The aim of the audit is to improve the patients’ experience in the ward round, to ensure all the patients feel included in their ward rounds, to find out if their physical health gets as much attention as their mental health and to establish they receive appropriate feedback of their treatment progress while being inpatient.

By carrying out the audit, our target was to ensure patients are prepared, that service users and carers are involved, clear goals are set, patient confidence is increased, there is direct patient interaction, and the ward round is a positive experience for both the patient and the care team.

This audit included 34 patients from our acute adult psychiatry mixed unit and perinatal psychiatry unit, who have had at least two ward rounds in the inpatient setting, have the capacity to consent to treatment and have insight to their mental health issues.

Data collection was done by a face to face patient interview with a questionnaire by the junior doctors in the wards. The questionnaire was discussed with the head of patient experience team and clinical audit & improvement facilitator team prior to starting the audit. Confidentiality was maintained and at no point were the patients requested to reveal their identity.

Among the patients admitted during the period of October 2022 to November 2022, 40 patients were chosen randomly. Among them, data was collected from 34 patients according to the inclusion criteria.

Based on the patients’ feedback and experience, 52.9% service users thought the ward round time tables ran by schedule, whereas 11.8% service users thought they did not run by schedule at all.

20.6% service users reported that they were not informed in advance, if there were any change in the ward round time schedule; whereas 41.2% service users were informed of the changed time schedule.

50% service users reported that they received appropriate support prior to the ward round should they need this, on the other hand 8.8% said they did not require any support, therefore refrained from answering the question.

Majority of the service users 94.1% reported that they were happy with the ward round physical environment, the sitting arrangement and the ambience and 88.23% service users reported being reviewed by the consultant at least once a week. None of the service users were found, who was not reviewed by the consultant at least once weekly during their stay in the inpatient wards.

47.1% service user reported that they did not feel confident and comfortable in front of all the professionals present in the ward round.

20.6% service users complained that their physical health was not getting as much attention as their mental health in the psychiatric wards and they were not referred for their physical health needs accordingly.

23.5% of service users had little to moderate understanding on what was being discussed in the ward round meeting, whereas 76.5% understood completely what was being advised in the ward round.

8.8% of the service users did not feel involved in their ward round at all and majority of the service users, 52.9% got regular feedback on the treatment progression and a chance to talk with their named nurse after the ward round.

Ward rounds are the formal meetings where service users come to the professionals with their queries and are informed about their progression on treatment. These meetings should be comfortable and palatable for both sides of the table. Further arrangements are required to improve the settings and make it more service user friendly to get the best outcome from ward rounds.

To ensure psychiatry admission assessments are well-documented and available via EmisWeb clinical notes system.

To assess whether replacing the clerk-in booklet with a digitalised version affects documentation of psychiatry admission assessments.

The standard was use of the current admission template with information under each heading. In addition, a Clinical Risk Assessment Framework for Teams (CRAFT) tool should be completed by the admitting doctor. Legal status, observation level and time-out status should be recorded.

A retrospective full-cycle audit of the first twenty patients admitted to Leverndale Hospital, Glasgow starting 1st Dec 2022, then 1st April 2023 for the second cycle. Patients were identified using EMISWeb admission dates and information from Medical Records. Data was taken from the EMISWeb record and analysed using Microsoft Excel – if incomplete paper notes were checked.

Use of the admission template and presence of meaningful content (excluding “n/a” and similar) under each heading was recorded. Data was collected on the documentation of legal status, observation level, time-out status, and CRAFT risk assessment by the admitting doctor. Perinatal psychiatry admissions and transfers between psychiatric units were excluded.

Medicines reconciliation was absent in 55% and allergies in 70%. CRAFT risk assessment was completed by the admitting doctor in 55% of cases.

Following round 1, a digitalised admission proforma was introduced, replacing the traditional admission booklet.

There was little improvement in usage of the admission proforma with the introduction of the digitalised version (80% vs 75% previously). Notably, the rates of CRAFT risk assessments by the admitting doctor fell in this 2nd cycle – from 55% to 40%.

Recording of allergy status (55% from 30%) and medications (95% from 45%) seemed to improve. Importantly quality of content was not appraised – many medication entries consisted of “as per HEPMA (electronic prescribing system)”.

100% of admission documentation was now available on EMISWeb, preventing information loss and allowing remote access from Community Mental Health Teams.

The introduction of a digitalised admission template had little impact on use of the proforma. However it meant that 100% of admission information was available digitally, versus 85% previously.

In both cycles the CRAFT risk assessment was often not completed by the admitting doctor. Given risk assessment is a key reason for “clerking in” psychiatric inpatients, this could be a focus for future quality improvement work.

In the second cycle, recording of medications and allergy status had improved significantly. Given small sample sizes, this may be due to chance.

The prevalence and subsequent physical health burden of alcohol use disorder is on the increase in almost all age groups in the UK and nearly 1 in 5 of the population will drink at hazardous levels. Those who drink heavily often have limited or patchy engagement with physical health services and improving this should be a focus of drug and alcohol services.

Our aim was to audit the proportion of clients attending the alcohol service at Lorraine Hewitt House (LHH) who had completed a fibroscan, to audit the outcomes of those fibroscans and to audit the outcomes of the onward referrals where they had been made.

Since starting the liver clinic, more than 100 fibroscans have been completed. These are typically offered to clients in the alcohol pathway and where it can be facilitated, they are done on the day, or otherwise booked in for scheduled appointments.

We audited the results of the scans, for liver stiffness and liver steatosis. Additionally, for those who had abnormal results requiring onward referral, we audited the outcomes of these referrals.

Outcomes and overall physical health were subsequently discussed with each patient who underwent a liver scan.

A total of 100 fibroscans were audited. This represents approximately one third of the clients with alcohol as their primary problem substance at LHH.

Every client had the results of their scan explained and discussed with them and were given lifestyle advice and interventions.

A total of 37 scans (37%) had all their parameters within the normal range. 16 (16%) showed an increased liver stiffness of >10kPa and 15 people (15%) gave consent and were subsequently referred to our local liver clinic. 13% had stage 1 steatosis (238–260dB/M), 18% had stage 2 steatosis (260–290dB/M) and 29% had stage 3 steatosis (>290/dB/M).

Of the 15 referrals made to liver clinic, 10 (66.7%) attended their liver clinic follow up appointments and 9 of these clients are awaiting further interventions – the remaining 1 client has been discharged back to their GP.

Of the remaining 5 referrals made to liver clinic, 2 are awaiting appointment dates and 3 are pending triage.

The physical health of clients attending drug and addiction services is often complicated and in need of specific and targeted interventions. Liver health is particularly relevant to the alcohol client group and integrating fibroscans into drug and addiction services facilitates better engagement and early assessment and intervention.

The completion of methadone and buprenorphine prescriptions, together: opioid substitution therapy (OST), must conform to legal requirements for the prescription of controlled drugs (CDs) as well as Home Office approved wording when writing instalment prescriptions.

Our service uses a part automated printing system for individual prescriptions and uses a manual record to track prescriptions issued for individual clients over time, a “script record”.

We aimed to audit the terms used on the internal script record as well to audit compliance of OST prescriptions with the legal requirements for CD prescriptions and Home Office Approved wording for instalments.

All prescriptions for methadone or buprenorphine over the course of a week that were prepared for signing were audited.

The prescriptions were audited against the legal requirements for writing CD prescriptions and against Home Office approved wording for instalment prescriptions.

The script record was audited against internal standards for variation of terms used to describe frequency of collection of instalments.

A total of 64 prescriptions were audited.

100% of prescriptions complied with the legal requirements for the prescription of CDs.

7 prescriptions (11%) omitted Home Office approved wording to instruct what should be done on days when the dispensing pharmacist was closed, i.e. that instalments should be dispensed on the prior open day.

46 prescriptions (72%) had additional Home Office approved wording that was not applicable to the script. For example additional wording to allow for pickup of part of an instalment following a missed day, when the prescription was only for daily supervised consumption to begin with.

Audit of the internal script record found a total of 13 different terms used to describe frequency of collection of instalments; there are 6 standardised terms used within the internal script record. On 2 occasions the frequency of collection of instalments was left blank.

It is essential that prescriptions for controlled drugs follow the legal requirements laid out for them; within the scope of our audit these were entirely adhered to.

There was however more variability in the use of the Home Office approved wording for instalments of OST. Scripts here tended to error for including additional wording not relevant to the specific script. Additionally, the service's own internal script record showed variability in the terms used to describe frequency of collection.

It is evidently important that the wording on prescriptions is clear and concise and the terms used internally are standardised.

Background:

The cumulative effect of having one or more prescription drugs with anticholinergic properties is known as the Anticholinergic Burden (ACB). ACB can increase mortality and morbidity. Adults with learning disability are a high-risk group for this.

Aims:

To evaluate Anticholinergic Burden (ACB) for adults with learning disability and co-existing mental health conditions and make practice recommendations.

A baseline audit was carried out over a period of 1 month on those treated within two specialist in-patient units in England. Routinely collected information including diagnosis, prescribed medication, clinical outcomes (Clinical Global Impression – CGI) and side-effect scales (ACB calculator, Anticholinergic Effect on Cognition – AEC, Liverpool University Neuroleptic Side-effect Rating Scale – LUNSERS, Glasgow Antipsychotic Side-effect Scale – GASS) were collated and analyzed using quantitative methods.

19 patients were included. Mean age was 37 years, 89% (n = 17) were male and 95% (n = 18) of white British ethnicity. The clinical diagnoses included 74% (n = 14) with mild learning disability, 68% (n = 13) with a major mental illness (psychosis or affective disorder), 53% (n = 10) with autism and 32 (n = 6) with a personality disorder. 89% (n = 17) were on antipsychotics, 63% (n = 12) on mood stabilizers, 58% (n = 11) on antimuscarinic drugs for antipsychotic side effects, 58% (n = 11) on anxiolytics, 32% (n = 6) on antidepressants and 89% (n = 17) on medication for physical conditions. Including pro re nata (prn) medication, the mean ACB calculator score was 6.68 and 4.21 on the AEC scale. On LUNSERS, the mean score was 23.13 (medium side effects), on GASS 8.87 (mild or absent side effects), on CGI efficacy index 6 (decided clinical improvement with side-effects not significantly interfering with functioning) and on CGI global improvement 2.37 (much improved).

The ACB in people with learning disability and mental health problems is high. While an ACB calculator score of 3+ is described as associated with increased mortality and morbidity in the general population, the mean score in this sample was double that if prescribed prn medication was included. Medication prescribed for both mental and physical health reasons. Despite the high ACB, they show good clinical improvement and functioning regarding their mental health. The scores on other side effect scales are not exceedingly high either. There is a need for more research to set the specific practice standards regarding ACB measurement and monitoring in this group. Adequate health education for patients and staff should be a priority to maintain vigilance regarding ACB effects.

The aim of this study was to understand current clinical practice, adherence to evidence-based guidelines, and the perceptions, knowledge and attitudes of the multidisciplinary team caring for inpatients with eating disorder/disordered eating on general adult psychiatric ward.

The audit was undertaken at inpatient general adult psychiatry ward between 1st July 2022 to 30th April 2023. A retrospective method was used to collect data on admissions of patients with eating disorder/disordered eating alongside qualitative data retrieved for perceptions, knowledge and attitudes of the multidisciplinary team (MDT) and use of and adherence to national guidelines. The data was collected from everyday bed state and MDT handover, admission summary, electronic notes which included physical health charts and discharge summaries. The MDT staff involved were nurses, doctors, health care assistants, dieticians, psychologist, and occupational therapist.

Patients were included if eating disorder management was indicated and undertaken at some stage during the admission, even if the eating disorder was not the primary reason for admission. The age group was above 18 years and included male and female patients. Eight discrete admissions (6 females, 1 male and 1 transgender patient) were included in the audit. Adverse events like refeeding syndrome, electrolyte derangement needing Intravenous/Nasogastric tube feeding, self-harm, level of cooperation between medical and community eating disorders team, community mental health teams and outcomes were recorded. Data analysis was done through Microsoft Excel. Percentages of patients who had met each of the standards were calculated. Documented practices were compared in line with standards of NICE (National Institute for Health and Care Excellence) guidelines and MEED (Medical Emergencies in Eating Disorders) guidelines.

The audit concluded that gaps exist between evidence-based practice and patient care. Despite being admitted due to concern about eating difficulties, a substantial number of patients were not given an eating disorder diagnosis on discharge. And the patients who had eating disorder as primary diagnosis had limited inreach support from specialist team.

There is major challenge in management of disordered eating presentations within inpatient general adult psychiatry units and inreach specialist support for those admitted with eating disorders as primary diagnosis. These findings emphasize for targeted implementation strategies to improve patient care and uptake of research into practice.

A large body of evidence suggests that experiences of, and access to mental healthcare in England varies according to ethnicity. Inequitable use of restrictive interventions is of particular concern, including within perinatal services: a national-level study of inpatients on Mother and Baby Units (MBU) in 2017 found that 28% of white patients were detained under the mental health act (MHA), compared with 61.5% of Black African, and 66 – 77% of Asian mothers. We carried out an audit with the aim of examining detention rates, length of stay, and time to first section 17 leave on an MBU in South Manchester according to ethnicity and English language ability, to compare with national averages.

We identified all patients discharged from Andersen Ward (an MBU) between March 2022 and March 2023. Using electronic medical records we extracted information on: ethnicity, language spoken (English vs other), mental health act status (detained under Section 2/3 vs informal), duration of admission, date of detention, date of first Section 17 leave. We calculated the percentage of patients who were detained according to ethnicity (White British, Mixed/other, Asian, Black), and the odds of detention according to ethnicity. Statistical significance was assessed using chi-squared testing. We also compared average length of stay and time to first section 17 leave by ethnicity.

74 patients had been discharged from the MBU within the audit period. 88% of Black inpatients were admitted under the Mental Health act, compared with 72.7% of Asian mothers, 33.3% of Mixed ethnicity or other ethnicities and 28.3% of white mothers. Differences in detention rates according to ethnicity were statistically significant. Of 11 mothers documented as having a language other than English as their primary language, all had been detained. Length of admission and days to first section 17 leave were not significantly different between ethnicities.

Many factors may contribute to the observed higher detention rates among non-White patients: language barriers and a lack of intercultural competence could lead to risk-averse decision-making during MHA assessments, and different help-seeking patterns might mean White mothers seek help earlier, or for less severe mental health problems. Recommendations include expanding access to high-quality interpreters; investigating factors underlying MHA decision-making through qualitative research; and improving cultural competence among section 12 approved clinicians by incorporating feedback from ethnic minority patients into training and refresher courses.

Individuals with severe mental illnesses are at an increased risk of morbidity and mortality from cardiovascular diseases compared with the general population. Dyslipidaemia is a well-established contributor to CVD risk, alongside factors such as obesity, hypertension, smoking, diabetes, and a sedentary lifestyle. Many patients with severe mental illnesses often exhibit a combination of these risk factors. Notably, second-generation antipsychotics, particularly clozapine, are associated with a significant risk to elevate lipid levels. However, dyslipidaemia is a treatable condition, and various interventions are available to decrease the risk, ultimately reducing the associated morbidity and mortality. Therefore, NICE guidelines recommend monitoring of lipid profile initially at baseline, 3 months and then annually and cardiovascular risk assessment by validated tools like QRISK3 or Assign Score (validated tool used in Scotland).

The first aim of this audit was to see if a lipid profile had been done within the past 12 months in patients on clozapine treatments and second aim was to see if cardiovascular risk had been assessed using a validated tool i.e. Assign Score and lastly to check if lipid results and Assign Score had been communicated to the General Practitioner.

The audit included 40 patients receiving clozapine treatment under the care of this local CMHT. We excluded 13 patients who were already on statin medication, those newly initiated on clozapine within the last three months or those who were aged below 30 years or above 74 years. The data collection spans from October 2022 to October 2023. Our analysis focused on bloods results in the last 12 months. After that, we searched for the cardiovascular risk assessment in last 12 months of patients’ electronic notes. Additionally, a comprehensive review of all communication records with General Practitioners was undertaken.

Lipid profile testing was done in 22 of 27 (81.1%) of the audited patients, revealing that a significant proportion, 59.9% (13 of 22), exhibited elevated total cholesterol levels exceeding 5mmol/L. However, the assessment of cardiovascular risk within the specified timeframe was notably low, with only 1 of 27 (3.70%) of the audited patients undergoing this evaluation. Furthermore, communication with General Practitioners (GPs) regarding lipid profiles was observed in a mere 4 of 22 (18.18%) of cases where such testing was conducted.

The clinical audit showed a good level of compliance with lipid profile monitoring; however, notable deficiencies were noted in the assessment of cardiovascular risk and communication with GPs. These findings emphasized the need to enhance our compliance with protocols for a more comprehensive approach to safeguard the cardiovascular health of patients receiving clozapine. As a result, we have proposed improvement strategy at our local CMHT meeting involving the implementation of a structured process, wherein the clozapine clinic nurse initiates an electronic task for the relevant medic to review the results. The medic is then tasked with calculating the cardiovascular risk and communicating both lipid results and the risk assessment to the GP, ensuring their inclusion in the annual review correspondence and subsequent management. A repeat audit will be done after 12 months.

1. 1. To measure the extent to which medication orders in inpatient prescription charts conform to the section in BNF (British National Formulary) on prescription writing.

2. 2. To implement changes with the intention of improving prescriptions and administration records.

Prescription charts of patients admitted in adult male and female psychiatry ward were analysed in three cycles, (1 September to 20 October 2022, then 1st December to 31st 2022 and then: 1st January 2023 to 28th February 2023) which added up to a total of 431, 170 and 490 prescriptions in respective cycles.

Each drug prescription was examined to see if it met the standards outlined in BNF.

Percentage of prescriptions meeting each standard was calculated in each cycle.

First Cycle was followed by presentation of BNF guidelines of prescription writing on 7th December 2022 and copies of those BNF guidelines were placed at both male and female nursing counters. After 1 month, a short re-audit was done to assess the improvement which was satisfactory but this audit's results were not presented. Lastly, after one year of presentation of BNF guidelines in the department, two months of prescription charts were re-audited in cycle 3.

• • Cycle 1: Initial evaluation revealed significant discrepancies in prescription accuracy and adherence to administration protocols. Key areas for improvement were identified and discussed with the postgraduate residents.

• • Cycle 2: Following the implementation of targeted interventions, a re-evaluation showed measurable improvements in prescription accuracy and compliance with administration protocols. However, areas for further improvement were still identified, particularly in the documentation of prescription changes.

• • Cycle 3: The final cycle demonstrated further improvements in prescription practices, with a significant reduction in discrepancies and errors.

• • Legibility remained high across all cycles, with a slight improvement in Cycle 3.

• • The use of generic drug names saw a remarkable increase from 40.6% in Cycle 1 to 84.69% in Cycle 3, indicating a strong adherence to best practices.

• • Block letters usage improved significantly from 17% in Cycle 1 to 71.42% in Cycle 3, enhancing the clarity of prescriptions.

• • The practice of providing a start date saw near-perfect compliance by Cycle 3, increasing from 82.8% in Cycle 1 to 99.18%.

Other findings were similar as well.

The audit successfully demonstrated the effectiveness of clinical audits in improving prescription quality in male and female adult wards. It highlighted the effectiveness of the interventions and the importance of continuous monitoring and feedback.

Seclusion facilities are frequently used in adult psychiatric intensive care units (PICUs). Seclusion refers to the supervision of a service user in a secure area.

Aim: To evaluate whether trust standards for seclusion review assessments at Park House Hospital were being met.

To measure the quality of junior medical review documentation to determine whether reviews of physical health, risk, medication, and mental state exams (MSEs) were included. The time frames in which reviews were being undertaken and the rationale for seclusion were considered.

A retrospective audit of notes on the electronic patient information system was completed. Those included were patients secluded between May 2022–October 2022. The majority of seclusions occur on the male PICU, or 136 suite. Eligible patients were identified following consultation with the business intelligence team within Greater Manchester Mental Health (GMMH). For those who had multiple periods of seclusion, the first episode of seclusion was audited. Data were obtained from the last recorded junior review prior to the seclusion episode being terminated. Progress notes and the internal MDT review documents were searched. This was compared against the local trust seclusion policy.

20 patients were included in the audit. The majority had a diagnosis of either paranoid schizophrenia (40%) or schizoaffective disorder (25%). 95% of seclusion reviews had a clearly documented initiation time and rationale for seclusion. Physical health considerations were documented in 75% of reviews. 50% of junior reviews documented an assessment of risk to others, compared with 5% of reviews with documented review of risk to self. Half of all reviews had evidence of a MSE and medication review, including the use of rapid tranquilisation (RT). Of the reviews eligible for initial medical review within 60 minutes, this was completed in 44% of cases.

Junior medical reviews have consistently documented the rationale for seclusion and physical health reviews. Areas for development include clear documentation of MSE however documentation may be limited due to time constraint, lack of engagement from the patient or if patients are asleep. The policy since time of audit has changed to reflect this, where consideration must now be given to “overall psychiatric health”. It was found that risk to self largely remains undocumented, despite trust policy. There is evidence to suggest risk to self may increase during a period of seclusion. Another area of development includes medical review documentation to specifically comment on use of RT.

To assess the quality of General Practitioner (GP) referrals to a Local Memory Service in South Sefton – a reaudit.

The quality of GP referrals received from primary care to the Memory Clinic at South Sefton Neighbourhood Centre (SSNC), Mersey Care NHS Foundation Trust, was assessed over three months. This reaudit was based on an initial similar audit conducted in 2019 of 106 GP referrals to SSNC.

The GP’s documented history and duration of memory loss, collateral history, and the impact of the patient's memory loss on activities of daily living (ADLs) were analysed. Also explored were the cognitive tests, physical examination, and completeness of blood investigations.

The expected standard for completeness was set at 100%. Achieved compliance for each parameter was graded 95% and above (green), 75% to 94% (yellow), and below 75% (red).

106 GP referrals were received in the SSNC Memory Service between June and August 2022. About 86% of the referrals had a history of memory loss noted by the referring GPs, while only 46% commented on the duration of memory loss. We observed increased documentation regarding the patient's history of memory loss, physical health status and cognitive testing. On the other hand, there was an 8% reduction in the referrals regarding the impact of memory loss on activities of daily living in comparison to the initial audit done in 2019.

About a quarter of all the GP referrals were accepted based on the information the GP provided on the first referral letter sent to the service. On the contrary, 70 referrals were either considered inappropriate or declined outright. Alternative diagnostic advice was given to the referring GPs in 12, and the GP asked to provide additional information in 9 of these 70 referrals. After the GP offered further details, 17 initially rejected referrals were accepted for assessment.

Even though there were some observed improvements in the information GPs provided on referrals made to the local memory service in 2022 compared with 2019, this still fell drastically below the expected standard. The finding from this re-audit process brings to the fore the need for improved partnerships between memory services professionals and GP colleagues.

A new referral proforma has been designed in collaboration with the local Integrated Care Board (ICB), detailing essential information that needs to be documented by the GP before a referral is sent to memory services

In Pakistan forensic psychiatry lacks behind as far as formal training and separate departments are concerned. In spite the cases are ever increasing. To find out the magnitude of the burden of forensic cases, current study was conceptualized. This audit would highlight the burden and endorse the demand of specific training in this area. A retrospective study was designed to determine the frequency of various psychiatric disorders, reasons and sources of referrals of the cases coming for forensic opinion to a tertiary care unit.

All 174 cases admitted to inpatient psychiatry department, Faisalabad for opining about psychiatric condition were included in the study through consecutive sampling techniques, only repeated cases were excluded. As the study was retrospective, data files were retrieved and desired variables were enlisted in SPSS to calculate the frequency and percentage of different variables.

Majority cases were male. One third were referred in year 2018. 47 (27%) criminal cases were being referred while 25 (14.3%) civil cases were received; most of the cases 102 (58.6%) were departmental (cases of the employees of different public departments). As per source of referral 72 (41.3 96%) cases were referred from courts directly, 21 (12.2 96%) cases were directly referred from various departments while most the cases 81 (46.5%) were referred from other public hospitals, As per diagnoses schizophrenia, depression and intellectual disability (ID) were the most prevalent diagnosis with 47 (27%), 41 (23.5%) and 33 (18.9%) cases respectively while 26 (14.9%) cases had no psychiatric diagnosis. 40 (22.9%) cases were advised treatment and follow up, most of these cases 26 (14.9%) were diagnosed as having depression; 30 (17.2%) cases were granted guardianship, 20 (11.4%) out of these were intellectually disabled; 18 (10.2%) cases were referred to other departments for long term psychiatric care institutions, these cases were diagnosed as having schizophrenia, BAD and epilepsy; 9 (5.1%) cases were advised adjustments in jobs, these were diagnosed as depression, schizophrenia and BAD; only 6 (3.4%) cases were suggested to board out on the basis of illness.

Department of psychiatry and behavioral sciences, FUM, Faisalabad, Pakistan is burdened with forensic cases that may be managed at other appropriate places. Society and policy makers need to be sanitized in order to make a framework for patients having mental disorder to avoid them ending as criminals or being involved in other forensic issues.

The primary aim was to analyze three months of admissions to Rowan Ward PICU (February 22 to April 2022) according to NAPICU's 2014 criteria, followed by implementing recommendations and conducting a re-audit (November 2022 to January 2023) to assess their impact. Secondary objectives included examining the link between prior PICU admissions and higher readmission rates, even when not clinically necessary.

Methods involved assessing each admission against NAPICU's criteria and reviewing the reason for admission (RFA) for appropriateness. Data collection utilized various sources, including SystmOne, Mental Health Act assessments, and referral documents. Collaborative analysis with the PICU consultant was conducted due to the subjective nature of RFA interpretation.

Results from the initial audit revealed that 12 out of 36 patients (33%) were deemed unsuitable for PICU admission, with 8 having prior PICU admissions (67%). Only 22% had documented multidisciplinary team (MDT) discussions. In the subsequent audit, 9 out of 38 patients (24%) were deemed unsuitable for PICU admission, with 2 having prior admissions (22%). Only 3% had documented MDT discussions.

There was a reduction in inappropriate admissions from 33% to 24% in the subsequent cycle. This improvement was linked to the implementation of recommendations from the first audit, such as introducing a standardized referral form, enhancing consultant-to-consultant communications, and forming a PICU outreach team. While the initial findings indicated higher readmission rates for patients with prior PICU admissions, this trend lessened in the subsequent evaluation. However, there is still insufficient documentation of Multidisciplinary Team (MDT) discussions, highlighting the need for a re-audit to accurately assess any changes.

This re-audit of rapid tranquillisation (RT) practices in patients over the age of 65 at a district general hospital took place as part of a wider quality improvement project to assess whether practices had improved following previous audits.

Data was accessed using the hospital's electronic patient record system. Drug charts for patients over 65 admitted to six wards (total n = 172) were reviewed. The wards comprised three geriatric wards, two medical wards, and one surgical ward. Drug charts were reviewed using the audit tool developed in previous audits, which has been designed to collect relevant data according to the recognised standard (in this case the local mental health trust's RT guidance). Data was collected on RT type, RT frequency of RT, RT route, indication documentation, post-RT monitoring, nature of prescription (PRN, stat, or regular), underlying diagnosis of delirium or dementia, and involvement of specialist teams.

• • Of the 172 audited patients, 9 (5.2%) received RT, compared with 13 out of 297 (4.3%) in the previous 2022 audit.

• • PRN remained the most common prescription pattern, with two designated as stat and the remaining three mostly stat but occasionally incorporating PRN. Intramuscular administration continued to be the most common route in both cycles.

• • In the current cycle, the maximum frequency was indicated in 55.5% of cases, whereas it was not indicated in the previous cycle.

• • In the current cycle, indications were documented for 88.8% of prescriptions, a significant increase from 50% in the previous cycle. Furthermore, there was almost 100% compliance in nursing/medical documentation of RT administration in patient notes, which was lacking in the previous audit.

• • Psych liaison or dementia team involvement was observed in around 33% of cases in the current cycle, whereas it was not evident in the previous cycle.

• • Post-sedation monitoring in line with policy was not evident in either cycle.

Overall, both audits highlighted consistent challenges in prescription practices and post-administration monitoring, albeit with variations in compliance levels and team involvement. Since the completion of this re-audit, a new RT policy has been approved which has much clearer guidance for the general hospital. This RT policy will be launched with a programme of teaching and training for the hospital. We aim to track progress by conducting a re-audit within 6–12 months.

• • To identify current practices regarding baseline tests monitoring for antipsychotic medications.

• • To identify potential causes for not adhering to the standard guidelines.

• • To ensure all the baseline tests have been documented and reviewed properly.

In a retrospective analysis, a cohort of 28 patient case notes was examined in June 2023 to assess the baseline physical health parameters within the Psychiatry department at Punjab Institute of Mental Health, Lahore, in accordance with the guidelines outlined in “The Maudsley Prescribing Guidelines in Psychiatry 13th edition.” The data was analyzed to fulfill the audit objectives, and significant trends were subsequently identified.

The baseline assessments encompassed a comprehensive blood count, urea and electrolyte analysis, liver function testing, blood glucose measurement, and blood pressure monitoring, all of which were conducted in 100% of the cases. Nevertheless, electrocardiography (ECG) was only carried out in 71% of the cases prior to the initiation of antipsychotic treatment. Regrettably, there was a lack of documentation regarding baseline weight/BMI monitoring, serum prolactin level assessment, and creatinine phosphokinase level measurement.

The audit revealed several areas of concern that warrant immediate attention and improvement. These include:

• • Protocols and Guidelines: The absence of defined protocols poses a significant challenge to maintaining consistent and standardized practices within the department.

• • Awareness and Training: There is a noticeable lack of awareness among medical staff, including doctors and nurses, regarding the importance and proper procedures for baseline assessments.

• • Sampling Errors: The occurrence of sampling errors during the data collection process has impacted the reliability and accuracy of the obtained results.

• • Administrative Challenges: Administrative issues have been identified as a barrier to the seamless implementation of baseline assessment protocols.

• • Resource Allocation: Insufficient funding for laboratory resources has hindered the comprehensive and timely conduct of essential tests.

• • Test Availability: The limitations in the availability of certain required tests have impeded the thoroughness of baseline assessments for patients.

Addressing these areas of improvement is critical to enhancing the quality of care and ensuring the holistic well-being of our patients. It is imperative to implement robust protocols, enhance staff awareness and training, rectify administrative challenges, secure adequate funding for resources, and ensure the availability of essential tests. These measures will contribute to the delivery of comprehensive and effective healthcare services within the Psychiatry department at Punjab Institute of Mental Health, Lahore.

Side-effects are a recognised burden of all medications and are linked to poor compliance. In psychiatry, poor compliance can result in a relapse and significant deterioration in mental health. This has an impact on both the patient and the wider healthcare system. It has been speculated that if patients had more control/recognition of side-effects, compliance would increase.

GASS is a self-rating scale for side-effects of antipsychotic medication. It has the added effect of being able to stratify side-effects by their severity and biological system involved (Central Nervous System (Sedating) effects, Neurological (Movement) disorders, Anticholinergic, Gastrointestinal and Endocrine). The form consists of 22 questions with a scoring sheet attached to the reverse. Symptoms are graded by frequency and patient's perceived burden.

The British National Formulary has ‘minimum standards’ expected. These are designed to create a standardised approach to side-effect reviewing, encouraging a proactive reviewing process. These are meant to take place: After initiation and dose titration, at 3 months and annually thereafter. The National Institute for Clinical Excellence Guideline CG178 and the Scottish Intercollegiate Guidelines Network (Guideline-131) both advocate this standardised approach with the gold standard adding a review at 1 month.

The aim for this project was to audit the current completion rate of GASS forms in inpatient wards. The secondary aim was to improve completion rates after intervention.

1. 1. Search case notes and extrapolate data to Microsoft excel.

2. 2. Review data and identify challenges perceived from staff.

3. 3. Implement changes targeting highlighted challenges.

   1. 1. Present at ward QI meetings.

   2. 2. Create & discuss Infographic for staff.

   3. 3. Highlight role/importance of forms and usefulness to clinicians.

4. 4. Re-audit after 2 months.

Initial results found a completion rate of 7% across both wards reviewed (n = 41). Within this, 1 form was actually valid. One of the wards had no completed forms. The post-intervention group had fewer patients involved (n = 35), but an increased number of completed forms. Completion rate had risen from 7% to 26% (3–9 patients). Within this, the valid forms had increased from 1 to 4.

There was a clear impact on completion rate after initial interventions. The sub-optimal increase in completion highlighted the ongoing need for further input to improve completion rates.

This was a small, local audit of patients in an acute inpatient psychiatric ward. There was a recognised limitation on the number of patients in the study and acuity of some patient's illness, preventing completion.

Our aim was to evaluate the extent to which the risk assessment protocol post self-harm incidents for patients aged over 65 at the Black Country Healthcare Trust is aligned with the recommendations set forth in the NICE Guideline (NG225). We specifically sought to determine whether safety plans are incorporated as recommended by the NICE Guideline (NG225), and in the absence of a distinct safety plan, whether essential components of such a plan are integrated within the risk assessment framework utilised following episodes of self-harm.

A retrospective audit was conducted utilizing data from the trust on self-harm incidents over a six-month duration. Of the 1,408 recorded incidents, 68 involved individuals aged 65 years or older. A sample of 30 incidents was randomly selected from this cohort to constitute the target sample for this study. Each case was anonymized with a unique identifier and subjected to a comprehensive review employing a bespoke data collection instrument, expressly developed for this audit. The review process was facilitated by the trust's digital record system (RIO). Data collated for analysis encompassed a range of variables, including demographic details, diagnostic classifications, geographical location, care setting, self-harm methodologies, the severity of the self-harm events, the origin of data, and compliance with the stipulated criteria of the NICE Guidance (NG225).

Comprehensive safety plans were present in a minority of cases, specifically 6.7% (2 out of 30 patients). The documentation of individual components of the safety plan, analysed separately, yielded the following results:

1. 1. Documentation of self-harm mechanisms was achieved in 70% of cases (21/30).

2. 2. Identification of precipitants or triggers was noted in 56.7% of cases (17/30).

3. 3. The formulation of coping strategies was documented in 20% of the sample (6/30).

4. 4. The enumeration of essential contacts was completed in 33.3% of cases (10/30).

5. 5. The identification of family members pertinent to the patient’s support network was noted in 33.3% of cases (10/30).

6. 6. The inclusion of contact details for these identified individuals was present in 30% of cases (9/30).

7. 7. Guidelines to ensure a safe environment were applicable and recorded in 38.9% of the relevant cases (7/18).

The majority of patients did not have a safety plan post self-harm incidents. Notwithstanding the absence of a comprehensive safety plan, critical elements prescribed by NICE Guidance (NG225) were insufficiently addressed within the risk assessment and subsequent management planning post self-harm.

The full cycle audit aimed to evaluate and enhance attendance rates at health appointments in a psychiatric care setting. The initial audit (Phase 1) identified baseline attendance rates and underlying factors contributing to missed appointments. The reaudit (Phase 2) was conducted to assess the effectiveness of implemented interventions from Phase 1 and to identify areas for continued improvement.

Both phases employed a retrospective evaluation methodology. Phase 1 reviewed records of 23 patients over two years, totaling 89 appointments. Phase 2, conducted as a follow-up, involved 19 patients with 39 appointments over a six-month period. Data collected included the number of attended and missed appointments, and reasons for non-attendance. Interventions after Phase 1 focused on addressing identified issues such as patient transfers, leave protocols, and transportation challenges.

Phase 1 recorded an attendance rate of 68.5%, with the missed appointment rate at 25.8%. Common reasons for non-attendance included patient decline and unclear reasons. Phase 2 showed a slight improvement in attendance rates (71.8%) but also an increased missed appointment rate (28.2%). Notable reasons for missed appointments in Phase 2 included patients on leave, ward cancellations, and transportation issues. The comparison revealed an improvement in attendance rates post-interventions, though challenges persisted, particularly in patient leaves and transportation.

The chi-square statistic is 2.2893 and the p-value is 0.3183. This indicates that there is no statistically significant difference between the attendance rates in Phase 1 and Phase 2. This suggests that the changes implemented between the two phases did not result in a statistically significant difference in attendance rates.

The full cycle audit demonstrated marginal improvements in appointment attendance rates following targeted interventions. While Phase 2 showed a higher attendance rate, it also highlighted ongoing challenges, particularly in managing patient leaves and transportation. These findings underscore the need for continuous monitoring and adaptable strategies to further enhance attendance rates. Recommendations include improved communication during patient transfers, proactive leave management, addressing transportation issues, and ongoing evaluation to sustain improvements in health appointment attendance in psychiatric settings.

We aim to see whether DNAR discussions are being undertaken at an appropriate time for our patients, as well as seeing whether these are recorded formally and regularly reviewed, as per local protocol. We also aim to see whether the immediate medical/nursing teams are aware of the local guidelines, as well as which of their patients have a DNAR in situ, and how to find this out. As an old-aged psychiatric unit, this is very important.

We used 2 methods of data collection. One was questionnaires that we gave out to medics, nurses, and HCAs on our wards. We collected quantitative data from them on whether they knew where DNAR forms were and which of their patients had DNAR forms. We then also collected quantitative data from our online notes, looking into which patients had DNARs, whether these were recorded online and in a physical copy, whether it was discussed on clerking, and whether it was regularly reviewed and documented in MDTs. We used data from 51 inpatients over 3 wards.

Over 30% of patients have a DNAR in situ across the 3 wards. The dementia-focussed wards have a higher number of DNARs in place. All patients with a DNAR had a purple form completed and kept on the ward. 75% of staff knew where these were. Only 20% of those with DNARs had these documented online as per local guidelines; only 45% of staff knew where to find this information online. Only 8% of patients had their DNAR status discussed on admission, and 10% in their first MDT. Only 60% staff knew which patients had a DNAR in situ.

There is evidence that purple forms are completed appropriately and stored well. The main issue is the online record-keeping; staff either don't know how to or that they can document this online. This is reiterated as many did not know where the information was online. This demonstrates a lack of knowledge and education.

DNAR conversations are not occurring in the first place; the status is not being regularly reviewed, leading to issues where these conversations are rushed during acute events. It is important to think about these things earlier to ensure everyone, patient, family and staff, understands the process and rationale.

Lack of staff knowledge on which patients have DNARs in situ could be a great issue if an acute event were to occur, and compromises patient safety.

To review compliance with current blood monitoring guidelines of Older Adult Community Mental Health (OACMHT) patients who are on clozapine within the community teams of Herefordshire and Worcestershire Health and Care NHS Trust. This is for full blood count, prolactin, glycated haemoglobin (HbA1C), liver function, renal function, lipid profile, glucose, and clozapine assay.

Our trust guidelines state the following blood parameters should be monitored every 6 months:

1. 1. Full Blood Count (FBC)

2. 2. Glucose (fasting if possible)

3. 3. Prolactin

4. 4. Urea & electrolytes (U&E)

5. 5. Lipid profile (fasting if possible)

6. 6. Liver Function Tests (LFT)

7. 7. HbA1c (annually)

8. 8. Clozapine plasma assay (annually)

We reached out to the medical secretaries of the following OACMHTs: Wyre Forest, Malvern Evesham & Pershore, Worcester & Droitwich, Redditch & Bromsgrove to collate a list of patients on clozapine. We then retrospectively looked at blood test results in the past 1 year from 31.12.22 to 31.12.23 and assessed compliance of the 8 haematological parameters.

In total, 7 patients were identified across the 4 OACMHTs caseloads who were on clozapine. In the past 1 year, we would expect 2 episodes of monitoring for FBC, Glucose, U&E, Prolactin, Lipid profile, and LFT, as well as 1 episode of HbA1C and clozapine drug levels.

Compliance for FBC monitoring for 2 episodes was achieved for 100% (n = 7) of the patients. Compliance for 2 episodes of glucose and prolactin monitoring were 0%. Compliance for 2 episodes of renal profile monitoring was 57% (n = 4), but 86% (n = 6) of the patients had at least 1 episode of renal profile monitoring. Compliance for 2 episodes of Lipid profile monitoring was 0%, however 43% (n = 3) of the patients had at least 1 test. In terms of LFTs, 71% (n = 5) of the patients achieved the expected 2 episodes of monitoring, and 100% of them at least 1 episode of monitoring. For HbA1C monitoring, 100% of the patients had the expected 1 episode of monitoring annually. For clozapine plasma levels, 43% (n = 3) of the patients achieved their expected annual episode of monitoring.

An interesting observation of note was that a number of blood parameter investigations were performed by GPs/hospitals as part of another investigation, not exclusively for the sole purpose of clozapine monitoring. For example, 50% of the U&Es, 33% of lipid profiles, 71% of LFTs, and 43% of HbA1c tests were done by the GP/hospital.

The OACMHTs within our trust achieved 100% compliance with FBC and HbA1c monitoring in the past 1 year. 71% compliance was achieved with LFT monitoring, 57% was achieved with U&E monitoring and 43% compliance was achieved with the annual clozapine monitoring.

With regards to tests done by GP/hospitals, on one hand, repeated phlebotomy of patients would come with increased direct medical (equipment, facilities) and non-medical (time) cost to service and intangible costs (pain) to patients. It would also not be cost effective to repeat these tests if done recently. Hence one could use recent test results as part of their monitoring routine. However, if these patients do not happen to see their GPs or have a hospital admission for unrelated issues, would they have missed their ideal monitoring targets? This unpredictability of timely monitoring raises the question of whether there is a need for the creation/standardisation of clozapine clinics within the OACMHTs, especially if the clozapine patient caseloads continue to grow.