To make a case for E-prescribing within the Paediatric Neurodevelopmental Team in Wrexham Maelor Hospital.

To trial a different way of approaching 6 monthly reviews within the ADHD clinic (option for remote reviews).

To show how we could reduce the carbon footprint of the ADHD clinic.

Process mapping was completed to consider areas in the ADHD prescribing process that could be made more sustainable.

For each patient appointment in the ADHD clinic a questionnaire was completed. The data collection period was over 3 weeks during August and September 2023. Data was collected and interpreted.

99 appointments were offered, 82 appointments attended. 77 appointments were face-to-face and 22 were via telephone. Of the face-to-face appointments, 54 families travelled in by car and 4 used public transport (2 taxis). Of those who commented 31 people found it hard to find parking by the clinic, 13 people did not.

Of the appointments attended face to face via car/taxi (57):

• • Average of 4.4 miles travel to the clinic (8.8 miles total journey)

• • Shortest journey 1.1 miles (2.2 miles total journey)

• • Longest journey 16 miles (32 miles total journey)

• • Total patient mileage for these appointments (assuming travel to and from clinic) 855.8 miles

• • Average journey 0.005t CO2

• • Total journeys 0.472t CO2

• • Assuming average sized petrol car used

• • Extrapolating this data for a whole year approximately: 8.024t CO2 from patient journeys to and from the ADHD clinic

We have made a case for e-prescribing within the ADHD clinic in Wrexham Maelor Hospital.

The current system impacts on:

• • Patient and carer's travel time and convenience.

• • Clinician's travel time.

• • Carbon emissions.

To replace pre-existing paper-based and informal handover systems with a confidential electronic handover system for on-call doctors across a large South London mental health trust, thereby improving the safety and quality of handovers.

A quality improvement project was registered within our trust. At baseline, we surveyed core trainees, GP trainees, and locum doctors about their experiences using a paper handover system for on-calls at the Bethlem Royal Hospital and Lambeth Hospital, South London and the Maudsley NHS Foundation Trust (SLaM). Their feedback guided the implantation of a confidential and secure electronic handover system integrated into the trust's Microsoft SharePoint, using the Microsoft To Do app and then Microsoft Teams. We alerted doctors to these changes via formal and informal means, such as trust inductions, emails and through communication with trust junior doctor representatives. After a period of 8 and 24 weeks, we assessed the initiative's success by collecting both qualitative and quantitative data from on-call doctors about their experience with the handover system. Based on feedback, we made multiple adjustments to improve the system, which was later adopted at Lambeth Hospital. The Microsoft To Do app was then replaced by a channel on Microsoft Teams to ensure wider access.

15 doctors responded to the baseline survey. Handover practices were varied and included paper-based handovers, phone calls, and emails. Mean doctors’ ratings for the pre-existing handover systems were 3.2/5 for overall quality (1: very poor; 5: very good) and 2.7/5 for safety (1: very unsafe; 5: very safe). 60% (n = 9) of doctors said tasks would sometimes be missed in the pre-existing handover system. 21 doctors responded to 2 post-change surveys. Mean doctors’ ratings of overall quality were 4.6/5 and safety were 4.5/5. Qualitative feedback highlighted that a verbal handover was still necessary to complement the electronic system, and that locum doctors would need to have access to the system as well as consultants and registrars during periods of industrial action.

An electronic handover system was successfully implemented to replace a predominantly paper-based handover system at two large mental health hospitals in South London, and on-call doctors reported improvements in handover safety and handover quality. Future work aims to implement a consistent electronic handover system across other hospitals in SLaM and other trusts and transition fully to Microsoft Teams for broader accessibility.

Stopping Overmedication of People with a Learning Disability, Autism or Both (STOMP) is an initiative of NHS England. This was in response to concerns raised as a result of the Winterbourne View scandal related to the inappropriate use and insufficient arrangements for the review of the prescription of psychotropic medication.

33,000–35,000 individuals with an intellectual disability (ID) are prescribed psychotropic medication daily. 20–45% are on antipsychotic medication, of which 14–30% take these to control behaviour problems rather than for specified psychiatric conditions. Psychotropic medications can have side effects with the potential to significantly impair an individual's quality of life.

This audit is to observe current practice of the prescription of psychotropic medication, with a view to identifying changes to the compliance with recommendations and outlining areas for further improvement in line with the Stopping Overmedication of People with a Learning Disability, Autism or Both (STOMP) initiative.

Data was collected from electronic records for randomly selected patients, 20 from each of the 4 Community Learning Disabilities Locality Teams within the Trust. The patients who were not currently prescribed psychotropic medication were excluded from the randomly selected samples.

There was good evidence that capacity, consent and best interests were considered, as well as multidisciplinary input. There was also good evidence of regular review of medication, side effects and treatment response. The results suggests that psychotropic medication continues to play a significant role in the management of patients presenting with behavioural problems, and more needs to be done to identify approaches that will help to reduce their use.

In this patient group it is sometimes the case that medication is prescribed legitimately for indications other than their British National Formulary (BNF) recommended use. However, the findings suggest that the rationale could be more clearly recorded. Close collaboration with primary care to provide a comprehensive medication history, the involvement of carers and family members in the active preparation for effective medication reviews and the involvement of the multidisciplinary team should continue to be encouraged and clearly recorded.

The aims of this project were to improve patient education and overall information distribution within the Memory Clinic within the Old Age Psychiatry department, based at Kingsway Care Centre, Dundee.

This project originated, after there were concerns raised from relatives of a patient who had recently been assessed in the Memory Clinic. A suggested area for improvement included distributing information to patients, highlighting any potential tests or topics of conversation that may be explored during a Memory Clinic appointment. In response, our team engaged in a thorough collaboration with our colleagues in Psychiatry and the Post-Diagnostic Services (PDS). As a result of this partnership, a summary sheet was compiled, highlighting the spectrum of cognitive testing and assessments that may be conducted, potential medicinal treatments and other significant considerations, including driving and Power of Attorney statuses. To ensure these resources were both accessible and informative, they were systemically distributed to patients. The materials were paired with feedback forms to capture patient experiences and insights, to be later collected by the PDS.

Whilst this project remains in the data gathering stages, provisional data has been very promising in showing improvement in clarity of information delivered to patients (both in current and future assessments), explanation to patients regarding medication and treatment options, and overall patient satisfaction.

Optimising educational resources for both patients and families attending the Memory Clinic through summary documentation can be utilised to improve overall patient satisfaction. Aiding patients’ understanding of their diagnosis and further management of this, allows them and their families to feel more included in their care and optimises the delivery of holistic care within Psychiatry of Old Age.

Promoting the well-being of staff is paramount within mental health services. However, a common issue arises where administrative personnel, often serving as the primary point of contact for service users, engage in mental health-related interactions without formal training. This deficiency can adversely affect their well-being, leading to diminished team morale and increased staff turnover, consequently impacting the quality of care provided by the Neighborhood Mental Health Team (NMHT). Moreover, it can contribute to dissatisfaction among service users, jeopardizing their rapport with the service. We aim to improve the wellbeing of staff and service users and to optimize service delivery at the local NMHT.

Data were gathered from a local NMHT catering to 1200 service users in the borough of Tower Hamlets in London. A pre- and post-implementation questionnaire was administered to both service users and six administrative staff members. The questionnaire highlighted several areas for improvement, including a lack of mental health understanding among administrative staff, reported low confidence when handling certain phone inquiries, and service user complaints. Change initiatives were then devised to address these concerns and evaluate their impact on enhancing the experience for both service users and administrative staff.

Administrative staff uniformly expressed the need for increased mental health training prior to commencing their roles. Implementation of targeted change initiatives led to noticeable improvements in service user satisfaction and staff confidence in managing phone interactions. These enhancements culminated in an overall advancement in service delivery.

Through the strategic implementation of change initiatives informed by our initial findings, we not only augmented mental health literacy among administrative staff and service users but also bolstered their well-being. Consequently, this directly translated into an amelioration of local service offerings. Further research is warranted to ascertain the long-term efficacy of these innovative interventions.

Following discharge from inpatient to community psychiatric services, the first 7 days is the most vulnerable and associated with an increased risk of suicide. According to the NICE Guideline 53, it is recommended that patients discharged from inpatient psychiatric services should be reviewed within 7 days by the relevant community services. Our aim was to determine how well we are adhering to this recommendation, appropriately documenting the appointment in the patients' discharge documents as well as the number of patients that attended the appointment.

We collected data on an excel spreadsheet of patients discharged from Huntly ward (a General Adult Psychiatry ward) in the Royal Cornhill Hospital from 01/09/2022 and 14/10/2022 (a period of 6 weeks).

The data collected included name, CHI, date of admission and discharge, community mental health team, follow-up appointment offered, appropriate documentation on Core discharge document and whether the patient attended the appointment.

After the first audit cycle, we had a discussion with the junior doctors on the ward highlighting the importance of 7 day follow up and the need for arranging with the Community mental health team prior to the discharge, documenting a date, time and name of the clinician for the 7 day follow up in the Core discharge document. We also encouraged the use of reminders like using the doctors' diary book on the ward to document anticipated discharges and adequate hand over of patients to the community mental health team at the start of each week's Multidisciplinary Teams meeting.

We subsequently did a re-audit on patients discharged from Huntly ward between 04/04/2023 and 12/05/2023 (6 weeks). We compared the results from the first cycle and the second cycle to identify a change.

First Audit cycle.

Over the 6-week period, 27 patients were admitted into the Huntly ward and 23 patients were discharged.

48% (n = 11/23) of discharged patients were offered a follow up appointment.

91% (n = 10/11) had this appointment documented in the Core discharge document.

100% (n = 7/7) attended the 7 day follow up appointment.

Re-Audit.

Over the 6 week period, 16 patients were admitted and discharged from Huntly ward.

81% (n = 13/16) were offered a 7 day follow up appointment and this was documented in the Core discharge document.

100% (n = 13/13) of the patients attended their 7 day follow up appointment.

The result showed good improvement from 48% to 81%.

Using reminders, properly liaising with the community mental health team, appropriately documenting a named clinician, date and time for the 7 day follow-up ensures that the patient attends.

The importance of offering support during the first week after discharge from psychiatric hospital should continue to be emphasized to prevent adverse outcome during this vulnerable period.

To ensure smooth running of Multidisciplinary team (MDT) in Community mental health team (CMHT) and reviewing MDT structure for better functioning at Parkview Mental health Resource centre.

On a Friday two Multidisciplinary teams (MDTs) were running online on Microsoft teams simultaneously. The same staff was running the two MDTs, so staff input could be limited at times and staff would dip in and out of MDTs. Discussion around ways of improving this so that both MDTs run smoothly. Also, there was no formal structure to MDT meetings. It was decided that improvement in Quality of MDT needs to be addressed.

Initially numerous discussions held online with Parkview team, nursing colleagues.

CMHT Quality improvement group was set up and a meeting was arranged where everyone's ideas were considered.

A pilot project was first introduced in March 2022 and audited in July 2022. Plan, do, study, act (PDSA) cycle was carried out.

Plan

Two nursing teams to be setup which will feed back into the two MDTs on alternate weeks. This will reduce nursing teams having to come in and out of one MDT to join other MDT, hence increasing the efficacy of the MDT.

Devise a new template to provide formal structure for the MDT presentation.

Do

Trial the new setup of two nursing teams.

Study

Ask all MDT staff members for feedback on the working of MDT.

Act

Reformat the Structured template and distribute to all staff members.

100% staff felt that new structure of MDT was useful.

84% staff satisfied with the new way of running of MDT.

84% staff satisfied with having designated teams for MDT.

Having Designated MDT teams and a structured format helped in robust functioning of the MDT in the CMHT.

Psychiatric inpatient hospital, although part of secondary care, is separate from a physical health hospital and therefore does not have access to electronic referral systems, which increases efficiency of referral processes. As part of an admission clerking for all inpatients in psychiatric hospitals, the admitting doctor takes a history of past medical issues, a physical examination, electrocardiogram and bloods. Depending on findings, further radiological and cardiac investigations may be warranted. Not having access to electronic referral systems can cause delay in delivering treatment for psychiatric inpatients, especially when referral pathways is unclear. The aim of this quality improvement project is to increase the knowledge of referrers in order to improve efficiency completing referrals and reduce incorrect referrals. With clinicians able to refer for routine imaging correctly and in an efficient manner, it is hoped that this will correlate with an improved quality of care received by patients.

Firstly we assessed the knowledge of currently employed trainee doctors, via a web-based survey, on how to refer for routine and commonly ordered radiological and cardiac investigations. Employed referrers included core trainee, GP and foundation year trainee doctors. We then created an electronic referral pack which includes a guidance and referral forms provided to clinicians when they start employment at Lambeth hospital and accessible to current trainees. A follow up survey then reassessed the knowledge of these referrers.

There was a total of 11 responses received from survey prior to sending out the electronic referral guidance pack, of which 100% believed that it would be helpful to have a referral guidance pack. A total of 4 responses were received after sending out the guidance. The surveys showed that there is improved knowledge of how to refer for routine radiological and cardiac investigations after guidance was sent. Prior to sending the guidance, 9.1% referrers were made aware of the referral process, and this increased to 50% after the referral guidance pack was sent out.

Trainee doctors in psychiatric hospitals require more support with physical health management in psychiatric hospitals, including referring for physical health investigations, as referrers cannot access electronic referral systems used in physical health hospitals. Results need to be correlated with clinical outcomes in future. A longer term project could include linking the electronic referral systems between psychiatric and physical health hospitals.

Clozapine, a second-generation antipsychotic licensed for treatment-resistant schizophrenia, has a well-documented side effect profile, the most common of which is decreased gastrointestinal motility. Clozapine-induced constipation occurs more frequently than blood dyscrasias and can lead to severe complications such as paralytic ileus and intestinal blockage; in extreme cases, it can be fatal, with a fatality rate of 20–30%. The risk of gastrointestinal hypomotility is most pronounced during the initial four months of treatment; hence, weekly assessments are imperative during this period. According to Lanarkshire's local guidelines, bowel habits should be assessed at baseline, during routine blood sampling, and ideally at every clinical interaction. Our audit aims to determine the frequency of bowel habit monitoring in inpatient settings and to ascertain the prevalence of laxative prescriptions among these patients.

Data were collected retrospectively from psychiatric inpatient wards in Lanarkshire for patients on Clozapine therapy. The review focused on electronic medical records to evaluate the regularity of bowel habit screening. Additionally, we examined the Hospital Electronic Prescribing and Medicines Administration (HEPMA) system to gather information on laxative prescriptions.

The audit revealed that bowel habit monitoring, which should be a standard practice at each clinical encounter, was found to be inconsistent. Regular assessments were documented for only 40% of patients. Monitoring was most thorough in rehabilitation wards, where patients on Clozapine had their gastrointestinal function assessed routinely through screening questionnaires. Furthermore, 80% of the surveyed patient population was documented as having been prescribed laxatives.

The documentation of bowel movements for inpatients on Clozapine was suboptimal, leading to the potential oversight of critical side effects. The audit highlights a discrepancy in adherence to national and Lanarkshire's local guidelines for the monitoring of inpatients treated with Clozapine. To rectify this, we recommend the implementation of a standardized screening protocol to assess constipation risk systematically. Proactive monitoring should be incorporated into regular clinical evaluations for patients on Clozapine, ensuring that this assessment occurs at every clinical interaction. This approach is crucial not only for patient safety but also for enhancing treatment efficacy and patient quality of life. Moreover, these measures will likely lead to improved documentation and compliance with established guidelines, thereby reducing the incidence of preventable complications associated with Clozapine-induced constipation.

The aim of our quality improvement project was to explore and improve care for patients who use sensory aids, with or without dementia, on an old age ward at King's College Hospital. We sought to do this by increasing the staff awareness of each patient's sensory needs and dementia status.

Guidelines state that sensory aids (glasses and hearing aids) are important in orientating patients with delirium and dementia, yet these devices frequently go missing during admission or are not being used appropriately. This could affect communication and therefore overall care, both physical and mental. It is widely understood that delirium and dementia are associated with increased morbidity and mortality. In this project we aimed to explore issues around sensory aid use and to identify and implement impactful changes.

2 Plan, Do, Study, Act cycles were conducted between October 2022 to February 2023. A driver diagram was created following staff interviews on the ward. The first cycle focused on increasing awareness of a form in electronic patient records (EPR) and the need for documenting each patient's sensory aid possessions and dementia status. This was done through bite-size teaching sessions to the team and monitoring of completion of this form. The second cycle included utilising a new laminated bedside checklist that is manually filled in and was aimed to serve as a visual cue of the patient's sensory impairment/dementia status. A survey was used at baseline and then repeated over the course of both cycles to evaluate awareness of staff (named nurse) of each patient's sensory impairment/dementia status on the ward.

Baseline survey showed that staff were unsure of the sensory aid needs (glasses, hearing aids, dentures) of 25% of patients and 46.7% when it came to dementia status. EPR form completion increased by 14% between 14/12/22 and 25/01/23, however this was not statistically significant. 18% of bedside checklists were filled after 4 weeks. Overall, there was a statistically significant decrease in staff not knowing the sensory impairment status (by 32%) as well as dementia status (by 40%).

Whilst uptake of the forms and bedside checklist was slow, the project did show an improvement in awareness of staff and our hypothesis is that this leads to better use of sensory aids. The next step would be to assess whether this leads to better care through further PDSA cycles.

This quality improvement project was conducted in an Early Intervention in Psychosis CMHT (Community Mental Health Team). We aimed to compare prescribing practices to the RCPsych gold standard for treatment of first episode psychosis. Following an initial audit, intervention was completed aiming to improve adherence to these guidelines and thereby the proportion of patients achieving remission.

An initial audit of the whole CMHT caseload (with exclusions for patients currently admitted to hospital, under the care of a home treatment team or awaiting assessment) was conducted in June 2021. This was completed from information contained in the electronic patient care record. This recorded for each patient details of whether an antipsychotic was recommended, if one was being taken, the dose, if remission was achieved and the number of previously trialled medications. Following this initial audit interventions were completed through designing a one-page flowchart to empower members of the wider multi-disciplinary team (in particular care coordinators) around prompting appropriate medication changes, with an accompanying education session. Following these interventions, a re-audit was completed in March 2023 and the two samples compared through descriptive statistics. In the first audit 269 patients were included (27 exclusions), and in the second 255 (49 exclusions).

The initial pre-intervention audit found that of patients taking medications, 33% (N = 172) hadn't achieved remission. In the follow up audit the proportion of patients taking medication without having achieved remission remained similar at 37% (N = 147). However, the proportion in this group receiving treatment on doses below the licenced maximum improved from 85% (N = 68) to 76% (N = 55). Those on treatment but not in remission who had sufficiently trialled 2 or more antipsychotics (and therefore would meet the criteria for treatment resistance) increased from 50% (N = 52) to 56% (N = 55). The proportion of this treatment-resistant group receiving clozapine remained low, but increased from 3.8% (N = 26) to 9.7% (N = 31).

This project demonstrated modest improvements in prescribing practice, with a small increase in symptomatic patients receiving gold-standard treatment both in terms of numbers of medication trialled and reaching maximum doses. However there remains a significant gap, with a large proportion of symptomatic cases still showing room for medication optimisation. In particular clozapine remains underutilised in this cohort, with only a small minority of patients who would meet the criteria for treatment-resistant psychosis being prescribed it. This leaves room for further interventions to improve prescribing practice.

• • The audit aims to improve the quality of physical health monitoring and physical health interventions that the EIP service provides to people with psychosis.

• • To ensure adherence to RCPsych standards for physical health monitoring in patients with First Episode Psychosis.

• • To ensure adherence to RCPsych standards for provision of required physical health interventions and health promotion in patients with First Episode Psychosis.

• • A retrospective case note audit and re-audit was conducted for 13 patients on the caseload of the North Wales EIP service from December 2022 to December 2023.

• • The case notes were audited against RCPsych standards for physical health monitoring and physical health interventions using an adapted version of the National Clinical Audit of Psychosis (NCAP) audit tool.

• • Alcohol and substance misuse screening status improved to 100% in re-audit.

• • There was significant improvement noted in Hypertension, Body Mass Index and Cholesterol screening.

• • Mental health medication review, advice or referral for diet and exercise with regards to weight gain/obesity and hypertension improved to 100%.

• • No specialist interventions were offered around health promotion and illness prevention as most of the patients were either not in the abnormal range, identified as high risk for developing the above mentioned physical health conditions or refused to have interventions for these conditions.

• • A definite increase was observed in frequency of interventions being reviewed and reoffered for those accepting and declining interventions at baseline.

• • Training for staff to complete bloods and physical health screening.

• • Increase availability of equipment to carry out physical health screening.

• • Monthly, three and six monthly prompts in the case notes for staff to discuss physical health interventions with patients.

• • Staff to use headings for physical health screening and interventions to improve documentation in case notes.

The community mental health team (CMHT) is actively involved in reviewing mental health patients who require commencing psychotropic medications. The responsibility to prescribe the psychotropic medications falls on the CMHT for the first 3 months. After this period, if the patient's mental health is stable, the prescribing role can be transferred to the GP by completion of an electronic shared care agreement (ESCA).

This project aimed to improve the management of emergency prescriptions (FP10s) requiring ESCA within the North Hub CMHT, BSMHFT focussing on reducing administrative time in receiving numerous urgent phone calls for repeat prescriptions, timely completion of ESCA and updating the electronic prescribing system.

Data collection was done by logging the numbers of the following on a weekly basis:

1. 1. FP10s issued.

2. 2. Calls related to FP10s.

3. 3. ESCA sent.

1. 1. Clinician prompt reminders to check ESCA status.

2. 2. Document FP10s instances on issue and inform patient about ESCA during outpatient appointments.

3. 3. A 4-week system for managing FP10s at reception desk.

4. 4. Increase consistent use of and access to EPMA.

This project resulted in a 14% reduction in the number of FP10s requiring ESCA and a 27% reduction in the number of calls for FP10s from January to August 2023. Data measuring sustainability in December 2023 showed a total reduction of 64% from the baseline of 28 FP10s per week at the beginning of the project (January 2023) to an average of 10 FP10s issued per week in December 2023.

In conclusion, patients benefit from having a clear understanding of where their medications will be issued from thus improving their experience with the mental health service. Having effective processes in the CMHT enables medical professionals to complete the ESCA in a timely manner. Altogether this reduces burden on all professionals and reduces costs of prescribing by transferring the prescribing responsibilities to GPs. This project has been effective in reducing the number of weekly emergency FP10s issued. The 4-week system of managing FP10s at reception has now been included in the Medication Management's new procedure and guidance and is being introduced across all CMHTs in BSMHFT.

There remains stigma surrounding electroconvulsive therapy (ECT) amongst junior doctors, as well as gaps in knowledge, recent studies have shown. The aim of this study is to reduce stigma and negative biases towards ECT among junior doctors in Hertfordshire.

This research strives to improve clinical knowledge regarding ECT amongst the same population of junior doctors.

After highlighting stigma and gaps in clinical knowledge amongst junior doctors, we aimed to implement an educational intervention to reduce these and assess the impact it made.

Over 80 doctors ranging from foundation year 1 doctors to consultants attended a weekly academic teaching for doctors working in Psychiatry. A 50-minute slot was set aside for a teaching session on ECT.

This included a pre- and post-teaching anonymous questionnaire, with open and closed questions, asking junior doctors about their previous exposure to ECT, and asking them to list three words they associated with ECT.

The teaching session included: what ECT is, indications, side effects, a short video explaining the procedure, an open discussion about stigma and ECT, a brief overview about the future of neuromodulation, and a consultant psychiatrist who is part of the ECT team talking through the before, during, after, and answering questions from the participants.

31 participants answered the pre-intervention questionnaire. Of the 31 respondents, 70% reported learning about ECT during medical school. However, 40% reported little teaching and only 13% had observed ECT. From thematic analysis of free text responses, 54% of respondents expressed detailed understanding of ECT, with 71% agreeing that ECT is a humane treatment. 80% expressed that ECT should be part of NICE guidelines. 50% of respondents conveyed that stigmatised portrayals of ECT in popular culture have influenced their negative opinion of ECT.

Of the 10 responses to the post-teaching questionnaire, 100% agreed that ECT is a humane treatment and that ECT should be part of NICE guidelines for treatment of severe/treatment-resistant depression. From thematic analysis, when asked to name 3 words they associated with ECT, 60% of participants described ECT as effective or successful and 40% described ECT as safe. 72% of the words used were positive descriptors.

ECT is not covered thoroughly during medical school. Before this teaching, about half of the trainees expressed a negative opinion of ECT due to popular culture. Post-teaching, positive opinions had increased, and more trainees (100%) agreed that ECT is a humane treatment and should be part of NICE guidelines.

Non-attended appointments can lead to adverse outcomes for a service and its users, including reduced service efficiency; increased waiting times; and impaired patient care. The audit objective was to explore whether DNA rates vary between the current modalities of face-to-face; virtual; and telephone. It was hoped that this would enable the service to better understand the reasons for patients not attending initial assessments and determine whether the modality may present a barrier.

A sample was obtained including all first assessment appointments between March 2022 and March 2023 (n = 386). Data included the modality for each initial appointment. Matched to this data, was whether the patient attended each appointment, creating a frequency of DNAs for each appointment modality across the year. Data analysis was conducted using Microsoft® Excel®. Beyond frequency and percentages, a chi-square test was used to assess for a statistical difference in appointment attendance between modalities.

For this one-year sample the overall attendance rate was 77%: with 299 appointments attended, and 87 ‘DNAs’. The DNA rates across the one-year sample were face-to-face (24%); virtual (22%); and telephone (23%).

The chi-square value produced when analysing the DNA rates between modalities was 0.92 (critical value 5.99). Hence, there was no statistically significant difference in DNA rates by modality.

Despite the absence of variation in DNA rates between modalities, the findings can be viewed as reassuring. The move to include multimedia alternatives to assessments does not appear to be impacting attendance when compared with assessments that continue to occur face-to-face. Balanced against this increased geographical inclusion afforded by remote appointments, is the competing equity issue of digital exclusion, highlighting the need for face-to-face appointment provision to remain accessible across the service.

This audit did not collect demographic data that may have provided insight into whether certain factors may have impacted attendance and could have acted as confounders, for example geographical location.

Introduction of a supportive reminder letter for patients, to bridge the wait between patient's referral and their initial assessment, was an outcome recommendation that was implemented by the service.

Mental illness is associated with poorer physical health and reduced life expectancy in comparison to the general population. This is influenced by many factors, one of which is medication related. Antipsychotics can have multi system effects on the body such as increasing the risk of metabolic syndrome and cardiovascular disease. Our objective was to understand current challenges when monitoring patients' physical health and thereby improve overall health outcomes.

Utilising a clinical audit template, the study group was 9 inpatients during cycle 1 and 10 inpatients during cycle 2, who were prescribed antipsychotics on an Old Age Psychiatry ward. Northumberland, Tyne and Wear (NTW) antipsychotic monitoring guidelines were used as criteria which stipulate that blood tests, ECGs, BMI, waist circumference, side effects and lifestyle effects should be recorded at defined intervals. A proforma highlighting these guidelines was created following audit cycle 1 and utilised by the MDT on the ward, the purpose of cycle 2 was to compare findings following the implementation of the proforma. The standard to meet was that 100% of patients should fulfil the guidelines. Data was collected by retrospectively reviewing paper and electronic notes.

Audit cycle 1 revealed 0 of the patients met the physical health criteria. 0 had the full set of required bloods in the correct timeframe, 0 had waist circumference checked and 2 and 1 patients had side effect and lifestyle effects documented respectively. By comparison, ECGs and BMIs were recorded well. Audit cycle 2 demonstrated significant improvement in all areas. 9 patients had bloods accurately measured. 3 and 6 had side effect and lifestyle reviews respectively. ECGs and BMIs continued to be monitored well. However, waist circumference remained poor with 1 patient recorded. Qualitative feedback when presenting these findings to the MDT highlighted an interest debate into the cost/benefit of measuring waist circumference with the main point being not wishing to cause undue anxiety to the patient.

The use of an accessible proforma clearly outlining the criteria to meet for each patient proved valuable in improving the monitoring of physical health parameters. This study highlighted a need for increased awareness of metabolic syndrome and the importance of empowering patients with knowledge regarding their healthcare to help tailor a patient-centred approach to physical health monitoring. Our presentation aims to encourage discussion among attendees around measuring waist circumference and raise awareness of metabolic syndrome.

Doctors completing on-call shifts at sites across a mental health trust identified a need to improve aspects of on-call work. This quality improvement project (QIP) aimed to improve response to trainee concerns arising from on-call work and support to junior doctors on-call.

A previous QIP cycle identified trainee concerns regarding on-call processes. In our first QIP cycle, surveys were sent to all consultants and SpRs working on non-residential on-call rotas, and Foundation, GP and Core Psychiatry trainees (on residential on-call rotas) in the Trust, regarding perceptions of on-call processes, senior support and on-call issues. A monthly, online forum was introduced in August 2023 to improve on-call feedback and communication. Trainees, consultants and SpRs from 2 localities were invited, along with representatives from the medical staffing team, medical education team and medical management. After 4 forums, participants who had attended an on-call forum were sent a further feedback survey collecting quantitative and qualitative data. Subsequently, forum frequency and scheduling were amended, advertisement improved, and the forum was expanded to include on-call doctors across the whole Trust.

First cycle data revealed consultant support for a regular meeting with trainees and senior colleagues to bring issues from on-calls for discussion (56% felt that an on-call forum would be helpful, 33% felt it might be helpful). Mean forum attendance was 14, with attendance from all grades. Feedback data from trainees (5 responses) was that most found the forum useful (80%); 80% felt listened to; all felt able to raise concerns, and all wanted the forums to continue. Qualitative feedback included: ‘we started a new QI project from the forum and many on-call guidelines became more defined.’ Consultant feedback (4 responses) was that most found the forums useful (75%); 100% gained a better understanding of trainee concerns; 100% thought forums should continue, although 50% thought the frequency should be reduced. Most consultants and trainees did not feel it would be useful to discuss clinical cases in the forums. Consultant qualitative feedback reported that the forum was helpful to understand trainee concerns, but there should be wider attendance.

Establishing an on-call forum was a valuable intervention for both consultants and trainees working on an on-call rota and has led to a further quality improvement project. Respondents felt that clinical supervision offered sufficient space to discuss clinical cases. Increasing trainee and consultant engagement with the forum is the next phase of this project.

The liaison psychiatry team at North Middlesex Hospital (NMH) noticed that many patients on clozapine were missing doses in hospital, risking the need for re-titration and deterioration in mental state. Although clozapine is a widely used medication in psychiatry, non-psychiatric clinicians may not be aware of the importance of compliance. In addition, clozapine is often not widely available in acute medical hospitals and ascertaining the correct dosage can be difficult as it is not prescribed by the GP. Furthermore, clozapine can cause a variety of side effects that our medical colleagues may not be familiar with.

The aim of this project was to improve clozapine prescribing at NMH and improve communication with the liaison psychiatry team.

We reviewed the notes of 97 admissions in which patients were dispensed clozapine from the hospital pharmacy during the period April 2020 to December 2023 to determine what proportion had missed a dose of clozapine, and the clinical implications of this. We also reviewed the reasons for the missed doses to gather information on what could be done to improve patient safety.

From July 2022 we began implementing changes. This included the creation of a hospital guideline, putting in place an automatic email that would be sent to the liaison team when clozapine was prescribed, placing an alert on the online prescribing system to emphasise the importance of not omitting doses, and providing teaching to clinicians.

We compared omissions of clozapine doses and referrals to the liaison team before and after changes were implemented. The percentage of patients inappropriately missing at least one dose fell from 67.4% to 31.1%. The proportion of patients who were referred to the liaison team rose from 40.8% to 89.2%.

We identified several recurring causes of missed doses. These included doctors not being aware of clozapine prescriptions or dosages, poor awareness that clozapine is a critical medicine and long stays in accident and emergency. There were also incidents where clozapine was stopped by the medical team without obtaining advice from psychiatric colleagues.

We were able to reduce the proportion of patients missing doses by improving awareness of clozapine compliance within the hospital. We were also able to improve communication between medical and psychiatric teams.

The clozapine guideline and prescribing alerts will continue to be utilised within the hospital. We plan to continue to provide regular teaching to rotational junior doctors and to pursue a similar project for lithium prescribing.

Alcohol misuse presents a major health concern in Northern Ireland with a 50% rise in alcohol-specific deaths in the past 10 years1. Excessive alcohol use may lead to fat deposition within the liver and risks progressive liver disease secondary to fibrosis and/or inflammation. The aim is to extend upon an existent Hepatology referral pathway for patients with alcohol misuse and liver fibrosis on Fibroscan; to include onward referral to primary care for investigations of patients shown to have FLD in absence of fibrosis and facilitate early identification and intervention of associated metabolic syndromes. There was previously no referral mechanism for screening for metabolic syndromes such as diabetes, hypertension and hypercholesterolemia for these patients.

Case records were reviewed for all patients offered a Fibroscan through the Belfast Addictions service. Patients identified with evidence of steatosis on Fibroscan without fibrosis/cirrhosis i.e. liver stiffness score < 8Kpa and controlled attenuation score (CAP) > 248, would trigger an onward referral to primary care for further investigation and management. A letter was sent notifying the patients’ registered GP of the Fibroscan result and NICE recommendations for follow up liver function testing, HbA1c, lipid profile and Q-risk scoring for consideration of lipid lowering medication. A review of patients’ electronic care record (ECR) 2 months following the dispatch of letters was conducted to identify those patients who received further investigations.

286 Fibroscans were conducted in the Belfast Addictions Service in 2023. Alcohol misuse was the indication for 92% of these scans with 32% identified as having evidence of fatty liver disease without fibrosis. This prompted onward referral for primary care follow up and letters were sent out to GPs from November 2023. Review of ECR 2 months post-intervention revealed of the 7 letters sent out in November, 57% (4) had follow up bloods and 75% (3) of those were shown to be deranged. Data collection is ongoing and will be complete by date of congress.

32% of the patients who had a Fibroscan in the Belfast Addictions service in 2023 had evidence of fatty liver disease without cirrhosis. Initial data shows a positive change in clinical practice and patient care, and builds upon the existing hepatology referral pathway.

Assessment and management of the mental health needs of patients with dementia has been identified as a key role for a mental health liaison team (MHLT). The existing practice for referrals of patients with dementia made to Barnsley Hospital's MHLT was for them to be redirected to the memory team for assessment, who have limited scope for in-reach work into hospital, rather than being assessed by MHLT who are based on the hospital site.

This project aimed to clarify the pathway for dementia referrals presenting with psychiatric issues at Barnsley Hospital and determine which patients should be seen by either MHLT or the memory team. It also aimed for MHLT to increase the number of dementia referrals assessed compared with existing practice and increase the proportion of face-to-face reviews for these patients.

2 periods of data collection took place within MHLT, where the outcome of referrals made from Barnsley Hospital for patients with diagnosed or suspected dementia requiring assessment was recorded. The first period recorded existing practice and the second period recorded practice following the implementation of a new pathway for referrals.

The new referral pathway was created in collaboration between MHLT, memory team and Barnsley Hospital's dementia nursing staff. MHLT would review cases of suspected dementia not currently open to memory team whilst referrals made for patients open to memory team would be referred to memory team initially, with the option of MHLT input subsequently being requested.

First data collection period 3–28 April 2023:

4 referrals in total.

2 were assessed by MHLT, 1 seen face-to-face, 1 by telephone. 2 were redirected to memory team.

Second data collection period 17 July–17 September 2023 following implementation of the pathway:

10 referrals in total.

7 were assessed by MHLT, 7 seen face-to-face. 3 were redirected to memory team.

The implementation of the pathway led to improved outcomes, with absolute increases of 20% in the proportion of referrals assessed by MHLT and of 45% in the proportion of patients assessed face-to-face. Undertaking the project also helped to identify that there was a training need for MHLT practitioners regarding dementia assessment and management. The next aim is for MHLT to assess 100% of dementia referrals following dementia training being delivered to the MHLT practitioners, and to continue regular MDT meetings to monitor the efficacy of the pathway and maintain collaboration between MHLT and the memory team.