the Nutritional Status of Patients Admitted to the General Adult Inpatient Wards in Mersey Care NHS Foundation Trust
Authors: Hyland Declan , Abulais Faraaz , Baruah Ranjan 
Published: August 2024

AimsObesity and malnutrition have increased prevalence in individuals with mental disorder. Patients with severe mental illness are at increased likelihood of developing weight-related comorbidities, particularly type II diabetes mellitus.Admission to the psychiatric ward provides an opportunity to address, not only the patient's mental health issues, but also any physical health issues.The aim of this re-audit was to assess whether patients were managed in compliance with the Mersey Care NHS Foundation Trust Nutritional Screening Protocol on eight general adult inpatient wards across the Trust.MethodsData from the first five admissions (starting from 1st April 2023) to eight general adult inpatient wards in the Trust was collected and assessed.A total of 40 inpatient admissions were identified. The results were collated and compared to the standard – Mersey Care's Nutritional and Hydration Policy.Results36 patients (90%) had a Malnutrition Universal Scoring Tool (MUST) completed within 72 hours of admission. Of the four patients (10%) who didn't have a MUST score within 72 hours of admission, three were completed after 72 hours.46% of patients had a MUST score of 0 (low risk), 31% a MUST score of 0 (high risk obesity), 10% a MUST score 1 (medium risk) and 13% a MUST score of 2 or above (high risk).Of the five patients with a MUST score of 2 or above (high risk), three (60%) were compliant with all elements of the Nutrition Screening Tool Care Plan. Of the 12 patients with a MUST score of 0 (high risk obesity), seven (58%) were compliant with all elements. Of the four patients with a MUST score of 1 (medium risk), all were compliant with all elements.Overall, 31 (79%) patients had every element of the Nutrition Screening Tool Care Plan completed.ConclusionThere was significant assurance of systems and processes in place and working well to ensure compliance, with only minor issues of concern identified.Whilst the MUST score within the first 72 hours following admission had been completed in most inpatients, referrals to the dietician had not been done consistently in line with Trust policy. This is an area that requires addressing. Some training may need to be delivered to underline the importance of adhering to Trust policies.An action plan to circulate the audit findings to all general adult inpatient wards across the Trust and re-auditing with a larger sample size across the Trust has been recommended.