Measure compliance with standards requiring baseline work up before Lithium therapy is commenced and subsequent Lithium level monitoring during the initiation phase

All inpatients and outpatients who were started on Lithium between 2018 and 2019 within the Leicestershire Partnership NHS trust. Case notes were of patients 128 were retrieved from the electronic system and an audit proforma was completed to ascertain adherence to auditing standards as per BNF and trust guidelines. Parameters monitored were full blood count (FBC), renal functions test including serum electrolytes, thyroid function test, and BMI before commencing Lithium, and serum Lithium periodically after. ECG was needed for those patients with cardiovascular illness. Data were systematically compiled and analyzed descriptively using Microsoft Excel

A total of 128 patients were included in the study. 111 (86.71%) had FBC, 118 (92.19%) had renal function test and electrolytes, 114 (89.06%) had thyroid function test while 99 (77.34%) had their BMI/weight recorded before initiating Lithium. 26 out of 36 patients with cardiovascular disorder had their ECG recorded. After Lithium was commenced, 108 (84.37%) had serum Lithium tested a week later, while only 89 (69.53%) had lithium monitored weekly. Trust guidelines recommend weekly monitoring for up to 4 weeks after a stable dose was reached. This was monitored in only 16 out of 128 patients.

Most of the patients had blood test done before being commenced on Lithium. However it was observed that serum Lithium was not adequately monitored at regular intervals after dose escalations. These finding indicate that there has to be greater awareness of the trust and BNF guidelines with regards to Lithium monitoring.

To assess follow-up of sodium levels for in-patients prescribed antidepressants in practice compare to the standard of 3 monthly sodium levels for all patients who are prescribed antidepressants and at risk of hyponatraemia

A list of the 20 most recently discharged patients from Meridian Ward, an older-adult functional inpatient ward, was prepared by the team administrator on 6th May 2020.

We audited the entire duration of our patient's stay on Meridian Ward (we did not include periods of their admission when they were on other wards) using the electronic notes system, Carenotes.

We also checked the electronic biochemistry results system, ICE, for sodium results, and the discharge summary for mentions of fluid restriction, medications and handover to GP of sodium-checking. We also checked scanned drug charts to see if they were on antidepressants and other implicated drugs.

For people with episodes of hyponatraemia, in order to retrieve further info we looked at discharge summary and searched the activity notes for the following terms

“Hyponat”

“sodium”

“fluid restrict”

“Low na”

We regarded the following conditions as risk factors for hyponatraemia:

cardiac

malignancy

respiratory

hypothyroid

renal

hepatic

stroke

We regarded following medications as risk factors:

opioids

diuretics

carbamazepine

theophylline

antipsychotics

NSAIDs

PPIs

ACE-I

ARBs

amiodarone

domperidone

sulphonylureas

14 of the 20 patients were taking antidepressants. Of those: 13 were eligible for regular sodium monitoring due to risk factors 11 of these had 3-monthly sodium levels during admission For only 2 of these did we make a plan for the GP to continue to monitor the sodium level in community 3 had an episode of hyponatraemia implicated antidepressants: sertraline plus mirtazapine mirtazapine (very serious episode which caused seizure) sertraline for 2 of them an appropriate plan was made 1 without a plan - a mild hyponatraemia with nothing documented in the notes

During their admission to Meridian Ward, 85% of patients taking antidepressants who had risk factors for hyponatraemia had three-monthly sodium levels in line with the trust guidance. However, only two patients (15%) had a plan for further sodium levels in the discharge summary sent to the GP. This highlights a need for improved awareness of risk factors for hyponatraemia and, in particular, improved communication with general practitioners who are going to take over prescribing of antidepressant medications.

Recommendations

3 monthly Na levels for all patients with risk factors

i.e. on any antidepressant prescribed PLUS any one of:

>80 years

History of low sodium

AKI during admission

Relevant comorbidities (see above)

>1 antidepressant

Other meds that can cause hyponatraemia

More frequent monitoring for all those with with multiple risk factors AND who are starting/increasing antidepressant:

baseline sodium plus repeat after 2 and 4 weeks

Communicate to GP the need for 3-monthly sodium monitoring for those with above risk factors

Re-audit in 6-12 months’ time

To check the extent to which National Institute of Clinical Excellence (NICE) guidelines were being followed in clinical practice with regards to prescribing antipsychotic medication to Child and Adolescent Mental Health Services (CAMHS) patients with a diagnosed learning disability (LD).

A data collection tool (based on a similar Royal College of Psychiatrists [RCPsych] audit) was filled out with retrospective data from patients’ clinical records, then analysed using Microsoft Excel and Microsoft Powerpoint.

The agreed standards were the NICE guidelines.

There were no ethical issues as the data were retrospective and anonymised.

Sample size was 13, comprising 7 males and 6 females.

All service users were less than 18 years of age.

7 out of the 13 patients who were prescribed antipsychotics had a Severe/Profound LD.

Among the 5 patients who had been prescribed antipsychotic medication, 4 were on Risperidone and 2 were on Aripiprazole. The reasons for starting antipsychotic medication were clearly documented for all 5, the most common reasons being overt aggressive behaviour and general agitation/anxiety.

Only 1 patient had antipsychotic medication initiated in the previous 12 months. NICE guidelines had been generally followed for the management of this case, with good documented evidence.

For the other 4 patients, in whom antipsychotic medication was initiated more than 12 months ago, there was a lack of documentation of the subsequent assessment of side effects, extra-pyramidal side effects, body weight, blood pressure, glycaemic control and lipid profile. 1 of these patients did not have a documented review of antipsychotic medication in the previous 6 months. For the other 3 patients, their medication reviews did not consider whether to reduce the dose or stop antipsychotic medication.

1 patient had been transferred to primary care, with a clear transfer of prescribing responsibility and documented evidence that written guidance was provided to primary care which addressed all the necessary management details.

Although there was clear documentation of reasons for initiating antipsychotics, there appeared to be a lack of awareness of NICE guidelines for antipsychotic medication reviews, side effect and metabolic markers assessment, and their documentation. This is an area for potential change in practice to conform better to national guidelines and improve patient care.

To ascertain the compliance of the Mental Health Service of Older People (MHSOP) memory clinics in obtaining ECGs, based on the agreed criteria.

Cholinesterase inhibitors are a main pharmacological treatment for Alzheimer's dementia (AD). These drugs may worsen pre-existing cardiac conditions or cause significant cardiac side effects. A baseline ECG can be beneficial before starting patients on these medications. Previously in Leicestershire, all memory clinic patients were receiving routine ECGs. However, new standards were set based on the NICE guidelines and criteria outlined in other regions, to reduce the use of this time consuming and expensive investigation for patients who may not require it.

A total of 120 patients attending memory clinics in Leicestershire over a 6 month period (April to September 2019), were randomly selected and their electronic records retrospectively reviewed. The data collection tool was designed to encompass the key aspects of the criteria for obtaining an ECG for those attending the memory clinic. The information was analysed using Microsoft Excel.

Of the 120 patients, 23 (19.2%) were diagnosed with AD, 10 (8.33%) with mixed and 19 (15.8%) with vascular dementia. 68 (56.7%) had a diagnosis of “other” which included mild cognitive impairment or diagnosis still under investigation. 0 patients were diagnosed with Lewy Body Dementia or Parkinson's dementia. Of the total number of patients, only 10 had an ECG done, 2 with a diagnosis of AD, 1 with mixed dementia, 1 with vascular dementia and 6 “other”. The 10 ECGs done were all requested by nursing staff.

Although 27 (22.5%) patients were identified to have a diagnosis of AD or mixed dementia, plus at least one of the criteria for an ECG, only 6 (22.2%) were discussed with the Multi-Disciplinary Team (MDT) following which only 3 of the 27 patients (11.1%) had an ECG

Despite having clear criteria for requesting an ECG for those attending the memory clinic, compliance over the 6 month period was low. The following recommendations may be useful in improving compliance:

Displaying the ECG algorithm in the memory service clinic rooms.

Raise awareness amongst memory service clinicians of the criteria for requesting ECGs.

A&E departments are busy places; with quick triage decisions required to prioritise urgent care to those who need it. This requires the use of predictions based on past experiences and probabilities. However, this runs the risk of patients being categorised by the prejudices and stigmas associated with their conditions; particularly in the case of mental health patients and the assumption they are otherwise ‘medically fit’. This is especially of concern when considering that mental health often deteriorates during acute physical illness.

Following a number of dangerous ‘near misses’, this audit was conducted to review the practice of triage and physical assessment of patients presenting to A&E with mental health symptoms. The aim was to compare practice against the Royal College of Emergency Medicine (RCEM) guidelines, to identify repeated issues and systemic vulnerabilities which endangered patients through a lack of appropriate assessment.

Using the online Electronic Patient Record (EPR) system, the notes of 100 patients referred to the Bolton Mental Health Liaison Team (MHLT) from Bolton A&E were reviewed. They were assessed for whether or not the patients had been appropriately physically assessed, according to the RCEM guidelines, before being referred to the MHLT. These results were analysed anonymously.

The findings showed that less than half (44%) of all referred patients had physical observations taken at all, and even fewer (37%) received the full, physical assessment before referral. Out of the patients identified as having abnormal physical observations only 58% were acted on. Many patients had no history or triage assessment completed; with triage referrals consisting of only the words “mental health”. Most importantly, the audit identified this lack of adequate physical assessment resulted in a 2% ‘near miss’ rate, including a missed diabetic ketoacidosis and delayed treatment for a missed overdose.

Following this audit and the above result, it is clear that triage and physical assessment of mental health patients attending A&E is inadequate; with resulting risk of severe consequences to patients. It is therefore recommended to co-develop joint guidelines and teaching to guide A&E and MHLT practitioners on the process of completing the physical assessment prior to referral. It is also recommended to repeat this audit throughout other hospital trusts, in order to review the local referral pathways to ensure adequate physical assessment to avoid any ‘near misses’ or serious incidents.

Patients prescribed antipsychotics are at risk of ill effects to their physical health. Our aims were to assess whether inpatients within a forensic service, on antipsychotic medications, were receiving annual physical health monitoring in accordance with current NICE and SIGN Guidelines. Based on these Guidelines the following objectives were identified:

• 1: Physical examination, BMI and blood pressure recorded within the past year

• 2: FBC recorded within the past year

• 3: U&Es recorded within past year

• 4: LFTs recorded within the past year

• 5: HbA1C / random glucose / fasting glucose recorded within the past year

• 6: Random lipids / fasting lipids recorded within the past year

Inclusion Criteria: Patients admitted for longer than a year currently prescribed an antipsychotic.

Data were collected cross-sectionally on 24/7/20 for all inpatients meeting the inclusion criteria. Medical notes and the blood results system were reviewed for results of any annual physical examinations and blood monitoring over the past year.

Anonymized data were analysed using Excel.

13 out of 17 inpatients fulfilled the inclusion criteria. Of these 13 inpatients, 9 (69.2%) were prescribed clozapine, 1 (7.7%) zuclopenthixol, 1 (7.7%) paliperidone and 1 (7.7%) amisulpride.

All patients had BMI and blood pressures recorded within the preceding month. Only 1 patient (7.7%) had an annual physical health examination within the past year.

Findings for bloods taken within the past year were as follows:

12 patients (92.3%) had an FBC recorded

9 patients (69.2%) had U + Es recorded

9 patients (69.2%) had LFTs recorded

11 patients (84.6%) had HBA1c recorded

7 patients (53.8%) had lipids recorded

There is scope for improvement with both annual physical examinations and blood monitoring.

All patients had regular BMIs and blood pressure recorded which is largely attributable to nursing staff protocols. Low compliance with full annual physical examination could be explained by there being no local system in place for annual physical health checks and also frequent changes in junior doctor ward cover.

Blood monitoring showed variable compliance with established standards. FBC monitoring had the best compliance, likely because the vast majority of our patients are prescribed clozapine, which necessitates minimal monthly FBC monitoring.

This audit was presented to the Forensic Team and thereafter it was agreed for a local system to be put in place for annual physical health checks in the summer each year. This will improve oportunities to optimise our patients health. We plan to re-audit at this time.

To investigate whether racial groups are proportionally represented in referrals for trauma, hearing voices, emotional regulation and psychological therapy.

To understand the psychological needs across racial groups in HMP Wormwood Scrubs, the UK's 4th-most diverse prison.

To see if the long-established under-representation of Asian males and over-representation of Mixed males in psychological services in the community is also occuring in the prison system.

Psychological referrals were recieved via the medical notes system (SystmOne), whereby a prisoner's name, age, location, racial group and reason for referral are trasnferred into the psychology referrals database.

773 referrals were made between October 2018 and May 2020. As the prison's population throughout this time period was fluid, the month of December 2019 was used as a reference for the general prison poipulation.

Racial groups were specified using the Office of National Statistics' 5-category classification system (White, Black, Asian, Mixed and Other).

There is a consistent under-representation of Asian males in psychological referrals in relation to their general prison population. Whilst this group makes up 17% of the population of the prison, only 10% of prisoners referred to psychological services identified as Asian.

Those identifying as Mixed are over-represented in trauma referrals and psychological therapy referrals. The prison's mixed population is 7%, whereas 16% of those being referred for these two reasons were from the same racial category.

The proportion of patients who identified as Black, White or Other and were referred for psychology input were found to be representitive of the wider prison population, suggesting no clear over or under-representation.

Trends seen in the community in regards to Asian males being under-represented in psychological services are also evident in one of the UK's most diverse prison populations.

Public health campaigning to reduce stigma and promote help seeking in BAME communities is of vital importance to provide the needed support for those silently dealing with psychological problems.

The two largest racial groups in the prison, White and Black individuals, where found to be proportionally represented in their respective referrals to psychological services.

One key finding was in regards to Mixed race individuals, who comprise 7% of the total prison population but 16% of psychology referrals. As this racial group is one of the fastest-growing in addition to be over-represented in referrals, it is vital to understand how provisions can be put in place to appropriately address the needs of this group.

According to the Royal College of Psychiatry, GMC guidelines and NHS England, it is necessary to consider remote consultation to enable service delivery to those requiring shielding or facing additional health risk, and to avoid transition of infection.

To audit whether the standards of Mobile and Remote access work are met.

To audit whether the standards of Consent to Examination and Treatment are met.

To also evaluate whether the remote consultation due to the COVID-19 pandemic is being explicitly documented or not.

To suggest to the policy makers the need to establish some standards of practice concerning remote consultation and consent in the COVID-19 pandemic

Inclusion criteria – sample of service users who had remote consultation in April, May, and mid-June 2020 by doctors of MHSOP community mental health team at Bassetlaw Hospital.

Data collection: Retrospective.

Data source(s) used: Patient/Client medical/care records

Anticipated benefits of this audit: Due to the nature of current COVID-19 pandemic situation, it is essential to minimise contacts with vulnerable groups to prevent transmission of infection. It is anticipated that the number of remote consultations will grow in the forthcoming months.

This audit creates an opportunity to develop a new policy and improve the quality of remote consultations documentation.

Documentation for remote consultation was done in 81% of case notes whereas documentation of consent obtained was present in 57% of patients’ electronic notes.

90% of entries had documentation of ‘addressed concerns’. Around 50-70% of patients’ documents showed good record keeping on domains of ‘ability to maintain effective communication’, ‘mental state examination’, ‘risk assessment’ and ‘ability to understand medication plus side effects’.

About 40% of documentation met standards for good record keeping on ‘management plan’, ‘concerns raised’, ‘chance given to ask about management plan’.

Most of the standards of good consultations are being met despite the change in the type of Consultation due to COVID-19. However, there are identified areas for improvement which could be focused on. For example, documentation can be clearer when consent is gained for remote consultation. It should not be presumed that, as patients are booked in a certain type of clinic, they have been properly consented beforehand.

Key Success: Almost in all domains 40% have met the standards

Key Concerns: There are areas where a lot of evidence is partially documented.

The above results can be explained as a consequence of a sudden change in the normal working pattern in a community-based setting, having minimal protocols and procedures on standards of working in the situation of COVID19 remote consultation.

Following this audit, we aim to increase the amount of information recorded during remote consultation.

The plan is to develop a template that would cover the requirements for a remote consultation recommended by national guidelines

The proposal of a letter template following a remote consultation will be disseminated to the MHSOP CMHT teams for any suggestions/approval.

We aimed to determine whether vitamin D is being tested on admission for psychiatric inpatients at a local inpatient hospital, to identify the level of vitamin D for this group and to establish whether vitamin D treatment provided is according to NICE guidance.

Emerging evidence suggests that psychiatric patients are more vulnerable to vitamin D deficiency, due to reduced sun exposure, social isolation, long inpatient stays and poor diet. Low vitamin D levels may also increase susceptibility to SARS CoV-2 infection and COVID-19 severity.

Standards were determined by local policies, RCPsych recommendations and NICE guidance. Data were collected retrospectively from electronic patient records and entered manually to a spreadsheet for analysis.

67% of patients had vitamin D tested on admission to hospital. Of the patients that had their vitamin D level tested, 39% patients had their result recorded. 48% either had a low vitamin D level or required replacement. 6 of 12 patients with a documented low vitamin D level had the correct vitamin D treatment, according to NICE guidance.

Of 46 patient records, nearly half had a documented low vitamin D level or were on treatment. We would therefore suggest that vitamin D testing should form part of the routine admission bloods. It is an important opportunity to detect deficiency or insufficiency for a potentially vulnerable group of patients. Intervention is simple and effective.

Results demonstrated room for improvement for vitamin D testing on admission to hospital, thus improving potential treatment and benefits for individual patients. The importance of recording blood results on to the electronic patient record was also highlighted.

We raised awareness and provided further education to all junior doctors, with creative posters and informative communications. Following the implementation of these changes a re-audit of 40 patients showed 75% had vitamin D tested on admission or during and of these, 58% either had a low vitamin D level or required replacement. 7 of 9 patients with a documented low vitamin D level had the correct vitamin D treatment, according to NICE guidance. Within this closed loop audit, we have reported moderate improvement in the testing of vitamin D for patients on admission to hospital along with a significant improvement in the treatment of vitamin D deficiency, according to NICE guidance.

To evaluate the provision of recommended medical equipment on forensic psychiatric inpatient wards in Mersey Care's secure division, as outlined by the Care Quality Commission (CQC) in their 2019 guidance “Brief Guide: Physical Healthcare In Mental Health Settings”. It has been documented that people with severe and enduring mental illness are at risk of dying on average 15 to 20 years earlier than people without, two thirds of which are due to avoidable physical illnesses. It was our aim to use these data to improve the provision of physical healthcare equipment on the wards of Mersey Care's secure division, in turn allowing for the safe assessment of patients in the acute setting, and the monitoring their chronic health conditions.

We conducted a closed loop, two cycle audit of all forensic inpatient wards in Mersey Care's secure division measuring the provision of physical health equipment against the CQC's 2019 guidance. The intervention was to present our findings and implement physical health equipment boxes in the clinic rooms on the wards. Low, medium, high, and secure learning disability (LD) wards were audited, with a control sample of non-secure wards (addiction, old age, general adult, and LD non-secure) in the initial cycle for comparison.

On initial audit, the mean availability of equipment across the secure division was 66% (range 50.9%-88.9%), and 75% across our sample of wards in the non-secure divisions (range 61.1%-88.9%). Following the intervention in the secure units, the mean availability increased to 73.5% (range 72.2%-77.8%). The mean percentage increase in equipment availability following intervention was 12.5% (range -12.5% to 41.8%).

Following the intervention, the re-audit conducted found an overall improvement with 73.5% of recommended equipment available. Despite this improvement in equipment availability in the secure unit wards, the equipment is still less available than on the non-secure control wards. Due to this, further intervention and another re-audit have been planned. In the second cycle, significant items such as disposable gloves, pulse oximeters, sphygmomanometers, thermometers and stethoscopes were available across all wards. This was an improvement from the initial audit and allows for the safe assessment of patients in the acute setting.

COVID-19 has had a significant impact on healthcare provision, accessibility and psychiatric presentations. We aim to investigate the impact of the pandemic on psychiatric services and the severity of presentations in Edinburgh, with a particular focus on the North-West Edinburgh Community Mental Health Team (NW CMHT).

Measures of the impact of the pandemic on NW CMHT were identified as referral numbers from primary care and Did Not Attend (DNA) rates. Royal Edinburgh Hospital admissions, detentions under the Mental Health (Care and Treatment) (Scotland) Act 2003 (MHA) and Out of Hours (OOH) contacts were used as proxy measures to explore the severity and urgency of presentations.

Quantitative data focussing on these parameters for patients aged 18–65 years in NW CMHT in 2019 and 2020 were collected from NHS Lothian Analytical Services. OOH data were only available Edinburgh-wide. All data were anonymised in line with NHS Lothian Information Governance Policy.

In order to assess the impact on staff, a questionnaire was created and disseminated, with qualitative data returned anonymously.

Referrals to NW CMHT decreased by 9.3% in 2020 (n = 2164) compared to 2019 (n = 2366). Referrals in April (n = 81) and May (n = 102) 2020 were far below the monthly average across the two years (n = 188).

Appointment numbers were very similar in 2019 (n = 3542) and 2020 (n = 3514). Despite this, DNA and cancellation rates decreased by 3.94% in 2020. Questionnaire results illustrated some of the challenges for staff of working during a pandemic.

Admissions to hospital reduced by 6.8% in 2020 (n = 219 vs n = 235). While MHA detentions in NW Edinburgh increased by only 1.8% (n = 173 vs n = 170), new Compulsory Treatment Orders (CTO) increased by 60%. Furthermore, OOH contacts across Edinburgh increased by 45.2% when compared to 2019.

The COVID-19 pandemic altered the way patients accessed healthcare. Uncertainty of the public in accessing primary care services early in the pandemic may have contributed to reduced referral numbers.

The increase in CTOs is suggestive of severe relapses in previously stable patients or new episodes of illness. The pandemic may have contributed to a reduction in early recognition, and referral, of those with major mental disorders resulting in more protracted or severe illness episodes. The increase in OOH crisis contacts supports such a hypothesis.

Despite what would be expected, DNA and cancellation rates in NW CMHT reduced. The contribution of telemedicine to this warrants further exploration as a means of delivering healthcare in an efficient and accessible way.

To ensure admission clerking includes salient features needed for the management of both physical and mental health of the patient and also to aid in administrative purposes.

The audit included a team of doctors reviewing the admission clerking notes for 50 patients in the General Adult Psychiatric unit in-patient ward.

We created a standard questionnaire-based on Intended learning outcome of core training in psychiatry CT1-CT3 from Royal College of Psychiatry and standard textbooks.

Our aim is to achieve 100 % compliance in clerking

It was noted that only 30% wrote their GMC number, 4% added route of admission of the patient and a mere 8% filled the Consultants name. Though almost everyone had written the presenting complaints, the other aspects such as history of presenting illness, medical and family history, Allergy status and substance misuse history were missing in many clerking notes. None of them had filled in details of personal history and very few did a risk assessment.

Further lacuna was noted with Mental state examination. Physical examination was also noted to be incomplete. While more than 50% had completed the Blood investigations and ECG, half of them had not documented it and that meant searching in the entire file. A mere 20% filled the nursing observation level whilst none had completed the formulation in the notes.

Admission clerking is a vital source of information that would be needed for the formulation of patients diagnosis and future management.

Apart from this, it also is needed for further continuity of care.

Hence this vital source of information will need to be shared with the junior doctors who will be clerking the patient and seeing them in the first instance.

We, therefore, intend to create a complete clerking proforma along with physical health proforma to aid us in this respect.

We will audit initially in the first round and then plan to introduce a proforma for Clerking and physical examination based on the findings.

We will re-audit to see if the standards are achieved after using the proforma and will consider a Quality improvement project based on this topic

There had been ongoing concerns with regard to covering daytime duty bleeps across the three sites in the Mental health Department, BCUHB, North Wales.

Frequent empty on-call slots meant some doctors being asked to hold the bleep between 9-5 in-order to cover the vacancy.

Some felt this added to the existing workload and that it was unfair and unsafe.

This issue was raised during a supervision session with the Educational supervisor, North Wales and an initial data collection was suggested.

Data were collected over 2 week period to look at the Daytime bleep duties between 9 am to 5 pm

We hoped the data would demonstrate certain patterns of the task being asked to perform.

The total number of bleeps were noted to be 249

Discharge notification and prescription writing was noted to be the commonest reason for bleep in East and Central while Routine review and Discharge notification was the reason to be bleeped major number of times in the West

Nearly 70% and 90% of the bleeps were found to be appropriate by the East and West respectively, while only a mere 15% were reported so in Central.

While 30% of these bleeps in the West were considered to be deferred, 70% bleeps were deferrable in the East and almost 95% in Central.

The general trend in all 3 centres was as follows:

All three centres have high numbers of bleeps for discharge, prescribing tasks and routine patient reviews

Most think planned discharge paperwork could be done in advance and jobs can be deferred if there is a ward/team doctor available

A simple solution could be some jobs being planned ahead (e.g TTO/Discharge Summaries, Re-write charts) and done by the team/ward doctor. ECG could be arranged to be done by nurses/ECG technicians. Some nurses/HCAs are trained in phlebotomy, however, they have not been utilising the skills. That needed to be reinforced in safety huddles meeting.

Apart from these suggestions, we were also wondering about the impact of the service models and how the juniors placed in the community mental health unit could stay involved in their team inpatients

Psychotropic medication is commonly used in people with Intellectual disabilities (ID). This may be attributed in part to an increased prevalence of mental illness in this population and the presence of challenging behaviour which has been shown to increase rates of prescribing. Whilst there are a number of studies looking at regularly prescribed medication there are few studies on “as and when” required (PRN) medication.

Psychotropic medication continues to be used to manage behavioural disturbances in people with ID. Where there is no clear cut psychiatric illness, the role of psychotropic medication is an adjunct to a comprehensive multimodal treatment plan.

The aim is to find out if prn psychotropic medication for behavioural disturbance is being used appropriately and safely in these individuals.

Files and PRN protocols of individuals known to be using prn psychotropic medications for the management of acute episodes of agitation and behavioural problems and supported by professional staff teams was studied.

We collected the data by contacting the residential homes, carers, Collecting details from case notes, from the Staff nurse who made the protocol for their patients

A questionnaire based on the standards mentioned above was developed and files and prn protocols were marked against these standards.

The standards from the medical file were 100 % achieved. Thus indicating the importance of the psychotropic prn medication and documentation of the same.

However, the protocol that needs to be with the patient/carers had some lacuna/deficits. Overall only in 53% of the case, standards were achieved. This needs to be highlighted to the team.

The Audit gave an insight into what needs to be improved.

THE FOLLOWING AREAS NEEDED IMPROVEMENT

1. 1. There should be a prn protocol/ similar instruction to the staff about the use of prn medication(written by appropriately trained professional)

2. 2. Prn protocol should be accessible to direct care staff

3. 3. There should be a description of when to use the prn medication

4. 4. There should be a description of what non-pharmacological de-escalation methods ought to be tried before using prn/ is there a detailed behaviour support plan available

5. 5. Protocol should describe what the medication is expected to do

6. 6. Protocol should describe the minimum time between doses if the first dose has not worked

7. 7. Protocol should state the maximum dose in 24 hour period

8. 8. Use of prn should be recorded

I hope this audit will help in improving the patient care with the right psychotropic prn medication, with correct doses and further details as mentioned in the standards of the protocol.

We also hope to ensure that in our area, prn psychotropic medication used for agitation and behavioural disturbance is used safely, appropriately and consistently by staff teams. This would be in accordance with the guidelines.

Our aim was to carry out an audit of summaries sent from inpatient psychiatric units across North Wales (namely Heddfan in Wrexham, Ablett in Rhyl, and Hergest in Bangor), against recommendations from ‘Standards for Inpatient Mental Health Services’ (RCPsych 2014) and PRSB Mental Health Discharge guidelines (2018).

Ablett summaries are typed onto and electronically sent through the Welsh Clinical Portal (WCP) directly to the GP. Hergest and Heddfan both have their own templates which are then sent to the GP and filed in the case notes. Data were collected from both sources. The first audit cycle used 25 discharges selected at random from the male and female open wards in each site (n = 75 summaries). Data were collected over 3 months time using the audit proforma.

All mandatory headings are automatically inputted into the WCP summary used in Ablett therefore documentation was 100% for information such as patient name, DOB, and GP Details. Documentation of allergies was poor across 3 sites, particularly in Hergest, in which there was no mention of allergy status in 96% of summaries. Only 13% of Ablett summaries and 0% of Hergest summaries reach the GP on the day of discharge, however, 100% of summaries from Heddfan do, possibly due to their method of ‘discharge notification’. The date and location of discharge were documented in 84% of Heddfan summaries, 100% of Hergest summaries, and 100% of Ablett summaries. This implies that this heading is already incorporated into the templates for the 2 sites which scored 100%. In the Ablett, medication was documented in 88%, but we found that in 49% of discharge summaries, the medication was the only field filled in! In these cases, the GP may not even know why the patient had been admitted. This is clearly unacceptable. Risk history is poorly documented across the sites, with 0% in Hergest and Heddfan, and 12% in Ablett. 0% of summaries across the Health Board mentioned crisis contacts. 0% of summaries in Heddfan and Ablett contained details of the patient's care coordinator.

Our audit has identified a lack of psychiatry-relevant headings in the discharge summaries, particularly for those working in Ablett.

Our aim was to evaluate psychotropic prescribing practices in adults with intellectual disability (ID) and autism spectrum disorder (ASD) across the Richmond Neurodevelopmental Service (NDS).

Stopping over-medication of people with a learning disability, autism or both with psychotropics (STOMP) aims to reduce the potential harm of inappropriate use of psychotropic medications. We aimed to evaluate our prescribing practices in keeping with STOMP and the NICE guidelines.

We collected information from our clinical records on patients that met the inclusion criteria (≥18 years + diagnosis of ID and autism) from October-November 2019. We gathered the following: age, sex, severity of ID, psychiatric diagnoses, psychotropic medication, presence of challenging behaviours, involvement of positive behaviour support (PBS) and documentation of a PBS plan.

32 patients met our criteria (3:1 Male-Female ratio with an age range of 20-74 (Median 33 years old)). All 32 patients showed evidence of challenging behaviours. In the cohort, mild ID represented 18.8% (n = 6), moderate ID 40.6% (n = 13) and severe ID 40.6% (n = 13).

17 patients (53%) had a PBS plan in place. For those without a PBS plan (47%, n = 15), a referral to behavioural analysis had been considered/requested in 67% (n = 10).

31 patients were on psychotropic medication and 84% (n = 26) had an indication documented in the notes although every patient had had a medication review in the last 6 months. 67.7% (n = 21) of the prescriptions were for challenging behaviours.

The average number of medications prescribed was 2 (median 2, mean 2.41) but this was reduced to 1 (median 1, mean 1.76) when additional psychiatric diagnoses and epilepsy were excluded.

Prescriptions are regularly reviewed in keeping with STOMP guidance but there is more scope for utilising behaviour analysis input as well as the need to improve documentation of the rationale for psychotropic medications.

The purpose of this audit was to identify all women being prescribed Sodium Valproate under the Bassetlaw Local Mental Health Team (LMHT) caseload to see how well latest prescribing guidelines are being met, and help set up a system allowing efficient monitoring of Sodium Valproate prescribing in the future.

Despite early concerns regarding potential teratogenicity, Sodium Valproate became a widely used anticonvulsant and mood stabiliser and is licensed for use in Epilepsy, Migraine prophylaxis and Bipolar affective disorder. Research evidence now shows its use in pregnancy increases risk of neurodevelopmental disorders to 40%, and serious birth defects to 10%. Despite research finding these risks prescribing practice did not significantly change. To better reflect these findings in clinical practice in 2018 the Pharmacovigilance Risk Assessment Committee recommended Sodium Valproate should not be used in pregnancy unless they have a form of epilepsy unresponsive to other anti-epileptic drugs, and all with childbearing potential should be enrolled in a pregnancy prevention programme (PPP). This was endorsed by UK Medicines and Healthcare Devices Regulatory Agency in April 2018 with launch of the PPP.

Standards:

Must be offered counselling about risks of valproate to unborn child and importance of effective contraception.

Annual specialist Review by a specialist now mandatory

Risk acknowledgement form must be updated at least annually.

The electronic RiO records for all female patients on the Bassetlaw LMHT caseload in the year 2019 were checked to identify those prescribed Valproate. For those prescribed Valproate, evidence of annual risk acknowledgement form, date of last appointment, underlying diagnosis and contraceptive method was checked. This data was stored together on an excel file and used to create a patient list to help allow future monitoring.

From 594 female patients identified, 27 (4.5%) were prescribed Sodium Valproate. Of these, 14 (52%) had PPP documentation uploaded, 24 (89%) had been reviewed within the last 12 months, and 13 (48%) had no documentation of contraceptive method.

This audit helped highlight there is likely a large population of patients not yet on the Pregnancy Prevention Programme. Creating a monitoring system in excel for female patients being prescribed Valproate can help improve adherence to latest guidelines, with a colour coding system to highlight those needing risk acknowledgement forms/appointments within the next three or six months. Educating patients and other healthcare professionals about risks will also help improve prescribing practice and avoid use in pregnancy.

The aim of the project was to assess completion rates for the VTE prophylaxis assessment for patients admitted to Dova Unit, Dane Garth. Another aim of the project was to identify areas for improvement and changes which could increase compliance rates.

In the first cycle of the audit 20 randomly selected patients admitted to Dova Unit, Dane Garth between June and December 2020 were identified and included in the project. Data were then collected from the online patient record system Rio and analysed using an excel spreadsheet.

In the second cycle of the audit 10 randomly selected patients admitted to Dova Unit, Dane Garth between January and February 2021 were identified and included in the project. Data were then collected from the online patient record system Rio, analysed using an excel spreadsheet and compared with the results obtained in the first cycle of the project.

In the first cycle of the audit the overall compliance was found to be 35%. VTE Risk assessment was completed for 50% of patients included in the study. ‘Active VTE on admission’ section of the VTE prophylaxis admission assessment was completed for 30% of patients included in the study. ‘Active VTE at 72 hours’ section was completed for 20% of the patients in the study and the ‘risk assessment for VTE' form was completed for 40% of patients included in the study.

In the second cycle of the audit the overall compliance was found to be 50%. VTE Risk assessment was completed for 60% of patients included in the study. ‘Active VTE on admission’ section of the VTE prophylaxis admission assessment was completed for 40% of patients included in the study. ‘Active VTE at 72 hours’ was completed for 40% of the patients included in the study and ‘risk assessment for VTE' form was completed for 60% of patients included in the study.

There was an overall improvement in the completion rates for the VTE prophylaxis admission assessment as a result of conducting the project. Working with the junior doctors and other healthcare professionals responsible for completing the VTE prophylaxis admission assessment, we aim to improve our completion rates of vital information even further.

The objectives/aims of the Audit include:

1. 1. To standardize and implement ICP for service users attending DNCC CAMHS team in accordance with the established policy.

2. 2. To achieve greater involvement of service users/parents in ICP.

3. 3. To standardize and improve treatment of care involving all members of one team.

Every patient should have a care plan. Each care plan has a set of needs and goals. These are agreed between the service user and key worker and are assessed and measured frequently. Consultation with each service user/parents, as far as practicable is important. Specification of treatment and care required in accordance with best practice should be recorded. Identification of the necessary resources should be recorded and discussed with service user and key worker. Records kept in one composite set of documentation, and a signed copy should be made available to the service user/parents.

First Cycle commenced 15th October 2019. 166 files were selected from CAMHS team. Data were collected from clinical records from time of admission into CAMHS service to the time of audit. The audit report was prepared on the 6th December 2019, and intervention discussed at the multidisciplinary team meeting and wider DNCC CAMHS academic meeting. Second Cycle 23rd March 2020. 30 files randomly selected and audited. Data were collected by Dr Uchechukwu Egbuta, Mr Cillian Howley, Dr Anitha Selvarajoo, under supervision of Dr Muhammad Iqbal and Dr Diana Meskauskaite.

Method of data input/analysis is IBM SPSS.

For each ICP, the following were looked at: Files with ICP, Identifiable key worker, Formulation, Goals, Action plan, Copy of ICP to young person/parents, Next Review Date, Projected discharge date.

Overall compliance shows 62% in first cycle, and 68% in second cycle after intervention.

There was a 6% quality improvement of ICPs in terms of overall compliance in applying the various components of ICP.

Each service user should have an individual care plan. Each individual care plan should be measured regularly. To develop a therapeutic individual care plan, a formulation of the case from history taking is essential looking at the bio-psychosocial model and should be service user focused. Care plans are part of clinical governance, therefore continuous re-audit every three months was recommended. The follow-up audit will be carried out by the multidisciplinary team members.

The DVLA has strict guidelines regarding how long a driver should stay off driving when they have certain mental health illnesses or severity of symptoms. It is difficult to give such advice if we are unaware of the patients’ that drive; especially when they do not volunteer this information for various reasons.

This audit was aimed at identifying people who have been admitted to the Ward 3 at the Mount Hospital and if they were asked about driving. The audit also looked at whether there were discussions around the driving requirements and DVLA guidelines in terms of their mental health diagnosis. The expected outcome of this project was to improve information gathering when clerking in a new patient and to ensure that elderly patients’ who drive are made aware of the DVLA guidelines.

This audit retrospectively examined the care of 50 patients on Ward 3 at the Mount Hospital, a mixed acute psychiatric ward for older people, between 1st April 2020 and 11th November 2020. All patients’ aged 65 years and over who were on admission within that period were audited. Data collection took place between 17th November and 17th December 2020; this involved reviewing patient records throughout their inpatient stay including paper notes and electronic records (on Care Director). Results were compiled using a pre-determined data collection tool and analysed using Microsoft Excel. The audit used the standards within the DVLA Guidance- Psychiatric Disorders: Assessing fitness to drive.

Only 1 (2%) patient had sufficiently documented evidence around driving and the impact of psychotropic medication on driving. DVLA information was given verbally in 3 (9%) patients and only 2 patients had this information passed on to their General Practitioner (GP). Only 3 (6%) patients were made aware of the DVLA guidelines and 2 (4%) patients made aware of their obligation to inform the DVLA

Generally, the compliance of psychiatrists in identifying all patients’ who drive is poor and seems even worse with elderly patients’. There was little documented evidence that patients were asked about their driving status on or during their admission, were given verbal or written information, had discussions around the impact of medication on driving or informed about their obligation to notify the DVLA. This study provides opportunity to improve practice by educating the medical workforce and raising awareness within the wider team. There also needs to be greater involvement and communication with GPs when completing discharge summaries.