To assess recording of allergy status for patients under the care of Sandwell CAMHS

This audit was performed at Sandwell CAMHS. The project was discussed and logged with the Trust's audit department.

Medical records of all patients (516 patients) seen between January and March 2022 by the medics in Sandwell CAMHS were examined for documentation of allergy status

For all patients the alert bar on Rio was examined to determine whether or not their allergy status was recorded.

A data collection tool was devised to collect information in accordance with the standard i.e, the drug allergy recorded or not and when recorded;

• • it is present

• • no known allergy

where present;

• • substance name

• • reaction

• • severity

• • date recorded

• • Evidence and Certainty

For the Recording of Allergy Status on Rio, the audit revealed:

1. A. 60 out of the 516 patients had their allergy status recorded.

Out of these 60 patients;

18 had possible allergy

42 had no known allergies

• B. 456 had no recordings of allergy status

• C. Those with possible Allergies;

The substance name was documented for all in Rio for those who had allergies indicated

12 of the 18 possible allergies had the allergic reaction documented

13 of the 18 possible allergies had the severity documented

3 of the 18 possible allergies had the date recorded

1 of the 18 possible allergies had evidence and certainty recorded

The audit revealed a poor recording of the allergy status

The following recommendations have been made:

Present audit at the Specialist mental health quality improvement group.

Clinicians should be made aware of the expected Nice Guidelines for documentation of allergy status.

Clinicians to update allergy status of patients every 6-12 months.

Develop an action plan and governance documentation with the specialist mental health quality improvement group.

The results of this audit have been shared with the Rio lead for them to consider making relevant changes in Rio i.e. The systems should include prompts for annual updates of allergy status.

A clear trust policy of documentation on how allergy status/adverse effects will be should be recorded Rio.

If possible, it should be included in the junior doctors' handbook and the eLearning.

To carry out a re- audit in 6 months to 1 year

To analyse the process of self-administration of medication (SAM) in an inpatient psychiatric rehabilitation setting in order to improve the MDT awareness and engagement with the process. The project also aims to improve the level of completion of the relevant SAM documentation in the department.

The medication prescriptions and self-administration charts (where present) for the patients on the ward were reviewed to identify errors or omissions in completion of the documentation.

Thereafter a number of interventions were completed. This included informal education sessions and follow-up written correspondence to the relevant staff (via email and the ward handover book). The potential for SAM was additionally prompted at the weekly MDT meeting in order to identify additional suitable patients for the process.

Three out of 18 inpatients were initially engaged to some degree with SAM at the start of the project. For the relevant patients involved, completion of attendance documentation and adherence to written instructions from 70% to 90%. Improvements in other aspects of the documentation were also observed. Following the prompted MDT discussions a further five patients were identified to commence SAM, who may otherwise have remained on traditional nurse-led medication administration.

Engagement with SAM was initially variable and therefore was improved by targeted discussions and more MDT involvement. Documentation was identified as a potential pitfall and completion improved due to the interventions above. During the project a number of medication errors were incidentally highlighted and were reported via the DATIX tool. This demonstrates the importance of risk awareness associated with the SAM process in order to improve patient safety. There should be an MDT approach when considering patients for SAM process as this can affect discharge decisions. SAM could also be considered outwith the inpatient rehabilitation setting (e.g in General Adult Psychiatry wards). SAM is important in order to promote patient autonomy and independence in a safe manner. In the future it would be useful to explore patient attitudes towards medication self-administration in order to identify barriers to concordance.

To evaluate the transitions of Aneurin Bevan University Health Board (ABUHB) Child and Adolescent Mental Health Service (CAMHS) patients to Adult Mental Health Services (AMHS) during the COVID-19 pandemic, against regional Health Board policy standards.

Following a review of the current ABUHB transitions policy and a focused review of the literature, relevant standards were elicited. Retrospective data of transition cases between April 2020 and March 2021 were collected using a standardised data-capture tool from CAMHS records using the EPEX system; cases were anonymised. A questionnaire was constructed and distributed by email to ABUHB CAMHS clinicians to gain further qualitative data.

A total of 34 patients were identified as CAMHS transition cases. 3 were identified as having a transitions co-ordinator, 6 had no record of AMHS having been informed with only 1 case documenting liaison with AMHS at the 6 month mark. 20 cases showed evidence of good patient support before and after transition, and 25 showed young person involvement in decision making. 28/34 cases showed evidence of good coordination of MDTs (multi-disciplinary teams).

There were 16 responses to the staff survey. 93% of respondents were aware of the transition policy, and 68.8% of clinicians strongly agreed/agreed with “I involve young people in their decision making process”. 25% of respondents strongly disagree/disagree when asked whether they work in collaboration with the AMHS. For “I believe my patients are ready to transition at the age of 18” 37.5% remained neutral.

Several of the standards outlined in the ABUHB transition policy are not being met. These include: naming a transition coordinator, informing AMHS 6 months prior to the patient turning 18, and involving the young person in the decision of transfer of care. COVID-19 has evidently impacted the transition process, but more audits must be conducted in order to compare these data to pre-pandemic times.

ADHD is a common neurodevelopmental disorder, which is usually diagnosed in childhood. The aim of this audit is to assess practitioners' compliance with NICE guideline NG87 in relation to the initial assessment and medication choice in children with ADHD (age 5 and over), prior to the commencement of ADHD medication.

The sample was children aged 5 years and over who have been diagnosed with ADHD and referred for medication initiation, in a Manchester CAMHS community team between May and October 2022. The audit tool used to collect the data included each of the standards and measured each individual patient's compliance. Information was collected from electronic patient records and paper notes.

Sample size was 32 patients.

Standard One stated that 100% of patients, before starting medication, should have a full assessment, including: a review to confirm they meet the criteria for ADHD and need treatment, mental health and social circumstances including coexisting psychiatric/neurodevelopmental conditions, educational/employment circumstances, risk assessment for substance misuse and care needs. Overall compliance was 9%.

Standard 2 stated that all patients should have a physical health review including medical history, medication, height, weight and physical observations and, a cardiovascular assessment. Overall compliance was 0%.

Standard 3 stated that 100% of patients who met specified criteria should be referred for a cardiology assessment prior to starting medication. Overall compliance was 28%.

Standard 4 stated that 100% of patients who met criteria for referral to cardiology or had a co-existing condition treated with a medicine that may pose cardiac risk should have an ECG completed. Overall compliance was 75%

Standard 5 stated that 100% of patients who have a blood pressure consistently above the 95th centile for age and height should be referred to paediatric hypertension specialist. Overall compliance was 9%.

Standard 6 stated that 100% of patients should be offered methylphenidate as first line treatment for ADHD or an alternative if they cannot tolerate stimulants. Overall compliance was 100%

Three major areas of improvement were identified. Cardiovascular risk assessments are not fully compliant due to lack of cardiac examination which could affect rates of cardiology referral as referral criteria include a murmur on examination.

Although 100% of patient had their height, weight and physical observations recorded, a significant proportion did not have these plotted on centile charts as recommended.

A minority of patients had a full biopsychosocial assessment, with a major deficit in risk assessment for substance misuse.

Seclusion is a restrictive intervention used when a patient presents with risks that cannot be safely managed in their current environment. The Mental Health Act 1983 Code of Practice (MHA CoP) provides clear recommendations for both frequency and content of medical seclusion reviews, with compliance previously audited within Cheshire and Wirral Partnership NHS Foundation Trust (CWP). Following the initial findings however, change was not implemented. A new audit has therefore been commenced to reassess baseline practice and identify areas requiring improvement.

The MHA CoP audit tool outlines the following timeframes for assessment: initial medical review within 1 hour, 4-hourly medical reviews until first internal multidisciplinary review, twice daily medical seclusion reviews with at least 1 by the Responsible Clinician. Documentation should evaluate: physical and mental health, medication adverse effects, observation level, prescribed medication, risk to others and self, need for ongoing seclusion. Data were collected retrospectively for all episodes of seclusion occurring in a CWP Psychiatric Intensive Care Unit during August 2022.

5 seclusion episodes related to 4 patients, ranging from 1 night to 15 days in duration. Regarding medical review frequency, 20% were seen face-to-face within 1 hour of seclusion commencing and 75% were seen 4-hourly until their internal multidisciplinary review. Mental health was more consistently commented on than physical health (97% vs 61% respectively), whilst medication was reviewed in 69% of assessments. Rationale for continuing seclusion was provided in 72%, referring to risk to others in 54%. Adverse medication effects and observation level were the least documented parameters (2%), followed by risk to self (7%).

Assessment time was often not explicitly stated and was substituted with time of documentation, meaning reviews may have occurred earlier than accounted for. The on-call doctor does cover multiple sites overnight, potentially contributing to delays in attending unforeseen time-sensitive tasks. Trust policy dictates constant visual observation must be maintained throughout seclusion and this is therefore not routinely subject to review or adjustment. Overall interpretation of the qualitative information was fairly subjective in a low number of seclusion episodes, however there was a notable lack of recording adverse medication effects and risk to self. Findings will be presented at junior doctor induction whilst a quick reference sheet is designed prior to reaudit. CWP's seclusion policy specifies medical review frequency, but does not outline expected content of documentation. There is scope to extend local policy and align with the MHA CoP.

The purpose of the audit was to assess the standard of communication to GPs from secondary mental health services and to ascertain whether the information included in letters to GPs was in accordance with the recommendations of RCPsych and PRSB. The audit cycle was completed by re auditing to identify how the recommendations from the first audit has improved the quality of communication to GPs.

The audit was conducted on three psychiatric units, in three sites across Betsi Cadwaladr University Health Board and clinic letters were studied to identify whether the information was as per recommendations from: RCPsych and PRSB.

The first audit used 121 letters in total from 3 sites, with the data being collected using audit proforma over a 2 week period from 04/04/22.

The re audit looked at 69 letters with data collection using audit proforma over one week period from 19/12/22.

Majority of letters sent to GP were lacking key information like details of Care coordinators ,medical comorbidities ,non psychiatric diagnosis, and actions for GP with this data missing in 91.7%, 61.22 %,79.59% and 71.43% respectively. Fill rates for other information like patients' details was 100% , psychiatric diagnosis was 83.47%, psychiatric medications , follow-up plan were 80.17%.

The results of the re-audit most letters contained Psychiatric Diagnosis (97.1%, previous 83.5%), Psychiatric Medication (91.4%)previous 80.17%), and Follow Up Plan(98.6%, previous 80.2%). Many letters did not include information regarding Medical Comorbidity (28.6% vs 31.4% ), Non-Psychiatric Medication (65.7% vs 34.7%), Details of Care Co-ordinator (54.3% vs 8.3% ) and Action for GP (27.1%, vs 44.6%).

The recommendations from first audit were to create local guidelines and templates with recommended headings for clinical letters, provide formal teaching for junior doctors and to re audit to see if the implemented changes has led to an improvement.

The re-audit showed improvement since the introduction of the template in majority of headings in GP letters with decline in fill rate for 2 headings and these changes varied among three sites.

Barriers identified affecting the overall outcome of the re audit were :template not being used, lack of training to juniors, and psychiatrist workload.

In conclusion , we aim to re-distribute the template and increase awareness with informal teaching sessions, provide information on template during induction for doctors and organize training sessions on three sites.

This is an audit evaluating the impact of inpatient COVID-19 restrictions on the frequency of recorded violent incidents on a male acute general psychiatric ward. The aim of this study is to compare the frequency of violent and disruptive behaviours between pre-COVID-19, COVID-19 and post-COVID-19 periods on the ward.

Inpatient adverse incidents on the ward are logged into an electronic system as ‘IR1’ (Incident Reporting) through Ulysses by healthcare professionals. Data on logged incidents between April 2019 and March 2022 were obtained by contacting the Ulysses technical team. The reported incidents were classed into ‘disruptive behaviour’, ‘violence to patient’ and ‘violence to staff’.

We chose to focus on the IR1s submitted between three twelve monthly time periods: Pre-COVID-19 (April 2019–March 2020), COVID-19 (April 2020–March 2021) and Post-COVID-19 (April 2021–March 2022). We opted for these cut off periods to be in line with the local trust guidelines with respect to COVID-19 restrictions.

Out of 155 incidents which occurred during pre-COVID-19 period, 38 incidents were disruptive behaviours, 24 were violence to patients and 93 were violence to staff. Of the 249 incidents during COVID-19 period, 66 incidents were disruptive behaviours, 46 were violence to patients and 137 were violence to staff. Of the 216 incidents during post COVID-19 period, 67 cases were disruptive behaviours, 53 were violence to patients and 96 were violence to staff.

There was 74% increase in disruptive behaviour between pre-COVID-19 and COVID-19 phase but no increase between COVID-19 and post-COVID-19 phase.

There was a 92% increase in violence to patients between pre-COVID-19 and COVID-19 phase and a 15% increase between COVID-19 and post-COVID-19 phase.

There was a 47% increase in violence to staff between pre-COVID-19 and COVID-19 phase, but a 30% reduction between COVID-19 and post COVID-19 phase.

Violence to staff makes up the highest proportion of violent incidents recorded, followed by disruptive behaviours and violence to patients. This trend was seen in all three time periods.

Our study showed that violent incidents in a male acute psychiatric ward increased during COVID-19 period when compared to pre-COVID-19 period. This could be explained by increased ward restrictions and difficulties in communication related to PPE use. Further studies would need to be conducted looking at trend in other services within the Trust. Our findings will be of importance in monitoring risks in similar circumstances in the future.

Women from Black and minority ethnic backgrounds have been shown to experience an increased burden of common postnatal mental health conditions and higher rates of involuntary admissions. However, evidence demonstrates disparities in these women accessing perinatal mental health support. Reasons behind barriers to access must be defined and addressed. Our aim was to explore ethnic inequalities in accessing Perinatal Mental Health Services in Southwark (SWK PMHS). We hypothesised that SWK PMHS would meet Royal college of Psychiatrists (RCPsych) gold standards in providing equitable access to care.

The Trust's local clinical database was used to extract our cohort of women aged 15–44 years with a birth episode in contact with SWK PMHS between September and December 2021. Individual data were collected via local clinical notes system to establish basic measures (demographics and ethnicity) and detailed information (referral outcome, interventions, safeguarding etc). Ethnicity data were compared to King's College Hospital birth records for 2021 and local census data via Office of National Statistics.

105 patients were analysed in total. Overall, there was poor recording of ethnicity and 6.6% of referrals had no ethnicity documented at all. At the point of referral, there was no clear inequity based on ethnicity, with data appearing reflective of local census and maternity records. However, there were concerning inequities in treatment received by women in minority ethnic groups. Out of four hospital admissions in total, three (75%) of the women were from a Black ethnic group and all were detained. There were fewer referrals for psychology intervention for women in minority ethnic groups compared to women in the White ethnic group, with particularly low numbers of referrals for women in Asian and Mixed ethnic groups (2/35 women). 83% of all antipsychotics prescribed (5 out of 6) were to women from the Black ethnic group with the remainder being women in the White ethnic group. There were 31 safeguarding alerts, with almost half (48%) from women in the Black ethnic group.

There were concerning variations in interventions and type of care received by women from minority ethnic groups. Women from Black and minority ethnic groups were underrepresented in accessing psychology intervention though conversely overrepresented for antipsychotic treatment, safeguarding alerts and involuntary admissions.

This suggests that contrary to our hypothesis, SWK PMHS is not meeting RCPsych Gold Standards. Our audit findings reflect literature that there are apparent barriers to women from ethnic minority groups accessing certain specialist mental health services.

We sought to review the changes in assessments within the Unscheduled Care Team (UCT) at Royal Cornhill in Aberdeen since the pandemic. Previous UCT data highlighted an increase in monthly assessments from October 2018 to October 2020 by 18% 240(204). We hoped to identify areas for intervention and reform within the UCT and the wider service.

An excel spreadsheet was distributed to clinicians on-call from 1st–31st October 2021 and 1st-31st October 2022. Data analysed included time of referral, the role of the clinician, source of referral (Enhanced Access, Acute medical admissions/A&E, Other Hospital Wards, Community Mental Health Teams (CMHT), Police, GP, GMEDS (out-of-hours GPs), and Other Sources), method of assessment, time taken to complete assessments, time taken to discuss assessments and assessment outcomes. The spreadsheet also had space for clinicians to provide additional qualitative data. Following the 2021 data collection, a PowerPoint presentation was given to members of staff with the initial findings from 2021. The UCT added additional practitioners to the twilight period 1700-2100 due to the noted increased demand during this period. They also spoke to CMHTs about Enhanced Access and to the Police directly, as they were the two most frequent referrers. Following the 2022 data collection, the 2021 and 2022 datasets were compared.

The overall number of assessments increased by 10% from 2021 to 2022 - 405(367). Additionally, total assessment time increased by 15% - 299(261) hours. In terms of assessment outcomes, the largest changes were seen in outpatient follow-up with CMHTs, with a 65% increase 238(144); UCT discharge, with a 43% decrease 64(112) and non-specified outcomes, with a 52% decrease 14(24). The largest changes in referral rates were from GMEDs 48(30) 60% increase, CMHTs 4(16) 75% decrease, GP 50(34) 47% increase. Enhanced access 96(95) and police referrals 78(77) remained the most stable, increasing by 1%.

There has been an evident increase in workload for the UCT since the pandemic, which could be managed with additional staffing for the team. The targeted interventions, both for Enhanced access and Police, have limited the increase of their referral rate. Similar targeted interventions and review of referral criteria may mitigate increased demand from other sources. Increasing outpatient CMHT follow-up after assessment may suggest that routine outpatient work may not be back to pre-pandemic levels; further study would be required to confirm this.

How frequently and to what quality are mental capacity assessments being recorded on inpatient acute ward? Capacity is the ability to consent to a particular decision and is defined in law by the Mental Capacity Act (MCA). Capacity to make decisions is an area of particular importance in mental health care, as many mental illnesses can lead to people losing the capacity to make some decisions. Capacity assessment is a two-stage process. If a patient passes Stage 1, then they have capacity. If they fail Stage 1 then the assessment progresses to Stage 2. The person being assessed must then be competent at every step of Stage 2 to then be deemed to have capacity. Documentation of capacity assessments should demonstrate this two-stage assessment.

The sample included all people who were inpatients during the data collection window of 05 to 09 Sep 2022.

For each person, their MHA status was recorded as this determined whether capacity to consent to admission was relevant. For each patient, their EPR was checked for any Mental Capacity Assessment proformas which were examined and recorded as being for admission, treatment, or something else. The cumulative case notes were then searched for any mention of ‘capacity’ and any additional capacity assessments were examined and added to the tool. All capacity assessments were reviewed against the defined standards.

Sample and demographics - 22 male inpatients. 21 patients subject to the MHA and 1 was an informal patient. The CTT rule applied to 7 patients.

Treatment - 17 of 22 had capacity assessment for treatment at admission. All of these were recorded using the proforma and all were in line with best practice guidance. 7 had the CTT rule applied to at the time of the audit. None of the records for these people included documentation of a repeated mental capacity assessment.

Something Else - 9 capacity assessments recorded for ‘something else’. Five were recorded on proforma and in line with best practice guidance. 4 capacity assessments were as case notes and didn't meet best practice criteria.

Capacity assessment for treatment is being conducted and recorded well at the time of admission, but not at the point that CTT rules apply from.

Most capacity assessments were recorded on the EPR proforma and all of these met best practice guidance. 4 capacity assessments were recorded in case notes and none of these met best practice guidance.

Good medical records are essential to the continuity of patient care. The aims of this audit were to evaluate the quality of ward review documentation in 7 Psychiatry wards in Essex Partnership University NHS Foundation Trust, to identify areas of improvement, to recommend strategies to improve record keeping, and to measure their effectiveness by comparing records in the 1st and 2nd cycles of audit.

A sample of 10 patients from each of the 7 wards was selected, for a total of 70 patients, in each of the 1st and 2nd cycles of the audit (Data were collected in the 1st cycle between 06-07-2021 and 22-07-2021, and 2nd cycle between 16-10-2022 and 07-11-2022). Samples were selected randomly among patients who were inpatient or discharged recently. The data were collected from the first, middle, and last ward reviews. If the patient was inpatient at the time of the data collection, data were collected from their first review, the last/most recent ward review, and one of the reviews in between. Patients who did not meet this criterion were excluded. Based on 1st cycle results, strategies were recommended to improve record keeping. After 15 months, 2nd cycle results were used to evaluate their effectiveness.

The results demonstrate significant areas of improvements in record keeping: a majority of questions did not meet the standard of 80% completion considered “satisfactory” in previous audits. In the 2nd cycle, 9 questions had a “satisfactory” completion rates. These were mandatory or automated questions and ones essential to immediate patient care. 7 questions had “average” completion rates above 45%. All (17) other questions and subquestions had “low” completion rates. Analysis of variations between cycles shows that question on “Responsible clinician” increased from 23.3% to 99.5% because it was automated. 4 other questions or sub-questions have seen a substantial increase in completion rate between the 1st and 2nd cycle. But our strategies’ effectiveness during the period of the audit has proven limited and difficult to trace.

It can be concluded that more efforts should be dedicated to improving medical record in the psychiatry wards of Essex Partnership University NHS Foundation Trust. The most effective strategy to secure high ward review docummentation rates remains to make questions mandatory or auto-complete when possible. More research is necessary to demonstrate the effectiveness of other strategies such as the education of junior doctors in induction and awareness posters in wards.

Patients with serious mental illness are more likely to suffer from serious physical health conditions, including: obesity, diabetes, heart failure and stroke. This, combined with the side effects of antipsychotic medication including weight gain and cardiac changes, means that patients with psychosis under the Early Intervention Services (EIS) taking antipsychotics require regular physical health monitoring, as per NICE guidelines. This includes: yearly BMI, blood pressure, ECG, blood tests (FBC, U+E, lipids, HbA1c, prolactin, LFT), alcohol status and smoking status. Our audit aims to assess the compliance of physical health checks for patients on antipsychotic medication under the EIS first episode psychosis team.

Patients on our caseload (for >6 months) between 01/2022 and 01/2023 (n=36) were included in this audit, and relevant data were collected using electronic records (i.e. carenotes and affinity). Data were recorded and stored electronically, and analysed using Excel and GraphPad. Patient information was discussed with their lead practitioner to ensure data collected was accurate. Our audit standard was set at 100%.

In terms of BMI, 91.67% (n=33) of patients had a recorded BMI, with 19.44% (n=7) of our patients being overweight and 19.44% (n=7) being classified as obese. Of the patients classified as overweight or obese (n=14), 85.71% (n=12) had received advice about their diet or exercise. Blood pressure measurements were available for 86.11% (n=31), and 13.89% (n=5) of these patients were found to have hypertension. Information relating to patients' alcohol, smoking and recreational drug use was recorded in 97.22% (n=35) of our patients.

Qrisk data were not collected in 22.73% (n=5) of patients who were eligible for measurement (n=22). Furthermore, ECG tests were not recorded in 72.22% of patients (n=26). Compliance with blood tests was less than the desired standard, with 75% (n=27) of patients having an up to date FBC, U+E, lipids and HbA1c measurement.

Specific areas of physical health monitoring are carried out to a high standard in the EIS service, but there are areas which warrant improvement, particularly Qrisk and ECG monitoring. The EIS team is to re-audit these outcomes in 3 months' time, after presentation of results to the team and physical health check clinics are employed.

This clinical audit aimed to assess how well the local Community Mental health services for Older people (MHSOP) was implementing the latest NICE and Tees, Esk and Wear Valleys (TEWV) guidelines in dementia service delivery, and to identify what impact (if any), the COVID-19 pandemic lockdown had on their service delivery. In the UK, there are over 800,000 people living with Dementia; providing sustainable individualised care for them has significant cost implications for health and social care services. In 2018, NICE published evidence-based guidelines on delivery of dementia care by professional services within a person-centred and supportive framework. These guidelines together with the TEWV guidelines on Person-centred Dementia care pathway published in 2019, set the standards for this audit.

The first cycle was performed between 7th Nov 2020 and 15th Jan 2021; we included patients who had received an initial and diagnostic assessment from the team by 12/2020.

Second cycle was done from 7th Nov 2021 and 31st March 2022; inclusion criteria were patients who had initial and diagnostic assessments by Jan 2022.

In each cycle, data from 20 patient records were collected using a tool designed from NICE guidelines and Trust policy on Dementia care standards.

In the first audit patients' consents for assessment and information sharing purposes was recorded in 80% of cases; this fell to 65% in the re-audit.

In the first audit at diagnostic assessments, 47% of patients were given relevant information regarding their prognosis and 26% about dementia and driving; these appreciated to 80% and 53% respectively. 16% of patients were given information in readily accessible formats as leaflets, increasing to 50% in the re-audit.

In both audits a carer's assessment was not offered up to the recommended standard, being (26% and 18% respectively).

This study has demonstrated a measurable improvement in the conduct of diagnostic assessments when local and national standards guiding dementia assessments are followed, and when identified action plans on areas needing improvement are implemented. It however shows that for such improvements to be sustained, the Trust and national guidelines and all identified action plans need to be consistently applied in practice. The findings also suggest that the COVID-19 lockdown restricted opportunities for sharing readily accessible information leaflets to patients, as borne out by the relatively poorer compliance of 16% in the first audit.

The aim of the audit is to measure performance against Bradford District Care Foundation Trusts (BDCFT's) ‘Antipsychotic Physical Health Monitoring Shared Care Guidelines’.

In September 2022, the audit project lead retrospectively reviewed the patient's electronic care record to establish their compliance to the standards.

The sample was drawn from the caseload of patients managed by the Intensive Home Treatment Team (IHTT) Bradford in September 2022. All patients who were initiated on antipsychotics by the IHTT were included in the audit. Patients who were initiated on antipsychotics by other teams such as Community mental health team (CMHT), Inpatient teams, etc, were excluded. A total sample size of 25 was used

All relevant areas of the record were checked, and data were collected on a data collection tool designed in Microsoft Excel and once collected these data were passed to the Clinical Audit team who completed the analysis using the same programme.

Demographics: 15 patients (60%) were male and 10 (40%) were female. Their ages ranged from 18 years to 55 years with a mean age of 37 years.

The results of the audit highlight that only 32% of patients had a full physical health check prior to the initiation of antipsychotics. A further 56% had an incomplete physical health check. None of the individual investigations were fully compliant, as identified in the table above. BMI/weight was the investigation completed the least even though all antipsychotics are known to carry a risk of weight gain. HbA1c was the least completed blood test. Only 40% of all patients had their physical health checks reviewed by a relevant professional after they had been completed.

It is important that all patients prescribed antipsychotic medication have the necessary baseline investigations completed to ensure that the medication is safely prescribed, and the results of this audit was shared within the team for their consideration and review.

In cases where antipsychotics was started without the baseline monitoring, It is assumed that this decision was taken on a balance of risks. General lifestyle factors such as diet and physical activity can have a significant impact on the patient's physical health, yet this investigation was completed less frequently than determining any illicit drug use and identifying the patient's smoking status.

Following physical health checks, results of these need to be reviewed by relevant clinicians with documented evidence to this.

Seclusion is a psychiatric treatment that is used as a “last resort” in light of deteriorating mental state. It involves the supervised confinement and isolation of a patient, away from other patients, in an area where the patient is not allowed to leave due to possible risk they pose to themselves and others in order to manage severe agitation and chaotic behaviour. The Trust policy defines a procedure for seclusion which encourages decision making in line with the Mental Health Code of Practice 2015 (MHCoP 2015) and encourages the clinicians to adhere to the policy, making decisions and care which should be duly documented following an assessment of ongoing concern, mental state, assessment of physical health, medication review, risk assessment in a timely fashion as stipulated in the policy.

This was a retrospective review of patients based on incidence reports completed at the commencement of seclusion on the Derbyshire Healthcare Trust between May and November 2022 . The electronic records were reviewed, and data analysed via Microsoft Excel, against trust standards:

• • Timing of seclusion review: 1hour and 4hourly medical review

• • Independent Multidisciplinary Team meeting within 12hours on seclusion

• • Documentation of seclusion

• • Review of ongoing concerns

• • Mental state examination

• • Physical health review

• • Medication review

• • Risk assessment

• • Review of need for seclusion

• • Intervention

107 incidences of seclusion that took place involving 61 patients were reviewed.

34% of patients were reviewed within the 1hour, 41% reviewed 4hourly and 47% had an internal MDT.

57% of medical reviews were documented with 50% clearly stating ongoing concerns, 47% carrying out a mental state examination and 42% had physical health reviews done. 44% had medication review done, 44% had risk assessment, 58% reviewed the need for seclusion and 52% had an intervention recorded.

The audit showed poor adherence to the Trust guidelines both in terms of the frequency of the review and the vital aspects of the review as included in the seclusion review template. There seemed to be poor use of the seclusion template among medics, which is meant to serve as a prompt for the expected standards, hence more awareness is to be created.

The areas of improvement also identified include the education and training of staff about the stipulation of the policy and clear documentation, with emphasis on the frequency as well as the quality of the reviews done.

Patients with psychiatric disorders have been well documented to have an increased risk of cardiovascular disease and consequently a higher incidence of premature mortality. Literature has shown that many psychiatric disorders, particularly major depressive disorder, bipolar affective disorder, attention deficit hyperactivity disorder, post-traumatic stress disorder, anxiety disorders, and schizophrenia have an increased risk of metabolic syndrome. This increased prevalence of metabolic syndrome, and as a result cardiovascular disease, has been linked to factors that clinicians are involved in, such as the prescription of antipsychotic medication. it is therefore important for clinicians to be able to appropriately monitor patients on antipsychotic medications.

Aim: To improve the physical health aspects of care for patients with psychiatric illnesses admitted as inpatients.

Objectives:

1. 1. To ensure appropriate monitoring of the metabolic parameters of patients on admission.

2. 2. To ensure appropriate ongoing monitoring of the metabolic parameters of patients during their hospital stay.

Data were collected independently by two people. The data were collected using PARIS, an online documentation program used by the Greater Manchester Mental Health (GMMH) trust, as well as the patients’ paper prescribing charts. A total of 20 patients were audited. Standards were set according to NICE guidelines on patients on long-term antipsychotics admitted to adult inpatient wards. A total of 14 standards were set. The areas audited were measurements of BMI, ECG, blood pressure, lipids, prolactin and urea and electrolytes at baseline, at prescribed time points, and at dose changes as required by guidance.

Overall, five of the standards were attained, seven of the standards were not attained, one standard could only be partially analysed, and one standard (monitoring at 12 months) could not be analysed due inadequate patient length of stay

Patients on long-term antipsychotics have an increased risk of cardiovascular disease and it is important that we are monitoring them frequently to avoid deterioration of their physical health and a further increase in their disease burden. This audit suggests three recommendations to ensure adequate monitoring.

1. 1. Consideration of a comprehensive admission proforma to help standardise the admissions process.

2. 2. The development of a tool to remind clinicians to recheck metabolic parameters for ongoing monitoring at 3 months, 6 months, and 12 months.

3. 3. Regular maintenance of the ECG machines to ensure no omissions in monitoring.

Antimanic agents are effective in the management of mood disorders and other neuropsychiatric conditions such as epilepsy and aggression. These medications may cause serious side-effects and affect vital organs; hence, specific checks are recommended before initiation and for continuous use of these medications. The aim of the audit was to check compliance with monitoring of antimanic agents (lithium, valproate, and carbamazepine) and to compare with the 2018 audit.

Preliminary data of all patients on the antimanic agents at Rampton Hospital from 01 December 2020 to 30 November 2021 were obtained from records.

Retrospective data were collected using a modified version of the 2018 audit tool. This includes patient hospital number, ward, medication initiation date, pre-initiation and monitoring tests. The tests were, depending on the medication; full blood count (FBC), thyroid function test (TFT), liver function test (LFT), electrolytes and urea (E&U), and electrocardiograph (ECG).

The audit criteria were based on the recommendation of the Maudsley Prescribing Guidelines (14th edition). A total of 16 standards were assessed overall.

A total of 98 patients were prescribed antimanic medications through the review period with valproate-59, lithium -32 and carbamazepine -7. Three patients on valproate and 3 on lithium had incomplete data and were excluded. Therefore, a total of 92 patients were included in the final audit (valproate-56, lithium-29 and carbamazepine-7).

Pre-initiation compliance for LFT and FBC for valproate were 35.8% and 41.5% respectively, while the monitoring compliance within 6 months were 85.7% and 87.5% respectively.

For lithium, pre -initiation compliance for ECG was 73.1%; TFT and U&E had 88.5% and 96.2% pre-initiation compliance respectively. There was 100% compliance with monitoring of lithium level at 3 months, and both U&E and TFT within 6 months.

For carbamazepine, the pre-initiation and monitoring compliance was 50% and 100% respectively for three tests (LFT, FBC and U&E).

There was improvement in all the standards when compared with the 2018 audit compliance except FBC monitoring for valproate within 6 months which dropped from 92% to 87.5%.

Only 6 standards had 100% compliance with the guidelines. Lithium monitoring was generally higher than for other mood stabilizers; pre-initiation monitoring was poor for both carbamazepine and valproate. There was general improvement in the standards compared with the 2018 audit.

The guidelines for monitoring mood stabilizers apart from lithium needs to be made popular especially pre-initiation monitoring for valproate and carbamazepine.

(1)To quantify the prevalence and duration of the prescribing of antipsychotics among people with a record of EUPD, particularly those without a mental health comorbidity that licenses an antipsychotic prescription; (2)To determine whether gender, age, and mental health comorbidities affect the likelihood of being prescribed antipsychotics; (3)To determine whether off-license use of antipsychotics among those with EUPD have ever been reviewed, with the aim of having these prescriptions stopped or reduced.

Study design: Retrospective cohort study.

Setting: Data sourced from Stroud Recovery's electronic patient record of 287 people. Cohort entry was defined as the date of referral to Stroud Recovery. End of follow-up was the date of audit (20/11/2022).

Primary outcome measures: Prevalence and duration of antipsychotic prescription among people with a record of EUPD within the Stroud Recovery caseload.

Of the 287 people registered with Stroud Recovery, 37 (13%) had a recorded diagnosis of EUPD. 30 (81%) were ever prescribed antipsychotics. Only 6 of these 30 people (20%) have a mental health comorbidity that licenses an antipsychotic prescription (3 with bipolar affective disorder; 2 with severe depression requiring antipsychotic augmentation; 1 with schizoaffective disorder).

The rest belonged to a subgroup of 24 people (80%) with recorded EUPD who were prescribed antipsychotics but with no history of co-morbid illness that licenses their use. This subgroup was predominantly female (75%) and aged 20–29 years (46%). Quetiapine was used in this subgroup the most, followed by olanzapine and aripiprazole. 12 (50%) have had more than one antipsychotic prescribed. None were prescribed for less than 1 week (defined by NICE as short-term use). In fact, the mean duration of antipsychotic prescription in this subgroup was 36.79 months. Only 10 (42%) had these prescriptions reviewed with the aim of having them stopped or reduced. None were offered a routine physical review.

According to NICE guidelines, antipsychotics are not recommended in the treatment of EUPD, not recommended in the treatment of medium to long-term impulsivity and other symptoms of EUPD, and antipsychotics should be reviewed for people with the aim of reducing and stopping unnecessary drug treatment. Contrary to NICE guidelines, in this community mental health service, antipsychotics are frequently prescribed for extended periods to people with recorded EUPD but with no history of a co-morbid illness that licenses their use. An urgent review of clinical practice is warranted, including the effectiveness of such prescribing and the need to monitor for adverse effects, including metabolic complications.

Local guidelines state that pulse rate, weight, ECG if indicated, and bloods (U&E, LFT) are monitored in patients prescribed an acetylcholinesterase inhibitor or memantine. This can affect management as the above parameters can affect medication selection and titration. Aberrant measurements can indicate drug related adverse events. Compliance to standards will optimise patient safety. This audit aims to assess compliance to these guidelines in one Memory Service in the Trust.

This is a single-centre, baseline, retrospective audit performed on 19/10/2022.

An internal database was used to identify all patients seen for a diagnostic assessment between September 2021 and October 2022. Patients who were prescribed an acetylcholinesterase inhibitor or memantine were eligible for selection. These were randomised to identify 30 cases.

Information was gathered through electronic patient notes, clinician diagnostic letters, referral forms, and pathology specimen result reporting software.

Compliance were as follows:

• • Pulse rate recorded: 97%

• • Weight recorded: 0%

• • ECG requested when indicated: 20%

• • Blood samples taken and the results recorded: 100%

Pulse rate is part of the assessment proforma and blood sampling is a requirement prior to referral. This suggests that having guidelines incorporated to local protocols enhances compliance.

Weight was not routinely monitored: the rationale behind this being part of the guidelines is that rivastigmine can cause weight loss as per the BNF due to loss of appetite. However, on speaking to the Memory Team, this was not routinely done in the service as staff appear to rely on reports of appetite loss.

ECG was not routinely done when patients fall under the criteria for indications. Clinicians appear to judge the requesting on ECGs pragmatically based on their clinical judgment rather than guidelines alone.

Blood pressure is not a requirement in the guidelines for monitoring so cannot be audited. However, this is essential for decision making of treatment commencement, titration, switching, or titration.

Findings suggest that local guidelines may need to be reviewed.

This audit suggests some general learning points as well as service-specific ones.

The incorporation of guidelines into routine practice such as proformas or the pathway itself contributes to good compliance. This may be due to these standards being auditable as well as acting as prompts for staff members or even requirements for patients to proceed in the pathway.

This was also a reminder that clinical judgment may differ from guidelines; this may not necessarily be an indicator of poor practice but may result from pragmatic decision making for individual patients.

The findings were presented at a consultant meeting, the result of which was that the guidelines will be reviewed with likely inclusion of blood pressure monitoring. This is an illustration of the role of audits and quality improvement in improving standards of care.

The aim of this audit is to assess use of the Mental Health Triage Form (MHTF) at the Royal Cornwall Hospital Emergency Department (ED), during June 2021 and to determine whether MHTF use increases rates of psychiatric-specific information being documented by ED staff. Patient attendances to Accident and Emergency (A&E) departments in the UK during 2020-21 decreased by 30.3% in comparison to 2019-20. However, attendances to A&E at the Royal Cornwall Hospital (RCH) in June 2021 increased by 51.2% compared to June 2020. Psychiatric patients accounted for 2% of attendances to A&E at RCH in June 2021. The Royal College of Emergency Medicine (RCEM) have recommended use of a mental health proforma document in line with recommendations from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) document ‘Treat as One’. Based on these guidelines, the Psychiatric Liaison department at RCH have a produced a local Mental Health Triage Form (MHTF) to be used in A&E when assessing and clerking psychiatric patients.

This was a retrospective audit of clinical records of 125 mental health cases attending the Accident & Emergency Department (A&E) at Royal Cornwall Hospital during June 2021, which were referred to Psychiatric Liaison.

NHS numbers were identified for each referral made during the study period. Each referral's A&E clerking documents were reviewed on an online patient records system. Information was recorded on whether each question in the Mental Health Triage Form had been answered with or without use of the form.

The Mental Health Triage Form (MHTF) was used in 44 out of 125 patients (35%). 15 patients (12%) had missing Accident & Emergency Department documentation on online records. Where the MHTF was used, there was an 25% average increase in information recorded. Over half of the questions on the MHTF were answered more when the form was used versus when it was not used.

Questions relating to the patients ‘Triage Code’, which are used to determine the level of observation, urgency of referral, and appropriate place of assessment, had the highest rates of improvement using the form.

Overall use of the Mental Health Triage Form during June 2021 reduced to 35% in comparison to 46% use during June 2020. This implied that patients attending the Accident & Emergency Department at the Royal Cornwall Hospital with psychiatric presentations were not being assessed fully. This may be due to various reasons such as staff unfamiliarity with the triage form and increasing pressure on Emergency Department services.