Aims

The National Institute for Health and Clinical Excellence (NICE) recommend that renal and thyroid function must be checked before lithium is prescribed and for all patients who are prescribed lithium should have their renal and thyroid function checked every six months, and their serum lithium checked every three months. The aim of this audit is to ascertain whether or not routine blood monitoring for bipolar disorder patients, taking lithium is in keeping with the guidelines.

Background

Lithium has been a mainstay in the management of bipolar disorder since the 1970's; indeed, lithium carbonate was first used in the early 1880's for the treatment of mania. Despite its usefulness however, the drawback of lithium treatment remains its very narrow therapeutic index, toxic side effects and as such its need for close therapeutic monitoring.

Method

A list of patients with a diagnosis of bipolar disorder being treated with lithium was collated from an electronic database of psychiatry patients in Cumbernauld Community and inpatients at Glencairn unit Coathill Hospital and Cleland Hospital. A retrospective analysis using Clinical Portal was conducted looking at blood results; Lithium levels checked 3 times a year and Kidney functions and Thyroid function checked twice a year, over the previous year. Our results were then compared to the NICE Guidelines for lithium monitoring to see if they complied with the expected routine monitoring schedule. We may have missed patients open to Community Psychiatric Nurses (CPN) but not open to Consultant psychiatrists. Other group that might have been missed could be open to General Practitioners but not to secondary care. We attempted to contact them but this was unsuccessful.

Result

Total of 690 patients were studied. Of 690 patients 51 patients had the diagnosis of Bipolar Affective Disorder. 49 percent of them were prescribed Lithium. 48percent had their Lithium bloods checked and 60 percent had their Kidney function and thyroid functions checked according to the guidelines. There were no data available for around 7 percent of patients but their Lithium levels were indicated only in Clinical notes.

Conclusion

This audit has demonstrated that Lithium monitoring falls short of conforming to accepted standards. Data obtained by this audit have prompted an electronic alert system for patients on Lithium endorsing primary care, mental health and laboratory staff to work together to ensure supporting recommended Lithium monitoring.

Aims

To evaluate attitudes in prescribing and utilising 'As Required' (referred to as PRN/Pro Re Nata) sedating medications (Benzodiazepines, Z-Drugs, Anti-psychotics, and Promethazine)

To evaulate current remote prescribing processes and improve safety and transparency

Method

Plan:

Review of remote prescribing policy. It was highlighted that current practice was not in line with NMC guidance of the time as no follow-up written instruction by a doctor was received. Concerns were also raised about the general safety of verbal communication of prescriptions out of hours. A survey was conducted to assess attitudes towards the prescription of ‘PRN medication’ and the role of psychological therapies as an alternative to both doctors and nurses working in ABUHB's Mental Health and Learning Disabilities division.

Do:

Survey results showed a nuanced response from both doctors and nurses but an agreement that there is a role for as required medication, especially in the context of acute mental distress, indicating safety around the process rather than elimination/reduction of PRN medication prescribing would be desired. This lead to an overhaul of the out of hours prescribing process between junior doctors and those receiving the ‘verbal order’ as detailed below: Phone conversation between a junior doctor and ward nurse receiving the verbal order. A digital form is then completed by the ward nurse including current regular medication, PRN medication (including times of use), physical health history, and any additional requested information such as QTc on 12 lead electrocardiogram (ECG) or current vital signs. The junior doctor may assist with obtaining the relevant information but there are clear prompts on the form, to ensure the pertinent questions regarding safe prescribing are considered by both parties. The dose and route of the medication are clearly documented by the junior doctor as well as time of prescription and the form is emailed back to the ward nurse. This process is far more transparent and much less prone to errors due to miscommunication. a. The prompts also save time ensuring the relevant information is on hand prior to discussion as opposed to searching for medication charts, ECGs, etc. b. Highlighting the importance of QTc monitoring to encourage safe prescription of anti-psychotics and Promethazine c. The prompts also highlight the importance of physical health and current vital signs with regards to safe prescribing d. The prompts are stored on a network drive alongside other verbal orders allowing for easier future auditing off remotely off and on site These changes were highlighted via email, junior doctor forums, and induction of new doctors.

Study

A Round 2 survey was drafted to evaluate the new process and forms with an aim to ensure uptake and to identify any issues. Despite using the same channels to identify survey participants, the response rate was much lower than the Round 1 survey. See Round 2 results.

Act

With the limited feedback obtained the main issue identified was with regards to rapid tranquilisation of an aggressive patient who poses a risk to self and others. In this scenario it was deemed a risk to wait for an email form to be completed. Clarification emails were sent to relevant professionals to clarify that the rapid tranquilisation policy does allow for verbal orders with a subsequent digital order form to be completed at a later time when it is safe to do so.

Result

Round 1

• Nurses n = 26

• Doctors n = 27

• Nursing

• 92% routinely request Z-Drugs and Benzodiazepines for treatment of insomnia

• 88% routinely request Benzodiazepines for treatment of agitation

• 73% routinely request Promethazine for for treatment of agitation

• 69% routinely request PRN Anti-Psychotics for treatment of agitation

• 35% would routinely request Promethazine for treatment of insomnia

• 19% would routinely request Haloperidol without a recent ECG (>3 months)

• 15% would request Benzodiazepines for treatment of psychotic symptoms

• 12% would request Lorazepam above British National Formulary maximum doses

• As required medications dispensed per shift

• 54% report 0 to 3 times

• 23% report 4 to 6 times

• 23% report 6 to 10 times

• Agitation was most commonly defined as

• 96% hostile behaviour/physical aggression

• 92% hostile/threatening/derogatory speech

• 81% visible anxiety

• 69% disturbed behaviour that is not threatening/derogatory towards others

• 31% patient reported anxiety without objective evidence

• PRN medication use reviewed by doctors

• Daily (8%)

• Weekly (85%)

• Monthly (8%)

• 5 most commmonly cited reasons contributing to PRN medication use

• 77% Ward atmosphere (ie. volatile ward environment)

• 69% Patient depdence (psychological/physiological)

• 54% Patient expectation

• 42% Limitted expectation of benefit from psychological skill utilisation

• 42% Usual habit/culture of prescribing by doctors

• What are your thoughts on the use of psychological interventions in an acute setting? [Open Ended, n = 22]

Reviewing the themes from the open ended responses:

• Nursing staff feel positively about psychological interventions in the right setting at the right time but find challenges to delivering them. Some staff cite the fact that a patient is admitted indicates their level of acuity requiring PRN utilization. Some responses indicate that patients may be medicating the normal human experience. Ward atmosphere, how ill the patient currently is, patient willingness, staff shortages, paperwork taking priority, lack of training in psychological therapies were all cited as challenges.

• Doctors

• 96% routinely prescribe Benzodiazepines for treatment of agitation

• 92% routinely prescribe Z-drugs and Benzodiazepines for treatment of insomnia

• 63% routinely prescribe PRN Anti-psychotics for treatment of agitation

• 38% routinely prescribe Promethazine for treatment of agitation

• 29% routinely prescribe Promethazine for treatment of insomnia

• 25% routinely prescribe Benzodiazepines for treatment of psychosis

• 12.5% routinely prescribe Lorazepam above British National Formulary maximum doses

• 8% routinely prescribe Haloperidol without a recent ECG (>3 months)

• Rapid Tranquilisation Policy

• 70% of doctors were familiar with the up to date Rapid Tranquilistion Policy

• 5 most commmonly cited reasons contributing to PRN medication use

• 19% nursing staff shortages

• 15% ward atmosphere (ie. volatile ward environment)

• 15% nursing staff expectations

• 11% usual habit of prescribing

• 11% patient expectations

• What are your thoughts on the use of psychological interventions in an acute setting (n = 26)?

Reviewing the themes from the open ended responses:

• Doctors are somewhat divided in their approach to psychological approaches, the majority stating or alluding to it being a first line management option but some citing staffing levels to be a deterrent. Others had a more nuanced view of it rather than a general first line treatment, requiring risk/benefit analyses before use. The minority did not know enough about psychological interventions or thought it often doesn't work.

• Round 2

• Nurses n = 8

• Doctors n = 8

• Nursing

• Total responded n = 8

• Acute psychiatric ward nurses n = 4

• Psychiatric intensive care unit nurses n = 4

• 50% were unaware that physical health emergencies and rapiq tranquilisation can allow for the older process of 'verbal orders' followed by the form due to the imminent risks associated with delaying treatment to complete the form

• 100% (n = 8) were familiar with the digital order forms

• 87.5% (n = 7) were familiar with the digital order policy

• With regards to form locations

• 87.5% (n = 7) had access to blank forms and would store them alongside paper medication charts

• 12.5% (n = 1) were not aware that the ‘verbal order’ policy was not digitised

With regards to digitised order requests:

• 75% (n = 6) did not report any change the frequency of requesting out of hours prescriptions

• 12.5% (n = 1) reported a reduction in requests

• 12.5% (n = 1) reported an increase in requests

• 75% (n = 6) reported that the digital order form puts up barriers to requesting medication out of hours

With regards to the form:

• 12.5% (n = 1) report that the form helps them formulate their requests

• 50% (n = 4) report that the form requires the appropriate amount of information

• 12.5% (n = 1) report that the form requires too much information

• 37.5% (n = 3) did not comment on the amount of information the form requires

With regards to safety:

• 25% (n = 2) report that the digitised system is safer

• 75% (n = 6) did not comment on safety

With regards to time to fill out the form:

• 87.5% (n = 7) report that the form is more time consuming

• 12.5% (n = 1) did not comment on time consumption

If given the option to revert to verbal orders:

• 37.5% (n = 3) would like to revert back to the old system

• 25% (n = 2) would like to remain on current system

• 37.5% (n = 3) did not comment on which system they'd prefer

• Doctors

• Total responded n = 8.

• Consultants n = 2

• Staff Grade doctors n = 1

• Core Trainees in Psychiatry n = 3

• Fixed term appointees n = 2

• 100% (n = 8) were familiar with the up to date rapid tranquilisation policy

• With regards to the digital order forms

• 62.5% regularly see them in patient files (n = 5)

• 37.5% occasionally become aware of them (n = 3)

• 0% were unaware of the new digital order forms (n = 0)

• With regards to inappropriate out of hours prescriptions

• 37.5% report that there was a reduction (n = 3)

• 50% report there being no significant change (n = 4)

• 12.5% report there being an increase (n = 1)

With regards to safety:

• n = 6 reported the new system to be safer

• n = 2 did not comment on safety

With regards to time:

• n = 2 report it being more time consuming to use the digital orders

• n = 6 did not comment on time consumption

• With regards to returning to verbal order forms

• n = 3 would like to remain on digital orders

• n = 5 did not comment on returning to verbal order forms

Other:

• n = 2 commented in the comment box that this change was overdue

• n = 1 commented that the forms give insight into patient presentations and management

Conclusion

Doctors routinely prescribe Z-drugs and benzodiazepines, and would generally consider Haloperidol as a second line over Promethazine (while nurses had a slight preference for requesting Promethazine over Haloperidol). The role of 12 lead electro-cardiogram monitoring would require further exploration in separate audits, as both Promethazine and Haloperidol can cause QTc interval prolongation [4,5].

Doctors most commonly cited expectations by nursing staff as the main driver for PRN medication prescription. Profound differences were present with regards to rationale behind PRN medication use when comparisons between doctors and nurses self-reports were made. The majority of nurses cited ward atmosphere and patient dependence/expectation as main drivers, whereas a minority of doctors shared those views. This represents a concerning disconnect between professionals, although it can be explained by the higher proportion of time ward nurses spend on mental health wards and in direct patient care. Nursing staff, being the dispensers of medication, would also likely be the main professionals contacted for the request of PRN medication by patients.

Nuanced views were given to the role of psychological redirection. This was shared between doctors and nurses, although many cited concerns about nursing staff shortages leading to a possible overreliance on PRN medication. A minority of doctors (n = 2) would recommend psychological redirection after first line rapid tranquilisation was exhausted. The counterargument being that someone admitted onto a ward tacitly implies a high level of acuity and reduced appropriateness of psychological techniques.

Hypnotics most commonly being requested likely reflects the difficult nature to initiate and maintain sleep is an acute ward setting.

On review of the Round 2 results indicate that doctors and nurses agree that the new system is safer although more time consuming. Concerns were raised about rapid tranquilisation and immediate emergencies, although the revised policy would allow for the verbal order policy to be followed with a digital order in these circumstances. This was clarified via further communication with relevant parties.

The changes were more received more positively by doctors than nurses, with some nurses opting for the older system if possible. It was also raised that this may be putting up barriers for out of hours prescriptions, although the required information is arguably succinct and only requests vital information for safe prescribing. Further exploration of these concerns would be indicated. The Round 2 results were limited by the low sample size compared to the first round.

Despite the limitations and concerns about the new system, digitising the system allows for further audits and studies to utilize much more robust methods of measuring out of hours prescriptions than self-reported measures employed in the initial rounds. Although they may not be directly compared to findings of this report, future baselines can be established and compared to in an objective manner.

Future Rounds

Proposed: To design and clearly display information on commonly requested medication by patients, empowering them to make more informed decisions on the medications they request. This could be in the form of leaflets patients could take or posters on areas where patients receive medication. One example is that Zopiclone is a very commonly requested medication on an as required basis although patients may not be as aware of the risks associated with chronic use.

Proposed: To design and clearly display information on psychologically informed techniques in patient areas such distress tolerance and sleep hygiene. This would be on mental health sites which do not currently display this information. To measure impact on PRN medication dispensation.

Proposed: Further exploration of patient perceived ward environment and measures that can be implemented to reduce anxiety/insomnia associated with inpatient admission.

Proposed: Exploration of proportion of inpatient initiated PRN medication progresses to long term use in the community (largely focused on hypnotics and benzodiazepines).

Aims

To develop and implement a QI training programme for trainees, Trust grade doctors and Consultants in Nottinghamshire Healthcare NHS Trust (NHFT) to enable them to deliver change in practice through acquisition of new knowledge and practical application of skills in QI projects using Model for Improvement.

Background

QI is crucial to improve patient care. Doctors are uniquely placed to input into patient safety and service delivery of healthcare. The skills required to be future clinical leaders and undertake improvement work are not innate and formal teaching and support is required.

What is DrQI?

DrQI is a trainee-led QI teaching programme developed in collaboration with Trainees improving patient safety through QI (TIPSQI) in North West deanery.

Method

A pre-implementation survey amongst doctors in NHFT in February 2019 (33 responses) suggested that 90% of doctors were interested in learning QI and about 48% preferred face-face workshops with support from the QI team.

A list of change ideas were created using a driver diagram with QI education and project support identified as key primary drivers.

PDSA cycles

Nine interactive workshops teaching key QI concepts (based on model for improvement) in NHFT, training more than 100 doctors. A workshop in Derbyshire Healthcare NHS Foundation Trust (70 doctors) and Nottingham University Hospital (20 doctors). Workshops were continually adapted based on qualitative and quantitative feedback. Different formats were tried including virtual sessions, game-based and problem-based learning approaches using small group activities.

Result

Pre-course and post-course questionnaires were used to assess change in understanding of individual components of QI methodology (SMART Aim, Driver diagram, PDSA cycles, outcome and process measures and run charts). Mean pre-course self-assessment score collated from seven QI workshops in NHFT (2019-2020) was 3.3 and mean post-course score was 7.68, showing an improvement in understanding of QI methodology.

Participants were asked to score the relevance (8.4) and quality of teaching (8.4) and the support from the QI team (7.4) on a scale of 1-10 (1 = poor and 10 = excellent). Additional free text feedback was obtained to help us improve the teaching programme.

Conclusion

Collaborative leadership trainee-led initiative to increase the QI capacity. A bottom up approach to complement the top down approach from the Trust QI team. Future steps include further collaboration and expansion of the scheme to other Trusts, Train the trainer sessions and building a network of QI champions.

Aims

The aim was to establish the prevalence of prescription of combined and high dose antipsychotics in the community mental health team and to see if such patients were being offered regular monitoring as advised by NICE guidelines.

Background

The use of high dose antipsychotic treatment (HDAT) should be in line with the recommendations of the Royal College of Psychiatrists Consensus statement on high dose antipsychotic Treatment. Such treatment should be initiated only when standard treatments have failed. As high dose prescribing of antipsychotic medications can potentially harm than benefit causing serious side effects and sudden death. Close monitoring and documentation are required. Also, reviewing these patients at regular intervals is recommended.

Method

A retrospective audit of 50 case notes of patients currently on antipsychotics was done. Case notes were selected randomly from a pool of 300 plus patients under the care of Isle of Wight NHS Trust in the HoNos Cluster 11 and 12 care pathways. Data were gathered on patients` demographics, diagnosis, medication monitoring. Data were analysed and discussed with consultant psychiatrist and senior mental health pharmacist. Patients who were not on any antipsychotic medications were not included in the audit.

Result

90% of the patients were on single antipsychotic (45 out of 50), 4.45% (2 out of 45)were above BNF recommended dose. 10% (5) patients were prescribed combined antipsychotics. 40% (2)of them were above BNF recommended maximum dose. A total of 8% (4 out of 50) patients were on above BNF recommended maximum dose. All the patients on high dose antipsychotics had a clear plan documented in the system. Documented monitoring of Full blood count was found in 75%, blood glucose in 50%, lipid in 75%, cardiac monitoring (Electrocardiogram or ECG) in 0%, physical health monitoring in 0%

Conclusion

As far as we know, this is the first time an audit has been done on the patients under the Community Mental Health Team on high dose antipsychotic treatment. The data showed areas of good practice as the majority of the patients were on monotherapy, and all the patients on a high dose or combined antipsychotics had clear management plans outlined in their notes. However, the audit also highlighted areas that currently need improvements such as regular monitoring of the patients on high dose and combined antipsychotics. It should also be clearly documented, recorded, and reviewed at six-monthly intervals.

Aims

National surveys show that over 56% of adults in England gamble annually, and of those surveyed, 0.5% were problem gamblers, equating to 300,000 problem gamblers at any point. The prevalence of problem gambling in patients with a substance misuse disorder ranges from 20.5% to 55%.

The audit aims to improve the care of patients with comorbid substance misuse and gambling disorder by assessing the extent to which the service currently enquires about and records problem gambling in its patient cohort.

It is hypothesised that as no formal recording process is in place locally, this information will not be recorded systematically and in a way that is easily retrievable by the service.

The audit will allow the service to assess whether changes need to be made to the initial assessment pathways into treatment for substance-related disorders to adequately record this information so that further assessment and onward referral can take place.

Method

All active patients (n = 2824) within the service had both their electronic initial assessments and their entire electronic notes screened for terms such as ‘betting’ and ‘gambling’ and this was recorded using an Excel spreadsheet. Prevalence rates across the teams (opiates, non-opiates and alcohol) were then calculated.

Result

The results showed that 0% of patients had any entries in their initial screening noting any gambling activity. Further scrutiny of the records revealed that only 3.5% (n-99) had ever discussed gambling with a worker in any of the services.

Conclusion

The majority (n = 52) of patients who had discussed gambling only had one positive search result, suggesting this was not followed-up in a systematic fashion. Recommendations are to revise the common assessment pro-forma to include a validated brief screening tool (lie/bet), where one positive answer triggers a further assessment with an appropriate clinician for consideration of referral to the local NHS gambling service.

Aims

We aim to improve waiting times in the Emergency Department and improve the overall quality of care of out-of-area patients by arranging for the liaison team to have access to the electronic notes system of a neighbouring trust.

Method

St Thomas’ Hospital is located in south London, right opposite the City of Westminster. As a result, approximately 20% of patients we see in mental health liaison are from that locality. Given that they belong to a different trust, we do not have access to their notes, which leads to a delay in trying to establish whether they are known to local mental health services. Often, staff are reluctant to divulge information. When information is shared, it is often late and/or incomplete. We approached the Chief Clinical Information Officer and Head of Information Governance from Central and North West London (CNWL) NHS Foundation Trust. We held weekly meetings which included both IT departments. Our IT had to install the electronic notes application (SystmOne) on our computers and open relevant firewall ports. The information is access through an NHS Smartcard, therefore CNWL had to authorise read-only Smartcard profiles for every member of the liaison team. A quick reference guide was created for all staff that would be using the new application. The system went live on 21 January 2021.

Result

We audited patient outcomes in December 2020 and February 2021 for initial comparison. In December 2020, the median time from referral to discharge was 6 hours 35 minutes. 25% of patients were admitted and 17% discharged with HTT. In February 2021, the median time from referral to discharge was 3 hours 19 minutes. 16% of patients were admitted and 5% discharged with HTT.

Conclusion

It is likely that by reducing the time required for collateral information, overall waiting times in the emergency department will be reduced. Clinicians are likely to feel more confident in their discharge planning if they have access to all clinical notes and previous risk assessments, which might in turn reduce referrals to HTT or admission. There should be further attempts by neighbouring NHS trusts, especially in London, to ensure access to their electronic notes system in order to reduce waiting times and improve the quality of patient care. We have already been approached for more information by a trust in North London who are interested in establishing access to a neighbouring trust's notes.

Aims

To ascertain whether baseline monitoring of cardiometabolic health parameters was undertaken for patients prescribed dose increases of, antipsychotic medications in an outpatient setting. Whether results from baseline tests were taken into consideration when prescribing antipsychotic medications.

Background

People with Severe Mental Illness have a reduction in life expectancy of 15-20 years. Chief factors implicated in this rate are smoking, obesity, metabolic dysfunction from diabetes, hypertension and stroke. Antipsychotic medications themselves are associated with increased risk of adverse cardiometabolic effects. The CATIE Study of patients prescribed atypical antipsychotics found that men were 85%, and women 137% more likely to have metabolic syndrome than control. Relative risk for type 2 diabetes and CHD in patients with metabolic syndrome is 1.5-5 times that of the general population.

Method

The Team caseload was accessed between the 6/11/18-13/11/18. Chronologically the first 40 patients on the list who had been prescribed an antipsychotic or advised re a dose increase of antipsychotic chosen. Data were then retrospectively collected from informatics and progress notes, document uploads, initial assessments and the ICE bloods system to populate an excel spreadsheet which is currently in use within North West Boroughs.

Result

Of the 40 patients, 50% (20) attended for physical health review. All who did not attend initial appointment were offered a second appointment. 15% (6) did not attend 2 appointments. 35% (14) were not offered a physical health appointment. 1 patient had BP documented (from full physical review during previous episode within 12 m). 2 patients had BMI documented; Smoking, alcohol and drug use status was documented in 42.5%(17), 57.5%(23) and 67.5%(27) of patients, respectively. And 67.5% (27) of patients had an HbA1c result within past 12 months on ICE and 62.5% (25) had lipid profile. At least 10 of these bloods were not requested by our team. 7 patients were given a blood form but did not have bloods done. 57% (4 of 7) abnormal HbA1c's were acknowledged and 20% (1 of 5) lipid profiles.

Conclusion

This audit demonstrates that baseline cardiometabolic monitoring could be improved for patients under the Assessment Team who are prescribed antipsychotics. Only half of the audited patients had had a physical health review, despite being prescribed, or their GP being advised regarding an increase in dose of, antipsychotic medication. It is important to note that 15% of patients were offered but failed to attend an appointment for physical health review.

Aims

To improve practice of Hospital Anticipatory Care Planning for inpatients of Organic Old Age Psychiatry wards in NHS Lanarkshire.

Background

Hospital Anticipatory Care Plans (HACPs) are important components of care for inpatients with progressive and life-limiting conditions. HACPs provide guidance on treatment escalation and limitation for individual patients, in the event that they become acutely unwell. In the Old Age Psychiatry Department at NHS Lanarkshire, HACP standards are as follows:

• HACP forms should be completed within 2 weeks of admission

• HACP information leaflets should be provided to relatives/carers

• HACPs should be discussed with relatives/carers

• If a patient without an HACP becomes acutely unwell, an HACP should be made, and the responsible Consultant informed

• HACP should be discussed within the multi-disciplinary team (MDT)

• HACPs should be regularly reviewed

• HACP and DNACPR forms should be kept at the front of the notes

• Superseded HACPs should be marked as obsolete

Method

Inpatient notes were reviewed in October 2019 and compared against the above standards.

The findings were presented at the Clinical Governance Meeting and Old Age Psychiatry Teaching Group in December 2019.

An ‘HACP Checklist’ was also created to prompt good practice.

Inpatient notes were reviewed again in July 2020.

Data from both time periods were compared.

Result

There was an improvement in:

The proportion of patients who had an HACP - from 59% to 96%

The proportion of patients who had an HACP made within 2 weeks of admission - from 35% to 78%

Documentation of HACP discussions with relatives/carers - documented for 77% of patients (from 47%)

Timing of HACP discussions with relatives/carers - took place within 2 weeks for 52% of patients (from 29%)

Documentation of HACP discussion by MDT - documented for 73% of patients (from 29%)

HACP Information Leaflets were only distributed to one patient's relatives/carers across both time points

Medical emergencies for patients with no HACP were infrequent and so comparison could not be made

HACPs were reviewed less frequently in July 2020 than in October 2019

HACP forms and DNACPR forms were always filed appropriately

Superseded HACP forms were always appropriately marked as obsolete

Conclusion

HACP practice mostly improved from October 2019 to July 2020. This may have been due to increased awareness of HACP Standards, following the presentation of initial data to inpatient teams.

A much larger influence, however, was likely to be the COVID-19 pandemic and associated efforts to improve HACP practice throughout the Health Board.

Aims

To evaluate the knowledge and experience of breastfeeding of staff working on a Mother and Baby Unit (MBU).

To assess the level of breastfeeding education of Staff on the MBU.

To identify any area of concern around breastfeeding on the MBU.

Method

A fourteen question questionnaire was designed with assistance of the medical team, midwife, and health visitor on the unit. The questionnaire was comprised of questions requiring “yes/no” and free text responses alongside Likert scales. The questionnaire focused on staff experience on breastfeeding, education levels and whether they felt Mothers were sufficiently supported. This questionnaire was distributed to all staff groups within the team to ascertain the level of expertise. 29 questionnaires were returned from a staff team of 31.

Result

Staff on this unit is made up of Multi-disciplinary professionals. Most respondents were Nursery Nurses (15%). 79% of staff had a lived experience of breastfeeding. Only 5 out of 29 respondents have had any breastfeeding training which was mainly in-house training, and these were the Health Visitor; Midwife and Nursery nurses. Of the respondents, 21% felt mothers who choose breastfeeding as their preferred mode of infant feeding were not adequately supported on the MBU. Seven percent were unsure and 72% felt women were adequately supported. 54% of staff were not aware of breastfeeding initiatives. 63% were able to list contraindications including names of psychotropic medications as well as personal choice and past medical history. The median rating in relation to confidence in skills on Likert scale of 1-10 was 5.

Conclusion

23 out of 29 professionals felt that Training would increase their confidence and skills in breast feeding support for women admitted to the unit. There is clear indication from the Staff Members that mothers on the MBU who choose breastfeeding as their preferred mode of infant feeding require further support. There is lack of confidence in staff's breastfeeding support in the MBU. An evaluation of patient's own experience of breastfeeding support they receive from staff is being undertaken alongside this, but data will be analysed later.

Aims

The aim of this project is to improve the quality of documentation and recording of the assessment and monitoring of patients commencing clozapine in BHSCT.

Background

Clozapine is an effective treatment for patients with schizophrenia who have not responded to at least two other antipsychotics. Due to clozapine's significant side effect profile patients must be carefully assessed prior to treatment initiation with close monitoring of their physical observations and reported side effects during initiation.

The BHSCT Clozapine Pathway currently uses a Clozapine Assessment Integrated Care Pathway (ICP) common to inpatient and outpatient clozapine titrations and a Clozapine Titration ICP which varies slightly between inpatient and outpatient titrations.

Method

The Clozapine ICPs of patients commenced on clozapine in BHSCT in a 9 month period commencing January 2019 were reviewed. Handwritten clinical records were used to collect data on rates of completion of all aspects of the pathway.

These results were used to identify areas of the pathway that were being poorly completed and the “Method for Improvement Model” used to trial changes to the pathway using Plan-Do-Study-Act (PDSA) cycles.

Result

20 patients in BHSCT were commenced on clozapine in the 9 month period. 1 Clozapine Initiation Pathway could not be located; therefore data were collected on 19 patients. 2 patients were initiated in the community and 17 patients initiated as inpatients.

The results showed that sections of the Clozapine Assessment ICP were poorly completed; for example only 27% of the “Patient Baseline Preparation Checklist” were complete, with 60% partially complete and 13% completely blank.

In the inpatient clozapine titration ICP the physical observations record was complete in only 20% of patients and the side effects monitoring record complete in only 13% of patients. Conversely the physical observations and side effects monitoring records were complete in 100% (n = 2) of patients.

Conclusion

BHSCT Clozapine Pathways were being poorly completed, with outpatient pathways being completed better than inpatient pathways. Analysis of the data shows that repetition of information in various parts of the pathway leads to gaps in documentation.

Parts of the pathway that were poorly completed have been redesigned and the impact of these changes assessed using the PDSA cycle method. It is hoped that this along with education of staff will lead to an improvement in the assessment and monitoring of patients being commenced on clozapine.

Aims

1. To standardise the doctor handovers for on-call duties

2. To ensure there is documented evidence of handover taking place at the end of each shift

Background

Since the introduction of the European working time directive the amount of hours that doctors are allowed to work has been reduced, resulting in increased handovers between teams. The National Patient Safety Committee and General Medical Council have recognised that this means we need to ensure handovers are as safe and robust as possible to ensure that patient safety is not compromised. A recent serious investigation report carried out at Chase Farm Hospital, London identified a lack of formalised handover between doctors as a contributing factor leading to patient harm. One of the recommendations of the report was for a Quality Improvement Project to be carried out in order to formalise handover.

The handover procedure at Chase Farm Hospital for core trainee doctors 'on-call' prior to this QIP was not standardised and consisted of an informal, verbal handover. Frustrations had been raised by doctors and other staff members that this current method of handover was unreliable and unsafe.

Method

We sent out a questionnaire about handover to all doctors on the on-call rota to help establish what intervention would be appropriate.

We then performed a retrospective collection of documented handovers within a two month time period.

Our intervention was to introduce an email handover procedure.

Following a two month trial of this intervention, we resent the questionnaire and performed a second retrospective collection of handover documentation.

Result

Prior to this QIP we found that 0% of on call handovers were being formally documented. After the introduction of our handover email 88% of handovers were being formally documented using the handover email.

Satisfaction with the handover procedure went from 0% being very satisfied and only 33% being satisfied to 50% being satisfied and 50% being very satisfied.

Conclusion

A standardised and documented handover procedure is crucial for patient safety and to allow doctors to communicate jobs effectively with each other.

A secure email for handover is a successful way of formalising the handover process.

Limitations include:

Access to the handover email for new staff or locum staff.

Ensuring that doctors who aren't on the on-call rota know how to use it to handover their ward jobs.

Aims

The South London and Maudsley High Support Rehabilitation Team supports a cohort of 120 long-term rehabilitation patients in the densely populated London borough of Southwark.

COVID-19 has a high transmission rate and is more lethal amongst the elderly, ethnic minorities and those with comorbidities.

For these reasons, COVID-19 poses a particular challenge to our patients. Most have significant comorbidities, live communally, engage infrequently with primary care and take high-risk medications like clozapine. Many are from black and minority ethnic backgrounds.

During the Spring coronavirus wave, we found that unwell patients or their carers would contact our service for advice ahead of 111, primary care or emergency services.

In response we designed a standard operating procedure to guide our response to possible cases. This aimed to ensure our advice and management for patients drew upon the latest emerging evidence.

We audited our work and the burden of disease within our service until November 2020.

Method

At a team level, we introduced same-day remote assessments structured around a standard operating procedure incorporating the latest primary care and national guidelines.

At a trust level, treatment guidelines were amended permitting consultant discretion when deciding whether an urgent blood count was required for those unwell on clozapine, and routine blood count monitoring was extended to 3 months for eligible patients

Result

By November 2020 we had only one confirmed case of COVID-19 on our caseload. This patient required ITU and recovered. Seven patients were judged ‘suspected’ to have suffered COVID-19 and eight were possible cases. One supported living accommodation had a possible outbreak.

Conclusion

We are surprised to have had just one confirmed case of COVID-19, despite the vulnerability of our cohort. The attentiveness of our patients and their carers to government guidelines will have contributed to this figure. They have shown remarkable resilience.

This pandemic has prompted trust-wide changes to clozapine monitoring and perhaps a permanently less intensive monitoring regime for some patients.

That our patients contacted our team ahead of 111, primary care or emergency services may reflect the close trust they place in us to support them through difficulty. It is fitting for a service aiming to provide holistic care that our scope should have expanded in this way during the pandemic. Community rehabilitation services are well placed to act as first responders.

Aims

To establish Safety Huddles (SH) on an acute general adult psychiatric ward, exploring links to restrictive practice. Additionally, to obtain multidisciplinary staff feedback on SH's impact on their workload/wellbeing and on patient care, and to identify barriers in implementation.

Background: A SH is a multidisciplinary daily briefing focused on patients most at risk, held at a fixed time and place, lasting max 5-10 minutes. Effective SH involve agreed actions, are informed by multidisciplinary staff feedback of data and provide the opportunity to appreciate and celebrate success in reducing harm. SH are a valuable team building activity, promoting situational awareness and helping with prioritising daily tasks.

Method

SH were introduced on September 2020. Templates were developed to prompt staff how to facilitate. Staff were encouraged to identify key goals and reflect on issues in the last and next 24 hours. Each participant was allocated a role, e.g. record keeping or dissemination of information. In December 2020, records of incidence of restrictive practice (numbers of restraints, seclusions and rapid tranquilisations) were obtained for the periods June-August 2020 and September-November 2020. Additionally, staff feedback was obtained through a short anonymous Survey Monkey questionnaire. It explored whether SH had an effect on patient care and staff's workload/wellbeing, and possible barriers to implementation.

Result

Comparing the two 3-month periods before and after SH implementation, restraint episodes were reduced from 47 to 21, seclusion episodes from 19 to 2, and rapid tranquilisation episodes from 10 to 3. Nine staff members responded to the feedback questionnaire. All believed SH had a positive impact on patient care, or had the potential to do so. Staff reported SH gave them insight into incidents, made them feel safer and prepared for the day, played a part in reducing restrictive practice, and empowered staff from all professional backgrounds by giving them a voice. Low or late participation, cancellation of SH because of clinical activity, and vague questions in the meeting template were identified as barriers in implementation.

Conclusion

Acute psychiatric wards regularly face challenges of high clinical activity, low staffing levels, bed pressures, and high-risk patient cohorts. SH contributed to reducing restrictive practice and creating a safer and more positive work environment. It is important to ensure SH are taking place daily, using an appropriate template to guide staff who may be new to facilitating. Accordingly, the impact on restrictive practice, patient care and staff wellbeing can be sustained long-term.

Aims

To assess DNA rates for initial assessment medical appointments offered for new referrals within an Older Adults CMHT.

To establish any correlation between waiting time and DNA rates.

To establish if the initial appointments offered were in keeping with the National guidelines (18 weeks) and our local Trust policy (1-4 weeks).

Background

In the Uk 15% of adults 60 and above suffer from a mental disorder. Despite the increasing mental health burden, analysis indicate that a quarter of mental health trust received less investment from 2017 to 2018. Financial pressures have also increased appointment waiting time. The NHS has stated that by 2023 there will be a 4-week waiting time for older adult mental health services. Current national guidelines state that initial referrals should be seen within 18 weeks.

Method

This is a retrospective audit looking at all first time referrals to an Older Adult CMHT in East Birmingham. 110 patients were included in this audit. Factors recorded included age, gender, reason for referral, waiting time for appointment, and whether this complies with guidelines.

Electronic patients' notes (RIO) were used for data collection.

Result

Out of 110 new referrals 11 were not offered any appointments. Out of the remaining 99, 13 cancelled and 8 did not attend.

In total, 78 attended the initial appointment offered, out of which 77 were seen within 18 weeks as per national guidelines. 43 patients were seen within the 4-week period (trust policy). 1 patient was offered an appointment at 19 weeks and 3 days from the referral date. The patients who did not attend their appointments were followed up except for one, to find out the reasons of the DNA. This included 2 (physically unwell), 1 (unaware of appointment), 1 (refused), 1 (forgot), 1 (couldn't get to clinic), 1 (asthma attack). Another appointment was offered to those who could attend.

Conclusion

There was no significant correlation between a longer waiting time and an increased DNA rate for first appointments. Even though the time for an initial appointment was within the NHS guidelines, only 56% of the appointments met our Trust's policy of a 4 week wait.

When discussing the results with the relevant team it was clear that a number of factors affected the waiting time including: number of available clinicians and a large catchment area.

Aims

NICE guidelines recommend that patients under Early Intervention (EI) in Psychosis Services have systematic monitoring and intervention of cardiometabolic risk factors. We undertook a Quality Improvement Project (QIP) in the Bath and North East Somerset (BaNES) EI Team to improve rates of compliance with national guidelines. We aimed to increase the percentage of service users with a physical health assessment documented in the past 12 months. Other aims included improving monitoring of physical health parameters in those taking antipsychotic medication and increasing the delivery of interventions for abnormal results.

Background

The most common cause of premature mortality in people who experience psychosis and schizophrenia is cardiovascular disease. The 'Standards for Early Intervention in Psychosis Service' states that patients should be offered personalised healthy lifestyle interventions, including advice on diet, physical activity, and access to smoking cessation services. Physical health should be monitored at least annually, with more frequent assessments if antipsychotic medication is prescribed.

Method

We identified seven key factors for improving physical health: Body Mass Index (BMI), Blood Pressure, Glucose Regulation, Blood Lipids, Smoking, Alcohol and Illicit drug use. Baseline compliance and intervention rates were measured in March 2019. Six ‘Plan, Do, Study, Act’ Cycles were completed over the following ten months. Examples of the changes made included: a new online diary and whiteboard, abbreviation of the assessment form, teaching for the EI team, and a new weekly ‘Physical Health and Wellbeing’ (PHeW) Clinic. This clinic involved phlebotomy, discussions around lifestyle choices, review of medication side effects, and neurological examination.

We measured the compliance with guidelines each month and the total number of interventions delivered at three-monthly intervals. We collected qualitative feedback on these changes in team meetings and with written questionnaires (including feedback from patients).

Result

Documentation of all key factors doubled from 30.2% at baseline to 63.3% in January 2020. The total number of interventions for raised BMI and lipid levels also increased. Feedback from staff and patients was positive. The clinic helped start conversations with patients about lifestyle choices, prompting improvements in weight, physical activity, lipid levels, and alcohol intake. Patient awareness and ownership over their physical health also improved.

Conclusion

This project utilised multiple strategies to reduce health complications for BaNES EI service users. A structural change in the assessment and management of physical health proved to be an effective and sustainable solution to optimise the health and wellbeing of this patient group.

Aims

During the first wave of coronavirus pandemic, many Psychiatry outpatient appointments moved rapidly to remote or ‘virtual’ to protect patients and staff from infection. Telephone consultations do not allow assessment of appearance or other visual aspects of behaviour/affect, yet these are core components of Mental State Examination. Videoconsultation software was unfamiliar to many mental health clinicians, with obstacles including hardware availability, software provision and skills, data security as well as lack of clinican motivation and confidence preventing rapid uptake. I wanted to take advantage of excellent IT support, and NHS England funding of software licence, to drive introduction of Attend Anywhere patient videoconsultation (‘telepsychiatry’) software within my local ADAPT (Anxiety, Depression and Personality Disorder,Trauma) Community Mental Health Team from April 2020 onwards.

Method

I assembled a small group of clinicans to take part in a local pilot of Attend Anywhere software. One Care Coordinator, a Consultant Psychologist, two Consultant Psychiatrists and myself completed satisfaction and confidience scores throughout an 8 week period. Number of videoconsultation outpatient appointments offered to and accepted by patients were also recorded. Weekly group meetings were deemed impossible to schedule given pandemic workloads, so we used 1:1 quick remote catchups, identifying and troubleshooting obstacles, working with IT implement a work-around when the team hit a technical brick wall.

Result

Clinician confidence and satisfaction increased significantly during this period, as did number of offered & completed video consultations.

Attend Anywhere consultations were used for up to 25% of clinician weekly workload.

Clinicians who manage their own diaries started quickly

It was difficult to successfully engage Administration team to organise Attend Anywhere test calls, leading to slow uptake for Consultant Psychiatrists who do not manage their own diaries.

Conclusion

Patient obstacles to use of Attend Anywhere appeared to be idiosyncratic and multifactorial, including poverty, digital exclusion, lack of privacy at home, and clinical history of online grooming. However, some patients already used Attend Anyhwere software with their physical health teams, while others prefer videocall to phone. Age was not an obstacle.

Once this small group of clinicians began to use software successfully, it had a snowball effect within the team and other clinicians asked to sign up for the service. Full support from Administration teams will be crucial to increasing videocalls within the service. Clinicians suggested offering videoconsultation as an opt-out service and requested additional functionality from the software to widen use.

Aims

This project aims to ensure all patients in the dementia ward 1 in Kingsway Care Centre, Dundee have daily bowel monitoring and achieve a normal bowel habit. The hypothesis is that patients are inadequately screened and substantial undiagnosed constipation exists.

Background

Constipation has a prevalence of 16-50% among individuals over 65 years old in the community. Psychiatric illnesses are known risk factors with older psychiatric patients 3-6 times more likely to be constipated. Untreated constipation may progress to serious complications such as bowel obstruction and bowel perforation. Delirium, often mislabelled as worsening psychiatric symptoms, also may occur leading to additional psychotropic medications being prescribed, further worsening the constipation.

Method

All patients in Ward 1, Kingsway Care Centre Dundee over 4 months were included, amounting to 25 patients. Data were gathered from stool charts weekly. Quality improvement framework was followed with two plan-do-study-act (PDSA) cycles completed. Normal bowel function was assessed against ROME IV constipation criteria and less than 75% of Bristol stool type 6 or 7 due to the risk of overflow diarrhoea and laxative overuse. In the first PDSA cycle, stool charts were modified to account for patients independently mobilising to the bathroom and daily documentation even if bowel movements were uncertain. The second PDSA cycle introduced a sticker on charts folder to “ask the patient” along with a staff education leaflet on the complications of constipation. Data were anonymised and analysed with run charts using Microsoft Excel.

Result

At baselines, 50% of patients had a stool chart. This increased to 90% in cycle 1, 100% in cycle 2. 28% of patients had any stools documented at baselines. This increased to 31% in cycle 1, 59% in cycle 2. At baselines, 0% of patients had a normal bowel habit. This maintained at 0% in cycle 1 but increased to 13% in cycle 2. No serious complications were found in patients assisted with toileting. However, 34% of independently mobile patients developed serious complications.

Conclusion

Poor documentation existed in all patients, particularly those independently mobile. Independently mobile patients were particularly at risk of serious complications of constipation compared to assisted patients. Introduction of new stool charts in the first PDSA cycle resulted in increased documentation but limited benefit for identification of constipation. The second PDSA cycle, targeting staff education and compliance, showed an increase in identification of constipation indicating limited staff knowledge as a key barrier to improvement in patients’ bowel habit.

Aims

This project aimed to improve physical health and to tackle obesity in patients detained in a low secure forensic psychiatric unit.

Background

People suffering from severe and enduring mental health problems have a life expectancy of 15-20 years less than the general population. The main cause of death is cardiovascular disease due to lifestyle factors, such as smoking, substance misuse and obesity.

Physical health problems such as metabolic syndrome, diabetes and heart disease have a knock on effect on motivation, self-esteem and concordance with treatment.

Over 60% of the general population and up to 80% of patients detained in forensic psychiatric units in the UK are classed as overweight or obese, with serious consequences to physical health.

Southfield Low Secure Unit is a 28 bed unit. Most patients suffer from treatment resistant schizophrenia and are prescribed high doses of antipsychotic medication, some up to 250% of the maximum recommended dose.

Method

Baseline data were collected using Body Mass Index (BMI) and Simple Physical Activity Questionnaire (SPAQ). Following the initial data collection, patients were involved in focus groups, community meetings and a monthly physical health action group. There was input from the care team including psychology, occupational therapy, nursing, catering and security. New activities have been made available such as “physical health and mental health education group”, “rambling group”, “gym sessions”, “patient focus groups” and “walking group”.

Result

This project has been running for 9 months and is ongoing.

There has been a modest change in the BMI – initial results ranging from BMI 23.6–42.8kg/m2. Of the initial cohort (n = 14), there has been weight loss (n = 3), weight gain (n = 3) and no change (n = 8).

The initial SPAQ results showed that on average patients spend 19.8 hours per day either in bed or doing sedentary activities and only 1.68 hours per day walking or doing physical activities. This pattern is being reassessed.

The qualitative data from patient focus groups shows increased interest in activities, motivation and desire to contribute to the project.

Conclusion

The preliminary results show an increase in patient motivation and engagement with available activities. There have also been patient-led challenges which were well received. Patients feel positive about the programme and valued for their input. Further support is required to maintain progress.

Aims

Identify differences in outcome measures between inpatient cohorts during the first year of the pandemic compared with preceding years.

Identify key elements in the treatment provided by identifying any trends in the outcome measures between 2015 and 2021.

Background

The Eden Unit at the Royal Cornhill Hospital (RCH) in Aberdeen is a ten-bed specialist centre for the inpatient treatment of eating disorders (ED). Strict measures to control the spread of COVID-19 have meant that important aspects of therapy in the Eden Unit are no longer permissible. It is not known whether handicaps to providing the previous service are reflected in recent outcomes.

Method

Values for age, length of stay (LOS), BMI, HbA1c (diabetic patients) and responses to three questionnaires: Eating Disorder Evaluation Questionnaire (EDE-Q); Depression Anxiety Stress Scale (DASS)-21; and Clinical Outcomes in Routine Evaluation (CORE). This data were collected for April 2020 to February 2021 (Pandemic) and compared with five preceding years, April 2015 to March 2020 (Pre-COVID). The project was registered with NHS Grampian Quality Assurance Team and approved by the MCN Quality Assurance subgroup. Ethical approval was not required. A data collection sheet allowed anonymised data to be entered into a Microsoft Excel TM Spreadsheet for analysis of baseline demographics.

Result

Average age of patients remained similar across the six years. Length of stay in the first year of the pandemic was significantly shortened. BMI on discharge in 2020/21 remained similar to preceding years. If relevant, HbA1c was measured throughout admission and comparison with BMI change reflected a focus on treating both diabetes and ED concurrently. Comparison of admission and discharge questionnaires to determine outcome measures proved difficult due to the small number of responses to both.

Conclusion

Shorter LOS during the pandemic was a significant finding. Despite this, BMI on discharge remained similar, suggesting a shift to weight restoration due to lack of opportunities for an holistic approach due to restrictions. Key elements of treatment include careful monitoring of HbA1c and concurrent management of Type I Diabetes for those patients. The low response rate to questionnaires raises concern regarding their use, in their current format, as effective tools to measure outcomes. Though low numbers of questionnaire responses prevent firm conclusion, it appears that the reduced opportunities for elements of treatment to be undertaken in the community may have contributed to increased anxiety levels on discharge.

Aims

This quality improvement project aims to improve the quality of information provided in the referrals from the older adult psychiatry department to radiology when requesting neuroradiological imaging.

The secondary outcome aims to standardise information on the referral proforma. We hypothesise that this improved referral proforma will lead to improved quality of reporting from the radiology department, which will form the second stage of this quality improvement project.

A further area of interest of this exercise is to establish whether standardised radiological scoring systems are requested in the referral, as these can be utilised as a means to standardise reported information.

Method

Retrospective electronic case analysis was performed on 50 consecutive radiology referrals for a period of 3 months from November 2019 to January 2020. Data were obtained from generic MRI and CT referral proforma and entered into a specifically designed data collection tool. Recorded were patient demographics, provisional diagnosis, modality of imaging, use of ACE-III cognitive score, radiological scoring systems, and inclusion and exclusion criteria.

Result

Results from 50 referrals have shown: 60% were male, 40% female. Average patient age of 74, ranging from 49 to 95. 58% were referred for CT head with 42% for MRI head. More than half of referrals quoted the ACE-III score. 26% of referrals stated exclusion criteria such as space occupying lesions, haemorrhages or infarcts. 10% of referrals requested specific neuro-radiological scoring scales. Specific scales which were requested included GCA (global cortical atrophy), MTA scale (medial temporal atrophy), Koedam scale (evidence of parietal atrophy) and Fazekas (evidence of vascular changes). Only 80% of referrals included the patients GP details on the referral form.

Conclusion

1. This quality improvement initiative has highlighted that the current level of information in referring patient to radiology is variable and dependent on the referrer.

2. All referrals should state exclusion criteria as per the NICE guidelines on neuroimaging in diagnosis of dementia.

3. Preliminary evidence suggests that requesting specific radiological rating scales could improve the quality of information received in the imaging report. The second part of this quality improvement initiative will aim to explore the impact of requesting these scales routinely.