This project was launched in January 2022 to improve handover between on-call teams and wards, following GMC concerns in 2020 with the out-of-hours handover process. In 2021, a ‘Hospital At Night’ Microsoft Teams evening meeting was successfully introduced. However there remained low satisfaction with other areas of the handover process, including use of paper forms to handover between shifts. The aims of the project were to review the current handover process and improve quality and satisfaction of handover. The target was to improve baseline satisfaction with the handover process by 20% (6 months after change implementation).

A driver diagram was built to identify factors contributing to quality and satisfaction with handover and develop change ideas.

Qualitative surveys using Likert rating scales were sent to all doctors to explore satisfaction with handover format and quality of information received. Opinions of doctors and the wider MDT were used to develop ideas and evaluate support for change. Surveys were repeated following each cycle.

From July 2022, interventions were introduced and monitored over four QIP cycles. This included an electronic handover in the form of a twice-daily email handover list, which was updated following feedback. Microsoft Teams morning weekend meetings were then introduced and modelled on the existing ‘Hospital At Night' protocol.

Following interventions, the percentage satisfaction with handover format improved from a baseline of 14% and was maintained at an average of 81% across 15 months.

The satisfaction with the quality of handover improved from 36% and was maintained at an average of 97%.

The weekend virtual handover has also been well received with 71% satisfaction. This maintains the satisfaction levels achieved with the ‘Hospital At Night' virtual handover. The involvement of the MDT has been high with 71% of doctors satisfied that the necessary team members are attending.

Introducing a standardised electronic twice-daily handover has improved satisfaction with and quality of handover. It has also improved communication between on-call teams and wards.

The introduction of additional virtual handover meetings at the weekend has also been well received. It allows another opportunity to strengthen clinical leadership and the MDT to work more effectively out-of-hours. Future intervention will be targeted at standardising the content of these meetings and attendance in line with the ‘Hospital At Night' protocol.

We aim to monitor local benefit from these changes, and expand this project to other hospital sites which are not yet using an electronic handover system.

NHS England defines serious incidents as events in health care where the consequences are so significant that they warrant a comprehensive response. Serious incidents are individually reviewed, as per national standard practice, in our liaison psychiatry service line at West London NHS Trust. The aims of these individual reviews include system wide learning, organizational accountability and to make changes to the system to prevent a repetition.

There is currently no mandated requirement for thematic review of incidents. Therefore, there is a risk that long-term learning may be limited and overarching themes spanning the incidents may be missed. To improve this process, we have undertaken a thematic review of all serious incidents over a 2-year period, across the three teams in the liaison psychiatry service line.

The aims of this quality improvement project therefore were:

To understand persistent or recurrent systemic factors that contribute to serious incidents.

To identify priority areas for system changes in order to improve the safety of liaison psychiatry services.

To ensure lessons learnt from incidents are embedded within the liaison psychiatry service.

This was a joint project undertaken by liaison psychiatry clinicians and the clinical governance team. Initially an inductive analysis of ten serious incidents took place. Over six months, we combed through the serious incident reports and collated the data. We then identified and stratified the key themes.

The 5 headline themes identified were:

1. 1. Risk assessment and risk management.

2. 2. Human factors.

3. 3. Issues with referrals.

4. 4. Triangle of care.

5. 5. Organisational factors.

The dominant theme which occurred across all cases was risk assessment and risk management. A narrow focus when considering risk and underestimation of risk led to the creation of suboptimal safety plans for patients. Our thematic analysis found a range of organisational factors, including the excessive demand on staff and resource limitations. Human factors are usually a reflection of organisational culture or system wide approaches. The issues we found with the implementation of the Triangle of Care reflect the need for a greater focus on involving families and carers.

The learning was shared with all staff in our annual development day, and this is planned to be an annual review of serious incidents across the liaison service. This approach should improve the depth of our learning and enable the service line to have an overview of the key themes which need to be addressed to deliver safer services.

Aim: To compare and evaluate three improvement collaboratives designs in terms of tangible and non-tangible benefits.

Background: Leading health systems have invested in substantial quality improvement capacity building, but little is known about the aggregate effect of these investments at the health system level.

Collaborative learning is one of the educational approaches of using groups to enhance learning through working together. Research shows that collaborative experiences that are active, social, contextual, engaging and student-owned leads to deeper learning.

CNWL organised three collaborative programmes with varying duration and distinct approaches to team selection, wrap-around support mechanisms, training design and post-collaborative QI support.

These three virtual collaborative programmes were co-designed with service users and carers to support 24 teams each in planning, delivering and sustaining improvements aligned with the Trust's Strategic Priorities.

All programmes provided knowledge on the Model for Improvement and co-production, enabling frontline ownership of safety solutions while building organisational QI capacity and capability.

Each collaborative was divided into Planning and Delivery phases. The evaluation, which covers a 3-year period, compares programme metrics to assess effectiveness, impact and identify areas for improvement.

Incorporating cognitive diversity is crucial in improving the learning process. Collaboratives play a vital role in achieving this, as they bring together different services, staff, and SU&C to drive improvement.

The benefits of collaborative work in quality improvement extend beyond the project data, as it can lead to positive unintended consequences such as a shift in team culture and the adoption of an improvement mindset. These outcomes gained on the journey should be evaluated and celebrated. Moreover, collaboration fosters a culture and platform for sharing and spreading learning beyond the team/service.

However, it is important to take the time to consider and compare different designs of collaboratives during the scoping phase. Factors such as the duration of the collaborative programme, the need for additional wrap-around support and the selection of measures to evaluate the programme should be carefully considered before proceeding.

Effects of changes

1. 1. Comparing different collaborative designs identified the key enablers to a successful project. They were application process brought teams together that were ready and willing to improve; targeted wrap-around support to Sponsors, SU&Cs, Coaches and having decision gateways in design enabled focused and candid conversations about team progression.

2. 2. Collaborative with longer time frame were more resource intensive but had a greater positive impact on safety culture, successful projects and sustained gains than the shorter duration.

3. 3. CNWL Added Value framework evaluated tangible and non-tangible benefits, i.e. staff experience, safety and learning culture, patient experience, streamlined processes and efficiencies gained.

It is important to look at the local context when designing a collaborative with their clinical setting.

A consideration should be based on resources available to support the entire duration of collaborative and what are the desired outcomes of the collaborative.

Aim:

80% of Central and North West London NHS Foundation Trust (CNWL) QI projects will have meaningful Service User & Carer involvement by August 2023 (baseline was 46%).

Background:

Service user and carer (SU&C) involvement is increasingly recognised as integral to healthcare improvement efforts. However, despite its many benefits, the meaningful involvement of service users and carers remains a challenge.

Thus, it is necessary to get an in-depth understanding of the barriers and enablers to embedding involvement in improvement practice at the individual, service and organisational levels. With this understanding and staff can then co-produce evidence-informed behaviour change interventions to improve SU&C involvement.

Patient representation and lived experience

This improvement work embraces a full and continuous partnership with SU&Cs.

SU&C worked with CNWL staff in the conception, execution, delivery and dissemination of this work including EbE Improvement Forum.

They, thus, serve as integral members of the project team where they provide valuable input based on their lived experiences and perspectives to help shape the direction of the work. As equal partners, it also helps foster a culture of mutual respect, collaboration, and trust between all the parties involved.

This work adopts the COM-B model. The approach to conduct semi-structured interviews (interview questions were based on COM-B model and behavioural change wheel) with frontline healthcare staff and SU&Cs. The interviews gave insights on the barriers and facilitators to SU&C involvement in healthcare improvement work.

This then generated operational-level and actionable change ideas to guide tailored strategies for enhancing involvement capabilities, widening involvement opportunities and enabling motivations using the model for Improvement. These change ideas were then co-tested with SU&C using the Model for Improvement approach.

This systematic approach enabled a cultural shift towards collaborative partnerships between healthcare staff and SU&C to contribute to the service improvement.

Measurement of improvement

1. 1. Qualitative data to understand enablers and barriers to involvement in improvement work.

2. 2. Percentage of all QI projects (registered on Life QI and scoring 1 or more on IHI Project Score) that have a SU&C involvement.

Effects of changes

Staff and SU&C interviews identified the key barriers as inadequate capability (lack of understanding and skills), limited opportunities (leadership, resources, access) and insufficient motivation (discomfort, inability, time limitations). Enablers included appreciating diverse perspectives, leadership support and buy-in, established processes, valuing insights and patient empowerment.

The outcome measure also showed an increase in the number of improvement projects at CNWL that have SU&C involvement from 46% to 80%.

Lesson Learnt:

This work has shown that by bringing multi-disciplinary staff and SU&Cs together generates cognitive diversity to the learning to drive improvement and sustain the gains. Furthermore, partnership working helped to create and establish learning culture within the healthcare service.

Message to others:

1. 1. Strong executive sponsorship helps to drive involvement across the organisation.

2. 2. By bringing staff and SU&Cs together generates cognitive diversity to the learning to drive improvement.

3. 3. Using well-known and established behavioural change model, such as COM-B model, helped to identify, design and synthesize behaviour change interventions.

Currently, there is an absence of clear guidelines or recommendations for individuals with an eating disorder (ED) and comorbid autism spectrum conditions (ASC).

The Maudsley ED team has pioneered a tailored approach for comorbid ED and ASC called the PEACE pathway.

Our aim is to adapt and implement a similar pathway within the Eden Unit (NHS Grampian inpatient eating disorder service).

Questionnaires targeted two key stakeholders: patients and staff.

Patient questionnaires had 18 multiple-choice questions on a Likert scale, along with space for comments. The questions aimed to assess inpatient care adequacy in terms of care, routine, environment, mealtimes, and staff members. There were also specific questions related to ASC, examining whether sensory and communicative needs are being met and taken into account.

Staff questionnaires had 10 ‘yes-or-no' questions, along with space for comments, and gauged attitudes toward managing comorbid ED and ASC.

6/7 patient questionnaires were completed. 3 patients have comorbid ASC.

One patient found the ward overwhelming due to ASC, while others found it suitable. All experienced distress transitioning from outpatient to inpatient services, with subsequent admissions proving less challenging when they knew what to expect. They were allowed to have safe sensory items e.g comfort toys, headphones etc.

Generally, they felt well-supported during distress and felt their communication needs were met by nurses and HCSWs but not always by dietitians and clinicians due to a lack of availability. Some were frustrated with vague menu descriptions and there was some diagnostic overshadowing over dislike of certain foods.

13/20 staff questionnaires were completed. It showed most staff did not have formal training in managing comorbid ASC and ED, and confidence and skills varied in proportion to time and experience in the service. All staff members expressed they would like formal training, through sessions such as monthly training, weekly huddles, or psychoeducation.

A significant proportion of inpatients have comorbid ED and ASC. Therefore, awareness of potentially greater needs around communication, environment, and sensory hyper- or hyposensitivity is important. There is a risk of diagnostic overshadowing as both ED and ASC can mimic similar symptoms: cognitive rigidity, fixation on certain things etc. So while not straightforward it is important to differentiate which symptoms are due to ASC and which are due to ED. Leveraging resources from the PEACE pathway website, both staff and patients can enhance their understanding of this complex comorbidity.

To audit the Shepway CMHSOP against the NICE guidelines in dementia and the Royal College of Psychiatrists recommendations for service provision in young onset dementia.

Data was collected retrospectively for all patients open to CMHSOP within the last 2 years with a diagnosis listed as dementia under the age of 65 years old.

The work up prior to diagnosis met some standards but improvements could be made in other areas. Mood was considered in all patients. The majority of patients (89%) had young onset blood tests if there was a clinical indication. However physical examination was only carried out in 43% of patients. In addition to this where physical examination was completed it was often limited to a brief note about the patient's gait and tremor.

Imaging standards were met within the Shepway CMHSOP with all patients having a scan, some patients being referred for additional specialist scans where indicated. There is also a neuroimaging MDT in which scans can be discussed with a neuro-radiologist.

The follow up care and support was an area that needs further development within Shepway CMHSOP. There is no named lead for those diagnosed with young onset dementia. Furthermore, only half of patients received a named practitioner to support their care. In addition to this only 79% were offered cognitive stimulation therapy and post diagnostic support which incorporate education for the carers. It is difficult to know if these options were discussed and declined by the patients, but if this is the case it would have been good practice to document.

The time from referral to diagnosis was similar in those with a dementia with a well established and clear subtype (Down syndrome) to those diagnosed with other types of young onset dementia, 6 months and 5.5 months respectively.

My audit identified areas for improvement in the workup to diagnosis and the aftercare to support those diagnosed and their carers in order to meet NICE guidelines and the Royal College of Psychiatrists recommendations for service provision in young onset dementia.

Shepway CMHSOP will develop a young onset dementia pathway to ensure those diagnosed are offered the appropriate investigations and support following their diagnosis in line with these guidelines.

Outcome measurement is central to transforming mental health care by quantifying change, enabling comparison and driving improvement. In recognition of this, the Royal College of Psychiatrists (RCPsych) has established a working group on outcome measures, led by an Associate Registrar.

To support routine outcome measurement capture in clinical services, RCPsych has developed the ‘Outcome Measurement in Psychiatry’ report.

The working group intends to launch a survey of Members to:

1. 1) Understand psychiatrists’ current use of outcome measures.

2. 2) Understand psychiatrists’ views on barriers and facilitators to the use of outcome measures.

3. 3) Get feedback on the College Report.

The ‘Outcome Measurement in Psychiatry’ report was developed with input from all RCPsych Faculties and is scheduled for publication prior to the RCPsych International Congress.

Feedback will be sought on the ‘Outcome Measurement in Psychiatry’ report about whether the guiding principles are right, and if the College should be endorsing specific measures or advocating for the routine use of outcome measures. This will be used to guide future revisions of the report.

The working group believes the proposed survey will enable it to explore the facilitators and barriers to routine outcomes data capture both locally and nationally, including:

• • how to consider organisational drivers and buy in of clinical staff

• • digital enablement

• • understanding time points in a chronic relapsing remitting condition in the community vs. episode of therapy or hospital admission

• • clinical burden/benefit and buy in

• • training.

The group intends to use the intelligence gather to inform, influence and shape policy that promotes routine outcome data capture and publish its findings for wider dissemination.

Outcome measurement is a top priority for the RCPsych. A new Associate Registrar and working group is spearheading the College's work in this area, publishing guidance and conducting further research. Engagement and learning from our colleagues would provide critical intelligence to inform and influence future policy and strategy to enable routine outcome gathering embedded in mental health services.

This project's purpose was to improve the identification and management of patients at risk of or suffering from alcohol withdrawal at the point of admission. Ultimately aiming to prevent avoidable harm to patients and reduce the burden on local services within NHS Ayrshire & Arran.

The project began in August 2023 with Alcohol & Drug Liaison Nurses (ADLN) carrying out twice daily walkthroughs of the Emergency Department and Combined Assessment Unit. ADLNs were instructed to engage with these clinical teams, helping to identify those at risk, provide management advice and accept relevant referrals. A retrospective audit was completed covering patients referred to the alcohol and drug liaison team (ADLT) in July 2023 and a prospective audit covering October 2023. Quantitative data gathered included prescription of benzodiazepines & Pabrinex, time from admission to prescription and administration of treatments, any changes to treatment advised, and whether treatments administered correctly. Additional qualitative data was gathered through a short staff survey carried out in November 2023 asking if the project had been helpful in identifying patients, improving management, and making staff feel supported.

There was a 33% increase in referrals from July (n = 15) to October (n = 20), with a slightly greater proportion coming from ED (80% vs 85%). The average time from admission to benzodiazepine prescription fell by 2hrs and to administration by 8hrs. However, changes were advised to benzodiazepines prescriptions more frequently (12% increase).

Pabrinex prescriptions were being completed overall for patients both before (92%) and after (100%) the project. Average time from admission to pabrinex prescription fell by 2hrs but to administration increased by 0.5hrs. Additionally, cases of incorrect pabrinex administration increased from 31% to 47% between the two periods.

Staff feedback was very positive; project was very (45%) or somewhat (35%) helpful in identifying patients at risk, very (30%) or somewhat (50%) helpful in managing alcohol withdrawal, and very (55%) or somewhat (20%) helpful in making staff feel more supported with this patient group.

This project demonstrated that additional support can improve identification of patients, speed of initial management decisions, and staff confidence. However, it also showed a significant knowledge/skills gap across both departments leading to continued problems with patients receiving timely and appropriate treatment. ADLN ward input cannot be continuous, as such practical changes are required to help maximize Liaison input. Following this project's recommendation, work has begun to develop an Alcohol Withdrawal Bundle and associated staff training.

Referrals for adult autism assessment to the Cambridgeshire Lifespan Autism Spectrum Service (CLASS) have increased from 430 in 2019 to 887 in 2023, with demand exceeding capacity. The team enrolled in the Royal College of Psychiatrists’ Quality Improvement (QI) Demand, Capacity and Flow (DCF) Collaborative. The agreed aim was to increase the number of diagnostic assessments by 51% per month.

Participants included the CLASS multi-disciplinary team (MDT), referrers, the provider improvement advisor and an autistic adult. Using the NHS Quality Service Improvement and Redesign (QSIR) six-step approach, a process map identified five key stages of the CLASS pathway. A project driver diagram was then used to identify change ideas in the referral, screening, pre-assessment, assessment and post-diagnostic stages.

Change ideas in the screening and assessment stages were prioritised and two Plan-Do-Study-Act (PDSA) cycles designed: PDSA 1) To reduce screening time by removing the first screening of referrals; PDSA 2) To increase the number of assessments conducted and completed in a single face-to-face appointment.

Data collected for PDSA 1 included: number of working days from date of referral to date added to waiting list and total screening time (minutes) per referral. Data were compared in a sample of 133 referrals from the two-stage screening process and 68 referrals from the one-stage process. Data collected for PDSA 2 included: average assessment time (minutes), average duration of open assessments, and the number of assessments completed within the same month. The data at Time 1 (before introducing PDSA 2) were compared with Time 2 (after PDSA 2) in a sample of 10 and nine referrals, respectively.

PDSA 1) Statistical Process Control (SPC) charts show a reduction in mean working days from 160 to 30 working days. The mean screening time per referral reduced from 33 minutes to 23 minutes. PDSA 2) SPC charts show that between Time 1 and Time 2 there was (i) a reduction in clinician time in minutes per assessment (m = 236.8 to m = 210), (ii) a reduction in working days assessment remained open (m = 39.4 to m = 6.4), (iii) a reduction in number of assessments involving multiple appointments (6 of 10 to 3 of 9), (iv) an increase in the number of assessments completed in the same month (3 of 10 to 7 of 9).

These results show promise towards increasing DCF across the pathway, but further PDSAs (e.g., digitalising reporting, refining the post-diagnostic pathway) need to be implemented to achieve the overall aim.

At-distance and out-of-region admissions form a significant proportion of inpatient admissions in CAMHS. The recent national “Far Away from Home” study which investigated the impacts of these admissions for young people, parents/carers and services identified an inconsistent and/or lack of easily accessible information about inpatient units. Parents and young people reported that when there was a lack of easily accessible information about the unit they would be admitted to, this increased their distress and negative views about the admission before they had even arrived. In contrast, those who found useful and positive information felt more reassured about the admission, even if it was far away. Our aim was to create an expert-by-experience designed standardised template of the minimum information that all inpatient units would be required to make publicly available.

We carried out regular expert consultation meetings with young people and parents/carers with lived experience to co-design a standardised template of information that units would provide for young people and their families on their websites and in printed form.

In early meetings the information currently presented by inpatient units was reviewed and discussed. Young people and parents/carers highlighted what they found helpful and unhelpful as well as what was missing. The young people and parents/carers discussed the layout, aesthetics, and functionality that they would like to see on unit websites. They also discussed the content which would be helpful for young people and their parents individually as well as what both groups would want to know. This included realistic and practical information about the unit itself, visiting, local amenities and available funding support.

In collaboration with young people and parents/carers we have created an expert-by-experience designed standardised template of information that all inpatient units will be asked to provide on their website. Better information provision prior to admission will reduce anxiety and uncertainty for young people and their families. We anticipate this project will also contribute towards improved staff/patient/carer relationships because of clearer expectations and understanding.

In light of increasing referral rates, the RQIP aimed to review all referrals made to PLT by the ED during April 2023. The purpose was to identify ways to improve working practices to benefit patients, the ED team and the PLT.

All ED referrals in April 2023 were identified and the following was gathered from each record.

Patient information:

1. 1. Record number, sex, age

Circumstances of attendance:

1. 2. Date/time

2. 3. Who directed patient to ED and arrival method

3. 4. Attendance reason

4. 5. Presence/absence of physical health condition requiring ED

5. 6. Intoxication on arrival and if assessment required after sobriety

6. 7. Outcome

Patient involvement with other services:

1. 8. Number of previous PLT referrals in past 90 days

2. 9. Currently under care of another team, if yes, were they contacted before ED attendance

3. 10. Contact with crisis team in previous 72hours

During April 2023 there were 356 referrals from ED to PLT. 284 represented single attendances and 72 represented repeat attendances by 44 patients. 34% (n = 123) self-presented to ED. Emergency services directed 21% (n = 75) to ED. 71% (n = 253) had physical health reasons to attend whilst the rest presented with mental health crisis alone (n = 103). 25% of patients attending ED and referred to PLT were intoxicated and a third of these did not require assessment following sobriety. 41% (n = 145) patients were open to another mental health team within the trust who could potentially have provided crisis input. Of all referrals 27% (n = 97) were signposted to other services, 26% (n = 93) left before they were seen. PLT referred 11% (n = 40) to crisis teams and 3% (n = 11) to Mental Health Act assessment.

Findings indicate that a large proportion of patients attending ED could have had their mental health needs met elsewhere in the absence of a medical reason for attending, thus potentially avoiding long waits in ED. Patients that are referred but leave before assessment, those without acute medical need to be in ED, those that do not require assessment after sobriety or those open to other planned care mental health teams may have their needs best met outside of the acute ED environment. It is hoped that community transformation work will enable community services to become more responsive to such needs.

The team propose working collaboratively with the acute trust and trialling embedding a PLT clinician in the ED triage process in order to redirect patients to the most appropriate care in a timely way.

A Patient Reported Outcome Measure (PROM) is a form that patients complete about their health status at a single point in time. The Recovering Quality of Life (ReQoL) questionnaire is a new PROM, developed in partnership with mental health service users to enable them to report on their mental state, and can be utilised by clinicians to track progress. The Commissioning for Quality and Innovation (CQUIN) framework set a target that 40% of adult and older adult patients accessing secondary mental health services should have their PROM recorded at least twice in a 6-month period. The primary aim of this quality improvement project was for 50% of patients under the Kent and Medway NHS Trust (KMPT) to be ReQoL compliant.

Following engagement with various stakeholders, a survey was circulated to better understand the barriers stopping staff from facilitating ReQoL completion. Moreover, a poster was created to raise awareness of ReQoLs and illustrate the practicalities behind gathering and recording patient scores. Additionally, local ‘champions’ were assigned for each community/inpatient mental health team to foster a sense of responsibility for PROM collection. Data on PROM compliance was obtained monthly, with meetings subsequently organised to scrutinise the results and brainstorm further ideas to drive improvement, such as providing patients with paper ReQoL copies to fill out in advance of their consultation/ward round.

The survey revealed that 23% of staff were unfamiliar with the ReQoL questionnaire, and only 31% routinely obtained and inputted ReQoLs. A lack of time to assist patients in filling out PROMs was the main barrier cited by staff, alongside ambiguity as to whose job it was to ensure ReQoL collection. Through the distribution of the poster, the establishment of local leads and other changes such as the paper ReQoL initiative, there was a notable uptick in the rates of PROM completion. Indeed, over a 4-month period, compliance rose locally from 46% to 61% at the acute inpatient unit, and from 0 to 21% in the community mental health service. However, over KMPT as a whole, change was modest.

This was a successful quality improvement project, resulting in an increase in PROM completion rates, especially at a local level. The measures implemented, particularly the poster and formation of ReQoL leads, were effective – although more work and participation is required to change Trust-wide compliance. Future ideas include adding a ReQoL tool into nurse/doctor clerking templates to reduce friction in completing PROMs.

Previous literature has reported that medical students are objectively and subjectively more stressed than the general population. The transition between medical school and commencing a career as a foundation doctor can cause a significant amount of stress. The first aim was to investigate stress and anxiety and how this may impact performance, with the aim being to better understand stress in medical students about to embark on a career as a doctor. The second aim was to create a simulated 1-1 on-call shift scenario to allow final year medical students to practice the skills and improve confidence.

16 final year medical students from two UK medical universities took part in a simulated on-call scenario acting as the foundation year 1 doctor. During the scenario, participants were scored on their performance. Fitbits measured heart rate data as an objective measure of stress. Subjective data was collected using the State-Trait Anxiety Inventory (STAI). They were asked a series of questions regarding their confidence before and after the scenario.

Participants reported higher states of anxiety after the on-call simulation compared with a regular day on placement (t=-6.93, p <0.001). There was a trend between reported higher levels of state anxiety and lower performance scores (r=-0.475, p=0.063.) There was no correlation between average heart rate and reported levels of state anxiety (r=0.452, p=0.105). Prior to the on-call scenario participants reported their confidence as follows; 26.09% no confidence, 65.22% slightly confident, 8.7% somewhat confident, 0% confident/very confident. After the scenario participants reported their confidence as follows; 4.35% no confidence, 34.78% slightly confident, 52.17% somewhat confident, confident 8.7% and 0% very confident. 100% of participants reported that they would recommend the session to colleagues.

The results highlight that an on-call scenario has a significant impact on the feelings of stress in medical students. It also shows that stress can have a negative impact on performance. However, experience completing a simulated on-call scenario helped to improve confidence and was recommended to colleagues. Future research should aim to further investigate acute stress in a real-life setting and use objective measures of stress. Over time researchers should aim to create a targeted intervention aimed at supporting medical students and junior doctors during their on-call and provide opportunities to improve confidence.

This quality improvement project aims to address the current gaps in safe handover between doctors on psychiatric wards by implementing a “live jobs list” that can be remotely accessed and edited by all members of the ward medical team. It should create accountability between different members of the medical team and allow colleagues to track which jobs have been started, completed or are not yet assigned; avoiding duplication or noncompletion of outstanding ward tasks.

Qualitative surveys were sent out to junior doctors working within inpatient psychiatric wards. The survey focussed on identifying the opinions of doctors about jobs lists and their views regarding collaborative vs. individualised lists. The survey was sent out prior to creating ward-specific online channels with collaborative task lists that could be accessed by the whole team. The survey was then repeated after 4 months of this system being implemented to see how it had changed the opinions of the doctors using it.

Of 21 participants, 95.2% had used individualised jobs lists (IJLs) with 52.4% having negative experiences of these. Only 76.2% of participants had used centralised jobs lists (CJLs) and 42.9% had negative experiences with these. Overall, 61.9% of participants preferred CJLs.

Negative experiences with IJLs focused on lack of accountability, duplication of tasks and unsafe handover. The negative experiences of CJLs revolved around colleagues not correctly using the platform and the process being time-consuming compared with IJLs due to preference of layout and user interface.

The MS Teams CJL was then implemented into multiple wards within an inpatient psychiatry setting. After 4 months of use, the majority of participants (80.9%) were in favour of CJLs; this could be categorised into three main reasons: 1) reduced risk of overlooking or duplicating tasks, 2) safer handover within the team especially due to shift patterns and sickness, 3) accountability within the wider team for clinical tasks. Those who preferred IJLs stated that the newer system was “difficult to adapt to” and that they lacked senior input on how to incorporate it.

Amongst inpatient psychiatry doctors, the use of a CJL has shown to be preferable due to improvements in efficiency, safety and accountability. Although there are barriers to overcome, namely regarding the initial implementation of the system and lack of customisation to individual preferences, this can be explored in the future with the aim to further increase the appeal to doctors working within a ward team.

This audit aimed to review prescribing in First Episode Psychosis (FEP) in Gloucestershire Health and Care NHS Trust, against NICE guidelines (CG 178) we hoped to develop prescribing guidelines for the Trust and to compare our results with Avon and Wiltshire Partnership (AWP) Trust's results of similar audit (AWP-235 Audit of Prescribing in FEP).

The sample was the Trust Early intervention (EI) caseload of patients with diagnosis FEP. We developed the audit tool based on AWP's audit methodology.

We gathered information about

• • The role of initial prescribers.

• • The prescribing of up to three antipsychotics.

• • Choices of antipsychotic medication, whether the patient was given choice and information about the antipsychotic.

• • Recorded reviews of side effects.

• • Duration of treatment.

• • Reasons for switching antipsychotic.

• • Whether clozapine was offered to patients where indicated.

• • Whether a recommended antipsychotic free period allowing for investigations and assessments was adhered to.

• • Other medications prescribed alongside the antipsychotics.

77 patients were identified.

• • Adherence to the NICE guideline criterion of initial prescriber being in secondary care was good.

• • Olanzapine was the preferred first antipsychotic choice for 50% of patients, aripiprazole was the most common choice as 2nd and 3rd antipsychotic (around 30% patients).

• • Recording of Information about antipsychotic treatment was lower than expected, about 30% of the sample at first choice, this increased to 50% for second choice and 40% at the third choice of antipsychotic.

• • Around 90% of the sample had recorded review of medication and its side effects.

• • 17% of the sample had duration of treatment less than 6 weeks at first antipsychotic, this dropped to 9% and 6% at second and third respectively.

• • Reasons for switching were mostly due to side effects and lack of efficacy. Refusal to take the antipsychotic was a common reason for switching to the third antipsychotic.

• • Only about 20% of patients who were eligible were offered clozapine.

• • An antipsychotic free period up to 7 days was adhered to in almost 70%.

As a result of the audit findings we have developed Trust prescribing guidelines for adults presenting with FEP, which include recommendation for 7-day antipsychotic free assessment period, need to involve patients and family/carers when making decisions about choice of medication and recorded discussion about clozapine for eligible patients.

The use of mentorship schemes may be a pragmatic approach to bridging the differential attainment gap for psychiatry trainees. There is robust evidence that mentorship improves outcomes for core trainees across several domains including exam pass rates, ARCP outcomes and clinical practice. A survey was developed to elicit core psychiatry trainees’ perspective about the need for mentoring as well as their expectations. This was an initial survey done as part of a Quality Improvement project focused on mentoring scheme for psychiatry core trainees in the East Midlands region.

A 16-item self-rated questionnaire was designed to elicit information relating to respondents’ demographics, professional qualifications, UK experience prior to commencement of training, perception of mentorship as an unmet need as well as expected focus of potential mentoring relationship. These were administered to psychiatry core trainees in the East Midlands region. The data was collected in February 2023.

About a quarter of the core trainees (n = 21) participated in the survey. Majority (47.6%) of the respondents had Black or Black British ethnic origin and 11 (52.4%) were in their second year of training. Although 13 (61.9%) had a non-UK primary medical qualification, majority had some months of UK experience before commencement of training (median = 1.4 years). Twenty (95%) of the respondents identified mentoring as an unmet need and they highlighted the areas of need.

This survey showed a high level of acceptance of the mentoring scheme among the trainees. Their expectations and suggestions helped further the design of the mentoring scheme which is currently ongoing.

• • Study current practices in Old Age Psychiatry (OAP) wards regarding Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) documentation.

• • Create an intervention to improve compliance with Scottish Government guidance.

Hypothesis:

• • An intervention could improve likely inconsistencies in current DNACPR practices.

Background: DNACPR forms are a contentious issue in the media, impacting patients and families’ views. The Scottish Government's ‘Cardiopulmonary resuscitation decisions – integrated adult policy: guidance’ from 2016 seeks to prevent inappropriate attempts at CPR and subsequent distress to patients and families. It makes various recommendations for clinicians when making these decisions and completing DNACPR forms.

This was a two-cycle retrospective audit utilising physical and electronic notes for all patients across two OAP wards at the Vale of Leven Hospital, Alexandria. Data were collected on demographics, presence and adequacy of DNACPR forms based on Scottish Government guidance. Between the first (12/09/22) and second (25/11/22) cycle, a poster to aid DNACPR decisions and documentation was created and displayed in the ward office.

There were a total of 13 patients in cycle 1 and 14 patients in cycle 2. The number of patients with forms increased from 3 to 8 between cycles (including all those with organic diagnoses in cycle 2). Between cycle 1 and 2, there were improvements in the proportion of forms: completed at admission (66.7% to 87.5%, respectively), correctly filed (66.7% to 100%), with review timeframes specified (0% to 62.5%) and consultant signatures (33.3% to 100%). The mean age of patients with DNACPR forms was higher than those without forms in both cycles (86.7 and 85.7 in cycle 1 respectively versus 77.9 and 77.7 in cycle 2). The mean number of comorbidities did not vary significantly between those with and without forms or between cycles.

The project revealed various shortcomings in DNACPR practices across both wards. The creation of a poster intervention helped to improve DNACPR practices and compliance with Scottish Government guidance. Despite this, notable areas for improvement still remain. Incorporating these new practices into hospital policy alongside more audit cycles could aid further progress in outstanding areas for improvement.

To improve communication in a Female Forensic Intellectual Disability ward.

Delamere ward is a medium secure Intellectual Disability female forensic ward in Merseycare NHS Foundation Trust. Admitted patients have varying levels of need and complexities. A Multidisciplinary Team (MDT) comprising of Medical, Nursing, Support workers, Psychology, Occupational therapists and Speech and Language therapists, among others, works with patients in this ward. The MDT meets regularly in various patient meetings with decisions taken communicated to patients and staff through existing means. Communication was noted to be ineffective, leading to patient frequent challenging behaviours and patient dissatisfaction.

The Quality Improvement project was registered with the local Trust Quality Improvement Department at the outset. Staff views on ward communication effectiveness were gathered using entrance and exit questionnaires. 12 and 9 staff members responded to the entrance and exit questionnaires respectively.

The project was conducted over a period of 12 weeks and was divided into Service user and Staff led initiatives. Service user initiatives focused on strengthening existing community meetings, use of ward health promotion boards, MDT walk arounds and utilisation of ward areas. Staff initiatives included introduction of daily morning handover meetings, strengthening of existing staff meetings, listening sessions with staff, and use of reflective sessions. Daily handover meetings were open to the whole ward team and attended per staff availability. Ward dynamics encompassing the previous day were discussed and documented. Qualitative staff views transcribed and compared pre and post project.

Implementation of the quality improvement project eased tension between the MDT and the wider team, helped foster more shared decision making, increased team participation, bridged the gap between fortnightly held ward rounds, created a platform for prompt information sharing, encouraged bidirectional flow of information and helped therapists plan their sessions accordingly.

Effective ward communication was beneficial to staff and patients alike, leading to better implementation of care plans, increased staff confidence and teamwork, and service user satisfaction.

Autistic burnout, a profound psychological state characterised by increased stress, exhaustion, and a decline in functional abilities, has begun to be documented in adults but remains under-recognised in children. This abstract aims to shed light on autistic burnout in children, particularly in the context of school avoidance, and calls for a comprehensive approach to recognition, understanding, and intervention in this area.

A retrospective audit was conducted on the case notes of 20 children, all diagnosed with autism, who had been unable to attend school for at least three months. The audit involved compiling a checklist of symptoms commonly associated with autistic burnout. This checklist included: chronic exhaustion, loss of skills previously acquired, diminished interest in activities, heightened sensory sensitivities, social withdrawal, mood dysregulation, and physical complaints. The primary objective was to investigate the presence of symptoms typically associated with autistic burnout in these children. To achieve this, information regarding these symptoms was extracted from their case notes.

Age: 8 to 17 years, 10 boys, 10 girls. 90% of the children had an EHCP (Education Health Care Plan). 100% of the children experienced chronic exhaustion, loss of skills & interests, increase in sensory needs, social withdrawal, mood dysregulation and physical symptoms.

The alarming trend of school refusal among autistic children is a phenomenon that merits close scrutiny, not only for its impact on the child's education but also for the broader implications including the significant burden on families. The uniformity in the reported symptoms across the group strongly indicates a shared underlying issue. In the context of autism, these symptoms align with what is known about autistic burnout. These symptoms can significantly impact the quality of life and daily functioning, including the ability to attend school. Understanding of these symptoms as part of autistic burnout could lead to better support strategies, accommodations, and potentially improved outcomes for autistic children who are refusing school. It necessitates a shift from a potentially punitive approach to one that is compassionate and accommodative, ensuring that strategies are in place to support autistic children's return to school when they are ready and able to do so. These findings highlight an urgent need for research into autistic burnout in children, recognition of this concept by health and education and a need to re-evaluate current educational practices and support systems for autistic children in school.

To improve the knowledge of the early intervention in psychosis team staff regarding support and referral options available for patients with suspected or confirmed autism spectrum conditions. We further aimed to develop additional knowledge within this team to help identify, assess and support people who may be neurodivergent with a primary focus on autism.

Starting in September 2022 the team completed a survey to understand baseline knowledge. Plan Do Study Act (PDSA) quality improvement cycles were then used to develop resources and disseminate knowledge within the team to help target the identified staff development areas. Following implementation the team completed a further survey to reassess the changes and ongoing areas of focus and to guide ongoing skill development.

3 PDSA cycles were completed with interventions including collecting data on local services to share within the team, collating these resources and sourcing training sessions. This demonstrated an improvement in many areas at the point of the second survey at which stage the team showed a better understanding of how to access autism assessments, the role of various local autism specific teams including admission avoidance urgent support processes and confidence in supporting people after diagnosis. Work continued following the second survey within the team with further training sessions and both medical and psychology colleagues upskilling to be able to complete autism assessments within our service in conjunction with the neurodevelopmental team. The early intervention team staff have been able to utilise the support of many of these services and often discuss these options now within team meetings.

Initially support and knowledge gaps were identified within our team and work was done to collect and share information about local services and processes to best allow us to support those within our psychosis service who also have an autism spectrum condition and this has been successfully implemented.

This work has grown over the past 2–3 years since the initial quality improvement work was developed and team knowledge has since continued to grow. This has included multiple team members now also being able to complete autism assessments formally in conjunction with the neurodevelopmental service with some assessments now finalised and significant ongoing work to improve experiences of those with both autism and psychosis.