This pilot study addresses the implementation of trauma-informed practice within healthcare settings. Given the profound impact of trauma on individuals’ health and well-being, there's an increasing recognition of the importance of integrating trauma-informed care into healthcare systems. This project aims to evaluate and enhance healthcare professionals' understanding, awareness, and confidence in implementing trauma-informed practices through targeted interventions.

The project initiated with a baseline assessment through surveys among healthcare professionals to gauge their initial understanding, awareness, and confidence levels in applying trauma-informed practices in their work environments (n = 9). Subsequently, a structured teaching session was conducted to provide education and training on trauma-informed care. Post-session, a reassessment survey measured improvements in awareness, understanding, and confidence levels (n = 5).

Following this, a visual aid – a comprehensive poster summarizing key aspects of trauma-informed practice – was created and displayed prominently in healthcare settings. A second cycle of the quality improvement initiative was undertaken, measuring outcomes after the implementation of the poster. Surveys were administered again to evaluate the impact of the visual aid on sustaining and further enhancing healthcare professionals’ adherence to trauma-informed practices (n = 3).

Post-teaching session assessments demonstrated a notable improvement in levels of awareness (44%), and confidence (56%) among healthcare professionals regarding trauma-informed practices, as well as recognition of signs & symptoms of trauma (44%). Subsequent to the poster's introduction, the second cycle of assessments showcased sustained levels of awareness, understanding, and confidence among the participants.

The project underscores the effectiveness of targeted interventions – educational sessions and visual aids – in augmenting healthcare professionals’ understanding, awareness, and confidence in implementing trauma-informed practices. The improvement in these metrics post-interventions emphasizes the value of ongoing education and visual support tools in fostering a trauma-informed approach within healthcare settings. Embedding such practices can significantly impact patient care, fostering a more supportive and empathetic environment for individuals affected by trauma.

1. 1. Identify changes in the services rendered in the Enhanced access/emergency service following the previously suggested modifications.

2. 2. Identify areas of possible improvement within the service to provide seamless emergency and out-of-hours mental health support to patients.

3. 3. Evaluate adherence to current guidelines for the Enhanced access/emergency service.

An audit of a total of 100 patients on the list was selected in chronological order. Patient documentation was reviewed against the current criteria for patients on the list, which included having a documented care plan in place, remaining open to a community mental health team, and having been reviewed at least within the last 6 months.

The data was then analysed and compared with the previous year's results to see if there was any significant change year over year.

Year on Year improvement:

1. 1. Total number of patients on the list had increased by 16.7%.

2. 2. The number of patients without a care plan on the list reduced by 6.

3. 3. The number of discharged patients on the list was also reduced by 1.

4. 4. The number of patients who had not been reviewed in six months reduced by 9.

While there had been some improvement in the service provision and adherence to the guidelines, there was still ample room for improvement, which would be achieved by adherence to the guidelines and protocols, to ensure better service improvement for enhanced access and out-of-hours emergency services to patients.

Clinical Global Impression Scale (CGI) is a recognised scoring system used to assess patients across a variety of medical specialties. In this study we aim to evaluate the use of the severity scale (CGI-S) in a female adult mental health unit. We aim to explore how frequently it is used to assess patients on admission and discharge and investigate its utility in predicting a variety of patient outcomes. We hypothesise that gaining a greater understanding of the significance of CGI-S scoring can enhance in-patient care by offering insights into factors such as probable length of stay and potential benefits of in-patient admission.

Patient data was collected retrospectively for the last 60 patients discharged. The resulting population data from an inpatient female ward which was then analysed using Microsoft Excel and Jamovi.

59 patients were included in the final data set. Population age at time of admission ranged from 18–68 years with a mean age of 38. The mean length of stay was found to be 40.2 days. 80% of patients had an admission CGI-S recorded with a mean score of 2.77. 71% had a discharge CGI-S recorded with a mean score of 1.79. 58% of patients had both admission and discharge CGI-S score recorded. The key findings of the study were a mean reduction of 1.09 in CGI-S scores, indicating an overall improvement in patient presentation by the point of discharge. Length of admission was increased by 14 days per 1 integer increase in admission CGI-S score. The data also suggests that the correlation between admission CGI-S and length of stay is statistically significant (p value of 0.016). It was also noted that patients with a discharge diagnosis of ‘Emotionally Unstable Personality Disorder’ had a smaller reduction in CGI-S score at point of discharge and required shorter hospital stays, compared with other diagnoses.

The results of this study imply that use of CGI-S scoring in adult inpatient units is beneficial. However, its value can be better seen with improved adherence to regular completion of scores during patient reviews and is an important step to prioritise. Increase in utilisation of this tool will also likely provide clinicians with guidance in predicting which patients are likely to benefit from lengthier admissions and those that might fare better with community support.

1. 1. To assess the current video gaming provisions on an inpatient CAMHS ward.

2. 2. To gather feedback from young people on the ward on the current provisions and gather suggestions for improvements.

3. 3. To implement any suggestions of improvements.

4. 4. To organise regular group gaming sessions for groups and to allow access for individual use.

5. 5. To gather feedback following implementation on how to improve further.

Using surveys, we gathered feedback on attitudes to recreational gaming, interest in gaming social events, preference for individual gaming and on thoughts of the current gaming facilities in a London inpatient CAMHS unit, from a cohort of young people admitted to the ward.

Based on this feedback we sourced funding for a Nintendo Switch from Gaming the Mind Charity and purchased a Nintendo Switch for the Unit along with preferred games.

Regular group gaming sessions were integrated into the ward activity schedule. Additionally, access for individual use was also facilitated.

Further feedback on implementation was gathered from the young people.

Based on initial survey feedback, a majority of young people on the ward indicated that they enjoyed gaming and that it was a good way to “have fun, relax or socialise”.

Feedback suggested the current provisions on the ward (consoles and games) were outdated and not used frequently.

Nintendo Switch received most suggestions for best new addition to the ward.

Game suggestions included: Mario Kart 8 deluxe, Wii sports, Splatoon 3, Mario super smash bros and Minecraft.

After implementation of social gaming events into ward timetable, follow up feedback was positive, suggesting that the majority of young people who engaged in recreational gaming activities on the ward benefited from this. Feedback suggested it was beneficial in terms of mood, socialising, and as a distraction from difficult emotions.

Improving access to recreational video gaming consoles and games within inpatient settings is a valuable way to offer activities to improve mood and social interactions between young people in an inpatient CAMHS setting. Follow up research into efficacy would be of benefit.

Mental health professionals are very likely to experience a patient death at least once in their careers. The Royal College of Psychiatrists published a framework for supporting mental health staff following the death of a patient by suicide. It states that ‘how the news about a patient's suicide is imparted influences the emotional impact of the death and is therefore very important'. We sought to explore how healthcare professionals are informed about patient deaths within Birmingham and Solihull Mental Health NHS Foundation Trust.

A 25-question survey was devised to explore how staff have been informed about patient deaths and the impact it had on them. This was emailed to all grades of doctors, nurses and allied healthcare professionals within the trust and results were collected over 11 days.

83 healthcare professionals completed the survey.72 respondents had experienced a patient death within the trust. Of 72, 48.6% of respondents felt they had not been informed about their most recent patient death in a sensitive manner. There was wide variability in the method by which staff were first informed. 27.8% of respondents first learned of the patient's death via an email from the trust lawyers, patient safety team or another party. Of these 20, 17 felt they had not been informed in a sensitive manner. 63.9% (n = 46) reported that they had not been signposted to any support. Qualitative data suggested that the way in which people were informed had a wide-ranging impact. Many respondents felt shocked and upset. With hindsight, people would have appreciated being informed face to face and being given time to reflect. Of the total 83 responses, 82% (n = 68) felt that there should be a specific policy about how staff are informed about patient deaths.

Results from this survey demonstrate a large scope for improvement in the way that staff are informed of patient deaths. Using these results, we will generate change ideas for a quality improvement project which aims to inform staff more sensitively about patient deaths. Feedback suggested implementation of a new protocol to guide team managers and consultants on how to inform staff; it may help to standardise the process and the support provided. Patient deaths have a significant impact on the mental health of staff; communicating this matter compassionately may help to alleviate immediate feelings of distress and mediate the long-term impact on staff wellbeing and satisfaction.

The key aim of this project was to update and modernise the hospital procedure on how patients access pornographic material whilst detained at Wathwood Hospital. Within the update, we aimed to promote inclusivity and acceptance of all patients’ sexual identities as well as utilising the opportunity to emphasise healthy consenting sexual relationships.

Patients in Forensic Mental Health settings are often inpatients for a significant amount of time, with multiple restrictions imposed on their private and family life. Current policy allows patients to purchase pornography for private use in their own room. It must be material of the same nature available in a main street outlet. In practice, material is usually purchased in DVD format from the Amazon website and subsequently screened for suitability by Security staff and finally approval by the Responsible Clinician. There have been numerous incident reports involving the trading of pornographic material.

Qualitative semi-structured group interviews (up to 5 people at a time) were conducted with patients in the medium-secure forensic services of Wathwood Hospital. They were recruited from the fortnightly Patient Forum. Anonymised questionnaires involving Likert scales and free text response spaces were also distributed at the Patient Forum. Data gathered investigated the percentage of patients who were aware of the current procedure, if they felt it worked well and what they thought the impact of accessing pornographic material might be. Staff were invited to complete a similar anonymised questionnaire, again considering their opinions on the positive or negative impacts of pornography for patients. In addition, we gathered data on whether there was a difference on the degree of comfort/discomfort about pornography, depending on whether the material involved opposite sex or same sex couples. In total, there were 40 survey participants.

Some key areas for concern were found, for example, only 17% of staff and 16% of patients thought the current policy works well despite 69% of staff and 84% of patients feeling it is a patient's right to access pornography. Free text and focus group feedback established many benefits to it. It was clear that there were some areas of difficulty in the hospital policy, which would benefit from being refreshed.

Staff and patients overall feel that access to pornography is important for many of the patients. We identified areas for improvement in how this is accessed and a need to continually be considering the need to consider meeting the holistic needs for the patients.

Child and Adolescent Mental Health Services (CAMHS) is a highly specialised service to which children with severe mental health problems are referred. The COVID-19 pandemic brought with it a lot of uncertainty, and healthcare systems across the UK struggled to cope with the added pressure. The aim of this systematic review is to analyse the literature exploring the effects of the COVID-19 pandemic on the severity of mental health conditions and referral rates to CAMHS services in the UK. The findings from this study will help the services understand the impact of the pandemic on referral rates to CAMHS, the severity of various mental health conditions, and how the services are managing.

An extensive search, following PRISMA guidelines, was undertaken across multiple electronic databases using a predetermined search strategy. Studies reporting on mental health conditions in children post-pandemic and on referral rates to CAMHS in the UK were included. Subsequently, data extraction, quality appraisal and qualitative analysis were performed in a descriptive style.

Initially, referrals to CAMHS decreased during the first lockdown, followed by a significant increase in referrals throughout the pandemic period. The referral rate to CAMHS remains steady until adolescence, with a rapid increase in referrals to the services during the teenage years. More adolescent girls were referred to CAMHS compared with boys and are at an increased risk of developing mental health conditions. A higher number of children and young persons presented with urgent referrals and heightened symptoms during the pandemic compared with the pre-pandemic levels. In particular, there was a significant increase in children presenting with eating disorder problems, accompanied by an increased severity of symptoms. Furthermore, there was an observed rise in depression and anxiety among children and young people, along with an increase in the use of antidepressant medication.

Referrals to CAMHS increased during the pandemic, with increased severity of symptoms observed, particularly in children and young people with eating disorders and neurodevelopmental conditions. Future research should explore the enduring impact of the pandemic on referral rates and presentations to CAMHS. This exploration is essential to aid senior managers and policymakers in decision-making, enabling the implementation of appropriate measures to manage the pattern of demands on CAMHS and shape the future service delivery of CAMHS in the UK.

To improve the detection of delirium amongst patients aged over 65 in Queen's Hospital, and then incorporate a clearer management pathway for these patients to be treated safely with more appropriate intervention and better follow up care. As part of the management pathway, the aim was to increase the delirium referrals made to the local Dementia and Delirium Team for quicker implementation and education regarding non-pharmacological interventions in treating delirium, whilst ensuring that Psychiatric Liaison Service (PLS) referrals for delirium were also appropriate.

A multi-phase approach to quality improvement and service development for patients with delirium has been adopted, and the first step is to improve the screening of patients over 65 years old with delirium and then to refer to appropriate teams accordingly. Our first intervention was changing the PLS referral form. It has been simplified with less input data required, and now includes a mandatory 4AT screening score for delirium, as well as a mandatory referral to the Dementia and Delirium Team for any patient with positive screening for delirium. The intervention was implemented in November 2023, with pre and post intervention data collected in October and December 2023 respectively. Data was collected prospectively and retrospectively using medical notes.

Queen's Hospital PLS received a total of 60 older adult referrals in October 2023 and 49 referrals in December 2023, of which the total proportion of referrals diagnosed with delirium was 47% and 35% respectively (12% absolute reduction). The proportion of patients referred to the PLS team with delirium, who did not require further intervention after initial assessment, had reduced by 29% (87% to 58%). The proportion of patients with delirium referred to PLS, who had also been appropriately screened and referred to the Dementia and Delirium Team prior to PLS assessment, has also increased by 4%. There has been a marked increase in total delirium referrals to the Dementia and Delirium team after intervention, from 31 referrals in October to 85 referrals in December (174% increase).

There is an improvement in screening for delirium, with marked increase in referrals made to the Dementia and Delirium team. There is a decrease in uncomplicated delirium referrals who do not require further PLS intervention and can be appropriately managed with the Dementia and Delirium team input.

An evaluation of the service and care provided to eating disordered patients referred to Tier 3 CAMHS within NHS Lanarkshire. Eating disorders are recognised as a relatively common disease with preventable mortality. The primary aim was to determine if patients with eating disorders adhere to the assessment and management as outlined in MEED and SIGN 164. The secondary aim was to scope the number of eating disordered cases to plan recruitment and training of specialist staff.

The pilot study was carried out in November 2022 and repeated in January 2024. The Electronic Patient Record and paper notes of eating disordered cases assessed in 2023 were used to audit against MEED and SIGN 164. Additional patient demographics including patient's age, sex, median BMI at initial appointment, working diagnosis and suspected co-morbidity were also collected. The service was further evaluated on its processes from source of referral, time taken to be seen, therapies offered and duration within service.

A total of 46 cases were identified in the audit compared to 57 in the pilot study. Most of the cases seen in 2023 were girls in their early teens (89% between the ages 13–16). 10% have a median % BMI <80%. 15 were given a diagnosis of AN (33%), 4 with BN (9%), 4 with ARFID (9%), 2 with OSFED (4%) and 19 with no formal diagnosis (42%). There was a high level of suspected comorbidity (80%).

Referrals were mostly made by GPs (87%), followed by school (11%) and other professionals (2%). The average time taken for the initial assessment was 63 days (40% were seen within 4 weeks). 14 (30%) of cases were offered FBT only whereas 3 (7%) had CBT-E. 7 (15%) did not receive any intervention and 19 (41%) were given other therapies.

With respect to the MEED risk markers, there had been improved recording of weight changes (40% to 80%), hydration status (40% to 70%), temperature (5% to 30%), bloods, over exercising (85% to 90%), purging (75% to 85%) and self-harm behaviours (85% to 90%). However there had been reduction in the recording of BP/HR (80% to 50%), ECG (75% to 40%) and engagement with services (75% to 60%).

Overall, there's some improvement in assessment and management of ED cases but the standard remains inadequate. This project has helped understand the gaps in services and provisions available. Ongoing evaluation is required to help steer service development and optimise patient care.

This project was launched in January 2022 to improve handover between on-call teams and wards, following GMC concerns in 2020 with the out-of-hours handover process. In 2021, a ‘Hospital At Night’ Microsoft Teams evening meeting was successfully introduced. However there remained low satisfaction with other areas of the handover process, including use of paper forms to handover between shifts. The aims of the project were to review the current handover process and improve quality and satisfaction of handover. The target was to improve baseline satisfaction with the handover process by 20% (6 months after change implementation).

A driver diagram was built to identify factors contributing to quality and satisfaction with handover and develop change ideas.

Qualitative surveys using Likert rating scales were sent to all doctors to explore satisfaction with handover format and quality of information received. Opinions of doctors and the wider MDT were used to develop ideas and evaluate support for change. Surveys were repeated following each cycle.

From July 2022, interventions were introduced and monitored over four QIP cycles. This included an electronic handover in the form of a twice-daily email handover list, which was updated following feedback. Microsoft Teams morning weekend meetings were then introduced and modelled on the existing ‘Hospital At Night' protocol.

Following interventions, the percentage satisfaction with handover format improved from a baseline of 14% and was maintained at an average of 81% across 15 months.

The satisfaction with the quality of handover improved from 36% and was maintained at an average of 97%.

The weekend virtual handover has also been well received with 71% satisfaction. This maintains the satisfaction levels achieved with the ‘Hospital At Night' virtual handover. The involvement of the MDT has been high with 71% of doctors satisfied that the necessary team members are attending.

Introducing a standardised electronic twice-daily handover has improved satisfaction with and quality of handover. It has also improved communication between on-call teams and wards.

The introduction of additional virtual handover meetings at the weekend has also been well received. It allows another opportunity to strengthen clinical leadership and the MDT to work more effectively out-of-hours. Future intervention will be targeted at standardising the content of these meetings and attendance in line with the ‘Hospital At Night' protocol.

We aim to monitor local benefit from these changes, and expand this project to other hospital sites which are not yet using an electronic handover system.

NHS England defines serious incidents as events in health care where the consequences are so significant that they warrant a comprehensive response. Serious incidents are individually reviewed, as per national standard practice, in our liaison psychiatry service line at West London NHS Trust. The aims of these individual reviews include system wide learning, organizational accountability and to make changes to the system to prevent a repetition.

There is currently no mandated requirement for thematic review of incidents. Therefore, there is a risk that long-term learning may be limited and overarching themes spanning the incidents may be missed. To improve this process, we have undertaken a thematic review of all serious incidents over a 2-year period, across the three teams in the liaison psychiatry service line.

The aims of this quality improvement project therefore were:

To understand persistent or recurrent systemic factors that contribute to serious incidents.

To identify priority areas for system changes in order to improve the safety of liaison psychiatry services.

To ensure lessons learnt from incidents are embedded within the liaison psychiatry service.

This was a joint project undertaken by liaison psychiatry clinicians and the clinical governance team. Initially an inductive analysis of ten serious incidents took place. Over six months, we combed through the serious incident reports and collated the data. We then identified and stratified the key themes.

The 5 headline themes identified were:

1. 1. Risk assessment and risk management.

2. 2. Human factors.

3. 3. Issues with referrals.

4. 4. Triangle of care.

5. 5. Organisational factors.

The dominant theme which occurred across all cases was risk assessment and risk management. A narrow focus when considering risk and underestimation of risk led to the creation of suboptimal safety plans for patients. Our thematic analysis found a range of organisational factors, including the excessive demand on staff and resource limitations. Human factors are usually a reflection of organisational culture or system wide approaches. The issues we found with the implementation of the Triangle of Care reflect the need for a greater focus on involving families and carers.

The learning was shared with all staff in our annual development day, and this is planned to be an annual review of serious incidents across the liaison service. This approach should improve the depth of our learning and enable the service line to have an overview of the key themes which need to be addressed to deliver safer services.

Aim: To compare and evaluate three improvement collaboratives designs in terms of tangible and non-tangible benefits.

Background: Leading health systems have invested in substantial quality improvement capacity building, but little is known about the aggregate effect of these investments at the health system level.

Collaborative learning is one of the educational approaches of using groups to enhance learning through working together. Research shows that collaborative experiences that are active, social, contextual, engaging and student-owned leads to deeper learning.

CNWL organised three collaborative programmes with varying duration and distinct approaches to team selection, wrap-around support mechanisms, training design and post-collaborative QI support.

These three virtual collaborative programmes were co-designed with service users and carers to support 24 teams each in planning, delivering and sustaining improvements aligned with the Trust's Strategic Priorities.

All programmes provided knowledge on the Model for Improvement and co-production, enabling frontline ownership of safety solutions while building organisational QI capacity and capability.

Each collaborative was divided into Planning and Delivery phases. The evaluation, which covers a 3-year period, compares programme metrics to assess effectiveness, impact and identify areas for improvement.

Incorporating cognitive diversity is crucial in improving the learning process. Collaboratives play a vital role in achieving this, as they bring together different services, staff, and SU&C to drive improvement.

The benefits of collaborative work in quality improvement extend beyond the project data, as it can lead to positive unintended consequences such as a shift in team culture and the adoption of an improvement mindset. These outcomes gained on the journey should be evaluated and celebrated. Moreover, collaboration fosters a culture and platform for sharing and spreading learning beyond the team/service.

However, it is important to take the time to consider and compare different designs of collaboratives during the scoping phase. Factors such as the duration of the collaborative programme, the need for additional wrap-around support and the selection of measures to evaluate the programme should be carefully considered before proceeding.

Effects of changes

1. 1. Comparing different collaborative designs identified the key enablers to a successful project. They were application process brought teams together that were ready and willing to improve; targeted wrap-around support to Sponsors, SU&Cs, Coaches and having decision gateways in design enabled focused and candid conversations about team progression.

2. 2. Collaborative with longer time frame were more resource intensive but had a greater positive impact on safety culture, successful projects and sustained gains than the shorter duration.

3. 3. CNWL Added Value framework evaluated tangible and non-tangible benefits, i.e. staff experience, safety and learning culture, patient experience, streamlined processes and efficiencies gained.

It is important to look at the local context when designing a collaborative with their clinical setting.

A consideration should be based on resources available to support the entire duration of collaborative and what are the desired outcomes of the collaborative.

Aim:

80% of Central and North West London NHS Foundation Trust (CNWL) QI projects will have meaningful Service User & Carer involvement by August 2023 (baseline was 46%).

Background:

Service user and carer (SU&C) involvement is increasingly recognised as integral to healthcare improvement efforts. However, despite its many benefits, the meaningful involvement of service users and carers remains a challenge.

Thus, it is necessary to get an in-depth understanding of the barriers and enablers to embedding involvement in improvement practice at the individual, service and organisational levels. With this understanding and staff can then co-produce evidence-informed behaviour change interventions to improve SU&C involvement.

Patient representation and lived experience

This improvement work embraces a full and continuous partnership with SU&Cs.

SU&C worked with CNWL staff in the conception, execution, delivery and dissemination of this work including EbE Improvement Forum.

They, thus, serve as integral members of the project team where they provide valuable input based on their lived experiences and perspectives to help shape the direction of the work. As equal partners, it also helps foster a culture of mutual respect, collaboration, and trust between all the parties involved.

This work adopts the COM-B model. The approach to conduct semi-structured interviews (interview questions were based on COM-B model and behavioural change wheel) with frontline healthcare staff and SU&Cs. The interviews gave insights on the barriers and facilitators to SU&C involvement in healthcare improvement work.

This then generated operational-level and actionable change ideas to guide tailored strategies for enhancing involvement capabilities, widening involvement opportunities and enabling motivations using the model for Improvement. These change ideas were then co-tested with SU&C using the Model for Improvement approach.

This systematic approach enabled a cultural shift towards collaborative partnerships between healthcare staff and SU&C to contribute to the service improvement.

Measurement of improvement

1. 1. Qualitative data to understand enablers and barriers to involvement in improvement work.

2. 2. Percentage of all QI projects (registered on Life QI and scoring 1 or more on IHI Project Score) that have a SU&C involvement.

Effects of changes

Staff and SU&C interviews identified the key barriers as inadequate capability (lack of understanding and skills), limited opportunities (leadership, resources, access) and insufficient motivation (discomfort, inability, time limitations). Enablers included appreciating diverse perspectives, leadership support and buy-in, established processes, valuing insights and patient empowerment.

The outcome measure also showed an increase in the number of improvement projects at CNWL that have SU&C involvement from 46% to 80%.

Lesson Learnt:

This work has shown that by bringing multi-disciplinary staff and SU&Cs together generates cognitive diversity to the learning to drive improvement and sustain the gains. Furthermore, partnership working helped to create and establish learning culture within the healthcare service.

Message to others:

1. 1. Strong executive sponsorship helps to drive involvement across the organisation.

2. 2. By bringing staff and SU&Cs together generates cognitive diversity to the learning to drive improvement.

3. 3. Using well-known and established behavioural change model, such as COM-B model, helped to identify, design and synthesize behaviour change interventions.

Currently, there is an absence of clear guidelines or recommendations for individuals with an eating disorder (ED) and comorbid autism spectrum conditions (ASC).

The Maudsley ED team has pioneered a tailored approach for comorbid ED and ASC called the PEACE pathway.

Our aim is to adapt and implement a similar pathway within the Eden Unit (NHS Grampian inpatient eating disorder service).

Questionnaires targeted two key stakeholders: patients and staff.

Patient questionnaires had 18 multiple-choice questions on a Likert scale, along with space for comments. The questions aimed to assess inpatient care adequacy in terms of care, routine, environment, mealtimes, and staff members. There were also specific questions related to ASC, examining whether sensory and communicative needs are being met and taken into account.

Staff questionnaires had 10 ‘yes-or-no' questions, along with space for comments, and gauged attitudes toward managing comorbid ED and ASC.

6/7 patient questionnaires were completed. 3 patients have comorbid ASC.

One patient found the ward overwhelming due to ASC, while others found it suitable. All experienced distress transitioning from outpatient to inpatient services, with subsequent admissions proving less challenging when they knew what to expect. They were allowed to have safe sensory items e.g comfort toys, headphones etc.

Generally, they felt well-supported during distress and felt their communication needs were met by nurses and HCSWs but not always by dietitians and clinicians due to a lack of availability. Some were frustrated with vague menu descriptions and there was some diagnostic overshadowing over dislike of certain foods.

13/20 staff questionnaires were completed. It showed most staff did not have formal training in managing comorbid ASC and ED, and confidence and skills varied in proportion to time and experience in the service. All staff members expressed they would like formal training, through sessions such as monthly training, weekly huddles, or psychoeducation.

A significant proportion of inpatients have comorbid ED and ASC. Therefore, awareness of potentially greater needs around communication, environment, and sensory hyper- or hyposensitivity is important. There is a risk of diagnostic overshadowing as both ED and ASC can mimic similar symptoms: cognitive rigidity, fixation on certain things etc. So while not straightforward it is important to differentiate which symptoms are due to ASC and which are due to ED. Leveraging resources from the PEACE pathway website, both staff and patients can enhance their understanding of this complex comorbidity.

To audit the Shepway CMHSOP against the NICE guidelines in dementia and the Royal College of Psychiatrists recommendations for service provision in young onset dementia.

Data was collected retrospectively for all patients open to CMHSOP within the last 2 years with a diagnosis listed as dementia under the age of 65 years old.

The work up prior to diagnosis met some standards but improvements could be made in other areas. Mood was considered in all patients. The majority of patients (89%) had young onset blood tests if there was a clinical indication. However physical examination was only carried out in 43% of patients. In addition to this where physical examination was completed it was often limited to a brief note about the patient's gait and tremor.

Imaging standards were met within the Shepway CMHSOP with all patients having a scan, some patients being referred for additional specialist scans where indicated. There is also a neuroimaging MDT in which scans can be discussed with a neuro-radiologist.

The follow up care and support was an area that needs further development within Shepway CMHSOP. There is no named lead for those diagnosed with young onset dementia. Furthermore, only half of patients received a named practitioner to support their care. In addition to this only 79% were offered cognitive stimulation therapy and post diagnostic support which incorporate education for the carers. It is difficult to know if these options were discussed and declined by the patients, but if this is the case it would have been good practice to document.

The time from referral to diagnosis was similar in those with a dementia with a well established and clear subtype (Down syndrome) to those diagnosed with other types of young onset dementia, 6 months and 5.5 months respectively.

My audit identified areas for improvement in the workup to diagnosis and the aftercare to support those diagnosed and their carers in order to meet NICE guidelines and the Royal College of Psychiatrists recommendations for service provision in young onset dementia.

Shepway CMHSOP will develop a young onset dementia pathway to ensure those diagnosed are offered the appropriate investigations and support following their diagnosis in line with these guidelines.

Outcome measurement is central to transforming mental health care by quantifying change, enabling comparison and driving improvement. In recognition of this, the Royal College of Psychiatrists (RCPsych) has established a working group on outcome measures, led by an Associate Registrar.

To support routine outcome measurement capture in clinical services, RCPsych has developed the ‘Outcome Measurement in Psychiatry’ report.

The working group intends to launch a survey of Members to:

1. 1) Understand psychiatrists’ current use of outcome measures.

2. 2) Understand psychiatrists’ views on barriers and facilitators to the use of outcome measures.

3. 3) Get feedback on the College Report.

The ‘Outcome Measurement in Psychiatry’ report was developed with input from all RCPsych Faculties and is scheduled for publication prior to the RCPsych International Congress.

Feedback will be sought on the ‘Outcome Measurement in Psychiatry’ report about whether the guiding principles are right, and if the College should be endorsing specific measures or advocating for the routine use of outcome measures. This will be used to guide future revisions of the report.

The working group believes the proposed survey will enable it to explore the facilitators and barriers to routine outcomes data capture both locally and nationally, including:

• • how to consider organisational drivers and buy in of clinical staff

• • digital enablement

• • understanding time points in a chronic relapsing remitting condition in the community vs. episode of therapy or hospital admission

• • clinical burden/benefit and buy in

• • training.

The group intends to use the intelligence gather to inform, influence and shape policy that promotes routine outcome data capture and publish its findings for wider dissemination.

Outcome measurement is a top priority for the RCPsych. A new Associate Registrar and working group is spearheading the College's work in this area, publishing guidance and conducting further research. Engagement and learning from our colleagues would provide critical intelligence to inform and influence future policy and strategy to enable routine outcome gathering embedded in mental health services.

This project's purpose was to improve the identification and management of patients at risk of or suffering from alcohol withdrawal at the point of admission. Ultimately aiming to prevent avoidable harm to patients and reduce the burden on local services within NHS Ayrshire & Arran.

The project began in August 2023 with Alcohol & Drug Liaison Nurses (ADLN) carrying out twice daily walkthroughs of the Emergency Department and Combined Assessment Unit. ADLNs were instructed to engage with these clinical teams, helping to identify those at risk, provide management advice and accept relevant referrals. A retrospective audit was completed covering patients referred to the alcohol and drug liaison team (ADLT) in July 2023 and a prospective audit covering October 2023. Quantitative data gathered included prescription of benzodiazepines & Pabrinex, time from admission to prescription and administration of treatments, any changes to treatment advised, and whether treatments administered correctly. Additional qualitative data was gathered through a short staff survey carried out in November 2023 asking if the project had been helpful in identifying patients, improving management, and making staff feel supported.

There was a 33% increase in referrals from July (n = 15) to October (n = 20), with a slightly greater proportion coming from ED (80% vs 85%). The average time from admission to benzodiazepine prescription fell by 2hrs and to administration by 8hrs. However, changes were advised to benzodiazepines prescriptions more frequently (12% increase).

Pabrinex prescriptions were being completed overall for patients both before (92%) and after (100%) the project. Average time from admission to pabrinex prescription fell by 2hrs but to administration increased by 0.5hrs. Additionally, cases of incorrect pabrinex administration increased from 31% to 47% between the two periods.

Staff feedback was very positive; project was very (45%) or somewhat (35%) helpful in identifying patients at risk, very (30%) or somewhat (50%) helpful in managing alcohol withdrawal, and very (55%) or somewhat (20%) helpful in making staff feel more supported with this patient group.

This project demonstrated that additional support can improve identification of patients, speed of initial management decisions, and staff confidence. However, it also showed a significant knowledge/skills gap across both departments leading to continued problems with patients receiving timely and appropriate treatment. ADLN ward input cannot be continuous, as such practical changes are required to help maximize Liaison input. Following this project's recommendation, work has begun to develop an Alcohol Withdrawal Bundle and associated staff training.

Referrals for adult autism assessment to the Cambridgeshire Lifespan Autism Spectrum Service (CLASS) have increased from 430 in 2019 to 887 in 2023, with demand exceeding capacity. The team enrolled in the Royal College of Psychiatrists’ Quality Improvement (QI) Demand, Capacity and Flow (DCF) Collaborative. The agreed aim was to increase the number of diagnostic assessments by 51% per month.

Participants included the CLASS multi-disciplinary team (MDT), referrers, the provider improvement advisor and an autistic adult. Using the NHS Quality Service Improvement and Redesign (QSIR) six-step approach, a process map identified five key stages of the CLASS pathway. A project driver diagram was then used to identify change ideas in the referral, screening, pre-assessment, assessment and post-diagnostic stages.

Change ideas in the screening and assessment stages were prioritised and two Plan-Do-Study-Act (PDSA) cycles designed: PDSA 1) To reduce screening time by removing the first screening of referrals; PDSA 2) To increase the number of assessments conducted and completed in a single face-to-face appointment.

Data collected for PDSA 1 included: number of working days from date of referral to date added to waiting list and total screening time (minutes) per referral. Data were compared in a sample of 133 referrals from the two-stage screening process and 68 referrals from the one-stage process. Data collected for PDSA 2 included: average assessment time (minutes), average duration of open assessments, and the number of assessments completed within the same month. The data at Time 1 (before introducing PDSA 2) were compared with Time 2 (after PDSA 2) in a sample of 10 and nine referrals, respectively.

PDSA 1) Statistical Process Control (SPC) charts show a reduction in mean working days from 160 to 30 working days. The mean screening time per referral reduced from 33 minutes to 23 minutes. PDSA 2) SPC charts show that between Time 1 and Time 2 there was (i) a reduction in clinician time in minutes per assessment (m = 236.8 to m = 210), (ii) a reduction in working days assessment remained open (m = 39.4 to m = 6.4), (iii) a reduction in number of assessments involving multiple appointments (6 of 10 to 3 of 9), (iv) an increase in the number of assessments completed in the same month (3 of 10 to 7 of 9).

These results show promise towards increasing DCF across the pathway, but further PDSAs (e.g., digitalising reporting, refining the post-diagnostic pathway) need to be implemented to achieve the overall aim.

At-distance and out-of-region admissions form a significant proportion of inpatient admissions in CAMHS. The recent national “Far Away from Home” study which investigated the impacts of these admissions for young people, parents/carers and services identified an inconsistent and/or lack of easily accessible information about inpatient units. Parents and young people reported that when there was a lack of easily accessible information about the unit they would be admitted to, this increased their distress and negative views about the admission before they had even arrived. In contrast, those who found useful and positive information felt more reassured about the admission, even if it was far away. Our aim was to create an expert-by-experience designed standardised template of the minimum information that all inpatient units would be required to make publicly available.

We carried out regular expert consultation meetings with young people and parents/carers with lived experience to co-design a standardised template of information that units would provide for young people and their families on their websites and in printed form.

In early meetings the information currently presented by inpatient units was reviewed and discussed. Young people and parents/carers highlighted what they found helpful and unhelpful as well as what was missing. The young people and parents/carers discussed the layout, aesthetics, and functionality that they would like to see on unit websites. They also discussed the content which would be helpful for young people and their parents individually as well as what both groups would want to know. This included realistic and practical information about the unit itself, visiting, local amenities and available funding support.

In collaboration with young people and parents/carers we have created an expert-by-experience designed standardised template of information that all inpatient units will be asked to provide on their website. Better information provision prior to admission will reduce anxiety and uncertainty for young people and their families. We anticipate this project will also contribute towards improved staff/patient/carer relationships because of clearer expectations and understanding.

In light of increasing referral rates, the RQIP aimed to review all referrals made to PLT by the ED during April 2023. The purpose was to identify ways to improve working practices to benefit patients, the ED team and the PLT.

All ED referrals in April 2023 were identified and the following was gathered from each record.

Patient information:

1. 1. Record number, sex, age

Circumstances of attendance:

1. 2. Date/time

2. 3. Who directed patient to ED and arrival method

3. 4. Attendance reason

4. 5. Presence/absence of physical health condition requiring ED

5. 6. Intoxication on arrival and if assessment required after sobriety

6. 7. Outcome

Patient involvement with other services:

1. 8. Number of previous PLT referrals in past 90 days

2. 9. Currently under care of another team, if yes, were they contacted before ED attendance

3. 10. Contact with crisis team in previous 72hours

During April 2023 there were 356 referrals from ED to PLT. 284 represented single attendances and 72 represented repeat attendances by 44 patients. 34% (n = 123) self-presented to ED. Emergency services directed 21% (n = 75) to ED. 71% (n = 253) had physical health reasons to attend whilst the rest presented with mental health crisis alone (n = 103). 25% of patients attending ED and referred to PLT were intoxicated and a third of these did not require assessment following sobriety. 41% (n = 145) patients were open to another mental health team within the trust who could potentially have provided crisis input. Of all referrals 27% (n = 97) were signposted to other services, 26% (n = 93) left before they were seen. PLT referred 11% (n = 40) to crisis teams and 3% (n = 11) to Mental Health Act assessment.

Findings indicate that a large proportion of patients attending ED could have had their mental health needs met elsewhere in the absence of a medical reason for attending, thus potentially avoiding long waits in ED. Patients that are referred but leave before assessment, those without acute medical need to be in ED, those that do not require assessment after sobriety or those open to other planned care mental health teams may have their needs best met outside of the acute ED environment. It is hoped that community transformation work will enable community services to become more responsive to such needs.

The team propose working collaboratively with the acute trust and trialling embedding a PLT clinician in the ED triage process in order to redirect patients to the most appropriate care in a timely way.