The aim of this study was to explore experiences of consultations with non-specialist health professionals in a group of young people with ASD and their parents and what they considered would help to improve these interactions.

Research has shown that general awareness around autism is poor among the general medical community and this can result in poor communication during medical consultations.

An opportunistic group of 4 young people with ASD and 8 parents from a local support group in Exeter were interviewed in an informal environment about their experiences of healthcare consultations after seeking verbal consent.

Among the 8 parents interviewed the themes emerging were a deep lack of understanding and awareness among medical staff of the challenges faced by individuals with autism, the importance of the doctor-patient relationship to allow children to open up to healthcare professionals, and the need for all children to be respected as individuals.

Among the 4 young people (13 to 19 years) with ASD interviewed they identified significant anxiety around waiting for appointments and expressed a desire for a distractor to relieve stress, questions posed by clinicians were often vague and should be clearer, 3D models/mannequins could be useful to support understanding of anatomy and physiology, patience and a calm demeanour were vital with a quiet clinical environment to avoid distraction, time for mental preparation is important and efforts should be made to avoid delays or cancellation of appointments where possible.

An interactive website was generated in the light of feedback from the client group and their parents, aiming to educate clinicians regarding the challenges faced by this client group and provide a guide suggesting how to facilitate effective consultation through the use of simple techniques to promote engagement/reduce anxiety in the clinical environment.

Simple changes to the approach to consultation with clients with ASD - a quiet consultation space, no delays and better communication - could reduce stress and promote positive interactions with a beneficial effect on healthcare delivery for this client group.

Improve confidence and experience of trainees performing preliminary medical reviews in the 136 suite.

Improve patient safety by increasing trainee's confidence in responding to emergency scenarios, including crash calls of patients in the 136 Suite.

To orientate trainees to the 136 suite and the emergency crash equipment, in order to better prepare trainees for emergency scenarios.

The authors encountered a crash call in the 136 suite, in which a patient had concealed an opiate overdose. The patient was successfully resuscitated but concerns were raised by the junior doctors that they were unaware of what or where the emergency equipment was kept in the 136 suite. Following a debrief session, we established that junior doctors needed more orientation to the 136 suite and more teaching on performing preliminary medical reviews and responding to emergency situations.

Trainees, were asked to complete an anonymous, qualitative questionnaire with 16 questions asking about their confidence to respond to emergency situations in the 136 suite.

Based on the feedback, an interactive teaching session was delivered two weeks later. The session covered a structured approach on how to perform a preliminary medical review and scenario-based teaching on emergency situations. Trainees were then shown the 136 facility, introduced to the lead nurse and shown the emergency crash equipment and drugs stores.

Trainees were then re-consulted, with the same questionnaire to ascertain whether confidence and knowledge had increased.

Following initial induction, only 25% of trainees felt confident performing 136 Suite preliminary reviews. 50% of trainees had encountered crash calls at Park House Hospital, however 93% did not receive orientation of emergency equipment locations. Only 44% of trainees felt confident managing a crash call; reasons included feeling ‘rusty, little recent experience, not being familiar with the equipment’.

Post-interactive teaching session, 89% now felt confident performing 136 Suite preliminary reviews. 100% knew where the crash equipment was located in the 136 Suite.

Trainees should receive a robust induction on how to perform 136 preliminary reviews and have orientation of the facility, including crash equipment during induction

Trainees require refresher training in addition to their basic life support training on common emergency scenarios encountered in psychiatric hospitals.

A resuscitation skills training session is being organised for new trainees and hopefully incorporated into each forthcoming rotation.

This study seeks to explore the prevalence and impact of homelessness in an adult sample of psychiatry referrals over a one-month period via the Emergency Department at St. James's Hospital.

Homelessness has now reached a crisis point in Ireland. In July 2019, there were 10,275 people documented as homeless nationwide, with the number of homeless families increasing by 178% since June 2015. The majority of individuals registered as homeless are located in Dublin. St. James's Hospital (SJH) provides psychiatric care to a population of 136,704 people across Dublin South-City within areas of significant deprivation according to the most recent social deprivation index.

All Emergency Department psychiatry referrals over a one-month period were recorded. Month of study was randomly generated. Data were collected from electronic records. Socio-demographic information was analysed. Data were anonymised and recorded using Microsoft Excel. Current homelessness statistics were accessed from the Department of Housing, Planning, and Local Government and compared to the data collected.

During the month of the Study (March 2019), 4315 adults accessed emergency homeless accommodation in Dublin. Of the 109 psychiatry referrals received through the Emergency Department at SJH during this time, over a quarter (28%) of those referred reported themselves to be homeless or living in temporary accommodation. An additional 5% were documented as living in residential or sheltered care at time of assessment. All of the referred homeless patients were unemployed (n = 30). 50% of homeless patients were referred to psychiatry following expressed thoughts or acts of self-harm. Illicit drug abuse was associated with 73% of referrals. Alcohol abuse was associated with 47%. Of those who were referred, under a quarter (23%) were assessed as having a major mental illness, and in the majority of these cases, illicit drug and alcohol abuse were compounding factors in exacerbating symptomatology. Of those referred, 66% had previously been reviewed by psychiatry during prior ED presentations and 60% of homeless presenters reported that they had previously been, or were currently linked in with community mental health teams.

Frequently, vulnerable patients most in need of social and psychiatric care, such as homeless people with addiction issues, are eclipsed from accessing supports. The high proportion of patients reporting to be homeless is cause for concern and suggests the need for tailored and integrated multi-disciplinary assessments and interventions at an Emergency Department level.

To provide awareness of safety concerns around use of alcohol hand sanitiser on a mental health ward, and to consider ways of improving how learning for a serious adverse incident in one trust can better be communicated to other trusts

DD a male patient with history of paranoid schizophrenia alongside historic illicit drug use and current alcohol dependency admitted detained to Bluestone hospital following bizarre behaviour at a wake. Had been non-compliant with medication. Transferred to PICU due to going AWOL and returning under influence of alcohol.

2nd April overnight staff noted him to become over-sedated, presenting with slurred speech and appeared under influence of alcohol – transferred to A + E due to deteriorating GCS – was intubated, and transferred to ICU. Blood alcohol level was 373. Several empty bottles of hand sanitiser from dispensers on ward found in his room and he later disclosed he had accessed further alcohol hand sanitiser in sluice while washing clothes

SAI learning outcomes from one healthcare trust in Northern Ireland not currently routinely shared with other trusts

Literature review carried out to search for reports of similar incidents – 1 previous review article suggesting one death and 11 other major complications from consumption of alcohol hand sanitiser over 5 year period 2005-2009.

Quality improvement steps implemented to address this risk

Ward policy was reviewed to ensure patients no longer had unsupervised access to wash clothes

Liaised with Infection Control to assess the need for alcohol hand sanitiser to be available to patients given the ward is effectively a community setting

Intoxication policy reviewed and education sessions on this provided to all medical and nursing staff

Regional regular PICU staff update seminar launched for purpose of bringing PICU staff from across Northern Ireland together to share learning from SAIs and cases

Infection control agreed alcohol hand sanitiser dispensers could be removed from wards and kept only in locked nursing office with use of visitors.

Learning from this case shared with other trusts locally at newly launched regional PICU update seminar

No further incidents to date

Patient access to alcohol hand sanitisers found to be a significant safety risk in PICU setting

Following implementation of quality improvement steps no further incidents of patients swallowing alcohol hand sanitiser

Improved awareness of risk of alcohol intoxication on ward with nursing staff escalating concerns to on-call doctor more frequently

Self-harm is a common presentation to acute hospitals, associated with increased risk of completed suicide. Safety plans are increasingly recommended to help patients recognise and prevent escalation of self-harm behaviours.

This project aimed to improve quality and documentation of safety planning for patients admitted at an acute general hospital due to self-harm, who were assessed by Liaison Psychiatry. We aimed to increase the number of patients given written safety plans on discharge by 50%.

The PDSA cycle model of quality improvement was used. A retrospective audit of clinical records was conducted over 3 months to establish baseline documentation of safety planning (n = 51). A template for a self-harm crisis plan, used in other areas of the Trust, was adopted, to be adapted to each patient. A leaflet for sources of crisis support and patient feedback form were developed and distributed to clinicians in the team. Data collection was repeated one month later (n = 48). The second set of interventions involved a training session for clinicians on developing safety plans in collaboration with patients, and a poster highlighting the process to be undertaken when discharging a patient admitted with self-harm.

Following initial interventions, 20% of patients had completed safety plans and 50% received advice, an increase of 20% and 40% respectively. The second PDSA cycle showed increase in numbers to 38% and 67% respectively.

Creating a crisis plan with a hospital-specific leaflet for the Liaison Psychiatry team increased the number of patients discharged with safety plans in place. 86% of patients who participated in safety-planning found the process helpful and felt likely to use the plan in future crises. This is an area of ongoing quality improvement which can be implemented in other hospitals to better equip patients with skills and support to reduce self-harm/suicide attempts.

Discharge summaries are vital documents that communicate information from hospital to primary care providers. The documents contain description of the patient's diagnostic findings, hospital management, laboratory results, medications list and arrangements for post-discharge follow-up. Ineffective communications between healthcare providers in the form of delayed or poor quality discharge summary may adversely affect patient care and safety.

The setting of this project is Gwent Specialist Substance Misuse Service (GSSMS) which is the statutory specialist addictions service within Aneurin Bevan University Health Board (ABUHB). GSSMS has been arranging and managing inpatient alcohol detoxes for many years. One of the issues highlighted by an inpatient alcohol detox audit in 2017 was discharge summaries were not being completed for every patient who was admitted with a compliance rate of only 57.7%. A quality improvement project was initiated following the presentation of the audit on a Staff Education Day.

The aim of the project is to increase the discharge summary completion rate from 57.7% to 80% by June 2019.

A discharge summary process map was developed to understand the possible causes of delay then Plan, Do, Study, Act (PDSA) methodology was utilised. The result of the original audit was taken as the baseline measurement and benchmarking activities and PDSA cycle were performed. Interventions included root cause analysis by way of brainstorming, education, communication and constructing a checklist.

There has been significant improvement with the compliance rate following the PDSA cycle. It went up to 100% before tapering off to 85% by the end of the project.

Awareness building, continuous monitoring and engagement of teams alongside regular feedback were shown to be the important factors to achieve and sustain the improvement.

Accurate and timely handover of clinical information is of great importance to continuity and safety of care. Psychiatry doctors typically cover a number of sites across a catchment when they are on-call. Consequently, handover between on-call teams and day teams in psychiatric hospitals is reliant on using the nursing staff as an intermediary to flag concerns or relying on the day teams proactively checking the notes on daily basis for outstanding tasks.

The key objective of this project was to use Microsoft teams to establish a handover system that is efficient, safe, reliable, easy to use and replicable.

A microsoft teams group was created comprising of all the medical staff members working at inpatient units across three sites that are part of Birmingham and Solihull Mental Health Trust. These members were divided into two groups - the ‘on-call team’ and the ‘day team’. Within the ‘day team’, every consultant was grouped with their junior doctors to form multiple subgroups.

A system was established wherein the two teams could communicate with each other by posting a message and tagging the appropriate team. A provision was made to create a channel for every ward to allow for easy segregation and monitoring of tasks.

Qualitative information about the use of the tool was monitored by monthly focus group meetings. A formal review of the messages was conducted after 8 weeks to assess the following parameters:

Number of messages posted

Number of messages acknowledged

Number of safety-related incidents

Initial evaluation of the results suggests that the new handover system was perceived to be safe, accurate and efficient while being intuitive and hassle-free. This increased the quantity and enhanced the quality of communication between the ‘on-call’ and the ‘day teams’ and allowed for early completion of tasks while reducing the number of safety-related incidents.

The Microsoft teams proved to be a viable alternate tool to create a virtual handover process that is efficient, safe, reliable and user-friendly. It also has the potential to enhance the communication between inpatient and community teams.

When the coronavirus disease 2019 pandemic hit the UK, clinicians within Pennine Care NHS Foundation Trust (a five-borough mental health trust) were faced with the challenge of rapidly switching to a novel way of assessing patients remotely.

The idea for a QI project on trainees’ experience with remote consultations was conceived in April 2020. We present our February 2021 results here.

We aimed to improve trainee confidence in conducting remote psychiatric assessments by at least 40%, to ensure effective and safe patient care during their 6 months placement.

Our discovery process included surveying trainees in April 2020 to explore experiences with remote psychiatric consultations, a literature search of current UK guidance and a local audit. The audit reviewed documentation of consent to remote consultations, with reference to standards as per NHS England remote consultation guidance. Key change ideas included publication of an article, ‘Remote consultations – top tips for clinical practitioners’, video-simulated remote consultations and a session on remote consultations in the trainee induction.

In the first ‘plan-do-study-act’ (PDSA) cycle, we presented key findings from the article in a video presentation, which was sent trust-wide. We measured confidence in conducting remote assessments pre- and post-presentation via a feedback survey. Unfortunately, response rates were low and in the second PDSA cycle we targeted a smaller cohort of trainees at the August 2020 induction, although encountered similar difficulties. In the third PDSA cycle, we collected real-time data using an interactive app at the February 2021 trainee induction, and measured pre- and post- confidence following a presentation and a video-simulated remote consultation.

2/34 respondents had accessed previous remote psychiatric consultation training and12/35 had some telepsychiatry experience. Pre-induction trainee confidence results revealed: extremely uncomfortable (16%), not confident (31%), neutral (47%), confident (6%) and very confident (0%) and post-induction confidence was 0%, 22%, 52%, 26% and 0%, respectively.

Our project started during the first peak of the pandemic, which may be a reason for initial limited response rates. Our results suggest that the remote psychiatric consultation trainee induction session has shown some improvement in trainee confidence; the ‘confident’ cohort improved from 6% to 26%.

Our next steps include collecting similar real-time data, mid-rotation and uploading video-simulated remote consultations to the Trust Intranet. We plan to complete the local audit cycle. We also plan to incorporate patient experience (from an ongoing systematic review) to inform a potential triage process post-pandemic, choosing between face-to-face versus remote consultations.

Project aim:

To reduce the use of oral psychotropic PRN* medication on Ward 3 AMHIC (Acute Mental Health Inpatient Centre) by 20% by May 2020

(*PRN = Pro re nata/As required)

On Ward 3, we identified a number of unintended negative consequences of PRN medication to both patients and staff.

These included issues with over-use, dependence and side effects; as well as loss of staff ownership and challenging interactions with patients, (including escalation to aggression).

Following the success of our Child and Adolescent Mental Health Inpatient colleagues in this area, we decided to embark on a project to change practice within our ward.

In order to quantify the problem, we first collected baseline data on current use of psychotropic PRN medication.

As a multidisciplinary project team, we then brainstormed potential contributory factors and displayed these visually as a driver diagram.

This divided our project into 3 main areas:

1. 1) Safe prescribing

2. 2) Safe administration,

3. 3) Safety culture.

Outcome: Number of doses of oral psychotropic PRN medication administered per week

Balancing: Violent incidents; IM administrations of psychotropic medication

Process: Time taken to complete interventions; Patient and staff satisfaction. Change ideas were selected and implemented sequentially, using Plan-Do-Study- Act methodology.

These included:

1. 1) Weekly review of PRN prescribing

2. 2) Nursing administration sheet

By the end of May 2020, we had exceeded our initial goal, reducing the weekly median number of doses of oral psychotropic PRN medication administered by over 30%.

Our balancing measures remained stable and we gained useful insights and development ideas from a staff survey.

Further change ideas were planned for implementation over the months that followed, however, the impact of the COVID-19 pandemic meant that the project lost some momentum.

Despite running into some difficulty over recent months, the team remain motivated to maintain and build upon our previous success.

In the past few weeks, “Calm Cards”, (a patient-centred intervention promoting use of individualised alternative coping strategies), have been introduced.

We hope that the outcomes of this intervention will be positive, both in terms of further reducing use of PRN medication and encouraging development of skills which can be utilised beyond the hospital environment.

We also intend to share our learning with colleagues and explore the possibility of introducing the project to other wards within the hospital.

Our aim: To reduce the number of Level 1* violent incidents in Ward 4 by 30% by April 2020

*Level 1 is defined as “Behaviour involving force, which causes or is intended to cause physical harm to others; but excludes assault on objects, threats or verbal abuse”

Ward 4 is Belfast Health and Social Care Trust's only PICU, with a total of 6 beds. Our project took place on the background of a recent move to a new purpose-built inpatient unit, as well as a trust-wide initiative to address levels of violence across inpatient psychiatry services.

We divided our project into 3 main areas:

Patient factors

Staff factors

Environmental factors

We identified and implemented a number of change ideas, using Plan-Do-Study- Act methodology, regularly meeting to review progress and plotting our data on a run chart.

Key patient interventions included a “Mutual Respect” exercise and regular “Community Meetings”.

Staff interventions included use of Safety Crosses, Daily Safety Briefings and the Broset Violence Checklist (BVC).

Environmental factors were continually assessed and escalated as appropriate.

We raised awareness of our project and gained feedback by creating a dedicated notice board, providing a staff information session and including it as an agenda item at ward meetings.

Our project measures were identified as:

Outcome: Number of level 1 violent incidents occurring per week

Balancing: Number of incidents in other categories; Patient satisfaction

Process: Staff safety rating; Engagement with interventions

Unfortunately, we were unable to meet our initial goal and there continued to be considerable variation in the number of weekly incidents.

We believe this was attributable to several factors, including the level of acuity within the ward during the project timeframe. It was noted that a relatively small number of patients contributed to a large proportion of the total incidents. Our results, therefore, did not reflect the success of interventions with other patients on the ward.

Despite this, we noted improvements in terms of patient and staff engagement with the project, including subjective reports of staff safety during shifts.

The unpredictable and complex nature of the PICU setting cannot be under-estimated and this ultimately impacted on achieving our intended outcome.

We do feel, however, that the project has had a positive impact and we hope we can build on this progress over the coming months.

Further interventions are being explored, including personalised daily activity schedules and attempts to reduce levels of continuous observations.

The aims of this quality improvement project were to determine if Nicotine Replacement Therapy was being prescribed correctly in Shannon Clinic in Northern Ireland and also to improve the rates of correct prescribing of Nicotine Replacement Therapy in the aforementioned unit.

There are several different types of Nicotine Replacement Therapy currently available. Shannon Clinic is a smoke-free clinical environment therefore patients who smoke are offered Nicotine Replacement Therapy on admission. When I was working at Shannon Clinic I became aware that there was no clear guidance available to medical staff on the wards regarding prescribing Nicotine Replacement Therapy and therefore I decided to carry out this quality improvement project.

An audit of drug charts was done on the patients who were under the care of the consultant that I worked with. In total nine drug charts were included in the audit. After the audit was complete, I produced a poster to show how to correctly prescribe Nicotine Replacement Therapy. A copy of this poster was placed on each ward in Shannon Clinic. After a period of time the drug charts were re-audited to see if there had been an improvement in the rates of correct prescribing of Nicotine Replacement Therapy.

In total, 22% of the drug charts which were included in the audit had Nicotine Replacement Therapy prescribed incorrectly on them. After the inclusion of a poster outlining how to prescribe Nicotine correctly on each ward in Shannon Clinic, 0% of drug charts had Nicotine Replacement Therapy prescribed incorrectly on them. This was an improvement of 22%.

This quality improvement project was successful at reducing the rates of incorrect Nicotine Replacement Therapy in Shannon Clinic. In the future it is my hope that this quality improvement project should lead to the correct prescribing of Nicotine Replacement Therapy for all patients in Shannon Clinic. It should also lead to an increased awareness regarding the different types of Nicotine Replacement Therapy for medical staff working in this clinical unit.

In many countries (including the UK and Australia) it is still common practice for hospital doctors to write letters to patients’ general practitioners (GPs) following outpatient consultations, and for patients to receive copies of these letters. However, experience suggests that hospital doctors who have changed their practice to include writing letters directly to patients have more patient centred consultations and experience smoother handovers with other members of their multidisciplinary teams. (Rayner et al, BMJ 2020)

The aim of the study was to obtain patient's views to improve the quality of clinical letters sent to them, hence the level of communication and standards of care.

An anonymous questionnaire was designed and posted to collect information from patients attending one of the South County Mental Health outpatient clinic in Derbyshire. 50 random patients were selected between March to November 2020. Patients were asked to provide suggestions to improve the quality of their clinic letters written directly to them and copies sent to their GPs.

Out of 50 patients 48% (n = 24) responded. Majority of patients (92%) expressed their wish to receive their clinic letters written directly to them and 79% preferred to be addressed as a second person in the letters. More than half (54%, N = 13) of them would like to have letter by post. Majority of them (92%, N = 22) wished to have their letter within a week of their consultations.

Patients attending clinics felt that the communication could be better improved through writing clearly: a) reflection of what was discussed during the consultation b) updated diagnosis c) a clear follow-up plan d) current level of support e) medication change f) emergency contact numbers g) actions to be carried out by their GP and further referrals should there be any.

Patients in community prefer to have their clinic letters directly addressing them in second person. It was noted that the letters needed to reflect accurately on what was discussed during the consultation in order to have patient centered consultations. This in turn would improve communication and thus rapport, trust and overall therapeutic relationship.

Short admissions for crisis management among young people suffering with Emotionally Unstable Personality Disorder (EUPD) as recommended in National Institute for Health and Care Excellence (NICE) 2009 guidelines are not routinely offered in the United Kingdom (UK). Our aim was to introduce crisis admissions lasting for 72 hours. During this brief admission the families of young people presenting with suicidal behaviour are offered an assessment and diagnosis of young person's difficulties, psychoeducation, and safety plan for future risky behaviour, in addition to respite.

Three-day Crisis admission was set up with the aim of reducing inappropriate long admissions in people who may have more negative effects from admission than positive ones. A need was felt for a brief admission pathway in order to be able to provide treatment for patients suffering from EUPD traits in keeping with NICE guidelines. NICE guidelines suggest that people with borderline personality disorder should be considered for acute psychiatric inpatient admission only for the management of crises involving significant risk to self or others that cannot be managed by other services. The guidelines also recommend ensuring that the decision is based on an explicit and joint understanding of the potential benefits and likely harm that may result from admission and agreeing to the length and purpose of the admission in advance.

A retrospective study comparing length of hospital stay in the 2018 (when this model was introduced) with previous years, the number of serious incidents was carried out to assess the impact of this new admission model. The rate of readmissions in the same year was also assessed. For qualitative feedback regarding the effectiveness of the crisis admission as an intervention, a survey was carried out to assess parent satisfaction and the nursing staff was asked for their views.

There was a marked reduction in the number of serious incidents linked to suicide and length of hospital stay was reduced to half in the year when the crisis admissions were introduced as compared to the previous year. Only about 10-15% of patients required re-admission in the same year. About 90% of parents gave a positive feedback confirming the effectiveness of this intervention.

72-hour crisis admissions for adolescents are effective, appropriate, clinically indicated alternative to routine admissions with a high parent satisfaction.

This project aimed to assess and improve the quality and frequency of documentation from Psychiatric Liaison Team (PLT) to ward-based medical colleagues against the Treat as One recommendations. From experience, we hypothesised that written documentation of information crucial to patient care is not consistently meeting standards. This communication breakdown directly affects patient safety, potentially introducing additional risks to our already vulnerable patient group.

Effective communication between PLT and our medical colleagues bridges the gap in providing continuity of care and ensures patients’ mental and physical health needs are met in acute trusts. The NCEPOD found that there remains many barriers to high quality mental healthcare provided to patients in general hospitals and recommended 7 elements that PLT documentations should encompass.

We audited initial PLT assessments and the resulting documentation to determine if these met the 7 standards set by NCEPOD. Baseline audit undertaken from 21-27/09/2020 encompassing 130 patient referrals to PLT.

A period of time was allotted to implement robust changes to improve the service. This included a streamlined e-template that automatically populates in the acute hospital eRecord system which prompts clinicians to document according to the NCEPOD standards, structured clinician training and education, and the nomination of “Treat as One Guardians” in the team to ensure that acute trust documentations are present during daily multidisciplinary meetings.

The cycle was then completed on 22-28/02/2021 with a re-audit capturing 55 referrals.

Implementation of our recommended changes saw an increase from 58% of documentations with ≥50% NCEPOD elements to 98% in the re-audit.

We also saw an increase in number of the NCEPOD 7 elements included following intervention: formulation (0% to 8%), legal status and capacity (47% to 79%), risk assessment (2% to 28%), risk management (18% to 53%), and discharge plan (2% to 29%).

Completion rate of acute trust documentation increased from 74% to 96%.

Our interventions also led to more contemporaneous communication, significantly reducing mean time from assessment to documentation in both acute trust and mental health records from 6.02 to 3.53 hours, (p = 0.04) and 6.12 to 3.50 hours, (p = 0.05) respectively.

Following our interventions, the results showed improving trends in the frequency and quality of our documentation with secondary outcomes showing increased documenting efficiency. Our current practice is not yet optimal and retains potential to adversely affect our patients. We propose further investigating barriers to change using the quality improvement PDSA (Plan, Do, Study, Act) methodology to continue innovating.

Our first aim was to first find out how confident general practitioners were about referring in to the Gloucester Recovery Team and managing psychotropic medications. Our second aim was to then improve general practitioner's self-rated scores of confidence in managing psychotropic medication whilst also improving general practitioner's satisfaction with waiting times for patient's referred to the Gloucester Recovery Team.

We planned to introduce an email address for GPs to use to seek medication and diagnostic advice for patients known to and not known to the Recovery Team. We initially introduced this for the ‘Team 2’ catchment area consisting of five practices within Gloucester. These were then read and replied to by the Team 2 consultant, Dr Ikram, as appropriate. A further survey was then sent out.. These results provided both quantitative ordinal data through a likert scale, which was then transformed into binomial data, such as those scoring ‘extremely confident’ ‘very confident’ ‘somewhat confident’ vs ‘not so confident’ and ‘not confident at all’ which is then compared using relative risk.

Our response rate for our initial survey was 8 general practitioners, and for our follow-up survey 1 general practitioner and 2 nurse prescribers. Confidence in continuing psychotropic medications increased from 7 out of the 8 (78%) stating somewhat confident to extremely confident to 3 out of the 3 (100%) after the introduction of the email; a relative change of 1.14 (95% confidence interval 0.87-1.48 p = 0.318). Confidence in initiating psychotropic medications increased from 4 out of the 8 (50%) stating somewhat confident to extremely confident to 2 out of the 3 (66%) after the introduction of the email; a relative change of 1.33 (95% confidence interval 0.46-3.84 p = 0.594).

Analysing the qualitative data showed the email address was used for a variety of requests and advice including: 1) A capacity assessment, 2) Initiating medications for depression and anxiety, 3) Medications during pregnancy, 4) Medication for those with Intellectual Disability, 5) Switching medication, 6) Medications for poor sleep and 7) Mood stabilising medication.

This change appeared to be well received, however the response rate was very low which makes full analysis difficult. We also included nurse practitioners working in primary mental health in our second survey, whereas the initial survey was only sent to GPs. This initiative was also only started for 5 of the GP practices within Gloucester, and there may be a different knowledge base/confidence amongst the other practices.

To ascertain whether patients prescribed second generation antipsychotics for off-label indications are being monitored and screened adequately for physical health side-effects.

The prevalence of off-label antipsychotic use has increased significantly over recent decades. Common off-licence uses include dementia, post-traumatic stress disorder, adjunctive treatment for unipolar depression and personality disorders. Recent studies have demonstrated that up to 65% of antipsychotic prescriptions are now off-label. Since the metabolic side-effects of second-generation antipsychotics are well-established, guidelines have emphasised the need for active, routine physical health screening of all individuals taking these drugs. However, there have been few studies or reviews which have specifically investigated screening rates of individuals receiving antipsychotic medications for off-licence indications.

An audit of patients taking second-generation antipsychotics for off-label indications, under the caseload of Neighbourhoods 1, 3 and 4 of Lewisham Assessment & Liaison team, was conducted. After isolating individual patients fulfilling inclusion criteria, patient investigation documents were requested from relevant GP practices. 40 patients were isolated in total, and data were successfully collected in 60% (n = 24). Data were collected via a proforma. This consisted of patient information, indications for antipsychotic use, and each variable to be monitored. The audit standard used was the recommendations of the 12th Maudsley guidelines. Data were then entered into SPSS and analysed.

The most common reasons for off-label antipsychotic prescribing were Emotionally Unstable Personality disorder (42%, n = 10) and depression (29%, n = 7). Findings demonstrated that 54% (n = 13) of patients audited had ‘basic’ blood screening (FBC, U&E, LFTs), however glucose (38%, n = 9), Prolactin (13%, n = 3), and Creatine Kinase (0%, n = 0), and monitoring was less frequent. 0% (n = 0) were completely monitored as per audit standard.

Primary care monitoring of off-label antipsychotics is unsatisfactory, with no patients having a complete set of investigations. Reasons for this are unclear at this stage, however based on initial discussion with GP surgeries, may be due to lack of education regarding screening investigations, patients lost between primary and secondary care services, and a lack of clarity regarding responsibility and designated roles. This audit will be expanded to also include patients from Neighbourhood 2 of the Lewisham Assessment & Liaison team. A more detailed investigation will be conducted into the barriers to physical health screening, such that a targeted intervention can be implanted.

To reduce incidents of inpatient violence and aggression at Nile Ward Psychiatric Intensive Care Unit (PICU), St Charles Hospital by at least 30% between December 2019 and December 2020. Reducing inpatient violence is a major quality improvement (QI) priority for CNWL NHS Foundation Trust.

As a Psychiatric Intensive Care Unit, Nile Ward looks after male patients suffering from severe mental illness (SMI). This usually includes patients presenting with high levels of violent and aggressive behaviour. Prior to this QI project, there were high levels of patient assaults towards staff and other patients. This required a lot of medication use, including rapid tranquilisation, restraint and the use of seclusion. This QI project was started to allow the Nile MDT to explore ways to reduce serious incidents on the ward in the least restrictive manner.

We implemented a number of change ideas within this project. Our change ideas included: 1. A new risk management tool : ‘Ragging', a daily risk assessment tool, was created to assess patients’ risk of violence and aggression to allow signposting of appropriate interventions to safely manage risk. 2. A brand new Staff Photo board : New photos of all permanent and bank staff displayed in the ward with no hierarchy of positions. 3. A new Patient Feedback board : Patient experience, comments and feedback displayed in common areas of the ward which are regularly updated. 4. Mutual Expectations between Staff and Patients: A set of expectations created in co-production with patients displayed in the communal areas of the ward to be followed by both staff and patients. 5. Gardening sessions : One of our newer change ideas during the COVID-19 pandemic was to provide a safe, socially distanced space for patients to be involved in growing and caring for the Nile Ward garden with our activities co-ordinator. 6. Optimisation of Physical Exercise : Focus on physical activity through garden fitness sessions and 1-1 fitness sessions in the gym. This was another change idea commenced during the COVID-19 pandemic. These sessions occur throughout the day with our fitness instructor and enable our patients to focus on their physical health & fitness. 7. Improved Ward Environment : Gym equipment were upgraded and the appearance of the ward gymnasium was enhanced using quality art created in co-production with patients.

There was a 43% reduction in the number of violent incidents in the ward following QI interventions. The details of the results will be depicted in pictorial form in the poster.

Our patients are able to recover in a safe environment with a reduced level of violence and aggression resulting in patients receiving less rapid tranquilisation and restrictive interventions. We have had fewer assaults on staff which has made our staff feel safer to work in a busy PICU. Staff feel more confident in their role through the use of the new risk assessment tool . Patients and staff alike have given positive feedback to the changes implemented in this QI project, with violence being successfully reduced by 43%. We hope that our QI project can be used as an example to show how QI methodology can enable Violence Reduction within mental health services.

St Charles is one of the largest inpatient mental health units in London with 8 wards and covers the boroughs of Kensington & Chelsea and Westminster. This project aimed was set up so that 95% of patients in St Charles Mental Health Centre would have a complete cardiometabolic health assessment by December 2020. This would include Weight, Smoking, Alcohol, Substance Use, Hypertension, Cholesterol and Diabetes assessments with necessary interventions recorded. The outcome of the intervention would improve overall physical health and life expectancy.

People with serious mental illness experience significantly worse physical health and shorter life expectancy of up to 10 to 15 years than the general population. CNWL is making Physical Health of patients in Mental Health Services a priority. Performance in this area has been challenging across the Trust because of:

• – Buy in from clinicians.

• – Staff did not feel empowered to discuss interventions with patients.

• – High sickness and absence as a result of COVID was found to directly correlate with reduced physical health monitoring/recording.

• – Lack of training in completing the SystmOne physical health template

Prior to the commencement of this project, the wards in St Charles Mental Health Centre completed physical health assessments on roughly 8% of the patients in February 2020. The QI project was implemented in June 2020. By September 2020, physical health recording across 8 wards across St Charles had increased to 89% following successful implementation of the interventions.

The following interventions resulted in a significant improvement in physical health cardiometabolic risk monitoring at a busy inpatient mental health setting:

• – Monthly physical heath meetings to enable shared learning with ward doctors, nurses and healthcare assistants.

• – Ongoing one-to-one and group support to train staff with completing and recording physical health assessments.

• – Tableau Physical Health Report regularly reviewed with MDT during ward round meetings.

• – Physical health leads given supernumerary days to run physical health clinics on the wards.

• – Fortnightly Physical health monitoring meetings with the Director of Nursing and Head of Governance.

There is a significant period of adjustment for new higher trainees in psychiatry given the presence of inter-trust differences in the National Health Services (NHS). It may take some time for a trainee to become familiar with the new administrative system and workflow of the new environment, which may be even longer for an international medical graduate (IMG). Although there is an existing induction system, having a written structured manual will assist the trainees to get through this process more easily. Hence, this Quality Improvement Project (QIP) outlined the creation of an induction manual that serves as a starter pack to facilitate the settling-in process of new North Wales higher trainees in psychiatry, i.e. the “Croeso i Seiciatreg Gogledd Cymru” (CiSGC) guide (means Welcome to North Wales Psychiatry in Welsh).

The induction manual was initially drafted by the authors based on the available printed policies and information online. Further input and from different stakeholders were obtained to triangulate and enrich the manual. Specific links and further references were included in the manual for the reference of prospective manual users. Authors’ contact details were included for any further clarification, suggestions or input.

The manual consisted of four sections: A) General Process before, during and after Reporting Duty, B) Trainees’ Duty, 3) Speciality-specific Guidance, and 4) Health Board-related Information. The General Process section covered the visa-related information, post-acceptance paperwork process, access to email and hospital informative system, medical practice-related issues (including section 12(2) approval and medical indemnity). The Trainees’ Duty section briefed on time-tabling and clinical duty. The Specialty-specific Guide provided important information related to training. Lastly, the section of Health Board-related Information highlighted the administrative structure of the NHS Health Board, important contact numbers, link to information. Specialty specific sections were created for general adult psychiatry and old age psychiatry as there is no other higher training of psychiatry in North Wales at the moment. Further sections in the pipeline include substance misuse and liaison psychiatry.

This induction manual is neither prescriptive nor exhaustive. It serves as a generic reference to facilitate new trainees in their adjustment process. Further review and revision will be conducted before every induction process to ensure the information is up-to-date and incorporating new input from the trainees.

Nervecentre is an application that can be used on mobile devices and desktop computers to record and view physical observations amongst other tools. An audit had been done previously assessing the practice of recording observations using paper documentation. That audit had recommended the use of Nervecentre to improve the recording of observations. This audit was undertaken following the introduction of Nervecentre for documentation of physical observations. The aims were to evaluate if the transition to electronic documentation of NEWS (National Early Warning Score) observations on Nervecentre has improved practice in comparison to paper documentation and to evaluate if our practice could be improved by implementing electronic observations for psychiatric observations in addition.

Data were collected over a 10-day period looking at all the documented observations from all inpatients on the MHSOP wards that met the inclusion criteria. Data were collected on the recording of psychiatric observations (recorded on paper charts) and physical observations (recorded on Nervecentre). The data were collated and analysed. The new data were compared to the original data from prior to the introduction of NerveCentre and the findings were presented at a local meeting.

This audit has highlighted that the documentation of physical observations on MHSOP wards has greatly improved since Nervecentre was introduced. There was an improvement in recording of physical observations in almost all domains measured. NEWS scores were correctly documented 100% of the time compared to 87% previously. Raised NEWS scores were correctly escalated to a senior and reviewed 80% of the time compared to 0% previously. It has also highlighted that the quality of documentation regarding psychiatric observations could be improved as we are not currently meeting local or national guidance.

The most likely cause for the improvement in the recording of the physical observations is the implementation of Nervecentre. Nervecentre prompts users when observations are due, removes the risk of calculation errors and allows for observations to be directly escalated. Implementing Nervecentre for psychiatric observations may similarly improve the quality of these observations therefore improving patient safety.