bluuebunny/crossref_metadata_2025_split huggingface dataset:
Aetiological Investigation of Epilepsy in Adults With a Learning Disability – a Community Audit
Authors: Carroll John , Winterhalder Robert 
Published: July 2023

AimsTo demonstrate adherence to national standards for the aetiological investigation of epilepsy in Bromley Community Learning Disability Team (CLDT), Oxleas NHS Foundation Trust. The National Institute for Health and Care Excellence (NICE) and International League Against Epilepsy (ILAE) advise strenuous attempts to identify the aetiology of epilepsy as it often carries significant treatment implications. The ILAE divides aetiology into six categories selected because of their potential therapeutic consequences (structural; genetic; infectious; metabolic; immune; unknown).MethodsAudit standards were derived from NICE and ILAE. The key standard was that 100% of patients should have sufficient aetiological investigation of their epilepsy, including a dysmorphism assessment, neuroimaging, and genomics, as appropriate. The population was defined as all patients open to the Epilepsy Service of Bromley CLDT in December 2021. Data were collected using a secure electronic database between December 2021 and January 2022.Results76 patients (52 male, 24 female) were audited, mean age 38 years (range 18-79 years). Learning disability severity included borderline (n=3), mild (n=28), moderate (n=24), severe (n=17) and profound (n=4). Identified aetiologies included structural (42%; n=32), genetic (13%; n=10), and infectious (5%; n=4), with one patient having both genetic and infectious aetiology. Aetiology was unknown in the remaining 41% (n=31) of patients, of which 58% (n=18) had outstanding investigations. In 72% (n=13), there was no apparent reason for investigations to be outstanding. Genomics was the commonest outstanding investigation (70%, n=14), followed by neuroimaging (20%, n=4) and dysmorphism assessment (10%, n=2). In addition, 40% (n=12) of patients were newly eligible for whole genome sequencing – a recent development within 12 months and thus excluded from outstanding investigations.ConclusionThis audit demonstrates adherence to national standards is below 100%. Where appropriate, patients with outstanding investigations should be approached. Dissemination of findings and an action plan are required before re-audit.
Stopping Over-Medication of People With a Learning Disability, Autism or Both (STOMP) – a Community Audit
Authors: Carroll John , Davies Jill 
Published: July 2023

AimsThe stopping over-medication of people with a learning disability, autism or both (STOMP) campaign was launched by NHS England in 2016 as part of the Transforming Care programme. It aims to reduce the inappropriate prescribing of psychotropic medication to manage challenging behaviour in the absence of a licenced indication. The current audit aimed to demonstrate adherence to national standards for STOMP within the community learning disability teams (CLDTs) of Oxleas NHS Foundation Trust. Additionally, a secondary aim was to compare current adherence to the previous audit undertaken in 2019.MethodsAudit standards were derived from national guidance by the Royal College of Psychiatrists and the National Institute for Health and Care Excellence. The population was defined as all patients open to a CLDT prescriber (medical or non-medical) between April 2020 - March 2021. A multidisciplinary working group agreed inclusion and exclusion criteria before designing an electronic audit questionnaire. A random sample of 20% of patients from each of the three CLDTs (Bexley, Bromley & Greenwich) was generated. Data were collected between October and November 2021.ResultsThe clinical records of 111 patients were reviewed, 86 of whom met inclusion criteria. Of these, 65 patients were taking psychotropic medication and progressed to full auditing. Key findings were: 85% of patients on established psychotropics had a medication review within the previous 6 months, of which 100% were assessed for their response to treatment and 86% were assessed for side effects; 78% of patients had their capacity to consent to treatment documented and, of those lacking capacity, 81% had a best interests decision documented. All but one of these key findings demonstrated an improvement compared to the 2019 audit.ConclusionOverall, this 2021 audit demonstrates a substantial improvement since the previous audit in 2019. However, adherence to national standards continues to be below 100%. Dissemination of findings and an updated action plan are indicated before re-audit in 2023.
Clozapine Serum Level Timing Audit: Medium Secure Rowan View
Authors: Daniels Charles 
Published: July 2023

AimsTo assess the degree of compliance for clozapine serum level timing post clozapine dose using synnovis (previously viapath) and maudsley 14th edition guidelines in a medium secure hospital.MethodsElectronic prescribing systems were reviewed on each ward to identify clozapine established patients. Viapaths electronic database was reviewed from 01 May 2021 (18 months) and recorded timings were compared to guidelines in Maudsley, 14th edition and synnovis. 12 hours was used as the guideline post dose in OD (once daily), BD (twice daily)/TDS (three times daily) regimes following the night time or evening dose.Results4 different types of clozapine prescribing regimes were identified – OD, BD am/nocte or evening, BD pm/night or evening and TDS. 45 patients in total.OD 12 - most recent bloods 8/12 patients were >15 hours. Total samples in 18 months >12 hours 63.6% (38/55). Total samples in 18 months >15 hours 56.3% (31/55). In the OD group 26 samples are from 2 patients both of whom have samples taken later than 14 hours.BD 26 - BD mane evening/nocte - 2/5 most recent samples were >15 hours. Total samples in 18 months >12 hours 51.6% (32/62). Total samples in 18 months >15 hours 12.9%(9/62). Need to consider – evening dose time 18:00 compared to 22:00 adding more time.BD pm evening/night 5 - 2/5 patients > 15 hours. 4/5 patients not at 13-14 hours. Total samples in 18 months >12 hours 75% (9/12). Total samples in 18 months >15 hours 25% (3/12)TDS 2 - 0 patient > 15 hours, 1 patient at 14 hours. Total samples at 18 months >12 hours - 41.7% (5/12). Total samples at 18 months >15 hours - 16.7% (2/12).ConclusionHigher than expected clozapine serum level timing inaccuracy was demonstrated, markedly in bespoke regimes - OD (56.3%) or BD pm evening/night regimes (25%) compared to traditional regimes (TDS 16.7 %, BD am nocte/evening 12.9%). Contributing factors are a knowledge gap amongst services, Maudsley guidelines don't consider bespoke timings when advising trough levels. Findings suggest bespoke regimes need greater consideration when assessing clozapine serum levels.Action from this initial audit involves informing teams regarding recent samples which are >15 hours post dose. Service education highlighting safety concerns of potential underestimation of clozapine serum level. Guideline change with support from pharmacy. Re audit in 12 months.
Physical Health Monitoring of Community Patients Under the Care of Adult Eating Disorder Service at Surrey and Borders Partnership NHS Foundation Trust
Authors: Fulmali Amit , Pathan Tayeem 
Published: July 2023

Aims1.To determine if the physical health monitoring of patients in the Eating disorder service is done in line with the recommendations of the National Institute of Clinical Excellence (NICE) guidelines and relevant MEED Guidance on Recognition and Management.2.To determine if the current local AEDS (Adult eating disorder services) guideline for physical health monitoring of Community patients, including blood tests and ECG is adequate for community patient cohort.Methods1.For every attendance of patients to the Outpatient Physical health monitoring Clinic (PHMC), it is expected that the physical health monitoring to be offered would include:
•Weight•Height (if first attendance)•BMI•HR (Pulse rate)•Sitting/Standing BP and•Temperature2.Relevant Blood tests and recent ECGs on a schedule based on patient's BMI or as needed based on clinical indication.24 patients were identified from April 2021 to December 2022. 7 patients were deemed inappropriate due to scant documentation. Of the remaining 17, 9 patients were randomly selected. 9 patients’ documentation were looked at all contacts with AEDS. The monitoring was audited at 3 single point of contact over the course of their first clinic appointment after April 2021, the middle and latest/last monitoring.Results1.At the first clinic after April 2021 the compliance was 100% for all parameters except for the monitoring of BMI and Temperature which was 88.9%.2.At the mid-point there was 100% compliance with BMI, weight, blood pressure and pulse monitoring, there was a drop in temperature monitoring to 77.8%.3.In the last clinic monitoring for pulse and temperature dropped to 88.9% and 77.8% respectively, all other parameters showed 100% compliance.4.The frequency of monitoring ECG and blood tests in the subsequent clinics gradually dropped from 100% to 66.7% and 88.9%.ConclusionReasons for decreased monitoring in Bloods and ECG.1.Documentation was missing.2.Investigations were delayed from the patient's side.3.Due to COVID-19 there was difficulty accessing the primary care appointments for investigations.4.The temperature equipment was not working properly.Recommendations1.Keeping a fixed format for documenting PHMC. New format for documentation introduced.2.Document all the parameters checked in the patients’ electronic records on the same day.3.PHMC clinical team to upskill on ECG via training.4.Introduce weekly ECG alongside phlebotomy clinics.5.SUSS test to be done for all RED (High risk) patients and should be clearly documented in the notes.
To Profile Patients Who Need Long Term Care Placement Following Admission to Acute Old Age Psychiatry Wards
Authors: Goveas Richard , Yao Fengyuan 
Published: July 2023

AimsThe Institute of Mental Health is the only tertiary Psychiatric Hospital in Singapore. It has two 29 bedded inpatient wards which provides acute care for the elderly with severe mental health problem. Over the past year there has been a trend of an increasing number of elderly patients who stay for a prolonged period of time as they require long term care placement and this increased length of stay leads to increasing healthcare costs, a reduction in availability of acute beds which in turn leads to elderly patients needing to be lodged in general adult wards. In 2022 the average length of stay for the elderly wards was 46 days as compared to the target of 21 days set by the hospital. Prolonged inpatient stays can lead to physical decompensation including reduced muscle strength, pulmonary capacity and osteoporosis.MethodsWe conducted a retrospective audit on 30 patients who were admitted between July and December 2022, requiring long term care placements. Our hypotheses were that patients with a diagnosis of dementia, who were frail and with caregiver burnout were more likely to require long term care placement. We subsequently designed a data collection form to collect the latter data and analysed them.ResultsOut of the 30 patients, 27 (90%) had a diagnosis of dementia, 25 (83.3%) were classified as frail (6 or more on the clinical frailty scale) and 23 (76.6%) had caregiver burnout, 12 (40%) family unable to look after patients in spite of community support and 3 (10%) had no next of kin.ConclusionPatients with dementia and frailty are more likely to require long term care placements. In the inpatient unit, we find that caregivers of these patients are burnt out because of their behaviour problems. We are embarking on an enriched model of care to reduce severe behavioural and psychological symptoms of dementia thereby reducing the need for restraints and its associated complications, and empowering caregivers to manage their behaviour problems.This audit also stressed the importance of addressing issues upstream. Referrals to community facilities like day care which provide exercise and rehabilitation for the elderly will help delay the consequences arising from frailty. We are also partnering primary care to assist with early identification of dementia and providing early interventions to prevent caregiver burnout.
A Re-Audit of the Assessment and Management of Patients With Alcohol Use Disorders Following Admission to the General Adult Inpatient Wards in Mersey Care NHS Foundation Trust
Authors: Hyland Declan , Baruah Ranjan , Hussain Mohammed , Buchan Hollie 
Published: July 2023

AimsThis re-audit aimed to determine the level of performance in the assessment and management of patients with alcohol use disorders following admission to one of the general adult inpatient wards in Mersey Care NHS Foundation Trust and to determine whether the level of performance has improved compared to the original audit done in 2021 and whether recommendations that were implemented following the original audit have been effective.MethodsA list of all inpatients on each of the eight general adult inpatient wards in the Trust was obtained. The electronic patient record (on RiO) and electronic prescription card (on EPMA) for each inpatient was scrutinised to obtain the required data. All data were collected retrospectively.ResultsA total of 149 inpatients were identified on the eight general adult inpatient wards. Using specific inclusion and exclusion criteria, 56 of the 149 inpatients formed the final sample. Of the 56 inpatients, 58% were male, 42% were female. An alcohol history was documented in 81% of the 56 inpatients, representing an improvement on the 45% in the original audit in 2021. An average weekly quantity of alcohol for the inpatient was documented in only 8% of cases, a drop from 22% in the original audit in 2021. There was minor improvement in documentation of a CIWA-R score for the inpatient on admission to the ward - an increase from 0.7% in 2021 to 4.0% in 2022. There were improvements on gamma GT and serum Magnesium level being checked on admission for the 2022 audit cohort compared with the 2021 audit cohort. There was also an improvement on referral of the inpatient to community alcohol services - 3% in the 2021 audit vs 7% in the 2022 audit.ConclusionThe findings from this re-audit indicate an improved level of performance in assessment and management of patients with alcohol use disorders following admission to the general adult inpatient ward since the original audit in 2021. Recommendations from this re-audit are: ensuring that taking and documenting a thorough alcohol history is included in the induction for junior trainees, the provision of education and training to both medical and nursing staff on the wards in using the CIWA-R to assess level of alcohol withdrawal and producing a flow chart on the assessment and management of alcohol use in patients following admission to the ward that can be displayed in the Treatment Room on each ward and in the Junior Doctors’ office.
An Audit on Glycosylated Haemoglobin & Fasting Plasma Glucose Blood Tests Done on Admission to an Older People's Inpatient Ward
Authors: Kyriacou Loui , Navanathan Julian , Anthony Yanik , Abbas Abdul-Rahman , Bansal Saakshi , Albert Michael 
Published: July 2023

AimsThe aim of this study was to determine the proportion of patients who had fasting plasma glucose and glycosylated haemoglobin (HbA1c) blood tests done on admission to an older people's inpatient ward at Kingfisher Court, Hertfordshire. Patients undergo a physical health assessment when they are admitted to the ward. This consists of a physical examination, an electrocardiogram and a panel of blood tests, which include a fasting plasma glucose and HbA1c. Given that people with severe mental illness have a greater burden of physical health conditions, such as diabetes, this physical health assessment can aid in optimising patients’ physical health and reducing this health inequality.MethodsA sample of 40 patients who were most recently discharged from the older people's inpatient ward were included in the audit. Four authors each independently reviewed 10 patient case notes and blood results. An audit collection tool was produced and data logged for each patient. The data collected were reviewed by all authors.Results57.5% (23) of the study population had admission blood tests that included a HBA1c level or plasma glucose. An individual with diet-controlled type 2 diabetes mellitus had a HBA1c of 55 mmol/mol and was subsequently started on metformin. Only 15% (6) of the study population had a plasma glucose test on admission. Their case notes did not specify whether these were fasted or random plasma glucose tests. 42.5% (17) of the study population did not have either a plasma glucose test or HBA1c test done.ConclusionThere was poor overall compliance with the trust protocol for blood tests on admission to the older people's inpatient ward. Plasma glucose tests were rarely done and it was not specified whether they were fasted or random tests, thus limiting their utility. The team therefore suggest that the fasting plasma glucose test be removed from the panel of admission blood tests. The focus should be on obtaining a HbA1c test. Amendments to the clerking proforma and doctors’ induction presentation should be made to emphasise the importance of the HbA1c test.
The Management of Short-Term Insomnia for Inpatients in an Adult Acute Admissions Ward: Audit of Compliance With Local and National Guidelines
Authors: Long Marie , Widdowson Rose 
Published: July 2023

AimsThis study sought to establish local adherence to the following recommendations for the management of short-term insomnia (under 3 months duration): 1. Sleep hygiene advice should be utilised prior to pharmacological management. 2. A non-benzodiazepine hypnotic medication should be prescribed. 3. A one-off trial dose of benzodiazepine or Z-drug should be prescribed prior to regular prescription.100% of patients reviewed by medical staff for insomnia are expected to meet the set standards.MethodsRetrospective analysis of a cohort of patients (n=21), in an Adult Acute Admissions Ward in the West of Scotland. Taken over seven days in January 2023. Electronic prescriptions and chronological notes were reviewed in order to identify patients reviewed by medical staff for short-term insomnia.ResultsOf the patients reviewed for insomnia (n=8):
•12.5% were offered sleep hygiene advice (n=1).•25% were prescribed a trial dose of non-benzodiazepine hypnotic medication (n=2).•25% % were prescribed regular non-benzodiazepine hypnotic medication with no trial dose (n=3).•50% were prescribed alternative sedative medication for insomnia (n=4).ConclusionCommonly, patients were not provided with sleep hygiene advice. The patients who were prescribed non-benzodiazepine hypnotic medication were often not prescribed a trial dose. Half of the patients were prescribed an alternative to a non-benzodiazepine hypnotic medication.
•Interventions will include:Creation of a sleep hygiene information leaflet to provide to inpatients, medical and nursing staff.•Presentation of data to medical and nursing staff.•Ensuring guidelines are available to all medical and nursing staff in the ward environment.•The audit will be repeated in six months after the interventions.
Medication Initiation in Children Newly Diagnosed With ADHD, Measured Against NICE Guideline NG87
Authors: McWilliams Emma , Markopoulou Eleni 
Published: July 2023

AimsADHD is a common neurodevelopmental disorder, which is usually diagnosed in childhood. The aim of this audit is to assess practitioners' compliance with NICE guideline NG87 in relation to the initial assessment and medication choice in children with ADHD (age 5 and over), prior to the commencement of ADHD medication.MethodsThe sample was children aged 5 years and over who have been diagnosed with ADHD and referred for medication initiation, in a Manchester CAMHS community team between May and October 2022. The audit tool used to collect the data included each of the standards and measured each individual patient's compliance. Information was collected from electronic patient records and paper notes.ResultsSample size was 32 patients.Standard One stated that 100% of patients, before starting medication, should have a full assessment, including: a review to confirm they meet the criteria for ADHD and need treatment, mental health and social circumstances including coexisting psychiatric/neurodevelopmental conditions, educational/employment circumstances, risk assessment for substance misuse and care needs. Overall compliance was 9%.Standard 2 stated that all patients should have a physical health review including medical history, medication, height, weight and physical observations and, a cardiovascular assessment. Overall compliance was 0%.Standard 3 stated that 100% of patients who met specified criteria should be referred for a cardiology assessment prior to starting medication. Overall compliance was 28%.Standard 4 stated that 100% of patients who met criteria for referral to cardiology or had a co-existing condition treated with a medicine that may pose cardiac risk should have an ECG completed. Overall compliance was 75%Standard 5 stated that 100% of patients who have a blood pressure consistently above the 95th centile for age and height should be referred to paediatric hypertension specialist. Overall compliance was 9%.Standard 6 stated that 100% of patients should be offered methylphenidate as first line treatment for ADHD or an alternative if they cannot tolerate stimulants. Overall compliance was 100%ConclusionThree major areas of improvement were identified. Cardiovascular risk assessments are not fully compliant due to lack of cardiac examination which could affect rates of cardiology referral as referral criteria include a murmur on examination.Although 100% of patient had their height, weight and physical observations recorded, a significant proportion did not have these plotted on centile charts as recommended.A minority of patients had a full biopsychosocial assessment, with a major deficit in risk assessment for substance misuse.