The National Institute for Health and Care Excellence (NICE) recommends routine testing and replacing vitamin D in adults considered high risk of deficiency. Evidence suggests high prevalence of vitamin D deficiency among those with alcohol dependence and those with chronic liver disease regardless of etiological factors. These findings are particularly important for Bridge House Detoxification Unit, where patients with complex substance use disorder (SUD), and multiple physical and mental health co-morbidities, undergo detoxification. The purpose of this audit project was to establish current levels of vitamin D testing on Bridge House Detoxification Unit in comparison to the standard set by NICE guideline PH56, and to improve it.

Data was collected retrospectively from a total of 76 patients, through 3 rounds of data collection. In each round all the patients discharged within a 2 months period were included. The Audit tool looked at whether vitamin D was tested on admission. Vitamin D level ranges were defined according to the Royal Osteoporosis Society: <25nmol/L is deficient, 25–50nmol/L inadequate, >50nmol/L is sufficient. After the first round, an intervention in the form of pre-populated blood form including vit D testing was introduced. This was to be used on the first day of admission. The second round measured improvement while the third round measured maintenance. Microsoft Excel was used to analyse data.

During the first round of data collection, no patient had their vitamin D tested. Following our intervention, 86.67% of our patients had their vitamin D tested suggesting significant improvement to compliance in the second round. In the third round, we were able to maintain compliance at 90%. Of the 44 patients that had their vitamin D tested after our intervention, 30 (68.18%) patients were within the deficient and inadequate thresholds, requiring vitamin D replacement.

This audit project examined international literature and local data identifying that vitamin D is indeed low among our patient group, therefore should be regarded as a high-risk group for vitamin D deficiency. There is sufficient evidence among the international literature that people with SUD suffer through significant physical and mental health effects of low vitamin D. A simple intervention of a prepopulated blood form was able to increase our compliance and maintained this.

1. 1. Measure compliance with NCEPOD Recommendations in the quality of physical healthcare provided to adult patients admitted to a mental health inpatient setting across the East and Central areas of North Wales.

2. 2. Guide further service development and improvement in the quality of physical health care provided in mental health inpatient settings in North Wales.

1. 1. A retrospective case notes audit of 10 patients each who were inpatient for at least one week duration on the adult mental health wards was conducted in April 2023 across the East and Central areas of North Wales.

2. 2. The audit was conducted using the NCEPOD audit Toolkit for “Physical Health in Mental hospitals”.

1. 1. Inpatients percentage (%) compliance against NCEPOD recommendation 1, 5, 6, 7, 9 and 11 was 0% for both East and Central areas of North Wales respectively.

2. 2. Recommendation 2 had 65% compliance for Central vs 61% for East.

3. 3. Recommendation 3 had 62% compliance for Central vs 25% for East.

4. 4. Recommendation 4 had 88% compliance for Central vs 40% for East.

5. 5. Recommendation 8 had 3% compliance for Central vs 20% for East.

6. 6. Recommendation 10 had 100% compliance for Central vs 94 % for East.

7. 7. Recommendation 12 had 72% compliance for Central vs 71% for East.

1. 1. Improve compliance with the NCEPOD recommendations in the quality of physical healthcare provided to adult patients in mental health inpatient settings.

2. 2. Develop a Trust wide policy document for physical health care in mental health inpatient settings in North Wales as per NCEPOD recommendations.

3. 3. Develop a new physical health assessment booklet for Betsi Cadwaladr University Health Board Mental Health and Learning Disabilities Division to be used by all inpatient staff for the provision of physical healthcare of mental health inpatients in line with the NCEPOD recommendations.

To evaluate whether a comprehensive biopsychosocial assessment is performed for patients presenting with self-harm or suicidal ideation in clinical practice, following National Institute for Health and Clinical Excellence guidelines 225 (NG225). We assessed Dorset Healthcare Liaison Psychiatry practitioners' compliance with a standardized biopsychosocial assessment template.

A standardized biopsychosocial assessment template, aligned with NG225, is utilised in all Dorset Healthcare Liaison Psychiatry services for conducting initial assessments. Included data were the initial assessments of adult patients presenting from 01/08/2023 to 30/09/2023 for the following indications: 1) a suicide attempt, 2) a self-harm incident, or 3) suicidal ideation. Any initial assessment that did not use the standardised template was excluded. Retrospective analysis of Rio records assessed compliance with each heading on the biopsychosocial assessment template.

A total of 60 records were included from Dorset Healthcare Psychiatry Liaison Services. Only one heading, the “Presenting Situation”, was documented in all assessments (100%). Psychiatric headings on the template showed high compliance: “Mental State Examination” and “Risk Summary” were each documented in 98% of assessments, and “Psychiatric Formulation” in 92%. The “Carer/Parent's Understanding of the Assessment” was the least assessed (40%). Other significant headings that showed moderate compliance were, “Safeguarding Concerns” (71%), “Physical Health History” (75%) and “Social Situation” (81%).

Our findings emphasize the need for more comprehensive biopsychosocial assessments in Dorset Healthcare Liaison Psychiatry services. While Liaison Psychiatry practitioners exhibit proficiency in evaluating psychiatric aspects, there is reduced compliance in assessing social aspects, notably in assessing family understanding. Future qualitative analyses will evaluate practical barriers and human factors affecting compliance with specific headings. Moreover, data collection can expand to encompass additional Mental Health services in a wider catchment area, including settings such as community and inpatient facilities.

Patients with disordered eating in psychiatry are considered highly complex in the acute hospital setting. In Spring 2023 a pilot for a specialised dietitian was introduced to identify and target such patients; aimed at reducing length of stay to the acute medical wards. Hospital admissions for eating disorder increased by 84% between 2015/16 and 2020/21; with increasing complexity of presentations and a demand for Specialist Eating Disorder (SEDU) beds, there are increasing numbers admitted to acute medical beds for initial treatment and management. In 2021 the Royal College of Psychiatrists published its updated guidance, Medical Emergencies in Eating Disorders (MEED). There is recognition that acute trusts must identify care pathways for the management of patients with eating disorders and severe food restriction for psychiatric reasons. This audit aims to show how these guidelines are being implemented locally and where there is a need for improvements in care pathways focusing particularly on length of stay, frequent attenders and avoiding hospital admissions.

A retrospective audit of 26 patients presenting between 01/03/2023 and 31/12/2023 was completed. Patients were identified from data collated by the specialist dietitian as having presented with an existing diagnosis of eating disorder or disordered eating in the context of psychiatry. Some patients were detained under the Mental Health Act. Some patients presented on multiple occasions to the acute hospital during this period; each inpatient episode was analysed independently. Data was collected retrospectively by analysing PICS documentation (electronic notes system) and entered into a data collection spreadsheet. A Google Form checklist was created to capture whether key points from MEED guidelines were met.

Demographic data, details of initial presentation and admission events were collated including the team initially referred to and how long after the initial admission this occurred. Outcomes of admission were also recorded. Data was quantitatively analysed to understands trends in referral process, MDT working (inclusion of emergency clinicians, acute medicine, psychiatrist, specialist dieticians and nursing colleagues). Average lengths of stay, number of attendances and planned admissions were also captured.

An overall reduction in length of stay for detained patients with dietetic and wider MDT input was noted from 50 days prior to January 2023, to 29 in the period from March 2023 onwards. Frequent attendance for electrolyte abnormalities was significantly improved though implementing MDT working with teams in the community and planned admissions from inpatient units or SEDUs for medical management reduced overall length of stay for those patients.

Electroconvulsive Therapy (ECT) is a treatment used for patients with severe depression, mania, catatonia, and schizophrenia. National Institute for Clinical Excellence (NICE) guidance for the use of ECT advises that for all patients, a risk/benefit assessment for the treatment should be made and documented with particular reference to anaesthetic risk and the adverse effect of cognitive impairment.

For patients who can consent to treatment, NICE recommends the use of patient information leaflets to help people to make an informed decision about their ECT treatment.

For patients who cannot consent to treatment, psychiatrists can authorise the use of ECT using the Mental Health Act. However, NICE recommends that any advance directive should be fully taken into account, and someone who speaks on behalf of the patient should be consulted.

This project aimed to audit whether the documentation of the consent process of patients undergoing ECT in NHS Grampian was in line with the above NICE Guidance.

The clinical notes and ECT folders of the six patients undergoing ECT treatment in NHS Grampian in January 2023 were reviewed in reference of the following domains:

1. 1) The clinical indication for ECT.

2. 2) If the patient (or their family/advocate) had the opportunity to receive the RCPsych Patient Information Leaflet for ECT.

3. 3) If a discussion about the risks/benefits of ECT had taken place with a patient, their family or advocate.

4. 4) If specific risks and side effects – namely anaesthetic risk and cognitive impairment – had been discussed with the patient, their family or advocate.

The project had been registered with the NHS Grampian Quality Improvement & Assurance Team prior to data collection beginning.

All of the notes reviewed (100%) had the clinical indication for ECT clearly documented.

Three (50%) of the patients had received the RCPsych Patient Information Leaflet for ECT.

A clear risk/benefit assessment discussion was documented in three (50%) of the patients' notes.

Specific discussion of side effects including cognitive impairment and anaesthetic risk was documented in three (50%) of the patients' notes.

There is a clear need for improvement in the documentation of the consent process for ECT in NHS Grampian. While the indication for receiving ECT is being clearly recorded, documentation of the risk/benefit assessment, discussion of specific side effects, and involvement of family or advocacy is less consistent. The introduction of the NHS Grampian standardised consent form is being considered as an option to improve this documentation. The documentation of the consent process for ECT can be re-audited once this form has been introduced.

In the intensive care unit (ICU), delirium occurs in up to 80% of patients on mechanical ventilation. Delirium is associated with an increased risk of morbidity and mortality, long-term cognitive decline, and risk of reintubation. This initial audit aims to identify areas of improvement in the early detection, prevention, and management of delirium in the ICU of the general hospital following trust guidelines.

In this baseline audit, data was collected about all inpatients on admission over a 7-week period (81 patients in total). The parameters audited were in accordance with trust guidance on the management of delirium and compliance to this was recorded. Parameters included: the correct use and documentation of screening tools, type and cause of delirium, pharmacological and non-pharmacological management, and other demographics such as sensory impairment and length of stay. Confused patients handed over verbally during ward rounds were also assessed again at the time, with documentation and parameters reviewed.

Of the 81 inpatients in the ICU, 20 were observed with delirium during their stay. The documentation of delirium via the CAM-ICU screening tool was incorrect in 25% of patients with delirium (PWDs). Furthermore, behaviour (including sleep) was only monitored for 15% of PWDs and 0% had a complete “This is me” document (support tool for patient-centred care).

Sensory aids were not available for 50% of PWDs and 25% of this group had drug/alcohol dependence. A diagnosis of delirium was only formally documented in 40% of PWDs and of these, 15% had the type of delirium documented. Only 8 PWDs received a specific management plan, with 6 PWDs receiving haloperidol or lorazepam for agitation. Non-pharmacological managements were not documented.

The average length of stay in the hospital was 20% longer in PWDs compared with non-delirium patients, with 10 deaths in the ICU; 50% of these being PWDs.

There is a lack of accurate documentation and a lack of medical optimisation for PWDs, which may lead to missed delirium diagnosis, greater risk of mortality and longer hospital stays. The results highlight a need for further education about delirium in the ICU, to increase awareness for better detection, prevention and promotion of appropriate delirium management and formal documentation as per trust guidelines. Furthermore, a need to consider alternative pharmacological management for delirium, specifically in the ICU where lorazepam and haloperidol may not be suitable in consideration of anaesthetic drug interactions and respiratory support requirements.

As admissions have the potential to contribute to iatrogenic harm, Mersey Care NHS Foundation Trust (MCFT) introduced an admission checklist to help the decision-making process around admitting people with Borderline Personality Disorder (BPD).

1. 1. To conduct an audit to review if the admission checklist was being used after its introduction.

2. 2. To provide data on the context of admission including the use of MHA.

Data from admissions for people with BPD to nine acute care wards in (MCFT) over a three-month period were collected and assessed for 21 parameters.

A total of 60 admissions were identified for 51 patients (9 patients had more than one admission).

None of the recorded 60 admissions had a completed BPD checklist at the time of admission.

36 (60%) of the decisions to admit took place during the Normal Working Hours (NWH), 24 (40%) out of hours (OOH).

33 (55%) informal admissions, 27 (45%) on Section 2 of the MHA.

NWH admissions were associated with a higher number of informal admissions compared with OOH admissions (24 vs 9 respectively).

3 out of 27 OOH admissions requested by Crisis Resolution and Home Treatment (CRHT) resulted in informal admissions. The remaining OOH admissions were following a Mental Health Act Assessment (MHAA) by trainee psychiatrists.

At the point of admission, 9 (15%) patients were not open to secondary mental health team in MCFT prior to their referral for MHAA; 48 (80%) patients were under Community Mental Health Teams and/or the CRHT; 12 (20%) were open to the Personality Disorder (PD) hub, and 3 (5%) were open to other mental health teams including eating disorders team, Attention Deficit Hyperactivity Disorder (ADHD), Addiction Services and Criminal Justice & Liaison Team (CJLT).

There was no engagement with completing the BPD admission checklist. 40% of ST doctors reported on a separate survey that they cannot locate the Checklist on patient information system.

Admission decisions made during NWH have led to significantly more informal admissions compared with during OOH where the MHA was more likely to be used.

An action plan was designed to improve engagement with the admission checklist:

• • Introductory training was provided to CRHT, approved mental health professionals (AMHPs), MHA second opinion doctors and psychiatry ST doctors.

• • Inpatient teams were asked to complete the checklist.

• • Bed Management to request an updated completed PD admission Checklist prior to admission.

• • Re-auditing in 6 months.

Research has found that having a mental health condition is associated with smoking, and difficulties remaining abstinent. It is also evidenced that there is desire to reduce the amount smoked and cease smoking altogether by those with mental health conditions. Smoking can also affect some medications used to treat mental health conditions.

To assess nicotine replacement management in inpatients at Rathbone Rehabilitation Centre (RRC) against Mersey Care NHS foundation Trust (MCFT) Nicotine Management Guidelines (SA20).

Data of all discharged patients from RRC over a 12-month period was collected following a standardised process and assessed for 6 parameters.

A total of 51 discharges were identified and the whole sample of 51 patients were audited.

47 (92%) were asked and recorded of their smoking status and 4 (8%) were not at the point of first contact on patient electronic records (Rio).

Of the 28 smokers who were identified on admission, 26 (93%) were offered support to stop smoking at that point. 3 other patients started smoking during admission.

Of the 31 patients who were identified as smokers (including 3 who began smoking during admission), 24 (77%) were offered support to stop smoking at regular intervals throughout their admission and 7(23%) were not.

Of the 28 smokers who did not wish to permanently stop smoking, there was documented evidence that 20 (71%) of these individuals were offered nicotine replacement treatment (NRT) in some form to manage temporary abstinence from smoking.

5 out of 31 smokers were referred to a Nicotine Dependence Treatment Advisor for counselling and support during their inpatient stay.

Below action plan was designed to improve compliance with MCFT Nicotine Management Guidelines (SA20):

Audit leads to communicate with every team member at RRC (Team meetings and emails) to remind them of the following:

1. ◦ To offer smokers support to stop smoking at regular intervals and document on Rio; via named nurse sessions or opportunistically.

2. ◦ To offer NRT where appropriate and document on Rio if accepted or declined during MDT reviews/named nurse session.

3. ◦ Ensure Physical Health Nursing Proforma is always completed on Rio, and if the service user is a smoker, to ensure referral status (referred/declined) to Nicotine management team is documented.

4. ◦ Increase awareness of referral pathway by putting up posters in relevant clinical areas.

To ascertain the service performance against the standards set by National Institute for Clinical Excellence (NICE) guidelines on physical health monitoring of children and adolescents prescribed antipsychotics.

Initial audit: April–June 2021.

Re-audit: January–February 2024.

Registered with the Lancashire and South Cumbria NHS Foundation Trust audit department. An audit tool was developed by the investigators. The investigators carried out a review of patient electronic records and clinical letters to gather information pertaining to initiation of antipsychotics and physical health monitoring.

Amongst other variables in this trust-wide audit, we considered age, ethnic background, reason of initiation of anti-psychotic, comorbid conditions among which most common is epilepsy, dose of antipsychotic used and distributions across various CCGs. Were they regularly reviewed by medic reviews and side effects monitored? We also looked at choice of antipsychotic used, which was largely aripiprazole and risperidone. Were antipsychotic bloods done or not and were we able to complete children's height and weight measurements whilst they were on antipsychotics? It was important that these are documented as being considered or ‘offered' even if could not be successfully completed due to e.g. challenging behaviour from the child. Detailed and comparative results can be shown in final submission along with charts.

The recommendations from initial audit were compared with the second audit, and whilst some of them were completed such as incorporating growth chart in the electronic records system, some ongoing challenges were identified. Positive and negative findings were both noted although the final conclusions lies in favour of good changes been made to service including the caseload becoming more ID specific in this age group.

To support evidence gathering for Esteem's RCPsych Early Intervention in Psychosis (EIP) network accreditation efforts, an audit was conducted to investigate compliance with EIPN's quality standards (QS) no. 33 and no. 36.

EIPN QS 33 = patients with first episode psychosis (FEP) are offered antipsychotic medication.

EIPN QS 36 = If the patient's illness does not respond to an adequate trial of two different antipsychotic medicines given sequentially, they are offered clozapine.

EIPN QS 36 is also specifically included in RCPsych's National Clinical Audit of Psychosis (NCAP) (listed as standard 4), but a more pragmatic definition is used, to factor in the issue of antipsychotic intolerance.

NCAP Standard 4 = People with FEP who have not responded adequately to or tolerated treatment with at least two antipsychotic drugs should be offered clozapine (NICE QS80).

This broader standard definition was used for this audit, to allow for results comparison with national data.

For EIPN QS 33, all patients on North East Esteem caseload (any primary diagnoses) for at least 6 months on 01/04/2023 were included.

For EIPN QS 36/NCAP Standard 4, the same inclusion criteria were used but refined to FEP cases only.

The electronic clinical records (EMIS) of such cases were reviewed manually by an ST5 and CT3 psychiatrist. Data on prescription history was collected then analysed in Microsoft Excel.

EIPN QS 33: 58 patients with any primary diagnosis were initially identified as being on NE Esteem caseload > 6 months as of 01/04/23. 58 (100%) patients were offered antipsychotic medication ⋅ 1 (2%) patient was prescribed an antipsychotic but never took it ⋅ 21 (36%) patients were only ever prescribed one antipsychotic ⋅ 17 (29%) patients were prescribed two antipsychotics sequentially trialled ⋅ 11 (19%) patients were prescribed three antipsychotics sequentially trialled ⋅ The remainder, 8 (14%) patients, had four or more antipsychotics sequentially prescribed (with the maximum number of trials being eight).

EIPN QS 36 / NCAP Standard 4: 55 patients with FEP diagnosis were initially identified as being on NE Esteem caseload > 6 months as of 01/04/23. 16 (29%) of these patients had at least three or more trials of antipsychotic medication, i.e. patients eligible for clozapine. However, only 5 (31%) of these 16 patients had either been prescribed clozapine (3 patients, 19%) or offered/trialled clozapine (2 patients, 13%). This 31% figure compares with 85% in Wales, 52% in England, and 50% in Ireland (NCAP 2021–22).

EIPN QS 33: The standard that patients with first episode psychosis are offered antipsychotic medication was fully met. About a third of patients required only one antipsychotic trial. Less than a third required two antipsychotic trials. One in five required three antipsychotic trials, and approximately one in seven patients required more than three antipsychotic trials.

EIPN QS 36/NCAP Standard 4: The number of eligible patients being offered or prescribed clozapine for first episode psychosis under care of NE Esteem falls well below NCAP averages for Wales, England and Ireland.

Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) has 28 Promises as part of its Strategy.

Promise 16 is to: Focus on collating, assessing and comparing the outcomes that our services deliver, which matter to local people, and investing in improving those outcomes year on year.

This audit in November 2023 looked at the practice of using outcome measures for CAMHS patients in order to highlight areas of development for the service to work toward achieving the promise.

We wanted to understand if young people were having outcome measures completed and if so, when, what and how often. We achieved this by using a dip sample of five patients each across the three different localities (Rotherham, Doncaster and Scunthorpe).

A report was generated to include all patients discharged from CAMHS in the preceding three months to September 2023. Young people who had been with the service less than six months were excluded from the audit. Five patients were chosen randomly from each locality and their electronic patient record on System One was studied.

Information in the patient records was compared against the audit standards and recorded in Excel so the data could be analysed.

The results showed that 11 of 15 young people had an outcome measure completed at some point during their episode of care. All five young people in Scunthorpe had an outcome measure recorded in their clinical records however this tended to only happen at the very start, meaning there was no basis for comparison. Four out of five patients in Doncaster had outcome measures in the clinical record and these were undertaken throughout the episodes of care. In Rotherham, two of five young people had outcome measures recorded in the clinical records.

The most frequently used outcome measure was the RCADS but the SDQ was also used.

There is work to be done to ensure the use of outcome measures becomes routine, and also to standardise both the type and frequency of use. The Trust is aiming to increase their use by utilising SystmOne's capabilities to interface with service user mobile devices to send out outcome measures to patients. There is also a plan to inform staff within the service about the expected use of outcome measures. This audit will be repeated in 2024 to see if the Trust are moving closer to delivering their promise.

To audit telephone referrals to Beechcroft inpatient unit.

Beechcroft inpatient unit is a step 5 regional child and adolescent mental health inpatient unit in Belfast. It receives a large volume of referrals from across all five health and social care trusts in Northern Ireland. The process of referral to Beechcroft can vary between trusts and clinicians; the majority of admissions are emergency. The demand for beds has risen by 30% since 2019. Emergency admissions are commonly telephone referrals whilst others submit written referrals. The referrals process is managed by the ward sisters, as there is no bed manager post. Referrals are discussed with a consultant psychiatrist.

Referrals received often lack key clinical information, which makes decisions around appropriateness of admission or prioritising multiple referrals difficult. Furthermore, as the admitting doctor relies on this information, missing clinical information could result in patient safety issues.

24 telephone referrals were recorded between August to December 2023. 5 referrals were excluded for either no request for a bed (3) or telephone update following previous written referral (2). 19 telephone referrals were analysed across 7 different criteria as below, based on necessary information.

Criteria 1 Patient identifiable information

Criteria 2 Source of referral/referrer details

Criteria 3 Current location of patient

Criteria 4 Legal status

Criteria 5 Presenting symptoms

Criteria 6 Working diagnosis

Criteria 7 Risks warranting admission

Yes    No   %Yes

Criteria 1   19    0   100

Criteria 2    19    0   100

Criteria 3   13    6   68

Criteria 4    14   5   74

Criteria 5   18   1    95

Criteria 6    2   17   11

Criteria 7   15   4   79

Total     100   33   75.2

Patient identifiable information and source was documented in all referrals. Only 10% of referrals included a working diagnosis. Location of patient, legal status and risks warranting admission were documented between 68 and 78%.

Crucial information such as working diagnosis was missing in 90%. Risks or legal status missing in up to a quarter of referrals. This has an impact on timely access, bed flow and potentially patient safety.

A need for improvement in receiving and documenting telephone referrals has been identified. To aid improvement in patient safety and flow, a bed manager for in hours has now been appointed. A standardised proforma for recording data will be developed by inpatient staff in collaboration with community staff to include the above criteria. A re-audit will be carried out following these service improvements.

To determine the number of patients within a service on sodium valproate for a psychiatric condition who have updated Annual Risk Acknowledgement forms in place.

It was firstly identified that within the NICE guidelines, it is recommended that all patients who are on sodium valproate should have an annual signed risk acknowledgement form in place. Following this, a list of patients was compiled who were currently prescribed this with the local area. Each patient was then checked to see if the valproate was prescribed by psychiatry or by neurology. This was then further divided into general adult and learning disability patients.

From this, a list of patients under the care of general adult psychiatry was compiled. The notes for these patients were obtained.

Data collection was then carried out. Each set of notes was reviewed by two individuals for the following:

1. 1. To identify if an annual risk assessment form was carried out.

2. 2. To check if this was within expiry date.

3. 3. To identify patient diagnosis.

4. 4. To identify the dose of sodium valproate.

5. 5. To confirm if these patients were females of childbearing age.

From the initial audit cycle, it was identified that 28 female patients who fell within the inclusion criteria were on valproate, and of these, 6 had forms in place. Of the 6 with forms in place, 50% had expired so needed to be replaced. 17 had no form in place, and for 4 patients it could not be certain if forms were present or not due to unavailability of records. Only 3 patients therefore had the correct form in place which were within expiry date. If we discount those with no data available, only 12% of patients had the correct annual risk acknowledgement form present and within expiry date.

Following the initial audit, two interventions were carried out:

1. 1. The data from the above audit was presented at a consultant meeting, highlighting the importance of ensuring these forms are kept up to date.

2. 2. It was decided that pharmacy would take a leading role in ensuring the annual risk assessment forms are updated.

Following 6 months, this patient cohort was re-audited, with further results obtained.

These results showed a reduction in patients prescribed sodium valproate from 28 to 19. 37% of all patients prescribed sodium valproate had forms, but of these, only 30% were up to date. Therefore, only 11% of patients had correct annual risk acknowledgement forms in place which were up to date.

These results showed an improvement in those who had at one time had a form in place, but roughly similar compliance with availability of up to date forms.

Overall it appears that there is a real lack of consistency in ensuring the annual risk assessment forms are in place. A very low percentage of patients have the correct form in place within expiry date, despite interventions which have taken place as part of this audit. Further efforts should therefore be made by teams to ensure that these forms are in place and up to date for all women of childbearing age on valproate.

On a positive note, it may be possible to surmise that the reduction in number of patients on sodium valproate may be linked to raised awareness of the risks to women of childbearing age.

Additionally, a significant number of patients had been sent forms in the post, but had not returned them. Some of these same patients had, in the time that they should have had updated risk forms put in place, been admitted to an inpatient psychiatric hospital. It is therefore important to consider in future if these forms should be updated whilst the patients are admitted to hospital, to increase the number of patients with these forms up to date and therefore improve safety for this cohort of patients. Given that many of these patients have a diagnosis of Bipolar Affective Disorder, they may find it more challenging to return the forms whilst in the community, particularly if unwell; the ICD–11 criteria does note that patients with this condition may suffer from “distractibility, impulsive behaviour and rapid changes in mood state.” Further research could therefore be carried out to determine if utilising inpatient admissions to discuss risks of their medications would be a beneficial way to improve compliance with Annual Risk Assessment Forms.

Lastly, we know that there has been discussion around implementation of such monitoring for men as well as for women. Should this be implemented within the NICE guidelines, further audits should be carried out to determine our compliance with this.

To assess the compliance of glucose monitoring for patients prescribed antipsychotics in the local outpatient Learning Disability Team.

A review was conducted of all outpatients seen in a 6 week period during September and October 2023. Each patient was reviewed to check their diagnosis or diagnoses, the antipsychotic medication they are currently on and if they have had the required tests done. These tests were considered, as per the NICE guidelines, to be a plasma glucose test or HbA1c test. It was checked to confirm if these tests had been carried out within the past 12 months, as per NICE.

• • 46/79 patients seen in a 6 week period at the outpatient clinic were found to be currently prescribed an antipsychotic.

• • 30 of those prescribed an antipsychotic were on risperidone (65%).

• • Of those prescribed any antipsychotic, 18 out of 46 had not had their glucose or HbA1c checked within the past 12 months (39%).

• • This therefore demonstrates 61% of patients on an antipsychotic had appropriate glucose monitoring within the time period audited.

Monitoring glucose levels for patients on antipsychotic medication is very important for patients with an Intellectual Disability. Patients in this cohort are known to be more likely to have diabetes and obesity than the general population. In addition, there are higher levels of inactivity and multi-morbidity. It is also important to note that over-prescribing of psychotropic medication to individuals with learning disabilities, particularly antipsychotic medications such as risperidone and olanzapine, may be contributing to levels of obesity and diabetes within this population.

NICE guidelines state that for patients prescribed an antipsychotic, plasma glucose or HbA1c should be checked 3 months after commencement of treatment, and then every 12 months whilst on treatment. For olanzapine and clozapine, levels should be checked after 1 month of commencing treatment. Symptoms of hyperglycaemia should also be asked about (such as polydipsia, polyuria and increased appetite).

The results from this audit demonstrate there is definitely room for improvement in our monitoring of glucose levels for these patients. From discussing this with colleagues, it appears that a multidisciplinary approach is needed to promote this change.

Going forward, therefore, interventions should include asking the nursing staff within the outpatient team to monitor for increased appetite, polydipsia and polyuria amongst patients, especially if they are on an antipsychotic. Additionally, for any patients seen in OPC who are prescribed an antipsychotic, it should be routinely checked when they last had a glucose or HBA1c test. If this was not within the past 12 months, this should be carried out by the GP or another appropriate member of the team.

Overall, the physical health of our patients with Intellectual Disabilities is paramount. Given the nature of their Intellectual Disability and depending on the severity, it may be very challenging for them to identify any new symptoms of diabetes themselves or to report these to carers. Therefore, when prescribing antipsychotic medication, it is vital to monitor the effects of this to ensure optimal patient care utilising a multidisciplinary team approach.

The NHS England Core20PLUS5 aims to reduce national healthcare inequalities by identifying five clinical areas requiring accelerated improvement for the most deprived 20% of the population. Three of these clinical areas are: Severe Mental Illness (SMI), Early Cancer Diagnosis and Maternity Care.

Hackney has the highest proportion of areas within the most deprived 10% nationally. The Hackney Rehabilitation and Recovery Team is a specialist service for those with SMI. While the service does not provide maternity care it is uniquely placed for women's health outreach work in this population. Research has shown that lower participation by those with SMI in screening may make them 2.5 times more likely to die prematurely from cancer. Bearing this in mind, this project aimed to improve early cancer diagnosis and management of women's health to improve health inequalities for females with SMI in Hackney.

I audited cancer screening compliance from the medical records of the 19 female patients under the Hackney Rehabilitation and Recovery Team and obtained patient feedback to explore barriers to access screening. I used a pool of possible keywords to perform a search for any discussion of women's health issues during contact with mental health professionals. Encouraging a culture of ‘Making Every Contact Count’, I presented the results of this audit at a Team Education Session, after which attendees received a personalised list detailing their caseload's outstanding health needs as identified from the audit. I led a weekly physical health clinic which addressed women's health issues. I designed a referral pathway for patients with complex psychiatric needs with the local cervical screening service which allows for longer appointments.

16% of the female patients under the care of the Hackney Rehabilitation and Recovery Service had never had a discussion covering women's health issues. 73% of mammograms and 53% of smear tests were outstanding. Barriers to access include a lack of knowledge of cancer screening programmes and practical issues in booking appointments. Some cited a lack of confidence in travelling to appointments and communication issues (access to a mobile phone, email address or post) as an issue.

Designing interventions to boost the uptake of cancer screening appointments for female patients with SMI is a practical application of the CORE20PLUS5 approach. An MDT approach including patient participation and feedback is key when developing effective outreach initiatives.

This audit reviewed the use of Treatment Escalation Plans (TEPs) on the Borders Specialist Dementia Unit (BSDU). We aimed to use data on completion rates and quality to adapt the TEP form to both improve practice and develop a more specialised form for use in inpatient old age psychiatry.

TEPs improve clinical decision-making in frail and elderly patient populations, and are commonly used on medical wards. However, these forms are primarily orientated towards acute medical environments and may not be appropriate for use in psychiatric inpatient settings, despite the clear benefits they could provide in this patient group.

This retrospective audit reviewed completion rates and quality of completed TEP forms for 10 BSDU inpatients in December 2023. Data was gathered by reviewing TEPs and using a data collection form to collate information on completion rates and quality of information provided. Both the TEP form and the ReSPECT form were used to review what information would be relevant to include when completing TEP forms for new admissions to BSDU.

Some sections of TEP forms were consistently well-completed – typically those that were quick to complete e.g. tick boxes. However, limitations of the existing TEP form reduced these sections’ usefulness in practice. Most significantly, the form does not indicate whether “ward level care” refers to care on the old age psychiatry ward, or transfer to a medical ward. The “Additional Information” section, which could be used to clarify the patient's ceiling of care and transfer status, was only completed in 40% of cases, despite being particularly relevant to the BSDU patient population. In addition, this audit highlighted that there is no process for reviewing TEPs to ensure they remain appropriate for the patient, which is particularly relevant for old age psychiatry inpatient populations due to their advancing frailty and quickly changing clinical picture.

This audit showed that the current TEP form is not ideally suited to old age psychiatry settings. However, this could be improved with simple adaptations such as distinguishing between psychiatric ward care and medical ward care, and adding a review date to ensure these forms are regularly updated in light of the advancing frailty of old age psychiatry inpatient populations. I would also recommend implementing an initial review of TEP forms shortly after patients are admitted, to ensure the information contained on them is accurate and that they are countersigned by the responsible consultant.

Discharge summaries act as a key source of condensed information of inpatient stay as well as follow-up plan. Its timely availability to primary care and other multi-disciplinary teams involved in patient care is vital, especially when patients are being managed out of locality by different teams.

The project aimed at assessing if discharge summaries for General Adult inpatients across all four localities of the Trust was made available and in a timely fashion on patient electronic records as well as to primary care using national guidelines as the standard. Using the same guidelines, it also evaluated the quality of the summaries based on the information contained.

Data was retrospectively collected in October 2023 for general adult inpatient discharges for the month of January 2023 across all four localities of Black Country Healthcare NHS Foundation Trust. Records for 148 out of the 152 discharges were assessed. Data was collected from electronic patient records Rio and evaluated on Microsoft Excel. The evaluation checked whether discharge summaries were available, duration between discharge and its availability on electronic records as well as contents of summary. Professional Record Standards Body and the RCPsych guidelines were used as standards.

28 of the 148 (18.9%) patients did not have a completed discharge summary. Of these, 14 (9.4%) were out of locality patients. The average duration from discharge to summary being made available was 12.7 days. Most of the summaries contained all relevant information as per guidelines.

The findings were presented to the Trust’s QI committee. It was concluded that while majority patients had a summary made available, there is a need for additional strategies to ensure summaries are available soon after discharge to ensure safe post-discharge care.

It was identified that the bed management team should notify parent teams of admissions and discharges promptly.

The medical secretary is to monitor the admissions register and ensure the junior doctors in the team complete discharge summaries in a timely manner.

Business intelligence team to use clinical coding to identify any missing discharge summaries and provide medical teams with a monthly report in case any are missed by the secretaries.

Once above recommendations are implemented, a re-audit would help to analyse the improvements in practice. The results would also help guide the Trust in developing a policy to harmonise processes across the Trust and thereby ensure safe patient care post-discharge.

Lifestyle medicine promotes the use of therapeutic lifestyle interventions to modify disturbed lifestyle factors which are thought to underlie chronic illnesses, including mental health conditions. It is important to identify and manage any disruptions in factors that lifestyle medicine has identified as being contributory towards sustaining good health. Aims were to identify the extent to which the early intervention in psychosis (EIP) medical team in Leicestershire are enquiring about the pillars of lifestyle medicine.

There are 6 pillars of lifestyle medicine, namely exercise, sleep, diet, refraining from toxins, positive social interactions and quality personal time. Motivation has been added as the 7th pillar for this audit. Gold standard would be to adequately explore all pillars at each medical review. Retrospective analysis was done of electronic patient records (SystmOne) for all patients on the EIP team case load, available on 19th May 2023. Information was gathered from the most recent medical review, using a predefined audit extraction tool. Information on each pillar was assessed based on whether it was fully explored, mentioned with some detail, mentioned with no further detail, or not mentioned at all. Data collection was carried out by three members of the team (TC, SA and DG).

495 patients were identified and 459 had information from a latest medical review found on SystmOne. For all domains, “not mentioned” was the leader, ranging from 48.6–70.8%). For all domains, except for refraining from toxins, the second most common finding was “mentioned with no further details”.

Our results suggest EIP medical staff are either not discussing many of the seven pillars of lifestyle medicine with patients, or not documenting them in sufficient detail. Limitations of the study include that it was the most recent medical review being audited and there could have been more detail documentation in previous reviews. Distribution of the findings and recommendations from the audit were shared with the team and an educational poster detailing lifestyle factors was created. The online system is being adapted to include an option to input lifestyle factors. Re-audit should be done in 12 months.

To investigate whether young people referred to a paediatric specialist fatigue service present with higher levels of autistic traits or have higher prevalence of Autistic Spectrum Disorders (ASD), than those found in the general population.

143 initial assessment reports of young people presenting to a paediatric specialist fatigue service were audited over a 5-month period to identify cases where a previous diagnosis of ASD has been documented, or the assessing clinician has recommended referral for an ASD assessment, or autistic traits have been documented in neurodevelopmental screening. Comparative data on age, gender, age of symptom onset, duration of symptoms, reported symptoms, comorbidity, family history, and sleep difficulties was then explored to help us identify/understand the profile of the young people who present to our service. Routine mental health screening questionnaire data from the Revised Children's Anxiety and Depression Scale (RCADS) was analysed in addition to clinical reports regarding mental health comorbidities.

Of the 143 young people presenting to the specialist fatigue service over the 5-month period, 16 had a diagnosis of ASD, and 41 were suspected as having ASD. In total, 39% of service users had, or were suspected of having, ASD. The prevalence was higher in female service users than males with a total of 48% of female service users having, or being suspecting of having ASD, compared with 22% of males. Comparative data demonstrated that autistic/suspected autistic young people presenting to the service were more likely than their neurotypical counterparts to be: over 13 years old, have a longer symptom duration before presentation, have an Educational Health Care Plan, report friendship difficulties, have a family history of neurodiversity, report sensory difficulties, and have sleep difficulties. RCADS scores found that the ASD group were more likely than the neurotypical group to have clinical levels of anxiety (58.3% vs 15.3%) and depression (80.6% vs 58.3%).

Our audit suggests that there is a higher prevalence of young people with ASD/ASD traits presenting to a paediatric fatigue service than found in the general population. Reasons for this may relate to undiagnosed ASD presenting as severe fatigue due to the energy draining nature of camouflaging, as well as sensory overload, known as autistic burnout. Do we need to develop a specialist treatment pathway which is better adapted to these young people's needs? We are planning a follow up study and focus groups to explore this complexity further.

West Lothian Psychiatry operates in a district general hospital, fostering a close working relationship between medical and psychiatric practitioners including the Psychiatric 2222 call (akin to medical emergency/cardiac arrest response). No other team like this has been identified in Scotland. Whilst there is a range of scenarios where this is used, there is no ‘gold standard' for defining a psychiatric emergency or how to document these. Preliminary data gathered between August and November 2022 revealed concerns regarding call appropriateness, medical staff proficiency in de-escalation and restraint on medical wards, inadequate handovers, and poor documentation. This prompted a collaborative quality improvement project, undertaken by psychiatric and medical team leaders. Part of this initiative was an audit to improve the documentation of psychiatric emergencies to achieve a 90% compliance rate using a new checklist.

Cycle 1 of the audit (December 2022 to April 2023) identified patients through the 2222 calls to switchboard (n = 54). TrakCare notes were reviewed to assess call rationale and outcomes, focusing on documentation by the attending psychiatric team. A documentation checklist within the electronic records system was designed and introduced in July 2023, for completion by the junior doctor. Cycle 2 (November 2023 to January 2024, n = 47) aimed to assess improvements by comparing results with the previous cycle.

There was a significant improvement in documentation rates with the checklist (44% to 90%). Indirect enhancements were observed in ward nursing documentation (65% to 83%) and medical ward doctor documentation (39% to 57%). Appropriateness of emergency calls increased from 65% to 74%, with attending doctors' participation in emergencies longer than 10 minutes rising to 68% from 47%. The initial audit revealed a lack of awareness among senior medical staff regarding overnight psychiatric emergency calls, especially in cases of repeated calls for the same individual. The improved documentation played a pivotal role in addressing this issue, facilitating effective information sharing and changes in patient management plans, reducing further emergency calls.

The documentation checklist significantly improved junior doctor documentation, positively impacting patient care and communication among staff. This successful intervention serves as a promising model that can be replicated in other documentation domains. Moreover, this project has set the stage for broader initiatives within a larger Quality Improvement framework. The ongoing efforts are directed towards establishing a shared model for the psychiatric emergency bleep, optimising staffing resources for restraint procedures and improving staff de-escalation skills.