To assess implementation of Trust Policy (Smoke Free Policy) on the acute adult mental health unit To evaluate barriers to implementation of local standards and NICE guidelines To evaluate if Q-Risk score is being calculated and noted.

There are about 34,000 people residents in mental health facilities in England and Wales on any one day (Commission for Healthcare Audit and Inspection 2005) and many of them smoke.

Smoke free policy implemented in the GMMH since 1st of July 2018.

Smoking is single largest preventable cause of ill health & premature mortality in England.

Smoking prevalence is significantly higher among people admitted to hospital due to the mental illness i.e. 70%

According to WHO SHS (second hand smoking), is a human carcinogen to which there is no safe level.

An audit tool questionnaire was used to collect the data on the Acute Mixed mental health ward setting i.e. Bronte Ward, Laureate House, Wythenshawe Hospital

Identified method: interview with each patient, PARIS documentation review and Patient's Kardex review.

Sample size: 23 and on re-audit 12.

Method of data input: Microsoft Excel

Data were analyzed by calculating percentage

The majority of the patients that took part in the Audit were smokers (91%), a high percentage overall. This indicate how important it is for a plan to be in place regarding smoking on the ward since there is a smoke free policy now in the GMMH. Our results showed that not everyone was asked regarding their smoking status (87%).

An important figure that came out from the results was that only 50% of the patients asked about their smoking status were told that there is a smoke free policy.

For a smoke free policy ward only 33% of the smokers that took part in the audit were provided with brief advice regarding smoking cessation which shows that there might be a need of a more precise implementation regarding support to receive brief intervention for smoking cessation, NRT and specialist advice.

The results also showed that the QRisk is not calculated, a useful marker of cardiovascular risk.

Give leaflets regarding smoking cessation on admission, offer support and advice to all the patients being on the ward. And re-audit in due course to see the effect of this intervention.

Constipation in patients on Clozapine is the biggest cause of mortality. We have no set protocol in LPT for how to manage and monitor Constipation in Clozapine initiation in the inpatient setting. Internationally protocols, (such as the Porirua protocol) exist but have not been widely used locally.

We wanted to assess local compliance with monitoring constipation in patients admitted to hospital and started on Clozapine. We also wanted to assess whether patients are prescribed PRN or regular laxatives, before considering implementing a local protocol.

In LPT we use the ZTAS system for prescribing Clozapine. They provided us with a list of patient IDs who had recently started on Clozapine.

We captured data on patients started on Clozapine.

1. 1. What date was this started?

2. 2. What date was either PRN or regular laxatives started?

3. 3. Was a bowel chart recorded?

4. 4. Any evidence of constipation or significant bowel issues relating to Clozapine?

We initially analysed 30 patients, (20 of whom were initiated on Clozapine as inpatients, and 10 as outpatients). A bowel chart was started in only 1 inpatient. Laxatives were started in 50% (15, only 3 of whom were outpatients). 14 were regular and 1 was a PRN prescription. 12 inpatients had constipation, and 1 outpatient suffered with constipation. 2 patients suffered with diarrhoea but there were no other significant issues with bowel problems.

From our initial data we can see that there are many inconsistencies in practice.

Existing patients on Clozapine attend a local clinic, (Clozapine clinic) where ongoing monitoring of constipation, (and other parameters, e.g. ECGs etc are completed).

We have written a new protocol which we will share, that the trust has implemented, that identifies when PRN and regular laxatives should be prescribed. We have also expanded the protocol to agree for initiation of Olanzapine bowel charts and PRN laxatives should be used.

GMC defines clinical supervisor as a trainer who is responsible for overseeing a specified trainee's clinical work throughout a placement in a clinical or medical environment and is appropriately trained to do so¹.

This AUDIT aimed to review the frequency, content and quality of clinical supervision for psychiatric trainees within Somerset NHS Foundation Trust. Both Severn deanery and Somerset NHS Foundation Trust both recommend psychiatry trainees have one hour of supervision per week, involving exploration of trainee clinical and educational needs.

All trainees working in Somerset NHS Foundation Trust psychiatry from February 2020 were invited to participate. A survey was designed to quantify the frequency of supervision amongst this cohort. Survey online software, SurveyMonkey, was chosen for the accessibility and user friendly modality and disseminated via email to all junior doctors (n = 27). Survey responses were collected in the last month of the placement (July–August 2020).

Questions on accomplishing workplace based assessments (WPBA), managing e-portfolio requirements were asked, with Likert scale responses available. Quality of supervision was explored via white space answers.

Surveys were reviewed by the AUDIT authors and descriptive data collected.

63% trainees responded (17 out of 27). Educational objectives were discussed at the beginning of the placement. Over half the respondents stated that time was not set aside to look at e-portfolio.

Workplace based assessments (WBPAs), and Case based discussions (CBDs) were more frequently achieved than observed assessments of clinical encounters (ACEs/Mini-ACEs) (assessment of clinical encounter).

30% core psychiatry trainees respondents (4 out of 7) discussed their audits/QI projects with their supervisors most/always. 42% (3 out of 7) had a discussion sometimes.

2 GP and foundation trainees stated they were unable to obtain community mental health experience. The response rate to this question was disappointing and we think it may be secondary to the pressures of the pandemic.

100% respondents described educational supervisors as supportive and approachable.

Whilst all respondents found their supervisors approachable and supportive, completion of formal WPBAs and portfolio reviews was suboptimal.

Following regional presentation of results, the pertinence of these findings for all trainees was highlighted. A supervision template has been created and extension of this initial audit to a regional quality improvement project is underway.

Specific recommendations included brief and regular supervisor check-ins with trainees regarding projects and psychotherapy competencies and a mid-placement review of portfolio.

Patients admitted to Roker ward (male organic psychiatric ward) should have a decreased anticholinergic burden of medication on discharge compared to admission. This will be demonstrated by a reduced score on the Anticholinergic Cognitive Burden (ACB) scale on discharge compared to admission. Target: 80%.

Where new medicines with anticholinergic burden are prescribed during admission, there should be evidence that the anticholinergic properties of these medications have been considered prior to prescribing (via documentation in care co-ordination reviews or progress notes). Target: 100%

Electronic records were searched for all discharges from Roker ward between 1/1/2019 – 31/12/2019. For each record the follwing information was recorded: demographics; primary diagnosis; total ACB score on admission; and total ACB score on discharge. For all new medications started with an ACB score of over zero, records were searched to establish whether there was evidence that the anticholinergic properties of these medications had been considered.

47 patients were identified who were discharged over the time period in question. 30 patients had no difference in ACB score between admission and discharge; 10 patients had a reduction in ACB score and 5 patients had an increase. A total of 9 new medications with ACB scores over zero had been started during all admissions; there were no occasions where there was documented evidence to show that the anticholinergic burden of these medications had been considered.

27% of patients had a reduction in their total ACB score during admission; the target was 80%.

The reasons for starting medications with an ACB score of greater than 1 were documented in 0% of cases; the target was 100%.

As both targets were missed by a significant margin, it was recognised that there were significant areas for improvement. The following plan was therefore implemented:

1. 1. Following discussion with the ward consultant and ward pharmacist, regular prescriber meetings have been set up which involve senior nursing staff, medical staff and pharmacy – anticholinergic burden is calculated for each patient as part of these meetings

2. 2. A re-audit is recommended after 6 months.

An audit was conducted to assess if thorough risk assessments had been documented in electronic clinical record notes (ECR) clerking for new patients in two acute mental health wards. Risk assessment is a vital part of admission clerking and when done well it can prevent early incidents and aid the ward nursing team greatly. During induction, junior doctors are advised to document assessed risks when clerking a new patient. A screening of the risks on admission could help determine the levels of observations required to minimise the identified risks whilst the patient awaits their first ward review.

The NHS numbers for the 30 current inpatients across male and female acute psychiatric wards were gathered at the time of the audit (February – March 2020). Admission clerking was analysed for a clear statement of patient risk to self, others or property. Within these categories quantitative results were obtained on how often the risk of self-harm, self-neglect, absconding, vulnerability or aggression was documented. The term ‘risk’ was used for each patient on their ECR notes to search for risk assessments in all entries other than admission clerking.

12 out of the 30 patients had a junior doctor risk assessment documented in their clerking (40%). 14 patients had no mention of risk assessment on admission (47%) and their first formal risk assessment was documented only in their senior ward review. Of the 12 assessments completed in clerking; all assessed self harm/suicide risk and violent risk to others, 1 mentioned risk of absconding, 8 mentioned risk of illicit substance use and 8 mentioned vulnerability. It was unclear if the risks documented were based on current or historic presentation. Junior doctors were anonymously surveyed following this audit and reported they did not feel confident in how to document a risk assessment or whether to document negative findings.

Clear documentation of risk assessment being performed was lacking in over half of junior doctor admission clerkings. When risks were assessed it was mainly violence/self harm risk documented not vulnerability and physical health risks. Based on these findings we have designed more comprehensive teaching on risk assessments and a template for how to complete a risk assessment. We feel the use of a template will ensure all elements of risk are clearly considered even if they are not present currently. This is being reaudited to assess if the changes have impacted the quality of risk assessment conducted.

An audit to assess the impact of an Integrated Psychological Medicine Service (IPMS) on healthcare utilization pre & post intervention. We hypothesized that an IPMS approach would reduce healthcare utilization.

The IPMS focusses on integrating biopsychosocial assessments into physical healthcare pathways. It has developed in stages as opportunities presented in different specialities leading to a heterogeneous non-standardised service. The key aim is involvement of mental health practitioners, psychologists & psychiatrists in complex patients with comorbidity or functional presentations in combination with the specialty MDT. This audit is the first attempt to gather data across all involved specialities and complete a randomised deep dive into cases.

Referrals into IMPS from July 2019 to June 2020 pulled 129 referrals, of which a 10% randomised sample of 13 patients was selected to analyse. 5 patients had one year of data either side of the duration of the IPMS intervention (excluding 8 patients with incomplete data sets).

We analysed; the duration & nature of the IPMS intervention, the number, duration & speciality of inpatient admissions & short stays, outpatient attendances, non-attendances & patient cancellations. Psychosocial information was also gathered. One non-randomised patient was analysed as a comparative case illustration.

Randomised patients; patient 78's utilisation remained static, patient 71 post-referral engaged with health psychology & reduced healthcare utilisation. Patient 7 increased healthcare utilisation post-referral secondary to health complications. Patient 54 did not attend & increased healthcare utilisation post-referral. Patient 106 had increased healthcare utilisation post-referral from a new health condition. The randomised sample identified limitations of using healthcare utilisation as an outcome measure when contrasted to the non-randomised case (which significantly reduced healthcare utilisation post-referral).

Correlation only can be inferred from the data due to sample size, limitations & confounding factors e.g. psycho-social life events, acquired illness. Alternative outcome measurements documented (e.g PHQ9/GAD7) were not reliably recorded across pathways.

The results evidenced that single cases can demonstrate highly desirable effects of a biopsychosocial approach but they can also skew data sets if results are pooled due to the small sample size & heterogeneous interventions. With some patients an increase in healthcare utilisation was appropriate for an improved clinical outcome. This audit identified that utilising healthcare utilisation as an outcome measure is a crude tool with significant limitations & the need to agree tailored outcome measures based on the type of intervention to assess the impact of IPMS.

To embed the use of reasonable adjustments for adults with autism within in mental health services.

The objectives of the project are as follows:

• To identify how many service users with a diagnosis of autism are under care of local mental health services

• Is there evidence that reasonable adjustments were considered for these service users

• If identified as needing reasonable adjusments is there evidence of such adjustments being made

We looked at service users with an established diagnosis of autism under care of Leeds and York NHS foundation trust to ascertain if reasonable adjustments have been considered. The audit is based on guidelines provided by Think Autism-department of health statutory guidance 2014. This is based on autism act 2009.

Data were collected for 30 cases in mainstream mental health services undr care of various teams including inpatient and community.

It was identified that in only 2/30 cases reasonable adjustments were considered and agreed upon. Only 1/30 service users had a disability status updated on electronic patient records. None of the service users had a hospital passport or reasonable adjustment care plan completed.None of the records had “good evidence” of reasonable adjustments.

These findings point to a wider issue for the trust as well as natioanlly as it indicates that autism is not being adequately taken into account for patients accessing our services. Due to the lack of reasonable adjustments adults with autism are potentially at increased risk to disengage leading to deterioration in their mental state and increase in risks.

These findings point to a wider issue for the trust as it indicates that autism is not being adequately taken into account for patients accessing our services. Due to the lack of reasonable adjustments adults with autism are potentially at increased risk to disengage leading to deterioration in their mental state and increase in risks.

We recommend training in autism for all healthcare professionals in the trust to improve their understanding of autism, including making reasonable adjustments.

We also recommend review trust procedure about recording diagnoses and disability status on electronic patient records. We recommend that the reasonable adjustments section on care director is more prominent and easily accessible.

We recommend that an ‘autism flag’ is prominent on patient records to alert staff to the presence of autism

This audit aimed to assess to what extent patients being referred for assessment of memory problems were receiving appropriate screening for reversible causes. We considered the blood tests recommended by the National Institute for Clinical Excellence (NICE).

Research into ‘reversible dementias’ identified numerous common underlying causes. As a result of this NICE complied comprehensive guidance on investigations which should be performed in the initial stages of assessing patients with memory problems, ideally at a primary care level. These investigations are also crucial at the point of secondary care assessment in order to make a confident diagnosis.

Details of patients referred by their GP to the Older Adult CMHT with memory problems over a one month period were collected. We then used the local laboratory database to note whether each of the eight recommended blood tests had been performed in the preceding 6 months. We measured this against an agreed standard of 95%.

After the first cycle of data collection we prepared business-card sized ‘aide memoirs’ for GPs that could serve as a quick reminder. These were sent out to all GPs in the area along with a letter outlining the audit findings.

Overall 31 patients were included in the first cycle. 15 patients had all 8 dementia blood screens (48%), 13 (42%) had some of the recommended tests and 3 patients had no screening tests at all (10%). On average patients had 76.6% of the recommended bloods completed. The most commonly completed tests were Full Blood Count (FBC) and Urea & Electrolytes (U&Es), with blood Glucose being the most frequently omitted.

In cycle 2, 20 patients were included. Of these patients, 10 had the full complement of screening bloods (50%); 8 had some tests completed (40%) and 2 patients had no screening tests complete (10%). On average 76% of tests were completed. There was an improvement in the rate of completion of both Glucose and Liver Function Tests from cycle1.

This audit demonstrated that current practice does not meet the national standard in general. Our intervention produced a modest improvement in the proportion of patients who received a full complement of dementia screening tests, as well as increasing the rate of patients receiving a blood glucose as part of their screening. It would likely be beneficial to consider further intervention and a 3rd audit cycle in due course.

To audit the completion of Adults with Incapacity (AWI) documents (Assessment of Capacity, Section 47 Certificate of Incapacity and Treatment Plan) to ensure they met the legal standards required. We hypothesised that the forms were not all completed comprehensively, particularly with regards to the Treatment Plans.

In addition to being legal documents, AWI documents provide an important framework to guide clinicians when giving treatment and balancing patient safety with patient autonomy. Correctly completed documents help provide vulnerable patients with ethical and lawful treatment that allows them to be treated with respect and dignity.

An audit was conducted across two Old Age Psychiatry wards at Ayrshire Central Hospital during October 2020. We assessed all AWI documents available on the wards (n = 20) using criteria based on the standards set by the Mental Welfare Commission for Scotland to ensure legal competence.

95% of the forms were signed and dated, and the nature of the incapacity was given in 100% of the documents. On the other hand, 35% of the forms gave no indication of the presence or absence of a guardian. Only one of those identified as having a guardian was consulted with regards to the treatment plan. Another member of staff was consulted on the Treatment Plan in 45% of cases. 30% of the Treatment Plans were not precisely worded enough to be considered justifiable for treatment. In the Certificate of Incapacity, two out-of-date certificates were found, and staff were notified immediately. 45% of certificates were considered over-generalised with regards to the description under medical treatment.

Overall, the forms were mostly signed and dated, with the nature of incapacity given. The two areas that appeared to be the most problematic were the issue of identifying and discussing plans with a guardian, and the specification of treatment covered by both the Certificate of Incapacity and the Treatment Plan.

Discussion with members of the healthcare team found some confusion over how to complete the forms and many cited a lack of formal training as the main reason for their uncertainty. In addition, accessing clear information online or on the wards on how to complete the forms was challenging. We intend to improve the completion of these documents by implementing teaching and a guidance poster, based on the areas that we identified as being problematic, and completing the audit cycle.

To identify whether patients admitted to the general adult inpatient wards at Clock View Hospital, an inpatient unit in Mersey Care NHS Foundation Trust, have an ECG performed following admission and whether, if this done, the ECG report is properly documented in the patient's electronic record, and whether those patients with an abnormal ECG have any further investigations requested.

An important risk factor for development of cardiac disease is use of psychotropic medications. Antipsychotics can increase the QTc interval.

NICE guidelines recommend that, before starting antipsychotic medication, an ECG should be offered if physical examination identifies cardiovascular risk factors, there is personal history of cardiac disease or if the individual is being admitted to hospital. The Royal College of Physicians states all patients should be assessed for cardiovascular disease, including having a routine ECG. Mersey Care's physical health policy recommends all new admissions to inpatient wards have an ECG performed within 24 hours of admission as part of their admission physical examination and investigation.

A sample of 60 patients discharged from the general adult wards at Clock View Hospital between 16th of July 2019 and 30th of September 2019 was obtained. An audit tool was designed and each patient's electronic record scrutinised to determine whether an ECG was performed within 24 hours of admission; in those patients who didn't, whether the reason why was recorded; and whether those patients who had an abnormal ECG were referred for further investigation. The quality of documentation of ECG reports was also analysed.

Age range of patients was 19–66 years. Only 31 patients had an ECG performed within 24 hours of admission. Of the remaining 29, there was documentation of why an ECG was not performed in only 16 cases. Thirteen patients had an abnormal ECG, but only three were referred for further investigation. Of the ECG reports that were analysed, only a minority met the required standard for “good”, with there being no documentation of the ECG report in one third of cases.

There is significant room for improvement in performance of ECG monitoring and documentation of the ECG report. The importance of the ECG as part of the admission process needs to be highlighted in the induction of junior doctors. Training nursing staff on the wards to perform ECGs would reduce the likelihood of unnecessary delay to a patient having an ECG done following admission.

To review the number of prescriptions of regular high-dose antipsychotics and combination antipsychotic therapy across the eight general adult inpatient wards in Mersey Care NHS Foundation Trust and examine whether these prescriptions followed Trust recommendations for high-dose antipsychotic therapy (HDAT).

The two main rationales behind prescribing HDAT are pharmacokinetics differ in individuals and so insufficient amounts of antipsychotic may reach the effect site at maximum dose in some patients and variations in the effect site between patients may mean higher doses are required to achieve therapeutic effect.

The electronic prescription records for all patients on the eight general adult inpatient wards were scrutinised. 121 patients were prescribed antipsychotic medication. Any patients on a combination of regular antipsychotic medication or on HDAT were identified. Any patient on combination therapy or HDAT was studied to determine if Clozapine had been considered. The electronic notes of HDAT patients were analysed to ascertain whether tests recommended by Trust guidelines – BMI, blood pressure (B.P), pulse rate, ECG, FBC, U and Es, LFTs, serum prolactin, serum cholesterol and HbA1c level had been performed prior to initiation and following any dose increase.

21 of 121 patients prescribed antipsychotic medication were on combination therapy. 11 were subject to HDAT. 8 of the 11 HDAT patients were on combination therapy. Clozapine was considered before initiating HDAT in 9 of the HDAT patients. Clozapine was considered in 13 of the 21 patients on combination antipsychotic therapy, but only two were initiated on Clozapine (combined with Olanzapine or Risperidone).

100% of HDAT patients had an ECG prior to initiation of HDAT; only 36% had one after dose increases above BNF maximum. 100% of HDAT patients had their BMI measured before initiation. 91% had baseline B.P and heart rate checked. Of the recommended blood tests, 100% of HDAT patients had baseline FBC, U and Es, LFTs and serum cholesterol. Fewer patients had a baseline HbA1c level (91%) or serum prolactin (46%) measured.

Prevalence of HDAT across the general adult inpatient wards in the Trust was 9%, much lower than the 28% reported in the HDAT audit completed by the Prescribing Observatory for Mental Health in 2012. Patients within Mersey Care are more likely to be prescribed combination therapy than HDAT. Not every HDAT patient has been considered for Clozapine. There is a need to ensure Trust monitoring guidelines for HDAT patients are being strictly adhered to.

This audit aims to establish whether patients have their BMI measured and recorded following admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust and whether, in those with a BMI >30 kg/m2, or >28 kg/m2 in those with weight-related comorbidities, they are referred to the dietetics service for input.

Obesity has an increased prevalence in those with mental disorder. There are many factors that influence this, e.g. sedentary lifestyle and poor dietary intake. Medication prescribed to treat mental disorders may increase risk of weight gain. Patients with severe mental illness are at increased likelihood of developing weight-related comorbidities, particularly type II diabetes mellitus.

Many patients with severe and enduring mental illness do not regularly access primary care services. Admission to the psychiatric ward therefore provides an opportunity to address, not only the patient's mental health issues, but also any physical health issues.

A list of all inpatients on the eight general adult wards was obtained on 3rd of December 2020. Inpatients on the Psychiatric Intensive Care Unit were also incorporated, providing a final sample of 148 inpatients.

An audit tool was designed, to collect demographic data for each inpatient – gender, age, ethnicity, psychiatric diagnosis, as well as BMI on admission and, if applicable, whether a referral to the dietetics service was made.

Of the 148 inpatients, 91 were male, 57 female. Patient age ranged from 19 to 71 years. The majority were of “white British” ethnicity. The most common mental disorder diagnosis was schizophrenia (35 patients). For 14 of the 148 inpatients, no BMI was measured on admission. In the 134 inpatients that had BMI measured, 74 were in one of the “overweight”, “obese”, “very obese” and “morbidly obese” categories. Thirty-four patients met the criteria for requiring referral to the dietetics service. Of these, four were not referred, five were offered referral but declined, 17 referrals were made for other reasons, e.g. BMI <18 kg/m2, and one patient was referred despite no BMI being recorded.

Current practice across the general adult inpatient wards in the trust indicates a proportion of patients do not have BMI recorded following admission. This may result in a valuable opportunity to address obesity being lost. There is a need to emphasise to ward staff the importance of recording BMI as part of the admission physical health screen and of the criteria for referring an inpatient to the dietetics service.

This audit aims to evaluate the prevalence of any weight-related comorbidities in patients following their admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust.

Obesity has an increased prevalence in those with mental disorder. There are many factors that influence this, e.g. sedentary lifestyle and poor dietary intake. Medication prescribed to treat mental disorders may increase risk of weight gain, particularly most of the second generation antipsychotics. Patients with severe mental illness are at increased likelihood of developing weight-related comorbidities - essential hypertension, ischaemic heart disease, hyperlipidaemia and type II diabetes mellitus.

Many patients with severe and enduring mental illness do not readily or regularly access primary care services. Admission to the psychiatric ward therefore provides an ideal opportunity to address, not only the patient's mental health issues, but also any physical health issues.

A list of all inpatients on the eight general adult wards was obtained on 3rd of December 2020. Inpatients on the Psychiatric Intensive Care Unit were also incorporated, providing a final sample of 148 inpatients.

An audit tool was designed, to collect demographic data for each inpatient – gender, age, ethnicity, psychiatric diagnosis, as well as the presence of any cardiovascular comorbidities and, if so, what were they and how many were present.

Of the 148 inpatients, 91 were male, 57 female. Patient age ranged from 19 to 71 years. The majority were of “white British” ethnicity. The most common mental disorder diagnosis was schizophrenia (35 inpatients), followed by schizoaffective disorder (22 inpatients). Twenty-one of the 148 patients had at least one weight-related comorbidity recorded. Only 2 of the 21 inpatients with a diagnosis of one or more weight-related comorbidity had a recorded BMI in the “healthy” range. The gender split for the presence of weight-related comorbidities was almost equal. The most common comorbidity recorded was type II diabetes mellitus. Most patients with a weight-related comorbidity had only one recorded, but three patients had two comorbidities recorded, and one patient had three recorded.

A significant proportion of patients admitted to the general adult inpatient wards in the trust have a weight-related comorbidity. Admission to hospital provides an ideal opportunity to review the management of any such comorbidity and optimise this as required. There is a need to ensure there is a strong focus on, not only the patient's mental health issues, but also his / her physical health status.

This audit aimed to establish whether patients undergo physical health monitoring within 24 hours of admission to one of the general adult inpatient wards in Mersey Care NHS Foundation Trust, as per Trust policy.

Mean life expectancy in individuals with severe and enduring mental illness (SMI) is 15-20 years shorter than that of the general population. A significant proportion of excess mortality in patients with SMI is due to natural causes, e.g. cardiovascular disease and type II diabetes mellitus. Although SMI patients are at greater risk of developing chronic physical health problems, they often receive worse health care than the general population. Shared care of SMI patients between primary and secondary healthcare professionals causes uncertainty over who is responsible for monitoring the physical health of these patients.

A list of all inpatients on the eight general adult wards in the Trust was obtained in September 2020, producing a sample of 135 inpatients.

An audit tool was designed, capturing demographic data – gender, age, ethnicity. The patient's psychiatric diagnosis was recorded. The tool captured whether each of the following were measured following admission – body mass index (BMI), blood pressure (B.P), serum cholesterol level, QRISK score and HbA1c level, and, if so, whether this was done within 24 hours of admission. For those patients who were smokers, being offered nicotine replacement therapy was documented.

Of the 135 inpatients, 10 didn't have any physical health monitoring completed and were excluded from the sample, making the final sample 125 inpatients. 68 of the inpatients were male, 57 were female. 98 had a diagnosis of an SMI, 27 did not. Most inpatients were of “white British” ethnicity. 91% of the sample had a BMI measured within 24 hours of admission, but only 62% had a B.P done, 59% had a serum cholesterol level done and 58% had an HbA1c level done within 24 hours of admission. 78% of eligible patients had a QRISK score calculated. 97% of inpatients who were smokers were offered nicotine replacement therapy, but only 13% accepted it.

The majority of patients admitted to the general adult inpatient wards have an SMI. The audit findings show need for improvement in physical health monitoring following admission. Creation and implementation of a checklist of physical health parameters to be measured within 24 hours of admission could help improve performance. Use of motivational interviewing may help increase uptake of nicotine replacement therapy in smokers.

This evaluation aimed to establish the prevalence of physical health comorbidities in SMI patients admitted to the general adult wards in Mersey Care NHS Foundation Trust.

Mean life expectancy in individuals with severe and enduring mental illness (SMI) is 15-20 years shorter than that of the general population. A significant proportion of excess mortality in patients with SMI is due to natural causes, e.g. cardiovascular disease and type II diabetes mellitus. Although SMI patients are at greater risk of developing chronic physical health problems, they often receive worse health care than the general population. SMI patients more likely to engage in unhealthy lifestyle behaviours, such as poor dietary choices, smoking and physical inactivity; Antipsychotic medication prescribed to these patients can cause adverse metabolic side effects.

A list of all inpatients on the eight general adult wards in the Trust was obtained in September 2020, producing a sample of 135 inpatients.

An audit tool was designed, capturing demographic data – gender, age, ethnicity, and also recording whether the patient had a diagnosis of an SMI (e.g. schizophrenia, bipolar affective disorder). The presence of any physical health comorbidities and whether the inpatient was a smoker was also recorded.

Of the 135 inpatients, 10 didn't have any physical health monitoring completed and were excluded from the sample, making the final sample 125 inpatients. 68 of the inpatients were male, 57 were female. 98 had a diagnosis of an SMI, 27 did not. Most inpatients were of “white British” ethnicity. Of the 98 SMI patients, 14 had type II diabetes mellitus, 11 had essential hypertension, 12 had chronic obstructive pulmonary disease and 22 were obese (i.e. a BMI > 30 kg/m2). 70 of the 98 patients with an SMI were smokers.

As expected, a significant proportion of patients with SMI admitted to the general adult inpatient wards are smokers. Whilst admission to hospital may not be considered an ideal time to get patients to consider quitting smoking, admission does at least provide an opportunity to educate patients on the negative effects on physical health that smoking has. This evaluation has highlighted that physical health comorbidities are common in this patient group. Admission to the psychiatric ward provides a golden opportunity to provide education to patients on the importance of making healthy lifestyle choices and also to assess any physical health comorbidities and ensure the management of any such comorbidities is optimised prior to discharge.

This was a re-audit of off-label prescribing of quetiapine in order to identify the number of patients on off-label quetiapine in HMP Elmley, to monitor compliance by the Mental Health Inreach Team (MHIRT) psychiatrists with the Royal College of Psychiatrists guideline on off-license prescribing, to compare findings with the baseline audit and to identify areas for improvement.

All patients on quetiapine in HMP Elmley were identified and their electronic patient record was reviewed against the standards outlined in the Royal College of Psychiatrists “Use of licensed medicines for unlicensed applications in psychiatric practice (2nd edition).

There were 60 residents on off-license quetiapine prescription in HMP Elmley.

Of this number, four had their prescription initiated by a general practitioner, either while in prison or in the community. Two residents were on quetiapine first prescribed while they were on admission in hospital. 5 patients had been initiated by the MHIRT psychiatrists. 38 residents were commenced off-license quetiapine by another psychiatrist, either while they were in the community or in another prison. In 17 patients, electronic records were inadequate to determine who had prescribed the quetiapine.

The number of inmates prescribed off-label quetiapine in HMP Elmley had dropped from 82 to 60 in the 1 year since the initial audit. Of these figures, prescriptions initiated by the MHIRT psychiatrists, had dropped from 28.1% (23/82) to 8.3% (5/60).

For those prescribed quetiapine by the HMP Elmley psychiatrists, notes were audited against the RCPsych guidelines:

• Licensed medication was considered first in 80.0%

• Risks and benefits were considered and documented in 80.0%

• The benefits and potential risks were explained to patient in 80.0%

• There was documentation of informed consent in 80.0%

• Quetiapine was started at a low dose and monitored in 100%

• No residents required withdrawal of medication due to ineffectiveness or adverse effects.

• Baseline physical health assessment was performed in 80.0%, though all had an ECG done.

Over the past year there has been an improvement in off-label antipsychotic prescribing practice within the MHIRT.

However, the number of off-label antipsychotic prescriptions still remains high throughout the prison. There should be continued effort at minimizing off-label prescribing within the MHIRT, monitored by auditing. However, work needs to be done jointly with other prescribers, such as GP colleagues, in order to avoid unnecessary prescriptions and to monitor regularly the physical and mental health of those on off-label quetiapine.

The enforcement of lockdowns and restrictions on non-essential contact have changed Community Mental Health Team (CMHT) practice. Therefore, this audit carried out its 4th cycle of physical health monitoring for patients on antipsychotics with severe mental illness (SMI) under the CMHT during the period of the COVID-19 pandemic in order to observe its impact on physical health monitoring. In addition, with the increased use of telepsychiatry substituting routine face-to-face appointments during the pandemic, this audit also reviews the effect of lockdown on maintenance of contact between CMHT and people with SMI.

Primary Objective: to compare the current clinical practice with the standards derived from NICE guidelines which include parameters like weight, body-mass index, blood pressure, ECG and blood tests, then compare with the previous three audit cycles, which collected identical data.

Secondary Objective: to monitor amount of contact between healthcare staff and people with SMI on antipsychotics during the three months of Welsh lockdown and compare current clinical practice with the clinical practice achieved in the identical period in 2019.

Method for Primary Objective: Clinical practice on physical health checks were split into 10 standards derived from the NICE guidelines (NICEQS80, Quality Standard 6). Data collection surrounding physical health checks of patients on antipsychotics from 26th June 2019 to 26th June 2020 were collected and compared with the previous three audit cycles, which collected identical data.

Method for Secondary Objective: Retrospective data surrounding amount and type of contact between CMHT and people with SMI was collected from 26th March 2020 to 26th June 2020, a period of enforced lockdown in Wales, and compared with the identical period in 2019.

The audit iterates trends over the last 4 cycles (2016/2017, 2017/2018, 2018/2019 and 2019/2020). The current audit cycle increased in 2/10 standards and decreased in 8/10 standards, compared with the average compliance in the 3 previous audit cycles. Out of the 10 derived standards, certain standards fared worse than others.

There was a 79% increase in the number of staff-patient contact during the lockdown period. The majority of the contact in 2019 was face-to-face (84.31%), however, as expected, in 2020 the majority of the contact was non face-to-face (61.75%). However, this was accompanied by an 85.79%

Despite being in a pandemic, patient contact was maintained. Physical health monitoring has decreased in the majority of standards, therefore greater attention is needed to address this. Recommendations are provided in the audit.

Venous thromboembolism (VTE) is a common disease amongst hospital patients. Within acute hospitals, there are well established protocols for risk assessment and prevention of VTE via mechanical and pharmacological prophylaxes.

In psychiatry, assessment of VTE risk is more commonly overlooked despite many inherent risk factors which are unique to acute psychiatric admissions; including antipsychotic medications, physical restraint, catatonic states, and poor nutritional and hydration status[1]. The risk is compounded in older adult psychiatric patients, in which both patient and admission-related risk factors can act synergistically.

Anecdotally, it was reported that VTE assessments were not being completed and documented on the electronic patient record system. Our aim was to introduce a physical VTE risk assessment to attach to paper drug charts, which would act as a prompt for junior doctors, and serve to increase rates of completion.

A baseline retrospective audit of all patients admitted to the older adult inpatient ward over an 11-week period (05/08/2019~20/10/2019) was undertaken. The number of completed electronic VTE risk assessments at admission, and at 24 hours post-admission were calculated.

Subsequently, a new paper VTE risk assessment proforma was developed, combining the Department of Health VTE risk assessment tool[3] with several VTE risk factors associated with psychiatric patients (catatonia, antipsychotic medication, reduced oral intake, psychomotor retardation). Education was provided to the ward doctors, and regular assessments of VTE risk was incorporated into the weekly MDT meetings.

A re-audit was completed to assess the completion rates of the new paper VTE proforma. A snapshot style audit of all inpatients on the ward on Thursday 24th February 2020 was performed.

The baseline audit included 23 patients admitted during the 11-week period, consisting of 21 men and two women. The mean age was 74 years. Three patients (13% of total admissions) had their VTE and bleeding risk assessed on admission.

Following the implementation of a new VTE risk assessment proforma, the re-audit showed that all 19 inpatients (100% of total admissions) had a completed assessment. Although none of the patients required mechanical prophylaxis, one patient was receiving ongoing treatment for pulmonary embolism.

VTE is a preventable disease, which historically has been under-recognised by psychiatric doctors. The introduction of a paper risk assessment proforma increased completion from 13% to 100%. It also prompted regular review of VTE risk during the weekly MDT meetings. This intervention may reduce the incidence of VTE-related pathology on the ward.

Patients with serious mental health illnesses die on average 15–20 years before the rest of the general population. Anti-psychotic medication, lifestyle and difficulty accessing healthcare services all have a detrimental effect on their life expectancy. To improve outcomes for these patients the Lester Tool; a method to assess the cardiovascular health of patients and implement change, was developed. Including the Lester Tool information in discharge letters allows transfer of information to other care providers (mainly GP's) who can implement and monitor any interventions made, improving outcomes for our patients. With this in mind, discharge documents should contain all of the information listed in the Lester Tool.

We aimed to check if 100% of data required by the Lester Tool is included in discharge documents of the inpatients at Foss Park Hospital.

20 patients from each of the male and female wards at Foss Park hospital, discharged in September or October 2020, were identified. A review of the discharge documents established whether the smoking status, BMI, ECG, blood pressure and blood results of each patient were recorded.

Of the 40 discharges, none had 100% compliance. On average across both wards; only 23% of the Lester tool information was included in the documents. On the female ward, 40% had none of data recorded, while on the male ward, 15% had none of the data recorded. Across both wards, not a single patient had details about their cholesterol ratio recorded, only 50% of BMI's were recorded and only 27% had a smoking status included.

Our results have shown that compliance with the Lester Tool falls short of what is expected. As a result, information about the physical health of our patients is not being communicated effectively with other care providers. This in turn can prevent patients being offered interventions needed to improve their cardiovascular health.

Identifying this shortcoming in the transfer of information will allow us to educate the staff in our organisation and ensure that all the necessary physical health details will be included in future discharge documents. The result being improved outcomes and longer life expectancy of patients with serious mental illnesses, satisfying the purpose of the Lester Tool.

To survey the prevalence of monitoring of vitamin D on an inpatient ward.

To audit the treatment if there is identified vitamin D deficiency or insufficiency

To compare differences between findings in audits

All inpatients admitted to Milford centre between August 2019 and August 2020 were selected as part of the sample size.

Data were collected by FY1 and FY2

Patients’ laboratory results were accessed to determine vitamin D levels.

E-notes were used to conclude who were vitamin D sufficient or deficient for treatment

The standard for the audit were as per:

Management of vitamin D deficiency or insufficiency in adults – CKS (2018)

The above was based on National Osteoporosis Society (NOS) guideline Vitamin D and bone health: a practical clinical guideline for patient management [National Osteoporosis Society, 2013] and Scientific Advisory Committee on Nutrition (SACN) guideline

2017

48/188 patients had vitamin D levels measured

36/48 patients had sufficient vitamin D levels

12/48 patients were either deficient or insufficient

12/12 patients were treated where found deficient or insufficient

2020

90/115 patients had vitamin D levels measured

47/90 patients had sufficient vitamin D Levels

43/90 patients had either insufficient or deficient vitamin D levels

22/43 patients had treatment documented in noted where found deficient or insufficient

Difficult to make comparisons with previous audit due to difference in number of patients tested

Vitamin D is routinely tested on Milford ward on admission hence the large number compared to the last audit

52% had noted to have sufficient levels of vitamin D

Concerning were results that only 51% of those deemed to have insufficient or deficient were treated based on notes

Potential reasons could be:

Prescribed in medication card and not documented in notes.

Vitamin D results checked in another ward, no supplementation given, and then transferred to Milford house.

Patients refused treatment but not documented adequately.

Patient discharged before results were received due to quick around

Results were deemed insufficient in terms of the range but very close to normal hence decision made not to start supplementation

Results to be disseminated with medical and nursing colleagues

Re-audit in September 2021