To determine the number of patients within a service on sodium valproate for a psychiatric condition who have updated Annual Risk Acknowledgement forms in place.

It was firstly identified that within the NICE guidelines, it is recommended that all patients who are on sodium valproate should have an annual signed risk acknowledgement form in place. Following this, a list of patients was compiled who were currently prescribed this with the local area. Each patient was then checked to see if the valproate was prescribed by psychiatry or by neurology. This was then further divided into general adult and learning disability patients.

From this, a list of patients under the care of general adult psychiatry was compiled. The notes for these patients were obtained.

Data collection was then carried out. Each set of notes was reviewed by two individuals for the following:

1. 1. To identify if an annual risk assessment form was carried out.

2. 2. To check if this was within expiry date.

3. 3. To identify patient diagnosis.

4. 4. To identify the dose of sodium valproate.

5. 5. To confirm if these patients were females of childbearing age.

From the initial audit cycle, it was identified that 28 female patients who fell within the inclusion criteria were on valproate, and of these, 6 had forms in place. Of the 6 with forms in place, 50% had expired so needed to be replaced. 17 had no form in place, and for 4 patients it could not be certain if forms were present or not due to unavailability of records. Only 3 patients therefore had the correct form in place which were within expiry date. If we discount those with no data available, only 12% of patients had the correct annual risk acknowledgement form present and within expiry date.

Following the initial audit, two interventions were carried out:

1. 1. The data from the above audit was presented at a consultant meeting, highlighting the importance of ensuring these forms are kept up to date.

2. 2. It was decided that pharmacy would take a leading role in ensuring the annual risk assessment forms are updated.

Following 6 months, this patient cohort was re-audited, with further results obtained.

These results showed a reduction in patients prescribed sodium valproate from 28 to 19. 37% of all patients prescribed sodium valproate had forms, but of these, only 30% were up to date. Therefore, only 11% of patients had correct annual risk acknowledgement forms in place which were up to date.

These results showed an improvement in those who had at one time had a form in place, but roughly similar compliance with availability of up to date forms.

Overall it appears that there is a real lack of consistency in ensuring the annual risk assessment forms are in place. A very low percentage of patients have the correct form in place within expiry date, despite interventions which have taken place as part of this audit. Further efforts should therefore be made by teams to ensure that these forms are in place and up to date for all women of childbearing age on valproate.

On a positive note, it may be possible to surmise that the reduction in number of patients on sodium valproate may be linked to raised awareness of the risks to women of childbearing age.

Additionally, a significant number of patients had been sent forms in the post, but had not returned them. Some of these same patients had, in the time that they should have had updated risk forms put in place, been admitted to an inpatient psychiatric hospital. It is therefore important to consider in future if these forms should be updated whilst the patients are admitted to hospital, to increase the number of patients with these forms up to date and therefore improve safety for this cohort of patients. Given that many of these patients have a diagnosis of Bipolar Affective Disorder, they may find it more challenging to return the forms whilst in the community, particularly if unwell; the ICD–11 criteria does note that patients with this condition may suffer from “distractibility, impulsive behaviour and rapid changes in mood state.” Further research could therefore be carried out to determine if utilising inpatient admissions to discuss risks of their medications would be a beneficial way to improve compliance with Annual Risk Assessment Forms.

Lastly, we know that there has been discussion around implementation of such monitoring for men as well as for women. Should this be implemented within the NICE guidelines, further audits should be carried out to determine our compliance with this.

To assess the compliance of glucose monitoring for patients prescribed antipsychotics in the local outpatient Learning Disability Team.

A review was conducted of all outpatients seen in a 6 week period during September and October 2023. Each patient was reviewed to check their diagnosis or diagnoses, the antipsychotic medication they are currently on and if they have had the required tests done. These tests were considered, as per the NICE guidelines, to be a plasma glucose test or HbA1c test. It was checked to confirm if these tests had been carried out within the past 12 months, as per NICE.

• • 46/79 patients seen in a 6 week period at the outpatient clinic were found to be currently prescribed an antipsychotic.

• • 30 of those prescribed an antipsychotic were on risperidone (65%).

• • Of those prescribed any antipsychotic, 18 out of 46 had not had their glucose or HbA1c checked within the past 12 months (39%).

• • This therefore demonstrates 61% of patients on an antipsychotic had appropriate glucose monitoring within the time period audited.

Monitoring glucose levels for patients on antipsychotic medication is very important for patients with an Intellectual Disability. Patients in this cohort are known to be more likely to have diabetes and obesity than the general population. In addition, there are higher levels of inactivity and multi-morbidity. It is also important to note that over-prescribing of psychotropic medication to individuals with learning disabilities, particularly antipsychotic medications such as risperidone and olanzapine, may be contributing to levels of obesity and diabetes within this population.

NICE guidelines state that for patients prescribed an antipsychotic, plasma glucose or HbA1c should be checked 3 months after commencement of treatment, and then every 12 months whilst on treatment. For olanzapine and clozapine, levels should be checked after 1 month of commencing treatment. Symptoms of hyperglycaemia should also be asked about (such as polydipsia, polyuria and increased appetite).

The results from this audit demonstrate there is definitely room for improvement in our monitoring of glucose levels for these patients. From discussing this with colleagues, it appears that a multidisciplinary approach is needed to promote this change.

Going forward, therefore, interventions should include asking the nursing staff within the outpatient team to monitor for increased appetite, polydipsia and polyuria amongst patients, especially if they are on an antipsychotic. Additionally, for any patients seen in OPC who are prescribed an antipsychotic, it should be routinely checked when they last had a glucose or HBA1c test. If this was not within the past 12 months, this should be carried out by the GP or another appropriate member of the team.

Overall, the physical health of our patients with Intellectual Disabilities is paramount. Given the nature of their Intellectual Disability and depending on the severity, it may be very challenging for them to identify any new symptoms of diabetes themselves or to report these to carers. Therefore, when prescribing antipsychotic medication, it is vital to monitor the effects of this to ensure optimal patient care utilising a multidisciplinary team approach.

The NHS England Core20PLUS5 aims to reduce national healthcare inequalities by identifying five clinical areas requiring accelerated improvement for the most deprived 20% of the population. Three of these clinical areas are: Severe Mental Illness (SMI), Early Cancer Diagnosis and Maternity Care.

Hackney has the highest proportion of areas within the most deprived 10% nationally. The Hackney Rehabilitation and Recovery Team is a specialist service for those with SMI. While the service does not provide maternity care it is uniquely placed for women's health outreach work in this population. Research has shown that lower participation by those with SMI in screening may make them 2.5 times more likely to die prematurely from cancer. Bearing this in mind, this project aimed to improve early cancer diagnosis and management of women's health to improve health inequalities for females with SMI in Hackney.

I audited cancer screening compliance from the medical records of the 19 female patients under the Hackney Rehabilitation and Recovery Team and obtained patient feedback to explore barriers to access screening. I used a pool of possible keywords to perform a search for any discussion of women's health issues during contact with mental health professionals. Encouraging a culture of ‘Making Every Contact Count’, I presented the results of this audit at a Team Education Session, after which attendees received a personalised list detailing their caseload's outstanding health needs as identified from the audit. I led a weekly physical health clinic which addressed women's health issues. I designed a referral pathway for patients with complex psychiatric needs with the local cervical screening service which allows for longer appointments.

16% of the female patients under the care of the Hackney Rehabilitation and Recovery Service had never had a discussion covering women's health issues. 73% of mammograms and 53% of smear tests were outstanding. Barriers to access include a lack of knowledge of cancer screening programmes and practical issues in booking appointments. Some cited a lack of confidence in travelling to appointments and communication issues (access to a mobile phone, email address or post) as an issue.

Designing interventions to boost the uptake of cancer screening appointments for female patients with SMI is a practical application of the CORE20PLUS5 approach. An MDT approach including patient participation and feedback is key when developing effective outreach initiatives.

This audit reviewed the use of Treatment Escalation Plans (TEPs) on the Borders Specialist Dementia Unit (BSDU). We aimed to use data on completion rates and quality to adapt the TEP form to both improve practice and develop a more specialised form for use in inpatient old age psychiatry.

TEPs improve clinical decision-making in frail and elderly patient populations, and are commonly used on medical wards. However, these forms are primarily orientated towards acute medical environments and may not be appropriate for use in psychiatric inpatient settings, despite the clear benefits they could provide in this patient group.

This retrospective audit reviewed completion rates and quality of completed TEP forms for 10 BSDU inpatients in December 2023. Data was gathered by reviewing TEPs and using a data collection form to collate information on completion rates and quality of information provided. Both the TEP form and the ReSPECT form were used to review what information would be relevant to include when completing TEP forms for new admissions to BSDU.

Some sections of TEP forms were consistently well-completed – typically those that were quick to complete e.g. tick boxes. However, limitations of the existing TEP form reduced these sections’ usefulness in practice. Most significantly, the form does not indicate whether “ward level care” refers to care on the old age psychiatry ward, or transfer to a medical ward. The “Additional Information” section, which could be used to clarify the patient's ceiling of care and transfer status, was only completed in 40% of cases, despite being particularly relevant to the BSDU patient population. In addition, this audit highlighted that there is no process for reviewing TEPs to ensure they remain appropriate for the patient, which is particularly relevant for old age psychiatry inpatient populations due to their advancing frailty and quickly changing clinical picture.

This audit showed that the current TEP form is not ideally suited to old age psychiatry settings. However, this could be improved with simple adaptations such as distinguishing between psychiatric ward care and medical ward care, and adding a review date to ensure these forms are regularly updated in light of the advancing frailty of old age psychiatry inpatient populations. I would also recommend implementing an initial review of TEP forms shortly after patients are admitted, to ensure the information contained on them is accurate and that they are countersigned by the responsible consultant.

Discharge summaries act as a key source of condensed information of inpatient stay as well as follow-up plan. Its timely availability to primary care and other multi-disciplinary teams involved in patient care is vital, especially when patients are being managed out of locality by different teams.

The project aimed at assessing if discharge summaries for General Adult inpatients across all four localities of the Trust was made available and in a timely fashion on patient electronic records as well as to primary care using national guidelines as the standard. Using the same guidelines, it also evaluated the quality of the summaries based on the information contained.

Data was retrospectively collected in October 2023 for general adult inpatient discharges for the month of January 2023 across all four localities of Black Country Healthcare NHS Foundation Trust. Records for 148 out of the 152 discharges were assessed. Data was collected from electronic patient records Rio and evaluated on Microsoft Excel. The evaluation checked whether discharge summaries were available, duration between discharge and its availability on electronic records as well as contents of summary. Professional Record Standards Body and the RCPsych guidelines were used as standards.

28 of the 148 (18.9%) patients did not have a completed discharge summary. Of these, 14 (9.4%) were out of locality patients. The average duration from discharge to summary being made available was 12.7 days. Most of the summaries contained all relevant information as per guidelines.

The findings were presented to the Trust’s QI committee. It was concluded that while majority patients had a summary made available, there is a need for additional strategies to ensure summaries are available soon after discharge to ensure safe post-discharge care.

It was identified that the bed management team should notify parent teams of admissions and discharges promptly.

The medical secretary is to monitor the admissions register and ensure the junior doctors in the team complete discharge summaries in a timely manner.

Business intelligence team to use clinical coding to identify any missing discharge summaries and provide medical teams with a monthly report in case any are missed by the secretaries.

Once above recommendations are implemented, a re-audit would help to analyse the improvements in practice. The results would also help guide the Trust in developing a policy to harmonise processes across the Trust and thereby ensure safe patient care post-discharge.

Lifestyle medicine promotes the use of therapeutic lifestyle interventions to modify disturbed lifestyle factors which are thought to underlie chronic illnesses, including mental health conditions. It is important to identify and manage any disruptions in factors that lifestyle medicine has identified as being contributory towards sustaining good health. Aims were to identify the extent to which the early intervention in psychosis (EIP) medical team in Leicestershire are enquiring about the pillars of lifestyle medicine.

There are 6 pillars of lifestyle medicine, namely exercise, sleep, diet, refraining from toxins, positive social interactions and quality personal time. Motivation has been added as the 7th pillar for this audit. Gold standard would be to adequately explore all pillars at each medical review. Retrospective analysis was done of electronic patient records (SystmOne) for all patients on the EIP team case load, available on 19th May 2023. Information was gathered from the most recent medical review, using a predefined audit extraction tool. Information on each pillar was assessed based on whether it was fully explored, mentioned with some detail, mentioned with no further detail, or not mentioned at all. Data collection was carried out by three members of the team (TC, SA and DG).

495 patients were identified and 459 had information from a latest medical review found on SystmOne. For all domains, “not mentioned” was the leader, ranging from 48.6–70.8%). For all domains, except for refraining from toxins, the second most common finding was “mentioned with no further details”.

Our results suggest EIP medical staff are either not discussing many of the seven pillars of lifestyle medicine with patients, or not documenting them in sufficient detail. Limitations of the study include that it was the most recent medical review being audited and there could have been more detail documentation in previous reviews. Distribution of the findings and recommendations from the audit were shared with the team and an educational poster detailing lifestyle factors was created. The online system is being adapted to include an option to input lifestyle factors. Re-audit should be done in 12 months.

To investigate whether young people referred to a paediatric specialist fatigue service present with higher levels of autistic traits or have higher prevalence of Autistic Spectrum Disorders (ASD), than those found in the general population.

143 initial assessment reports of young people presenting to a paediatric specialist fatigue service were audited over a 5-month period to identify cases where a previous diagnosis of ASD has been documented, or the assessing clinician has recommended referral for an ASD assessment, or autistic traits have been documented in neurodevelopmental screening. Comparative data on age, gender, age of symptom onset, duration of symptoms, reported symptoms, comorbidity, family history, and sleep difficulties was then explored to help us identify/understand the profile of the young people who present to our service. Routine mental health screening questionnaire data from the Revised Children's Anxiety and Depression Scale (RCADS) was analysed in addition to clinical reports regarding mental health comorbidities.

Of the 143 young people presenting to the specialist fatigue service over the 5-month period, 16 had a diagnosis of ASD, and 41 were suspected as having ASD. In total, 39% of service users had, or were suspected of having, ASD. The prevalence was higher in female service users than males with a total of 48% of female service users having, or being suspecting of having ASD, compared with 22% of males. Comparative data demonstrated that autistic/suspected autistic young people presenting to the service were more likely than their neurotypical counterparts to be: over 13 years old, have a longer symptom duration before presentation, have an Educational Health Care Plan, report friendship difficulties, have a family history of neurodiversity, report sensory difficulties, and have sleep difficulties. RCADS scores found that the ASD group were more likely than the neurotypical group to have clinical levels of anxiety (58.3% vs 15.3%) and depression (80.6% vs 58.3%).

Our audit suggests that there is a higher prevalence of young people with ASD/ASD traits presenting to a paediatric fatigue service than found in the general population. Reasons for this may relate to undiagnosed ASD presenting as severe fatigue due to the energy draining nature of camouflaging, as well as sensory overload, known as autistic burnout. Do we need to develop a specialist treatment pathway which is better adapted to these young people's needs? We are planning a follow up study and focus groups to explore this complexity further.

West Lothian Psychiatry operates in a district general hospital, fostering a close working relationship between medical and psychiatric practitioners including the Psychiatric 2222 call (akin to medical emergency/cardiac arrest response). No other team like this has been identified in Scotland. Whilst there is a range of scenarios where this is used, there is no ‘gold standard' for defining a psychiatric emergency or how to document these. Preliminary data gathered between August and November 2022 revealed concerns regarding call appropriateness, medical staff proficiency in de-escalation and restraint on medical wards, inadequate handovers, and poor documentation. This prompted a collaborative quality improvement project, undertaken by psychiatric and medical team leaders. Part of this initiative was an audit to improve the documentation of psychiatric emergencies to achieve a 90% compliance rate using a new checklist.

Cycle 1 of the audit (December 2022 to April 2023) identified patients through the 2222 calls to switchboard (n = 54). TrakCare notes were reviewed to assess call rationale and outcomes, focusing on documentation by the attending psychiatric team. A documentation checklist within the electronic records system was designed and introduced in July 2023, for completion by the junior doctor. Cycle 2 (November 2023 to January 2024, n = 47) aimed to assess improvements by comparing results with the previous cycle.

There was a significant improvement in documentation rates with the checklist (44% to 90%). Indirect enhancements were observed in ward nursing documentation (65% to 83%) and medical ward doctor documentation (39% to 57%). Appropriateness of emergency calls increased from 65% to 74%, with attending doctors' participation in emergencies longer than 10 minutes rising to 68% from 47%. The initial audit revealed a lack of awareness among senior medical staff regarding overnight psychiatric emergency calls, especially in cases of repeated calls for the same individual. The improved documentation played a pivotal role in addressing this issue, facilitating effective information sharing and changes in patient management plans, reducing further emergency calls.

The documentation checklist significantly improved junior doctor documentation, positively impacting patient care and communication among staff. This successful intervention serves as a promising model that can be replicated in other documentation domains. Moreover, this project has set the stage for broader initiatives within a larger Quality Improvement framework. The ongoing efforts are directed towards establishing a shared model for the psychiatric emergency bleep, optimising staffing resources for restraint procedures and improving staff de-escalation skills.

The National Institute for Health and Care Excellence (NICE) offers guidance for prescribing and monitoring of antipsychotic medications. In this audit we sought to investigate if our unit was compliant with this guidance.

The audit was carried out on a 28 bedded older adult inpatient psychiatric unit. The notes of all patients admitted to this ward on 27/11/2023 were reviewed. Any patient on an antipsychotic was included in the audit. Four standards reflecting the prescribing and monitoring of antipsychotics were identified. These were:

1. 1.3.5.1 The choice of antipsychotic medication should be made by the service user and healthcare professional together, taking into account the views of the carer if the service user agrees.

2. 1.3.6.1 Before starting antipsychotic medication, undertake and record the baseline investigations.

3. 1.3.6.2 Before starting antipsychotic medication, offer the person with psychosis or schizophrenia an electrocardiogram (ECG).

4. 1.3.6.3 Treatment with antipsychotic medication should be considered an explicit individual therapeutic trial.

5. 1.3.6.4 Monitor and record the following (response to treatment – side effects – adherence – physical health) regularly and systematically throughout treatment.

These five areas of guidance were broken down into 22 domains which are outlined in results below.

Of 28 patients admitted to the ward, 22 were on antipsychotic medication.

1.3.5.1: Medication benefits were discussed and documented in 9/19 cases (47%), with 3 patients refusing to engage in this discussion. Side effects were discussed and documented in 5/21 cases (23%).

1.3.6.1: Patients underwent a range of investigations. In some cases, the patient hadn't been on the medication for long enough to require additional tests. Some patients were excluded as they refused testing. Glycosylated Haemoglobin (100%), Weight (100%), Pulse and Blood Pressure (100%), Blood Lipid Profile (86%), Prolactin Levels (77%), Assessment of nutritional status, diet (77%), baseline fasting blood glucose (38%), Level of Physical Activity (31%), Assessment of any movement disorder (22%), Waist Circumference (0%).

1.3.6.2: An ECG was offered in 94% of cases.

1.3.6.3: The rationale of continuing, changing or stopping the medication was recorded in 86% cases and no patients had antipsychotic doses above BNF maximum.

1.3.6.4: Overall physical health monitoring, weekly weights and, pulse and BP at 12 weeks (100%). Adherence and response to treatment were both 95%. Measurement of glycaemic control (57%), movement disorders (14%) and side effects (13%).

While there are areas of good practice, there are a number of significant omissions. Remedies to these deficits will be proposed.

Hypothesis: Choice letters generated by Child & Adolescent Mental Health Services (CAMHS) South Edinburgh are not consistent in quality and content.

Aims:

1. 1. To assess the consistency and quality of letters generated by clinicians following Choice appointments in CAMHS South.

2. 2. To observe the range of resources shared in Choice letters.

Patients were identified retrospectively from the team Choice diary.

Choice or Complex Choice appointments attended between 13th October–27th November 2023 at CAMHS South were included. See Soon appointments and appointments that were not attended or cancelled were excluded.

Standards to which all letters should adhere were devised from the CAPA (Choice & Partnership Approach) Book and the CAMHS South Choice Handbook.

Standards: current concerns, background information, patient goals, clinician impression, choices discussed, choices made, self-help agreed, services required, maximum two sides of A4, copy to patient, copy to referrer, sent within two weeks.

Letters were accessed via electronic records and analysed with a proforma.

A maximum of three letters per clinician was included.

A log of resources and frequency shared was kept.

57 appointments were attended, with 50 letters generated by 22 clinicians.

Adherence to standards in 50 available letters:

Current concerns 92%

Background information 96%

Patient goals 40%

Clinician impression 62%

Choices discussed 22%

Choices made 100%

Self-help agreed 52%

Services required 100%

Maximum two sides of A4 50%

Copy to patient 88%

Copy to referrer 100%

Sent within two weeks 72%

94 different resources were shared in the letters, with minimum 0 resources and maximum 19 resources per letter.

There were areas of good quality and consistency in Choice letters, including documentation of current concerns, background information, and highlighting of required services. These are areas likely to feature in most assessments regardless of clinician background.

There were areas that require improvement, including documentation of goals, clinician impression, self-help agreed, and keeping to a maximum of two sides of A4. These areas are perhaps more obscure for different types of clinician.

A wide range of resources were shared in Choice letters with a considerable amount of variability in number of resources. This suggests differing levels of individualisation of resources to the patient.

Since this audit, CAMHS South have implemented additional Choice training, electronic canned text for letters, and collation of Choice guidance. There is a plan to re-audit following these interventions.

• • To improve documentation of antidepressant prescribing in our service, aiming to improve frequency of review, and guide measurement of outcomes.

• • Identify patients requiring medical review.

The standards that we audited against are that, for patients under The Early Intervention in Psychosis Service (EIPS), a diagnosis should be recorded alongside each antidepressant prescription and, according to EIPN guidelines, psychotropic medications should be reviewed every 6 months.

Population data from the UK indicates that lack of recording of a diagnosis is associated with increased duration of treatment, and reduced frequency of mental health reviews.

It was recorded for each patient whether they had an antidepressant prescribed, which medication, the documented indication, and their most recent medical review. Data was collected in a ‘snapshot' cross section of all 89 patients on the caseload in December 2023.

Data was obtained from carenotes by reviewing clinic letters and clinical notes; and cross-referencing with GP records.

33 patients (37%) were prescribed an antidepressant. Of these, 25 (76%) had a recorded indication. The commonest indication was mixed anxiety and depression followed by depression. Sertraline was by far the commonest prescribed antidepressant (52%) followed by mirtazapine. 3 patients were prescribed combination antidepressants. 67 patients (84%) had had a medical review within 6 months.

Among patients with a first episode of psychosis, there is a significant comorbidity of depression and anxiety spectrum disorders.

Our standard was met for most patients but there were several exceptions, and we considered why 8 patients did not have a listed diagnosis. There can be a degree of diagnostic uncertainty in distinguishing anxiety and depressive disorders from negative symptoms, and the affective changes that are an established part of recovery from an acute psychotic episode. In these circumstances it may be appropriate to consider a trial of antidepressants in consultation with the patient. Some of these patients also have been on long-term therapy which preceded their referral to EIPS, leading to uncertainty of the indication and pre-morbid status.

We conclude the following recommendations:

1. 1. Prompt a review of antidepressant use in those identified without a clear indication, discussing risks and benefits with the patient at next review.

2. 2. Arrange medical reviews for those exceeding the 6-monthly window.

3. 3. Record last review for patients under shared care.

4. 4. Re-audit in 6 months to monitor improvement.

We audited the adherence to part of the minimum admission standards for Mental Health, Learning Disabilities and Addictions Services (MHLDA) for 6 acute wards, across two sites (UHH and UHW) in NHS Lanarkshire. We focussed on the section of the standards that the admitting junior doctor/ANP is responsible for. This comprised:

• • An admission assessment (including presenting complaint, history of current episode of illness, medication, mental state examination and risk assessment).

• • Physical health assessment (examination, bloods, ECG, VTE assessment), medicine reconciliation and prescribing on HEPMA - within 12 hours.

Five individuals collected data across both sites and both cycles. For our first cycle, all admissions in March 2023 were retrospectively reviewed, a total of 94 admissions (UHH 47, UHW 47). Electronic notes/systems were reviewed (Morse, Clinical Portal, Hepma, Trakcare).

This first cycle demonstrated poor adherence to the minimum admissions standards. A proforma for admission statement was created, including prompts for the admission assessment and for the components of the physical health assessment, medicines reconciliation and prescribing. Presentations were made at postgraduate teaching and at ANP teaching. The majority of people were unaware of the existence of the admission standards or did not know where to find them. The admission standards document and the proforma were circulated via email and added to the shared R drive. A second cycle was completed, reviewing all admissions in July 2023, a total of 74 admissions (UHH 41, UHW 33). The proforma has now been included in the induction material for new doctors.

Following interventions, there was improvement in completion of admission statement (90% vs 81%). There was improvement in the inclusion of all components, most notably MSE (91% vs 71%) and risk assessment (59% vs 18%). Where the proforma was used (57%), all aspects of admission statement were present (97–100%). When not used, there was variable inclusion of the different components (7–90%). There was improvement in the completion of all components of physical health assessment (except small decrease in medicine reconciliation). In every case of missing components with no documentation as to why, the proforma had not been used.

Development of a proforma for admission assessment has led to improved completion of admission assessment, physical health assessment, medicines reconciliation and prescribing within 12 hours. Qualitative feedback is being sought on the proforma from junior doctors, ANPs and senior medics to guide next steps and further improvements. Review of the admissions standards guidance is now due.

The primary aim is to ensure patients receive recommended acute wound care. Specific objectives include improving wound management, enhancing antimicrobial stewardship, and aligning practices with national guidelines.

A retrospective audit spanning May to October 2023 assessed prescriptions for in-patients receiving antibiotics for wound management. Detailed patient records were scrutinized to evaluate compliance with standards, including wound assessment documentation, antibiotic indication adherence, tetanus status recording, and wound swab collection.

A total of 21 patients/encounters met the criteria for inclusion. Documentation deficiencies were prevalent, with only 61.9% of prescriptions featuring complete wound assessments. Additionally, antibiotic indications met NICE criteria in only 42.8% of cases, while tetanus status documentation was absent across all records. Despite 76% receiving first-line antibiotics, only 19% had wound swabs collected.

Self-harm rates in the United Kingdom, particularly among those with mental health disorders, are alarming. Hospitalizations are often required to address acute self-inflicted wounds, yet in-patient settings present unique challenges exacerbating self-harming tendencies.

This audit underscores the imperative of optimizing acute wound management in in-patient settings. By implementing evidence-based practices and addressing identified deficiencies, healthcare providers can enhance patient outcomes and ensure optimal care delivery.

At a time of increased pressures across the whole forensic estate, The Orchard Clinic Medium Secure Unit faced the additional challenge of having to close multiple acute admission beds.

This led to challenges in determining how to triage patients in the face of multiple external pressures, frustrations for clinicians managing severely ill patients in prison and human rights concerns for those unfit to stand trial but remanded to custody to await a bed.

The need for an objective tool to aid triage decisions became apparent. We therefore piloted the use of the DUNDRUM triage urgency manual, a structured professional judgement tool to aid triage decisions for forensic units.

The aims of introducing this tool were to ensure decisions are more consistent and reliable, ensure scientifically valid items are not forgotten, make decision making processes more transparent, demonstrate equality of access to services and reduce chance of serious error.

This audit reviewed all acute admissions to The Orchard Clinic between Aug 22–Aug 23. This covered a period 6 months prior to the introduction of the tool and 6 months after.

In order to determine if the use of the tool improved our triage making decisions the Dundrum score was retrospectively calculated for admissions and those on the waiting list during the first 6 month period of the audit. The same information was recorded for those following the introduction of the tool in the second 6-month period.

Prior to introduction of the DUNDRUM, the team's triage decisions were not in line with validated tools, those with lower DUNDRUM scores were prioritised over those with higher scores. Following introduction of the tool our triage decisions improved. Common themes emerged when we analysed the reasons why our triage decisions were out of line with validated tools. These included patients in hospital settings taking precedence over those in prison, patients admitted without prior discussion at bed management meetings, legal urgency taking precedence over clinical and lack of available HDU space.

Prior to the introduction of the DUNDRUM triage urgency manual the audit demonstrates that the team's triage decisions were not in line with validated tools. This improved following training and use of the tool at bed management meetings. The Orchard Clinic has now formalised use of this tool within bed management meetings. We are currently in the process of re-auditing over a 12-month period.

National guidelines (NICE) recommend that prolactin should be monitored every 12 months for patients on antipsychotics, excluding patients on aripiprazole, clozapine, quetiapine or on doses of less than 20mg daily of olanzapine. The purpose of this audit was to investigate whether patients under our services who are prescribed antipsychotics implicated in causing hyperprolactinemia, were having regular annual prolactin measurements as per the guidelines and whether abnormal results were being actioned appropriately.

A total of 61 patients were surveyed, as a random selection from the Outpatient Consultant case load in Rochdale CMHT. This was a retrospective analysis looking at annual prolactin measurements over 5 years between 01/01/2017 and 31/12/2022. This included all patients who had been stabilised on an antipsychotic for more than 2 years, and excluded patients on antipsychotics that did not cause significant prolactin rise (and so do not require annual prolactin measurements as per NICE guidelines).

Our results showed that the majority of patients were not having regular annual prolactin measurements, with only 3.3% of patients having prolactin measured annually 100% of the time. 23% of patients had no prolactin measurements at all while on antipsychotic treatment during the time period assessed. In cases were there was an elevated prolactin reading, only 15% of these readings had a documented action plan.

This audit has demonstrated that the overall compliance with the NICE standards for annual prolactin monitoring for people on antipsychotic medication is of a poor standard, and we highlight possible reasons why this may not be done and areas for improvement.

This study aimed to assess the post-discharge follow-up processes for psychiatric patients, specifically focusing on a 72-hour follow-up with documented Mental State Examination (MSE) and the presence of a comprehensive care plan, including up-to-date risk assessments and handover documentation.

Conducted across three psychiatric units – Heddfan, Ablett, and Hergest – and associated Community Mental Health Team (CMHT) sites within Betsi Cadwaladr University Health Board, the audit spanned eight weeks (14/08/2023 to 16/10/2023). Adhering to NICE guidelines (NG-53) and CCQI Standards for Community-Based Mental Health Services-2017, data collection focused on the specified criteria.

Analysis revealed that 23% of patients did not receive a 72-hour follow-up post-discharge, attributed to reasons such as patient refusal or missed appointments. Only 74% of patients had documented risk assessments, posing challenges to follow-up teams. Despite the hospital's controlled environment, transitioning patients into the community demands updated risk assessments. While 87% of patients had documented mental state examinations during follow-ups, there's room for improvement in this crucial activity.

In summary, the study emphasizes the importance of meticulous documentation and communication in the transition from inpatient psychiatric care to community settings. Challenges in achieving comprehensive follow-up documentation, with only 67% meeting criteria, were identified. The presence of an online Medication Therapy and Electronic Discharge system faced obstacles in printout availability. Designating a responsible individual for care plans pre-discharge and commendable adherence to thorough assessments during inpatient stays (83%) underscore efforts for a holistic approach. Future enhancements should target improving medication information integration and fortifying collaboration between inpatient and community teams. Addressing these aspects not only prevents medication-related errors but also ensures a seamless and patient-focused transition, enhancing the overall quality of mental health care delivery.

Additional Authors: Dr Minahil Junaid, Betsi Cadwaladr University Health Board, Rhyl; Dr Moheet Rahal, Betsi Cadwaladr University Health Board, Rhyl; Dr Aanika Nawr Hoque, Betsi Cadwaladr University Health Board, Wrexham; Raghdah Faisal, Betsi Cadwaladr University Health Board, Bangor, Amin Rezk, Betsi Cadwaladr University Health Board, Wrexham; Mostafa Negm, Betsi Cadwaladr University Health Board, Wrexham.

To compare current practice in local Rehabilitation in audit across North and West Rehab Kent units against standards of ‘Triangle of Care’.

Standard 1.3:

Carer's views and knowledge are sought throughout the assessment and treatment process.

Standard 5.2:

An early formal appointment is offered to the carer to hear their story, and history and address the carer's concerns.

Standard 5.10:

The carer is involved in the discharge planning process.

A previous audit was conducted in 2019 using Triangle of Care and AIMS standards. We decided to see whether the standards have been upheld.

We included all 43 patients admitted over the previous 6-months. No patient had National Opt-Out. The source of information was the RIO system. The data were analysed by 2 investigators.

A data collection form was used:

Question for Standard 1.3: Were the carer's views and knowledge sought throughout the assessment and treatment process? If this was not the case, the reasons were to be specified.

Question for standard Standard 5.2: Was an early formal appointment offered to the carer to hear their story history and address the carer's concerns?

Question for standard Standard 5.10: Was the carer involved in the discharge planning process?

Standard 1.3:

83.72% had contact with a variety of team members throughout their relative's admission. Reasons for non-involvement included lack of consent, unavailable carers, non-attendance, and carer's preference.

Standard 5.2:

Only 60.53% of carers had an early appointment offer, and the expectation that this should occur in 80% of cases was unmet.

Standard 5.10:

(90%) of the patients had carers involved in the discharge planning process, meeting the required standard.

Best Practice:

The audit results demonstrate that carers are involved in their relative's care throughout the admission and discharge process.

Lessons learned:

Compared with the previous audit in 2019, when the criteria for Standard 5.2 were met, carers were offered a formal early meeting significantly less often. Possible reasons could be the pandemic and resulting changes in practice have certainly led to a reduction in face-to-face meetings. Offering individual time to all carers is essential, and efforts should be made to integrate this into practice.

Next steps:

To allocate a team member to offer a meeting with the carer.

To discuss the outcomes with the Carer Champions on each unit, to review what form their support currently takes, and consider how this could link in with the requirements of Standard 5.2.

To re-audit in 1 year.

To ensure that there is a clear rationale for commencing service users on psychotropic medications.

To ensure that the prescription of psychotropic medications is evidence-based and that they are in line with the Trusts and NICE guidelines.

Ensure that psychotropic medications are regularly reviewed by the managing team.

To ensure that information about medications is adequately shared with patients and carers.

To ensure that service users are well-monitored for side effects.

A 2-week retrospective audit on Phoenix ward.

Clinical information from all the current service users on psychotropic medication was reviewed.

The clinical information was collated from all 8 service users’ medication cards, ward round documents, MDT reviews, and electronic notes (PARIS), and these were analyzed by the inpatient specialty registrar.

1. 1. We attained a 100% mark in some areas of our prescribing such as indicating the rationale, the maximum dose for medication, and also prescribing within BNF limits.

2. 2. We however could not evidence proper information sharing with patients (only 40% documented).

3. 3. We could not evidence sufficient information sharing with carers (only 20% documented).

4. 4. PRN medication was mostly prescribed as a range rather than a clear dose, which gave rise to subjective dispensing bias.

5. 5. Side effect monitoring was documented for 85% of patients, meanwhile, the standard for this is 100%.

Clinicians are to ensure that medication information is always shared with service users, and their carers, and this is documented.

Clinicians are to also ensure that PRN medications are prescribed as a single dose rather than as a dose range.

Ward staff are to ensure that they are monitoring side effects and documenting these clearly on electronic notes and ward round documents.

The MDT is to ensure that all regular and PRN medications are reviewed regularly during ward rounds.

Present this audit, share relevant findings with the clinical team, and monitor the implementation of the action plans by doing a reaudit in 6 months.

• • To find out the proportion of patients for whom the dates of births of their children, age and their due date were recorded during their initial assessment as a means of reducing risks through safeguarding.

• • According to the Royal College of Psychiatrists: Standards for Community Perinatal Mental Health Services 5th Edition (2020), Under Section 5 – Rights, Infant Welfare and Safeguarding: during the initial assessment, the baby's age and date of birth and mother's due date should be recorded as part of the infants' physical and emotional care needs assessment.

• • All new patients discussed during multidisciplinary team meetings within a 2 month period from 01/08/2023 to 30/09/2023 were identified

• • Their clinical records were audited.

• • This information was cross-checked with the information provided on their referral letters.

• • Patients attending preconception counselling were excluded.

• • The initial results were presented in one of the multidisciplinary team meetings.

• • The recording of the children's ages, date of birth or due dates of their mothers was re-audited two months later.

Audit

• • A total of 70 new patients were discussed within the initial two months period.

• • 25 out of the 70 (36%) did not attend their appointments and two patients (3%) cancelled their appointment.

• • 1 patient who attended for preconception counselling was excluded.

• • Of the remaining 42 patients that were assessed, 6 (14%) were primigravida while 36 (86%) patients were multiparous patients.

• • 15 out of the 42 (36%) had their children's age, dates of birth and due date recorded while 27 out of the 42 (64%) lacked this record.

Re-audit

• • A total of 65 patients were identified during the re-audit period

• • 18 out of the 65 patients (28%) did not attend their appointment and one patient cancelled her appointment.

• • One patient that attended for preconception counselling was excluded from the re-audit process.

• • Of the remaining 45 patients that were assessed, 2 (4%) were primigravida and the remaining 43 (96%) were multiparous women.

• • The age, dates of birth and the due date were recorded for 26 (58%) out of 45 patients while 19 out of the 45 patients (42%) did not have this record.

• • The children's ages were commonly recorded compared with their date of birth.

• • Gestational ages of the pregnant mothers were commonly recorded compared with their due dates.

• • Date of birth is needed for a quick check on a child for safeguarding reasons and this is useful during the admission of mothers onto a mother and baby unit.

• • The re-audit showed a significant improvement in the documentation of this information in the patients' records.

Sleep disorders, such as insomnia, are common in the general population and in patients with psychiatric conditions including the behavioural addiction Gambling Disorder (GD). The NHS Southern Gambling Service (SGS) is a tertiary centre providing evidence-based assessment and treatment for people affected by GD across the South-East of England. We aimed to assess the prevalence of sleep problems in help-seeking adults with gambling difficulties, including the association with gambling severity and other measures of psychopathology, and determine if 1) sleep is appropriately assessed and 2) whether sleep disorders are appropriately diagnosed and managed, in line with NICE guidelines, in this particular cohort.

All patients referred from September 2022–October 2023 who completed an initial clinician assessment were included. Gathered data included age, gender, pre-existing physical health conditions, and scores from the following questionnaires: Gambling Symptoms Assessment Scale (GSAS), Pathological Gambling Yale-Brown Obsessive Compulsive Scale (PG-YBOCS), Brief Pittsburgh Sleep Quality Index (B-PSQI), Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder 7 (GAD-7). Data analysis was performed under ethical approval (23/HRA/0279). Relationships between gambling severity and sleep quality, and depressive/anxiety symptoms were explored (using Pearson correlation coefficient). In patients with a B-PSQI score > 5 (suggestive of underlying sleep disorder), we determined whether sleep problems were appropriately assessed and managed.

83 patients completed an initial clinician assessment (81% male, average age 38 years). Baseline B-PSQI scores were weekly positively correlated with gambling severity on the GSAS (r = 0.18) and the PG-YBOCS (r = 0.10) and anxiety symptoms severity on the GAD-7 (r = 0.26). Baseline B-PSQI scores were moderately positively correlated with depressive symptom severity on the PHQ-9 (r = 0.39) and higher B-PSQI scores were noted in patients reporting suicidality.

54/83 (65%) patients had a baseline B-PSQI score > 5, of these, seven (13%) had a clearly documented management plan for insomnia in line with NICE guidelines.

Most patients referred to SGS had baseline B-PSQI scores suggestive of current sleep problems. B-PSQI scores were positively correlated with gambling severity and severity of anxiety and depression. Findings highlight that sleep problems are common in people presenting to the NHS gambling service, but also that there is scope to improve and extend signposting for affected individuals to receive sleep-specific support. The audit findings have been presented to the SGS team; resources for the assessment and management of sleep problems have been shared and a re-audit is planned for Summer 2024.

Additional authors: Dr. Jodi Pitt, Esther Gladstone, Dr. Peter Hellyer.