The Institute of Mental Health is the only tertiary Psychiatric Hospital in Singapore. It has two 29 bedded inpatient wards which provide acute care for the elderly with severe mental health conditions including dementia. Restraints are one of the methods employed in managing agitation in patients with dementia. The physical consequences of restraints are reduced mobility resulting in decreased muscle tone and mass, bone demineralisation, orthostatic hypotension, and atelectasis. This results in patients who are more prone to falls, aspiration pneumonia, deep vein thrombosis/pulmonary embolism and ulcers. The psychological consequences include aggravating agitation, feelings of humiliation, negative emotions like anger and despair. Hence, we embarked on a program to reduce the use of physical restraints in the management of agitation in patients with dementia.

Baseline restraint hours were collected from 7am to 9pm for all dementia patients who were restrained for agitation for a period of 5 months. Patients on Geri chair with seatbelt used primarily for fall prevention were not included. The Pittsburgh Agitation Scale was used to measure agitation.

The nursing staff were trained on the Enriched model for targeting behaviour and on the VIPS (Valuing people, Individualised care, Personal perspectives, Social environment) framework for person centred care. Restraint hours were collected post intervention as well as benzodiazepine usage data over both periods to monitor any changes in the usage.

The baseline data (preintervention) over a 5-month period determined that patients with dementia who were agitated were being restrained on an average for 3.33 hrs per day from the period of January to May 2021. Following the training of nursing staff on the enriched model of care and the use of VIPS framework for person centered care the restraint hours reduced to 1.48hr per day over 5 months from January to May 2022. Benzodiazepines usage went down from 0.34mg at baseline to 0.17mg per dementia patient per day post intervention.

Nonpharmacological interventions (enriched model and VIPS framework for person centered care) using a multidisciplinary team approach is effective in the management of agitation resulting from dementia and should be used as a first line in the management of such conditions.

To implement a robust and reliable medical handover process in the Bluestone Unit, Craigavon Area Hospital, Southern Health and Social Care Trust. Following discussion with Junior Medical Staff, Doctors did not feel confident that they were always aware of outstanding physical investigations or any acutely unwell patients on the inpatient wards. This could lead to patient safety issues which we aimed to address using the PDSA model for effective change management.

A) Twice daily face to face handover was introduced at 09:00 and 16:45 in the Junior Doctor's office, easily accessible to staff. A standardised handover template was already in existence. The outgoing Doctor On-Call overnight would complete this to handover any outstanding tasks. The Doctor carrying the On-Call bleep during the day would then use this template to lead a formal, face to face handover with a team of Junior Doctors covering each of the inpatient wards. This helped to clarify which wards were covered and ensure timely, effective allocation of tasks.

B) A formal, face to face “weekend handover” was introduced at 15:30 in the Conference Room every Friday afternoon.

A survey was sent to twelve Junior Doctors to gather formal feedback both before and after these interventions.

Following these two interventions:

1. 1. 91.67% feel there is now a structured and comprehensive daily handover. 91.67% felt this was not the case before.

2. 2. 63.64% feel there is now always a successfully completed morning handover. 0% felt this was the case before.

3. 3. 83.33% feel there is now always a successfully completed weekend handover. 41.67% felt this was not the case before.

4. 4. 75% feel they are always aware of sick patients when On-Call. 25% felt they were not at all aware before and 66.67% felt they were only occasionally aware before.

5. 5. 91.67% feel they are always aware of outstanding bloods to chase. 8.33% felt always confident before.

6. 6. 83.33% feel they are always aware of outstanding investigations to chase. 16.67% felt always confident before.

7. 7. 90.9% feel they know which wards are covered and uncovered when carrying On-Call bleep. 9.09% felt they knew before.

The implementation of a formal handover process has significantly improved Doctors' awareness of outstanding tasks and ward cover, which is likely to benefit patient safety moving forward. Further action is necessary to improve communication between medical and nursing colleagues regarding physical investigations performed and appropriate, timely follow up.

The poster will discuss our Quality Improvement project around improving access to mental health assessments for asylum seekers and refugees and why this model of care proved to be useful in reducing barriers to accessing specialist mental health services for these patients.

The clinic was launched as part of the Advancing Mental Health Equality (AMHE) Collaborative, which is a 3-year programme run by the National Collaborating Centre for Mental Health at the Royal College of Psychiatrists, and Norfolk and Suffolk NHS Foundation Trust (NSFT) was one of the organisations that signed up to this initiative.

The clinic was named SHIFA, which stands for (Supporting Holistic and Integrated Forced Migrants Assessments). SHIFA means ‘Healing’ in Arabic, Turkish, Urdu, Kurdish and Pashtu (languages spoken by many patients accessing this clinic) and the name was selected in collaboration with staff and service users.

What are the objectives of the SHIFA clinic?

• • To offer a trauma-informed approach to the assessment of forced migrants. This is an essential objective of the SHIFA clinic as the trauma-informed approaches are guided by trust, rapport and offering person-centred care.

• • Reduce barriers to mental health care for people seeking asylum, refugees and people forced to migrate.

• • Work collaboratively across the systems to bridge the gap among different services to improve the person-centred and continuity of care and avoid the re-traumatising effect of re-telling their stories.

• • Co-production and putting the voice of our service users and carers at the heart of everything we do.

• • Share learning and embed inclusive practice within the mental health services in NSFT and other organisations.

We will provide data on patients seen in the clinic, the diagnosis and treatment. We will also give examples of the feedback we received from professionals and service users and why this model successfully provided collaborative and joint working opportunities with various services working with these patients.

The QI project represented in this clinic has provided a local solution to meeting the needs of forced migrants in our community, reducing mental health inequalities. It ran without funding initially and was successful in receiving funding due to the clear difference it made in providing good quality care for these patients.

Similar projects can be easily implemented in various mental health trusts.

Attention-deficit/hyperactivity disorder (ADHD) is frequently associated with other psychiatric conditions, including psychotic disorders. There is evidence for shared genetic susceptibility to both conditions (Hamshere ML, Stergiakouli E, Langley K, et al. Shared polygenic contribution between childhood attention-deficit hyperactivity disorder and adult schizophrenia. Br J Psychiatry. 2013;203(2):107–111) and first-degree relatives of people with ADHD have twice the risk of having schizophrenia compared with healthy controls (Larsson H, Rydén E, Boman M, et al. Risk of bipolar disorder and schizophrenia in relatives of people with attention-deficit hyperactivity disorder. Br J Psychiatry. 2013;203(2):103–106)

There are treatment challenges, and monitoring of physical health has differences with the Early Intervention Psychosis standards following antipsychotic monitoring.

Combined outcomes (symptomatic and functional recovery) may be worse unless addressing ADHD in addition to psychosis, and addressing substance use is important.

Primary objective/aim:

To create an integrated pathway through a clinical practice guideline for patients with ADHD in early intervention for psychosis service.

Secondary objectives/aims:

Identify the prevalence of ADHD in EIP service.

Little is known about the prevalence of comorbid ADHD in adults under the care of early intervention for psychosis (EIP) services in the UK. A previous audit and quality improvement project examining all (adolescent and adult) patients (age 14–65 years) conducted in October 2022 showed a prevalence of 3.6% comorbid diagnosed ADHD in our EIP service.

Audit tools to identify the prevalence of ADHD in patients with First episode psychosis. Re-audit to monitor the the trajectory of the cases.

Measurable: Using EIP caseload cross-sectional data, data of monitoring and management from electronic patient notes system (SystmOne).

A clinical pathway was developed to integrate the diagnostic and treatment pathway to manage ADHD in an early intervention psychosis service.

Service evaluation

We identified all adult patients (between the ages of 18 and 65 years) on the caseload of the EIP service in Northamptonshire Healthcare NHS Foundation Trust, dated 5 September 2023. Data collected included age, gender, ethnicity, primary psychosis diagnosis, psychotropic and ADHD medication prescribed and risk profile that included a history or presence of substance use. Data was anonymised.

Quality improvement

Following from a previous ADHD service evaluation and QIP in EIP (2022) we identified further problem areas that included significant delays in suspected comorbid ADHD in adult patients under EIP care, as well as challenges for those already referred and attempts made by the adult ADHD service for screening and assessment (poor engagement), as well as challenges to patient functional recovery and outcomes in those with comorbid diagnosed and suspected ADHD and psychosis.

174 of 183 (95%) patients on the caseload at the time of the study review date were adults. Of the adult patients, 5 of 174 (2.9%) patients had a known diagnosis of ADHD, all dating back to childhood/adolescence. An additional 4 patients had been referred for ADHD assessment.

There are treatment challenges, and monitoring of physical health has differences with the Early Intervention Psychosis (EIP) standards following antipsychotic monitoring, hence why we have implemented in a lead-up ADHD in EIP Quality Improvement Project a NICE concordant care plan that includes physical health monitoring content and frequency.

Combined outcomes (symptomatic and functional recovery) may be worse unless ADHD related symptoms and functional impairment are addressed, in addition to psychosis, and addressing substance use is also important, given that in people with substance use disorder, the prevalence of ADHD is estimated to be as high as 21% (Rohner et al. 2023), with a lifetime prevalence of drug use disorder 27.7% (Anker et al. 2020). Of interest, in our cohort, 3/5 (60%) patients had a history of substance use (40% drug-induced psychosis diagnosis).

Our study patient profile included all young Caucasian males, with a mean age of 22 years (range 19–28 years). Of interest is that our current ongoing pilot case for the integrated clinical pathway is a young mixed-race female. Females are more likely to be undiagnosed, and clinical presentation can be different (Attoe & Climie 2023).

There are challenges with suspected ADHD and diagnostic assessment. In our Trust we have a stand-alone adult ADHD diagnostic assessment service for formal diagnosis, using DSM criteria with 3 phases of assessment. However, this service has significant referral rates, and due to capacity and resources, has a very long waiting list (18 months to 2 years).

As part of our quality improvement effort, we have collaboratively (with the adult ADHD service) worked towards an integrated pathway to improve efficiency and time to diagnostic assessment (reduce delays) for patients in EIP suspected with comorbid ADHD, with our first pilot case ongoing. We have developed a clinical pathway to aid clinicians in management of those with confirmed and suspected comorbid ADHD, to improve patient outcomes.

There are further training needs to effectively support and manage ADHD comorbidity in those with psychosis under the care of Early Intervention Psychosis.

We are a 17 bedded acute mental health ward in a busy inner-city hospital. A handover of all patients, with the multi-disciplinary team, takes place every morning (Whiteboard round). The clinical team felt that the information provided during this meeting needed a review, to ensure relevant patient information is being disseminated, and right clinical decisions are being made in a timely manner.

The team decided to focus on improving links with Community Mental Health Hubs (CMHH) to ensure continuity of care. The challenge the inpatient team faced is the need to interface with community mental health teams from two London boroughs, as the unit became the main admission hospital for Kensington & Chelsea and Westminster (KCW) patients.

The main aim is that 80% of KCW patients' CMHH (including new referrals) will be contacted within 24 hours of them being admitted onto the ward by April 2024.

As part of this QI project, weekly meetings were commenced, with a team comprising doctors, nursing staff (both inpatient and from local community team) and an Expert by Experience (EbE). A questionnaire was produced and circulated to ward colleagues about their views on the quality of whiteboard. A more focused questionnaire was then sent out around CMHH involvement in a patient's admission journey. We took a deep dive into the structure of the local community teams (at least 10 identified) and how referral processes work, as it was evident that staff were unclear at times on who/how to refer.

From this, the first change idea was formed: “information sheets” were produced showing which GPs correspond to which teams, and that patients can be referred this way. The Plan Do Study Act (PDSA) was applied to make these sheets visible to all staff. The outcome measure used was how many patients had CMHH referral/contact within 24 hours.

Data is being collected daily, by reviewing patients notes to see if CMHHs have been contacted. Since commencement of the first PDSA cycle in December 2023, of the twenty-three patients admitted, nineteen have been eligible. Of these nineteen patients, fifteen patients (79%) have had contact or referrals made to their CMHH within 24 hours.

Results suggest that the aim is on the way to being met. Our next change idea is to obtain formal feedback from staff and patients on this process.

To implement a digital handover system within Oxleas inpatient sites to improve the visibility of tasks both completed and pending, to reduce the number of tasks missed and to provide a clear audit trail relating to tasks handed over.

Junior doctors providing on-call cover to acute sites across all 3 boroughs served by Oxleas were invited to complete a questionnaire relating to the efficacy of handover. With this data & information gathered through discussions with the trust's informatics team, a digital handover system, based in Microsoft Teams, was developed. This was piloted and refined through 6 PDSA cycles from September 2022 – August 2023 before being implemented across all Oxleas acute sites from August 2023. Further questionnaires were completed 1 month & 6 months after its roll out to assess the impact of the change.

Doctors were asked to complete a questionnaire at 3 time points: pre-intervention (T0, 20 respondents), 1-month post-intervention (T1, 13 respondents), and 6-months post-intervention (T2, 12 respondents).

• • At T0, 92.3% of respondents reported tasks created by the on-call team had been missed due to staff not being aware, this reduced to 11.1% at T1, and 28.6% at T2.

• • At T0, 23.1% of respondents agree/strongly agree that it is easy to view tasks that have been done on their ward out-of-hours.

• • By comparison, at T1 69.2% reported the digital handover system has made it easier to view what had been done on a ward out-of-hours, rising to 83.3% at T2.

• • At T1, 76.9% reported the digital handover system has made it easier to view tasks when on-call, rising to 83.3% at T2.

• • At T0, 30% agree/strongly agree that the outgoing on-call doctor leaves a written record of tasks completed and outstanding. This rose to 69.3% at T1, and 41.7% at T2.

There is strong evidence that effective handover is a key aspect of clinical care, and failure of this is a preventable cause of patient harm. The initial questionnaire highlighted issues with the efficacy and safety of the handover process within acute sites at Oxleas, which the digital system sought to address. After implementation of the digital system, the findings demonstrated improvements in the handover process, with visibility increasing for tasks both completed & in progress, and fewer reports of tasks being missed by the ward-based doctors, which was maintained over the 6-month follow up period.

• • To ensure all patients on a low secure female inpatient unit have bone health risk factors assessed, identified and interventions initiated within 3 months of admission.

• • The above to be achieved through creation of a Bone Health proforma, integration of a Bone Health checklist into the Intellectual Disability (ID) Annual Health Check and delivery of bone health education for patients and staff.

Background

Intellectual Disability has been shown to be associated with poor bone health, osteoporosis and increased fracture risk. The current NICE guidelines and risk tools (QFRACTURE), do not adequately reflect the true risk within this patient group who present with additional risks of epilepsy, antiepileptic medication and greater likelihood of low vitamin D. Bone health has not routinely been monitored in this population hitherto. This quality improvement project sought to develop a process whereby potential risk factors for poor bone health were identified and managed effectively.

The project was undertaken between February 2022 – October 2023 on a female low secure unit. All 8 patients on the unit were included. A baseline screening of risk factors was conducted to assess current practice and explore the clinical need for the project. Most patients were found to have multiple risk factors which had not previously been highlighted, indicating the need for formalised monitoring. Based on questionnaire feedback, a Bone Health Care Plan, a risk factor checklist which was integrated with patients’ ID Annual Health check and Educational workshops were developed. Primary and secondary drivers were identified at the outset and plan, do, study, act cycles were used to refine change ideas. The changes were evaluated using quantitative and qualitative measures.

Every inpatient has a completed Bone Health Care Plan. Twenty-five percent of patients were identified as having a particularly high risk and have had referrals accepted for Dual-energy X-ray absorptiometry (DEXA) scans. All patients are using a new easy-read ID Annual Health Check form with Bone Health checklist incorporated. All staff and patients were given the opportunity to attend a series of four bone health workshops, 43% of patients attended at least one session. Positive written and verbal feedback was received from both patients and staff.

100% of service users have had their risk factors for bone health assessed and any necessary interventions applied. There is now an embedded process for reviewing the bone health of these patients annually where previously there was no regular monitoring.

To investigate the themes within young people and parents/carers’ experiences of the admission process. A focus was placed on potential targets for change to improve experiences of CAMHS admission.

Young people and parents/carers with an experience of inpatient CAMHS admission within the past two years were approached by the Involvement team of an NHS trust. Focus groups and interviews were conducted capturing the views of 8 young people and two parents/carers. The notes and transcripts from these conversations were analysed using Braun and Clarke thematic analysis.

Two key themes were identified within the data. The first focussed on information provision and communication. This captured young people's experiences of both: what information was available to them, e.g., websites and leaflets, and how this information was conveyed to them. The second theme brought together the young people's interpersonal experiences during the admission process. Within this, the impact of consistent contacts as well as both positive and negative transient encounters was highlighted.

Admission to a psychiatric ward is often a highly distressing time for young people and their families. The provision of easily accessible, clear, and correct information can improve their expectations and initial impressions of a unit. How this information is presented is also important. Consistent staff support and response to distress and difficulties during this time can also shape the perspectives of young people and their parents/carers.

Clear, accurate, and young person friendly information about a unit and the admissions process could be an easily achievable change which units could make to improve young person experiences. Improvements to clinicians’ skills and response may represent a more complex and expensive goal.

The project aims to improve carers’ engagement for patients admitted to our male Psychiatric Intensive Care Unit by improving communication between staff and carers; and by involving carers more in patients’ care.

Hypothesis:

Among patients admitted to PICU, there is inconsistency in communication with carers and in involving carers in patients’ care. We expect an improvement in these parameters with the quality improvement project.

Background:

Within PICUs, patients with severe psychiatric illness face social isolation. Challenges arise when carers are not engaged, impeding patient support and personalised care. Involving carers becomes crucial for informed decision-making, ensuring both patients and carers actively participate in the care process. National Association of PICUs and The Royal College of Psychiatrists' Guidance for PICU sets out recommendations regarding timelines and types of interventions to be offered to carers.

Initial baseline data was collected by reviewing patient electronic notes.

We then tested interventions to improve carers’ engagement by using the Plan-Do-Study-Act (PDSA) methodology over 2 cycles. In the first cycle, we engaged the nursing staff by presenting the baseline data and recommendations to improve carers’ engagement. In the second cycle, we introduced an admission protocol to ensure carers were engaged consistently. The parameters assessed were documentation of carers details; contacting carers within 24 hours of admission; documenting carers' views in care plan; inviting carers to Care Plan Approach (CPA) meetings and offer an appointment for carers with staff.

Data was collected after each PDSA cycle to monitor change.

Of the patients admitted to PICU, 29% had their carers’ details documented at baseline, 40% after the first PDSA and 80% after the second PDSA. 42% of carers were contacted within 24 hours of admission at baseline; 66% and 30% after the two PDSA. 50% of carers had their views included in the care plan at baseline; 0% and 30% after the interventions. At baseline, 42% of patients’ carers were invited to the CPA meeting, 66% and 30% after the two PDSA cycles. 50% of patients’ carers were offered an appointment with staff at baseline, 66% and 30% after the two interventions.

As a result of this quality improvement project there has been an improvement in engaging carers of patients admitted to PICU. This was not sustained for the second cycle due to many regular senior staff being on leave during Christmas. The next steps will be to implement this consistently and produce a carers’ information pack.

As part of a wider quality improvement project (QIP) aiming to improve trainees’ experiences with ‘Raising Concerns’ in a large mental health trust, we sought to improve the trainee representative (rep) structure. This would give trainees more transparent processes and provide intermediaries by which to raise concerns. Based on change ideas generated from our driver diagram, roles were created to coordinate meetings and represent specific groups of trainees and on-call rotas.

Prior to August 2022, there were an undefined number of ‘Senior House Officer’ (SHO) reps who were recruited informally by the Post-Graduate Medical Education Team. The duties of these reps were not clearly detailed. As part of our first ‘Plan, Do, Study, Act’ (PDSA) cycle, we identified groups of trainees that needed additional representation (International Medical Graduates [IMGs], Less than Full Time trainees [LTFT]) and introduced a Wellbeing Rep to cover all training grades. Specifically for SHOs, we introduced three core roles (Rota/Placement, Inclusion, and Social) and individual roles for the six on-call rotas. Following the implementation of this rep structure, we gathered quantitative data, including whether trainees had utilised the reps and how effective they were in raising concerns, and qualitative feedback. We gathered data from both the reps and the whole cohort of trainees. We then started another PDSA cycle in August 2023.

On a 1–5 scale (5 = very effective), the average response from trainees for how effective the trust reps were in supporting raising concerns was 3.8 (5 responders), with no trainees who responded feeling that any of the rep roles needed restructuring. However, the rep survey highlighted that the following roles needed restructuring: Rota/Placement rep, Social rep, and Rota reps. The Rota/Placement role was highlighted as being unnecessary due to the existence of individual rota reps, but there was a need for a ‘lead’ rep to coordinate rep meetings and induction. Unfortunately, a Social rep was not recruited, however it was identified that due to the importance of the role more than one trainee may be required to arrange social events.

Overall, the trainee response to the new rep structure has been neutral/effective, but we hope to obtain more responses in the next PDSA cycle. The rep feedback highlighted the need for coordinator roles to improve cohesion. The results have informed change ideas which we implemented in August 2023. The second PDSA cycle will be completed in July 2024.

Trainees on the psychiatry on-call rota at a London acute inpatient unit reported a lack of confidence in asking male patients about sexual dysfunction during clerking. Research shows that history-taking barriers include embarrassment, time shortage and task prioritisation. Sexual dysfunction is prevalent amongst the general population, markedly so amongst people with mental health diagnoses.

In response, we designed a quality improvement project (QIP) to improve confidence by addressing the need for good history-taking and the technique for doing so.

To gauge trainee confidence, we produced and disseminated an online questionnaire with a mixture of qualitative and quantitative questions.

Based on the data collected, we contacted a local sexual health consultant and requested a teaching session on the importance of sexual history-taking, the impact of not doing so, barriers to history-taking and how to ask about sexual dysfunction.

A follow-up questionnaire was produced and disseminated.

The results of the first questionnaire showed that 100% of respondents (n = 10) did not ask male patients questions about their sexual function, on admission. The main reasons for this were embarrassment for themselves (25%) and the patient (66.7%), lack of confidence on how to word these questions (50%), lack of time (58.3%) and feeling that these questions are not relevant (33.3%).

Following the teaching session, 71.4% of respondents said that they would ask male patients questions about symptoms of sexual dysfunction on admission. The majority of responses quoted that the teaching had increased their confidence, decreased their embarrassment in asking these questions, and helped them to understand the relevance of asking these questions. Two respondents queried the appropriateness of asking acutely unwell patients these questions on admission and if these questions could be asked during a patient's admission instead.

Limitations: Small sample size of results; slight drop in responses from first questionnaire to second questionnaire; questionnaire only asking questions about male patients, not female patients.

This QIP shows that a single, simple intervention can improve trainee confidence in the short term. This intervention can be applied across the UK. Online teaching can improve access to the expertise of local sexual health consultants. This QIP also provides a basis for further analysis: whether single interventions can improve trainee confidence in the long term, when is the best time to ask questions about sexual function and applying this intervention to female sexual function history-taking.

When Kingfisher Mother and Baby Unit (MBU) opened in 2019 personality disorder and severe self-harming behaviours were exclusion criteria for admission. Complex Post Traumatic Stress Disorder (C-PTSD) with its emotional dysregulation, interpersonal difficulties and common presence of self-harm was similarly categorised.

Currently, C-PTSD presentations are frequently admitted to the MBU, making up around 45.9% of admissions. There is increasing understanding of the importance of effective and trauma informed treatment in admission outcomes, particularly in reducing trans-generational trauma. This requires appropriate skills and training in staff.

Service users were identified retrospectively over a 24-month period and categorised into C-PTSD traits (trait) and non-C-PTSD traits (non-trait). Comparisons of routine outcome measures (ROMs) identified higher distress in the C-PTSD group and reduced satisfaction. Staff survey highlighted areas of anxiety and low confidence in working with service users with C-PTSD traits.

Actions were divided into three streams – Admission, Transitions and Communication. Staff training needs were identified and training given. Admission processes were reviewed with a focus group including past service users and changes based on DBT principles were implemented. A leaflet was developed to aid communication with service users considering MBU admission via Outreach and Community Perinatal teams.

Surveys were the primary source of data before and after changes. As of September 2023 the majority of training had been rolled out but numbers completing the training survey were too small to draw conclusions. Anecdotal feedback was predominantly positive and the survey will be repeated at the same time as other data in March 2024.

Ward process changes started in late August 2023 and routine outcome measure data will be compared at 6 months (March 2024). Again anecdotal feedback is positive.

The leaflet was rolled out for use by community teams and service users in November 2023 and feedback via survey will be collected in March 2024.

Evaluation of routine outcome measures showed poorer outcomes and experiences for patients with traits of Complex-PTSD. Staff survey highlighted lack of confidence in managing the same. Consultation with a range of staff and past service users led to changes in admission practices, communication prior to admission via a leaflet, and staff training. Anecdotal feedback since implementation has been positive but we hope to see this confirmed in the Routine Outcome Measures and surveys 6 months after the changes were implemented.

Controlled physical restraint is a commonly used, but controversial practice in inpatient psychiatric settings, at times bringing psychiatric practice into potential conflict with accepted medical ethical standards for preserving autonomy and bodily-integrity. However, physical restraint can produce high levels of patient distress, re-traumatise those who have experienced physical or sexual abuse, and may lead to inadvertent bodily injury, and even death on rare occasions. There is an international consensus to attempt to reduce restrictive practices, including physical restraint, as demonstrated in the World Health Organization's Quality Rights Initiative. Post-restraint patient debriefing can promote recovery, prevent future restraint, and promote a more ethical and humanising care environment.

We aimed to audit the frequency of restraint events, and post-restraint debriefs offered to patients in a single, London-based, male acute psychiatric ward.

In the pre-intervention sample, data was extracted from the records of patients admitted over a six-month period (n = 75), to identify the number of patients who had undergone restraint and the number who had been debriefed. The search terms “restrain”, “PMVA”, “response team” and “debrief” were used. After each restraint event, the notes for the following two weeks were reviewed to see if a debrief was delivered.

The intervention consisted of a single description and dissemination of the results in a ward business meeting, with instruction that all staff members within the ward multidisciplinary team can help provide debrief if appropriate to do so. Where a patient was known to have been restrained, debriefs were offered during subsequent ward round reviews as appropriate.

In the post-intervention sample, we collected data from patients admitted over a 10-month period (n = 89).

We used Chi-Squared testing to compare categorical variables pre- and post-intervention.

Pre-intervention, 15 patients underwent restraint and of these, 8 patients (53.33%) were debriefed. Post-intervention, 21 patients underwent restraint and of these, 10 patients (47.62%) were debriefed. There was no statistical difference in the proportion of patients offered a psychological debrief (p = 0.735).

Following a single intervention there was not a sustained difference in the proportion of post-restraint debriefs offered. It is likely more sustained interventions would bring about more substantive practice change. Incorporating the need for post-restraint debriefs in daily ward safety-huddles, or in structured “ward round proformas”, may increase the proportion of patients offered post-restraint debriefing. It is possible that the note review strategy did not capture all debriefs delivered.

The urgent referral system to outpatient psychiatry in NHS Lothian is intended for patients who require to be seen within 5 days. However, many of the referrals are not deemed this urgent upon triage. This project aims to illustrate the extent of this issue and highlight potential reasons, in order to improve the pathway for patients referred on to secondary care services.

Over a 3 month period from August 2023 to November 2023, all urgent referrals received by an Edinburgh sector general adult psychiatry outpatient's department were reviewed. Data was collected on broad presenting complaint, whether or not the referral was deemed urgent upon triage, whether it contained a factor in line with RefHelp guidance for urgency, and what the end outcome of the referral was.

During the 3 month period, there were 92 urgent referrals. Of these, only 12% were deemed urgent upon triage. Almost all accepted referrals related to concerns around potential psychotic illness (82%). Although only 12% of referrals were accepted as urgent, 35% had factors which, in accordance with RefHelp guidance, would be cause for considering an urgent referral.

There were a variety of disposals including “soon” appointments, redirection to other services such as Thrive or offering advice to the referring clinician. The most common outcome was the offer of a “soon” appointment, closely followed by redirection to the Thrive team.

The majority of urgent referrals were not deemed urgent at triage. There was a clear discrepancy between referrals containing urgency factors according to RefHelp and those offered urgent appointments. This would suggest that the available guidance is not sufficiently clear.

Many referrals were redirected to other services, including Thrive. This redirection may reflect a lack of awareness and a further project may examine Thrive referrals to establish if the number initially sent to psychiatry outpatients is significant.

Additionally, several referrals were triaged as “soon” and seen in 6–8 weeks, as opposed to waiting for a routine appointment. Though RefHelp advises highlighting routine referrals which may be a priority, this pathway was not being used and there is no direct route for “soon” referrals.

Next steps may include liaison with primary care teams to establish views and concerns, updating RefHelp guidance and adding a further referral pathway to address the apparent gap for “soon” referrals.

We conducted a quality improvement project in a female rehabilitation unit, with an aim to reduce the total anticholinergic burden.

Most patients were reluctant to change the medications that they have been taking for long time. Hospital staff were also concerned about the potential risk of destabilising the mental health of patients who are currently stable.

As a first step, we used ACB (Anticholinergic Burden) calculator to calculate ACB score

We agreed on a realistic safe target. We decided not to include patients who are on clozapine. Information related to anticholinergic burden was shared with nursing team and staff members. This was discussed in MDT meetings to answer any questions.

Team collaboratively created an information leaflet, including an easy read version. Group sessions and 1:1 sessions were arranged with patients to discuss the potential side effects.

Medication changes were carried out following a consultation with patients.

ACB score of all 15 patients were over 3. One patient is over the age of 65. Five patients scored more than 10 on total ACB score. Two patients were on clozapine.

Promethazine, procyclidine, hyoscine hydrobromide, oxybutynin and clozapine were causing most of the anticholinergic burden.

We decided not to change medications of two patients who were on clozapine. For the remaining patients procyclidine and promethazine were reviewed and stopped following a consultation. All 12 patients' ACB score is now less than 10. There has been a reduction of 3–6 points.

This project has helped in reducing the ACB burden successfully. Promethazine with an ACB score of 3 was stopped for all patients. Some patients received promazine instead of promethazine. Procyclidine has been stopped for several patients and for some patients it has been changed from regular to PRN (to take when required). Consideration has been given to reduce the dose of typical antipsychotic medication instead of using procyclidine to treat extrapyramidal side effects.

Providing information and then reviewing the prescription of promethazine and procyclidine has resulted in significant reduction in the total ACB score.

Patients not attending appointments without letting the service know prior (referred to as did not attend – DNA) is a significant problem in community mental health (CMH). However, there are limited studies conducted in the United Kingdom on this issue. Patients forgetting appointments was a reoccurring reason for DNAs in the literature. To address this, we aimed to assess the impact of raising staff awareness on recording patient consent to receive text message reminders of appointments and increasing the frequency of reminders on DNA rates in Arndale House (a CMH service covering Dartford, Gravesend and Swanley as part of the Kent and Medway NHS and Social Care Partnership Trust – KMPT).

DNA rates at Arndale House from August to October 2023 were assessed to determine a baseline before implementing interventions. Following this, two interventions were put in place; the first occurred on 18/10/23, consisting of an online teaching session for the staff at Arndale on documenting patients’ consent to receive text message reminders for their appointments. Posters with instructions on this were posted on the trust intranet and set up within the building. The second intervention occurred on 20/11/23 and included sending out text message reminders more frequently, from three and one day prior to appointments to seven days beforehand as well. DNA rates for November were analysed to assess the impact of intervention one and December for intervention two. Patient characteristics were also examined monthly to identify any trends among those who DNA. The analysis comprised 109 patients (69 for pre-intervention, 27 for intervention one, and 13 for intervention two).

Pre-intervention DNA rates were 13.4%, 17.5%, and 13.5%, respectively. The incidence of DNA increased to 19.9% after intervention one. However, this was lower than November 2022. The rate for intervention two was 11.6%, lower than that of December 2022. Being White, having a mood disorder and having mental health disorders which fell under more than one category were prominent among those who DNA.

Increasing the frequency of text message reminders of appointments had a significant impact on reducing DNA rates, highlighting a potential intervention which can be implemented in CMH to tackle the issue of DNAs.

The Quality Improvement Project (QIP) for the Café of Royal College of Psychiatrists (RCPsych) Portfolio (CoRP) was initiated to address the challenges faced by UK postgraduate psychiatric trainees in utilizing the RCPsych Portfolio effectively. The primary objective of this project is to enhance trainees' confidence and competence in using the portfolio. Additionally, CoRP aims to establish a robust, sustainable ecosystem of peer coaching and mentorship to support continuous learning and development among trainees.

The CoRP employs a unique, multi-faceted approach, leveraging a scalable coaching and mentoring model. Firstly, the program focuses on increasing its visibility among trainee groups through targeted communication and marketing efforts. Secondly, CoRP provides on-demand sessions to cater to the varied schedules and job plans of trainees, offering flexibility and accessibility. The sessions offer a mix of coaching, mentorship, and guidance, tailored to the specific needs and learning styles of each trainee. Furthermore, the project fosters an environment where trainees can learn from peers and experienced professionals, enhancing the learning experience and promoting a culture of collaborative learning.

The implementation of the CoRP has led to significant improvements in trainees' confidence in using the RCPsych Portfolio. This outcome is evidenced by the data collected from pre- and post-session surveys, which show a marked increase in trainees' self-reported confidence levels. The project has successfully conducted a series of sessions that focus on various aspects of portfolio management and learning. These sessions have been well-received, with positive feedback from participants indicating that the program meets its intended objectives. However, the project acknowledges the need for long-term data to understand its impact on the Annual Review of Competency Progression (ARCP) outcomes and to assess its sustainability over time.

The CoRP has demonstrated immediate, positive effects in enhancing the skills of psychiatric trainees in using the portfolio. Its strengths lie in the scalability of the model and the incorporation of coaching and mentorship principles, which have proven effective in addressing the needs of trainees. However, the project recognizes that further evaluation is needed to establish a clear correlation between improved portfolio skills and ARCP outcomes. To this end, future plans include the continuous expansion and repetition of the program every six months to accommodate new trainees. Additionally, ongoing evaluation will be conducted to measure the program's long-term effectiveness and sustainability. This will ensure that CoRP continues to evolve and adapt to the changing needs of psychiatric trainees, ultimately contributing to their professional development and success in their field.

To explore reasons why patients under the learning disability community psychiatry team were not attending their appointments.

To explore patient preferences for type of appointments offered (F2F, telephone or video) aiming to improve access and attendance, whilst promoting reasonable adjustments for patients with learning disabilities.

To improve efficiency in terms of number of patients seen and reduce wasted clinical and admin time in relation to DNA appointments, by reducing the ‘did not attend’ (DNA) rates by 20%.

With the support of the QI team using methodology including fishbone diagrams and PDSA cycles, electronic data on the number of DNA psychiatry appointments were collated from January 2022 onwards and recorded monthly.

Each DNA appointment was coded with a reason given for non-attendance. The data was then reviewed and analysed to identify any common themes around non-attendance.

A questionnaire was initially trialled with a small sample of patients who had not attended to explore reasons for non-attendance and preference regarding appointment type. The questionnaire was then sent to all CTPLDW patients who had missed appointments. An easy-read version was also sent to promote accessibility amongst the patient group. The data was collated and reviewed.

Most common reasons for patients not attending their psychiatry outpatient clinic appointments under the CTPLDW team were identified:

2022: 35 patients DNA – 28.6% citing communication/correspondence issues.

2023: 30 patients DNA – 33.3% citing communication/correspondence issues.

Additional reasons for non-attendance included issues with residential homes, sickness and transport.

An anecdotally high number of DNAs were noted by CTPLDW. The data collected thus far has helped us to define and understand the issues. The main factors identified revolve around communication and correspondence of appointment times.

The next step in our quality improvement project is to trial text reminders for patients and carers to assist in remembering appointments, to assess whether this change idea helps to decrease the number of DNAs.

Future change ideas include development of resources to support attendance (e.g. adjusted appointment letters with QR codes for access/maps, reminder letters in easy-read format and video tours).

CTPLDW would like to offer a more personalised approach with a service that promotes reasonable adjustments and reduces barriers to access, thereby reducing the number of DNA appointments.

Background: Handover aims to achieve the efficient communication of clinical information when responsibility for patients is transferred. The Royal Edinburgh Hospital (REH), a specialist hospital serving the Lothians, has repeatedly received “red flags” (ranked in the bottom 2% of benchmarked areas) on the handover section of the Scottish training survey (STS) and GMC national training survey of doctors in training (DiT).

Aims:

• • Survey DiT to understand their experience of handover.

• • Introduce a new structured handover process.

• • Re-audit parameters after intervention.

Data from REH DiT were extracted from an anonymised handover survey, disseminated to all psychiatry DiT in Scotland in January 2023. Multiple choice and free-text questions covered handover timings, format, structure, and attendance. The survey was repeated after intervention. In addition, data from the STS were analysed. The intervention consisted of altering shift times to include protected time for handover, introducing a dedicated room, training in the use of an electronic system to record tasks, involvement of senior doctors, and dissemination of the new changes to procedure.

A total of 12 survey responses (25% response rate) pre-intervention (25% FY2s, 17% GPSTs, 58% core trainees) and 14 post-intervention (14% FY2s, 14% GPSTs, 71% core trainees) were analysed. The proportion of respondents reporting that handover always happened at times of shift change increased from 7% to 93% post-intervention. The proportion of those reporting that there was protected time for handover rose from 0% to 50%, and the use of a predetermined structure/format increased from 0% to 43%. After intervention, 86% of DiT felt adequately supported during handover (compared with 17% pre-intervention) and 93% of respondents felt handover ‘allowed for the efficient and effective transfer of information to protect patient safety’ (33% pre-intervention). Prior to the process change, 83% of DiT felt there was no clear senior leadership at handover; this fell to 21%. Post-intervention the use of WhatsApp/texts to hand over information fell by 100%. The new system was welcomed by trainees, but teething problems were identified.

The new process led to improvements in the frequency, consistency, format, recording, and senior support of handover. Issues with the use of video call software and electronic medical records systems have been identified, and work is ongoing to address these in an iterative quality improvement process. Good clinical handover benefits patients (fewer mistakes and increased safety, better continuity of care, improved satisfaction) and clinicians (improved communication skills, increased accountability, feel more informed, improved job satisfaction).

Background: Nature and degree of mental illness can impair abilities of patients to drive safely which puts their own safety and safety of others at risk. There is also an ongoing concern of patients not being properly informed on their duty to inform the DVLA and potentially to stop driving for an extended period.

Aims:

1. 1. To assess if risk assessment of patients in term of driving status was completed at time of admission, during their stay on ward, and if any advice regarding fitness to drive was given at time of discharge.

2. 2. To improve patients being asked about driving status on admission to 100% of patients.

3. 3. To improve rates of service users being informed of the DVLA guidance following a mental health illness to 100% of patients.

It is a Quality Improvement (QI) project. Baseline information on current practices were assessed against local fitness to drive policy of Leicestershire Partnership NHS Trust in May 2023. Data was collected from 10 inpatient (6 general adult & 4 old age) wards. All patients who were discharged in the month of January 2023 were included for audit. Information was collected about driving status of patients at time of admission, during their stay on ward, and if any advice regarding fitness to drive was given at time of discharge. Data was recorded anonymously. Results are reported in percentages for descriptive statistics.

Risk assessment was completed in 95% of patients on admission. About 12% (15/128) of the patients were driving at the time of admission, 80% of them were female. Assessment of driving risk during admission only took place in 11.7% (13/128) of cases. Advice on fitness to drive at time of discharge was given only in 12.5% (16/128) of cases. About ¼ of patients who were driving at time of admission, did not receive advice on fitness to drive at time of discharge from hospital.

There is a huge gap in clinical practice regarding compliance with fitness to drive policy. There is an urgent need to improve awareness among mental health teams that they have a role with regard to assessment of their patients’ risks and fitness to drive. An educational training video will be prepared and shared with clinicians in December 2023 to fill gaps in the service. Further information will be collected on practices related to fitness to drive policy in March 2024 for further evaluation of services.