Lithium is a mood-stabiliser with a narrow therapeutic index. Patients are known to be at risk of lithium toxicity if they are unaware of how to recognise its signs. NICE guidelines outline the information that must be relayed to these patients. Furthermore, GMC Good Medical Practice highlights the importance of clear and contemporaneous patient records that contain relevant clinical information.

The aim of this two-cycle audit was to assess the quality of documentation for patients reviewed in lithium clinic and to analyse the consistency of the notes recorded to ensure high quality care provision and communication within the department, in line with the NICE guidelines.

The inclusion criteria were patients over the age of 65, prescribed lithium and were actively reviewed in the monthly lithium clinic at the Older Person's Mental Health Service (OPMHS) at Princess of Wales Hospital in Wales.

A data collection form was created to ensure all the relevant data in line with NICE guidelines was captured including serum lithium level, lithium dose, other psychotropics, side effects, renal function, patient mood, safety netting advice provided including signs of toxicity and awareness of lithium card. A standard of 100% was set for this data to be captured for each patient.

Cycle 1 was completed in November 2023 where a total of 18 patient records were selected (N = 18). Lithium dose, lithium level and renal function were recorded in over 83.3% (n = 15) of the files audited. Details on psychotropics were recorded in 61.1% (n = 11), side effects in 50% (n = 9) and patient mood in 77.8% (n = 14). Safety netting advice was recorded in 11.1% (n = 2). Furthermore, it was noted data recorded varied between clinicians.

The results of this audit were disseminated to OPMHS team. A proforma was introduced to encourage capture of all relevant information and to ensure consistency. Feedback was collected from clinicians using the proformas and relevant changes were made.

A second cycle of this audit was carried out after the proforma was introduced to the subsequent clinic (N = 12). This showed an improvement in record-keeping including lithium dose, lithium levels, psychotropics and side effects of 100% (n = 12). Renal function and mood were recorded in 91.7% (n = 11) of files and safety netting advice provision in 75% (n = 9) of files audited.

Introduction of a proforma is a simple and effective way to ensure relevant and important details are documented. This is not only for good clinical practice, but for medico-legal reasons also.

Antipsychotic medications are commonly used in the management of psychiatric disorders, including in older adults. However, the use of these medications in older adults can be associated with a higher risk of adverse effects such as cardiovascular event and extrapyramidal symptoms.

This retrospective audit aimed to evaluate adherence to antipsychotic prescribing and monitoring guidelines in a Psychiatric Unit for Older Adult Females in Kent and Medway NHS and Social Care Partnership Trust (KMPT).

The audit criteria encompassed various aspects of documentation and medication management, including diagnosis documentation, indication, age, comorbidities, consent, baseline assessments, monitoring, review, and follow-up care. Data from two months’ records were analysed leading to an action plan with slight amendments to the user-friendly template for ward round and a physical health monitoring poster for junior doctors and ward staff. These initiatives aim to improve patient care, streamline documentation, while accommodating the rotation of junior doctors. A re-audit is planned post implementation.

This audit’s limitations included the study’s single-site nature, potential sample size constraints and reliance on accurate documentation.

The audit achieved 100% compliance in documenting patient age and MHA status, meeting legal requirements. Weight, BMI, and baseline blood pressure exhibited full compliance. Baseline ECGs had an 86.66% compliance rate, while QTc interval documentation reached 100%. Antipsychotic indication and weekly reviews were documented at 100%, with an 83.33% rate for rationale documentation for medication changes. Comorbidities were fully documented, but extrapyramidal symptom and sedation monitoring showed a 46.66% compliance rate. Baseline blood tests, including glucose, bA1c, lipid profile, electrolytes, renal and liver function, thyroid function, and prolactin levels, generally had high compliance, but lipid profile and liver function achieved 73.33%. Repeat blood tests varied, with electrolytes and renal function at 100%, while thyroid function and prolactin levels scored lower at 26.66% and 46.66%. Continued monitoring of weight, BMI, and blood pressure remained fully compliant. Compliance for repeating ECGs within recommended timeframes reached 53.33%, and recommendations to GPs for yearly ECGs and blood monitoring achieved 50%.

In summary, the audit identified areas of commendable high and medium compliance with antipsychotic prescribing guidelines in a Psychiatric Unit for Older Adult Females in KMPT. An action plan has been formulated to not only enhance patient care but also to refine the documentation process positively further, fostering continued progress in the provision of high-quality care.

The audit aimed to study missed seizure frequency, management, and restimulation rate at NHFT's ECT clinic.

We conducted a retrospective analysis of ECT treatments administered between October 1, 2021, and March 21, 2023, collecting data on stimulation frequency and doses, duration of motor seizures and EEG activity, and patients' demographics. The study compared current practice with the NHFT ECT protocol, which defines missed seizures as treatments failing to induce convulsions and EEG activity. Management entails restimulation at least once or twice according to the stimulus dosing protocol during the seizure-threshold (ST) determination phase or by increasing the dose by 10% (50 millicoulombs) during the treatment phase, alternatively recording reasons for not re-stimulating. The ratio of missed seizures to total stimulations was used to determine the missed seizure rate, and the ratio of total restimulations to missed seizures was used to calculate the restimulation rate.

The clinic provided 268 treatment sessions and 26 courses of bilateral ECT to 23 patients aged 17–84 years, primarily female (60%) and Caucasian (74%), with a 12.6% missed fit rate and a 67.5% restimulation rate. Thirty missed seizures occurred during the initial ST determination phase, with twenty-two restimulated. Four of these could not be restimulated due to the maximum limit of three stimulations per ECT session. Seven missed seizures occurred later in the treatment phase, with three restimulated. For restimulations during the seizure-threshold determination phase, only eight of the twenty-two restimulation doses matched the stimulus dosing chart, and over half of these patients were stimulated at a lower-than-recommended dose. Once a seizure was generated and the threshold was identified, suboptimal maintenance doses were chosen, with 47% of patients stimulated on the same dose and 37% on doses only marginally over the ST in consecutive sessions. During the treatment phase, two out of three restimulations were performed with a dose lower than the specified 10% increase. The reasons for deviating from the guidelines were not documented.

National audits of ECT clinics in 1981 and 1992 showed 50% and 25% missed seizure rates, respectively. Bridgend ECT Clinic maintained a missed fit rate of ≤5% over a 6-year period, which is half that of NHFT. Missed seizures have been associated with treatment failure and post-ECT adverse effects; hence, to effectively manage them, we propose that all ECT administration personnel be familiar with the NHFT ECT protocol, including the stimulus-dosing protocol, and document any clinical grounds for deviations.

This audit assesses communication practices regarding interactions between lamotrigine and oral contraceptives in North West Sussex (NWS) Specialist Perinatal Mental Health Services (SPMHS).

The predicted outcome includes increasing awareness about potential interaction between lamotrigine and contraceptives with resulting impact on patient safety.

Lamotrigine is used for epilepsy and mental health disorders but can interact with contraceptives, affecting efficacy and safety. NICE recommends it for bipolar depression, relapse prevention and recurrent depression. Interactions with hormonal contraceptives can influence effectiveness of either drug and increase the risk of side effects. Patients on lamotrigine should be counselled so they can make an informed decision about taking the medication.

Reviewed records of all patient on the caseload on 21st June 2023. Collected data for lamotrigine prescription, indication, contraceptive method, and documented counselling. Calculated percentage of patients counselled on lamotrigine-contraceptive interaction.

In 261 patient records, 11.9% were previously or currently on lamotrigine or had a discussion about starting lamotrigine. 6.1% currently and 3.1% previously on lamotrigine. Counselling on lamotrigine's interaction with oral contraceptives was documented with 3.1%, while 74.2% received none. Indications for lamotrigine use were epilepsy 9.7% and mood stabiliser 90.3%. Of 27 patients who weren't currently pregnant, 9 of them were informed of the interaction risk while 18 were not. Contraception methods were documented for 10 individuals.

Findings showed the need for increased awareness about the interaction and documentation of appropriate discussions to inform their choice.

The Royal College of Psychiatrists provides guidance regarding the experience of Foundation Doctors and Core Trainees, during their Psychiatry rotations. At The Mount, an Older Adult Mental Health unit in Leeds, it was observed by trainees that management of physical health conditions was occupying a large portion of their time.

Aims:

1. 1. Measure how much time is spent on physical health activities, between Foundation Doctors and Core Trainees at The Mount.

2. 2. Consider the impact of physical health workload on the doctors’ experience of Psychiatry.

3. 3. Explore the mental health experience of doctors during this rotation.

This Audit was conducted in three stages:

1. 1. Anonymous collection of quantitative data regarding the proportion of time spent on physical health work. This data was collected for current doctors across all wards, for a two-week period in October 2023.

2. 2. A focus group of junior and senior doctors, to consider onward actions.

3. 3. An anonymous qualitative survey regarding mental health experiences and suggestions for improvement. This was circulated to any Foundation Doctor or Core Trainee who worked at The Mount in the past 12-months, via an online survey.

The quantitative survey showed that Foundation Doctors and Core Trainees at The Mount were spending at least half their time on physical health jobs, such as: clinical reviews, skills such as blood tests and ECGs, and referrals to other clinicians or specialties. This was considered unsurprising by doctors at all levels during the focus group.

The qualitative survey explored this further, with observations that doctors were sometimes unable to attend MDT meetings, tribunals or CPAs due to the high physical health workload. It was felt that senior staff were proactive in offering support, however trainees still felt that opportunities for mental health experience were limited.

Suggestions for improvement were made during the survey, including:

1. 1. Increased input by senior medical staff, such as GPs or Geriatric Trainees.

2. 2. Additional staff to support with upkeep of equipment, or skills such as phlebotomy.

3. 3. Increased use of technology rather than paper charts.

4. 4. Greater clarity regarding minimum staffing and whether locum doctors can be arranged to cover gaps.

In summary, the physical health workload for Foundation Doctors and Core Trainees was noted to be significant and impacting their mental health experience. Following this Audit, consultants at The Mount will be meeting with Senior Leadership to discuss methods for improving the training experience.

To review the practice of management of clozapine plasma levels in Solihull CMHTs between April and September 2023. Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) clozapine guidelines were issued in January 2023 and further ratified in December 2023. The standard set out in the January 2023 guideline was that service users with elevated clozapine levels >600mcg/L should be assessed for signs of toxicity and consideration given to a dose reduction. Those with levels above 1000mcg/L should be reviewed urgently.

Clozapine blood clinic diaries were reviewed in order to obtain a list of 48 service users who had attended for clozapine blood tests between April and September 2023. Blood results were reviewed for clozapine level results. For those service users whose clozapine level had been over 600mcg/L, clinical notes were reviewed to determine whether they had been screened for clozapine toxicity.

Of the 48 service users prescribed clozapine, 24 had clozapine levels over 600mcg/L and 11 had levels over 1000mcg/L. Of the service users with clozapine levels over 600mcg/L, 16 (67%) were screened for toxicity. Of those with clozapine levels over 1000mcg/L, 9 (82%) were screened for toxicity.

Between April and September 2023, Solihull CMHTs demonstrated an understanding of the need for actioning elevated plasma levels as a priority, however, this could be further improved. The risks of adverse effects and toxicity with clozapine increase with raised plasma levels, particularly with levels over 1000mcg/L. Therefore, it is important that raised plasma levels are actioned accordingly. Locally, we have implemented a flow chart which summarises the updated clozapine guidelines, to assist clinicians in interpreting and acting on high clozapine levels and to prompt clinicians to review service users for signs of toxicity. We hope to incorporate this visual aid into the updated BSMHFT guidelines.

Rapid Tranquilisation (RT) is the parenteral (intramuscular) administration of medication to calm or sedate an agitated, violent or aggressive patient in a timely and safe manner. This audit specifically looks at the clinical practice in the use of rapid tranquilisation in inpatient MHSOP against trust policy. The aim of this audit is to assess the effectiveness of RT and if other methods of de-escalation are being utilized first to provide better care for patients and utilize the least restrictive management options possible.

The audit was registered, and care was taken to uphold ethics, access patient information appropriately, and to ensure that data collected was both relevant and ensured confidentiality. All incidents of RT were identified across both wards of Auckland Park Hospital from the period of August to October 2023. DATIX numbers were identified to show incidents of RT from the specified period, these numbers were used to identify patient ID with liaison with relevant staff members. Patient ID was used to review the incident, specifically to investigate de-escalation techniques documented and effectiveness of RT. Only parenteral RT incidents were included to assess if appropriate measures were taken beforehand.

A total of six Incident reports were identified over the three-month period. In all cases the choice and dose of the medication was within the current recommendations. 33% of incidents utilised promethazine 25mg while the other 66% utilised lorazepam either 1mg or 500mcg. All patients had baseline observations recorded on NEWS chart prior to the incident, however only 33% of incidents involved full recordings of observations at appropriate intervals on the NEWS chart. The reason for this in all cases was due to patient refusing observations which was documented. There were no documented side effects but 33% of incidents involved a raised NEWS score post RT. In all cases the NEWS score resolved spontaneously within the post RT monitoring period. In 100% of incidents de-escalation techniques were utilised and documented and evidence of post RT debrief with the patient was shown. 66% of incidents involved a medication review post RT as per recommendations.

Guidelines are being followed with good effect regarding RT in MHSOP. It is important to always undertake nonpharmacological de-escalation methods prior to considering RT which is reflected in the low numbers of RT during this period. Recommendations are made to follow local guidance as well as to exhaust nonpharmacological de-escalation methods to reduce the need for RT.

Section 136 of the Mental Health Act 1983 allows for a person who appears to a constable to be suffering from a mental disorder and needing immediate care to be removed to a place of safety (POS) for their protection or the protection of others.

The legislation recommends that prior to making a decision to detain on Section 136, the constable must, if practicable, consult mental health services for information to guide decision making.

The 136 suite is the preferred POS except for patients requiring urgent medical treatment in which case the Emergency Department (ED) is preferred. If the 136 suite is unavailable, then alternatives like the ED may be used.

This audit examines the use of the Birmingham City Hospital Emergency Department as a POS following Section 136 detention, the adherence to the aforementioned legislation and the outcomes of the assessments.

The audit was approved by the clinical governance team and a list of all Birmingham City Hospital patients detained under Section 136 for a three-month period (January–March 2022) was retrospectively obtained. Clinical records were examined, and the relevant data was extracted from the clinical notes.

Information including the reason for use of the ED as a POS, police contact with mental health services prior to detaining, time taken prior to assessment, reasons for mental health act assessment (MHAA) delays, and outcomes were collected and collated using Microsoft Excel.

The ED at City Hospital was used a place of safety for 80 patients in this period. In 52.5% of cases the ED was used as a place of safety due to lack of space at the POS. Contact with mental health services prior to detention was documented in only 29% of cases. The average time for a MHAA to take place in the period under review was 11.5 hours. Only 20% of these cases ended up detained under the mental health act.

The results show poor adherence in the use of Section 136 to the recommendations of the legislation. Improvements are needed on time taken for assessments and use of ED as a place of safety due to unavailability of beds at the s136 suite. The police should be re-educated on the importance of contacting mental health services prior to detaining patients on Section 136. The audit result was presented at a clinical governance meeting and repeat audits are planned across all the emergency departments in Birmingham.

This clinical audit aimed to assess if the recording of patients seen for their diagnostic appointments in memory clinic measures up to the minimum standards required in the delivery of dementia services. This standard mandated primarily that a minimum body of key information must be promptly recorded by clinicians, in patient electronic records within 24 hours, as stipulated by Trust and NICE guidelines.

The first cycle was conducted from 16 October 2022 to 10 February 2023. In this cycle random sampling was used to select 25 patients on the caseloads of the mental health services for older people. Before the start of the second phase all diagnosing clinicians within the team were informed about the project and the expected improvements against which compliance would be audited. The second phase was conducted between 10 February 2023 to 31 March 2023 and another 25 patients on the caseloads were obtained via random sampling for the second cycle. Inclusion criteria for both phases were patients who had received a diagnostic assessment in these periods.

In the first set of records, the minimum body of information was recorded in 90–100% of cases according to the team's recommended standards namely diagnostic information, prognostic information, treatment plans, post-diagnostic contact plans and documentations being made within 24hrs of consultation. In the Set 2 the minimum body of information was recorded in 95–100% records studied. That is, diagnosis, treatment, medication treatment plans (prescription plans), and post-diagnostic contact plans were covered in the diagnostic sessions. In particular, case note documentations were made within 24 hours in all but one of the records applicable.

Given that a diagnosis of dementia can be life-changing, not discussing prognostic information would not prepare patients and carers adequately with information on how to live well with dementia following their diagnosis. This could potentially lead to poor adjustment to the condition and anxiety for some. At a trust-wide level, this means there is still room for improvement for the trust as regards dementia care ideals recommended by NICE.

In outpatient settings, depot administrations are done to a large extent by Community mental health nurses and other trained clinical personnel who are not psychiatrists. As a result of this, there is a possibility that patients who are having depot medications are not reviewed by a psychiatrist for a long duration of time which can be more than a year. The aim of this audit is to find out if patients currently taking depot medication under a General Adult Community Mental Health Service in North Norfolk are being reviewed by a psychiatrist according to the standard guidelines. The Maudsley prescribing guidelines states that all patients receiving long-term treatment with antipsychotics medication should be seen by their responsible psychiatrist at least once a year (ideally more frequently) to review their treatment and progress.

List of patients currently on depot medication were taken from the spreadsheet on the Unit's Shared drive. All 47 patients currently receiving depot medication on this list were reviewed. The review period was from Ist January 2023 to 31st December 2023. Psychiatrist Review included Reviews/Appointments by Consultant Psychiatrists, Specialty registrars, Trainee doctors and GPST doctors in psychiatry posting.

It was recorded that 28 patients on depot medication have been reviewed within the last one year which is approximately 60% of the patients currently on depot medication. 19 patients who are currently on depot medication have not been reviewed by a psychiatrist in the last one year, which is approximately 40% of the patients on depot medication. Out of the 19 patients who have not been reviewed in the last one year by a psychiatrist, only 8 of them were offered an appointment.

We can conclude only 60% of patients currently on depot medication were seen by a psychiatrist for a medication review in the last one year. This fell below the expected target of having 100% of these patients meeting with the standard that states all patients receiving long-term treatment with antipsychotic medication should be seen by their responsible psychiatrist at least once a year. A significant proportion of patients might have been deprived of an adequate assessment of their progress and response to treatment and the review of the side effects of these depot medications. These findings have been discussed with the Community Team Manager who has agreed to facilitate that these patients are reviewed promptly.

This comprehensive study seeks to evaluate the adherence of (CAMHS) service, Black Country Healthcare National Health Service (NHS) Foundation Trust to National Institute for Health and Care Excellence (NICE) guidelines in prescribing medications for children diagnosed with Autism Spectrum Disorder (ASD). Our primary objectives include identifying variations in prescribing practices across different localities within the trust and identifying specific areas that may benefit from improvement.

A meticulous retrospective analysis was conducted on 142 randomly selected cases involving children diagnosed with ASD and prescribed psychotropic or sleep medications. A comprehensive analysis of patient records, encompassing progress notes and clinic letters, facilitated the gathering of extensive data. The evaluation centred around benchmarking adherence to NICE guidelines. Throughout the process, strict adherence to ethical standards was maintained.

Within the cohort of 142 children diagnosed with ASD, 44% underwent alternative interventions before medication initiation. Notable variations were observed across localities, with 87% receiving psychological therapy as an alternative intervention. Documentation of consent for commencing medication was present in 62% of cases. Specialists consistently initiated psychotropic medications at the minimum effective dose, and 70% of cases had a follow-up within 3–4 weeks. Sleep medications were prescribed to 77% of the cohort, with 55.5% of those undergoing alternative interventions before prescription.

The study's findings underscore significant variations in adherence to NICE guidelines, emphasizing the critical importance of exploring alternative treatment modalities before resorting to medication. Furthermore, collaboration with supporting agencies is highlighted as a crucial aspect of comprehensive care. The documentation of consent forms for all patients is deemed imperative, and adherence to specified intervals for reviewing medication side effects, as outlined in the guidelines, is considered crucial for optimal and safe patient care.

Lithium is the recommended first-line pharmacological treatment for bipolar disorder and as an augmentation of the treatment for depression. Both NICE and local guidelines stipulate the need for patient counselling regarding side effects, interactions and toxicity, alongside strict monitoring requirements for initiation and maintenance.

We aimed to assess compliance with these guidelines for patients prescribed lithium on a functional older adult inpatient ward in Hertfordshire Partnership NHS Foundation Trust (HPFT). Additionally, following feedback from the local crisis and community colleagues, concerns were emphasised around inconsistent communication on discharge. We therefore also aimed to evaluate the introduction of a small-scale intervention to the method of discharge communication.

A retrospective analysis of electronic patient records was undertaken for the 43 patients within HPFT prescribed lithium during their inpatient stay on a functional older adult ward over a five-year period (2019–2023).

Lithium monitoring on drug initiation was assessed for compliance with the standards set by NICE guidelines for the management of bipolar disorder. For all patients prescribed lithium, we also noted demographics, diagnosis, rate of side effects and toxicity, discontinuation, and documentation of discharge communication to the community. A standardised template for communication with community and crisis colleagues was introduced, and its impact was assessed.

58% (n = 25) of patients were initiated on lithium, with 80% (n = 20) of them having documentation of counselling. Baseline blood tests were consistently recorded for all newly prescribed lithium patients (n = 25), and regular serum monitoring was present in all patients. Common side effects included tremors (26%; n = 11) and polyuria (7%; n = 3), while in 63% of patients (n = 27), no side effects were noted. Toxicity occurred in four cases, leading to discontinuation in 50% of them.

Prior to concerns being highlighted around handovers to community colleagues, there was specific documentation of a handover in 19% (n = 6) of cases. Following consultation with stakeholders and consensus regarding the trial of a template for communication to the patient's community consultant, documentation improved to 75% (n = 6).

All patients in this study who were initiated or maintained on lithium received serum monitoring as inpatients in accordance with NICE guidelines. The introduction of small-scale improvements with a standardised template has been effective, significantly improving discharge communication with community colleagues for patients on lithium. Further research is necessary to elucidate the impact of these changes on patient care in the community by gathering feedback from a diverse group of community colleagues.

The audit aims to check compliance of prescribers to the following National Institute of Clinical Excellence (NICE) guidelines:

• • NG134, CG31: Antidepressants are prescribed in conjunction with psychological therapy.

• • NG134: A risk-benefit discussion took place.

• • NG134 Written information was given.

• • NG134, CG31: First-line medication was prescribed in the first instance.

• • NG134: An off-licence medication is only prescribed after a review.

• • NG134: A consent form is signed if an off-licence is prescribed.

All patients under CAMHS and receiving antidepressant therapy was considered. People on the caseload currently an inpatient were excluded. The audit was performed in October 2023. 86 eligible patients were randomised; 30 were selected for case review. Clinic letters and internal case notes were reviewed to check compliance.

Areas of good compliance: antidepressants prescribed with psychological therapy, risk-benefit discussions took place, first-line medications prescribed in the first instance, off-licence medications prescribed only afer review.

Areas of moderate compliance: written information given with prescriptions.

Areas of no compliance: consent form does not form part of standard practice or local guidelines.

The local CAMHS service showed good compliance to NICE guidelines around antidepressant prescribing. Presentation to the local team is required to remind clinicians of the need to document parts of the consultation such as giving written information. A discussion with the regional consultant body yielded the outcome that the service will adhere to local Trust guidelines of internal case notes documenting consent rather than a signed form. The standards for the re-audit in 6 months will reflect this.

This audit aimed to understand the practice of advance care planning with regard to cardiopulmonary resuscitation (CPR) in an older adult inpatient setting and to ultimately improve practices to conform to nationally set standards.

The aims of the audit were:

1. (1) To determine the prevalence of advance care planning decisions relating to CPR in patients admitted to two older adult psychiatric wards at Thurrock Community Hospital.

2. (2) To confirm that the practice of discussion and documentation of ‘Do Not Attempt Cardiopulmonary Resuscitation' (DNA-CPR) decisions is consistent with current national standards.

First, we scrutinized whether the patient's preferences for CPR as a life-sustaining treatment were documented or known to the primary care physician at the time of admission, and whether there was a DNA-CPR order in place at the time of admission.

Next, we looked at whether a discussion about CPR was facilitated with the patient (or those close to the patient) during the admission, whether the patient was involved in the discussion surrounding CPR and the reasons for their exclusion (if excluded), and at what point in time during the admission this discussion was carried out and whether it was properly documented.

Finally, we assessed the level of completion of the DNA-CPR form itself.

Total sample: 38 patients.

13 out of 38 patients (34.21%) had a DNA-CPR form in place.

10 out of 13 DNA-CPR forms (76.92%) were complete in all aspects.

Discussion relating to DNA-CPR was not carried out in 29 out of 38 patients (76.32%) during their current admission.

Mental Capacity Assessments and Best Interest meetings were not documented as having been carried out as was necessary in the 4 patients (0%) who did not have a designated Lasting Power of Attorney.

Discussions about advance care planning and DNA-CPR were not being carried out in a timely manner as per the national guidelines.

Patients with serious mental disorders like psychosis may pose a significant risk to themselves and others when they drive. The DVLA has set out guidance for driving for patients with psychiatric disorders, substance use disorders, and for those taking psychotropic medications. It's good medical practice to identify risks associated with driving, discuss, advise appropriately, and document the same in the clinical notes.

To assess the compliance of the mental health professionals at Rathbone Rehabilitation Centre (RRC) with DVLA guidelines regarding patients about driving restrictions, documenting this appropriately and to increase awareness of the DVLA guidelines.

Data of all the discharged patients from RRC over a 12-month period was collected following a standardised process and assessed for 6 parameters.

A total of 51 discharges were identified and audited against the DVLA guidelines.

51 (100%) patients had a mental health diagnosis documented on patient electronic records (Rio).

9 (18%) of patients had their driving status documented. 42 (82%) did not.

Of the 9 patients whose driving status was recorded, 6 did not drive and are thus labelled not applicable for subsequent criteria. The type of vehicle driven was not documented in any of the cases and therefore was 0%.

Of the 3 patients who drive, 2 (67%) had been informed that their condition may affect their ability to drive.

67% had documented evidence of receiving advice on driving restrictions.

67% had documented evidence that the practitioner has informed the patient that they have a legal duty to inform the DVLA about their condition.

An action plan was designed to improve compliance with DVLA guidelines for practitioners managing inpatients.

• • On admission all patients should be asked for their driving status and the result documented on Rio. This could be done on the clerking admissions proforma on Rio.

• • For all patients that do drive, the types of vehicles they drive should be documented–this can also be included in the clerking admissions proforma on Rio.

• • At their first ward review/discharge meeting and whenever relevant, patients should be informed whether their condition affects their ability to drive and if so, what the restrictions are. They should be informed of the legal requirements regarding informing the DVLA and documented.

• • To consider driving status when assessing risk.

NICE guidelines stipulate that alternative causative factors for Behavioural and Psychiatric Symptoms of Dementia (BPSD) must be considered before starting antipsychotic treatment. The symptoms of BPSD include agitation, aggression, wandering, hoarding, sexual disinhibition, shouting, repeated questioning, sleep disturbance, depression, anxiety and psychosis. Those who do develop non-cognitive symptoms or behaviours should at first be assessed to exclude alternative causes, such as physical health issues (pain/infection), side effects of medication, environmental factors, psychosocial factors, individual biography (e.g. religious beliefs) etc. Then, non-pharmacological approaches should always be used as the first line in treating behavioural problems before antipsychotics (e.g. haloperidol or risperidone) are started at a low dose and titrated up. Once these have been started, the patient should be reviewed at 6 weeks. The rationale for conducting this audit is to try and understand if the antipsychotic prescribing in the ward is in line with the NICE guidelines.

A retrospective study to compare the treatment of all the patients admitted for dementia in the Old age psychiatry wards located in University Hospital Llandough from November 2022–April 2023 with the NICE guidelines.

Out of the 39 patients who met the criteria, the results indicate a predominant prevalence of Alzheimer's (46%), followed by mixed dementia (23%) and vascular dementia (21%), among the diagnosed cases. In 67% of instances, healthcare professionals have considered alternative causative factors for the observed symptoms beyond the identified dementia subtypes. In 62% of cases, patients received treatment for alternative causes, while non-pharmacological approaches were attempted in 51%. The utilization rates among patients indicate a predominant prescription of risperidone at 77%, followed by quetiapine at 31%, olanzapine at 10%, and aripiprazole at 5%. 95% of patients were commenced treatment at the lowest dose, while information for 3% (1 patient) was not available. 62% were monitored according to guidelines and 56% were reviewed every 6 weeks.

There is room for improvement in terms of considering other causes of behavioural symptoms, utilizing non-pharmacological approaches, and adherence to monitoring and review intervals outlined in the guidelines. These findings underscore the importance of continuous evaluation and refinement of clinical practices to enhance the overall management of BPSD in dementia patients.

Aim:

To develop better prioritisation and assessment of high-risk patients.

Standard:

RCPsych Junior MARSIPAN guidelines advise that reasonable aims for a first presentation to primary care involve physical examination and referral to the appropriate CAMHS or paediatric service depending on the level of risk. The framework set out within the guidelines can be used to highlight areas useful to assess and grade concern.

NICE guidelines also state that in primary care, when assessing for an eating disorder or deciding whether to refer people for assessment, the following should be considered: BMI or body weight for their age, rapid weight loss, restrictive eating practices, mental health problems, physical signs of malnutrition, poor circulation and behaviours such as excessive exercise, unexplained electrolyte imbalance or hypoglycaemia.

Indicator and target: Proportion of GP referrals which contain information to allow risk assessment and prioritisation of referrals within CAMHS.

Eating disorder referrals were reviewed over a three month period. Using EMIS, SCI store referrals were reviewed to check the source of referral and information included.

Referrals were checked against the following criteria: weight, degree of weight loss, fluid intake, calorie intake, heart rate, blood pressure, mental health screening, compensatory behaviours and blood analysis.

First cycle Results: from period from May–July 2021, comprising 8 referrals. The percentage of referrals which included information on the following were: weight 25%; weight loss 50%; calorie intake 37.5%; fluid intake 12.5%; heart rate 0%, blood pressure 12%, mental health 62%, compensatory behaviours 12.5%, bloods analysis 25%.

Action plan: Pro forma was developed to increase awareness of the information that is useful to CAMHS to prioritise and assess risk as per standards expected from NICE and Junior MARSIPAN guidelines.

This was circulated to East Renfrewshire GP practices in August 2021.

Second cycle Results: Referrals were reviewed in the period after the pro forma was circulated from Sept–Dec 2021. This comprised of 4 referrals. Upon review results showed that the percentage of referrals which included information on the following were: weight 100%; weight loss 50%; calorie intake 25%; fluid intake 25%; heart rate 25%, blood pressure 50%, mental health 100%, compensatory behaviours 75%, bloods analysis 50%.

The audit showed, that following the pro forma being circulated, there was an improvement in proportion of referrals which contained appropriate information (26% compared with 55% cumulative percentage of information included).

The aim of the audit is to improve the patients’ experience in the ward round, to ensure all the patients feel included in their ward rounds, to find out if their physical health gets as much attention as their mental health and to establish they receive appropriate feedback of their treatment progress while being inpatient.

By carrying out the audit, our target was to ensure patients are prepared, that service users and carers are involved, clear goals are set, patient confidence is increased, there is direct patient interaction, and the ward round is a positive experience for both the patient and the care team.

This audit included 34 patients from our acute adult psychiatry mixed unit and perinatal psychiatry unit, who have had at least two ward rounds in the inpatient setting, have the capacity to consent to treatment and have insight to their mental health issues.

Data collection was done by a face to face patient interview with a questionnaire by the junior doctors in the wards. The questionnaire was discussed with the head of patient experience team and clinical audit & improvement facilitator team prior to starting the audit. Confidentiality was maintained and at no point were the patients requested to reveal their identity.

Among the patients admitted during the period of October 2022 to November 2022, 40 patients were chosen randomly. Among them, data was collected from 34 patients according to the inclusion criteria.

Based on the patients’ feedback and experience, 52.9% service users thought the ward round time tables ran by schedule, whereas 11.8% service users thought they did not run by schedule at all.

20.6% service users reported that they were not informed in advance, if there were any change in the ward round time schedule; whereas 41.2% service users were informed of the changed time schedule.

50% service users reported that they received appropriate support prior to the ward round should they need this, on the other hand 8.8% said they did not require any support, therefore refrained from answering the question.

Majority of the service users 94.1% reported that they were happy with the ward round physical environment, the sitting arrangement and the ambience and 88.23% service users reported being reviewed by the consultant at least once a week. None of the service users were found, who was not reviewed by the consultant at least once weekly during their stay in the inpatient wards.

47.1% service user reported that they did not feel confident and comfortable in front of all the professionals present in the ward round.

20.6% service users complained that their physical health was not getting as much attention as their mental health in the psychiatric wards and they were not referred for their physical health needs accordingly.

23.5% of service users had little to moderate understanding on what was being discussed in the ward round meeting, whereas 76.5% understood completely what was being advised in the ward round.

8.8% of the service users did not feel involved in their ward round at all and majority of the service users, 52.9% got regular feedback on the treatment progression and a chance to talk with their named nurse after the ward round.

Ward rounds are the formal meetings where service users come to the professionals with their queries and are informed about their progression on treatment. These meetings should be comfortable and palatable for both sides of the table. Further arrangements are required to improve the settings and make it more service user friendly to get the best outcome from ward rounds.

To ensure psychiatry admission assessments are well-documented and available via EmisWeb clinical notes system.

To assess whether replacing the clerk-in booklet with a digitalised version affects documentation of psychiatry admission assessments.

The standard was use of the current admission template with information under each heading. In addition, a Clinical Risk Assessment Framework for Teams (CRAFT) tool should be completed by the admitting doctor. Legal status, observation level and time-out status should be recorded.

A retrospective full-cycle audit of the first twenty patients admitted to Leverndale Hospital, Glasgow starting 1st Dec 2022, then 1st April 2023 for the second cycle. Patients were identified using EMISWeb admission dates and information from Medical Records. Data was taken from the EMISWeb record and analysed using Microsoft Excel – if incomplete paper notes were checked.

Use of the admission template and presence of meaningful content (excluding “n/a” and similar) under each heading was recorded. Data was collected on the documentation of legal status, observation level, time-out status, and CRAFT risk assessment by the admitting doctor. Perinatal psychiatry admissions and transfers between psychiatric units were excluded.

Medicines reconciliation was absent in 55% and allergies in 70%. CRAFT risk assessment was completed by the admitting doctor in 55% of cases.

Following round 1, a digitalised admission proforma was introduced, replacing the traditional admission booklet.

There was little improvement in usage of the admission proforma with the introduction of the digitalised version (80% vs 75% previously). Notably, the rates of CRAFT risk assessments by the admitting doctor fell in this 2nd cycle – from 55% to 40%.

Recording of allergy status (55% from 30%) and medications (95% from 45%) seemed to improve. Importantly quality of content was not appraised – many medication entries consisted of “as per HEPMA (electronic prescribing system)”.

100% of admission documentation was now available on EMISWeb, preventing information loss and allowing remote access from Community Mental Health Teams.

The introduction of a digitalised admission template had little impact on use of the proforma. However it meant that 100% of admission information was available digitally, versus 85% previously.

In both cycles the CRAFT risk assessment was often not completed by the admitting doctor. Given risk assessment is a key reason for “clerking in” psychiatric inpatients, this could be a focus for future quality improvement work.

In the second cycle, recording of medications and allergy status had improved significantly. Given small sample sizes, this may be due to chance.

The prevalence and subsequent physical health burden of alcohol use disorder is on the increase in almost all age groups in the UK and nearly 1 in 5 of the population will drink at hazardous levels. Those who drink heavily often have limited or patchy engagement with physical health services and improving this should be a focus of drug and alcohol services.

Our aim was to audit the proportion of clients attending the alcohol service at Lorraine Hewitt House (LHH) who had completed a fibroscan, to audit the outcomes of those fibroscans and to audit the outcomes of the onward referrals where they had been made.

Since starting the liver clinic, more than 100 fibroscans have been completed. These are typically offered to clients in the alcohol pathway and where it can be facilitated, they are done on the day, or otherwise booked in for scheduled appointments.

We audited the results of the scans, for liver stiffness and liver steatosis. Additionally, for those who had abnormal results requiring onward referral, we audited the outcomes of these referrals.

Outcomes and overall physical health were subsequently discussed with each patient who underwent a liver scan.

A total of 100 fibroscans were audited. This represents approximately one third of the clients with alcohol as their primary problem substance at LHH.

Every client had the results of their scan explained and discussed with them and were given lifestyle advice and interventions.

A total of 37 scans (37%) had all their parameters within the normal range. 16 (16%) showed an increased liver stiffness of >10kPa and 15 people (15%) gave consent and were subsequently referred to our local liver clinic. 13% had stage 1 steatosis (238–260dB/M), 18% had stage 2 steatosis (260–290dB/M) and 29% had stage 3 steatosis (>290/dB/M).

Of the 15 referrals made to liver clinic, 10 (66.7%) attended their liver clinic follow up appointments and 9 of these clients are awaiting further interventions – the remaining 1 client has been discharged back to their GP.

Of the remaining 5 referrals made to liver clinic, 2 are awaiting appointment dates and 3 are pending triage.

The physical health of clients attending drug and addiction services is often complicated and in need of specific and targeted interventions. Liver health is particularly relevant to the alcohol client group and integrating fibroscans into drug and addiction services facilitates better engagement and early assessment and intervention.