For patients with depression, the likelihood of remission decreases with each subsequent treatment failure. Per European Medicines Agency guidance, treatment resistant depression (TRD) is defined as nonresponse to ≥2 consecutive treatments at adequate dosage and duration in the current depressive episode. In ESCAPE-TRD (NCT04338321), esketamine nasal spray (NS) increased the probability of achieving remission and remaining relapsefree, compared with quetiapine extended release (QXR) in patients with TRD. Here, we report the efficacy of esketamine NS vs QXR in patient subgroups with 2 or ≥3 consecutive prior treatment failures (PTFs).

ESCAPETRD was a phase IIIb trial comparing the efficacy of esketamine NS with QXR in patients with TRD. Patients (N = 676) were randomised 1:1 to esketamine NS (n = 336; 56/84 mg; twice weekly, weekly, or every 2 weeks [wks]) or QXR (n = 340; 150–300 mg daily, both in combination with an ongoing selective serotonin reuptake inhibitor/serotonin norepinephrine reuptake inhibitor. Randomisation was stratified by age (18-64 years; 65–74 years) and PTFs (2; ≥3).

The primary endpoint of remission (Montgomery-Åsberg Depression Rating Scale total score ≤10) at Wk8 and the secondary endpoint of remaining relapse-free through Wk32 after remission at Wk8, were analysed in PTF patient subgroups and compared between study arms, with treatment discontinuation considered as a negative outcome. The effect on time to remission was assessed using hazard ratios (HR) from a Cox regression model.

Of the randomised patients, 415 (61.4%; esketamine NS: 204, QXR: 211) had experienced 2 PTFs and 261 (38.6%; esketamine NS: 132, QXR: 129) had experienced ≥3.

Of patients with 2 PTFs, 54/204 (26.5%) esketamine NS-treated patients and 46/211 (21.8%) Q-XR-treated patients achieved remission at Wk8 (p = 0.267). Of patients with ≥3 PTFs, 37/132 (28.0%) and 14/129 (10.9%) patients achieved remission at Wk8 in esketamine NS and Q-XR arms, respectively (p < 0.001). Of patients with 2 and ≥3 PTFs, 49/204 (24.0%) and 24/132 (18.2%) of esketamine NS-treated patients and 38/211 (18.0%) and 10/129 (7.8%) of Q-XR-treated patients achieved remission at Wk8 without relapse to Wk32 (p = 0.133 and p = 0.013), respectively.

Esketamine NS significantly improved time to remission, with a greater effect in the ≥3 PTF subgroup (2 PTFs: HR = 1.547 [95% confidence interval (CI) 1.210–1.976]; p < 0.001 vs ≥3 PTFs: HR = 2.066 [95% CI 1.469–2.907]; p < 0.001).

Esketamine NS demonstrated a significantly superior remission rate versus QXR at Wk8 in patients with ≥3 PTFs, and significantly shorter time to remission versus Q-XR in both subgroups.

1. The need to ensure ECG is done before commencing Psychotropic medications. 2. The need to ensure both medical and non-medical staff cooperate in ensuring ECG monitoring is done according to guidelines. 3. The need to help Nurses acquire competence in performing ECG

A total of 101 patients were reviewed, all with various diagnoses, cardiovascular risks, and on different medications. Of these, 61 were included while 40 were excluded.

The exclusion criteria include:

1. 1. Transfer from another trust to Frays ward

2. 2. Transfer or step down from ICU to Frays ward

3. 3. Transfer from frays ward on the day of admission

4. 4. Patients who are already on treatment and recently had physical health assessments.

5. 5. Admitted before August and after January

Some of the patients were already known to mental health services and had been on medications. While others were having contact with mental health services for the first time.

After the exclusion, only about 61 patients were included in the study over the 5-month period.

Data were collected on the following:

1. 1. Date of admission

2. 2. Date ECG was done.

3. 3. Date medication was commenced.

4. 4. QTc readings

5. 5. Type of medication commenced.

6. 6. Days between admission and completion of ECG were extrapolated.

7. 7. Days between admission and commencement of medication were also extrapolated.

All the above data were analysed and presented in charts, tables, and graphs.

Some Limitations identified:

Lack of standard admission register

Lack of discharge register

Missing ECG reports

Recruitment and participation of team members due to multiple training activities on Frays

1. 1. A total number of 48 patients had ECG while 13 of them did not. Some refused to give consent or were not mentally/clinically stable.

2. 2. A total of patients that had Baseline ECG before the commencement of medications on admission was 22(36%), while 39(64%) had ECG after the commencement of medications. The vast majority of the non-compliant patients were due to failure to consent at the time of admission.

3. 3. Timeline for Baseline ECG vs commencement of medications: 16 patients had within 24 hours, 10 patients had after 24 hours, 16 patients had within one week and 4 patients had after one week.

4. 4. Concerning QTc pattern; A total of 37 patients had normal, 10 patients had borderline and 1 had prolonged

5. 5. Patients with other ECG abnormalities: Out of the 48 patients that had ECG at one point during the admission, about 44 of them had a Normal sinus rhythm while 4 were abnormal. However, all the abnormal ECGs were asymptomatic

Although the vast majority of service users in this study had normal ECG readings and overall low cardiovascular risk, the compliance rate with Trust/NICE guidelines are significantly low. Apart from falling short of Trust and NICE policies, this increases the chances of missed diagnosis, especially in people with pre-existing cardiac conditions.

Efforts must be intensified to ensure the vast majority of service users get thorough physical health assessments including ECG before psychotropic medications are commenced.

Twelve GP surgeries refer adults with suspected ADHD to Horsham Assessment and Treatment Service (ATS). Patients are referred by GPs via letter and an adult ADHD self-report scale (ASRS). Letter contents are variable and some referrals are rejected. There is no gold standard or national guideline for what referral information is required. We used a combination of guidelines and advice from The Royal College of Psychiatrists, The National Institute for Health and Care Excellence, and ADHD UK. Aims: to evaluate the current quality of the referrals, to obtain GP’' views on the referral process, to make the process more efficient and clearer, and with that improve patient experience.

A retrospective data collection method was used. 57 patients were referred between 31st August 2021 and 1st April 2022. We reviewed 54 referral letters (3 were excluded). Main information looked for: presenting difficulties, resultant impairments, confirmation some symptoms present in childhood, past medical history, family history and if an ASRS was attached. We sent a questionnaire to obtain GPs’ opinions on the referral process and how to improve this.

Results of reviewing referral letters:

• • 89% of referrals explained the current difficulties

• • 52% described the resultant impairments

• • 61% of referrals mentioned if symptoms had been present in childhood

• • 91% of referrals contained past medical history and current medication

• • No referrals mentioned family history

• • 6% of referrals contained some physical health data

• • 85% of referrals to ATS were accepted; 13% rejected as ASRS not attached.

Results from GP questionnaires: 11 surveys were returned. Most GPs were not confident in making a referral or what information is required, and did not understand the referral process. GPs would like a referral form, a flowchart outlining the referral process and information for patients about ADHD assessment.

89% of referrals explained current difficulties. Just over half described the resultant impairments, and confirmed if there were symptoms in childhood. Most referrals contained past medical history. 6% contained some physical health data. Only 85% of referrals were accepted. GPs would like a referral form, a flowchart and information for patients.

Results were distributed to staff in ATS and we will distribute results to GPs. We have created a referral form and flowchart to make the referral process more efficient and clearer, and to improve patient experience. We will re-evaluate this after a few weeks, so we can compare with previous data collected.

To ensure that patients who are high intensity users of acute mental health services (136 suite, Liaison, and inpatient admissions) have a ‘safety plan’ in place .This should contain person centred and specific recommendations to avert crisis and guide acute clinicians in managing care in a crisis situation.

Audit of electronic health care records of top 10 patients who most frequent attend each of s136 suite, LPS and inpatient wards (26 in total) in the period 05/2021 to 04/2022.

Process mapping

Driver diagram

Coproduction via patient engagement team

Focus group-across care groups and lived experience

-Audit of 26 identified HIU – whilst most (>80%) had a ‘safety plan’ in place, these lacked sufficient detail to avert ‘crisis’ and guide appropriate treatment should the situation escalate. The most frequent diagnosis was EUPD (77%). Most (93%) were open to CPA pathway.

• • Process mapping – visual representation of crisis planning process within CPA process.

• • Driver Diagram – primary and secondary drivers leading to change ideas of: additional ‘HIU response plan’ template; best practice example to guide care coordinators; process of flagging up HIU to community mental health services.

• • Focus group – themes included the importance of : joint working across care groups’ transparency with patients regarding professional opinion; consistency of interventions during a ‘crisis’; and coproduction of safety plans.

• • HIU response plans are incorporated into the safety plans of 20/26 HIUs.

• • PDSA process ongoing – quality assurance and clinical effectiveness of changes to be reviewed. Further change ideas sought through QI process.

High intensity users who often present in ‘crisis’ to acute mental health services, have unmet needs.

This cohort require an additional framework to meet their needs.

When patients experience a mental health ‘crisis’, a consistent and clear treatment response is experienced as helpful.

Safety/crisis planning is thus an important aspect of meeting needs.

HIU response plans’ can be incorporated into a patients ‘safety plan’ to ensure that individualised and specific guidance is available.

Best practice example of ‘HIU response plans’ can empower community mental health colleagues to co-produce such plans.

Near Me is a tele-psychiatry platform for conducting video consultation appointment in Child and Adolescent Mental Health Services (CAMHS) in NHS Orkney (NHSO). This model of consultation was introduced in NHSO CAMHS during the COVID-19 pandemic. The performance in offering effective clinical intervention in the domains of quality of care will determined through the experiences of both users and providers of care in this respect.

To assess the perception and experiences of service users (clinicians, patients and their families) on the use of Near Me in NHS Orkney Child and Adolescent Mental Health Services by applying the domains of quality of care as a measure. To enable all stakeholders (policy planners, users and providers) to identify gaps and barriers in the use of Near Me and to inform change in practice.

A survey was developed using the Telehealth Usability Questionnaire which is a validated tool to generate responses on the key domains of quality of care measures of appropriateness, reliability, access, timeliness, usefulness, effectiveness, interaction, quality, efficiency, safety, satisfaction and possibility of future use for both users and providers of care.

The survey was made available on social media platforms including websites and online adverts for clinicians, patients and their families in Orkney to complete for a period for 10 weeks.

28 responses were received with 14 completed responses (6 staffs & 8 patients and families) and 14 uncompleted responses (4 staffs and 10 patients & families).

A mean rank test was applied to appropriately evaluate the responses received.

Over 50% of respondents show high level of satisfaction in the use of tele-psychiatry services in all domains of quality of care in Orkney NHS CAMHS.

Access, timeliness and safety are highly positively rated by both clinicians and service users.

Improvement in network connections, improved coordination and understanding of technology will enhance the service.

Better understanding of the handling of technical problems in tele-psychiatry services should be addressed

Reduction of in-person interactions was identified by some respondents as concern.

Tele-psychiatry is highly useful and accepted as revealed by the survey but network connections for the Near me platform needs to be improved. Face to face consultations should not be discounted and should be available where possible for better engagement.

As the first survey of the use of tele-psychiatry in NHS Orkney, this study will serve to establish a baseline for future evaluation of tele psychiatry services in NHS Orkney CAMHS.

-A service development project was developed to establish the current capacity in administrative support for the medical workforce and to understand if there are gaps in support that can be addressed to reduce the time medics spend completing administrative tasks. -The project aims to make practical recommendations to enable medical staff to increase the clinical time spent with patients and, therefore, less time on administrative tasks. Previously published data also show that extensive administrative tasks impacting the clinician’' well-being can lead to burnout.

-Separate surveys were developed for Doctors and Administrators; each group completed the surveys separately.

• • Results were analysed and shared with the relevant stakeholders

• • Practical recommendations were made with a focus on cost-effectiveness and safety.

• • Engagement sessions with medical colleagues and the administrative workforce to reflect on various options and ideas to improve administrative support for the medical workforce.

• • A cost-effective approach was identified and recommended to the Trust Board for approval and implementation

Doctors surveyed identified that almost half of the medical workforce share administrator with the whole team, type their letters, felt they had sufficient administrative support and were prepared to use a voice recognition IT package. However, two-thirds needed more administrative help for their additional roles.

• • Administrators surveyed identified that almost two-thirds of the administrative workforce felt they should be providing full dedicated‘'Name’' support to Consultants, SAS and Junior Doctors. Over three-quarters felt they needed more time to complete all the tasks outlined in their job description (such as typing Docto’'s letters). In addition, almost three-quarters could not provide dedicated support to doctors.

  Most agreed that new roles similar to Medical Secretary role would release Doctor time from administrative tasks.

-The project has improved relationships and understanding of roles and work pressures from a clinical and administrative perspective.

• • The Trust has more transparent data and qualitative evidence gained through project meetings and surveys.

• • Staff felt engaged in the process, and positive feedback was provided throughout the project.

• • Understanding the problems experienced in practice and engaging peers was crucial to meeting the Trus’'s vision of being a clinically led organisation.

• • Care Group modelling undertaken with consideration of COVID-19 Lessons learnt around agile working included administration support, ensuring the appropriate numbers and skills relevant to service demand and ensuring Doctors have dedicated, full support rather than shared with teams.

• • Voice recognition programmes will also be explored through the Agile Working Group to free up Clinical time.

• • Communication to both Doctors and administrators to brief on findings and next steps distributed through various channels in the Trust.

• • The Medical Staffing Board formally thanked the author.

To establish if the Mental Health Act Code of Practice was being followed in the mental health inpatient ward population in Wishaw General Hospital. Specifically, those who were subject to detention with a Compulsory Treatment Order (CTO) under the Mental Health Act and whether or not documentation of consent to treatment was being kept.

Over the course of one week beginning on 1st December 2022, we reviewed the inpatient population within acute psychiatric wards (Wards 1-3) at Wishaw General Hospital to determine the nature of patient admissions, informal or under detention, specifically Short Term Detention Certificate (STDC) or Compulsory Treatment Order(CTO). A total of 57 inpatient notes were evaluated, including those of 10 patients with STDC and 14 with CTO. From these 14 patients, we determined whether T2b(240) or T3b(240) forms were clearly documented in both paper and electronic records (MORSE).

One of the three patients on Ward 1 who were subject to CTO had both electronic and physical documentation of the T3B form. In the physical notes of two patients, the T2B or T3B form, as well as the reason and specific treatment, were adequately described.

Seven of the eight patients subject to CTO in Ward 2 had adequate documentation of the cause and particular treatment, as well as clear documentation of the T2B or T3B form in their physical notes. None of these patient’' electronic notes contained any documentation. As the last patient was less than two months into CTO, they did not fit the criteria for the T2B or T3B consent forms.

All three patients subject to CTO from Ward 3 had clear documentation of T3B forms in their physical notes, as well as appropriate documentation of their cause and treatment. There was no documentation on these patient’' electronic notes.

Overall, the clinical documentation was accurate with strict adherence to mental health act code of practice. 100% of patients requiring consent to treatment documentation either via T2B or T3B form were completed and available for review in the paper notes. Of note however, only 1 patient had CTO documentation and consent to treatment documentation available on electronic records (MORSE) which would allow remote viewing.

We propose the practice to upload detention certificates and consent to treatment forms to Electronic data (MORSE within the “files” tab). This information will be shared with ward staff to encourage copy and filing of documentation within this section on MORSE (electronic records).

To create greater capacity within the general adult psychiatry outpatient clinic to facilitate urgent medical review for patients when needed, and to reduce delays for those receiving ongoing routine care within existing resources by improving joint working processes within the multidisciplinary team. To support safe discharges to primary care and promote ongoing recovery by improving access to community resources and the voluntary sector.

Caseload review for all patients under the outpatient clinics within South Leicestershire community mental health team began in August 2022. A template was developed in consultation with clinical colleagues and approved by the Trust clinical governance process. This includes salient clinical variables such stability, risk and medication. A consultant psychiatrist and senior nurse spend 2-4 hours weekly reviewing each patient's electronic record chronologically from those waiting the longest for an appointment. Using the template, one of the following for the patient's next appointment is determined, based on patient need:

• • Nurse discharge clinic

• • Outpatient discharge clinic

• • Outpatient clinic for ongoing treatment

• • Transfer to another service (eg ADHD)

A pilot nurse discharge clinic was carried out offering face to face reviews for patients identified as clinically stable for discharge over 4 weeks, with regular senior nursing supervision and medical input as required.

Between August 2022 to January 2023, 700 out of a total of 1717 caseload reviews have been completed. 39% of these are identified as suitable to be reviewed for discharge.

In the pilot nurse discharge clinic, 137 patients were offered appointments: 82 were discharged, 16 did not attend, and 39 subsequently needed an outpatient appointment. There have been no serious incidents, complaints or re-referrals.

The waiting time for an urgent outpatient appointment has reduced from six weeks to one week and for routine outpatient care from six months to four weeks.

No work related absence for staff, and qualitative feedback from the multidisciplinary team has been positive.

Reduction in high outpatient caseloads is achievable through robust multiprofessional caseload review, and patients can be safely discharged from the care of consultant psychiatrists by multidisciplinary team working. This creates greater capacity, flexibility and flow for those who need ongoing outpatient care to receive this is a timely manner, improving the safety and quality of patient care. This has also fostered a greater sense of cohesion for staff within the team.

Antipsychotic use is associated with haematological, metabolic and cardiovascular abnormalities. If not monitored and acted upon, these contribute to the increased burden of physical health problems in those with severe mental illness. Appropriate monitoring (including blood tests and ECGs) is required in accordance with NICE guidelines. The aim of our project was to assess our adherence (within a medium-secure forensic inpatient setting) to guidelines, and to improve procedures and processes within the unit. The majority of our patients are taking antipsychotic medication, but prior to our project there was no system in place to determine who was due which monitoring tests and when. Our suspicion was that patients’ physical health was not being adequately monitored especially given the unit's lack of input from general practitioners.

Our initial audit of patient notes took place in October 2022, assessing whether each of our 35 patients had had appropriate ECG and blood monitoring. After gathering these initial data we then systematically offered patients their monitoring. We set up processes to ensure this would be completed in a timely and organised fashion in the future, via creating a spreadsheet available on the shared drive and a chart within the doctor's office, adding instructions to the departmental junior doctor handbook, and liaising with colleagues.

Of 35 patients, 34 (97%) were prescribed antipsychotics, 18 (51%) of these at ‘high dose’. Of those 34, blood tests for 22 (65%) patients were out of date or not completed as per NICE guidelines. ECGs for 21 (62%) patients were either missing or out of date. Following our gathering of the initial data and systematic completion of patient monitoring, at the time of re-audit in January 2023 monitoring was either completed or offered (with patient refusal) for 34 (100%) of patients.

We identified that monitoring of physical health in those prescribed antipsychotics within our unit was sub-par, with the majority of patients not up to date with bloods or ECGs as per NICE guidelines when initial data were collected in October 2022. Following our project, at the time of re-audit in January 2023 monitoring was either completed or offered to 100% of patients. We have implemented systems to ensure this continues in the future, beyond junior doctor changeovers. This has potential application to other longer-stay psychiatric wards such as general adult rehabilitation wards and other forensic units.

Within NHS Ayrshire and Arran for psychiatric inpatient admissions, the admitting clinician is to directly handover clinical details and relevant aspects of mental state, risk and management plan to the inpatient duty doctor. Over 2022, there was concerns this process was not being followed, resulting in prescription errors, difficulty in assessing risk at admission and difficulty in prioritising workload. The aim of the project was to first assess pre-intervention rates of handover for inpatient admissions. Then with these data, look for interventions. The final aim was to re-asses post-intervention, analysing if interventions improved rates of handover.

Pre-intervention quantitative data were gathered over a three week period in April 2022, with Junior Doctors noting for admissions to Woodland View Psychiatric Hospital whether handover had been received, or if the Duty Doctor had been alerted at all to the admission prior to patient's arrival on the ward.

Qualitative data were also gathered, specifically asking what factors admitting clinicians found impacted ability to handover.

Data were presented at the monthly division of psychiatry meeting, and subsequently interventions were discussed in a meeting with Hospital bed managers, Hospital co-coordinators and the clinical director for inpatient care. The outcome resulted in change to the local hospital admission protocol, with bed managers prompting the importance of handover, and transferring admitting clinician's phone calls to the duty doctor at the time admissions are accepted by bed managers.

Post-Intervention, the same criteria assessed in April 2022 was reassessed in January 2023.

Pre-intervention, of 25 admissions, a handover was provided for 32% of patients. Duty doctor was alerted to 52% of admissions prior to the patient's arrival on the ward. Post-intervention, this increased to 71% and 82% respectively for 17 patients admitted in January 2023.

Qualitative themes thought to impact ability of handover were admitting clinicians feeling there was already a number of calls made when admitting, and one with duty doctor could be neglected. Secondly the clinicians thought another member of the team would alert duty doctor of admissions.

The project met its aims, showing pre-intervention rates of handover as low, and post-intervention rates rising after the admission process was changed, taking on the feedback from admitting clinicians. Given rates remain still significantly below 100%, there is still further work to be done. Results are due to be shared again with bed managers and at division to discuss further interventions.

Adults with learning disabilities have traditionally been excluded from psychosis research studies and intervention trials because of their learning disabilities. There is a distinct lack of knowledge about adults with learning disabilities and their lived experience of psychosis including specific symptoms such as voice hearing. Interventions such as Hearing Voices Groups (HVG) have been developed without thorough understanding of what these experiences mean for this population, I found one pilot study ran by South London and Maudsley (SLAM) in 2018 (1)

• • Understand more about voice hearing experiences in people with a learning disability

• • Evaluate whether an adapted HVG is acceptable and affective in this patient group

• • To obtain feedback in order to improve the group for future practice

We set up a hearing voices group for people under the Bristol Community Learning Disability Team (CLDT) who experience hearing voices which causes them distress. The sessions for the group were inspired by ideas from the book “People with Intellectual Disabilities Hear Voices too” published by Psychologist Dr John Cheetham, which we adapted into accessible session plans. The group consisted of 6 service users and was facilitated by me and 3 mental health nurses and ran for 8 weeks on a weekly basis for 1 hour 30 mins. Each participant worked through an accessible handout which we then collated at the end to create a take home workbook of all the material covered throughout the group, as well as individual feedback from the group facilitators.

We used CORE-LD 30 and World Health Organisation Quality of Life (WHOQOL-8) tool pre-group and post-group which are both validated tools for use in people with a learning disability. We also conducted an adapted Maastricht's interview with each service user to understand more about their voice hearing experiences and a post group feedback questionnaire.

All participants had a reduction in their CORE-LD score with lower scores indicating fewer distressing symptoms and lower risk to self, with an average reduction in score of 39%. Themes of why they thought they heard voices included: bereavement, bad neighbours, doing something bad in the past. When asked what the voices say, they were mostly negative insults towards the service user or telling them to harm themselves. Feedback post group included: more sessions/more time, learnt ways of coping with voices, helped to speak about the voices, felt safe and less alone, enjoyed sharing experiences, understand voices.

The NICE Guidelines 2017 Quality statement 4 states that we should be tailoring psychological interventions for people with learning disabilities. Previously there were specific interventions for people with a learning disability within the LD service. The evaluation of this group helps to support the effectiveness in adapting a well-established intervention and the value of offering this on a continued basis in the Bristol CLDT.

We performed a Quality Improvement Project in an inpatient Old Age Adult ward to increase patients’ relatives, friends and carers’ (RFCs’) knowledge about important aspects of hospital admission, through the provision of an information pack. By increasing this knowledge, we aimed to improve RFC satisfaction surrounding the admission process. Previously published evidence has shown that increasing the perception of involvement of RFCs in a patient's admission promotes greater satisfaction within this group. Adequate information provision is regarded as an important part of promoting perceived involvement; conversely, a lack of information provision and communication has been associated with dissatisfaction with hospital admissions among RFCs.

Using a survey directed towards members (n=9) of the ward MDT, we identified several topics relating to hospital admission that were regarded as high priority for inclusion in an information pack. MDT members were also asked about their perception of RFC satisfaction in the admission process. RFCs (n=8) were asked how well-informed they felt about these topics with a separate survey, and their level of satisfaction with the admission process. An information pack was created based on the results of these surveys and distributed to RFCs. The RFC survey was then repeated to assess improvements in RFC knowledge and satisfaction.

Perceived RFC satisfaction among staff members prior to the publication of the information pack was lower than actual RFC satisfaction. RFC satisfaction with and knowledge about the admission process increased following the distribution of the care pack.

Admission information packs can be used on inpatient old age wards to improve patient family, friend and carer knowledge and satisfaction.

Patients with severe mental illness have reduced life expectancy, representing one of the most significant health disparities. Although the cause is multifactorial, cardiovascular disease & other comorbid chronic conditions play an essential role. Individuals with mental illness often face considerable barriers to accomplishing their health and well-being goals. As a result, there is a growing interest nationally and internationally and research evidence for the role of lifestyle interventions in managing mental health conditions. NICE guidelines now reflect this, recognizing the impact of physical health comorbidity and recommending monitoring of metabolic status and cardiovascular risk (using the Q-RISK3 tool) in the management of schizophrenia & bipolar. AIMS: -Phase 1: to identify & analyse lifestyle parameters contributing to patient’' health & leading to excessive disease burden and the QRISK3 calculations for patients in the Haywards Health catchment area on depot antipsychotics. -Phase 2: make recommendations focused on lifestyle factors interventions in addition to standard care-Phase 3: to re-assess following the recommendations from phase 2.

Phase 1 Steps:

• • Identifying all patients on depot antipsychotics living in the defined catchment area.

• • Data Collection from the electronic clinical record: diagnoses, gender, physical activity, alcohol intake, smoking, lipids, employment, BMI, blood pressure, QRISK3.

• • Analyse results.

• • Make Phase 1 Recommendations

Phase 2: Implement phase 1 recommendations

Phase 3: Use the electronic records to conduct a second analysis assessing the offer of intervention to patients, reassessing the lifestyle parameters and QRISK3 calculation

Phase 1 Results: All patients identified (6) had a detailed overview of the lifestyle parameters assessed. None of the patients had the QRISK®3 calculation in phase 1.

A series of recommendations were made at the end of Phase 1 in view of initial results.

• • Disseminate results locally, including in primary care

• • Ascertain up-to-date information regarding physical health and lifestyle parameters in the OPC reviews; include in the letters to GP updates on the category of lifestyle parameters included in this project.

• • Discussion with patients on the impact of lifestyle factors in the OPC reviews

• • Signpost patients to resources they can use to support implementing positive lifestyle choices

• • QRISK®3 measurement

• • 1:1 psychoeducational session focusing on improving lifestyle choices.

• • Engage patients to engage in co-producing psychoeducational sessions aimed at improving lifestyle choices.

Phase 2: implement phase 1 recommendations (October 2022-September 2023)

Phase 3: re-assess in October 2023

Patient-initiated verbal sexual harassment (PIVSH) is common in the healthcare workplace, however institutes often neglect to address it. Objectives: (1) Define extent of PIVSH among staff at South London and the Maudsley Trust (sLaM), (2) Characterise the impact of PIVSH on staff, (3) Understand barriers to reporting PIVSH, (4) Inform policy and training to support staff.

A questionnaire from Scruggs et al. (2020) was adapted with types of PIVSH on a standardised scale of severity from ‘most’ to ‘least’ harassing. The anonymous, retrospective, online survey was disseminated to sLaM staff via Trust-wide communications, staff networks and Whatsapp groups. Descriptive statistics were used to analyse quantitative data (PIVSH frequency, confidence to respond to PIVSH, reporting practices). Respondents used free text to describe the impact of PIVSH, reasons for not reporting harassment, and views on the role of the Trust and supervisors in addressing PIVSH. Qualitative data were analysed using thematic analysis and externally validated.

42 responses were received across staff groups. 95.2% respondents had experienced PIVSH in the last year. 26.2% had formally reported an incident of PIVSH, with only 30.8% stating the report had been actioned by a senior. ‘Less severe’ harassment types were the most common, and the type staff were least confident to address. Five themes were identified in thematic analysis:

1. 1. Nature of PIVSH: Unwanted, covert, influenced by victim demographics, the situation, and motivation of the perpetrator

2. 2. Response to PIVSH: Victim's emotional and practical response, and of the wider MDT

3. 3. Impact on trainee: Personal (desensitisation, feeling unsupported) and professional (time off, moved teams, avoidance of wards)

4. 4. Barriers to action: Practical barriers to reporting (lack of time, complexity) and organisational culture (‘patient unwell’ justification, trivialisation, lack of trust in management)

5. 5. Areas of improvement identified: Written policy on PIVSH clearly communicated to staff and patients; wider cultural changes of zero tolerance to PIVSH; open discussion and reporting, backed up by education and training; formalised support post-PIVSH event

There is a negative impact of PIVSH on staff at sLaM and it is not properly recognised. The NHS is its staff and we cannot afford to neglect their well-being. Action as a result of this survey will include:

1. 1. Creation of a training package with Maudsley Simulation

2. 2. Development of informational posters for clinical spaces

3. 3. Write up-to-date trust policy on PIVSH

Antipsychotics are linked to increased cardiometabolic risk. The National Institute for Health and Care Excellence (NICE) and the Royal College of Psychiatrists have developed guidance on PHM to mitigate this risk. Both risks and guidance are age-blind, and very relevant to Older Adults due to age-related increase in cardiovascular risk. The COVID-19 pandemic boosted digital healthcare, which remains relevant due to rocketing demand and stretched services. This is a Quality Improvement Project aiming to improve physical health monitoring (PHM) for safe antipsychotic prescribing in an Older Adult Community Mental Health Team in South Wales. Baseline data, a virtual clinic model and preliminary results of the first Plan-Do-Study-Act cycle are presented.

An audit was conducted (06/2021–12/2021), with continuous prospective data collection thereafter. A scoping exercise was conducted to establish available resources. A local protocol/operational framework was developed. Education interventions (03/2022-on-going), a junior-doctor-led virtual PHM clinic and a phlebotomy/electrocardiogram (ECG) pathway (10/2022-on-going) were designed and implemented.

Baseline (06/2021-09/2022): completed lifestyle advice=0%, physical observations=3%, blood tests=3%, ECG=3% of eligible patients. No patient (0%) had the full PHM as per guidance. Mean overall compliance with guidance/patient=9%. Pareto chart: no clear pathway and lack of prescriber awareness were the main reasons (>95%) for poor performance.

Scoping exercise: No Health-Board/Trust-wide approach for Older Adults and PHM is problematic in all localities. General Practitioners assertive regarding no responsibility/funding to deliver PHM for at least the first 12 months or until antipsychotic dose and mental state are stable. Geriatric teams, district nurses, general adult teams stretched and unable to support. Care home staff lack training and resources. Phlebotomy and ECG departments of local hospitals could support but no pathway.

First PDSA cycle (preliminary):

Change idea 1: staff education: clear shift (04/2022 onwards). Proportion of trained staff reached 100% in December 2022, and remains 100% in January 2023.

Change idea 2: virtual PHM clinic (10/2022 to 01/2023) – mean overall compliance with guidance/patient = 69% (vs. 9% baseline). Proportion of patients with complete PHM as per guidance reached 50% in January 2023. 75% patient response rate.

Change idea 3: phlebotomy/ECG pathway (10/2022 to 01/2023) – proportion of patients with bloods and ECG done reached 67% in January 2023.

Preliminary data suggest an encouraging trend for significant continuous improvement which, from a clinical perspective, is already significant. However, more data are required to draw safe conclusions regarding the clinical and cost effectiveness of this model of a virtual PHM clinic.

A previous audit of use of rapid tranquillisation in older adults conducted in 2019 identified high rates of use of sedation, and poor adherence to local guidelines. Following this audit, a number of quality improvement (QI) initiatives were undertaken in order to try to improve practice, including multiple teaching sessions to a variety of staff. This re-audit was conducted to study whether initiatives had been effective in line with the Plan Do Study Act cycle of Quality Improvement.

Using the same audit tool developed in 2019, six wards (2 geriatric, 3 medical and 1 surgical) were audited. Patients over 65 given oral or intramuscular sedating medications had their drug charts and notes reviewed. Data were collected on type of sedation, route prescribed, whether it was prescribed regularly or PRN, whether an indication was documented, underlying diagnosis and what monitoring took place post sedation.

297 drug charts were reviewed, and 13 patients were prescribed rapid tranquilisation (RT). The maximum daily dose was included in 63% of prescriptions similar to that of the first audit (58%). The most common route of administration was intramuscular, unlike the previous audit which was oral/intramuscular.

50% of prescriptions documented an indication, of which 25% were illegible. Whilst in the first audit the figure was 33%.

Of all the patients prescribed RT, 77% had a diagnosis of delirium, 77% had a diagnosis of dementia and about 53.8% had both. In both audits 100% of patients had a diagnosis of dementia or delirium. Most prescriptions were for lorazepam (75%). There was no evidence of observations being taken in line with post RT monitoring in the trust policy in both audits

Further work needs to be done to improve practice. Interventions to date have not been effective. Further plans for QI work include updating the RT policy to be more specific and useful for the acute trust, to fit in with a recently introduced electronic records system (ERS) and to include a clear section on older adults with signposting to the delirium and dementia policies. As well as adding prompts and protocols to the ERS to support safe prescribing and dispensing of RT. Teaching will be repeated and a poster has been developed and promoted on all the wards. The project group are planning to join the trust's ‘medication safety huddle’ regularly to include pharmacists in teaching and work. The audit will be repeated in three months time.

NICE guideline CG183 states that “both the drug and the description of the reaction must be documented on all forms of prescription and in a patient's medical records”. Black Country Partnership NHS Foundation Trust (BCPNFT) documents allergy status on both paper drug charts and the Electronic Patient Record“"Ri”" (EPR). Incomplete Allergy Status on EPR poses a significant patient safety risk, particularly in an era of hybrid working and out of hours input from remotely based clinicians. The standard for this audit is that 100% of drug charts and Rio notes should have allergy status documented. The BCPNFT is a collection of psychiatric services across four towns- Dudley, Walsall, West Bromwich and Wolverhampton. The aim was to ensure consistent practice and standards across all sites. Following the initial data collection, discussion of findings and Action Plan (AP), and to ensure consistent standards, it was agreed to expand the project to include all General Adult in-patient units.

A data collection tool was designed collaboratively with the QI Department, to capture demographics, diagnosis, admission duration, legal status and allergy status both written and digital. This tool applied for all 96 older adult in-patients across the four localities within the trust on 03.10.22. The only exclusion criteria was admission within 24 hours of the data collection date.

Data Collection: 100% of Paper Drug Charts had allergy status documented, only 70% have type or severity of allergic reaction documented. Despite 76% of in-patients admission of 4 weeks or longer, only 62% of patients had their allergy status documented on EPR, this varied from 30-100% across individual wards. EPR allergy status documented: Wolverhampton 93% West Bromwich 100% Dudley 33% Walsall 39%

The results from all four localities were presented at the respective locality post graduate teaching, the EPR configuration team meeting and the QI Group meeting to gain Multi-Disciplinary Team feedback for both low documentation rates and high variability across sites. Based on this feedback, the AP comprised of incorporating an Allergy Status prompt into the electronic clerking document, visual prompts of stickers and posters across all wards. Also, liaising with Pharmacy to request they also update the allergy status on EPR; and Ward Matrons who have added an Allergy Status alert onto their bed state view. Data will then recollected post AP interventions, across all older and working age adult inpatient wards- a sample size of around 300 patients. The second data collection is currently being undertaken.

Our Care Improvement System is an integrated quality and performance system designed to develop co-ordinated approach to managing performance at all levels of the organisation, ensuring everything we do is aligned to achieving our goals set out in our Trust strategy. The aim of this programme is to help the team move away from typical firefighting routines, towards a more structured routine of problem solving, applying quality improvement tools and methodology.

Five members of multidisciplinary team (MDT) in a Lewisham Community Mental Health Team were chosen as the core working team. They underwent four-month training programme which was one day per month plus weekly team coaching sessions from the Trust's Quality Improvement lead. One targeted measure was identified. This was to focus on improving patient discharges for more manageable caseloads, and ultimately provide a better staff and patient experience. A3 methodology was adopted to provide a structured framework for thinking through the problem. This included: problem statement, current situation, aims statement, root cause analysis, change ideas, actions, progress and benefits, and insights. In parallel, daily improvement huddles (15-minute long team meetings) were adopted to enable the team to problem solve other identified improvement work. The huddles follow a set structure of reviewing work in progress, new improvement opportunities, work that needs to be escalated and celebrated. This work was gradually widened to include the entire team.

The team's caseload was observed to be continuously going up from 200 in September 2021 to 264 in October 2022. We aimed to increase the number of safe discharges and to sustain a steady team caseload. Root cause analysis utilising a fishbone diagram identified barriers to discharge, such as lack of MDT approach and structure to discharge planning. Change ideas included creation of standard work, describing how an MDT discharge meeting would work. Actions were agreed to implement structured weekly MDT discharge meetings where four cases are discussed and safe discharge plans agreed, sharing responsibility for discharge decision. This has allowed us to reduce and maintain a steady caseload with 258 patients in January 2023.

Implementing Our Care Improvement System has not only provided a structure to our improvement work and improved our caseload but has also consolidated our team in working together for a common goal. We have naturally implemented structure to all other team meetings, which have now become more focused and productive, making our team a more rewarding place to work.

The objective of this project was to switch the default search engine used on CNWL computers from Google/Bing to Ecosia. Both Google and Bing have poor ethical and environmental credentials. Ecosia, in contrast, is a not-for-profit, certified B-Corporation which funds tree planting and community projects around the world. Ecosia searches display ads (just like any other search engine) however it donates 100% of its profits towards high-impact agroforestry, tree planting and forest protection.

The first step was to pitch the proposal to the Trust's Sustainability Lead. Then, information governance and cyber security teams performed assessments and gave clearance. An ICT technician was allocated the task and they configured the switch for a pilot group of 38 staff, with the help of step-by-step guides produced by Ecosia. After a short trial, the pilot group completed a questionnaire. Following satisfactory feedback, the ICT technician switched the default search engine to Ecosia for the entire Trust staff group. A Trust-wide email informed staff of the change and provided opportunity for feedback to be given via an online survey.

A CNWL tree count is sent monthly from Ecosia. Over the first four months, an estimated 32,872 trees were planted using the funding generated by CNWL.

The pilot survey showed 80% of participants agreed that CNWL should use Ecosia as its default search engine (0% = should not; 20% = undecided). 62% felt Ecosia performed the same as the previous search engine (14% = much better; 5% = somewhat better; 20% = somewhat worse; 0% = much worse). 86% said they would use Ecosia on their personal devices. Further comments included:“"This is a great initiative from the trust, who in many realms benefit private profit enterprises to the detriment of our planet.”;“"As a Trust, in addition to using Ecosia, we should look for other similar measures, on the grounds that every step towards sustainability makes a cumulative impact”"; “Google performs better than Ecosia”. It is noted that if an Ecosia search does not yield the required results, it can easily be switched to Google by clicking ‘More’ —> ‘Google’.

Switching to Ecosia is an achievable action that health organisations can take. Collectively we can fund the protection and regeneration of forests, which benefits people and the planet, and engages staff in climate action. The next step is for other Trusts to switch, with an ultimate goal of all NHS organisations using Ecosia.

The Royal College of Psychiatrists, UK, is the professional body responsible for education and training, and setting and raising standards in psychiatry. It is an increasingly international organisation with approximately a fifth of members living outside the UK. In partnership with the UK-charity Medical Aid for Palestinians (MAP), the college was invited to develop a national strategy for child and adolescent mental health in Palestine for the Ministry of Health. Children are at higher risk of developing mental illness when living in overcrowded areas with ongoing shelling, siege, and other acts of violence as is the case in Gaza. A significant proportion of Palestinian children experience serious psychological distress especially anxiety and post-traumatic stress disorder (PTSD), with children reporting not wanting to be apart from their parents. The aim of the strategy is to set key priorities for child and adolescent mental health so that funders, institutions, organizations and community members align their activities in a coordinated and efficient way.

Information was gathered from an extensive literature review and three in-person missions to visit the West Bank to meet key stakeholders from governmental and non-governemental organizations including the Ministries of Health, Education and Social Development and the only Child and Adolescent Mental Health Services in Halhoul, north of Hebron. A thematic meeting was held in August 2022 and a feedback meeting in December 2022. All comments and feedback were reviewed and incorporated into the final document for submission to the Ministry of Health for official approval.

Today's child in Palestine bears the burden of decades of violence, conflict and hardships that have accumulated during their lives and those of their parents and grandparents. In total, 2242 Palestinian children have been killed by Israeli military forces between the years 2000 and 2022. Childhood is not a given for Palestinian children, but instead something that must be determined, retrieved, and understood within a complex web of implications mandated by the dynamics of power that are in play. As a testament to the Palestinian people's ability to adapt, endure and demonstrate sumud (steadfastness), through strong family and community relations, many children show remarkable resilience. However, there are children and families who require additional support and expert care.

Demand for child and adolescent mental health services is not being met by current clinical services which are fragmented and under-funded. Clinical pathways to refer vulnerable young people suffering from mental illness do not exist; nor do day or inpatient facilities for young people who require specialist interventions or admission, be it for severe mental illnesses or high risk behaviours. The lack of clear child protection protocols and limited availability of supportive family counselling and therapy compounds the pressure on caregivers. Vulnerable children are left exposed.

Every child deserves a childhood and a future. This national strategy takes a holistic view of childhood and adolescence, using the multi-level framework for child and adolescent well-being developed by the United Nations Children's Fund (UNICEF).

The strategy's vision is for every Palestinian child's mental health and well-being to be promoted and protected throughout their developmental journey into adulthood by strong multi-sectorial support networks and for mental illnesses to be detected and treated by collaborative, effective systems of care, free from stigmatization, discrimination and marginalization so they can live fulfilling lives as integrated members of society. This vision is build on four pillars of‘'Rights and Regulation’'‘'Prevention and Promotion’'‘'Capacity Buildling and Clinical Service’' and‘'Community Integration and Contribution’' The vision can be realised through the implementation of ten initiatives, each with their own action plan and outcome measure, with the critical enablers of funding and stakeholder participation and collaboration.