Hypothesis: Choice letters generated by Child & Adolescent Mental Health Services (CAMHS) South Edinburgh are not consistent in quality and content.

Aims:

1. 1. To assess the consistency and quality of letters generated by clinicians following Choice appointments in CAMHS South.

2. 2. To observe the range of resources shared in Choice letters.

Patients were identified retrospectively from the team Choice diary.

Choice or Complex Choice appointments attended between 13th October–27th November 2023 at CAMHS South were included. See Soon appointments and appointments that were not attended or cancelled were excluded.

Standards to which all letters should adhere were devised from the CAPA (Choice & Partnership Approach) Book and the CAMHS South Choice Handbook.

Standards: current concerns, background information, patient goals, clinician impression, choices discussed, choices made, self-help agreed, services required, maximum two sides of A4, copy to patient, copy to referrer, sent within two weeks.

Letters were accessed via electronic records and analysed with a proforma.

A maximum of three letters per clinician was included.

A log of resources and frequency shared was kept.

57 appointments were attended, with 50 letters generated by 22 clinicians.

Adherence to standards in 50 available letters:

Current concerns 92%

Background information 96%

Patient goals 40%

Clinician impression 62%

Choices discussed 22%

Choices made 100%

Self-help agreed 52%

Services required 100%

Maximum two sides of A4 50%

Copy to patient 88%

Copy to referrer 100%

Sent within two weeks 72%

94 different resources were shared in the letters, with minimum 0 resources and maximum 19 resources per letter.

There were areas of good quality and consistency in Choice letters, including documentation of current concerns, background information, and highlighting of required services. These are areas likely to feature in most assessments regardless of clinician background.

There were areas that require improvement, including documentation of goals, clinician impression, self-help agreed, and keeping to a maximum of two sides of A4. These areas are perhaps more obscure for different types of clinician.

A wide range of resources were shared in Choice letters with a considerable amount of variability in number of resources. This suggests differing levels of individualisation of resources to the patient.

Since this audit, CAMHS South have implemented additional Choice training, electronic canned text for letters, and collation of Choice guidance. There is a plan to re-audit following these interventions.

• • To improve documentation of antidepressant prescribing in our service, aiming to improve frequency of review, and guide measurement of outcomes.

• • Identify patients requiring medical review.

The standards that we audited against are that, for patients under The Early Intervention in Psychosis Service (EIPS), a diagnosis should be recorded alongside each antidepressant prescription and, according to EIPN guidelines, psychotropic medications should be reviewed every 6 months.

Population data from the UK indicates that lack of recording of a diagnosis is associated with increased duration of treatment, and reduced frequency of mental health reviews.

It was recorded for each patient whether they had an antidepressant prescribed, which medication, the documented indication, and their most recent medical review. Data was collected in a ‘snapshot' cross section of all 89 patients on the caseload in December 2023.

Data was obtained from carenotes by reviewing clinic letters and clinical notes; and cross-referencing with GP records.

33 patients (37%) were prescribed an antidepressant. Of these, 25 (76%) had a recorded indication. The commonest indication was mixed anxiety and depression followed by depression. Sertraline was by far the commonest prescribed antidepressant (52%) followed by mirtazapine. 3 patients were prescribed combination antidepressants. 67 patients (84%) had had a medical review within 6 months.

Among patients with a first episode of psychosis, there is a significant comorbidity of depression and anxiety spectrum disorders.

Our standard was met for most patients but there were several exceptions, and we considered why 8 patients did not have a listed diagnosis. There can be a degree of diagnostic uncertainty in distinguishing anxiety and depressive disorders from negative symptoms, and the affective changes that are an established part of recovery from an acute psychotic episode. In these circumstances it may be appropriate to consider a trial of antidepressants in consultation with the patient. Some of these patients also have been on long-term therapy which preceded their referral to EIPS, leading to uncertainty of the indication and pre-morbid status.

We conclude the following recommendations:

1. 1. Prompt a review of antidepressant use in those identified without a clear indication, discussing risks and benefits with the patient at next review.

2. 2. Arrange medical reviews for those exceeding the 6-monthly window.

3. 3. Record last review for patients under shared care.

4. 4. Re-audit in 6 months to monitor improvement.

We audited the adherence to part of the minimum admission standards for Mental Health, Learning Disabilities and Addictions Services (MHLDA) for 6 acute wards, across two sites (UHH and UHW) in NHS Lanarkshire. We focussed on the section of the standards that the admitting junior doctor/ANP is responsible for. This comprised:

• • An admission assessment (including presenting complaint, history of current episode of illness, medication, mental state examination and risk assessment).

• • Physical health assessment (examination, bloods, ECG, VTE assessment), medicine reconciliation and prescribing on HEPMA - within 12 hours.

Five individuals collected data across both sites and both cycles. For our first cycle, all admissions in March 2023 were retrospectively reviewed, a total of 94 admissions (UHH 47, UHW 47). Electronic notes/systems were reviewed (Morse, Clinical Portal, Hepma, Trakcare).

This first cycle demonstrated poor adherence to the minimum admissions standards. A proforma for admission statement was created, including prompts for the admission assessment and for the components of the physical health assessment, medicines reconciliation and prescribing. Presentations were made at postgraduate teaching and at ANP teaching. The majority of people were unaware of the existence of the admission standards or did not know where to find them. The admission standards document and the proforma were circulated via email and added to the shared R drive. A second cycle was completed, reviewing all admissions in July 2023, a total of 74 admissions (UHH 41, UHW 33). The proforma has now been included in the induction material for new doctors.

Following interventions, there was improvement in completion of admission statement (90% vs 81%). There was improvement in the inclusion of all components, most notably MSE (91% vs 71%) and risk assessment (59% vs 18%). Where the proforma was used (57%), all aspects of admission statement were present (97–100%). When not used, there was variable inclusion of the different components (7–90%). There was improvement in the completion of all components of physical health assessment (except small decrease in medicine reconciliation). In every case of missing components with no documentation as to why, the proforma had not been used.

Development of a proforma for admission assessment has led to improved completion of admission assessment, physical health assessment, medicines reconciliation and prescribing within 12 hours. Qualitative feedback is being sought on the proforma from junior doctors, ANPs and senior medics to guide next steps and further improvements. Review of the admissions standards guidance is now due.

The primary aim is to ensure patients receive recommended acute wound care. Specific objectives include improving wound management, enhancing antimicrobial stewardship, and aligning practices with national guidelines.

A retrospective audit spanning May to October 2023 assessed prescriptions for in-patients receiving antibiotics for wound management. Detailed patient records were scrutinized to evaluate compliance with standards, including wound assessment documentation, antibiotic indication adherence, tetanus status recording, and wound swab collection.

A total of 21 patients/encounters met the criteria for inclusion. Documentation deficiencies were prevalent, with only 61.9% of prescriptions featuring complete wound assessments. Additionally, antibiotic indications met NICE criteria in only 42.8% of cases, while tetanus status documentation was absent across all records. Despite 76% receiving first-line antibiotics, only 19% had wound swabs collected.

Self-harm rates in the United Kingdom, particularly among those with mental health disorders, are alarming. Hospitalizations are often required to address acute self-inflicted wounds, yet in-patient settings present unique challenges exacerbating self-harming tendencies.

This audit underscores the imperative of optimizing acute wound management in in-patient settings. By implementing evidence-based practices and addressing identified deficiencies, healthcare providers can enhance patient outcomes and ensure optimal care delivery.

At a time of increased pressures across the whole forensic estate, The Orchard Clinic Medium Secure Unit faced the additional challenge of having to close multiple acute admission beds.

This led to challenges in determining how to triage patients in the face of multiple external pressures, frustrations for clinicians managing severely ill patients in prison and human rights concerns for those unfit to stand trial but remanded to custody to await a bed.

The need for an objective tool to aid triage decisions became apparent. We therefore piloted the use of the DUNDRUM triage urgency manual, a structured professional judgement tool to aid triage decisions for forensic units.

The aims of introducing this tool were to ensure decisions are more consistent and reliable, ensure scientifically valid items are not forgotten, make decision making processes more transparent, demonstrate equality of access to services and reduce chance of serious error.

This audit reviewed all acute admissions to The Orchard Clinic between Aug 22–Aug 23. This covered a period 6 months prior to the introduction of the tool and 6 months after.

In order to determine if the use of the tool improved our triage making decisions the Dundrum score was retrospectively calculated for admissions and those on the waiting list during the first 6 month period of the audit. The same information was recorded for those following the introduction of the tool in the second 6-month period.

Prior to introduction of the DUNDRUM, the team's triage decisions were not in line with validated tools, those with lower DUNDRUM scores were prioritised over those with higher scores. Following introduction of the tool our triage decisions improved. Common themes emerged when we analysed the reasons why our triage decisions were out of line with validated tools. These included patients in hospital settings taking precedence over those in prison, patients admitted without prior discussion at bed management meetings, legal urgency taking precedence over clinical and lack of available HDU space.

Prior to the introduction of the DUNDRUM triage urgency manual the audit demonstrates that the team's triage decisions were not in line with validated tools. This improved following training and use of the tool at bed management meetings. The Orchard Clinic has now formalised use of this tool within bed management meetings. We are currently in the process of re-auditing over a 12-month period.

National guidelines (NICE) recommend that prolactin should be monitored every 12 months for patients on antipsychotics, excluding patients on aripiprazole, clozapine, quetiapine or on doses of less than 20mg daily of olanzapine. The purpose of this audit was to investigate whether patients under our services who are prescribed antipsychotics implicated in causing hyperprolactinemia, were having regular annual prolactin measurements as per the guidelines and whether abnormal results were being actioned appropriately.

A total of 61 patients were surveyed, as a random selection from the Outpatient Consultant case load in Rochdale CMHT. This was a retrospective analysis looking at annual prolactin measurements over 5 years between 01/01/2017 and 31/12/2022. This included all patients who had been stabilised on an antipsychotic for more than 2 years, and excluded patients on antipsychotics that did not cause significant prolactin rise (and so do not require annual prolactin measurements as per NICE guidelines).

Our results showed that the majority of patients were not having regular annual prolactin measurements, with only 3.3% of patients having prolactin measured annually 100% of the time. 23% of patients had no prolactin measurements at all while on antipsychotic treatment during the time period assessed. In cases were there was an elevated prolactin reading, only 15% of these readings had a documented action plan.

This audit has demonstrated that the overall compliance with the NICE standards for annual prolactin monitoring for people on antipsychotic medication is of a poor standard, and we highlight possible reasons why this may not be done and areas for improvement.

This study aimed to assess the post-discharge follow-up processes for psychiatric patients, specifically focusing on a 72-hour follow-up with documented Mental State Examination (MSE) and the presence of a comprehensive care plan, including up-to-date risk assessments and handover documentation.

Conducted across three psychiatric units – Heddfan, Ablett, and Hergest – and associated Community Mental Health Team (CMHT) sites within Betsi Cadwaladr University Health Board, the audit spanned eight weeks (14/08/2023 to 16/10/2023). Adhering to NICE guidelines (NG-53) and CCQI Standards for Community-Based Mental Health Services-2017, data collection focused on the specified criteria.

Analysis revealed that 23% of patients did not receive a 72-hour follow-up post-discharge, attributed to reasons such as patient refusal or missed appointments. Only 74% of patients had documented risk assessments, posing challenges to follow-up teams. Despite the hospital's controlled environment, transitioning patients into the community demands updated risk assessments. While 87% of patients had documented mental state examinations during follow-ups, there's room for improvement in this crucial activity.

In summary, the study emphasizes the importance of meticulous documentation and communication in the transition from inpatient psychiatric care to community settings. Challenges in achieving comprehensive follow-up documentation, with only 67% meeting criteria, were identified. The presence of an online Medication Therapy and Electronic Discharge system faced obstacles in printout availability. Designating a responsible individual for care plans pre-discharge and commendable adherence to thorough assessments during inpatient stays (83%) underscore efforts for a holistic approach. Future enhancements should target improving medication information integration and fortifying collaboration between inpatient and community teams. Addressing these aspects not only prevents medication-related errors but also ensures a seamless and patient-focused transition, enhancing the overall quality of mental health care delivery.

Additional Authors: Dr Minahil Junaid, Betsi Cadwaladr University Health Board, Rhyl; Dr Moheet Rahal, Betsi Cadwaladr University Health Board, Rhyl; Dr Aanika Nawr Hoque, Betsi Cadwaladr University Health Board, Wrexham; Raghdah Faisal, Betsi Cadwaladr University Health Board, Bangor, Amin Rezk, Betsi Cadwaladr University Health Board, Wrexham; Mostafa Negm, Betsi Cadwaladr University Health Board, Wrexham.

To compare current practice in local Rehabilitation in audit across North and West Rehab Kent units against standards of ‘Triangle of Care’.

Standard 1.3:

Carer's views and knowledge are sought throughout the assessment and treatment process.

Standard 5.2:

An early formal appointment is offered to the carer to hear their story, and history and address the carer's concerns.

Standard 5.10:

The carer is involved in the discharge planning process.

A previous audit was conducted in 2019 using Triangle of Care and AIMS standards. We decided to see whether the standards have been upheld.

We included all 43 patients admitted over the previous 6-months. No patient had National Opt-Out. The source of information was the RIO system. The data were analysed by 2 investigators.

A data collection form was used:

Question for Standard 1.3: Were the carer's views and knowledge sought throughout the assessment and treatment process? If this was not the case, the reasons were to be specified.

Question for standard Standard 5.2: Was an early formal appointment offered to the carer to hear their story history and address the carer's concerns?

Question for standard Standard 5.10: Was the carer involved in the discharge planning process?

Standard 1.3:

83.72% had contact with a variety of team members throughout their relative's admission. Reasons for non-involvement included lack of consent, unavailable carers, non-attendance, and carer's preference.

Standard 5.2:

Only 60.53% of carers had an early appointment offer, and the expectation that this should occur in 80% of cases was unmet.

Standard 5.10:

(90%) of the patients had carers involved in the discharge planning process, meeting the required standard.

Best Practice:

The audit results demonstrate that carers are involved in their relative's care throughout the admission and discharge process.

Lessons learned:

Compared with the previous audit in 2019, when the criteria for Standard 5.2 were met, carers were offered a formal early meeting significantly less often. Possible reasons could be the pandemic and resulting changes in practice have certainly led to a reduction in face-to-face meetings. Offering individual time to all carers is essential, and efforts should be made to integrate this into practice.

Next steps:

To allocate a team member to offer a meeting with the carer.

To discuss the outcomes with the Carer Champions on each unit, to review what form their support currently takes, and consider how this could link in with the requirements of Standard 5.2.

To re-audit in 1 year.

To ensure that there is a clear rationale for commencing service users on psychotropic medications.

To ensure that the prescription of psychotropic medications is evidence-based and that they are in line with the Trusts and NICE guidelines.

Ensure that psychotropic medications are regularly reviewed by the managing team.

To ensure that information about medications is adequately shared with patients and carers.

To ensure that service users are well-monitored for side effects.

A 2-week retrospective audit on Phoenix ward.

Clinical information from all the current service users on psychotropic medication was reviewed.

The clinical information was collated from all 8 service users’ medication cards, ward round documents, MDT reviews, and electronic notes (PARIS), and these were analyzed by the inpatient specialty registrar.

1. 1. We attained a 100% mark in some areas of our prescribing such as indicating the rationale, the maximum dose for medication, and also prescribing within BNF limits.

2. 2. We however could not evidence proper information sharing with patients (only 40% documented).

3. 3. We could not evidence sufficient information sharing with carers (only 20% documented).

4. 4. PRN medication was mostly prescribed as a range rather than a clear dose, which gave rise to subjective dispensing bias.

5. 5. Side effect monitoring was documented for 85% of patients, meanwhile, the standard for this is 100%.

Clinicians are to ensure that medication information is always shared with service users, and their carers, and this is documented.

Clinicians are to also ensure that PRN medications are prescribed as a single dose rather than as a dose range.

Ward staff are to ensure that they are monitoring side effects and documenting these clearly on electronic notes and ward round documents.

The MDT is to ensure that all regular and PRN medications are reviewed regularly during ward rounds.

Present this audit, share relevant findings with the clinical team, and monitor the implementation of the action plans by doing a reaudit in 6 months.

• • To find out the proportion of patients for whom the dates of births of their children, age and their due date were recorded during their initial assessment as a means of reducing risks through safeguarding.

• • According to the Royal College of Psychiatrists: Standards for Community Perinatal Mental Health Services 5th Edition (2020), Under Section 5 – Rights, Infant Welfare and Safeguarding: during the initial assessment, the baby's age and date of birth and mother's due date should be recorded as part of the infants' physical and emotional care needs assessment.

• • All new patients discussed during multidisciplinary team meetings within a 2 month period from 01/08/2023 to 30/09/2023 were identified

• • Their clinical records were audited.

• • This information was cross-checked with the information provided on their referral letters.

• • Patients attending preconception counselling were excluded.

• • The initial results were presented in one of the multidisciplinary team meetings.

• • The recording of the children's ages, date of birth or due dates of their mothers was re-audited two months later.

Audit

• • A total of 70 new patients were discussed within the initial two months period.

• • 25 out of the 70 (36%) did not attend their appointments and two patients (3%) cancelled their appointment.

• • 1 patient who attended for preconception counselling was excluded.

• • Of the remaining 42 patients that were assessed, 6 (14%) were primigravida while 36 (86%) patients were multiparous patients.

• • 15 out of the 42 (36%) had their children's age, dates of birth and due date recorded while 27 out of the 42 (64%) lacked this record.

Re-audit

• • A total of 65 patients were identified during the re-audit period

• • 18 out of the 65 patients (28%) did not attend their appointment and one patient cancelled her appointment.

• • One patient that attended for preconception counselling was excluded from the re-audit process.

• • Of the remaining 45 patients that were assessed, 2 (4%) were primigravida and the remaining 43 (96%) were multiparous women.

• • The age, dates of birth and the due date were recorded for 26 (58%) out of 45 patients while 19 out of the 45 patients (42%) did not have this record.

• • The children's ages were commonly recorded compared with their date of birth.

• • Gestational ages of the pregnant mothers were commonly recorded compared with their due dates.

• • Date of birth is needed for a quick check on a child for safeguarding reasons and this is useful during the admission of mothers onto a mother and baby unit.

• • The re-audit showed a significant improvement in the documentation of this information in the patients' records.

Sleep disorders, such as insomnia, are common in the general population and in patients with psychiatric conditions including the behavioural addiction Gambling Disorder (GD). The NHS Southern Gambling Service (SGS) is a tertiary centre providing evidence-based assessment and treatment for people affected by GD across the South-East of England. We aimed to assess the prevalence of sleep problems in help-seeking adults with gambling difficulties, including the association with gambling severity and other measures of psychopathology, and determine if 1) sleep is appropriately assessed and 2) whether sleep disorders are appropriately diagnosed and managed, in line with NICE guidelines, in this particular cohort.

All patients referred from September 2022–October 2023 who completed an initial clinician assessment were included. Gathered data included age, gender, pre-existing physical health conditions, and scores from the following questionnaires: Gambling Symptoms Assessment Scale (GSAS), Pathological Gambling Yale-Brown Obsessive Compulsive Scale (PG-YBOCS), Brief Pittsburgh Sleep Quality Index (B-PSQI), Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder 7 (GAD-7). Data analysis was performed under ethical approval (23/HRA/0279). Relationships between gambling severity and sleep quality, and depressive/anxiety symptoms were explored (using Pearson correlation coefficient). In patients with a B-PSQI score > 5 (suggestive of underlying sleep disorder), we determined whether sleep problems were appropriately assessed and managed.

83 patients completed an initial clinician assessment (81% male, average age 38 years). Baseline B-PSQI scores were weekly positively correlated with gambling severity on the GSAS (r = 0.18) and the PG-YBOCS (r = 0.10) and anxiety symptoms severity on the GAD-7 (r = 0.26). Baseline B-PSQI scores were moderately positively correlated with depressive symptom severity on the PHQ-9 (r = 0.39) and higher B-PSQI scores were noted in patients reporting suicidality.

54/83 (65%) patients had a baseline B-PSQI score > 5, of these, seven (13%) had a clearly documented management plan for insomnia in line with NICE guidelines.

Most patients referred to SGS had baseline B-PSQI scores suggestive of current sleep problems. B-PSQI scores were positively correlated with gambling severity and severity of anxiety and depression. Findings highlight that sleep problems are common in people presenting to the NHS gambling service, but also that there is scope to improve and extend signposting for affected individuals to receive sleep-specific support. The audit findings have been presented to the SGS team; resources for the assessment and management of sleep problems have been shared and a re-audit is planned for Summer 2024.

Additional authors: Dr. Jodi Pitt, Esther Gladstone, Dr. Peter Hellyer.

Current guidelines provide for short-term relief of symptoms using benzodiazepines, but patients, including those with complex emotional disorders often seek these medicines for longer. The current audit aims to review clinical practice in respect of benzodiazepine prescribing against national and local guidelines.

Retrospective analysis of all benzodiazepines prescriptions during the study period (March–December 2021 and January–December 2023). Data was assessed against National Institute for Health and Care Excellence, British National Formulary and local Trust guidelines using a proforma and spreadsheet. The study authors separately reviewed prescribing for separate years of the study.

In the 2021 subsample, (9/15) 60% of patients received a benzodiazepine for less than one month. All of these patients had a psychotic disorder diagnosis. 6/15 (40%) received a benzodiazepine for more than 4 weeks, with an average duration of 5 months. Of these, only one patient had a diagnosis of a Personality Disorder. 7 patients in total (46%) were offered psychological interventions. Patients receiving benzodiazepines for more than 4 weeks were offered a tailored management plan to address their use.

In the 2023 re-audit, 10/51 (20%) patients received a benzodiazepine for greater than one month. The common indications were agitation, anxiety and crisis management. The commonest diagnoses were Personality Disorder, Post-Traumatic Stress Disorder and Schizoaffective Disorder. 4/10 (40%) patients with a Personality Disorder were prescribed a benzodiazepine for more than 4 weeks. The average duration of benzodiazepine prescribing was 11 weeks.

Although benzodiazepines continued to be commonly used for a range of conditions, the proportion of patients not compliant with the one month, recommended duration for prescribing was reduced by half. There was a general reduction in the overall duration of prescribing but patients with a Personality Disorder continued to receive benzodiazepines for longer than recommended.

This audit aims to address the critical link between antipsychotics and impulsive behaviors, particularly pathological gambling, by emphasizing the importance of assessing patients' gambling history before initiating antipsychotic treatment. The focus is on patients under the care of the Bolton Early Intervention in Psychosis (EIT) service, with the aim of meeting the standard set by NICE guidelines, ensuring that 100% of patients started on antipsychotics are asked about their previous gambling history.

Data was collected from prescription and shared care protocol lists for patients prescribed antipsychotics in the last six months. The PARIS progress notes and clinical correspondence were then searched to determine if patients had been asked about gambling.

The audit revealed a significant gap in the practice, with minimal adherence to NICE guidelines regarding assessing gambling history before prescribing antipsychotics. Out of 35 patients, only one was asked about gambling history.

The recommendations for improvement include incorporating a gambling prompt into the medical review proforma, educating the team about the importance of this assessment, and adding the Problem Gambling Severity Index to the initial review by EIT.

The NICE guidelines NG97 (1.5) currently recommend to consider memantine in addition to acetylcholinesterase inhibitors in the management of moderate to severe Alzheimer's dementia, if tolerated, as opposed to the mono-therapeutic management with either class of drug. This management practice was adopted by the trust and updated on Trust guidelines.

I noted that most of the patients on follow up in memory clinic, had a generic diagnosis of dementia subtypes, without a mention of the degree of severity of the illness and as such, on monotherapy.

Aim

This audit serves to establish the practice in recent years, if patients diagnosed with dementia, were diagnosed, and managed according to the severity of their condition.

If not, for necessary changes to be implemented in practice and a re-audit carried out.

The audit was conducted in February 2023 as a retrospective study. We analysed records of 60 patients seen for a diagnostic appointment in Middlesbrough Memory Service between January 2020 and December 2020.

All referrals made to the memory clinic within 2020 were retrieved from trust electronic records and 5 patients were selected at random from each month using the google random number generator, and analysed on Excel.

The most common dementia diagnosis was mixed dementia (Alzheimer's + vascular disease) with 40% of diagnoses, followed by Alzheimer's disease at 39%, while Lewy body dementia was least diagnosed at 8%.

Assessment: Only 46 records completed the dementia diagnostic pathway (initial assessment, ACE III, CT scan alongside pre-referral blood screen), the other 14 patients were unable to complete this pathway due to functional decline.

Severity of illness: Of the patients evaluated, only 7% had the severity of disease in their diagnosis, which were all Moderate severity. 93% had generic diagnosis.

Pharmacological Treatment: 46 out of 60 patients evaluated, were on medication.

And all were on monotherapy, irrespective of disease severity, with majority being on anticholinesterase inhibitors (Donepezil) being the first and most popular choice.

Severity of disease condition were not identified or documented.

The use of combination therapy is yet to be considered at the diagnostic stage. This should be implemented before discharging a patient with moderate to severe disease. Although, local best practice is to offer this as early as moderate disease is identified.

Combination therapy is yet to be adopted in the organic pathway.

To determine if the physical health monitoring of day-care patients in the Adult Eating disorder service (AEDS) is done in line with the recommendations of NICE guidelines and relevant Medical Emergencies in Eating Disorders (MEED) Guidance on Recognition and Management.

1. For every attendance of patients to the day-care Clinic it is expected that the physical health monitoring to be offered would include:

• • Weight

• • Height (if first attendance)

• • BMI

• • HR (Pulse rate)

• • Sitting/Standing BP

• • Temperature

2. Relevant blood tests and ECGs on a schedule based on patient's BMI or as needed based on clinical indication.

23 patients were identified as having been seen in AEDS day-care centre between April 2021 till the point of discharge. 9 were deemed inappropriate due to incomplete information. Of the remaining 14, 9 patients were randomly selected, their documentation were looked from admission to day-care to the point of discharge. The monitoring was audited at 3 points of contact over the course of their first clinic appointment, the middle and point of discharge.

1. 1. Comparing data from previous audit, the average admission in day-care decreased from 5.5 to 3.5 months.

2. 2. There was overall improvement in the ECG and blood test monitoring.

3. 3. At the admission and the last assessment there was 100% monitoring of BMI, weight, blood pressure and pulse.

4. 4. There was a drop in temperature monitoring by 11.1% in the first and last assessment due to faulty equipment.

5. 5. The ECG and bloods percentage dropped by 11.1% at all the monitoring points.

6. 6. At the midpoint there was no documentation of BMI, Blood Pressure, and pulse for 1 patient.

1. 1. Investigations were delayed from the patient's side.

2. 2. Due to COVID there was difficulty in accessing the primary care appointments for investigations.

3. 3. The temperature equipment was not working properly.

Recommendations:

1. 1. Keeping a fixed format for documenting day-care visits on the SystmOne software. A Sample format made available for documentation.

2. 2. Document all the parameters checked in the patients’ electronic records on the same day.

3. 3. Day-care clinical team to upskill on ECG via training.

4. 4. Team Resources to be allocated to have in-house ECG in day-care.

5. 5. SUSS test to be done for all RED (High risk) patients as clinically indicated and clearly document in the notes, e.g. SUSS: done/not done and reason with date SUSS conducted on.

To assess whether patients admitted to the forensic secure rehabilitation ward are transferred with their physical health notes.

Most patients admitted to secure rehabilitation do not have an open GP record due to last registration with primary care having been many years previous as a result of a lengthy prison/hospital stay. Additionally, patients may be referred from an out of area prison or hospital. A comprehensive psychiatric history paperwork is obtained at referral. This audit was to assess how many patients currently on the rehabilitation ward arrived with complete physical health notes. We defined a complete set of physical health notes to mean:

1. 1. Records from medical consultations linked to physical health during time in prison or psychiatric hospital.

2. 2. Any physical health history prior to current incarceration/admission episode from primary and secondary care.

3. 3. Complete prescription of physical health related medications including allergies, doses, regime, and indication.

Retrospective review of patient electronic records sent by discharging institution when the patient was transferred to the rehabilitation ward.

Data collected: List of documentation of patient's physical health records around transfer time. Identification of the contents of the records provided by the transferring ward.

We then compared the information available to our criteria for complete physical health notes.

Participants: All current residents of the male secure rehabilitation ward (n = 12) were included.

7 out of the 12 patients included were transferred to the secure ward with notes that fulfilled the criteria as set by audit team.

Two patients were transferred with only the prescription of current medications. There was however, a brief physical health summary in care coordination notes sent earlier.

One patient was transferred with the prescription and a brief list of their past medical history.

The remaining 2 patients were transferred without any formal physical health documentation prior to transfer, however, they were transferred from an adjacent ward and therefore, all records were already on the electronic records. There was no formal verbal or written physical health handover.

It is important for our ward to ensure we have comprehensive and complete physical health summary for each patient on admission.

A proforma will be used at preadmission meetings from February 2024 to request specific information from discharging wards. We will re-audit in February 2025 to assess improvement in records requested and obtained.

This audit assesses the adherence to and effectiveness of rapid tranquilization protocols in a tertiary care psychiatric facility in Pakistan, particularly focusing on the use of intramuscular (IM) haloperidol and promethazine. The evaluation also includes an analysis of how these practices align with the prescribed guidelines for managing psychiatric emergencies.

A comprehensive retrospective analysis of patient records from January to December 2023 was conducted. The focus was on assessing the sequence of interventions (de-escalation techniques, oral medication, IM administration), medication choices, adherence to protocol steps, and documentation of patient monitoring post-administration. Descriptive and inferential statistical methods were applied to analyze the data.

Among 482 patient records:

The primary diagnoses included schizophrenia (44%), bipolar disorder (29%), and severe depression with psychotic features (27%). IM haloperidol and promethazine were predominantly used, with 68% of cases bypassing oral medication or de-escalation attempts. Only 60% of cases showed adherence to the recommended protocol steps, including assessment for medical causes and optimization of regular prescriptions. In 12% of cases, a second injection was necessary, with the interval between injections undocumented in 15% of these cases. Vital monitoring post-administration was not recorded in 30% of cases. Medication unavailability was an issue in 8% of aggressive cases. Protocol deviations included the omission of recommended pre-treatments, such as ECG for haloperidol and the lack of alternative options like buccal midazolam or inhaled loxapine.

The audit reveals significant deviations from established guidelines in the rapid tranquilization process. The frequent omission of non-invasive interventions and the lack of consistent monitoring and documentation practices highlight areas needing immediate improvement. Training in de-escalation techniques, adherence to step-wise intervention protocols, and ensuring the availability of a range of medications are crucial. This study underscores the importance of aligning psychiatric emergency practices with established guidelines to ensure patient safety and effective treatment outcomes.

This audit aimed to assess the recognition and management of perimenopausal symptoms in women diagnosed with depression at the Psychiatry Outpatient Department (OPD) of Benazir Bhutto Hospital, Pakistan. It focused on identifying gaps in screening for perimenopausal symptoms among these patients.

Conducted over a year, this retrospective audit included 250 women aged 45–55 years, previously diagnosed with depression. Post-diagnosis screening for perimenopausal symptoms was performed using the Menopause-Specific Quality of Life Questionnaire (MENQOL) and the Greene Climacteric Scale. Data on initial diagnostic criteria, treatment modalities, and patient outcomes were reviewed. Follow-up interviews provided insights into ongoing symptom management and treatment satisfaction.

The retrospective screening revealed that 78% of these women had significant perimenopausal symptoms per the Greene Climacteric Scale, which were initially overlooked. MENQOL results showed 65% experiencing a substantial impact on quality of life due to menopausal symptoms. Treatment primarily consisted of antidepressants (used by 82% of patients), while 8% received psychological counseling, and 10% were advised on lifestyle adjustments and non-hormonal therapies. Only 45% of the patients reported satisfactory symptom management, indicating a potential discrepancy between the treatments for depression and the underlying perimenopausal condition.

The audit at Benazir Bhutto Hospital demonstrates a high incidence of undiagnosed perimenopausal symptoms in women treated for depression, suggesting a critical need for improved screening protocols. The results indicate that integrating perimenopausal symptom assessment into the initial diagnostic process for depression could lead to more effective, individualized treatment strategies. This approach may enhance the overall treatment satisfaction and quality of life for perimenopausal women, underscoring the importance of holistic patient care in psychiatric settings.

1. 1. To evaluate standards of practice regarding initiation and administration of covert medication(s), with comparison to the previous audit completed in January 2021.

2. 2. To highlight improvements and weaknesses requiring further recommendations for effective future practice.

This clinical audit assessed the current practice in Amber Ward (Old Age Ward for Dementia patients) against the same standards of practise used in the previous audit.

The Audit Checklist included 10 standards from Maudsley prescribing guidelines for Covert Medication Pathway.

A retrospective review of the paper and electronic records of 21 service users initiated on a covert medication plan between January 2021 and June 2022 was carried out.

A descriptive statistic on the data and presented results in tables comparing frequencies and percentages with the data from previous audit was then performed.

1. 1. An increase in percentage of documented evidence of covert medication plan being discussed with a relative with Lasting Power of Attorney or in a Best Interest Meeting to 95% (n = 20) from 85% (n = 12) in the previous audit.

2. 2. An increase in percentage of documented evidence of pharmacy input on covert medication administration plan to 100% (n = 21) from 47% (n = 7) in the previous audit.

3. 3. An increase in percentage of documented evidence of covert medication administration in the drug charts to 100% (n = 21) from 53% (n = 8) in the previous audit.

4. 4. An increase in percentage of documented evidence of covert medication review date on the covert medication initiation forms to 85% (n = 18) from 67% (n = 10) in previous audit.

5. 5. A decrease in percentage of documented evidence of MDT discussion prior to starting covert medication plan to 90% (n = 19) from 100% (n = 15) in previous audit.

This re-audit showed some improvement with 100% compliance in 4 out of 10 standards, however, there's still room for improvement to get the compliance to 100% across all the standards.

We therefore recommended strict adherence to existing covert medication initiation plan form, with particular attention to be paid to the standard of proper documentation of the details of MDT discussions around covert medication plan initiation, as there was surprisingly a reduction noted in this standard.

Finally, we recommended that another re-audit be considered within 2 years of completion of this re-audit.

Hyperprolactinaemia has long-term complications including reduced bone mineral density (BMD). People with an intellectual disability (ID) have a greater burden of disease and reduced life expectancy compared with the general population, including an increased risk of osteoporosis and fractures. There is a higher prevalence of antipsychotic prescriptions in people with ID which increases the risk of hyperprolactinaemia. Therefore, regular serum prolactin monitoring is important in this group. The aims of this audit were:

1. 1. To identify how many patients with ID are prescribed antipsychotic medication and of these, how many have had prolactin levels measured in the last 12 months.

2. 2. To identify how many patients had elevated prolactin levels (>530 mIU/L).

3. 3. To identify if results had been managed as per current guidelines.

Data was reviewed from the Richmond and Kingston psychiatry caseloads using the electronic patient record, Care Notes. Each patient was reviewed against the inclusion criteria of diagnosis of ID and currently prescribed antipsychotic medication.

125 patient records were reviewed on Care Notes. 50 patients were excluded as they were not prescribed an antipsychotic medication. The remaining 75 patients met the inclusion criteria.

75 patients were prescribed an antipsychotic. Of the 10 different antipsychotics prescribed, the most common were risperidone (50.7%) and olanzapine (30.7%). Of those prescribed an antipsychotic, 39 (52.0%) had their prolactin levels measured in the last 12 months.

The prolactin levels measured ranged from 82 mIU/L to 4890 mIU/L. 16 (41.0%) patients had elevated prolactin levels. In those with elevated prolactin, 68.8% were prescribed risperidone.

Of the patients with elevated levels, 81.3% had their results discussed with them and treatment options considered. The majority of patients were monitored and screened for symptoms. In some cases, psychotropic medication was reduced with a view to stopping and others continued to be monitored. Two patients were prescribed aripiprazole 2.5mg as an adjunct.

Those who had not had their prolactin levels discussed were all awaiting appointments as the blood tests had been taken recently.

A key area identified is how to increase uptake of blood tests in this patient group. Closer liaison with GP surgeries and proactive discussions with patients about the importance of screening for hyperprolactinaemia may help to improve outcomes. Referral to our in-house needle desensitisation service may also be helpful.

There is also scope for future research regarding the management of hyperprolactinaemia in the ID population due to the increased risk of reduced BMD.