• • To enable identification, recall of all women (18–60 years) who may be of childbearing potential and are currently prescribed sodium valproate and identify those that are at risk.

• • To check that the patients continue to meet the conditions of the Pregnancy Prevention Programme.

• • To ensure that the guidelines by MHRA are adequately followed.

• • To evaluate our practice relating to completing the Risk Acknowledgement Form for Sodium Valproate.

First audit cycle August 2021:

From the General Adult Database (NHS GRAMPIAN), we identified 33 women between the ages of 18–60 years who were prescribed Sodium Valproate as a mood stabiliser in the period between August 2020 until August 2021. Data were obtained from patients’ records to ensure patients were still open to psychiatry services, compliant with Sodium Valproate, had regular contact with specialists and identified Valproate risk acknowledge form existed and adequately filled.

Univariate analysis was used to analyze the result.

THE INCLUSION CRITERIA:

• • Adult female patients(18–60) who are open to psychiatry services.

• • On Sodium Valproate as a mood stabilizer.

A second audit was conducted using the same standards and timescale as for the primary audit. Using telephone and emails, the teams were contacted and encouraged to complete the relevant documentation.

First audit cycle August 2021:

• • There were a total of 33 patients included in the audit.

• • 97% of the patients were in contact with psychiatry services and specialists.

• • Only one patient had an Annual Risk Acknowledgement Form (ARAF) filled and scanned to her E-notes.

• • 66% of women were between the ages of 45–60 years of age.

The results showed 39 female patients (18–60) were on Sodium Valproate as a mood stabiliser. The mean age was 45 (18–60). We identified Completed Annual Risk Acknowledgement Form (ARAF) forms on 21 patients.

The proportion of completed ARAF was increased from 3% to 54%.

Conclusion of the first cycle:

97% of the patients were in contact with psychiatry services and specialists.

• Only one patient had an Annual Risk Acknowledgement Form (ARAF) filled and scanned to her E-notes.

Conclusion of the second cycle:

There was a significant increase in compliance with the MHRA guidelines regarding Sodium Valproate prescription in women of childbearing age in our department.

The proportion of completed ARAF was increased from 3% to 54%.

• • Valproate is highly teratogenic, and evidence supports that use in pregnancy leads to neurodevelopmental disorders (approx. 30– 40% risk) and congenital malformations (approx. 10% risk).

• • Valproate must not be used in women and girls of childbearing potential unless the conditions of the Pregnancy Prevention Programme are met and only if other treatments are ineffective or not tolerated, as judged by an experienced specialist.

• • The MHRA advises that all healthcare professionals must continue to identify and review all female patients on valproate.

• • The Annual Risk Acknowledgement Form should be used for all future reviews of female patients on valproate

• • Specialists should comply with guidance given on the form if they consider the patient is not at risk of pregnancy, including the need for review in case her risk status changes.

To evaluate whether the practice in the generic CAMHS team Winsford is in line with the guidelines recommended by NICE in identification and management of depression in CYP. To formulate an action plan that might be needed for the recommendations that are not met currently.

To collect the relevant information about the identification and management of depression in young people in our community center by following methods:

1. 1. Review of online case notes, protocols, pathway descriptions, screening forms and proformas

2. 2. Random review of the last 12 months of practice with random five cases studied per case manager regarding identification and management of depression in the children and young people at the center. To assess this, a proforma will be prepared from the guidelines relevant to the team members. This proforma will be sent to all the clinical workers of the team who will be required to fill it and return it to the lead author.

I am working on this audit currently and will be obtaining the results in two months’ time and hopefully will be able to submit the audit poster well before the International Congress.

This audit will help the team to assess how diligently they are following the recommended NICE guidelines for the identification and management of depression in children and young people and to make appropriate changes in the process to meet the guidelines that are not currently met.

In view of the limited number of acute inpatient beds relative to demand in England, a thorough assessment prior to referral is paramount in ascertaining clinical need. A comprehensive risk assessment is crucial in light of patient safety and assessing risk to others. Moreover, the appropriateness of an acute bed should be considered, and whether psychiatric intensive care or forensic services may be more appropriate for the patient. In line with this, the Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) admissions policy details standards of the assessment prior to referral to acute inpatient services. Pre-referral assessment should be carried out by a multidisciplinary team including a senior doctor. It should include rationale and plan of care for admission, risk assessment and section status on admission alongside type of bed being requested. Referrals are accepted from multiple teams including Home Treatment, the Place of Safety and Liaison Psychiatry. Aim: To audit adherence to the pre-referral policy for acute inpatient admissions to a male and female ward in BSMHFT, including comprehensive assessment, plan of care and consideration of appropriate bed type.

A retrospective audit of pre-referral documentation for all admissions from April to September 2019 to a male and separate female acute inpatient unit at the Zinnia Centre, Birmingham was carried out. This included 83 male admissions and 82 female admissions. Documentation was reviewed on the clinical system Rio. Parameters reviewed included assessing clinician, assessment summary, capacity assessment, consideration of bed type, plan of care and section details.

Overall, almost half of admissions (49%) were assessed by a full Mental Health Act team, 34% by a senior psychiatric doctor and the remainder by psychiatric nurses in the referring department. An up-to-date assessment summary was completed in the majority of cases (67%) prior to referral. Risk assessments were completed in 82% of cases. 35% of cases included a detailed plan of care which met audit standards. Capacity assessment alongside outcome was documented in 13% of cases. The type of bed was only considered in 13% of cases.

Whilst assessment and risk documentation was completed in the majority of cases, few cases had a clear plan of care and appropriateness of bed type was rarely considered in assessment. Greater adherence to the pre-referral process could facilitate treatment decisions during admission and seek to ensure a safer inpatient environment.

Attention Deficit Hyperactivity Disorder (ADHD) in adults is a growing clinical problem and its prevalence among patients being referred to the General Adult Psychiatry clinic is rapidly increasing. The treatment of ADHD involves the use of medications such as methylphenidate, atomoxetine and lisdexamfetamine. These medications can cause significant adverse effects including arrhythmias, hypertension and appetite suppression. NICE guidelines stipulate that individuals on such medications should have weight, blood pressure and heart rate monitored every 6 months. The aim of this closed-loop audit was to assess if weight, heart rate and blood pressure are being monitored in line with current NICE guidelines in those who are on medication to treat ADHD in a Community Mental Health Team in Glasgow.

Patients with an ADHD diagnosis were identified through a search of electronic case records. Electronic records were reviewed for each patient identified to assess if weight, heart rate and blood pressure had been recorded in the last 6 months. The results of the first cycle of this audit was presented at a local meeting in May 2021 with relevant clinicians present. The patient cohort identified was subsequently re-audited in December 2021 to assess if there had been an improvement in the monitoring of these medications.

30 patients were identified who had an ADHD diagnosis. 15 male and 15 female patients were identified. Patient age ranged from 18–50. 10 patients did not engage with services and were so subsequently excluded from our analyses. There was a substantial improvement in the monitoring of weight, heart rate and blood pressure in the second cycle compared with the first cycle of this audit. 45% of patients had their weight recorded (previously 15%), 40% had their heart rate recorded (previously 8%) and 50% had their blood pressure monitored (previously 19%).

There has been a significant improvement in monitoring heart rate, blood pressure and weight every 6 months in line with NICE guidelines in the second cycle compared with the first cycle of this audit. However, we are still not currently meeting NICE guidelines. This is of particular clinical significance given the increasing prevalence of patients with an ADHD diagnosis and subsequent increase in the use of these medications. The COVID-19 pandemic and the reduction in face-to-face reviews has likely had an impact on our ability to monitor these medications.

Aim: Evaluate the recording of the Anti-Cholinergic Burden (ACB) score for patients referred to the West Leeds Memory Assessment Service (MAS). Objectives: 1) Calculate the Anti cholinergic Burden score of all patients referred to the West MAS in June 2021 where this has not already been done. 2) Determine if there is a need to review the process for assessing this component of the cognitive assessment in MAS.

All patients who were referred to the West MAS in June 2021 were included in this project. Data were collected from GP referral letters, the referral meeting documentation and patients’ GP prescriptions.

These records were checked for a documented ACB score. If ACB scores were not found, they were calculated based on a patient's GP prescription. Several ACB calculators were used to do this, as NICE does not recommend a specific scoring system.

There were 60 referrals in June 2021. Within this data set, there were no documented ACB scores found at the point of referral.

The different scoring systems used led to considerably different ACB scores, with the lowest figure suggesting 20.4% of patients had a raised ACB score (n = 10).

In all three scoring systems used, the medication most frequently leading to a larger anticholinergic burden is Amitriptyline.

Within the service, during the referral process we are not routinely documenting anticholinergic burden. We are in the process of agreeing a standardised ACB tool to review all new referrals to the service and determine how we can communicate these findings with referrers. We are looking to improve local awareness of ACB scoring across the memory pathway and will undertake a re-audit of practice in 3 months to establish if the proposed changes improve our results

An increasing proportion of patients presenting in crisis to Newham Home Treatment Team (NHTT) had been noted to exhibit clinical signs and symptoms of neurodiversity. The aim of our project was to identify the number of confirmed and suspected autism and ADHD cases over a 12 month period. We also collated data on gender, age, presenting complaint, medication, and use of screening tools.

The project involved a retrospective case note review of the NHTT (South) caseload from November 1st 2020-October 31st 2021. This involved searching caseload and electronic patient records on RiO for keywords: “autism”, “ADHD”, “ASD”, “Asperger”, “Attention Deficit Hyperactivity Disorder”, “AQ10”. Patients were included if neurodiversity was suspected or already diagnosed. Data were collected on age at presentation, gender, presenting complaint, NHTT diagnosis, other diagnoses, Autism Spectrum Quotient (AQ-10) score, whether screening for attention deficit hyperactivity disorder (ADHD) was completed, age at first presentation to services, and medications at discharge.

Over a 12 month period 49 patients (out of 258) presenting to NHTT South raised clinical suspicion of neurodiversity, representing 19% of the caseload and on average one new patient per week. The majority of these (47) related to autism, 13 of which had confirmed diagnosis (M = 26, F = 23). Of the 36 for whom there was clinical suspicion of autism, an AQ10 score was recorded for 18. 14 patients were suspected to have ADHD, 6 of which were confirmed (M = 5, F = 9). There was not a significant impact of gender. The majority of patients included (33) presented with a mood disorder (M = 15, F = 18), and a minority (13) with psychotic disorders (M = 7, F = 6). Over half of patients included presented with suicidality (M = 11, F = 14), and just under half had received a diagnosis of personality disorder (M = 7, F = 16). 21 patients were prescribed anti-psychotic medication (M = 13, F = 8), and 24 were prescribed an antidepressant (M = 9, F = 15).

Our findings demonstrate that neurodiversity may currently be under-diagnosed and is often mis-diagnosed, with suspicion frequently raised in previously undiagnosed adult psychiatric patients presenting in crisis. There is need for increased awareness of presenting features of neurodiversity within secondary mental health care services, and particular screening for patients experiencing suicidality may be beneficial. The AQ10 is under-utilised as an independent screening tool, and should be promoted to aid in identifying neurodiversity. Patients who may be neurodiverse are frequently prescribed antipsychotic and antidepressant medication, and further studies exploring prescribing practices in this patient sub-set may be useful.

1) To re-audit the current practice of depot prescribing within the Wolverhampton Older Adult Enhanced Community Mental Health Teams (ECMHT). 2) To assess whether the implementation of a memory aid for prescribers has improved compliance of current practice to the Black Country Healthcare Foundation Trust (BCHFT) standard operating procedures (SOP) protocol.

All depot cards were identified from the Wolverhampton Older Adult ECMHT in January 2022. The cards were assessed for their compliance with the 15 standards for depot prescription writing as set out by the BCHFT SOP protocol. If a standard was not met, reasons for non-compliance were documented. The compliance rate for each standard was then compared to the results from a previous audit performed in January 2021.

A total of 13 depot cards were identified. Out of the 15 standards, 6 of them had a 100% compliance rate. The two standards with the lowest compliance rate were ‘Standard 3’ and ‘Standard 7’. Standard 3 states that “Prescriptions should be signed and dated appropriately, including full signature and name printed”. This standard only achieved 15% compliance. This was a 60% reduction from the previous 75% compliance. Standard 7 states that “The interval expressed should be using the word ‘every’”. This standard achieved a compliance rate of 31%. This was a 12% improvement from the previous 19%.

This re-audit has shown there is still significant room for improvement regarding depot prescribing. The reason for non-compliance to Standard 3 was largely due to prescribers not printing their names alongside their signatures. This is likely due to the lack of an assigned space for “Prescriber's name” to be printed on the form. Also, like the previous audit in 2021, prescribers are still not using the word ‘every’ when filling in the frequency of depots (Standard 7). Despite this, there is a 12% improvement in compliance rate which shows that the memory aid did help some prescribers to comply to Standard 7.

These results will be discussed at the trust's Clinical Audit and Effectiveness Committee meeting. We will then revise the community depot cards to include columns for both prescriber's signature and name. Finally, we will harmonise depot cards from all localities in BCHFT. We will continue to include the memory aid at the front of all depot card folders as it has proven effective. We aim to complete these by March 2022.

The risk for cardiovascular-related death is predicted to be higher in individuals with Serious Mental Illness (SMI) due to increased prevalence of common cardiac risk factors like smoking, physical inactivity, poor diet, substance use and hyperlipidemia among them.

The aim of this retrospective study was to evaluate the physical health of patients with SMI in various settings- acute inpatient, tertiary care hospital and community.

We estimated the cardiovascular disease risk of schizophrenia patients with the aid of Framingham Risk Score (FRS) assessment tool, which can quantitatively predict both the heart age and 10-year CVD Risk percentage of patients aged ≥ 30 years. The clozapine to norclozapine ratio was compared with triglyceride levels, body weight, BMI, and fasting blood glucose in patients after treatment with clozapine. Southlake Regional Health Center's practice was compared with the national standards set by Diabetes Canada 2018 guidelines by conducting a clinical audit.

68 non-diabetic, patients aged ≥ 30 years with all the risk factor records for FRS assessment were selected from a cohort of 183 patients registered in the schizophrenia clinic of Southlake Regional Health Centre. The data were collected from patient records from the 75 patients registered with Assertive Community Treatment Team in Georgina, Ontario.

The sample size of the study on inpatients was 49 participants from the acute psychiatry ward consisting of 28 females and 21 males during the month of November 2021.

Males, on average, were found to have an intermediate 10-year CVD risk (~11.2%; FRS total points: 11.27) in comparison to females who, on average, had a low 10-year CVD risk (~7.3%; FRS total points: 11.19). 26% of the patients using FRS were calculated to be at high risk and 28% with intermediate risk of developing a CVD. The average heart age of the sample patients was 60 years, which was 9 years higher than the total average age (51 years). The investigated biomarkers of Hemoglobin A1C, triglycerides, and glucose serum concentration were examined graphically, separated into categories of the ratio measurements of 0–2, 2–3, and 3+. For all biomarkers, lower values were more desirable. Triglycerides were the lowest in the 3+ ratio category. Hemoglobin A1C and glucose serum concentration were lowest in the 0–2 ratio category.100% of patients with diabetes had their blood sugar levels measured and 66.67% were referred to an endocrinologist. In patients without diabetes, 91.30% had their blood sugar levels measured, 39.13% had their HbA1C levels measured, and 6.52% had neither their HbA1C, nor their blood sugar levels measured.

Cardiovascular complication can be one of the leading causes of death in the next 10 years among schizophrenia patients due to age, poor lifestyle choices, and current estimations via the FRS assessment tool. Further studies need to be conducted with a larger sample size and more recent data to examine any adverse lifestyle changes in schizophrenia patients during the pandemic, which could have negatively influenced their cardiovascular health. It is recommended that doctors weigh the risks vs benefits of prescribing clozapine to patients with high triglyceride levels.

To establish whether our practice is meeting NICE and Maudsley guidelines in establishing baseline prolactin levels in an inpatient set-up before starting treatment with antipsychotic medications with a medium or high-risk of causing hyperprolactinaemia.

Data were collected retrospectively from case notes of 127 patients from 9 wards at Surrey and Borders Partnership NHS Foundation Trust (SABP).

We reviewed if the baseline prolactin was measured for inpatients before commencing on antipsychotics with medium or high risk of hyperprolactinemia.

We reviewed if patients with elevated prolactin levels were assessed and managed appropriately.

SABP is currently achieving 43% in recording serum prolactin levels for inpatients who are on antipsychotics with medium or high-risk of hyperprolactinemia respectively.

Inpatient ward 76 patients out of total 127 were on antipsychotics with medium to high-risk of developing hyperprolactinemia.33 patients had their serum prolactin checked bringing the compliance to 43%,2 patients were excluded due to incomplete data bringing the sample size to 31.

3 had elevated prolactin. Out of 3 patients,1 patient was managed appropriately with MRI brain, followed by change of antipsychotic medication and repeat prolactin levels. For 1 patient, prolactin

level was rechecked. Unfortunately, no documentation of assessment of symptoms of hyperprolactinemia was found in all three patients case notes.

The trust is falling short of meeting NICE and Maudsley guidelines of monitoring prolactin level. It is possible to introduce a robust system within the Trust so that we are complaint with a NICE and Maudsley prolactin monitoring guidelines.

We need to local Trust guidelines for management of hyperprolactinaemia in line with NICE and Maudsley guideline of monitoring prolactin levels.

Safety netting advice and leaflets explaining symptoms of hyperprolactinaemia should be provided to all the patients on antipsychotics with medium to high risk of developing hyperprolactinemia.

Re-audit for adherence of all inpatient wards at Park House Hospital to Trust Consent to Treatment policy. Improve hospital compliance to Trust Consent to Treatment policy. Reduce prescribing errors. Improve trainee confidence and knowledge of Consent to Treatment

• • Cross sectional audit.

• • Data collected between 8th and 12th November 2021

• • All wards in Park House Hospital

• • 5 patient records and medication charts reviewed per ward.

• • Proforma used.

• • Data analysed using Excel.

• • Interactive teaching on Consent to Treatment delivered by Dr McKnight to Core Psychiatry Trainees on 3rd July 2020.

• • Dr McKnight presented the original audit data and consulted the Pharmacists and Consultants to assess and improve ward systems for recording Consent to Treatment. (26th May and 30th April 2021).

• • Dr McKnight presented to Greater Manchester Mental Health, Mental Health Act and Mental Capacity Act Quality Improvement Group (30th June 2020).

• • No wards had 100% capacity forms documented, kept in medication charts and uploaded to Paris.

• • 7/9 wards had 100% compliance for completing T2/3/S62 forms.

• • 6/9 wards had 100% compliance rate for retaining the T2/3/S62 forms in the medication charts.

• • 78% T2/3/S62 forms were uploaded to PARIS.

• • 80% medication charts matched T2/3 forms.

When Dr McKnight asked trainees, “Do you feel confident with your knowledge of consent to treatment” only 24% answered yes, 35% answered no and 41% a little.

When asked, “Do you check Consent to treatment forms before prescribing?” 32% answered yes, 24% no, 34% sometimes and 10% that they didn't know what they were.

During the post-teaching quiz, trainees were asked, “Has this teaching session improved your knowledge and confidence regarding Consent to Treatment?” 91% answered yes, 0% answered no and 9% answered a little.

Discussion with Consultants and Pharmacists concluded that it may be beneficial for wards to include Capacity to Consent and Consent to Treatment within ward round proformas

• • The two main concerns of the initial audit and re-audit, relate to Treatment Capacity and Consent forms compliance and prescribing.

• • New trainees rotate into the Trust every 6 months and levels of knowledge surrounding Consent to Treatment varies depending on trainee experience. Trainees require teaching on Consent to Treatment as part of their induction and teaching programme.

• • Based on the multidisciplinary nature of ensuring compliance to Consent to Treatment the authors propose monthly ward auditing of Consent to Treatment, which they believe will lead to better compliance rates across the hospital.

To audit completed liaison service high risk care plans against local and national guidelines.

Sample comprised of a snapshot of all liaison patients currently on the case load on 14th December 2021. Electronic notes were reviewed to identify High Risk Care Plans (HRCPs) and audit completion against local guidance. Currently there is no national guidelines.

In addition staff from the liaison team were surveyed to consider their confidence in completing HRCPs in order to direct staff training. Acute hospital staff were also surveyed to ascertain positive and negative aspects of the current HRCPs, in order to suggest quality improvements ahead of the upcoming integration of new Digital notes system.

Sample size 284. High Risk Care Plans completed 11, with an additional 2 required but not found in the notes.

Non pharmacological deescalation advice was specified in only 2/11.

Regular medication was documented in 5/11.

Specialist rapid tranquillisation medication advice in 8/11.

8/11 made reference to the local rapid tranquillisation policy, which was not made available in the notes.

Absconsion risk is documented in 8/11 and advised level of observation 10/11.

According to local guidelines High Risk Care Plans were appropriate for 4.6% of the liaison case load, but record was included in the notes for 3.9%. Of those completed mandatory fields including non pharmacological deescalation and rapid tranquillisation advice were not always complete. Reference to rapid tranquillisation policy not immediately available in the notes is largely unhelpful in an emergency.

Our local target is for 100% completion of appropriate high risk care plans and full documentation for each of the mandatory fields in the high risk care plan. Improved training and record keeping is required.

Staff survey suggested unfamiliarity with document and unclear boundaries between standard and patient specific information impaired utility of high risk care plans. We recommend familiarising staff with the document and encourage highlighted font for key information.

This audit is looking at COVID-19 vaccine uptake in an acute adult psychiatric setting as part of the national drive to minimize COVID-19 infection. The aims of this audit are to identify: the number of patients that have been offered vaccination in a ward setting; the acceptability of the vaccination and the reasons for non-acceptance of vaccine.

A total of 339 patients were admitted to acute adult psychiatric wards (Male, Female, PICU) at Highbury Hospital, Nottingham between February to August 2021. Data on the following parameters: demographics (age, sex, ethnicity), section status, HoNOS cluster, admission length and vaccine data (offered, accepted, received) using the RIO system and Health Informatics.

Out of 339 patients, 31% (n = 105) had received or planned to receive the first dose of vaccine prior to admission. 43% (n = 100) of 234 patients who hadn't received vaccine were offered. Out of the patients who were offered vaccine, 59% (n = 59) accepted. 92% (n = 55) of patients who accepted vaccine, received vaccine. Those offered vaccination had an average length of stay of 117 days whilst those not offered had a shorter average length of stay of 81 days.

For patients who were offered vaccine, those who were sectioned and in psychotic clusters refused vaccine compared to non-psychotic and informal patients. Deprivation, gender, age, admission length had no statistical significance in vaccine uptake for patients who were offered.

Patients listed the following reasons for refusing the vaccine: media distrust; vaccine not effective; already had COVID-19; doesn't want it; believes vaccine made by consultant; doesn't want bad reaction; “Scientists and politicians are liars”; “I am fine and don't need it"; “Don't trust it and don't like needles”; “Don't want to be part of the game”; “Have had covid twice and, if I get it, I'd prefer my body to fight it”.

Our current vaccine acceptance rate of 59% is lower than those found nationally (80%) and in a medium secure psychiatric hospital (77%). The trust policy recommends all eligible patients should be offered the vaccine; our offer rate is lower than this standard. The low offer rate may be explained by vaccines being offered in rounds leading to patients possibly being missed. Our acceptance rate could be enhanced by improving our vaccination care plans for formally admitted psychotic patients.

Elderly patients are more vulnerable due to the higher prevalence of underlying physical health problems. Hence, it is prudent to have a baseline and regular update on the physical health assessment for all old age mental health inpatients. This paper is aimed to discuss the clinical audit findings on the physical health assessment are done in accordance to the trust policy.

The clinical audit was conducted in a local elderly inpatient mental health unit over a period of a week. The standard used was based on the local Health Board Policy on acute inpatient admission, which includes an admission clerking with details on physical health need and physical examination should be done within 12 hours of admission, blood investigations and medication chart should be completed within two hours of admission, and an ECG (electrocardiography) should be done at the point of admission.

A total of 21 elderly inpatients admission clerking were analysed. It is noted that over 95 cases admission did not adhere to the prescribed standard. Only 67% of the admission clerking was completed within 12 hours, while only 52% of the admission had physical examination done. Only 24% of the admission completed their blood investigations within two hours and 14% of them had ECG done at the point of admission. Although 90% of medication chart was completed within two hours of admission, there is still room for improvement. Feedback from the junior doctors revealed a multifactorial contribution to the failure of meeting the standards: patient being agitated during admission, lack of communication among different teams, lacking an online documentation system on handover, and the heavy workload on junior doctors on venepuncture and ECG.

The clinical audit has shown a huge area of improvement is needed in terms of the physical health assessment and documentation for elderly inpatient psychiatry unit.

We recommend having a good handover system, training more nurses and HCWs in phlebotomy and ECGs, having ward based doctor cover to improve the adherence for future.

We will be presenting this audit in post grad teaching and junior doctor forum with a plan to conduct a regional audit to compare the adherence on the three different hospital under the same health board.

In Bolton Early Intervention Team (EIT) it was noticed that patients prescribed antipsychotics frequently required a change in medication due to side effects. Similar issues had been identified in Avon and Wiltshire NHS Foundation Trust where a prescribing guideline was developed which won the NICE Shared Learning Award in 2020. This recommends prescribing Aripiprazole first line and cautions using Olanzapine or typical antipsychotics first due to their side effects. The aim of this project was to identify which antipsychotic drugs are currently prescribed in first episode of psychosis (FEP) in Bolton EIT patients and to audit adherence to National Institute of Clinical Excellence antipsychotic prescribing guideline CG178.

The sample included all adults with FEP accepted by Bolton EIT across a four-month period from 01/12/20 until 31/03/21. Fifty-two people were identified.

Measured standards were documentation of prescribing rationale, discussion regarding medication side effects and weekly weight monitoring for six weeks following initiation. Antipsychotic choice and need for a change within six months of initiation was recorded. Data were collected retrospectively from patients’ electronic records.

Thirty-eight patients had been prescribed an antipsychotic – fifteen as inpatients, seventeen by Bolton EIT and six by the Home Treatment Team.

Of the fifteen inpatients Olanzapine (8) and Zuclopenthixol (3) were the most common choice. 5/15 had a documented rationale, and side effects were discussed with 3/15 patients. Weekly weight monitoring was performed in 7/15.

Of the 17 people who started antipsychotic medication once under Bolton EIT Quetiapine (6), Olanzapine (6) and Aripiprazole (5) were the most common choices. 12/17 had a documented rationale and 13/17 were consulted regarding side effects. Weekly weight monitoring was not performed for any of these patients.

Within six months, sixteen antipsychotic prescriptions (42%) were changed due to side effects (9), inefficacy (6) and non-compliance (1). The drugs changed were Olanzapine (6) Quetiapine (6) Zuclopenthixol (2) Aripiprazole (1) and Chlorpromazine (1).

Those initiated on antipsychotics as inpatients need better involvement in decision-making and consultation about side effects. A community initiative should be introduced to offer weekly weight monitoring. Further work is required to understand the rationale for frequently prescribing Olanzapine and Zuclopenthixol in inpatient services, and to consider why Aripiprazole is infrequently used first line.

All detained patients should have a leave risk discussion carried out prior to commencement of home leave. Driving risk must be clearly discussed and captured during the assessment. Driving advice as per DVLA guidance must be documented in case notes and discharge summaries. The aim was to audit and reaudit the use and quality of the driving risk assessment during leave risk discussions within adult mental health inpatient wards at one site under the Tees, Esk and Wear Valleys NHS Foundation Trust. The authors hypothesise that compliance to local policies could be improved upon.

Standards were set based on local policies. The audit was conducted across all adult acute inpatient wards within the identified mental health hospital. All inpatients who went on a period of home leave during their admission and ultimately discharged during the period from 1 April 2021 to 30 April 2021 (initial audit) and 1 October 2021 to 31 October 2021 (reaudit) were assessed. The data were collected using an audit tool. An Excel spreadsheet was used to collate data: specifically driving status of the patient, whether a leave risk discussion which captured driving risk was carried out, and whether DVLA advice was captured on discharge letters.

48 patients (19 were drivers) during the initial audit and 27 patients (9 were drivers) during the reaudit met the inclusion criteria. For the initial audit, overall compliance for leave risk discussion (73%), specifically for driving risk assessment, did not meet target compliance. Only 5% of drivers were given written DVLA guidance on discharge letters. The reaudit showed a 100% compliance in the use and quality of leave risk discussion. 56% of patients had written confirmation of discussion on DVLA driving advice recorded on discharge summary.

There has been significant improvement in the use and quality of leave risk discussion, and documentation of DVLA driving advice on discharge summary during the reaudit.

The results were discussed at the Regional Audit meeting and the Inpatient Leadership Meeting. The following improvement plan was agreed and implemented:

1. 1. Regular communication amongst Multi-Disciplinary Team (MDT) during Leave Risk Discussion. One healthcare professional assigned to inform patient of the advice and capture conversation on case notes.

2. 2. Junior doctor induction to reiterate importance of capturing DVLA advice on discharge letters.

3. 3. MDT to discuss driving risk and advice during discharge meetings. “Driving advice discussion” to be added to discharge meeting checklist.

Women with perinatal mental illness are at increased risk for severe illness with COVID-19. Vaccination against COVID-19 is strongly recommended by JCVI (Joint Committee on Vaccination and Immunisation) and RCOG guidance. Mental health professionals should proactively inform their patients about COVID-19 vaccination and also address any concerns or misinformation, should they be raised. The aim of this audit was to evaluate the rate of uptake of the COVID-19 vaccine among patients under the West Kent community perinatal mental health team. In addition, we aimed to identify factors that deter patients from taking the COVID-19 vaccine. In patients who were hesitant to take the vaccine, we offered further information to aid their decision-making process.

We identified patients under the care of the West Kent perinatal mental health community team on 27/10/2021. We excluded patients who were discharged from the team in subsequent weeks during data collection. We collected patient demographics including highest level of education, ethnicity, religion and socio-economic status. Patients’ COVID-19 vaccine status was obtained via GP records or through telephone contact.

If patients had not had their COVID-19 vaccine, they were contacted to enquire whether they were planning to take the vaccine, if not, to ascertain reasons for refusal and whether they wanted additional information about the vaccine. Those women who requested additional information were offered the RCOG information sheet and decision aid.

Amongst 86 patients included in the audit, 59% (n = 51) had taken both dose of the COVID-19 vaccine and 12% (n = 10) had taken a single dose. 29% (n = 25) were unvaccinated.

68% (n = 17) of unvaccinated patients were pregnant and 32% (n = 8) were postnatal. All women who did not accept COVID-19 vaccine were contacted to offer further information. Following this contact, 39% (n = 9) decided to accept the vaccine, 52% (n = 12) refused the vaccine and 26% (n = 6) were uncertain but were willing to consider taking the vaccine in the future.

The reasons for hesitancy in accepting the vaccine included a lack of trust in the vaccine, concerns around its development over a short period of time, concerns around close associates experiencing illness or side effects after taking the vaccine and scepticism over efficacy of the vaccine. Few women did not wish to take the vaccine during their pregnancy, but were willing to consider it after the birth of their baby.

We identified potential areas to optimise uptake of COVID-19 vaccines by discussing the importance, safety, efficacy and providing up-to-date information regarding COVID-19 vaccine in the perinatal period.

This is a re-audit of Benzodiazepine and Z-hypnotic drugs prescriptions in two community treatment teams (CTTs) in the Cumbria Northumberland Tyne and Wear (CNTW) Trust, comparing with previous audits in 2009, 2017 and 2018 to check whether areas of good practice were maintained, and progress was made.

We reviewed caseloads of four CNTW consultants in the two CTTs which included 554 patient encounters with 60 encounters where benzodiazepines or z-drugs were prescribed. Nine missing data sets brought the total audit sample to 51. For these 51, prescribing information was gathered from RiO and assessed against standards derived from CNTW Trust Policy and BNF prescribing guidance. To be compliant, 90–100% of prescriptions needed to meet the standard.

Overall, the rate of prescribing of benzodiazepines and Z- drugs increased from previous audit (7% in 2018, now 10.8%). Good areas of practice maintained were as follows (all 100%): all teams were compliant in prescribing within BNF limits, refrained from prescribing diazepam in 10 mg formulation, and no pregnant/post-partum women were prescribed these medications.

Although non-compliant, there were clear improvements in documenting indicated use (2018: 61.65%, 2021: 80.8%), and providing prescriptions of <4 weeks in duration (2018: 58.2%, 2021: 79.2%)

Key areas of concern were as follows: poor documentation of indication, duration of treatment and plans for review/discontinuation (compliance ranged from 31.5% - 81.2% in these areas). There was poor documentation of what verbal advice was given (0–16.9%), and lack of clearly documented tapering/discontinuation plans for those on long-term prescriptions (16.1%). The provision of written advice reduced from previous audit (2018: 10.7%, 2021: 5.8%). As 41/51 encounters were via telephone or video due to COVID-19 pandemic, this may have impacted on results.

Despite improvement in some areas, there remains scope for ongoing improvement in other areas. To improve these, we plan to produce and distribute an educational email to all prescribers, including the following: information on this audit and its findings, prescribing guidelines, relevant e-links to patient information leaflets as well as the audit proforma used for this audit, to encourage prescribers to undertake self-directed practice. A poster will be distributed, highlighting prescribing guidelines and standards, to be printed and displayed in clinical areas as reminder of prescribing responsibilities and the importance of documentation. Prescribers will be encouraged to participate in a small quiz to test learning. Efficacy of these measures will be assessed with a re-audit in one years’ time.

The aim of the project was to improve the routine incorporation of driving advice based on Driver and Vehicle Licensing Agency (DVLA) guidance into discharge planning by responsible inpatient teams. This would optimize patient safety, demonstrate good clinical practice (trust and professional body values) and minimize/prevent the emergence of accidents/unfair loss of licenses/unfair attribution of driving accidents caused by people who have been under recent or ongoing inpatient care.

The following questions: “Do you have a valid license”, “Do you own/have access to a vehicle”, “Do you currently drive” were developed as a standard template for gathering patients’ driving information.

These questions were embedded within:

1. 1. Barriers to ward discharge discussions

2. 2. Trust-wide communications via screensaver and circular

Answers to these questions were to be clearly documented on patient's records to serve as prompts for the responsible discharging team to take up providing the appropriate advice.

After a specified period, the electronic discharge notification (EDN) database was searched for patients with relevant diagnosis who were discharged from all the general adult/older adult acute inpatient wards within a specified period. The patients’ records were then checked for documentation of relevant driving information evidenced by documentation of answers to the screening questions as well as recorded evidence of DVLA discussion/advice held since date of diagnosis or admission.

The standards audited against were all patients:

1. 1. should have their driving licence status recorded during their admission

2. 2. should have their access to a vehicle recorded during their admission

3. 3. with a relevant mental health diagnosis should have a record of advice regarding driving given in bespoke and DVLA informed manner during ward discharge planning by the responsible discharging team

4. 4. should have documentation of the outcome of the driving advice given by the responsible team in their records

28 patients with relevant DVLA notifiable mental health conditions were audited. 11% (n = 3) had driving licence status recorded. 14% (n = 4) had access to a vehicle recorded. 7% (n = 2) had driving advice given. Only one patient had outcome of driving advice recorded. No best practice was identified.

Documentation of driving information, DVLA signposting advice and outcome for patients with relevant mental health diagnosis is a crucial part of patient risk assessment and management as these patients are not free from posing a driving risk on discharge. The trust is implementing actions to improve the routine incorporation of driving advice based on DVLA guidance into discharge planning.

To ascertain whether current medical assessment and management of self-inflicted head injuries in an inpatient CAMHS setting conforms with current NICE guidance.

Incidents of self-inflicted head injury were identified on the incident logging system Ulysses. Incidents were matched to entries on Paris, the online clinical notes system. Data were collected from Paris on whether the incident was reviewed by a doctor, time until doctor review and which components of the NICE guidance were completed during the review. The data were collated into an Excel spreadsheet and analysed.

Inclusion criteria were CAMHS inpatients at 1 Greater Manchester hospital during November 2021 who had an incident of ‘head banging’ recorded on Ulysses. Exclusion criteria were patients on ward A as the ward was found to have its own care plans for managing head banging rather than escalating to doctors.

There were 52 incidents of head banging logged. 56% (n = 29) of incidents received a doctor review and 32% (n = 17) did not. For 10% (n = 5) of incidents a doctor review was declined and for 2% (n = 1) a review was conducted for another indication. The mean time taken until review was 4.3 hours with a range of 1 to 16 hours.

NICE guidance lists 9 components of the history that should be covered. 1 component met the 100% target and 1 component was documented in > 50% of incidents. The remaining 7 components were documented in < 50% of incidents.

NICE guidance lists 16 components of physical examination that should be completed. No components of the physical examination met the 100% target. 5 components were documented in > 50% of incidents. The remaining 11 components were documented in <50% of incidents.

NICE guidance recommends verbal and written safety netting advice is given. Advice was given in 16% (n = 5) of incidents. NICE recommends a responsible adult remains with the patient for 24 hours, this was documented in 77% (n = 22) of incidents. NICE recommends ongoing doctor concerns necessitate patient transfer to A&E. Concerns/lack of concerns were documented in 6.6% (n = 2) of incidents.

This audit has demonstrated inconsistencies between doctor's documentation of self-inflicted head injuries in an inpatient CAMHS setting. The reviews do not meet the standards outlined by NICE. There is a good emphasis on gross neurology but less awareness of the need to document more subtle pathology and ongoing monitoring requirements.

To improve the Psychiatry induction for DiTs in Fife.

The purpose of induction is to provide Doctors in Training (DiT) with a smooth, supported transition between roles. Delivered well, it will promote confidence and also provide a thorough grounding in the key requirements of the role and clarity regarding sources of help.

A recent report, commissioned by the GMC, identified the key areas which should be covered in induction. The findings demonstrated a clear link between inadequate inductions to the impact on doctors’ well-being and patient safety issues.

A questionnaire was issued to DiTs completing Psychiatry inductions in August and December 2021. Questions focused on the following key areas highlighted in the GMC report:

• • Gaining access to workplace settings and systems

• • Physical orientation of workplace

• • Team inductions

• • Daytime role and out of hours working and rotas.

• • Familiarisation with common cases/procedures that doctors may deal with in this speciality: risk management, use of the MHA

Questionnaire Results: Key Issues highlighted

August 2021

• • FY2 to ST6 inducted together: differing experience levels

• • Differences in site inductions (psychiatry is spread across 3 hospitals in Fife)

• • Issues obtaining swipe cards/keys

• • IT access for emails and various computer systems delayed

• • Computer systems training not done

December 2021

• • Lack of psychiatry experience of FY2s

• • Continued IT access issues initially

In September 2021, a working group was established comprising DiT representatives and those responsible for induction. The August 2021 results were disseminated and key improvements were identified in areas covered by the clinical induction:

• • An improved induction check list universal for all sites.

• • Induction documents for each role detailing responsibilities and useful information.

• • Integration of IT training.

Plans have been made to provide simulation events which would give DiTs practical experience in a safe environment of various topics e.g., risk management in psychiatry. Additionally, there are plans to revise induction for speciality trainees.