To improve the quality of the information included in discharge summaries to GPs from HTT. To gather the views of local GPs as to what constitutes a good discharge summary. To streamline the process for creating the discharge summaries by developing a proforma, incorporating the views of local GPs.

1. 1. A cross sectional analysis of discharge summaries sent by HTT was performed.

2. 2. Each summary was assessed if they included certain information and the reader also made comments.

3. 3. A questionnaire was sent to local GPs asking for feedback on discharge summaries they had received.

4. 4. The information from the cross sectional analysis and questionnaire were used to create a discharge summary proforma.

5. 5. The findings and proforma were presented to the HTT. The team brainstormed further ideas which were incorporated in to the proforma.

6. 6. The proforma was sent to the team to begin using.

7. 7. The cross sectional analysis was repeated 6 weeks later.

Initial cross sectional analysis:

46 patients (2 excluded).

25% of patients were discharged to the GP.

Over 80% contained all the information required.

Common issues included copy and pasting large amounts of irrelevant information, missing information, use of a lot of abbreviations with no explanation, unclear discharge medication, unclear discharge plans and not specifying who would prescribe.

GP questionnaire:

8 respondents. All GPs felt that they would want a brief summary of treatment, discharge medication (with any changes highlighted) and a plan with actions for the GP. They also felt that details of follow up with contact details for the community team would be useful. Brevity was mentioned as being of key importance, as was explaining abbreviations.

Second cross sectional analysis:

31 patients (6 excluded).

8% of patients were discharged to the GP.

12% of summaries had fully utilised the proforma and a further 16% had partially utilised it. With regards to the summaries not using the proforma the results were variable. The summaries which either fully or partially used the proforma covered all information screened for and were noted to be informative and easy to read.

A discharge summary proforma created using direct GP feedback is a useful tool to cover all the relevant information however the uptake of use of the proforma was poor. The reasons for the poor uptake would benefit from further assessment with a view to improving it further.

The Medical Emergencies in Eating Disorders (MEED) guidelines include a scoring system, the MEED Score, which is an all-age risk assessment of the physical safety and risk to life of patients with eating disorders. Accurate MEED Scores are therefore fundamental for patient safety. However, MEED Scores can be timely and confusing for unfamiliar professionals. The MEED Score Calculator is a spreadsheet consisting of a colour-coded table with each MEED Score category. Red, Amber and Green are selected based on the described parameter and totals are automatically calculated. Additional “Background and Instructions” and “Medical Management” pages explain how to use the calculator and how to manage medical issues arising from MEED Scores. The aims of the MEED Score Calculator project are to: 1) Increase confidence amongst healthcare professionals completing MEED Scores 2) Increase efficiency of completing MEED Scores

• • A preliminary survey questioning MEED Score confidence and efficiency was sent to healthcare professionals who complete MEED scores

• • The MEED Score Calculator was created using Microsoft Excel

• • Upon completion of the survey, the MEED Score Calculator was distributed via email

• • Three months later, the secondary survey was sent to users, focusing on calculator use and the impact on MEED Scoring efficiency and confidence

• • 20 participants completed the preliminary survey

• • 10 participants completed the secondary survey

• • 60% of respondents now use the MEED Score Calculator when completing MEED Scores

• • 0% prefer not using the calculator (40% haven't completed a MEED Score since having Calculator access)

• • 60% of respondents report increased confidence completing MEED Scores

• • 89% of respondents report reduced time spent completing MEED Scores

• • *Result collection ongoing

The MEED Score Calculator increases confidence and efficiency of MEED scoring amongst healthcare professionals, achieving both aims.

Furthermore, due to positive feedback from eating disorder professionals, the MEED Score Calculator was included in the Kernow Local Medical Committee newsletter to raise awareness amongst Cornwall GPs. It is also due to be added to local clinical referral guidelines for GP referrals to eating disorder services. Additionally, we aim to make further improvements to the Calculator based on user feedback.

We hope for knowledge of this simple tool to spread throughout relevant primary and secondary care settings, making MEED Scoring more accessible and quicker for healthcare professionals. We anticipate that with this, we will see improvement in the robustness of physical monitoring and the quality of referrals. Thus, reducing risk of adverse physical health outcomes in this vulnerable cohort.

The licensed indications for Sodium Valproate are narrow however the medication is commonly prescribed amongst mental health services in the UK. Such practice can be associated with ineffective and poorly tolerated treatment, especially given the limited evidence re efficacy of 'off label' use of Valproate.

Aims and auditable outcomes

• • Annual review of risk benefit balance for those on continued Valproate treatment to include asking about adverse effects, medication adherence and therapeutic benefit Any 'off label' prescription of Valproate, should be explained to the patient and documented

• • Clinician's reasons for initiating Valproate treatment should be documented in clinical records

• • Plasma level monitoring of Valproate treatment should not be used unless there is evidence of concerns about medication adherence, dose related side effects and/or ineffectiveness

• • Prior to initiating Valproate, the following should be documented in the clinical records: Full Blood Count (FBC), Liver Function Tests (LFTs) and Weight and/or BMI

• • Review within first three months of Valproate treatment should include: Screening for common side effects and assessment of the response of treatment

Only 7 of 51 patients on the ECRS caseload were eligible for the study i.e. currently prescribed Valproate, irrespective of age.

Audit forms provided by POMH team. Clinical records used to complete included all electronic/paper notes, letters, and other patient information available to clinical team.

Due to nature of information required we involved doctors and nurses from the clinical team.

6/7 (86%) of patients had clinical reasoning for Valproate prescription documented in their clinical records - 5/7 (71%) were prescribed 'off-label' - mainly as adjunct for refractory Schizophrenia.

7/7 (100%) of patients had a documented review in the past year which included asking about adherence to their Valproate medication.

2/7 (29%) of patients had plasma monitoring of Valproate treatment in the past year as part of routine hospital admission blood tests. No evidence of concerns for the other patients documented otherwise.

5/7 (71%) had treatment initiated with Valproate more than 5 years ago, hence unable to see if prescription initiations were explained to patients due to lack of historical records.

First cycle of this internal audit which forms part of a wider national prescribing audit, demonstrates that the ECRS team are generally meeting current standards for Valproate prescription.

Despite the majority (71%) being initiated >5y ago - 86% of our patients have documented clinical reasons for ongoing prescription, with100% having a documented review in the past year.

Raising concerns is a duty for all doctors. However, a scoping exercise within a large mental health Trust demonstrated that trainees experience difficulties in raising both patient safety and training concerns. As part of a trainee-led quality improvement (QI) project within this Trust, our aim was to develop a pulse survey to capture the current likelihood of trainees raising concerns and factors influencing this.

An online survey was developed using ‘plan do study act’ (PDSA) methodology. The initial draft was informed by data from the Autumn 2021 scoping exercise. The survey was refined using a collaborative trainee-led approach. It was tested by trainees involved in the QI project followed by two other trainees and was revised accordingly.

Trainees across all training grades were invited to complete the survey through various communication channels. The pulse survey will be repeated monthly with a two-week response window.

Ten trainees out of 103 responded to the first pulse survey open from 18th to 31st January 2023 (response rate 9.7%). Seven respondents were core trainees and three were higher trainees.

Respondents were more likely to raise patient safety concerns than training concerns (average score of 3.8 out of 5, where 5 equals ‘very likely’, versus 3.4 out of 5 respectively). Of the three respondents who had experienced a patient safety concern in the past 2 weeks, only two had used any existing process to raise it. These data were replicated for training concerns.

No respondents were confident that effective action would be taken if they raised a training concern, while less than half of respondents were confident that effective action would be taken if it were a patient safety concern.

The reasons for the low response rate are likely varied. However, there may be some similar underlying reasons for low engagement in surveys and low engagement in raising concerns. Given this, a more negative picture of trainees’ likelihood of raising concerns may have been portrayed if more trainees engaged in the survey.

Engaging trainees to provide insight into their likelihood of raising concerns is challenging. Despite the low response rate, this initial pulse survey demonstrated that trainees continue to experience barriers to raising concerns. PDSA methodology will continue to be used to optimise the monthly pulse survey response rate. The key QI outcome measures will also be integrated into pre and post intervention surveys as a pragmatic approach to evaluate specific change ideas.

To evaluate the overall experience and satisfaction with Attend Anywhere video consultations in adult CMHT. The increased use of the digital world is evident via Ofcom Tele Report 2019. UK Government's Five Year Forward View and initiatives, such as ‘Digital First’, aim to reduce face-to-face consultations. Past reports have shown video consultations to be non-inferior to face-to-face consultations in systematic reviews and qualitative studies.The contagious nature of the COVID-19 outbreak limited face-to-face consultations. This led to video consultations via Attend Anywhere (AA). AA is accessed anywhere via the web on Google or Safari with a good internet connection. It provides a single, consistent entry point with an online waiting area on the service's webpage.

1. 1. Two separate questionnaires were designed, one each for service users and staff, to capture relevant information at the end of AA consultation. Additional clinical questions for staff included.

2. 2. Data were collected anonymously for 2 months from 1st April 2020.

Total respondent 44= 20 service users and 24 staff.

1. 1. For Service Users:

The respondents’ age range was 19-62 years, 80% females. The majority were follow-ups with three new assessments. About half of them had previous contact with the staff. 15 consultations were carried out by the doctor, four by the psychologist, and one was a joint doctor-psychologist consultation.

95% reported their overall experience to be very good-good. 90% found it easy to use: 95% said they would use it again.

1. 2. For Staff:

The respondents’ age range was 30-50 years, 87% females. The majority were follow-up assessments with one-third new. 16/24 respondents were doctors and eight psychologists. 58% had a previous meeting with service users.

83% reported the overall experience as very good to good: one third felt it's time-saving. 100% reported it's easy to use, would re-use and recommend to others.

For clinical questions, the responses were very good-good as Rapport 87%; Risk assessment 83%; care plan 83%; History taking 78%; Mental state/Cognition 66% and providing support 65%.

Overall, the majority of respondents at an Adult CMHT found video consultations easy to use with readiness to use them again. Video consultations offer several advantages over telephone reviews, e.g. for developing rapport, assessing mental state, etc.

These data are limited to the pilot project and a detailed review is planned for qualitative information with a larger cohort. Following this successful pilot and promising results, video consultations have been rolled out to other trust clinical areas.

The authors designed a unique simulation training programme exclusively for the liaison practitioners based in Aintree University Hospital Mental Health Liaison Team (MHLT). The simulation training aimed to improve the knowledge, confidence and competence of liaison practitioners through exposing them to realistic mental health related scenarios in an Accident and Emergency department (AED) and teaching them clinical skills in a safe environment.

The programme had been delivered by a Liaison Psychiatrist, core and higher trainees in once-monthly session lasting 45 minutes. Six clinical scenarios were picked based on the most common AED presentations. Scripts for all six scenarios were prepared in advance and both content and quality were checked with a liaison consultant psychiatrist. The scenarios depicted the journey of a patient being referred by the AED doctor to MHLT. Various clinical skills were embedded in the training programme including history taking, risk assessment, eliciting psychopathology, brief physical examination, managing co-morbid physical and mental health conditions, use of Mental capacity and Mental Health Act, and collaborative working with AED colleagues. Each station lasted 10-15 minutes and was accompanied by pre-briefing and debriefing with a higher trainee and experienced liaison psychiatrist for a further 30 minutes.

Liaison practitioners rated their confidence managing common but complex scenarios on Likert scales from 1 to 5 immediately before and after the session. Free-text questions explored practitioner's favourite aspects of the training, areas of further improvement and topics they would like the authors to include in the future training. Feedback had guided subsequent programme development and topic selection.

The strength of the target audience was between 6 and 15 nurses per session, with increasing attendance at each session. Dropouts were mainly related to their busy shifts in AED. On average, Likert scale scores were between 1-2 before and 5 after sessions (100% in all feedback forms), indicating a statistically significant improvement in overall confidence and competence. Participants highlighted the format, real-life performance, quality of clinical scenarios and power point slides including group discussions as the most useful aspects of the training. 100% of respondents felt that the content covered was useful and the session content was pitched at the appropriate level.

Overall, 'Train 2 Retain' Simulation training was well-received amongst liaison practitioners. Embedding simulation training can improve the confidence and skills of liaison practitioners working in a busy AED setting which will improve well-being and staff retention. The next phase in the development of the training will be to include competence-based assessment and involving practitioners from other liaison services within the trust.

Clozapine is an atypical antipsychotic used mainly in treatment resistant schizophrenia. Clozapine is known to have various side effects including neutropenia, agranulocytosis, constipation, hypersalivation, myoclonus, tachycardia, dry mouth, gastrointestinal reflux, and hypotension. Therefore, it is important that patients have regular monitoring of their physical health through blood tests and side effect monitoring. The Glasgow anti-psychotic side effect questionnaire allows patients to report side effects whilst on clozapine. This can then be used to review patients’ symptoms and treat them as required. The aim of our project was to review compliance of current blood monitoring of patients on clozapine with NICE guidelines and elucidate the effectiveness of the Glasgow anti-psychotic questionnaire in reporting of side-effects. Thirdly, we aimed to introduce a robust new monitoring system to ensure that clozapine monitoring was optimum.

Compliance of the current blood monitoring was checked by reviewing the blood results for all 68 patients on clozapine. The latest blood results were compared to observe if they were within the required timeframe as per NICE. Secondly, the Glasgow antipsychotic questionnaire was distributed to patients on clozapine and then data collated. Following, this a new computer spreadsheet monitoring system was introduced to improve compliance. This allowed patients with overdue monitoring to be flagged up.

The overall compliance for the various blood parameters varied from 3% to 100% (glucose- 3%, prolactin- 19%, lipid profile- 68%, HbA1c- 69%, liver function- 72%, renal function- 74%, and full blood count- 100%). Following the introduction of a new monitoring system the overall compliance improved as follows (glucose- 8%, prolactin- 32%, lipid profile- 81%, HbA1c- 61%, liver function- 90%, renal function- 88% and full blood count- 100%). We observed a 41% uptake of the Glasgow antipsychotic questionnaire. The most common reported side effects included hypersalivation (86%), GI side effects (nausea and gastric reflux- 64%), postural hypotension (56%) and anticholinergic side effects (blurry vision and dry mouth- 46%).

The findings show that the previous system was not effective. The introduction of a computer-based spreadsheet to flag up patients for clozapine monitoring has substantiality improved compliance with guidelines. The Glasgow anti-psychotic self-reporting questionnaire is effective in allowing patients to report the symptoms that they are experiencing. These changes continue to be utilised in our team.

An ECG should be undertaken as part of physical health monitoring for newly admitted patients and as part of antipsychotic initiation and monitoring. This project compared patient experience between a traditional 12 lead ECG and a 6 lead hand held ECG device (KardiaMobile 6L device). The intention was to make ECGs within perinatal mental health better tolerated, subsequently improving physical health monitoring. On our mother and baby unit, patients were reluctant to expose the chest area to have a 12 lead ECG performed due to factors including breastfeeding and feeling self-conscious about postnatal body changes. Inability to perform 12 lead ECGs, due to lack of patient consent, increased the chance of antipsychotic prescribing without baseline monitoring. We sought to find an alternative, more acceptable way to monitor physical health in this cohort, so we could improve the safety of prescribing medications and patient care as a whole.

Data were gathered prospectively over a three-month period, on our eight-bed perinatal inpatient unit. Each patient had a 12 lead ECG performed on admission and then a hand held 6 lead ECG performed for monitoring purposes. Patients with pre-existing cardiac comorbidities were excluded. All ECGs were interpreted by a trained clinician, and patients provided formal feedback on their experience of having a traditional 12 lead ECG and a handheld ECG undertaken.

14 patients were included. All preferred the hand held ECG compared to the traditional 12 lead. Patients felt the 12 lead ECG was intrusive, describing feelings of anxiety and being uncomfortable, particularly with the amount of wires and stickers required. With the hand held device patients felt more relaxed, found the procedure easier to have done, and that it was quicker to be undertaken. All agreed they would be more likely to have regular ECGs performed if it was with the hand held device.

Although a 12 lead ECG is gold standard, in patients who decline a traditional ECG, this handheld ECG would be a safer alternative rather than no ECG being undertaken.

Patient feedback is overwhelmingly positive towards the use of the handheld ECG device, particularly as less body exposure is needed. In addition the shorter time to undertake an ECG is advantageous within the perinatal setting, as mothers are also busy caring for their infants.

The greater acceptability in this cohort should lead to better physical health monitoring, both improving patient experience and prescribing safety.

By July 2021, we will increase the percentage of full recording of physical health data for 90% of patients

-Completion of recording (green results) was measured using Tableau Software for a 10 week period from Jan- March 2021 (baseline), then monthly during the study

• • PDSA cycles were conducted between April and July 2021 with analysis and changes tested monthly as per PDSA methodology. This informed future interventions.

• • We involved staff in designing a flowchart/protocol of how to book patients into the well-being clinic and sought opinions on how recordings could be improved.

• • In March, prior to any changes being implemented, staff were reminded to complete recording of physical health data. This improved percentage of recordings up to 62% by 1 st April.

• • Following this, a training session about the well-being clinic was arranged for all EIS staff.

• • A further session was arranged for staff to devise a flowchart of how the process will operate and generate further ideas.

• • A reminder system was put in place with the team leader emailing care co-ordinators monthly.

• • By 1 st July, percentage of complete recordings were 73%.

• • We decided to continue with the project and to increase the frequency of reminders to fortnightly. This helped to improve the percentage of complete recordings to 90% by September 2021.

• • We learnt that education and training amongst all staff was needed to improve the recording of physical health data.

• • Improved utilisation of the physical health well-being clinic helped to streamline physical health assessments and helped to reduce the workload of EIS staff (also promotes sustainability).

• • Involving staff in designing and implementing changes leads to better adherence in improving physical health recording.

• • More time was needed for the interventions to be implemented in our service (target reached later than original timeframe), but this should now be sustainable.

• • Reminder systems will need to continue to ensure that performance is maintained, with further training provided as required.

Our aim was for 80% of new referrals for behaviours that challenge within Tower Hamlets Community Learning Disability service to have an MDT coordinated approach by July 2022. This followed concerns about disjointed care and long waits for therapeutic support when being referred between different MDT branches within the service having a negative impact on patient care.

An MDT project team was formed and weekly meetings were arranged. A driver diagram was created. Our primary outcome measure was determined: percentage of referred patients per week that had MDT coordinated assessments, with data being collected manually from electronic progress notes and MDT meeting minutes. Number of referrals per week was recorded as a process measure. Baseline data were added to the Life QI web platform upon collection, allowing generation of run charts for outcome and process measures. The time-frame over which referrals were recorded was changed from weekly to fortnightly, to help differentiate graphically between zero values resulting from the absence of MDT coordination and those resulting from no referrals being received on a given week. Attempts were made to obtain service user input via easy-read questionnaires and subsequent discussion in a service user participation group. A weekly Positive Behavioural Support meeting was set up and a Positive Behavioural Support database was established, and the combination of these changes simplified data collection and gave a focus to MDT working and collaboration for these service users. Data were recorded from 28/06/2021 to 03/07/2022 initially and subsequently extended to 06/11/2022 as part of a further PDSA cycle.

A shift in proportion of service users referred with behaviour that challenges who had MDT involvement at the point of allocation was observed, to above the mean value of 0.5, commencing 07/02/2022, this shift was sustained until the project's endpoint. In terms of our process measure, the median number of new behaviour that challenges referrals per fortnightly period to psychiatry and psychology was one. This ranged from 0-4 referrals per fortnightly period, but no sustained change in this value was observed over the course of the project.

Implementing a new behaviour that challenges database and weekly meeting to focus on MDT coordinated working in those newly referred with behaviour that challenges has been successful in leading to a measurable and sustained improvement in the proportion of those service users receiving timely MDT coordinated care.

To investigate if current practice regarding the use of seclusion in an adult ID assessment and treatment unit was in keeping with the newly developed NHS Highland Seclusion Policy.

Case notes were reviewed for all patients who had had a period of seclusion between 20 September and October 2022.

Data were collected regarding the following:

• • Administration of seclusion (date; time started; medication used prior; reason for administration & duration);

• • 15 min interval monitoring (record of patient's mental & physical state including presentation, behaviour, conscious levels, respirations & appearance)

• • Review at 2 and 4 hours (including plans on how to end seclusion)

• • Documented Datix submitted and Monitoring of improvements.

Thematic analysis showed that the most common reason for the use of seclusion was due to increasing agitation and aggression.

Data collection showed that the following information was missing from case records:

• • Use of anxiolytic before seclusion;

• • Under the 15 minute interval recording - respiration rate & appearance was missed most of the times;

• • Review at 2 hours: Plans to end seclusion was often missed; Review at 4 hours: on most occasions the duty consultant was not informed. They could give valuable insight and plans on stopping seclusion if it has prolonged more than 4 hours.

• • Datix was not sent every time seclusion commenced and this is needed as it would further provide to better identify and manage patients needing it.

Seclusion places people at risk. It is vital to ensure that there is robust monitoring of the patient's mental and physical state to reduce the risks associated with seclusion and, in particular, when medication which may lead to respiratory depression has been used. Seclusion should be used for the shortest time possible - explicit consideration of when and how to end seclusion provides an opportunity to limit the length of this highly restrictive intervention and minimise the impact on the person.

The results of the audit were shared with the staff team via the Seclusion Policy Short Life Working Group and will allow subsequent drafts of the service protocol to reflect good clinical practice. Results were also shared via the internal teaching programme and at the Clinical Governance forum. An additional session will also be provided during the induction plan for new trainees. Finally, a reaudit will be done to assess changes in seclusion practice.

Gathering honest feedback on experiences of clinical rotations is vital to allow improvement of training. However, our current local systems lack anonymity, which may lead to reduced confidence in providing honest views. Aim: To provide trainees with a method of giving honest and protected feedback to improve future training posts.

A Survey Monkey feedback form which was sent to core trainees across West Yorkshire in July 2022. This allowed feedback for up to 6 rotations, meaning those finishing CT3 could retrospectively review all their placements. The data were analysed by the project leads, grouped into themes, and anonymised.

We received responses for a total of 57 posts from 23 core trainees (total trainees July 2022 = 71), some of whom responded for multiple posts. Types of posts reviewed included: General Adult (40.4%), Older Adult (24.6%), Child and Adolescent Mental Health (8.8%), Forensics (7%), Learning Disability (5.3%) and Psychotherapy/Liaison (3.5%). 10.5% of responses did not specify the speciality.Overall, respondents strongly recommended 51.8% (n=29) and recommended 12.5% (n=7) of posts to other trainees. Respondents strongly did not recommend 5.3% (n=3) and did not recommend 1.8% (n=1) of posts to other trainees. Positive themes included having a range of experiences and a supportive team. Trainees valued having a range of cases with appropriate autonomy. They liked having a job that was busy enough to gain the required experience but not too busy to impede training and learning opportunities. An accessible and supportive supervisor who provided regular supervision with completion of work based placed assessments was also important.Negative themes included lack of regular supervision and heavy workload, which impacted a trainee's ability to attend teaching and participate in other aspects of professional development. Feedback for inpatient posts suggested that physical health obligations sometimes limited training opportunities.

Our results have shown that training needs are varied between trainees. It is therefore important that trainees have honest discussions with their supervisors about their needs and areas for development. Overall, trainees would recommend the majority (64.3%) of posts reviewed, however areas for improvement were highlighted. These may include extra training opportunities and increased physical health support. The main limitation of our evaluation was the low survey uptake (32.4%) in comparison to total trainee numbers. We hope that sharing our findings with both trainers and trainees will improve future responses.

Of the medication-related incidents that have been reported in supported living placements, many involved high-risk psychotropic medications such as Clozapine, Lithium and Sodium Valproate. An evaluation of these incidents found problems with administration and inadequate monitoring. Consequently, a virtual education programme was commissioned to educate support staff in living placements in South West Hertfordshire which showed strong positive evidence that the training session improved learning and management surrounding psychotropic medication. This education programme has now been expanded to supported living facilities in the North of the trust to further ameliorate safe medication management and care provision within these placements. The aim of this teaching programme is to provide an educational platform to improve the knowledge and risks associated with Clozapine, Lithium and Sodium Valproate in an effort to reduce medication-related incidents within the placements.

Virtual training was developed and delivered for support staff across supported living facilities in the Northern directory of the trust. This teaching was collaboratively designed and delivered by a multidisciplinary team including pharmacists, doctors and nurses. The virtual nature of the session lent increased accessibility to staff members from various regions.

28 staff members from 6 support living facilities covering a resident population of over 65,000 people attended the 3-hour virtual education programme. Quantitative studies run on the pilot lecture in the high-risk psychotropic learning programme found strong evidence that this training leads to increased understanding of the administration, management and risk profiling of the aforementioned high-risk medication.

Education surrounding high-risk medication will reduce long-term incidences of medication-related adverse events. The expansion of this learning programme to the entirety of the Hertfordshire trust is a step further in improving patient care within local mental health services.

Cardiovascular death is the leading cause of early mortality in patients with schizophrenia. We audited physical health monitoring (via Lester tool) of all patients diagnosed with schizophrenia over the past year. There were 163 patients, 60% were up-to-date on blood tests, but only 28% had an up-to-date ECG. We found poor documentation of lifestyle risk factors (smoking/alcohol/weight) and recording of interventions that were offered to modify these. We felt it was important to try a pro-active model of engagement and intervention in order to improve outcomes and empower patients in collaboration with GPs.

A subset of the cohort (35 patients) were invited along for an all-inclusive check up with a doctor at the psychiatry clinic (blood tests, discussion and advice regarding lifestyle risk factors and on-site ECG utilising the new Kardia 6L) lasting 30 minutes. Information was collated and then distributed via a letter to the GP, the consultant psychiatrist and the patient.

Of the 35 patients invited to attend the physical health check-up, 18 (51%) attended. All patients then underwent physical health monitoring and discussion of how to improve their risk factors. The Kardia6L allowed for QTc monitoring to occur quickly and easily in the outpatient setting and was liked and accepted by patients. We found that most patients were overweight (88%) and were undertaking less than 30 minutes of exercise a day (50%). Half of the patients required active medical intervention (statin, blood pressure or diabetes medication). The Kardia6L allowed us to attain 88% compliance with achieving up-to-date ECGs and provided instant results to the clinicians/patients.

In this first phase of the quality improvement project we were able to show that half of the patients were willing to attend for in person monitoring. Patient engagement was better as intervention was being delivered at their usual CMHT by their Psychiatrists. The model of a shared letter between patient, GP and psychiatry encouraged shared responsibility for carrying these issues forward. From participating in the project the psychiatry team plan to review patient's medication and develop a robust intervention plan regarding weight loss/exercise/diet from the CMHT in collaboration with GPs as there are clear issues affecting our patient's health long term. The Kardia6L proved to be a quick/easy way to monitor QTc safely in an outpatient setting and allowed us to provide this as one step process at CMHT without requiring referral to Cardiology while improving compliance with annual ECGs.

1. 1. To improve ward round efficacy and efficiency.

2. 2. To make ward rounds more patient informed and create an updated ward round patient “preparation sheet”.

3. 3. To improve collaboration and communication between the multidisciplinary team (MDT).

4. 4. To review and modify ward round/Care Programme Approach (CPA) proformas.

1. 1. Quality Improvement training was delivered to the MDT.

2. 2. An anonymous Likert scale survey was completed by the MDT (n=10), to gather views on ward round experience and documentation.

3. 3. Patients: 2 interactive, breakout sessions (n=4) were facilitated to:

   • • Explore their experience of ward rounds through discussion and Likert scale questionnaires (n=4).

   • • Review the existing patient preparation sheet and coproduce a revised version.

4. 4. MDT: 4 interactive, breakout sessions were facilitated with staff (n=10) to create a:

   • • Process map of ward rounds.

   • • Fish bone diagram of the challenges within ward rounds.

   • • Reverse fish bone diagram, to consider solutions.

   • • Revised ward round and nursing proformas.

5. 5. A driver diagram was developed to generate change ideas.

6. 6. A scoping exercise was completed, comparing ward round proformas within the rehab division, to consider areas of best practice.

7. 7. A Plan Do Study Act (PDSA) cycle was initiated.

1. 1. Patient discussion and questionnaire feedback re: ward round experience was positive. Patients felt “respected”, “supported,” “understood team roles” and “plans” within ward rounds.

2. 2. Patients mostly agreed with the current format of the patient preparation sheet, however wanted a visual prompt, for their recovery areas. A diagram, “My recovery wheel”, was designed, to include diet, hobbies, mood, exercise, substances etc.

3. 3. Staff felt “respected”, and “listened to” and “understood their roles” in the staff survey; MDT proformas and time keeping were highlighted as requiring improvement.

4. 4. The fishbone diagram identified challenges within: staffing, procedural factors, time, resources/equipment, training and education, communication, proformas and patient engagement.

5. 5. New, succinct, MDT ward round proformas were designed, with focus on rehab goals, in order to facilitate the patient journey and discharge pathway.

6. 6. A ward round prompt sheet for the chair was created.

1. 1. Both MDT and patients feel largely positive re: ward round experience.

2. 2. The improved patient preparation sheet is more patient centred, after being co-produced with patients.

3. 3. The MDT highlighted multifactorial challenges pertaining to ward rounds running in an efficacious and efficient manner.

4. 4. The next cycle of the project will focus on testing the new forms and change ideas.

Multidisciplinary team (MDT) meetings provide a timely opportunity per week where a range of professionals involved in the service user's care come together to discuss patients and make an informed decisions as a team. With an increase in psychiatry community mental health team (CMHT) caseload (referrals in March 2021 were +5%), it is paramount we think of more efficient ways of running routine CMHT practises. Our aim was to identify the inefficiencies that surround the Aston & Nechelle's weekly MDT meetings & derive feasible modifications to make the protected team discussion time more efficient.

The PDSA (Plan-Do-Study-Act) cycle quality improvement methodology was used. A mixed qualitative & quantitative methodology was utilised. An observational study was carried out pre-intervention by two new members over 20 MDT meetings. Qualitative data were collected by identifying the key delays in MDT. Comparison of pre-intervention & post-intervention efficiency was established by quantifying the percentage of MDTs overrunning their allocated time. Satisfaction of the MDT members (n=10) with the new practise was also recorded via a questionnaire post-intervention. Our data collectors identified three main primary drivers: Systems, process & documentation.

The interventions under process included a structured agenda, table of patients for discussion & allocating designated roles within MDT. The primary driver of System, focused on creating AccurX proformas as a way to ease the use of AccurX (an integrated software program in Rio for securely contacting patients) during MDT. MDT members were trained informally to use AccurX & Smartcard (NHS spine search for patient demographic details). Finally, a standardised documentation style was trialled by creating proformas with a streamlined set of options under each agenda.

Pre-intervention showed that >90% of MDTs were starting late & >50% were running over the allocated time. Post QI implementations, 80% of MDTs ran within allocated time. 90% of people found the MDT has increased efficiency, with 30% rating it as ‘very efficient’.

The current CMHT MDT meetings have scope for more efficient practises. We should consider feasible modifications in the realm of system, process & documentation as a stepping stone to increase efficiency. This QI project suggests benefits for the wider implementation of such interventions to other CMHTs within the area.

After experiencing disappointment due to numerous patients not turning up to their memory assessment service (MAS) appointments as well as the effect of losing man-hours due to this we decided to investigate how best to improve the attendance rates of our MAS patients. The initial frustration occurred when several patients for multiple team members were not attending their appointments. When followed up they stated that they had not received the required letters or follow up telephone calls prompting them to attend their appointments. This led to the initial hypotheses that a formal structure was required in part to aid in the delivery of this service and improve attendance.

We initially investigated the percentage of patient's that did not attend their appointments from the period of August 2022 to December 2022. This was achieved utilising the trust's data collection team. From these initial raw data we processed and calculated the delay between appointment allocation and a letter being sent out as well as basic percentages of patients not attending each month. What we realised was that there was no strict average and our admin team were not aware of any pathway that they could utilise as a guideline for the management of patient appointments. We therefore outlined the overall process of the appointment pathway and formed this. Upon this foundation we subsequently ironed out the optimal points of contact between our admin team and patients and when this could be accomplished and documented. The aims of these points of contact overall was to improve the rates of patients not attending their appointments and improving our target of appointment attendance. We subsequently re-evaluated our patient attendance five months after the formation of the posters, which were affixed in the admin and memory nurse rooms at our base.

The results overall were quite promising and did appear to show a change based upon the formalisation of the MAS appointment pathway.

The results showed a positive improvement to the attendance rate of the MAS patients and also demonstrated the empowerment that a team can have when a formal pathway is in place. This fully completed audit cycle demonstrated the importance of such a pathway and how to address what is often a multi-faceted problem for many community based services. Our conclusion appears to support our hypotheses that a formal pathway can often improve the provision of a service.

The aim was to provide psychoeducation sessions to inpatients at a London adolescent mental health unit, admitted with first episode psychosis, at the recovery stage of admission. The COVID-19 pandemic-associated rise in admissions and clinical demand meant psychologists within the unit struggled to provide psychoeducation sessions; a deficit in care was identified and junior doctors established a psychoeducation group to meet this clinical need.

Course participants were three adolescent inpatients from black and ethnic minority backgrounds who were informal/voluntary patients approaching discharge. This ensured adequate insight into their mental health disorder and its impact on functioning, to effectively benefit from psychoeducation, and capacity to consent to this pilot programme.

Doctors liaised with psychologists, occupational therapists and nursing colleagues to create this holistic, patient-centred course, suited to patients’ current psychosocial abilities with appropriate accommodations for age, developmental level and stage in recovery.

The team provided effectual, engaging content to deliver key messages while ensuring sessions were enjoyable for teenagers. Use of repetition accounted for residual effects of psychosis such as impaired concentration and memory. Patients actively participated with use of colourful visual aids, created interactively to consolidate learning. Peer discussion and personal reflection was supported, balanced with the need for patient confidentiality.

Through post-course feedback, patients agreed sessions provided better understanding of their diagnosis and difficulties, and felt more empowered in managing their recovery. They reported highly enjoying the group and actively looking forward to sessions. Patients were able to recall key points and take home messages several weeks after content delivery, suggesting effective learning had taken place.

Doctors involved in creation and delivery of the course experienced greater rapport and empathy with patients, greater understanding of psychosis as a condition and its wider impact on the individual and their family. Deeper understanding of relapse prevention interventions allowed juniors doctors to take a more active role in discharge planning, with greater appreciation for patients’ biopsychosocial needs.

Psychoeducation sessions were highly impactful for patients and doctors involved, and are anticipated to have a positive effect on prognosis, likely reduced relapse rate and increased engagement with community care. The earlier deficit in care was successfully filled through this doctor-led psychoeducation course.

Next steps involve standardising content and training colleagues to deliver a more extensive course to larger numbers of inpatients. The project has been heavily patient-centred with involvement of young people throughout, and aims to consult more closely with patients during further development.

Valproate is a licensed medicine prescribed within mental health settings for bipolar disorder. It is a known teratogen, affecting approximately 20,000 people and costing the NHS £181 billion. This was a multidisciplinary project involving Surrey Heartlands Medicines Safety Team and Surrey and Borders Partnership NHS Foundation Trust, who developed a solution to reduce human suffering and cost by adhering to the Medicines and Healthcare Products Regulatory Agency (MHRA) valproate regulations through a clinical and digital redesign. The aim was to identify females in primary and secondary care across Surrey who take valproate for mental illness and to implement a pregnancy prevention programme for them by July 2022, using a digital clinical pathway supporting clinicians in the implementation process.

The method used was a combination of the Model for Improvement, the sequence for improvement from East London NHS Foundation Trust, UX design, and Agile project management. A valproate working group was formed with professionals from multiple disciplines to identify, understand and solve the problem. The solution was designed through co-production and project management methods that ensured a patient-centric solution.

A digital registry of all females of childbearing potential who are prescribed valproate was created. A bespoke electronic GP referral form for valproate reviews was implemented. A one-stop valproate dashboard was developed to support documentation. A live digital visualisation feature was added within the secondary care electronic patient record to ensure compliance with MHRA guidelines. Easy-to-read materials for females with learning disabilities and sensitively worded appointment letters that inform patients of the risks and importance of attending annual reviews were created. In addition, collaboration with the National Valproate Patient Safety Officer allowed the implementation of Systematized Nomenclature of Medicine Clinical Terms (SNOMED) codes to simplify the exchange of clinical information between systems.

The project has the potential to reduce harm and improve the patient experience, serving as a template for other medications with strong regulatory controls. Collaboration between primary and secondary care, clinicians, pharmacists and digital colleagues, and co-design with people prescribed valproate were essential to the success of the project. Ongoing work is required to ensure valproate-related materials are available in an accessible format for every person prescribed valproate. Valproate has also been implicated in paternal adverse effects, and this project solution is future-proofed to identify men on valproate. Through this work, people will only be treated with valproate in a way that safeguards the health of unborn children.

To provide an overview of the Royal Australian and New Zealand College of Psychiatrists’ (RANZCP) work to improve support for those with an intellectual or developmental disability.

People with intellectual disability experience significantly higher rates of physical and mental health conditions in comparison to the general population. However, there can be multiple barriers to effective health care including, but not limited to, stigma and discrimination, the training of health professionals and a failure to consider the specific needs of people with intellectual disability in health and disability policy leading to deficits in funding to support generic services or develop specialist service models.

In Australia, a Disability Royal Commission was established in 2019 in response to community concern about reports of violence against, and the neglect, abuse and exploitation of, people with disability. The RANZCP has provided information to the Royal Commission and appeared at a public hearing focused on the education and training of health professionals in relation to people with cognitive disability. In 2022, the RANZCP published new position statements on autism and intellectual disability to address the unmet needs faced by people with autism and intellectual disability and provide a foundation for future College advocacy for improving resourcing and mental health support for these groups.

The new RANZCP position statements on autism and intellectual disability make a number of systemic recommendations to address the mental health needs of autistic people and intellectual disability including:

• • providing adequate funding to ensure appropriate policy implementation

• • educating and training health providers in the mental health needs of autistic people and people with intellectual disability

• • including the voices of autistic people to support a more inclusive approach to policy development and service design

• • collecting data on the needs of people with intellectual disability who are living with mental health conditions to support better service planning and better health outcomes.

• • In response to recommendations from the Disability Royal Commission, the RANZCP is also revising its training syllabus to include additional requirements for cognitive disability and has reviewed its CPD program to determine whether CPD for the provision of health care to people with intellectual disability should be enhanced.

The RANZCP is committed to addressing the unmet mental health needs and significant challenges of people with autism and intellectual disability and advocating for improving resourcing and mental health support for these groups.