1- What percentages of people presenting to general hospital that are referred to Liaison Psychiatry service have Substance misuse problems? 2- Are the assessments by Liaison Psychiatry services identifying substance misuse problems? 3- If substance misuse problem is identified then are we offering any advice/intervention/referral

To look at 100 consecutive assessments by using an audit proforma to capture information required to answer above questions.

In 78% of cases there was evidence documented that the patient was asked about alcohol use. In 22% - no evidence patient was asked about alcohol use.

• – 77% documentation about drug use. 23% no evidence documented that the patient was asked.

• – Of those asked about their alcohol use (n = 62), a misuse problem was identified by clinicians making the assessment in 6 cases (10% of those asked).

• – Of those asked about their drug use (n = 61), a misuse problem was identified by clinicians making the assessment in 8 of cases (13% of those asked).

Of those with a substance misuse problem identified (n = 15), 20% identified misuse of both alcohol and drugs, 40% identified misuse of alcohol only, and 40% identified misuse of drugs only.

• – Of those with a substance misuse problem identified (n = 15), 73% were offered advice or an intervention, and 27% had no intervention documented.

Just over a fifth of patients assessed were not asked about alcohol or drug use. This has improved since August 2020 when nearly half of the patients assessed were not asked about alcohol or drug use.

• – Since audit in August 2020, there has been a 21% increase in documentation of advice or intervention being offered to patients identified to have a substance misuse problem.

Disordered sleep is common, affecting 20–30%of children aged 1–5 years and often continues later into childhood. Neurodevelopmental disorders and psychiatric comorbidities pose a greater risk. The audit aimed to determine whether clinical prescribing practice of melatonin in Burlington House, Sefton CAMHS reflected current NICE recommendations. NICE suggest that first-line treatments for children with sleep problems include good sleep hygiene and behavioural therapy (including sleep diary).

Nice guideline CG170 provides guidance on Autism management. BNFC states that melatonin therapy should be reviewed every 6 months. Records of children currently prescribed modified release melatonin were checked to see if they met the inclusion criteria. Data were collected retrospectively from clinical case files and pharmacy records (December 2020- February 2021).

The results showed 18 young persons received melatonin for insomnia with ASD, 26 for insomnia without ASD, 3 for likely ASD and none for Smith Magenis syndrome. 36 received Specialist CAMHS review, 9 received Community Pediatrics review and 2 GP review. All patients received melatonin as per dose recommendations with 6 monthly reviews. Documentation on sleep hygiene was unclear.

We concluded that Melatonin prescribing in community CAMHS tends to be high and discussion on sleep hygiene measures must be given importance.

This audit aimed to assess the adherence to the anti-psychotic policy for delirium in the medical wards. It aimed to assess compliance with each of the guidelines mentioned in the health board's policy which is based on the National Institute for Health and Cares Excellence (NICE) guidelines.

After registering the audit, the Acute medical ward was approached for the hospital numbers of all the patients admitted in the months between January and March 2021, and 70 case records were screened. Case notes of patients above 18 years who were diagnosed with delirium including those after managing alcohol withdrawal were included. Those who were admitted only with alcohol withdrawal delirium were excluded. 47 case records were selected for data collection. A proforma was prepared based on the policy available in the intranet and data were entered.

Retrospective data of 47 patients who had delirium were analysed which included 18 males and 29 females. The mean age of the participants was 80.7 years (range 40–101; SD + 30). The mean days of referral after admission were 28(+7.07). 34%were diagnosed to have delirium by the treating team,8.5% were diagnosed by the Emergency Department (ED) team and 57.4% were diagnosed by the liaison psychiatric team. 57% had another psychiatric diagnosis. The cause for delirium was mentioned in 55% of the records and the most common cause was urinary tract infection (31%) followed by multifactorial delirium (27%). Antipsychotics were prescribed for 57% and among those who received 74% received risperidone, 15% received olanzapine, and 11% haloperidol. Compliance was 100% in prescribing appropriate antipsychotics, maximum dose, investigations (expect x-ray chest and CT scan), only 54% compliance was observed with regards to stopping the antipsychotic before discharge and in 23% it was mentioned to be monitored by the GP and another 23% by the treating team.

This audit has displayed the lacuna in the prescription of antipsychotics for patients diagnosed with delirium. Periodic programs will be planned and executed for training the liaison practitioners and the staff in the medical wards regarding the diagnosis and management of delirium especially the prescription of antipsychotics. A re-audit will be conducted after 6 months.

There is increasing recognition of the use of psychotropic medication in young people with intellectual disability (ID) at a population level but little is known about day-to-day prescribing practice. This project aimed to characterise medication use in this group and assess standards of prescribing practice with reference to RCPsych guidelines.

Data werecollected by case note review of young people prescribed psychotropic medication within a community ID CAMHS Service. An index prescription was assessed against standards of prescribing - this was the longest standing script for each young person in the study.

73 young people were recruited, aged 7–20 years, predominantly with moderate or severe ID. There was a high degree of comorbidity predominantly with autistic spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD) and anxiety presentations. Diagnoses did not differ by sex (p > 0.05) however behaviours that challenge were proportionately higher in females (p = 0.014). A high proportion of youngsters displayed behaviours that challenge (68.5%, n = 50) and almost all of these young people (96%, n = 48) had an additional diagnosis. ADHD presentations were negatively associated with behaviours that challenge (p = 0.047).

The hypnotic melatonin was most frequently used medication (56.2%, n = 41) followed by SSRI's (49.3%, n = 36) and antipsychotics (20.5%, n = 15). It was common for use of multiple medications (67.1%, n = 49), typically combining melatonin with a stimulant, SSRI or antipsychotic medication (61%, n = 31). Medications were generally used at modest doses.

The index prescription was in place for a median of 25 months (IQR 28.5, Range 1–108). The indication for prescribing was well documented (98.6%, n = 72) however severity (67.1%, n = 49) and frequency (56.2%, n = 41) recording was poorer. 6-monthly review rate was relatively low (62.5%, n = 40) but the likelihood of review did not reduce with increasing prescription length (p > 0.05). Review of medication response (94.2%, n = 65) and side-effects (73.9%, n = 51) was good. Overall there was poor documentation around consent-to-treatment procedures for young people over 16 years of age with only 17.2% (n = 5) having valid authorisation for medication in their case notes.

This study provides rich clinical data about current clinical practice around prescribing in youngsters with ID. Comorbidity is common and results suggest there may be a bias in labelling behaviours that challenge in males as ADHD-related. A range of (multiple) psychotropic medications are used, often for long-periods despite a lack of evidence base. Clinicians are encouraged to ensure rigorous review and consent-to-treatment processes to minimise harms and over-prescribing in this vulnerable population.

In England, 64.8% of adults are currently classified as overweight or obese, with rates even higher in the North East at 68.6%, especially in adults with severe mental health illnesses. This additional body weight has the potential to increase the risk of developing a number of serious health conditions including diabetes, heart disease and even cancer. Studies have shown that patients with schizophrenia have a 2.8–3.5 increased likelihood of significant weight gain and reduction in life expectancy of 15–20 years, mainly due to preventable physical illness. Monitoring of risk factors for this, particularly weight gain, is therefore crucial. The NICE Guideline (2014) recommends that patients are routinely categorised into BMI categories to assist with obesity identification, management, and monitoring. A waist measurement is also advised to help with risk stratification. Patients with psychosis or schizophrenia, especially those taking anti-psychotics are also recommended to be offered a combined healthy eating and physical activity programme by their mental healthcare provider. Finally, patients with rapid or excessive weight gain, abnormal lipid levels or problems with blood glucose management should be offered appropriate interventions. Our main objective was to identify whether the obesity assessment, monitoring and intervention care delivered by our community team is in line with current guidance.

A total of 12 residents living in community forensic supported accommodation and currently taking antipsychotic medications were included. Data reviewed were from September 2020 to September 2021. Data audited were from electronic medical records.

This audit found that 10 out of 12 patients (83%) fell into either the overweight or obese BMI categories (seven obese and three overweight). Only four patients had agreed to have their waist circumference measured, which meant only four patients were able to be appropriately risk stratified. One patient was identified as pre-diabetic and another diabetic. All patients identified to be overweight or obese received appropriate lifestyle advice. Qrisk scores, to assess cardiovascular risk, were calculated for the majority of eligible patients, except for two.

This audit highlights that patients who are on regular antipsychotic treatment and living in the community are at high risk of obesity and its associated complications. It is important to perform regular health checks in this cohort due to this risk, both to improve their quality of life and prevent significant morbidity and mortality. Waist circumference measurements should be encouraged to enable risk stratification and accurate documentation will enable timely treatment intensification.

The Driver and Vehicle Licensing Agency (DVLA) in England, Scotland and Wales are legally responsible for deciding if a person is medically unfit to drive. This means they need to know if a person holding a driving licence has a condition or is undergoing treatment that may now, or in the future, affect their safety as a driver. The driver is legally responsible for telling the DVLA about any such condition or treatment. Doctors should therefore alert patients to conditions and treatments that might affect their ability to drive and remind them of their duty to tell the appropriate agency. Patients with acute schizophrenia or an acute psychotic disorder must not drive and must notify the DVLA. In alliance with the above, the GMC advises that clinicians have a responsibility to explain the above information to the patient and inform them that they have a legal duty to inform the DVLA. Doctors should also inform patients that relevant medical information may need disclosing about them to the DVLA if they continue to drive against advice, and any advice given should be documented. The main objective of this audit is to identify if notification of DVLA for forensic patients living in supported accommodation, is in accordance with the DVLA guidelines.

A total of 12 residents living in community forensic supported accommodation who have a notifiable diagnosis were included. Data collection took place in September 2021, looking through all previous records relating to the search words “DVLA”, “drive”, “driving” and “license”. Data audited were from the trust's electronic patient records.

Diagnoses included paranoid schizophrenia, delusional disorder and personality disorder. Antipsychotic medications included Olanzapine (oral and IM), Clozapine and Zuclopenthixol +/- antidepressants. Legal status included community treatment orders (civil section), voluntary community patients and those on a conditionally discharged restriction under secretary of State supervision. Two patients held full driving licences and a further two held provisional licences, with DVLA documented discussions and notification compliance at 100%. The remaining eight patients had no documentation regarding driving nor DVLA discussions or notification.

This audit found that DVLA discussions are not currently well documented, with only four patient records that have this recorded. Although it is the clinical team's responsibility to advise the patient to notify the DVLA, it is ultimately the patient's responsibility to notify the DVLA themselves. DVLA discussions need to be had regardless of driving status and documentation should reflect this.

Medicine reconciliation in community teams is guided by trust guidance, which emphasises that for all new patients accepted into a community team, staff should be aware of all current medication (both psychotropic medication and those prescribed for physical health needs). This information needs to be considered at each review to inform safe prescribing. Upon this background, concordance between electronic mental health records and general practice shared records of medications and allergy status for patients residing at a community forensic supported accommodation was audited in order to identify areas for improvement in practice.

Data were collected from mental health electronic records (Rio) and general practice records (Health Information Exchange). All patients residing full-time at a community forensic supported accommodation in Cumbria Northumberland Tyne and Wear NHS Foundation Trust during January 2022 were included. Concordance between the records in medication and allergy status was assessed. Initial assessment was performed by one reviewer and 100% of included records were then cross checked by a second reviewer. Data collection was intended to pick up any mismatch in the records. Standards were set at 100% concordance.

Eight patients were included. For allergy status, in two patients’ (25%) records showed allergies which were present in electronic mental health records were not present in general practice records. The reasons as to lack of documentation of allergy status in general practice records were unclear. Cross check of the discharge summaries to primary care from the wards where allergies were originally identified indicates that allergies were clearly documented.

For medication, discrepancies between records were found in two patients (25%). In these patients, medications present on general practice records were not present on mental health records. These were both physical health medications (vitamin D supplements) which were being prescribed regularly by primary care and had been omitted during transcription onto electronic mental health records.

• 1) Currently, standard practice is for updates of medication on mental health records to take place every four months as part of quarterly care coordination reviews. Electronic mental health records should not be relied upon solely to check patients’ medication: while they provide a snapshot, cross checking with primary care records and pharmacy remains a must. This is current practice and ensures patient safety.

• 2) Primary care to be made aware of the omissions and requested to update their records as per the discharge summaries.

• 3) Continue regular re-audits every four months

Antipsychotic use is associated with cardiovascular and metabolic side-effects, which may contribute to increase mortality and morbidity in this patient group. This highlights the importance of physical health monitoring. We aimed to assess our compliance with the more stringent NICE guidelines, updated in September 2021.

Half of BEIS team's caseload was audited (n = 67) during October 2021 for compliance with NICE's monitoring guidelines for patients initiated on antipsychotic medication. These included initial and, if indicated, repeat monitoring of body mass index (BMI), pulse, blood pressure (BP), blood results, electrocardiogram, and adverse effects. Patients who were not on antipsychotics were excluded. 61% of patients were initiated on antipsychotics as inpatients, and 39% were outpatients. These patients have been started on antipsychotics within the last three years. Data were collected via electronic record systems. 80% compliance was set as the standard, in line with National Clinical Audit of Psychosis standards.

In the first three months of antipsychotic initiation (61% as inpatients, 39% in the community) six out of nine parameters met standards (ranging from 2% to 100%), with BMI measurement (weekly), pulse and BP measurements and one month repeat haemoglobin A1C (HbA1c) failing. When only accounting for patients who were started on antipsychotics in outpatient settings (BEIS or crisis team), compliance was only met on two parameters.

Three months post initiation, when patients were mainly monitored in the community, only three of the nine parameters met compliance (lipids, HBA1c, and side-effects).

Adherence to the NICE standards for physical health monitoring in the community poses significant challenges. Possible barriers include reduced patient contact during the pandemic, lack of awareness of monitoring requirements, poor documentation (particularly of declined screening) and a lack of time and resources. There is also a possibility of unnecessarily stringent and impractical guidelines which are difficult to achieve in outpatient settings – such as weekly BMI. We plan to implement interventions including providing a checklist for medical and nursing staff and encouraging patients to monitor their own blood pressure and weight at home. We will reaudit the same parameters in 6 months’ time.

To ensure physical health and resuscitation equipment on all wards in a mental health hospital fulfil relevant standards. A closed-loop audit of this was performed on four acute adult inpatient wards after implementing interventions.

Data were collected from treatment rooms on each ward, with standards based on Physical Health in Mental Health; Final Report of a Scoping Group (Royal College of Psychiatrists) and Mental Health Inpatient Care Equipment and Drug Lists (Resuscitation Council UK) – parallel to the trust approved standards.

Percentage of availability and functionality against audit standards were tabulated and interventions were carried out, including:

1. 1. Awareness presentations at trust clinical governance meetings.

2. 2. Each ward to have own complete sets of physical health and resuscitation equipment.

3. 3. Policy for wards to register their physical health equipment and service details on the trust maintenance services database. The medical device engineering team to complete maintenance and repair as needed.

4. 4. Resuscitation equipment on each ward being checked weekly and replaced as needed (monthly before).

A re-audit was performed one year post intervention on four acute adult inpatient wards in the mental health hospital using similar parameters.

1. 1. In general, 90.0% of the standards are met (out of 160 pieces of equipment, 144 are in stock and functional), similar to that of previous year (90.0%).

2. 2. Decrease in overall available and functional physical health equipment: 76.6% (49/64) compared to 83.8% last year.

3. 3. Increase in overall in overall available and functional resuscitation equipment: 99.2% (95/96) compared to 94.2% last year.

There is a significant decrease in percentage of overall available and functional physical health equipment; while that of resuscitation equipment has significantly improved when checked and corrected weekly using the trust Resuscitation Check Form.

Action plan:

1. 1. All unavailable/ inadequate equipment to be reordered or sent for maintenance immediately.

2. 2. Discussion in the upcoming trust Physical Health Nurses Forum and Medical Devices Standards Group on audit recommendations below:

   • . Allocation of named permanent staff member to check presence and functionality of medical equipment regularly.

   • a. Creating a checklist similar to the Resuscitation Check Form for physical health equipment.

3. 3. Discussion in the trust Resus Standards Group on ‘My Kit Check’ (MKC), a centrally monitored electronic checking platform with alerts automatically sent for incomplete checks or expired resuscitation items (e.g., AED batteries, anaphylaxis kit) that are not replaced. A funding request has been submitted for this.

Smoking is the single largest cause of preventable death. Smoking prevalence is higher in people with mental disorders and impacts on physical health, mental health and bioavailability of psychotropic medications. Evidence-based interventions exist to support smoking cessation (SC)/reduction in people with mental disorders, although evidence suggests less provision compared to the general population. We aim to determine the unmet SC needs and associated causes in a community secondary mental health service, in order to advise appropriate service response. This audit will inform relevant work of the RCPsych Public Mental Health Implementation Centre as a case example.

From the caseload of 364 patients, a sample of 91 case records was randomly selected for recording of smoking and provision of treatment. A survey of 31 smokers and 12 ex-smokers identified patient attitude and barriers in SC. Information on availability and nature of other SC provision in the community was gathered from staff and relevant services.

A sample of case records found 44% (n = 40) of patients were smokers compared to 13,5% in the general UK population. 31 patients were offered SC advice of whom 2 were recorded as wanting to quit. Nicotine Replacement Therapy (NRT) was offered to 13 patients and 5 were referred to SC services (SCS). Aside from smoking status, limited information on smoking was recorded.

The survey revealed that 20/31 smokers wanted to reduce or quit smoking, of whom 10 used NRT. Six were referred to SCS which helped 3 reduce. Four ex-smokers used SCS, which helped 3 to quit. Most frequently reported barriers in SC were habit, social isolation, availability of tobacco, and stress. Frequently reported enhancers in SC were NRT, allocated support with follow-up, social interventions and family support.

Regarding current service provision, we identified that local GP's did not prescribe NRT. Targeted SCS exist exclusively for inpatients and the only community SCS available offered 12 SC sessions without targeting needs of people with mental disorder.

Despite high smoking prevalence in our caseload, there is an implementation gap in providing and recording SC advice and treatment, both in our service as in local primary care and community services. Provision of evidence-based interventions and coordination with GP's and SCS could prove useful in narrowing this gap. Results from this local project could be explored on a larger scale to address the implementation gap in SC in this population at high risk of smoking associated harm.

Chlamydia, a sexually transmitted bacterial infection caused by Chlamydia Trachomatis can result in long-term complications for affected individuals. The National chlamydia screening programme recommends screening at-risk young persons, however for the vulnerable patients at the Forensic Child and Adolescent Mental Health Service (FCAMHS), there has been no audit to determine the completion rate. This audit aim to (1) Determine the demographics of young persons on admission (2) To determine the rate of chlamydia screening as well as the percentage of patients who qualified for a Chlamydia screening(3) To determine the rate of documentation for completed tests.

This was a retrospective study. The medical electronic records of patients who met the inclusion criteria was searched. All the three mixed-sex adolescent forensic wards (2 medium secure units and one low secure unit) at FCAMHS Ardenleigh, Birmingham were sampled.

All patients that were on admission aged above 15 years of age were recruited.

A total sample size of 19 was obtained for the initial audit and 12 for the re-audit.

Data collection

Data were collected by the author for the initial-audit and re-audit by searching the clinical progress notes, the investigation results and the physical health rethink forms. An excel software was used for analysis.

Demographics

There were 11 males (57.9%) and 8 females (42.1%) in the initial audit

In the re-audit, there were 7 males (58.3) and 5 females (41.7). Some of the patients were still on admission at the time of the re-audit, hence the percentages were calculated differently. The mean age and average length of admission was also calculated.

Chlamydia screening

In the initial audit, the percentage of patients tested for Chlamydia was 11.5%, even though 36.8% of patients met the criteria for Chlamydia screening. In the re-audit, 25.0% were tested, and 41.7% met the criteria for Chlamydia screening.

Physical health (Rethink) forms

The physical health form was completed for majority of patients 73.7% in the initial audit although, this was not compatible with screening rates. Before the re-audit was concluded, the physical health forms were no longer in use.

The audit highlighted an overall improvement in the rate of screening following recommendations from initial audit. The inclusion of Chlamydia screening in admission processes could be useful in improving sexual health.

A consideration for patient dignity in end-of-life care dictates that good clinical judgment should be exercised in advance resuscitation decisions. The COVID-19 pandemic, and its inherent risks to caregivers, only adds to this importance. Our aim was to audit the standards for the DNACPR policy at Mount Carmel Hospital (MCH), which is Malta's major inpatient psychiatric hospital, against those at Saint Vincent De Paule Residence (SVPR), which is a long-term care facility where DNACPR decisions are taken by geriatricians as opposed to psychiatrists.

Resuscitation status designation and rates of form completion were measured in the five chronic psychiatric inpatient wards at MCH. This 98-patient population was compared against an age-matched cohort from SVPR to evaluate differences in decision-making.

Medical comorbidities and frailty scores (measured using the Clinical Frailty Scale) were compared between the two groups. As far as age-groups would allow, as many patients with a psychiatric comorbidity as possible were included from SVPR (36).

Z-score testing for two population proportions was used to evaluate the differences in resuscitation status designation. The Independent Sample T-Test was used to compare means in medical comorbidity and frailty. A p-value of <0.05 was used to assume statistical significance.

Rates of resuscitation form completion were 73.47% and 94.90% in MCH and SVPR, respectively. In those patients with completed documentation, 9.72% of patients were designated as “Not for CPR” in MCH, compared to 61.29% in SVPR.

Between these two age-matched cohorts, the mean frailty score was slightly greater in SVPR, which was not statistically significant (5.83 vs 5.48, p = 0.1456). The mean number of medical comorbidities was significantly greater in the SVPR cohort (3.50 vs 2.47, p = 0.0002).

This striking difference in DNACPR designation suggests that geriatricians have a higher threshold for determining whether a patient would benefit from CPR compared to psychiatrists. Furthermore, rates of resuscitation form completion at MCH were disappointing. The greater likelihood for chronic psychiatric inpatients to be designated “For CPR” may be due to the perception that this entails a higher level care. In reality, in older, frailer patients, CPR may only prolong suffering, while a “Not for CPR” decision does not necessarily imply an omission of care.

In Malta, we've tailored resuscitation training to the inpatient psychiatry setting, which includes stations on decision-making and COVID-19.

The MHRA is a comprehensive form on our electronic patient records system. It includes 11 sections assessing different risk categories, with tick boxes to evidence input from various members of the MDT. Anecdotal experience suggested that these forms were sometimes incomplete and often lacked input from MDT members other than nursing staff. We aimed to increase the completion rate and multidisciplinary team (MDT) involvement, particularly doctor involvement, in the electronic MHRA documentation on an acute inpatient psychiatric assessment ward at the Royal Edinburgh Hospital.

• • Baseline survey (November cohort of 12 patients): data collection on number of sections completed (total number = 11) and whether the ‘psychiatrist’ box was ticked, indicating medical input.

• • Intervention: doctors on the ward reviewed all inpatient MHRAs, added additional assessments if appropriate, and ticked ‘psychiatrist’ involvement in the MHRA.

• • Repeat survey (February cohort of 11 patients): data collection as before and review of findings.

In our baseline survey (November 2021), 75% (9/12) of patients had all sections of the MHRA completed. 33% (4/12) had the ‘psychiatrist’ box ticked. In our repeat survey (February 2022), 91% (10/11) of patients had all sections of the MHRA completed. 100% (11/11) had the ‘psychiatrist’ box ticked.

Accurate assessment and management of risk is an important factor in the safety of patients and staff on acute psychiatric wards. Our baseline data showed that risk assessments had limited medical input and at times had sections which were not filled in at all. Review of the MHRA by medical staff improved this, and in some cases found and added relevant information which had been missed. As a person dependent intervention, this may not be a sustainable change. As a first step to introduce a sustainable system change, a visual prompt has been introduced, in the form of a blue triangle icon in the duty room whiteboard to highlight whether each patient has a complete and up to date MHRA. Further interventions could include integrating a review of the MHRA in weekly ward rounds. This audit also raised the issue of some relevant information having been missed from risk assessments and showed that further audit of the quality of risk assessments is indicated.

Assess if variation exists for routine blood tests performed on admission, evaluate compliance with MPFT guidelines when performing routine admission blood tests, compare results with the previous audit completed in October/November 2020 and identify strategies to improve and standardise admission blood tests.

Retrospective blood result data were collected for all admissions to Norbury House (PICU) at St George's Hospital in Stafford over a two month period. For the original audit, this was between October and November 2020, following which a staff education programme raised awareness of trust guidelines regarding admission blood tests. This was then re-audited in May and June 2021 to assess its impact. Patients transferred from acute wards were included but repeat admissions were omitted. Data analysis was completed through Microsoft Excel.

17 patients were included in the audit in October and November 2020 while 13 patients were included for the May and June 2021 audit. As per trust guidelines, the number of patients having the appropriate admission blood tests increased to 69% in 2021. Certain mandatory blood tests were requested far more regularly such as TFTs increasing from 71% in 2020 to 100% in 2021. Other vital blood tests on admission also increased substantially, such as Glucose increasing from 6% of admissions in 2020 to 69% in 2021 and Prolactin increasing from 77% in 2020 to 100% in 2021. All mandatory blood tests either increased in frequency or maintained a 100% completion rate, with the exception of Calcium which decreased slightly from 94% in 2020 to 92% in 2021.

In the 2020 audit, unnecessary blood tests were requested for 88% of patients which was reduced substantially to just 21% of admissions in the 2021 audit. The total number of unnecessary tests also greatly reduced from 23 tests in total in 2020 to 3 in 2021.

It is vital that patients being admitted to the PICU have the appropriate blood tests completed on admission, as they may be prescribed psychotropic medication that impacts their physical health and may have been self-neglecting prior to admission. Although the audit shows that the interventions completed following the last review have been hugely successful in improving compliance with trust guidelines and reducing waste of NHS resources, there is still significant room for improvement through the continual education of staff. This should then be re-audited again in Spring 2022 to ensure that the improvement continues.

In 2018 the Psychiatry Ward Review Safety Checklist was created for ward reviews on the Trust electronic clinical recording system with the aim to improve the documentation of legal and safety information. In 2019 an audit was conducted to ensure compliance with the safety checklist and in 2022 a re-audit was conducted to evaluate the effectiveness of the ward review checklist. Both audits examined 6 questions: Have you discussed the legal status of the patient? Is the patient for resuscitation? Does the patient currently have capacity for admission? Does the patient demonstrate deteriorating health? Does the patient have any physical health concerns? Review indication, current dosage and side effects of medications.

A retrospective case note review of three ward round assessments of a sample of 25 patients. First male and first female admission of the month to Tower Ward (Landermere Centre, Clacton On Sea) were selected over the period from 1st December 2020 to 1st December 2021. Inclusion criteria: all patients. Exclusion criteria: None.

We maintained the same standards as the previous audit in 2018 and 2019: 80% completion.

12 male and 13 female patients were identified.

Q1. This was documented in 88% patients during the 1st week, and in 100% patients in mid-point stay and pre-discharge. In 2019 it was documented in 93% of the cohort.

Q2. This was documented in 42% in the 1st week, in 53% patients in midpoint and 45% in pre-discharge review. In 2019 this was recorded as 39% compliancy.

Q3. This was documented in 92% in the 1st week and midpoint, and in 67% during the pre-discharge review. In 2019 capacity was only documented in 14% of the cohort.

Q4. It was directly mentioned in 100% patients in all three reviews. In 2019 this was recorded in 64% of cases.

Q5. It was documented in 92% in the 1st week and mid-point review, and in 88% of the cohort in the pre-discharge review. In 2019 it was recorded for 69% of the cohort.

Q6. The information was included in 88% of the cohort during the 1st week, in 83% in mid-point and 75% in the pre-discharge review. In 2019 it was recorded for 81% of the cohort.

Compared to the 2019 audit the overall compliance with the documentation was satisfactory (over 80%) in all audited points with the exception of question 2 regarding resuscitation status for all audited weeks (40–50%).

The aim of this study was to assess the legibility as well as components of a prescription prescribed by doctors in tertiary care hospitals of Rawalpindi, Pakistan.

An analytical cross-sectional study was conducted in pharmacies of two allied hospitals of Rawalpindi Medical University. Data were collected using stratified randomized sampling. A total of 661 prescriptions were selected and analysed for legibility by three experts. SPSS version 26.00 and Graph Pad Prism were used to enter and analyze the data. Descriptive statistics, correlational model and multinomial logistic regression were applied.

A total of 1982 drugs were prescribed in 661 prescriptions. A total of 46.0% prescriptions were classified in grade 2 and 32.1% in grade 3. On average, 55.74% prescriptions were found to be complete. On average, prescriber's information, patient's information and medication details were present in 72.64%, 57.25%, and 36.73% prescriptions, respectively. Grade 1 (AOR = 0.62), grade 2 (AOR = 0.83), and grade 3 (AOR = 0.85) prescriptions had less odds of being complete compared to grade 4 prescriptions.

Majority of the prescriptions prescribed at tertiary care hospitals were barely legible and also quite a number of prescriptions were incomplete.

'STOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organizations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life'. Our aim was to reduce the percentage of psychotropic burden on the LD and/or autism caseload in Tower Hamlets.

We reviewed the internal LD caseload that fit STOMP eligibility criteria (prescribed antipsychotics without an indicated mental health diagnosis).

We calculated the% of BNF maximum dose for individual service users, aimed to reduced this, and reviewing the cumulative dose reduction achieved across the service, before and after an intervention.

The primary intervention was the introduction of a pharmacy led clinic for service users meeting the criteria. This allowed closer f/u from LD pharmacist, thorough medication histories independent of their routine psychiatric reviews, and using GASS and BAI scales to quantify change achieved to their quality of life.

We used early and rigourous people participation to consider the role medications (and their overprescription) in service users quality of life, and asked what service users want out of these medication reviews. Several focus groups were ran without People Participation Lead.

Prior to starting of clinic - Of 29 STOMP eligible patients within TH CLDS, we have reduced antipsychotics in 8 of them through general raising awareness of STOMP (presentations to staff, reviews of GP letters to identify service users within the caseload who are likely to benefit and/or be receptive to dose reductions etc). So far total reduction of 45.4%, (and a total of three patients have been stopped all together).

The majority of the results and intervention are yet to be collated, and we are collecting these over the next 2 months, but provisionally we hope to conclude that by reducing the quantity of psychotropic medication we prescribe will improve the quality of life for our service users

Background: Huntington's disease (HD), due to the pathological expansion of CAG trinucleotide repeats within the Huntington's gene on chromosome 4p (1), is an autosomal dominant progressive neurodegenerative disease with motor, cognitive and neuropsychiatric symptoms that includes irritability and agitation in an estimated 38–73% of HD patients (2) which is characterized by impatience and a tendency to become angry in response to minimal provocation. Expert consensus recommends implementation of environmental and behavioural strategies then commencing treatment with SSRI's, Neuroleptics or Anti-Epileptic Drugs (AED) (3). No previous papers, to our knowledge, have examined the newest antiepileptic agents or have identified the most efficacious antiepileptics for this use. Aim: We present a review of the literature describing antiepileptic treatments for agitation and irritability in HD focusing on identification of the most efficacious antiepileptics and the role of newer antiepileptic agents for this use.

A search in the main database sources (EMBASE, MEDLINE, Allied and Complementary medicine) was performed in order to obtain a comprehensive evaluation of available antiepileptic psychopharmacological treatments in HD for agitation and irritability.

Antiepileptic (AED) agents described in consensus statements and case studies have included sodium valproate, carbamazepine and lamotrigine, which work by inhibition of voltage gated Na and Ca channels, and are often combined with antipsychotic agents for improvement of pathological mood swings and irritability. However, none of the papers identified were Level III or better.

No specific mood stabilizing antiepileptic psychopharmacological treatment of the Psychiatric symptoms of irritability and agitation in HD was identified. Overall, the use of AED have weak evidence base with no quantifiable outcome measures, such as such as the Disruptive or Aggressive Behavior behavioural subscale of the Unified Huntington's Disease Rating Scale or the Neuropsychiatric Inventory, indicating improvement of symptoms identified. Surveys and expert opinions were based on their personal knowledge of the HD populations and the selection of the experts surveyed was not systematic which could influence the practice pattern results. The review indicates a pressing need for treatment studies to determine which psychopharmacological and behavioral treatments are most efficacious.