bluuebunny/crossref_metadata_2025_split huggingface dataset:
Improving Adolescent Care in a Cross-Sector System
Authors: Ravishankar Aarthi , Holliday Tom , Fraser Lauren , Biggin-Lamming James 
Published: June 2022

AimsAdolescence represents a critical life stage in which there is rapid physical, cognitive and psychosocial development. It is the time where the patterns and foundations for future health are laid and thus presents a unique opportunity to promote health and subsequently improve life-long well-being and reduce health inequalities. Mental health problems represent the greatest contributors to disease burden for this population and this contribution is forecast to rise. The World Health Organisation state that adolescents and young adults (AYAs) need health services that are supportive, equitable and effective. The project aims to scope out Adolescent care at London North West University Healthcare NHS Trust (LNWH) with a view to improve quality of care for this group of patients.MethodsQuantitative data obtained assessed patterns of presentation to the Emergency department (ED). Qualitative data were obtained through stakeholders Interviews with professionals, adolescent patients and their caregivers. As of January 2022, 113 stakeholders were interviewed. The data obtained informed the creation of the ‘LNWH AYA Manifesto.’ This was converted into a questionnaire for all professionals involved in the care of AYA patients to assess organisational culture around AYA Care.ResultsIt was found that AYA care at LNWH lies across a complex cross-sector system. The commonest code for presentation to the ED for those ages 13 to 25 was ‘depressive disorder’. Key themes from stakeholder interviews included: 1) AYAs are not always provided with age-appropriate care 2) Acute Trusts may serve as a catalyst for change for AYA patients and Youth workers may be better placed to connect with them 3) There is a need for an integrated approach to physical and mental health with better relationships needed between the Acute teams and CAMHS. The ‘LNWH AYA Manifesto’ questionnaire found disparate opinions regarding the approach to integrated physical and mental health; of the 34 responses obtained 23.5% reported not feeling confident with recognising and managing mental health and social issues in AYAs and 41.1% believed that physical and mental health problems should be addressed separately by the relevant specialties.ConclusionAYA care lies across a complex cross-sector system and thus requires a multifactorial approach to create a culture change towards prioritising this population. One such intervention proposed is the introduction of a Youth Worker outreach model similar to the King's Adolescent Outreach Service as a way to create a shift towards an integrated approach to physical and mental health care.
End of Life Care on a Neuropsychiatric Inpatient Ward for Patients with Huntington's Disease: An Overview of Issues and a Project to Optimise Care
Authors: Roberts Kris , Nielsen Fiona , Dale Maria , Kiani Reza 
Published: June 2022

AimsMill Lodge is a 14-bed inpatient neuropsychiatric ward in Leicestershire, UK. The service primarily functions for patients with Huntington's Disease (HD), a disorder that significantly reduces life expectancy. End of Life (EoL) care is necessitated in the inpatient setting. This project therefore aims to optimise EoL care in our specialist HD unit. Specific objectives are to: establish the levels of staff confidence in dealing with EoL care; identify specific areas of EoL care that staff felt could be improved; and to introduce a series of initiatives to optimise EoL care for our patients using a QI framework.MethodsWe commenced involvement with the local QI team to develop the project. The first stage of intervention included the planning and delivery of a stakeholder event on EoL care specific to HD with the assistance of regional palliative care colleagues.As well as our inpatient nursing and medical staff and the palliative care teams, local GPs, district nursing colleagues, speech and language therapists and psychologists attended. The session comprised an educational overview for all colleagues of HD itself and palliation was discussed at length.The meeting also comprised an open forum where we were able to identify barriers and facilitators to optimal care from all aspects of the assembled MDT.ResultsTo date our interactions have revealed that staff confidence in dealing with the different aspects of EoL care was low. This included issues with care-planning; medications; communication with patients and staff; and when to refer for specialist help.Other processes identified as difficult included paperwork that was not consistent across teams; district nursing colleagues having to liaise with multiple medical team members to ensure continuity of care; and the doses of EoL medications required in this patient group to mitigate involuntary movements that were previously controlled with multiple high-dose oral medications.ConclusionStaff without specialist knowledge require support. The efforts made to improve collaboration with external colleagues broke down barriers that were preventing optimal care and allowed all parties to express their opinions and feelings. This allowed us to transparently appraise our current processes and provide guidance on this difficult area.The journey of optimisation continues, with further practical educational interventions planned, such as syringe-driver training, and efforts to improve shared documentation and enhanced communication and collaborative working between different disciplines.Optimal, collaborative EoL care from a confident staff-group is possible and a most important part of care for this unique patient group.
Is Attachment Theory the Answer to a Complex Healthcare System?
Authors: Salmoiraghi Alberto , Kerti Amy 
Published: June 2022

AimsThis article proposes the need for a theoretical framework that can be applied to underpin the varied idiosyncratic mental health systems.MethodsBowlby's Attachment Theory defines a set of values that are required for a developing child to acquire a stable base which allow for healthy psychological development into adulthood. These values and behaviours may serve as a caring and holistic framework for people using mental health services.ResultsThe outcomes in mental health remain unsatisfactory and services are overall fragmented and increasingly specialised. Ongoing recognition of the inter-related relationship between a person's immediate and social environment and their mental health are frequently overlooked as services become ever stretched in terms of finances, capacity and limited resources including support for staff. The emphasis of treatment is on illness instead of the multifactorial humanity of the individuals using the services. A key outcome of mental health provision is recovery but instead, recovery is compromised by a reductive approach to care that may paradoxically compromise rights, autonomy, confidence and self-belief when people are at their most vulnerable. This creates feelings of mistrust, uncertainty and a limited sense of safety toward services.Attachment theory takes into account the individual, their experiences, their social world and the significant people in their lives. The principles required for the developing child to develop a secure attachment from a stable base are similar to those required for people experiencing mental illness to facilitate recovery and develop resilience to help manage and reduce episodes of relapse.Systems that work well, frequently exhibit values underlying models of care that include continuity, consistency, respect, safety, autonomy, human rights, freedom, supportive, trusting relationships and collaboration. The opposite of that seen in what presents as autocratic and risk-averse approaches of many mental health services.The principles required to enable a child to develop into a psychologically well-adjusted adult are similar to those required when a person is at their most vulnerable. Episodes of mental illness can be a time for reflection and growth, with the right care and therapeutic intervention, illness can also be a time to learn and develop skills for greater resilience in future.ConclusionThis paper outlines the implications and cultural changes that are required so that the principles of attachment theory can serve as a theoretical framework across mental health services to provide a stable base for people using the services and staff providing the care.
Moving From Peripheral Project to Integrated Governance: Developing System Sustainability in Excellence Reporting
Authors: Scott Jessica , Ledger Jennifer , Smith Helen 
Published: June 2022

AimsThere has been increasing recognition that healthy cultures within NHS organisations are key to delivering high-quality, safe care (King's Fund). A focus towards developing systems which recognise and learn from excellence has been shown to improve services’ safety and contribute to staff's morale (Kelly et al. 2016). In 2019 Secure Services at Devon Partnership NHS Trust (DPT) developed an Excellence reporting system. Once successfully piloted, the intention was to extend to other departments before expanding to the entire Trust. Our aims initially were SMART: for 13 reports per week in Secure services and 8 in Perinatal (a smaller team). As we expanded the aim became qualitative: for a system to be embedded so staff could as readily and instinctively report Excellence as they could an error.MethodsWe developed our Theory of Change using Deming's theory of profound knowledge, ran a series of PDSAs, and introduced an Excellence system. We engaged early adopters, sent hand-written cards and shared data widely.Learning included understanding setting up the system, and the importance of a team rather than an individual holding the system. We took this forward to bring the system to Perinatal. We continued to run PDSAs, then ran monthly trust-wide meetings providing space to learn from other directorates.ResultsStaff were initially excited, reports submitted, feedback good, then a plateau and slump.Something was stopping the system perpetuating. When staff received timely thanks, and others heard about it, staff would go on to promote excellence. However, this was not possible without sufficient admin resources.In early 2021 we changed tact and approached the top: we presented data to Directors who recognised the value and agreed to support. We then set about publicising the system, and demonstrating at trust-wide meetings.By July 2021 we saw 10 reports per week in the Specialist Directorate.By early 2022 reports were being inputted from staff across all directorates and our monthly meetings began to focus on sharing the learning.ConclusionWe recognised the system's potential impact on safety and staff morale but struggled to sustain the system and support dwindled when staff were stretched.After approaching leaders, then allocated resources, it allowed for more success. However, it is not yet fully embedded in our Trust's culture.A lot of our work happened during COVID-19 and despite challenges there has been a new-found flexibility to innovate, greater ease to negotiate, and instigate change.
A Quality Improvement Project on Improving Electronic Prescribing System in an Adult Mental Health unit
Authors: Warner Chloe , Caygill Matthew , Prasad Suveera 
Published: June 2022

AimsMedication tasks are an integral part of a junior doctor's job. However, these can often be timely and use hours that could be spent doing other therapeutic work, especially due to the cumbersome nature of SystmOne. Our aim was to review the amount, type, and time spent on medication tasks and evaluate ways in which the system could be made more efficient and time effective, to release doctors to complete other clinical ward activities.MethodsWe used prospective data collection, with two ten-day cycles carried out across the 46 bedded adult mental health unit (AMHU). Data were collected by all junior doctors working on the AMHU and every medication task was recorded on a designated document at the time of completion. This included data such as time the task was created, related ward, sender, type of task, amount of medications per task and minutes taken to complete.ResultsDuring the first ten-day cycle of data collection, we found that collectively we spent 21.5 hours completing medication related tasks. 10 hours were spent ordering medications, seven of which were ordering ward stock. Tasks involving completely re-prescribing the medication for the action to be completed took 12.6 hours. The data showed that 42% of tasks were completed on Mondays.Following cycle one we discussed the data with the AMHU pharmacy team, ward managers and consultants. Subsequent alterations were made to the stocklists for the wards, ward timings were aligned and a collective tasks system created to reduce duplication of tasks.During the second cycle of data, in total 16 hours were spent on medication tasks. There was a total of 7.45 hours spent ordering medications, 3.35 hours were ordering ward stock. Re-prescribing tasks took 9.7 hours.ConclusionFrom the results of the second cycle of data we can see the recommendations from cycle one have been effective in reducing the amount of time spent ordering medications by 25.8%. This highlights the importance of regularly updating the stocklists and utilising MDT working to maximise efficiency. We also confirmed that Monday was the heaviest day for tasks, which should be considered for staffing. As 46% of overall time was still spent ordering medications, we presented this data at the medicines management committee. Following this, recommendations have been taken to SystmOne for IT system alterations to improve efficiency of the system and allow junior/trainee doctors to focus more time on the clinical care of patients and learning.
Open Mental Health: A Mental Health Eco System Developed in Collaboration With Communities
Authors: Yeandle Jane , Oke Sarah , Papadopoulos Andreas 
Published: June 2022

AimsSomerset drew upon the Community Mental Health (MH) Service Framework, and local experience and recognised that too often service user experience of mental health was beset with artificial barriers, gateways and eligibility with people sometimes needing to deteriorate before they got the vital support they needed. In addition, we recognised that the gap between secondary care and primary care was experienced by service users as a “cliff edge”. The radical redesign of mental offers in Somerset aimed to deliver an experience of “no wrong door” and where, via a partnership between health, social care and Voluntary, Community and Social Enterprise (VCSE), people's needs could be met; both in terms of specific mental health offers as well as tackling the wider determinants of mental ill health.MethodsOMH was launched early 2019, just before the pandemic, and so traditional project methodology did not always apply. Instead all partners focused on standing up the offer at pace in order to support the population within Somerset with the emotional and psychological consequences of the pandemic, and any pre existing challenges. The model was co-produced with Experts by Experience significantly contributing to the shape of the offers.The model developed comprised of two key facets:
•A mental health offer, where the needs of individuals, families and carers are met by a range of health, social care and VCSE partners (including the wider determinants of mental well being such as finance / housing)•A mental health eco system developed in collaboration with communities (including underserved communities), where support is available throughout geographical communities and communities of identity.ResultsThe project has delivered both quantitively and qualitatively. Over 4100 additional appointments are offered to people in Somerset per month and reported outcomes and evaluation has been very positive. Work is underway to collate further Patient Related Outcome Measures. Following a Realist Evaluation methodology, the researcher in residence has highlighted the culture changes that are key to delivering the aspirations of the Community MH Service framework. These include; the narrative of “no wrong door”, an increased and open range of offers and interventions, blended staffing models across traditional organisational boundaries, partnership working, the role of lived experience and the ambition of addressing inequalities.ConclusionOMH, the product of Community MH Transformation in Somerset, is a radical and co produced redesign of MH services in partnership with the VCSE and Local Authority that has improved access and support to all people in Somerset.
Prevalence and Correlates of Benzodiazepines' Prescriptions in an Inpatient Setting
Authors: Zahreddine Nada , Chalil Rahna Theruvath , Abrar Sohail 
Published: June 2022

AimsThe National Institute for Health and Care Excellence guidelines state that benzodiazepines (BZD) should not be taken for longer than four weeks. However, there are no recommendations specifically addressing the use and misuse of BZD in inpatient settings and their prescription at discharge. A recent study (Panes et al., 2020) recommended aiming for BZD’ total withdrawal or, at least, dose reduction at discharge to reduce the risk of misuse in the community which can lead to dependence and serious side effects. Our study aimed to 1. describe BZD’ prescriptions on an acute female ward, before admission, during admission, at the time of discharge and at four and eight weeks post-discharge, 2. identify potential sociodemographic, clinical and therapeutic correlates/predictors of BZD’ prescriptions, 3. develop a strategy to reduce BZD’ prescriptions or, at least, to reduce the dose of BZD prescribed at discharge.MethodsData collection was done retrospectively through electronic medical and prescribing records and included admissions to Avocet Ward, between May and October 2021. Variables collected were age, ethnicity, length of stay, Mental Health Act status, diagnosis, comorbid drugs or alcohol misuse, Home Treatment Team involvement at discharge, community teams, prescriptions of regular and Pro Re Nata BZD and “z-drugs” prior to admission, during admission, at discharge, and at 4 weeks and 8 weeks post-discharge, maximum dose of regular BZD during admission and the dose at discharge.ResultsAmong the 59 admissions included, 25.4% had BZD before admission, 81.4% during admission (with a mean maximum dose of regular BZD of 38.8 mg (SD = 17.3) of diazepam equivalent), 50.8% at discharge (with a mean dose of 28.5 mg (SD = 18.5) of regular BZD), 35.6% 4 weeks post-discharge and 27.1% 8 weeks post-discharge. The odds of having regular BZD during admission were 7.4 times more likely for those on regular BZD before admission after controlling for other variables (95%CI: 1.1, 50). The maximum dose of regular BZD during admission was positively correlated with the dose of regular BZD at discharge (r(15) = .67, p < .01). Among the regular BZD prescribed during admission (N = 23), 26.1% were fully discontinued by the time of discharge and 43.5% were titrated down, while 30.4% remained at the same maximum dose prescribed during admission.ConclusionBZD prescriptions are common at discharge from inpatient settings and can be associated with BZD misuse in the community. We suggest strategies to avoid this issue.
Legal Parameters of Practice in Psychiatry
Authors: Barmpagianni Christina , Cremin Patrick , Fialho Antonio , Qazi Afaf 
Published: June 2022

AimsThe amended Mental Health Act (MHA) of 2007 gave Psychiatrists the right to detain, assess and treat individuals with mental health disorders, not only with a view to offer medical treatment but also to ensure their safety and that of the public, by containing them. This meant that patients diagnosed with disorders such as Antisocial Personality (APD), previously un-detainable under the MHA of 1983, would no longer be considered untreatable and could be sectioned, if appropriate. The idea was then generated, that Psychiatrists would now assume the role of custodians of potentially dangerous people and raised the concern that all persons with APD would be perceived as dangerous and find themselves at a dynamic risk of being sectioned under the revised MHA. The balance between the role of Psychiatrists as medical professionals versus this new, unpopular role as figures of public order was and still is, debatable.MethodsWe present the case of a patient with a background of Depression and Post-traumatic Stress Disorder with aggressive features, who during a consultation revealed a powerful homicidal urge and fantasies directed to an individual he believed had wronged him. The patient had access to the individual and had attempted to confront him. He had no forensic history, nor had he expressed criminal intent before. This triggered a safeguarding response, the consensus being that advice should be sought from the Forensics team, not only to protect the potential victim but also the potential perpetrator from the consequences of a criminal act.ResultsConsidering the lack of police involvement, plans, or weapons; the separation between patient and potential victim; and the patient's distress associated with the disclosure of the homicidal fantasies, the level of risk was deemed to not merit disclosure. Closer risk assessment with ongoing psychological and pharmacological interventions created a therapeutic alliance which allowed for open communication with regards to the dynamic nature of the risk and the potential for any further disclosure.ConclusionWithin the definition of Duty of Care lie responsibilities beyond the strictly medical role of clinicians. Not unlike the duty to inform the DVLA about a patient's fitness to drive, breaking confidentiality for the purposes of patient or public safety is not a power that makes Psychiatrists figures of Authority, but a responsibility that is part of their role. At the same time, we should bear in mind that the license to disclose is also a license not to disclose.