Aims

The COVID-19 pandemic has had a drastic effect on the mental health of the global population that is likely to be felt for years to come. One group particuarly likely to be affected by this in the immediate future are the healthcare professionals working on the frontline of the NHS pandemic response. As members of a foundation cohort of these junior doctors we aimed to create a way to quanitfy the wellbeing of ourselves and our colleagues at this challeging time. We aimed to use a combination of numerous tools to monitor foundation doctors in Blackburn during this crisis. This would inform which measures would be best suited to be put in place to protect this cohort from early burnout and poor mental health in the future.

Method

We designed a survey of 25 questions which we invited our foundation colleagues to fill in anonymously during the first and second waves of the pandemic in response to times when foundation doctors were redeployed to aid the frontline. The survey has been based on the PHQ9, GAD7, Epworth Sleepiness scale, Physician wellbeing index, Medical students wellbeing index, Maslach burnout inventory BMA burnout questionnaire and the QOL scale.

Result

From a cohort of around 140 foundation doctors we had 46 participants in our trial of this tool; 46% had been redeployed and 54% not redeployed. Over 50% of survey respondents reported high stress, poor motivation and depersonalisation over the two weeks at the peak of the pandemic, key early signs of burnout. Lack of interest in their work, poor sleep and anhedonia were increased across both groups (redeployed and non redeployed). The interventions after the first wave data which repondents found beneficial included; financial reassurances during redeployments, protected non clinical areas for rest, a named individual senior staff member for wellbeing support.

Conclusion

Key issues the survey raised were fed back to foundation programme leads in monthly meetings. This allowed us with our foundation leads to make targeted changes in order to support foundation doctors at this time. Without the data from this tool which we tailored to the foundation experience we believe these rapidly worsening issues during the pandemic would not have been addressed so swiftly. We then resurveyed the foundation cohort to assess which of these interventions have been most widely used and appreciated.

Aims

Clinical substance misuse presentations are commonly managed by Psychiatry Core Trainees (CTs) out of hours. However, specialist teaching is not included in the Maudsley Training Program (MTP) induction. We aimed to investigate whether this was of clinical concern and, if so identify interventions to address it.

Background

The association of substance misuse disorder and mental illness is widely recognised. The Adult Psychiatric Morbidity Survey 2014 reported that half of people dependent on drugs other than cannabis were receiving mental health treatment. Substance use substantially impacts clinical risk; 57% of patient suicides in 2017 had a history of substance misuse. It also effects emergency psychiatric services: 55-80% of patients detained under S136 are intoxicated. Therefore, it is imperative for patient safety that CTs can assess and manage these patients appropriately.

The Royal College of Psychiatrists recognises the need for specialist substance misuse knowledge and skills, and lists this as a key ‘Intended Learning Outcome’ for CTs. Unfortunately, the availability of specialist drug and alcohol service placements for CTs has significantly declined. Only one placement is available per MTP rotation. Teaching is therefore relied upon to gain these competencies.

Method

Using a cross-sectional survey we explored CTs confidence in recognising and managing substance misuse presentations, knowledge of where to seek guidance and asked for teaching suggestions. We surveyed two CT1 cohorts in 2017 and 2019.

Result

Fifty-one CTs took the survey. Of these 92% did not feel prepared to manage acute substance intoxication or withdrawal and 96% would like relevant teaching at the start of CT1. Furthermore, 67% did not know where they could seek guidance.

CTs felt confident at recognising and managing alcohol related presentations. However, they were less confident in recognising opioid withdrawal, how to safely prescribe opioid substitution therapy (OST), and the usual doses of OST (65%, 94%, 94% rated ‘neither confident nor not confident’ or below, respectively). CTs were not confident at recognising GBL and cannabinoid withdrawal, principles of harm minimisation, assessing readiness to change, delivering Brief Interventions and teaching patients to use Naloxone.

Conclusion

The results were exceptionally similar between cohorts, demonstrating reliability of our findings and that CTs lack of substance misuse knowledge is a significant clinical concern.

To address this deficit of knowledge, we are writing an introductory lecture with supporting guidance in the induction pack, developing an online video resource, and moving key substance misuse lectures to earlier in the MTP taught programme.

Aims

To offer a psychoeducation and reflective practice group for nursing staff (NS) and health care assistants (HCAs) working on a Trauma and Orthopaedics Ward in Southmead Hospital, Bristol. To explore the staff experience of having a reflective space, and how this impacted on their attitudes and knowledge and confidence in psychiatric presentations.

Background

Reflective practice can raise the quality and consistency of nursing care, but it is not part of everyday culture and practice. Southmead Hospital is a trauma centre and the surgical NS and HCAs care for multiple patients following self-harm or suicide attempts. They report at times not having the mental health knowledge and confidence to appropriately manage patients on the ward and are at high risk of occupational stress and burnout. Our mental health liaison team (MHLT) identified this need and offered to provide a space to address these concerns and evaluate the impact of this intervention.

Method

After liaising with the ward manager, I developed and provided a fortnightly forty-minute psychoeducation and reflective practice group for NS and HCAs on one Trauma and Orthopaedic ward in Southmead Hospital. Topics were rotated and included suicidal ideation, self-harming behaviour, mind and body link, the stress -vulnerability model and verbal aggression.

The staff were asked to complete anonymous paired pre-and post-course questionnaires about their attitudes and confidence regarding mental health difficulties. This questionnaire included both quantitative components (e.g. 1–5 Likert scales) and qualitative components (free text boxes) which were analysed and coded accordingly.

Result

Quantitative results showed that staff felt it was important to learn about mental health conditions and have a reflective space. Their confidence and knowledge improved in understanding and managing psychiatric presentations. Qualitative results revealed several common themes – (i) Space; staff valued a protected, structured, safe space, (ii) Relationships: staff valued sharing with colleagues and supporting each other, (iii) Sharing and learning; staff valued a space to think about patient's formulations, discuss common experiences, express their own emotions and learn from each other and (iv) Psychoeducation; the staff welcomed ideas of ways to communicate with patients and specific skills to use on the wards.

Conclusion

Trauma and Orthopaedic NS and HCAs perceived a range of benefits from participating in a psychoeducation and reflective practice group. Further research is required to evaluate whether reflective practice groups help to reduce staff burnout and can change the ward ethos to improve the patient experience.

Aims

During the recent lockdown, it was difficult for those with complex needs associated with learning disability and autism to source timely support. Despite the challenges posed by the COVID-19 epidemic, several resourceful initiatives were implemented, across the clinical landscape

The Self-guided CCaRM Programme was developed as a format for on-line workshops with those concerned. The expectation was to reframe support already there, and streamline further support to best effect.

Method

This programme evolved from the Complex Case and Recovery Management Framework (The CCaRM*), developed within Merseycare Specialist LD Services. This value-based platform was being used by the Specialist Support Team (SST) to support people in the community with LD and Autism with complex needs. With lockdown constraints, the service became reliant on working indirectly through family and carers.

Primary Driver:

• 1:The priority during the lockdown was to make sure how quickly to carry on functioning ,when everyone was distant from each other, and not been able to see people who have Learning Disability & Autism with complex needs.

• 2: Bringing CCARM to the people as a internet based intervention as CcARM was successfully practice with specialist services.

• 3: To provide a format for service users and then career to better review and reframe the care needs, to better effect for themselves

During the recent lockdown, for those with complex needs associated with learning disability and autism:

It was difficult for people to source timely support for themselves.

It was difficult for specialist teams to reach them with useful advice

Secondary Drivers:

• 1:To reframe support already there and to streamline farther support to best effect.

• 2:Increase Engagement:

• 3:Ensure Accessibility

• 4:Continuing workshops through COVID-Pandemic with no gaps in between-in first PDSA cycle

Change Ideas

• 1: The approach to counter the impact of Lockdown in a critical area

• 2: To adapt the CCARM framework to the online environment.

• 3: Simplification to improve over all engagement within the process

A skype-based workshop was convened for all relevant parties. In advance, attendees reviewed concerns using the 6 self-guided CCaRM headings, in line with the original CCaRM, as follows:

• Having a good circle of support

• Having a good shared understanding

• Having clear problem areas thought about

• Social Participation and Living a Good Life

• Keeping people safe and well

• Making progress

For each theme, areas of strengths, concerns, and possible fresh approaches were explored. Subsequently, collaborative care plans were refreshed accordingly.

Result

There were 8 such workshops conducted in first PDSA cycle . Participants included support staff and family members, though no service users in this period. All gave positive feedback: that the experience helped with understanding and confidence in roles, and generated fresh ideas to try.

Conclusion

• • This approach helped counter the impact of lockdown in a critical area.

• • It was interesting to adapt the CCaRM framework to the online environment.

• • The perforce simplification seemed to improve the engagement of carers

• • Further work needs to explore potential service user involvement also, and to evaluate the approach longer term.

Aims

The COVID-19 pandemic has caused significant disruption to activities of daily living, which in turn has had a profound impact on the mental wellbeing of the public. An e-guide was designed to provide remote support to the general public through the application of a Behavioural Activation approach. Interactive, brief evidence-based exercises were included in the e-guide, along with mood ratings after each exercise to assess any improvements observed.

Method

The e-guide was designed using the Xerte On- Line Toolkits open source software. Videos and interactive exercises were embedded within the resource, forming part of the brief intervention based on cognitivist and behaviourist principles. Information and further support was also provided for young people and parents. Videos from the public highlighting their experiences during the pandemic were also sourced and included (with consent). A pilot was launched to assess the impact of the e-guide. Participants were recruited from Cardiff University, mental health services and a local charity.

Result

The e-guide was piloted on a sample of volunteers (n = 3), who completed a brief survey after engaging with the resource. Following the results of the pilot, the e-guide was promoted by the university's marketing team and made available to the public. At the 6-month mark, the e-guide had been accessed by 3228 individuals throughout the UK.

Conclusion

The e-guide has since been disseminated by support services for young people, places of employment and eduction institutions. The national impact of the e-guide is evidenced from the number of people accessing the resource exceeding 3000. With the long-term effects of the pandemic taking hold, it remains crucial to support the wellbeing of the general public through such initiatives that are administered remotely

Aims

A Quality Improvement project with the aim to increase the number of patients discharged with a GP discharge summary from the Chase Farm Place of Safety over a 12 month time period by 50%.

Background

An initial audit was conducted at Chase Farm Place of Safety (POS) to see if patients held under Section 136 of the Mental Health Act (S136) and then discharged home had a GP discharge letter completed and sent. The audit revealed that 0.02% of patients who were under S136 and discharged home did have a discharge letter sent to the GP.

As a result of the initial audit, key stakeholders were contacted, and involved in the intervention design and implementation. The intervention was introduced and all doctors working in the trust were emailed the new protocol

Method

We implemented the following intervention:

If a patient was registered at a GP Practice then the nursing staff in the POS copied the entry of the discharging doctor from the electronic progress notes and pasted this in to the S136 discharge template on the electronic progress notes and this was emailed to the GP.

We informed Doctors to be aware that their entry would go out to the GP and should contain the following: Impression, Outcome/Plan, Specific Risk /Safeguarding concerns and specific management plans.

Result

In the initial audit the notes of all patients discharged from the POS under S136 were reviewed over a 3 month period between November and January 2018. We found that 2 out of 89 patients (0.02%) had a completed GP summary which was emailed to the GP Practice.

After the intervention was introduced the notes were audited between July and September 2019. We found 33 out of 60 patients (55%) had a completed GP summary which was emailed to the GP Practice.

Conclusion

There was an improvement of 54.8% in the number of discharge summaries. Further consideration needs to be given to improving this percentage and understanding what remaining barriers there are.

Background

Efficient handovers are integral to patient care. Challenges to handover for liaison psychiatry included high patient and staff turnover and varied handover approaches across the multidisciplinary team (MDT).

Method

MDT focus groups and questionnaires explored change ideas. PDSA cycles were used to design a structured handover.

We aimed to:

Reduce handover time to 30 minutes.

Improve communication using the SBAR tool.

Implement a multidisciplinary teaching schedule in the time saved.

Daily measures:

Handover timing

Team Satisfaction (Individuals ranked handover as ‘good’, ‘average’, or ‘poor’)

Weekly measures:

Semi-qualitative questionnaires triangulated areas for improvement.

Emails, posters and team meetings provided team feedback regarding QI progress.

Result

A structured twice-daily handover format incorporating SBAR, allocated handover coordinators and documentation was created. Weekly MDT teaching sessions were developed.

Over 4 weeks, ‘good’ handover ratings increased from 22% to 65%; ‘poor’ ratings decreased from 25% to 8%. Mean handover time decreased from 37 minutes to 28.5.

The team viewed SBAR as a positive efficiency-promoting tool. MDT teaching improved team communication and confidence. Documentation is an area to improve.

Conclusion

Structured handover has promoted efficiency and effective information-sharing amongst the liaison psychiatry team.

Interdisciplinary teaching can promote inclusive team feeling and encourage confidence across the MDT.

Aims

The aim of this quality improvement evaluation project is to establish the standard of current practice in relation to reviewing confusion inducing drugs (CIDs) at the time of referral, as it has been hypothesised that these medications contribute to short term cognitive impairment. This is essential in order to establish the validity of the diagnostic processes of dementia syndrome in the memory assessment services.

Background

It has long been established that anti-cholinergic medications (ACMs) have contributed to short-term cognitive impairment in patients taking them. This is compounded with the fact that these medications may be continued without review, for longer than was originally intended. The impact of polypharmacy, subsequent anti-cholinergic burden, and the overlapping presence of delirium, may call into question the validity of a diagnosis of dementia in patients who have not been correctly vetted during the course of their assessment. This quality improvement evaluation aims to assess whether patients’ medications are being reviewed before diagnosing a memory disorder. This is in accordance with guidance set out by the NG97 NICE guidelines, The Royal College of Psychiatrists Memory Service National Accreditation Programme (MSNAP), and the National Institute on Ageing and Alzheimer's Association (NIA-AA).

Method

All new referrals to the memory assessment service during July and August 2019 were systematically reviewed and data extracted from the memory referral document and entries on RIO from first point of contact. The following data were recorded: patient ID, GPCOG/6CIT score, final diagnosis, CID prescriptions and CID review.

Result

The results were collated using a data-set of 216 patients (136 females and 80 males,) of which the mean age was 79 years. It was noted that 36% of patients had not had any sort of cognitive assessment before referral, which identifies an area for improvement. However the most substantial finding was that only 10 patients (5%) had a CID prescription review documented in the RIO notes.

Conclusion

Our data suggest that in our memory assessment service, only a small proportion of patients are having a documented review of their CIDs prior to diagnosis of dementia. In order to improve this and thus improve compliance with guidelines from the Royal College of Psychiatrists MSNAP and the NIA-AA, measures will be taken to issue each dementia support worker and nurse with a CID prescription review card, which will list those medications to consider and flag for review.

Aims

The increased morbidity and mortality relating to the poor physical health of patients with severe mental illness has repeatedly been an area identified as requiring improvement. Despite this, no national minimum standard has been published around the minimum level of physical health equipment that should be available within an inpatient psychiatric setting.

The aim of this project was to improve and standardise availability of physical health equipment across the five clinical areas within a medium secure inpatient forensic setting, thus enabling optimal and timely medical care and physical examination of patients to occur.

Method

This project used a combination of audit and quality improvement practices. An audit standard was created and current practice was established within the 5 clinical areas of a Medium Secure Forensic Unit. Improvements were made in a systematic and measured way and two audit cycles were completed.

Result

At baseline, the attainment of audit standard ranged from 14-76%. Clinical areas were sharing equipment and there was an inconsistency as to where and how equipment was being stored. Changes implemented included redistribution and reorganisation of equipment which increased attainment to between 48% - 86%. Following this further equipment was ordered and the equipment was separated into that which was required on a daily basis to conduct physical observations and more specialist specific examination equipment. Re-audit found attainment across the five clinical areas being between 90-100%.

Conclusion

Monitoring of physical health within psychiatric inpatient settings is a key area of patient care, and is frequently identified as requiring improvement. Without access to equipment to monitor and assess physical health, this becomes challenging and potentially poorly completed. By standardizing available equipment and furthermore through practical steps such as separating the equipment required on a daily basis and that used less frequently the retention of equipment improved. This enables delivery of high quality, timely and thorough monitoring and assessment of physical health to be achievable.

Aims

Primary aim: To increase the proportion of patients receiving a full cardiometabolic screen whilst on the ward to 75%.

Secondary aims: To improve communication with GPs regarding cardiometabolic health, to improve the rates of intervention when abnormalities are found to 75%.

Background

People with serious mental illness are known to have significantly increased risk of cardiometabolic syndrome than the general population. Estimates suggest there would be up to 12,000 fewer deaths from cardiovascular disease if people with serious mental illness had the same outcomes as the general population. People with serious mental illness die on average 20 years earlier than the general population due to preventable physical health problems.

Whilst on the ward, we have an excellent opportunity to screen and treat patients with cardiometabolic risk factors, yet screens are often incomplete, not acted upon, or simply not carried out.

Method

Using the Plan-Do-Study-Act (PDSA) methodology, we trialed interventions to improve the cardiometabolic screening process on out 16 bed inpatient ward. Across 8 cycles, we set up a protocol to ensure all new patients received a full cardiometabolic screen during their admission reviews, engaged nursing staff with the process and managed inconsistencies with blood transportation and delivery. We also started using British Heart Foundation information leaflets, and treating patients in accordance with the Lester Tool: Positive Cardiometabolic Health Resource. We made design changes to the discharge summary template allowing for clear communication with GPs on discharge.

Result

At the end of 8 cycles, we had achieved 100% compliance with the full cardiometabolic screen (as defined by the Lester Tool) from a baseline of just 25%. We also improved intervention with identified abnormalities from a baseline of 0% to 100%.

Conclusion

Improvements in cardiometabolic screening and treatment were possible using the PDSA methodology. Given the success of this quality improvement project, we plan to introduce our methodology onto other wards in the trust.

Aims

The primary aim of the project was to improve attitudes towards the COVID-19 vaccine in forensic mental health staff at a large regional tertiary forensic psychiatry unit. The main variable examined was attitudes towards safety of the vaccine. Secondary aims included decreasing misinformation about the vaccine and improving vaccine uptake.

Method

Paper questionnaires were distributed to willing staff members across 6 forensic inpatient wards within the North London Forensic Service. Participants included a range of allied health professionals including nurses, health care assistants, ward managers, occupational therapists, assistant therapists and administrative staff. Questionnaires used a mixture of Likert scale for agreement/disagreement with statements and yes/no questions.

Plan-Do-Study-Act (PDSA) methodology was utilised in implementing changes, and repeat questionnaires used to measure changes in attitude and behaviour. Change ideas implemented included the creation of ‘mythbusters’ posters which target vaccine misinformation, the creation and distribution of posters of staff members who had already taken their vaccine, the creation of vaccine champions to aid engagement in conversation about the vaccine, vaccine information packs being distributed to all wards and the opportunity for staff to ‘drop-in’ to clinics for information about the vaccine.

Result

Vaccine uptake improved from 7% before interventions to 69% after interventions.

The proportion of people very unlikely or unlikely to get the vaccine reduced from 25% to just 9%. The proportion of those feeling neutral reduced from 32% to 6%. The proportion of those either likely or very likely to get the vaccine increased from 34% to 85%.

Before interventions only 20% felt that the vaccine was either safe or very safe. This improved to 63% after interventions

Before interventions, only 27% of respondents felt they had received enough information by the trust to make an informed decision. After interventions, 80% said they had received enough information.

The project was successful in reducing misinformation in every domain. Particularly reassuring was the reduction to zero of some of the most harmful misinformation claims, such as the presence of a tracking chip in the vaccine and the belief that COVID does not exist.

71% of respondents indicated the interventions we set out changed their view on the COVID-19 vaccine.

Conclusion

The changes implemented lead to clear improvements in all domains measured, suggesting targeted information is an effective strategy in improving uptake and attitudes around the vaccination program.

Aims

The aim of this project was to improve the booking and attendance of patients under Southwark Team for Early Psychosis (STEP) into the physical health clinic.

Background

STEP is an Early Intervention Service which provides treatment to 230 adults (18-65 years) with first episode psychosis in the community. In line with national and trust guidance, physical health checks are completed at baseline, 3 months, 6 months and annually, through a weekly physical health clinic run by the core trainee (CT). This is an essential opportunity to assess and monitor patients’ physical health and aid decisions regarding psychotropic medications, which is particularly important given the increased morbidity and mortality in this group and their reduced engagement with health services. It was noted that attendance to the clinic was poor and there was no guidance about how to communicate the results to the General Practitioner (GP).

Method

Data on the number of clinic appointments booked and attended were collected over 3 defined 9 week intervals between 17/09/18 and 29/07/19. The interventions were implemented prior to the third round of data collection and included an educational session to the STEP team and a protocol for booking and running the clinic to be used by the CT. We devised a physical health questionnaire to be completed by patients on arrival, which includes a summary of the Maudsley guidelines for antipsychotic monitoring. Finally, we created a template letter to communicate the results to the GP.

Result

Following the interventions, the percentage of available clinic slots booked increased from an average of 27.8% to 100%. The proportion of slots attended reduced from an average of 80% to 50%. However, the absolute number of patients booked into clinic increased from an average of 10 patients over 9 weeks pre-intervention, of which an average of 8 patients attended, to 36 patients post-intervention, of which 18 attended.

Conclusion

We observed full utilisation of available clinic slots post-intervention and an increase in the absolute number of patients attending. Given the ongoing use of the protocols developed, we expect these changes to be sustainable. The number of patients attending could be further increased by training additional staff to run the clinic more often and more flexibly. The number of Did-Not-Attends could be reduced by care-coordinators sending reminder texts prior to the appointments.

Aims

Sleep is essential for optimal physiological functioning, but often interrupted in hospital settings. Disturbed sleep is associated with relapse of mood disorders and multiple comorbidities including impaired immunological function and increased cardiovascular risk. There are unique environmental challenges on psychiatry wards, such as overnight monitoring. Recent studies highlight the importance of evaluating and managing inpatient sleep disturbance. Aims include exploring the extent to which patients’ sleep is impacted by inpatient admission, elucidating causes of sleep disturbance and determining ways to improve sleep during admission.

Method

Patients aged 18–65 years, who consented and were expected to be inpatients for a week, were approached after 72 hours of admission (n = 35). Quantitative and qualitative data, including on pre-hospital and hospital sleep quantity and quality, were gathered, as part of a cohort characterisation. Questionnaires using Pittsburgh Sleep Quality Index elements were used to gather data. Offering earplugs as a sleep-aid intervention was implemented, with sleep quantity and quality reassessed 72 hours post-intervention. In response to feedback, sound monitoring at regular intervals overnight was undertaken using a decibel-metre to determine noise baseline and variation.

Result

All patients approached agreed to participate. Pre-hospital average sleep quantity was 5.2 hours, with restedness score of 4.3, and 71% patients rating their sleep as ‘bad’. After 72 hours post-admission, average sleep length was 6.5 hours and restedness 5.3. Of patients who accepted earplugs (59%), there were improvements to mean sleep quality and quantity (7.6 hours), with 86% patients rating earplugs helpful. All patients surveyed thought that earplugs should be offered routinely on admission. 70% of patients were prescribed benzodiazepines or z-drugs as required. Self-reported factors affecting sleep included noise, psychiatric symptoms and medication side effects, with 13 patients mentioning the former. Sound monitoring recorded an average decibel level with a range of 35–75 dB, with peaks reaching 95 dB.

Conclusion

Poor sleep in hospital is widespread. There is a need to understand and address modifiable environmental and ward factors implicated in sleep disturbance within inpatient settings. Pharmacological options for sedation are common, but it is important to focus on alternative options of low-cost, non-pharmacological interventions which promote sleep optimisation and enhance inpatient care.

Aims

To develop a new service model that engages and improves the provision of palliative care to PWUS.

Background

Although people who use substances (PWUS) continue to die prematurely compared to the general population, they are now more likely to die from chronic diseases rather than from drug-related deaths. Challenges to providing palliative care to PWUS include delayed care-seeking behaviours, complex drug interactions and lack of healthcare provider experience.

Method

An informal factorial analysis elucidated population needs through: a review of local databases to estimate the prevalence of palliative need, a thematic review into the deaths of patients in specialist drug services and, a survey of health practitioners’ knowledge and attitudes. These informed the service development phase which involves three key components: 1. A systems approach to increasing patient identification, incorporating key multi-disciplinary stakeholders across hospital- and community-based care 2. Targeted training of healthcare providers and 3. Medicines management for symptom palliation amidst concurrent substance use (including substitution treatments).

Result

The palliative needs of PWUS are under-identified: the local substance service was not partaking in the palliative referral pathway. Only 7% of a local hospice's annual caseload was recognised as having substance use problems. The care pathway was described as fragmented. Although >80% of surveyed palliative care practitioners had experienced caring for PWUS, confidence and knowledge around managing withdrawal, pain and opioid substitution therapies was poor.

Conclusion

A new pathway is designed to identify PWUS and in their last year of life at key treatment points e.g., accident and emergency, ward-based care. The pathway will then streamline referrals to relevant specialist services depending on complexity of palliative/dependency need. Teaching resources and prescribing guidelines have been developed in collaboration with secondary care pain specialists.

Aims

To explore the level of supervision between training and non-training posts at LSCFT.

Background

• • Supervision is defined as ‘provision of guidance and feedback on matters of personal, professional and educational development in the context of a trainees' experience of providing safe and appropriate patient care’.

• • Along with the trainees, doctors working in non-training posts such as staff grade, specialty doctors, trust grade doctors (TJD)and MTI (Medical training initiative) doctors form an integral part of patient care in the NHS.

Method

• • A mixed method approach was adopted with both qualitative and quantitative data collected simultaneously in the form of an online questionnaire.

• • An anonymous online questionnaire was sent to junior doctors currently in training and non-training posts at LSCFT in 2019 using Meridian software.

Result

1- Quantitative Data: - Participants included were doctors in training post such as Foundation Doctors (5), Psychiatry Core Trainees (6), GP STs (2) and doctors in non-training post such as TJD (4), Specialty Doctors (2) and MTI doctors (4). Based on the Meridian score, 84% of doctors were satisfied with the supervision. It was found that 72% of doctors received weekly supervisions, 10% monthly (1 TJD, 1 Foundation trainee) and16% bi-monthly (1 MTI, 1 SAS, 2 CTs). The data suggested that there was no difference in the frequency of supervisions between training and non-training posts at LSCFT.

2- Qualitative Data: - The feedback was common as there was no major difference between training and non-training doctors.

• • Positives – WPBAs, discussion on reflections, management of complex cases and medication, personal issues affecting work.

• • Negatives – Limited discussion on QI, Audit, Research and Psychotherapy.

- More specific help, need more support at times.

Conclusion

1. 1. To prepare a checklist of contents to be discussed during supervision.

2. 2. To prepare a timeline chart of supervision.

3. 3. Preparing a ‘menu’ of QI projects that junior doctors can sign up to at the start of each post.

4. 4. To formulate training packages available to support junior doctors with QI/Audits.

Aims

Dashboards provide a visual summary of relevant data to track performance against key indicators over time. They are used in healthcare to monitor the quality of patient care and to identify potential quality improvement projects. There is little published evidence of them being used in mental health services, especially in forensic psychiatric care.

This project aims to design a dashboard for use in a forensic and intensive psychiatric care unit, by specifying measures and ideal features it would include.

To develop a model for a quality dashboard for use

To decide which measures would be reported on the dashboard

To find reliable methods of assessing said measures

To explore staff preferences as to how the dashboard would display data, and how they would like the information to be disseminated

To use blank data to design a mock dashboard interface for feedback

Method

A literature search was conducted on healthcare dashboards and quality improvement projects taking place on low-secure psychiatric wards similar to the Blair unit. Potential outcome measures and methods of assessing them were researched. Staff thoughts on the dashboard, and which measures they would like to see included, were explored in interviews and using a survey

Result

Blank data were fed into excel to create example graphs for a mock dashboard. The results section details: measures to be included, such as staff turnover rate, absences, and patient satisfaction levels; how they can be assessed; and specific features of the dashboard, such as the capability to track trends in selected quality indicators over a period of time. Further development of this project out with the 4 week development timeframe will require cooperation from IT services and unit management staff.

Conclusion

Many staff suggestions, whilst valuable measures, were more suitable for use in a clinical or nursing dashboard, rather than a quality dashboard. COVID-19 factored into reasons why staff requested certain measures, and also meant that less staff were available to be contacted about the project. This project has limitations based on the four-week timeframe, but could be further developed by staff on the unit if desired.

Aims

Hyperprolactinaemia is a problem secondary to antipsychotic use. Current management guidelines are heterogeneous and impractical. We aimed to assess coherence to common themes monitoring and intervention, reasons for failure, and to design new guidance for both general use Barnet, Enfield and Haringey Mental Health Trust (BEHMHT) and beyond.

We hypothesised that performance would be poor and new guidance warranted.

Background

Hyperprolactinaemia is defined as blood prolactin of >530 miu/L in females and >424 miu/L in males, with 49.9% is due to medication. Several agents are deemed higher risk Symptom profiles and risk are idiosyncratic and there are adverse long-term outcomes. Treatment is based on symptom profile and severity and cause. Current guidance is trust specific or advised through The Maudlsey Prescribing Guidelines.

Comprehensive and practical guidance reflecting front-line limitations is lacking. There is no clear delineation of a risk stratified pathway.

Method

We wished to ascertain data on surveillance, aetiology and signpost opportunities for service improvement. We also designed ‘risk strata’ to guide intervention.

A random sample (n30) was selected from Enfield South Locality Team and data captured using local records. No ethical considerations were raised.

A number of audit standards (95%) were developed based on previous guidance and agreed within the team and included frequency of monitoring, time to review and need for further referral.

New guidance was developed based on results, MDT agreement and consultation with medical specialities.

Result

Data (n 30) showed predominant male bias to sample (66%) and average age of 48.87 yrs. Predominant diagnoses were Paranoid Schizophrenia (53.33%) and Schizoaffective disorder (33.33%.) Only 7/30 (23.33%) had undergone testing within the last year.

Of those sampled, 2 (6.667%) had a new diagnoses of Hyperprolactinaemia, one on routine monitoring, one incidentally on admission to hospital. Both were on high risk agents. Both were reviewed and treated within one month. No audit standards were met, but no further referrals were required.

Reasons for failure varied, but included loss to follow-up, no test requested or appointments missed.

Conclusion

Based on these data it was noted that monitoring was poor and reasons for failure varied. New Guidance was developed in response. The scope and validity of this guidance was agreed by MDT and awaits formal ratification.

Re-audit will occur in 2020, and if successful the guidance submitted to other Trusts and RCPSYCH for national use.

No financial interests to declare.

Aims

We aimed to evaluate the use of the Situation, Background, Assessment and Recommendation communication tool (SBAR) at two large psychiatric hospitals, in order to design new approaches to teach and reinforce its sustained use. In doing so we hope to improve communication, staff experience and outcomes for patients.

We hypothesised that use prior to intervention would be low and attitudes inconsistent between teams and objective data.

Background

SBAR is a communication tool developed to accurately refer information with improved outcomes within the NHS. Within psychiatry there is evidence of relatively poor care of medical problems leading to adverse outcomes in a group more susceptible to multiple physical illnesses. The reasons for this include a cultural ethos of learned helplessness in staff and lack of medical knowledge.

The use of SBAR is likely to overcome these issues.

Method

Surveys were presented to doctors and nurses staff at two Psychiatric Hospitals, Chase Farm and Edgeware. Inclusion in the survey was voluntary and anonymous. Questions elucidated topics ranging from awareness of SBAR through to its use and benefits.

Objective data were also collected, looking at handover gathered during the survey period. This was collected via phone from the duty physician over a five-day period, twice-daily. Qualitative data on handover content was collected at CFH.

Audit standards around knowledge, use and outcomes were set. Data were collected and analysed in house.

Result

The data (n23) showed that most nurses reported awareness (86.96%) ease of use (86.96%) actual use (60.87%) efficacy in communication (78.26%) value in understanding patients (78.26%) and agreement with mandatory use (78.26%.)

Doctor reports (n14) showed that although 100% were aware of SBAR, no respondents thought nurse-led communication was adequate, or that SBAR was used. The majority thought that mandatory SBAR use would improve communication (92.86%) and patient care (100%)

Objective data (pooled) of referrals showed that on 6.52% used SBAR. Qualitative data showed that handover was often inaccurate, lacking in information and unsafe. Suggestions for teaching included written or video media, or taught classes.

All audit standards were failed.

Conclusion

SBAR is an effective tool for improving communication and patient outcomes, and is well perceived by the MDT. However, it is poorly used with psychiatry leading to adverse outcomes. Reported use is undermined by objective data. Its mandatory use is well supported and new teaching initiatives are thus being designed to remedy this and improve client experience.

Aims

To improve the confidence and preparedness of junior doctors in managing medical or psychiatric emergencies when on call at an inpatient psychiatric unit.

Background

Facilities for emergency care differ between acute medical and psychiatric units. Protocols for managing acutely deteriorating patients and those requiring immediate resuscitation differ across these organisations.

Managing medical emergencies can be stressful for all involved. Junior doctors rotate between services where the level of support varies depending on specialty and setting. For doctors who have worked in a setting where the minimum emergency response includes a Resuscitation team, moving to an environment with less support available is a challenge.

In our unit, the protocol following an urgent call is for the on-call doctor (who has access to basic resuscitation equipment) to attend and assess the need for paramedics and transfer to local hospital. Stress can be worsened by change of environment, change of expectation and concern about best management in new settings.

Method

A cohort of junior doctors were recruited. Baseline assessment included rating their confidence level (scale 1- 10), listing common medical and psychiatric scenarios they had experienced and those they felt least confident managing. Over a period of 10 weeks, follow-up data was obtained. Interventions to improve confidence were assessed during this period, including a handbook and a teaching session on emergency medications. At the end of the project a wordcloud was created in response to the request to “choose 5 words to describe your feelings when called to an emergency”. Identified themes have been fed back to relevant senior staff and will form the basis of future projects.

Result

The initial average confidence score improved from 4.9 to 9.2 and was sustained out to 14 weeks. According the word cloud the most commonly used words were “morale” and “education”.

Conclusion

Prior to the study, confidence levels amongst the Junior Doctors was low. Introduction of the handbook and teaching session led to an improvement which was sustained. Key themes identified using a word cloud were “morale” and “education”.

For junior doctors moving from between services, different expectations and protocol for management of emergencies can influence confidence levels. Psychiatric units should be cognisant of these concerns and implement evidence-based intervention to support junior doctor confidence and improve quality of working experience.

Aims

A quality improvement project was undertaken to understand the perception of trainees about the quality of the local induction delivered by Birmingham and Solihull Mental Health Foundation Trust (BSMHFT). The primary aim was to evaluate the current local induction programme, following concerns raised by previous trainees in National Training Survey (General Medical Council) and local inspection. Our secondary aim was to devise a revised induction programme based on the trainees’ identified needs.

Method

Two anonymised questionnaire surveys were emailed to all Foundation Year Trainees, Core Psychiatry Trainees and General Practice Speciality Trainees working in BSMHFT, in December 2019 and March 2020, using trust survey monkey.

Result

The overall response to survey was 60 percent. 44.44 percent of the responses came from Core Psychiatry Trainees, with 27.78 percent responses each from Foundation Year Trainees and GP Speciality Trainees. Local induction was defined as induction specific to place of work (47.06%), trust based induction (41.18%) or all of the above options (11.76%) by trainees. 83.33% of all trainees had received local induction, whereas 16.67% did not have any local induction at the start of their post. 11.12% trainees were very satisfied and 44.44% were satisfied with local induction. 72.22 percent of the trainees were informed about of the local induction, prior to starting the post.

33.3% trainees had a paper version, 22.22% had an electronic version of local induction pack, whereas 44.44% had no induction pack. 55.55% of those trainees who had an induction pack, 43.75% found it very helpful and 56.25% did not find it helpful.88.89% thought having a local induction would be helpful, whereas 11.11 percent did not feel it would help. 94.44% of the trainees completed a local orientation checklist with their consultants. Some of the trainees experienced difficulty in gaining access to electronic prescribing, electronic patient record system (RIO), and identity badges (ID) at the beginning of their post.

Conclusion

11.12% trainees were very satisfied, 44.44% were satisfied, 22.22 % were neither satisfied nor dissatisfied and 22 % were dissatisfied, with local induction. 88.89% of the trainees thought having a local induction pack would be helpful. Based on the trainees identified needs we developed a template for local induction pack for each post. Clinical supervisors have agreed to take the lead in preparing the local induction pack specific to their post with trainees.We aim to repeat the survey after implementing the changes identified by trainees based on their training needs.