To establish if new departmental guidelines regarding Anaesthetic to ECT Time Interval (AETI) documentation were being followed. The guideline states that the average time from end of Propofol administration to the time of stimulus delivery should be at least 120 seconds. AETI should be recorded at all ECT sessions including the initial titration sessions when the seizure threshold is being established. The aim of the guidance is to reduce the impact of the Propofol use on seizure threshold and quality. By improving seizure quality, the stimulus dose required to elicit an adequate seizure can be kept to a minimum which is associated with a lower risk of cognitive side effects during ECT.

Review of electronic RiO notes and ECT prescription documentation for patients who received ECT treatment using Propofol as the induction agent at Hopewood Park ECT Department over a 4 week period in August 2022. Analysis of data collected and presentation to department.

6 patients met inclusion criteria, age range 35-78. The indication for ECT was severe depressive illness (4) or catatonia (2). In total there were 30 ECT treatment sessions included, of those, 23 (76%) had AETI times documented. There was no clear correlation between sessions for patients who did not have an AETI time recorded and those who did. Two were documented as unsuccessful seizures and needed further dose titration. The others happened to be the first treatment dose of ECT given following titration session. The treatments where AETI time was recorded were all equal to or more than 120s (mean AETI was 151.7s). Therefore, 100% of the AETI times that were recorded did meet this standard.

76% of patient treatments had AETI recorded and of those recorded 100% met the standard of being >120s. To improve documentation, a prompt box is to be added to the ECT documentation sheet. The AETI guidelines are to be uploaded to the Trust Intranet Page and displayed in the ECT department. The guideline is planned to be rolled out across the other two ECT departments in the Trust in the coming months. Further work is planned to gather data pre- and post- Trust wide roll out to observe any trends in dose escalation or other clinical factors.

The audit assessed whether physical health forms, which are separate from admission clerking notes, were being completed for new admissions on the ward. A physical exam has to be carried out for every new admission and the findings recorded on the form within 24 hours of the admission. After the first audit cycle, recommendations were to be made and interventions carried out. A re-audit was completed to assess the compliance.

The records of all patients admitted onto a ward at a mental health unit on the 1st of October 2022 were reviewed to determine whether the admitting doctors had completed the physical health form or not. This was recorded on an excel sheet as complete, recorded on clerking but form not complete, or patient was not seen. After data extraction, junior doctors were reminded about the form personally and a poster was made informing junior doctors about the form which was placed in the junior doctor's room. A re-audit was carried out four months later.

The audit showed that the forms for 75% of patients were not completed by the duty doctor on admission. Out of the forms that were not completed, one patient was not clerked in on time and one patient did not want to see the doctor and refused examination. Therefore, 65% of patients were examined and examination recorded on admission clerking, but the form was not completed. On the second cycle, 35% of the forms were not completed with one patient refusing examination, thus, 30% of the forms were not completed despite examination being carried out.

The recommendations and interventions proved to be successful as the compliance in completed forms increased. Further interventions such as frequent reminders and mentioning the importance of the form on induction could be made. A third cycle to assess compliance among the new junior doctors rotating onto the unit could be completed to assess the effectiveness of these interventions.

The aim of the audit was to assess whether patients on the ward were receiving 1:1 sessions with their named nurse and to assess the frequency of these sessions per week after many patients stated that they were not receiving such sessions. The role of the named nurse is to engage therapeutically with the patient and thus ensure the well-being, safety and satisfaction of the patient while communicating and enforcing the treatment plan. The named nurse answers the patient's questions and helps the patient with tasks such as preparing documentation. The named nurse also acts as an advocate of the patient and communicates the needs and requests of the patient to the team. The recommended frequency of 1:1 sessions is twice a week.

The electronic records of the patients admitted to a mental health ward were examined to assess whether they were having their documented 1:1 sessions with their named nurse on the 15th of October 2022. This was recorded on an excel sheet anonymously as “complete” and “not complete.” The frequency of these sessions per week was also recorded on the same excel sheet. The audit was repeated on the 15th of January 2023 and the same parameters examined. Improvement was facilitated via speaking to nursing staff, explaining the importance of 1:1 sessions and reminding them of physical health forms in the morning meetings.

The results showed that 4 patients had 1:1 sessions out of 20 admitted patients. 2 out of the 4 patients who had 1:1 sessions had them at least twice a week while the others had them once a week. The repeat audit 3 months later showed 12 out of 20 patients had 1:1 sessions and 5 of those patients had them at least twice a week.

The audit showed some improvement. It is likely that the task can be forgotten on a busy ward and reminding staff regularly is imperative. Further improvement can be managed by using posters in the nursing station to remind staff.

The Institute of Mental Health is the only tertiary Psychiatric Hospital in Singapore. It has two 29 bedded inpatient wards which provides acute care for the elderly with severe mental health problem. Over the past year there has been a trend of an increasing number of elderly patients who stay for a prolonged period of time as they require long term care placement and this increased length of stay leads to increasing healthcare costs, a reduction in availability of acute beds which in turn leads to elderly patients needing to be lodged in general adult wards. In 2022 the average length of stay for the elderly wards was 46 days as compared to the target of 21 days set by the hospital. Prolonged inpatient stays can lead to physical decompensation including reduced muscle strength, pulmonary capacity and osteoporosis.

We conducted a retrospective audit on 30 patients who were admitted between July and December 2022, requiring long term care placements. Our hypotheses were that patients with a diagnosis of dementia, who were frail and with caregiver burnout were more likely to require long term care placement. We subsequently designed a data collection form to collect the latter data and analysed them.

Out of the 30 patients, 27 (90%) had a diagnosis of dementia, 25 (83.3%) were classified as frail (6 or more on the clinical frailty scale) and 23 (76.6%) had caregiver burnout, 12 (40%) family unable to look after patients in spite of community support and 3 (10%) had no next of kin.

Patients with dementia and frailty are more likely to require long term care placements. In the inpatient unit, we find that caregivers of these patients are burnt out because of their behaviour problems. We are embarking on an enriched model of care to reduce severe behavioural and psychological symptoms of dementia thereby reducing the need for restraints and its associated complications, and empowering caregivers to manage their behaviour problems.

This audit also stressed the importance of addressing issues upstream. Referrals to community facilities like day care which provide exercise and rehabilitation for the elderly will help delay the consequences arising from frailty. We are also partnering primary care to assist with early identification of dementia and providing early interventions to prevent caregiver burnout.

• • The working interface between inpatient and community mental health teams can ensure a smooth and safe transition for service users following admission to the hospital.

• • It is the first opportunity to reassess this aspect of service after the pandemic as the original audit was done before the lockdown.

• • To follow up on amber results and to identify if the data captured from the previous audit has improved.

• • This clinical audit project also reviewed how often community mental health teams and service users met during a patient's inpatient stay.

• • The audit was conducted at West Park Hospital, Darlington. Information was collated from a consecutive group of female inpatients that were discharged from Elm Ward between 01/02/2021 and 23/03/2021. The audit data collection was performed between 01/05/2021 and 31/05/2021.

• • Data were collected retrospectively and was obtained from the inpatient medical records system (PARIS), and input into a designated audit tool.

• • Medical records were reviewed for the duration of each inpatient episode, and the criteria and standards above were applied.

• • The data demonstrate that in the vast majority of cases, the ward invited the community team to the relevant meetings during the patient admission (96%) which indicates the improvement in compliance with virtual meetings

• • In 100% of cases, there were contacts between the community team through MS Teams or directly through phone or face to face (the number of contacts depends on the length of admission, shown in the figure below)

• • The percentage of patients that were offered a written copy of the care plan was observed to have increased when this is compared to the original Audit

• • The percentage of patients whose GP doctor was informed also increased to 20%, however, that is still at red remarks

• • An amber compliance rating was assigned to this clinical audit report. High compliance was achieved for evidence of the reason for admission, anticipated risks, and capacity communicated to the ward by the care coordinator/crisis team.

• • There is evidence of inviting the care coordinator/crisis team staff to the initial formulation meeting and review/MDT meetings. However, some elements of the Admission, Transfer, and Discharge policy required improvements, particularly in relation to information about expected length of stay communicated to the ward by care coordinators/crisis team staff

• • It should be clear who should be responsible to inform the patient's GP within 24 hours of admission

• • Still, compliance with offering patients a written copy of the care plan (care document/ intervention plan), is low.

It is well established in the evidence base that mortality and suicide risk increases following discharge from an inpatient admission, leading to the national implementation of ‘72 hour follow-up’. However, there is little data examining outcomes following discharge from an admission to a Crisis Resolution & Home Treatment Team. Following a number of noted Serious Untoward Incidents at a trust level, we sought to examine the standard of follow up post discharge from all four Black Country CRHT's (Dudley, Walsall, Sandwell and Wolverhampton) in order to improve policy and thus patient outcomes.

The caseloads for all four CRHT's for the period of 1st-31st December 2021 were obtained. The clinical notes system RIO was searched and scrutinised for each patient to determine when the patient's next planned follow-up following discharge from that particular spell in CRHT took place. This was compared to the audits standard: all patients discharged from CRHT should receive some form of planned follow-up in the 3 month period post discharge.

All of the patients discharged from Wolverhampton CRHT received 72 hour follow-up as conducted by members of their own team, however despite this 12% of the total caseload were either lost to long term follow-up or went into crisis before planned follow-up could take place. With regard to Dudley and Sandwell, only 51% and 47% of patients respectively were routinely followed-up within 3 months. A total of 30 patients across all 4 CRHT's went into crisis before planned follow-up took place. One patient ended their life 4 months following discharge from the CRHT; no planned follow-up took place. All of Walsall CRHT's patients were followed up on discharge unless they were discharged directly back to their GP.

Timely, regular and robust follow-up embedded in the community mental health team is paramount to the provision of safe psychiatric care. This audit has also uncovered the need for follow-up for patients discharged from CRHT to their GP, as this cohort of patients is sizeable. However we argue that a one off ’72 hour/7 day follow-up’ is insufficient when reducing morbidity and mortality, and robust long term care plans and regular follow-up should instead be a feature of longer term community mental health care.

The Triage and Assessment Team (T&AT) at South Kensington and Chelsea Mental Health Centre have conducted a research project to assess our written communication with General Practitioners (GPs) in primary care. We are responsible for screening and assessing new patients referred by GPs to the South Kensington and Chelsea Mental Health Centre community mental health team (CMHT) department.The aim is to ensure all patients referred from primary care, receive care from the most appropriate health professional(s) in the timeliest way and that we communicate with their referrer in a timely and helpful manner. We aim to deliver a service that is safe, effective and helpful to patients, carers and their referrers. The purpose of this study is to understand the referrers’ experience of our communications with them when they refer to the T&AT.

A pre-intervention survey was sent out in November 2022 to GPs who work and are part of the Brompton and South Kensington primary care networks (PCNs).

We received an equal number of responses from Brompton and South Kensington GPs respectively. Quantitative and qualitative data were both collected. We had a cross section of respondents including trainees, salaried GPs and partners.

From the quantitative data, the majority of respondents reported they were reasonably satisfied with our communication with respect to timeliness, clarity and clinical relevance of our communication.

Respondents were less satisfied with the balance struck between clinical detail on the one hand and recommendations for the mental health shared care plan.

A qualitative analysis of respondents all free text comments and identified three main themes: the local referral pathway, the use of SystmOne computer software programme, and recommendations for improving communications between GPs and the T&AT at CMHT.

We have acknowledged concerns about the complex mental health referral pathway together with suggestions about improving the functionality of SystmOne across the GP and CMHT interface into the regular discussions we have with our respective PCNs.

The Triage and Assessment Team are designing improvements to the consistency, timeliness and relevance of our GP communications.

Once these improvements have been implemented, we will send out a post-intervention survey to GPs and reassess their satisfaction levels with our new mode of communication.

This re-audit aimed to determine the level of performance in the assessment and management of patients with alcohol use disorders following admission to one of the general adult inpatient wards in Mersey Care NHS Foundation Trust and to determine whether the level of performance has improved compared to the original audit done in 2021 and whether recommendations that were implemented following the original audit have been effective.

A list of all inpatients on each of the eight general adult inpatient wards in the Trust was obtained. The electronic patient record (on RiO) and electronic prescription card (on EPMA) for each inpatient was scrutinised to obtain the required data. All data were collected retrospectively.

A total of 149 inpatients were identified on the eight general adult inpatient wards. Using specific inclusion and exclusion criteria, 56 of the 149 inpatients formed the final sample. Of the 56 inpatients, 58% were male, 42% were female. An alcohol history was documented in 81% of the 56 inpatients, representing an improvement on the 45% in the original audit in 2021. An average weekly quantity of alcohol for the inpatient was documented in only 8% of cases, a drop from 22% in the original audit in 2021. There was minor improvement in documentation of a CIWA-R score for the inpatient on admission to the ward - an increase from 0.7% in 2021 to 4.0% in 2022. There were improvements on gamma GT and serum Magnesium level being checked on admission for the 2022 audit cohort compared with the 2021 audit cohort. There was also an improvement on referral of the inpatient to community alcohol services - 3% in the 2021 audit vs 7% in the 2022 audit.

The findings from this re-audit indicate an improved level of performance in assessment and management of patients with alcohol use disorders following admission to the general adult inpatient ward since the original audit in 2021. Recommendations from this re-audit are: ensuring that taking and documenting a thorough alcohol history is included in the induction for junior trainees, the provision of education and training to both medical and nursing staff on the wards in using the CIWA-R to assess level of alcohol withdrawal and producing a flow chart on the assessment and management of alcohol use in patients following admission to the ward that can be displayed in the Treatment Room on each ward and in the Junior Doctors’ office.

To evaluate the usefulness of the "Well-being Clinic", a specialized service aimed at reducing the dose of antipsychotic medication prescribed for patients with behavioural and psychological symptoms of dementia (BPSD). The aim of the service was to have a sustained reduction of at least 50% of the antipsychotic dose in at least 50% of the sample size.

A retrospective quantitative study was performed, looking at the 6 month period between August 2022 and January 2023. Two data parameters were obtained. One, the percentage of reduction of the antipsychotic dose for each patient. Two, the number of reviews done for each patient over the specified time period.

Out of a sample size of 21 patients prescribed antipsychotics for BPSD, only 1 (5%) had a sustained reduction of at least 50% of the antipsychotic dose. 2 (10%) had a dose reduction of less than 50%, 14 (67%) had no change and 4 (19%) had a dose increase.

3 patients (14%) had 3 reviews in the 6 month period, whereas 10 (48%) had 2 reviews, 5 (24%) had 1 review and 3 (14%) had no reviews.

The Well-being Clinic intends to reduce harm to patients by reducing their antipsychotic dose. However, only 5% had a satisfactory dose reduction and 62% were reviewed at least once in 3 months.

Recommended actions include increasing the frequency of reviews to once in 6 weeks (in accordance with national guidelines) and implementing regular monitoring of electrocardiograms (ECGs), vital signs and blood markers to further improve practice.

INTRODUCTION: The term ‘psychosis’ is used in NICE guidelines to refer to the group of psychotic disorders that includes schizophrenia, schizoaffective disorder, schizophreniform disorder, and delusional disorder as identified by the International Classification of Diseases – 10th revision (ICD 10; World Health Organization, 1992).BACKGROUND: Children and young people with psychosis and schizophrenia have poorer physical health than the general population as get older. Life expectancy is reduced by 16 to 25 years (Brown et al., 2010; Parks et al 2006).AIMS & OBJECTIVES: To compare the west-midlands child psychiatrist practice with the standard NICE clinical guidelines on baseline physical and metabolic investigations before prescribing antipsychotics in children and adolescents. To compare if fulfilling criteria. Early detection and intervention in order to delay or possibly prevent the onset of psychosis and schizophrenia. To improve the services.

• • The sample was collected via ‘WEST MIDLANDS CAMHS CONSULTANT SURVEY’.

• • Information collection through the questionnaire.

• • Nine members of the west midlands CAMHS Consultant CLENT group participated in 2019.

• • Indications to use antipsychotics, Record keeping and Assessment of nutritional status & level of physical activity: 100%.

• • Pulse and B.P check: 88.9% yes, 11% not always.

• • Weight and Height plotted on growth chart: 77.8% yes, 22% not always.

• • Antipsychotics (must be initiated by suitably qualified health care professional with expertise in prescribing: 33% consultant, 55% doctor, 11.1% doctor or nurse.

• • Assessment of movement disorders was done by 44.4%always, 11.1% never and 44.4% sometimes.

• • Lipid Profile was checked by 44.4% always, 11.1% never and 44.4% sometimes.

• • Fasting blood Glucose and Hb1ac check: 33.3% yes, 66.7% never and 33.3% sometimes.

Data collected suggest meeting the set standards for indications of antipsychotics, record keeping and physical activity checks but not in other domains.

Recommendations:

• • To create a checklist Performa for physical / metabolic Health Checks for children and adolescent initiated on antipsychotic medications under the care of CAMHS.

• • Clinicians to stay up to date with NICE guidelines.

• • To regularly monitor physical health and blood test before prescribing antipsychotics.

• • To re-audit after introducing Performa in our CAMHS centre, if effective to introduce it in other local CAMHS centres after negotiation with them.

BACKGROUND: Local algorithms are in place which outline the required process for arranging a Mental Health Act assessment. It requires one doctor from the patient's allocated care team or Trust on-call consultant during the working hours and one doctor from the on-call team (registrar/Consultant- if no registrar) during out of hours. Concerns were raised that on-call doctors were not always asked to participate in assessments in accordance with Trust protocol. AIMS: To improve the on-call assessment process at Northstaffs Combined Healthcare NHS Trust (NSCHT). OBJECTIVES: To determine: Whether NSCHT doctors from the on-call rota participate in Mental Health Act assessments, as appropriate. Any patterns relating to day, time of day or location of assessment which correlate with on-call doctors not participating in assessments appropriately. Any areas where the required standards relating to on-call assessments are not being met. As well to take this opportunity to note down how long was admission following mental health act assessment and if any role of substance misuse.

All assessments undertaken during November and December 2020 were identified by the Mental Health Law Team. This resulted in a total for analysis of n=141 cases. Data collection was undertaken by Working Group members using a form devised by the Clinical Audit Department and entered online for analysis. Analysis was subsequently undertaken using SPSS and validated according to departmental protocol.

MHAA was done 35% inpatient, 30% Section 136 Suite, 14% community, 12% UHNM, 3% access, 2% police custody and 4% in other areas/ out of areas. Outcome were that 45% detained under section 2 MHA, 35% on section 3 MHA, 2% admitted informally and 18% neither detained nor admitted. 26% of the time substance misuse (acute / chronic) formed part of assessment.

• • Overall results showed that at least one NSCHT doctor was involved in 91% of assessments undertaken, with roughly two thirds of doctors being Consultants and one third Registrars.

• • Focusing on assessments undertaken in the Section 136 suite, at least one NSCHT doctor was involved in 92% of assessments undertaken, with roughly half of doctors being Consultants and half Registrars.

• • Focusing on out of hours assessments, at least one NSCHT doctor was involved in 89% of assessments undertaken, with roughly two thirds of doctors being Consultants and one third Registrars.

• Recommendations:

• • To amend the Section 136 form to add the role of the doctor in the assessment.

• • Results to be presented and discussed at the Mental Health Law Governance Group-completed.

• • Results to be presented to the Acute and Urgent Care Directorate-completed.

• • Executive Summary to be presented to the Clinical Effectiveness Group-completed.

Aims and auditable outcomes: We aim to ensure 100% patients on clozapine have annual physical health checks. By ensuring all patients prescribed clozapine therapy receive an annual physical health check and medic review, we aim to improve patient safety and prevent serious harm from occurring in cases that could be avoided.

All patients aged over 18 years prescribed Clozapine, who were under the assessment and treatment service in Eastbourne, were identified using Carenotes, our electronic patient records system.

78% of patients on clozapine had been reviewed by a doctor in the past 12 months. 32% of patients had attended a physical health review within the past 12 months. One patient had not had a medical review for several years.

Our audit has shown that there are no clear guidelines on the long term monitoring of clozapine in regards to physical health reviews and psychiatric assessment. Using best practice it appears annual review should be the minimal standard, however further evaluation of this is recommended at trust level.

In response to these results and the current guidance, we would like to implement the following:

• • Create a database for all patients on Clozapine under the care of Eastbourne ATS.

• • Create a spreadsheet looked after by one member of admin staff to be updated regularly

• • The physical health lead nurse to be informed of physical health checks due by admin

1. 1. To evaluate the clinical practice and documentation of remote patient consultations in memory assessment service during COVID-19 pandemic

2. 2. To gather the views of clinicians and patients on the benefits and challenges of remote patient consultations 3.To understand the role of digital psychiatry in our services after the pandemic

An audit tool and feedback questionnaires for patients and clinicians were completed through discussions and consensus with multidisciplinary team. RCPsych guidance for cognitive assessments was also considered.

A random sample of 20 patients was identified who had virtual consultations. Rio clinical records were used for data collection using audit tool.

Patients and clinicians were sent questionnaires

Evaluation of clinical practice

The audit demonstrated that all the relevant documentation was completed in vast majority of cases and the clinical practice was not significantly affected by the consultations being carried out virtually. Mental state examination was identified as one aspect which got partially completed in 4 out of 20 assessments during the remote consultations

Patient survey

Patient survey showed that the purpose of the consultation was mostly served by remote appointments. Almost 90% fedback that the communication was clear and they were able to engage freely and effectively with the clinicians. 55% reported preference for face to face meetings in future. 28% preferred remote consultations citing not having to travel as the main reason for their choice. Another benefit identified was relatives who don't live locally could also attend the virtual meetings to support the patients and to offer useful information

Clinicians’ survey

From clinicians’ perspective, the main advantages were reduced travel time, improved time efficiency, and reduced risk of infection. The main disadvantages were inability to get the full clinical picture compared to face-to-face appointments, technological challenges, and lack of personal touch.43% reported that the job satisfaction has improved from hybrid working

There are certainly benefits and advantages for remote consultations from the perspective of both patients and clinicians. While majority of clinicians prefer a combination of remote working and face-to-face consultations, more than half of patients expressed preference for face-to-face appointments. This audit demonstrates that, although remote consultation is not the gold standard method in assessing cognitive functions and dementia diagnosis, it was useful for obtaining most of the relevant information to enable diagnosis and initiating treatment in timely manner. We also found that approximately 437 miles of travelling was prevented because of the possibility of virtual meetings

To investigate adherence to NICE and STOMP guidelines for the pharmacological management of patients with intellectual disability (ID) and challenging behaviour (CB) in a large acute mental health trust over three audit cycles

The electronic records of a purposive sample of patients with ID and CB under the care of the ID Team at a large acute mental health trust were retrospectively reviewed over three audit cycles (conducted in 2013, 2014 and 2021).

The sample sizes were 31 (2013), 17 (2014) and 35 (2021). Over the three cycles, most patients had moderate (35%, 47%, 49%) or severe ID (42%, 35%, 31%). Common co-diagnoses included autistic spectrum disorder (45%, 47%, 69%), mood disorders (23%,18%,17%) and epilepsy (16%, 24%,31%).

Target behaviours for intervention were aggression (42%, 27%, 49%), agitation (10%, 40%, 40%) and self-injurious behaviour (28%, 20% and 20%).

Medications used for CB were antipsychotics (61%, 24%, 62%), benzodiazepines (20%, 29%, 42%), antidepressants (13%, 35%, 42%) and mood stabilizers (6%, 12%, 9%)

The number of patients on multiple medications to manage CB declined over the years, with an increasing number receiving singular drug therapy (19%, 35%, 34%).

Over the three audited years, there were improvements in risk assessment (68%, 94%, 100%), descriptions of the nature of targeted behaviours (74%, 100%, 100%), metabolic monitoring (0%, 0%, 95%), documentation of successful and unsuccessful interventions (48%, 65%, 86%).

Adherence to certain standards however declined over time or remained difficult to achieve: complete evaluation of mental (87%, 94%, 60%) and physical health (61%, 88%, 60%), documentation of consent (19%, 76%, 46%), documentation of discussions regarding potential side effects (32%, 47%, 50%) and 6 weeks’ review of medications’ efficacy (52%, 65%, 50%). A positive behaviour support care plan was available in 75% of cases in 2021 and had not been audited in previous cycles.

This retrospective analysis highlights a reduction in the use of polypharmacy to manage CB in patients with ID over time. Adherence to standards remains patchy across the years with improvements in risk assessments and metabolic monitoring. Standards necessitating outpatient intervention such as review of medication efficacy, evaluation of mental and physical well-being were hard to achieve, in part explained by service changes and pressures related to the COVID-19 pandemic. Future improvements may require increased pharmacy-led reviews.

Early Intervention in Psychosis (EIP) services provide an evidence-based approach to the identification and treatment of patients experiencing a first episode of psychosis (FEP). The NICE access and waiting time standard is that 60% of people experiencing FEP are treated with an approved care package within two weeks of referral. This is defined by allocation of an EIP care coordinator, though the offer of antipsychotics is also important. The aims of this audit were to (1) Collect data on EIP referral to treatment pathways and explore delays (2) Explore the origin of EIP referrals (3) Explore timings of referrals to review with a prescriber (4) Compare two audit periods to assess recommendation efficacy and provide future recommendations to reduce delays.

Two retrospective audits were carried out on patients accepted onto the FEP pathway at EIP Liverpool in May & June 2020 (34 patients) and December 2021 (11 patients).

Data were collected for each patient on time spent at stages of the referral pathway from initial referral to mental health services to first medical review with an EIP clinician. Further data included each patient's first point of contact with mental health services, the referral origin and first contact with a prescriber.

Data were collected using electronic health records. Duplicate referrals and extended inpatient admissions were excluded from prescriber analysis. Initial audit results from 2020 were compared with the re-audit in 2021, assessing for changes in pathway provision and compliance with the NICE standard.

The results found that there was a 43.5% increase in wait time on the EIP referral pathway between the periods audited in 2020 and 2021, from an average of 9.8 to 22.5 days, related to the COVID-19 pandemic. The primary delays for both periods were referral assessment, care coordinator allocation and prescriber review.

The type of prescriber reviewing remained consistent, with reviews being conducted by a consultant for >50% of patients in both periods.

Between the two audited periods, the average pathway to care time increased to over the NICE standard despite implemented recommendations from the initial audit.

Stages of the referral pathway facing significant delays came from within the service, due to an increase in referrals, an increase in patients experiencing FEP by 50% and a change in the origin of referrals. A framework for improvement is recommended to improve pathways to care and outcomes for patients experiencing FEP within the EIP service.

Challenging behaviours often results in exclusion from communities and is associated with worse outcomes for patients with Intellectual Disability (ID). Due to substantial cut backs in local community service provisions across Highland for people with ID, placements have dwindled and recent trends indicate a high demand for “crisis” inpatient admission for PWID with co-morbid mental health and/or pervasive developmental disorders. This project aims to thematically analyse the admission trends to the Intellectual Disability Assessment and Treatment Unit (IDATU) in NHS Highland over a 5 year period (2018-2022).

All patients admitted to and discharged from the IDATU over a 5 year (2018-2022) period were identified. Their case notes were reviewed and details on the primary reason for admission were manually gleaned from the admission clerking document. Data were also gathered for demographics, diagnosed mental disorder, legal status and length of admission.

Total 18 new admissions were identified. All had established ID and/or co-morbid mental illness, autism, & other organic conditions. The average age was 30.2 years. 81% of admissions were formal. Length of admission varied from 1 to 814 days.

Allowing for some overlap, admission themes mainly fell into 3 categories: challenging behaviour related- Aggression, Abscond, Self-Neglect, Suicidal (50%), Decline in mental/Physical health- Psychosis, Confusion, Weight Loss (16.7%) and manageability- Vulnerability, Breakdown of social situations (33.3%).

Several themes were identified amongst the stated reasons for admission in case notes. A pattern emerged whereby these fell into 3 different headings as shown by the table here.

The above three themes identified are not surprising. A combination of behaviours grouped as “challenging” and also felt to be “unmanageable” were cited as primary reasons for admission.

Notwithstanding the dwindling of community resources and workforce attrition within the ID Service in recent years, the actual numbers admitted to IDATU was roughly down by 50% comparing a 5 year analysis done from 2012-2017 (34 Vs 18).

Robust scrutiny/tightening of IDATU admission criteria, along with other new service initiatives may have helped mitigate against any inappropriate use of IDATU beds.

Given the established and well researched risk of institutionalisation, it is of interest to us that our findings suggest that the services employed by the State to reduce this risk were already involved in a large proportion of cases. It is our recommendation that future service development planning should focus, incentive, invest and expand robust community ID services and resources within Highland.

The aim of this study was to determine the proportion of patients who had fasting plasma glucose and glycosylated haemoglobin (HbA1c) blood tests done on admission to an older people's inpatient ward at Kingfisher Court, Hertfordshire. Patients undergo a physical health assessment when they are admitted to the ward. This consists of a physical examination, an electrocardiogram and a panel of blood tests, which include a fasting plasma glucose and HbA1c. Given that people with severe mental illness have a greater burden of physical health conditions, such as diabetes, this physical health assessment can aid in optimising patients’ physical health and reducing this health inequality.

A sample of 40 patients who were most recently discharged from the older people's inpatient ward were included in the audit. Four authors each independently reviewed 10 patient case notes and blood results. An audit collection tool was produced and data logged for each patient. The data collected were reviewed by all authors.

57.5% (23) of the study population had admission blood tests that included a HBA1c level or plasma glucose. An individual with diet-controlled type 2 diabetes mellitus had a HBA1c of 55 mmol/mol and was subsequently started on metformin. Only 15% (6) of the study population had a plasma glucose test on admission. Their case notes did not specify whether these were fasted or random plasma glucose tests. 42.5% (17) of the study population did not have either a plasma glucose test or HBA1c test done.

There was poor overall compliance with the trust protocol for blood tests on admission to the older people's inpatient ward. Plasma glucose tests were rarely done and it was not specified whether they were fasted or random tests, thus limiting their utility. The team therefore suggest that the fasting plasma glucose test be removed from the panel of admission blood tests. The focus should be on obtaining a HbA1c test. Amendments to the clerking proforma and doctors’ induction presentation should be made to emphasise the importance of the HbA1c test.

1. 1. To evaluate current adherence with the Royal College of Psychiatrists guidance “Standards for Inpatient Mental Health Services”: Were the blood tests carried out within 24-hours of admission?

2. 2. We standardised the blood test parameters that are required following admission to our PICU ward and measured if all relevant blood tests* were completed during admission.

3. 3. Re-audit after implementation of a standardised policy.*(Full blood count, urea and electrolytes, liver function tests and lipid profile, CRP, thyroid function tests, vitamin B12, folate, prolactin, vitamin D, calcium and HbA1c%).

First cycle is an audit of electronic patient records for all admissions to the PICU ward in a two-month period by using an audit proforma to capture information to answer the questions above.

After implementing a standardised guideline for PICU, second cycle was conducted over a two-month period for the re-audit.

In the first cycle, a total of 20 patient records were audited. 30% had bloods taken within 24 hours of admission to PICU. 10% of patients had bloods taken on their previous ward. 40% of patients declined/unsafe, and 20% were not done in the timeframe.

69% of patients directly admitted to PICU had all the relevant admission blood tests completed and 23% had some of the blood tests done. These numbers were lower for the patients transferred to PICU from other wards.

In the second cycle, a total of 16 patient records were audited. There was an improvement in number of patients having bloods done within 24 hours of admission with only 6% not done in the timeframe.

Of the patients directly admitted to PICU, all the consenting patients (89%) had all the standardised blood tests. These figures remained lower for those patients transferred from other wards without an indication to retest the bloods.

The standardised guideline for PICU that was implemented after the first cycle consisted of a pre-filled blood test request form which included all relevant parameters detailed above.

This had a positive impact with a significant percentage increase in the total number of patients directly admitted to PICU having all relevant admission blood tests completed at re-audit (77% to 100%).

There was also a significant percentage increase (80% to 94%) of bloods taken within 24 hours of admission to PICU.

The next step will be to implement these pre-filled forms across all wards in the KMPT trust.

The Royal College of Psychiatry (RCPsych) Consensus and the NICE guidelines have set out quality standards for the prescription of antipsychotics. There are concerns, however, regarding the over prescription across different psychiatric units: doses above BNF limits, multiple antipsychotics prescribed, lack of adequate monitoring of physical health and lack of availability of a clear rationale when high dose antipsychotic therapy (HDAT) is used. In the current audit, we sought to review the frequency HDAT is used in a female rehabilitation ward of patients with psychosis and a male rehabilitation ward of patients with dual diagnosis psychosis and/or autism. We also examined whether appropriate considerations are taken prior to prescribing HDAT and if the mandatory monitoring is in place when someone is on HDAT.

A set of standards was set out and an audit tool was formulated that took the format of a table for data collection. Data were collected and anonymised, by looking at the medication charts and patients’ records, to identify if essential steps prior to/during HDAT prescribing are followed. All service users, 10 in each ward, that were in admission during the period between 7th and 13th November 2022, where included in the study.

Data were compared directly with standards set out based on NICE guidelines and the RCPsych consensus. The data were input into Excel spreadsheet, then analysed and presented in tabular and graphs’ format.

A total of 20 medication charts were reviewed over the five-day period. Only one out of ten individuals with ASD in Springs Centre was treated on HDAT and a clear rationale was documented to justify its use. All patients in both wards had the HDAT form and side effects scale form completed and filed. All patients had documentation of HDAT use on T2/T3 forms.

40% of patients at Kenton Lodge were on HDAT. These patients required use of at least one depot due to lack of compliance. There was four patients overall treated on combination of antipsychotics. One patient did not have physical health monitoring at baseline due to refusing consent.

In a small proportion of cases, HDAT may be justified, as long as the safety implications are considered and monitoring requirements observed.

We recommend that audits of high dose antipsychotic prescribing can be performed periodically as a matter of routine practice. Also, to introduce a formal psychosis assessment scale to identify whether improvement has been accomplished since HDAT initiation.

This study sought to establish local adherence to the following recommendations for the management of short-term insomnia (under 3 months duration): 1. Sleep hygiene advice should be utilised prior to pharmacological management. 2. A non-benzodiazepine hypnotic medication should be prescribed. 3. A one-off trial dose of benzodiazepine or Z-drug should be prescribed prior to regular prescription.100% of patients reviewed by medical staff for insomnia are expected to meet the set standards.

Retrospective analysis of a cohort of patients (n=21), in an Adult Acute Admissions Ward in the West of Scotland. Taken over seven days in January 2023. Electronic prescriptions and chronological notes were reviewed in order to identify patients reviewed by medical staff for short-term insomnia.

Of the patients reviewed for insomnia (n=8):

• • 12.5% were offered sleep hygiene advice (n=1).

• • 25% were prescribed a trial dose of non-benzodiazepine hypnotic medication (n=2).

• • 25% % were prescribed regular non-benzodiazepine hypnotic medication with no trial dose (n=3).

• • 50% were prescribed alternative sedative medication for insomnia (n=4).

Commonly, patients were not provided with sleep hygiene advice. The patients who were prescribed non-benzodiazepine hypnotic medication were often not prescribed a trial dose. Half of the patients were prescribed an alternative to a non-benzodiazepine hypnotic medication.

• • Interventions will include:

  Creation of a sleep hygiene information leaflet to provide to inpatients, medical and nursing staff.

• • Presentation of data to medical and nursing staff.

• • Ensuring guidelines are available to all medical and nursing staff in the ward environment.

• • The audit will be repeated in six months after the interventions.