bluuebunny/crossref_metadata_2025_split huggingface dataset:
Audit: Medical Seclusion Reviews at Derbyshire Healthcare NHS Foundation Trust
Authors: Okoro Esther , Adepoju Jane , Ramji Abbas 
Published: July 2023

AimsSeclusion is a psychiatric treatment that is used as a “last resort” in light of deteriorating mental state. It involves the supervised confinement and isolation of a patient, away from other patients, in an area where the patient is not allowed to leave due to possible risk they pose to themselves and others in order to manage severe agitation and chaotic behaviour. The Trust policy defines a procedure for seclusion which encourages decision making in line with the Mental Health Code of Practice 2015 (MHCoP 2015) and encourages the clinicians to adhere to the policy, making decisions and care which should be duly documented following an assessment of ongoing concern, mental state, assessment of physical health, medication review, risk assessment in a timely fashion as stipulated in the policy.MethodsThis was a retrospective review of patients based on incidence reports completed at the commencement of seclusion on the Derbyshire Healthcare Trust between May and November 2022 . The electronic records were reviewed, and data analysed via Microsoft Excel, against trust standards:
•Timing of seclusion review: 1hour and 4hourly medical review•Independent Multidisciplinary Team meeting within 12hours on seclusion•Documentation of seclusion•Review of ongoing concerns•Mental state examination•Physical health review•Medication review•Risk assessment•Review of need for seclusion•InterventionResults107 incidences of seclusion that took place involving 61 patients were reviewed.34% of patients were reviewed within the 1hour, 41% reviewed 4hourly and 47% had an internal MDT.57% of medical reviews were documented with 50% clearly stating ongoing concerns, 47% carrying out a mental state examination and 42% had physical health reviews done. 44% had medication review done, 44% had risk assessment, 58% reviewed the need for seclusion and 52% had an intervention recorded.ConclusionThe audit showed poor adherence to the Trust guidelines both in terms of the frequency of the review and the vital aspects of the review as included in the seclusion review template. There seemed to be poor use of the seclusion template among medics, which is meant to serve as a prompt for the expected standards, hence more awareness is to be created.The areas of improvement also identified include the education and training of staff about the stipulation of the policy and clear documentation, with emphasis on the frequency as well as the quality of the reviews done.
An Audit on the Prescribing of Antipsychotics Among People With Recorded Emotionally Unstable Personality Disorder (EUPD) Within a Community Mental Health Service in Stroud, Gloucestershire
Authors: Palermo Amir , Dibben Claire 
Published: July 2023

Aims(1)To quantify the prevalence and duration of the prescribing of antipsychotics among people with a record of EUPD, particularly those without a mental health comorbidity that licenses an antipsychotic prescription; (2)To determine whether gender, age, and mental health comorbidities affect the likelihood of being prescribed antipsychotics; (3)To determine whether off-license use of antipsychotics among those with EUPD have ever been reviewed, with the aim of having these prescriptions stopped or reduced.MethodsStudy design: Retrospective cohort study.Setting: Data sourced from Stroud Recovery's electronic patient record of 287 people. Cohort entry was defined as the date of referral to Stroud Recovery. End of follow-up was the date of audit (20/11/2022).Primary outcome measures: Prevalence and duration of antipsychotic prescription among people with a record of EUPD within the Stroud Recovery caseload.ResultsOf the 287 people registered with Stroud Recovery, 37 (13%) had a recorded diagnosis of EUPD. 30 (81%) were ever prescribed antipsychotics. Only 6 of these 30 people (20%) have a mental health comorbidity that licenses an antipsychotic prescription (3 with bipolar affective disorder; 2 with severe depression requiring antipsychotic augmentation; 1 with schizoaffective disorder).The rest belonged to a subgroup of 24 people (80%) with recorded EUPD who were prescribed antipsychotics but with no history of co-morbid illness that licenses their use. This subgroup was predominantly female (75%) and aged 20–29 years (46%). Quetiapine was used in this subgroup the most, followed by olanzapine and aripiprazole. 12 (50%) have had more than one antipsychotic prescribed. None were prescribed for less than 1 week (defined by NICE as short-term use). In fact, the mean duration of antipsychotic prescription in this subgroup was 36.79 months. Only 10 (42%) had these prescriptions reviewed with the aim of having them stopped or reduced. None were offered a routine physical review.ConclusionAccording to NICE guidelines, antipsychotics are not recommended in the treatment of EUPD, not recommended in the treatment of medium to long-term impulsivity and other symptoms of EUPD, and antipsychotics should be reviewed for people with the aim of reducing and stopping unnecessary drug treatment. Contrary to NICE guidelines, in this community mental health service, antipsychotics are frequently prescribed for extended periods to people with recorded EUPD but with no history of a co-morbid illness that licenses their use. An urgent review of clinical practice is warranted, including the effectiveness of such prescribing and the need to monitor for adverse effects, including metabolic complications.
Physical Health Monitoring in the Memory Service
Authors: Pattiata Cara , Olusoga Tolulope 
Published: July 2023

AimsLocal guidelines state that pulse rate, weight, ECG if indicated, and bloods (U&E, LFT) are monitored in patients prescribed an acetylcholinesterase inhibitor or memantine. This can affect management as the above parameters can affect medication selection and titration. Aberrant measurements can indicate drug related adverse events. Compliance to standards will optimise patient safety. This audit aims to assess compliance to these guidelines in one Memory Service in the Trust.MethodsThis is a single-centre, baseline, retrospective audit performed on 19/10/2022.An internal database was used to identify all patients seen for a diagnostic assessment between September 2021 and October 2022. Patients who were prescribed an acetylcholinesterase inhibitor or memantine were eligible for selection. These were randomised to identify 30 cases.Information was gathered through electronic patient notes, clinician diagnostic letters, referral forms, and pathology specimen result reporting software.ResultsCompliance were as follows:
•Pulse rate recorded: 97%•Weight recorded: 0%•ECG requested when indicated: 20%•Blood samples taken and the results recorded: 100%Pulse rate is part of the assessment proforma and blood sampling is a requirement prior to referral. This suggests that having guidelines incorporated to local protocols enhances compliance.Weight was not routinely monitored: the rationale behind this being part of the guidelines is that rivastigmine can cause weight loss as per the BNF due to loss of appetite. However, on speaking to the Memory Team, this was not routinely done in the service as staff appear to rely on reports of appetite loss.ECG was not routinely done when patients fall under the criteria for indications. Clinicians appear to judge the requesting on ECGs pragmatically based on their clinical judgment rather than guidelines alone.Blood pressure is not a requirement in the guidelines for monitoring so cannot be audited. However, this is essential for decision making of treatment commencement, titration, switching, or titration.Findings suggest that local guidelines may need to be reviewed.ConclusionThis audit suggests some general learning points as well as service-specific ones.The incorporation of guidelines into routine practice such as proformas or the pathway itself contributes to good compliance. This may be due to these standards being auditable as well as acting as prompts for staff members or even requirements for patients to proceed in the pathway.This was also a reminder that clinical judgment may differ from guidelines; this may not necessarily be an indicator of poor practice but may result from pragmatic decision making for individual patients.The findings were presented at a consultant meeting, the result of which was that the guidelines will be reviewed with likely inclusion of blood pressure monitoring. This is an illustration of the role of audits and quality improvement in improving standards of care.
Mental Health Triage Form Use in Emergency Department Clerking – Audit at Royal Cornwall Hospital
Authors: Pradhan Alisha , Lee William , Batley Nathan , Burton Suzanne , Wyatt Zoe 
Published: July 2023

AimsThe aim of this audit is to assess use of the Mental Health Triage Form (MHTF) at the Royal Cornwall Hospital Emergency Department (ED), during June 2021 and to determine whether MHTF use increases rates of psychiatric-specific information being documented by ED staff. Patient attendances to Accident and Emergency (A&E) departments in the UK during 2020-21 decreased by 30.3% in comparison to 2019-20. However, attendances to A&E at the Royal Cornwall Hospital (RCH) in June 2021 increased by 51.2% compared to June 2020. Psychiatric patients accounted for 2% of attendances to A&E at RCH in June 2021. The Royal College of Emergency Medicine (RCEM) have recommended use of a mental health proforma document in line with recommendations from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) document ‘Treat as One’. Based on these guidelines, the Psychiatric Liaison department at RCH have a produced a local Mental Health Triage Form (MHTF) to be used in A&E when assessing and clerking psychiatric patients.MethodsThis was a retrospective audit of clinical records of 125 mental health cases attending the Accident & Emergency Department (A&E) at Royal Cornwall Hospital during June 2021, which were referred to Psychiatric Liaison.NHS numbers were identified for each referral made during the study period. Each referral's A&E clerking documents were reviewed on an online patient records system. Information was recorded on whether each question in the Mental Health Triage Form had been answered with or without use of the form.ResultsThe Mental Health Triage Form (MHTF) was used in 44 out of 125 patients (35%). 15 patients (12%) had missing Accident & Emergency Department documentation on online records. Where the MHTF was used, there was an 25% average increase in information recorded. Over half of the questions on the MHTF were answered more when the form was used versus when it was not used.Questions relating to the patients ‘Triage Code’, which are used to determine the level of observation, urgency of referral, and appropriate place of assessment, had the highest rates of improvement using the form.ConclusionOverall use of the Mental Health Triage Form during June 2021 reduced to 35% in comparison to 46% use during June 2020. This implied that patients attending the Accident & Emergency Department at the Royal Cornwall Hospital with psychiatric presentations were not being assessed fully. This may be due to various reasons such as staff unfamiliarity with the triage form and increasing pressure on Emergency Department services.
Introduction of a Standardised Admissions Template Improves Adherence to Physical Health Assessment Standards on Admission to an Inpatient Psychiatry Unit
Authors: Pulley Rachael , Dillon Shaina , Pillai Roshanna 
Published: July 2023

AimsThe risk of omitting an admission Electrocardiogram (ECG) in psychiatric inpatients can be high - patients may be more likely to have comorbid disease or require antipsychotic medication. Lack of an ECG represents inadequate physical health assessment, and may impact on morbidity and mortality from physical illness – impairing the ability to safely treat psychiatric illness, for example with antipsychotic medications. This audit aimed to establish achievement of admission ECG within 24hours, and to improve this if possible.MethodsTwo doctors gathered data retrospectively using written and electronic admission records for 41 psychiatric admissions in a one week period in September 2019.Following the first audit cycle demonstrating low levels of policy adherence, an admission proforma containing prompts and requiring a signature of the admitting doctor was introduced. Data collection was repeated on 16 admissions during September 2020 using an identical process.ResultsThe intervention led to an increase in ECGs performed within 24hours (65% to 83% in 18-65 year olds, 52% to 60% in over 65 year olds), whilst documentation of delayed ECGs being justified and reattempted also improved (28% to 100% in 18-65 year olds, and 50% to 100% in over 65 year olds).The proforma was utilised in 75% of audited general adult admissions, and 66% of audited older adult admissions.ConclusionThis admission unit was failing to meet expected standards of physical health assessment, which could result in harm. Reasons for this varied, but were attributed to inconsistent admission processes resulting in junior staff being unaware of the requirement, or miscommunication between staff. Handover of outstanding tasks occurred, but was not taken ownership of.Data collection was unfortunately impaired by reduced patient numbers secondary to COVID-19 admission processes – particularly in the older adult ward. As such some of the results in those over 65 years are positive, but may be spurious. It would be useful to repeat the audit once admission levels return to normal.The unified assessment document provided a framework for inclusion of all relevant elements and reminders for the admitting doctor. It required formal responsibility to be taken by the admitting doctor to ensure completion. Qualitative feedback demonstrated that it improved the quality and ease of admission documentation, and enabled thorough assessments which were useful when planning patient care and discharge letters.This audit demonstrated that use of an assessment proforma results in improved adherence to physical healthcare policies, and contribute towards improved patient care.
A Trust Wide Audit Evaluating Prescribing Practices in Clients With Emotionally Unstable Personality Disorder (EUPD)
Authors: Rangan Tarun , Mishra Monisha , Jaura Taimoor , Wratten Camille , White Andrew 
Published: July 2023

AimsThe aim of this audit was to evaluate prescribing practices in patients with EUPD at South West London and St George's Mental Health NHS Trust and compare these to NICE guidance on the management of EUPD. We are aware that for a multitude of reasons including high levels of distress and long waiting times for psychological therapy, clients with EUPD are often prescribed psychotropic medication. NICE guidance states that drug treatment including antipsychotics should not be used specifically for EUPD or for associated behavioural symptoms. Drug treatment for comorbid conditions and short-term use of sedative medication may be considered as part of a crisis treatment plan. If prescribing, NICE recommends that written material be provided to the client along with regular treatment reviews.MethodsWe obtained a list of patients in the trust with a recorded diagnosis of EUPD on their electronic patient record (EPR) system (N=869). 10% of these clients were randomly sampled (N=87).The notes were assessed for any prescribed psychiatric medication including the documented rationale for prescribing. We also assessed if medication use was consistent with NICE recommended time limited crisis prescribing and whether there was evidence of regular reviews of prescribed medication and of written material being provided to the client.ResultsOf the sampled clients, 81.6% (n=71) were prescribed medication. Of these, 39.4%( n=28) had medication use consistent with NICE recommended time limited prescribing, and 57.7%( n=41) had timely reviews of medication. 4.2% (n=3) of those prescribed medication had evidence on their EPR of written material being provided.ConclusionOur results highlight the extent of drug prescribing for EUPD within the trust. Over half of patients sampled had timely reviews of prescribed medication. However, most were not consistent with NICE recommended time limited prescribing. The results were presented to the trust's Clinical Reference Group. A Working Group has now been formed to help bring prescribing practices better in line with NICE guidance, specifically around the provision and recording of written information of drug treatment to patients and reducing inappropriate prescribing and polypharmacy.
Improving Physical Health Monitoring for Patients Diagnosed With Emotionally Unstable Personality Disorder
Authors: Thomas Emily Simon , Smith Ozias , Berry Verity 
Published: July 2023

AimsThe aim of this work was to apply the well established standards for patients suffering from diagnoses classed as Severe Mental Illness (SMI) to patients with a diagnosis of emotionally unstable personality disorder (EUPD) in our EUPD psychotherapy service. This patient population is also known to suffer lower life expectancy and greater physical comorbidities than the general population, and indeed than patients with other personality disorders, and this represents part of the holistic care we hope to offer in our service. In order to bring this in line, we were aiming for an annual medical review including: height, weight, blood pressure, blood tests including lipids, up to date information about alcohol and substance misuse.MethodsOne month before a patient's 6-week and 12-month review we liaised with their general practitioner (GP) for the above information. We then followed up as needed. In the first cycle of this work (January through July 2022) we found that we were able to establish contact with patients' GPs and there was qualitative evidence from patient testimonials about improved relationships with their GPs. However, the information that we were receiving was not complete - 0% had all the information that was requested.Following discussion in the team, a proforma was developed to make it as clear as possible to the GP which information we were seeking. We more proactively engaged GPs and patients' other physical care teams, including neurology teams. Where patients had home monitoring equipment like a blood pressure cuff or scales, we also collected information from these. Compliance was reviewed again at the end of the next six-month cycle (August 2022-January 2023).ResultsBetween the first cycle, from January 2022 through July 2022 and the second cycle from August 2022 through January 2023, we improved compliance toward the target of having all these data points documented for all patients from 0 to 57%. This included 100% compliance for blood pressure and pulse measures and 86% compliance for documented weight.We also note improved relationship between patients and GPs and other healthcare professionals including a patient testimonial “Having not had the support of Waterview dedicated staff and the group I probably would not attend any of the hospital appointments.”ConclusionIntroducing the proforma significantly improved compliance with physical health monitoring targets from 0 to 57%. Further work within the team and with GPs including education on the diagnosis may improve this further.
A Re-Audit of Teesside On-Call Email System
Authors: Singh Aashna , Ali Mohamed , Kishore Satyam , Dobson Rachel , Atewogboye Oluwatosin 
Published: July 2023

AimsAn on-call email system was put in place to facilitate communication between wards and the on-call doctor, allowing prioritisation of duties according to green, amber and red tasks. Information regarding the patient, nature of request and clinical background are expected in the request form. The doctor is expected to respond to the email within 45 minutes. We completed a re-audit to compare if expected standards were reached in practice and attempt to find any areas of practice that could be improved.MethodsWe collected information on request forms, presence of adequate information and response time by reviewing the Teesside on-call email inbox. One day was randomly chosen from each week for a 24 month period and all emails were reviewed from chosen days. This amounted to (N=680) emails. The compliance was measured against local trust criteria with expected standard of 100%. We assessed four parameters of completion of request forms, providing adequate information including clinical information, patient identification and location, and response within 45 minutes by the doctor.ResultsThe compliance in all four standards was subpar, with notable decrease in compliance from previous results. Compliance was less than 70% across all standards, where previously three standards were above this mark. There was a notable increase in requests with inappropriate tasks defined as non-urgent tasks as per trust guidelines.ConclusionBetter communication can be ensured with use of SBAR (Situation, Background, Assessment, Recommendation) in the request forms. Mutual sharing of information between doctors, nursing staff and administration with regard to appropriate written communication could constitute the base for structural change and improvement within the workplace. New staff members and doctors should be inducted with regards to the process of on-call email communication. Regular re-auditing and sharing of results is essential to the monitoring of change in compliance.