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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We gathered information about

• • The role of initial prescribers.

• • The prescribing of up to three antipsychotics.

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

• • Recorded reviews of side effects.

• • Duration of treatment.

• • Reasons for switching antipsychotic.

• • Whether clozapine was offered to patients where indicated.

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

• • Other medications prescribed alongside the antipsychotics.

77 patients were identified.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hypothesis:

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

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

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

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

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

To improve communication in a Female Forensic Intellectual Disability ward.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

To evaluate the current use of the GASS scale in monitoring patients on antipsychotic depot medications at Guildford CMHRS, we conducted a comprehensive assessment and compared it with trust guidelines. The guidelines recommend GASS scale completion at specific intervals: 12 weeks and 6 months post-initiation, annually thereafter, and at each dose titration.

We conducted a review of patient depot charts and SystmOne notes for individuals on antipsychotic depot medications, in accordance with trust guidelines. Cases were randomly selected from the total number of patients on these medications. Following the initial audit, which was shared at Guildford CMHRS, a recommendation was made for staff to utilize the GASS Scale during outpatient appointments and document scores on both charts and SystmOne. A follow-up audit after six months was performed to evaluate any improvements.

In the initial audit of 60 cases receiving antipsychotic depot injections, GASS was conducted in 8 cases (26.6%), with 7 cases (23.3%) completed within the last year. In the re-audit of 58 cases, GASS was completed in 16 cases (55.17%), all within the last year.

The re-audit highlights a notable increase in completion rates, yet opportunities for improvement persist. Additional suggestions for enhancing completion encompass regular refresher courses on Trust Guidelines, ensuring Pharmacy Team adherence to guidelines for patients on antipsychotics, and motivating medics and nursing staff to complete and document the GASS Scale. Consistent re-auditing is recommended for continuous improvement.

To improve the overall experience of IMG Doctors at BSMHFT. To demonstrate this, we targeted an increase in percentage of doctors rating their experience as excellent in our survey.

Employing the “Model for improvement”, we co -produced all aspects of project with subject matter experts (IMGs).

• • What are we trying to accomplish? We co-produced process map/aim.

• • How will we know that a change is an improvement? Co-produced survey, circulated monthly, data collected and analysed.

• • What change can we make that will result in an improvement: Co-produced change ideas from process map, survey data and weekly meetings. Commenced testing some change ideas in this phase.

  Other QI tools utilized include Driver diagram and family of measures.

• • Change strategies (PDSA cycles):

  These include:

• ◦ IMG specific session at Trust Induction. 15 minutes slot allocated to introduce project and encourage involvement.

• ◦ IMG whatsapp group.

• ◦ IMG Forum.

• ◦ Dedicated Email Inbox.

• ◦ Learning/career progression sessions.

• ◦ Social events.

• ◦ IMG representative.

Outcome measure (Aim) - 5 months of survey data obtained. An average of 10 IMGs responded to monthly survey. Data presented on statistical process chart (SPC) revealed a median value of 33% of respondents (IMGs) rated their experience as excellent.

Process measures –

• • Trust Induction – 2 PDSA cycles completed. 15 IMGS joined the Whatsapp group following induction sessions. 24 IMGs joined the IMG mailing list.

• • Whatsapp group – Completed 9 PDSA cycles. Average of 3 IMGs joined per week. 69 members at present. Data indicates informal posts, planned activities, information sharing, and spontaneous queries encouraged engagement.

• • IMG Forum – one PDSA cycle completed. 20 IMGs attended. Feedback was obtained and 63% of respondents rated the effectiveness of the session as excellent.

• • Social event – one event arranged; 16 IMGs attended.

From this phase of the QI project, we have been able to foster an increased sense of community peer support and camaraderie amongst IMGs. This is highlighted by increased numbers in WhatsApp group, mailing list and attendance at events.

The change ideas positively impacted participation, engagement, and satisfaction with the project providing a previously unavailable psychological safe space.

33% of respondents rated their overall experience as excellent from the monthly surveys that were sent out.

In terms of next steps, we aim to implement other change ideas and aim to increasing respondents’ rating as excellent to 50% by December 2024.

STOMP (stopping the over-medication of people with a learning disability, autism, or both) is a national project launched by NHS England in 2016. The objective is to curb the excessive use of psychotropic medication in individuals with a learning disability, autism, or both to manage behaviour that challenges. This means ensuring that medications are prescribed at the lowest effective dose for the shortest duration of time, and aiming to discontinue if appropriate.

We aim to broaden the implementation of the STOMP initiative to a relatively new residential nursing home in Northern Ireland that is home to individuals with learning disabilities and complex care needs. The residents are discussed at monthly MDT meetings attended by psychiatry, positive behaviour support (PBS) practitioners, activities coordinators, and nursing home managers.

The inclusion criteria for STOMP are 1. Diagnosis of learning disability, autism, or both, 2. Currently taking psychotropic medication primarily for behaviour that challenges and 3. No diagnosis of severe and enduring mental illness. Five patients were eligible for STOMP.

Outpatient letters and medication prescriptions from the time of admission were compared with the most recent outpatient letters and medication prescriptions.

The five residents were on a range of psychotropic medications including antipsychotics, antidepressants, benzodiazepines, and antihistamines. Following STOMP implementation there was a reduction in psychotropic medication for 80% of the residents.

Patient 1: Reduction in antipsychotic from 75% BNF max daily dose to 40%.

Patient 2: Previously on two antipsychotics with combined use of 75% BNF max daily dose – both medications now discontinued.

Patient 3: Reduction in antipsychotic from 69% max daily BNF dose to 50%, PRN antihistamine discontinued.

Patient 4: PRN antipsychotic discontinued from 15% max daily BNF dose, benzodiazepine use reduced by 5%.

Patient 5: Antipsychotic use increased from 25% max daily BNF dose to 33%.

There was a reduction in psychotropic medication in 80% of the residents. This is an encouraging finding and shows that the STOMP initiative can be expanded to include residential nursing homes. Despite relatively limited resources for STOMP implementation in our local service, we have shown that by keeping the STOMP ethos at the centre of our thinking during monthly MDT meetings involving nursing home management, PBS practitioners, psychiatry, and activities coordinators, we can make sustained reductions in psychotropic prescribing.

All medical staff working within NHS psychiatric hospitals in the UK are required to complete mandatory life support training. However, there is no such mandatory requirement for associated training around the effective use of the emergency medical equipment used during medical emergencies on inpatient psychiatric wards. This quality improvement project focused on developing a sustainable educational intervention aimed at all staff types within one London inpatient psychiatric hospital. Staff of all grades and roles encountered frequent difficulties and delays in relation to the emergency medical bags and equipment, including issues around skill and confidence.

A survey was initially sent to medical and nursing staff working on an inpatient psychiatric unit, which highlighted participants’ lack of confidence in using the equipment. It emerged that staff exclusively handled the emergency medical equipment during relatively rare emergencies. This resulted in unfamiliarity with the equipment and consequent difficulties in using it competently. A novel educational intervention dedicated to upskilling staff with emergency medical equipment was created, focusing on contents and use of individual equipment within the medical emergency bag. Pre- and post-intervention quantitative feedback regarding confidence and familiarity was obtained using feedback forms containing Likert scales. Qualitative feedback was also obtained.

More than six training cycles, each consisting of at least five training sessions, have now been completed with both qualitative and quantitative measures of improvement captured. Individuals noted on average a 31.62% (±3.605%) improvement in self-reported confidence and familiarity with equipment. The most frequently identified positive themes were that the intervention familiarised staff with equipment and was educational, whilst the most frequent suggestion for improvement were requests for additional sessions. From single idea to sustainable quality improvement, the team broadened and gained stakeholder support including clinical and nursing directors, pharmacy, junior doctors, nurses, and matrons.

The intervention has achieved sustainability and is being explored in other partnership psychiatric hospitals. Despite reported increased confidence in handling the emergency equipment, there is ongoing need to develop, maintain and practice these skills, across both the nursing and medical staff, to achieve better outcomes for psychiatric inpatients. Trainee psychiatrists intend to develop the project further, and the training will be incorporated as a mandatory requirement. The project links to the quality standards for mental health point 12 of the Resuscitation council UK. Next stage developments of the project include linking to feedback from emergencies as well as incorporating into existing simulation training.

To audit compliance with electronic admission documentation relating to substance use.

The initial admission forms in the electronic records of all current patients on the male ward were reviewed (n = 12). The information in core admission document was compared with other substance abuse history information on records.

Seven of the twelve patients were asked about substance misuse during their admission review. 5 patients were not asked. One of these patients had no history of substance use but his alcohol use history was also unclear in other records. 9 patients had at the very least met the ICD–10 criteria of harmful use of alcohol. 11 patients had at the very least met the ICD 10 criteria for harmful use of illegal substances. Two patients had excessive amount of alcohol use to the point of dependence since teenage. Mean age of onset of both substance and alcohol use was 11, with range of 0 to 20. The most commonly misused substances were alcohol and cannabis (11 out of 12 patients). Eight patients had abused drugs other than cannabis. All but one of these then progressed to using other substances. The reasons for using substances and attitudes to substance and alcohol use were not explored in admission assessment in most cases.

Admission assessment to a rehabilitation ward is also an opportunity to screen for any barriers to recovery as well to use brief motivational interviewing intervention if appropriate clinically. There is a need to improve the quality of our admission assessment in relation to substance use history.

Most of our patients had a very early onset of alcohol and substance use, as young as age 8. Apart from one outlier, all had started using substances and alcohol by age 15. This raises concerns regarding missed early prevention and safeguarding opportunities.

Missing data is a challenge that most researchers encounter. It is a concern that continues to be analyzed and addressed for solutions. Missing data occurs when there is no data stored for certain variables relating to participants. In health surveys, when participants answer in the form of “I don't know” or “I'd prefer not to answer”, these responses can, in many cases, be categorized as missing data responses from a participant in a specific category or question.

The eight-item Patient Health Questionnaire (PHQ-8) is an essential tool in healthcare and clinical settings to assess an individual's mental health, specifically related to symptoms of depression. The items are scored on a scale from 0 to 3 with the total score obtained by summing the scores for each item. Higher PHQ-8 scores indicate the presence of depressive symptoms.

We used empirical data from a previous study on depression symptoms in patients with coronary heart disease to study the effect of considering the answers “I do not know” and “I prefer not to answer” as missing values when estimating the percentage of depression using PHQ-8. Moreover, we studied the effect of the complete case analysis and multiple imputation on parameter estimates and confidence intervals. The outcome of this study aims to shed light on the development of missing data procedural knowledge and provide methodological support for public health decision-making when data with missing values are collected.

Furthermore, this study aims to prevent the exclusion of missing data rather than to generate data.

A simulation study with 1000 replicates was performed. Four common statistical machine learning methods for handling missing values were included in this study. These are K-Nearest Neighbor (KNN), K-Means, Classification and Regression Trees (CART), and Random Forest (RF) imputations. Five clusters were used for KNN and K-mean. Likewise, five multiple imputations were used for the CART and RF methods. The simulation was based on publicly available data with available PHQ-8 data for 1096 subjects. In the simulation study and for each replication, multivariate missing values were generated using the missing-at-random (MAR) assumption with 10%, 20%, 30%, 40%, and 50% proportions of missingness. The percent of depression was calculated using the PHQ-8 questionnaire and a comparison was made between estimated actual depression, complete-case analysis, KNN, Kmean, RF, and CART, respectively.

The Median age of the subjects was 69 (interquartile range: 61–67) and more males (72.9%) than females were included in the data. The estimated actual depression was 16.8, whereas the estimated percentage of depression varies between 6.9–13.5, 16.2–16.7, 16.3–16.7, 16.6–16.7 and 16.7–16.8 for the complete case, KNN, Kmean, RF and CART respectively.

The results of this simulation study show that missing PHQ-8 data are best handled by applying multiple imputations based on CART or RF. However, using K-Means or KNN leads to a good estimate of the true percentage of depression. Furthermore, the results of this simulation study show that complete-case analysis leads to biased estimates of the true percentage of depression. Nevertheless, further investigation is needed to address the problem of missing PHQ-8 data under the assumption of missing not at random.

UCL 5th year medical students undertake 3-week North London Mental Health Partnership inpatient psychiatric wards placements.

Before this project the management of these placements was at the discretion of individual ward teams. A varied, and potentially unsatisfactory, medical student experience resulted.

This project sought to implement a structured approach to placements.

Ward teaching best practice was, for the purposes of this project, considered to be (i) sending students a welcome email prior to placement, (ii) issuing placement timetable, (iii) using tutorial materials for onward tuition.

Project aims: 75% of wards sending welcome email, 75% issuing timetables, 75% using tutorial materials, 75% of students stating placement exceeded expectations.

This project consists of 1 PDSA cycle.

Prior to project baseline measures of ward teaching best practice were collected. The project started at the commencement of 2022/2023 academic year; duration: 12 weeks. The intervention was that inpatient medical teams were supported to send an introductory email to each student cohort, provide a placement timetable, and use supplied tutorial materials.

Questionnaires were emailed to inpatient medical teams at 6 and 12 weeks and to medical students at the end of placements. Medical team questionnaire covered engagement with best practice teaching. The student questionnaire addressed placement experience.

Outcomes at project conclusion:

• • 33.3% of wards sent introductory email.

• • 66.7% of wards issued a placement timetable.

• • 16.7% of wards used tutorial materials.

• • Less than 75% of student reported that the placement exceeded expectations.

The medical inpatient teams did not engage with this project as hoped. Feedback suggested reasons:

• • Lack of knowledge about the project.

• • Time pressures.

• • Perceived lack of medical student engagement.

• • Team had preferred teaching practices.

Despite this intervention, student inpatient placement experience remains varied.

It may have been optimistic to expect medical teams to change their established practice regarding medical students with only very modest additional support.

Some teams are enthusiastic and thoughtful about student teaching. Other are less so; this may be associated with temporary staff.

Following PDSA cycle 1 no further cycles were attempted as outcome suggested an alternative approach is required.

Possibilities for further PSDA cycles include:

• • Supporting placements via regular teaching-focused ward team meetings where expertise can be shared.

• • Appointing ward teaching fellows.

• • Explicitly rewarding inpatient teams displaying teaching excellence.

This service improvement project seeks to empower individuals diagnosed with Functional Neurological Disorders (FND) by delivering comprehensive information, facilitating informed choices about their care, and encouraging an active role in managing their health.

Information was gathered relating the concerns and expectations of FND patients upon receiving a diagnosis or attending the neuropsychiatric clinic at a regional neuroscience centre. The identification of a patient information leaflet as a valuable resource became apparent. Consequently, a meticulously designed leaflet was developed to educate patients about their condition, providing useful tips and resources. The content of the leaflets underwent a thorough series of reviews, incorporating input from various professionals within the multidisciplinary team, with additional consideration given to feedback from service users. To assess the impact of this intervention, feedback is required from both clinicians and end-users.

The patient information leaflet contains information designed to enlighten patients about their condition, incorporating psychoeducational content on self-help strategies and available treatment modalities. It also highlights support resources available to them. The leaflet can be conveniently stored in the neurology and neuropsychiatric clinic areas for easy clinician access and distribution to relevant patients. Additionally, it is available in PDF format, enabling clinicians to print it in satellite clinics, and medical secretaries can email it to patients along with clinic letters as directed by the clinicians. Initial feedback from patients and clinicians has been overwhelmingly positive, with many considering it an essential intervention.

This service improvement, realized through a relatively modest intervention, can lead to a substantial impact on patient care and satisfaction. Providing patients with pertinent information is crucial for fostering informed decision-making and empowering them to take an active role in their care. Especially for conditions historically stigmatized and misunderstood, it is imperative to disseminate up-to-date information, establishing a reliable and endorsed source to dispel stigma for both patients and their families.

Discharge letters to general practitioners (GPs) are pertinent in summarising patients' care in secondary healthcare settings and communicating follow-up management plans for continuity of care. 26 GPs from 13 GP surgeries in the West Midlands thought that discharge letters lacked important information and standardisation. We developed a quality improvement (QI) project to standardise GP discharge summaries within the liaison psychiatry services for older people in Nottinghamshire Healthcare NHS Trust. We aimed to ensure that 100% of GP discharge letters are written in a standardised format and meet the mandatory subheadings within six months.

A comprehensive literature search was performed, and we invited six GPs across Nottinghamshire to comment on the quality of anonymised discharge summaries written by our colleagues. After discussing the findings with our stakeholders, we developed a new discharge summary template with the subheadings of ‘Reason for Liaison Psychiatry Involvement’, ‘Summary’, ‘Diagnosis (if applicable)’, ‘Risk Formulation’, and ‘Treatment or Plan of Action’.

We held a team meeting and distributed a guidance document with scoring criteria for each subheading for our clinical colleagues to practise for two weeks. Subsequently, 75 discharge summaries were randomly selected and independently scored across seven weeks by an internal team member and an external QI data analyst to improve inter-rater reliability. 98 discharge summaries written six weeks before the new letter template was introduced were retrospectively scored for baseline measurement.

At baseline, the discharge summary scores ranged between 6 and 20 (out of a maximum of 20), depending on the individual completing them. The mean score was 12.3.

The implementation of the new discharge summary template improved the mean score to 19.0, irrespective of the author. The mean score was consistent across seven weeks.

Most of our colleagues did not face significant challenges in learning a new style of writing and for some, a standardised template reduced administrative time. The same GPs reviewed the new set of anonymised discharge summaries and were satisfied with the new summary format.

Formulating a standardised discharge summary template which adhered to professional guidelines was pivotal in improving the quality of GP discharge summaries. GP involvement throughout the project convinced stakeholders and colleagues to commit to a new writing template and tremendously helped achieve our project aim.

Presentations of severe Eating Disorders (ED) to the Tertiary Eating Disorders Specialist Service (TESS) in Lanarkshire have increased in recent years. Our criteria has also expanded to include severe Avoidant-Restrictive Food Intake Disorder (ARFID), increasing demand for a multidisciplinary team (MDT) approach for patients at high physical risk with less typical ED presentations. Medical Emergencies in Eating Disorders (MEED) recommends MDT working and development of pathways to support these patients.

The “EDIT subteam” was thus developed in March 2023, comprising: TESS psychiatrist, TESS GP, dietician, assistant practitioner, and TESS psychologist.

For TESS patients at high physical risk, high risk of hospitalisation, and who would benefit from a trial of “stepping up” treatment, we aimed to employ coordinated MDT intervention to 1. optimise community treatment, 2. regularly review risk and 3. reduce need for hospital admission.

Each patient was discussed at a weekly MDT meeting attended by EDIT subteam, where risk assessment and management plan was agreed.

6-month review was conducted using meeting minutes, staff survey and group discussion, with consideration given to: number of patients prevented from requiring hospital, number of patients admitted to hospital and consideration if different levels of intervention could have prevented this, staff satisfaction and review of the MDT complement.

22 patients – 17 female, 5 male – were included on EDIT for the first 6 months. At point of step-down from EDIT, 13 had ongoing TESS community input, 5 were admitted to hospital, 3 were discharged from TESS and 1 transferred to Community Mental Health Team.

Most EDIT patients received input from multiple domains of the MDT. Given baseline low admission rates and complexity of patient presentation, we were unable to determine how many hospital admissions were prevented, but consensus was that overall, a higher level of care was provided. It was not felt that different levels of intervention could have prevented any of the 5 admissions. Staff feedback was positive: EDIT improved communication, provided job role diversification, contained and shared risk, improved awareness of care plans and resulted in better-considered onward referrals.

Areas for improvement included a lack of Occupational Therapy and nursing, and concern about EDIT patients skipping waiting lists.

The EDIT subteam provides an avenue for high risk patients to be regularly discussed in an MDT setting – although impossible to empirically quantify if admissions were reduced, consensus within TESS was that the introduction of EDIT has improved community treatment for this group of patients.

To reach the target of 100% for VTE (venous thromboembolism) prophylaxis data submitted for all St Charles Older Adult inpatients.

It was found at the start of the QI project, the service was at 63% (August 2023). I reviewed this data and discussed it with the ward managers of the older adult inpatient wards and implemented two PDSA cycles. I went through the ward list of service users and noted on the database who had an outstanding VTE prophylaxis check. From this, I then created a section for the nursing handovers to include whether each service user had their VTE prophylaxis forms filled in and whether VTE prophylaxis was appropriately prescribed. The wards have a weekly MDT meeting where this could be discussed and all staff could be reminded to document the VTE data on the trust data system. I rechecked the data two months later to see if the data had improved. Following this, I created a VTE poster to be distributed via email to ward staff and hung up in the ward doctors' offices to help educate staff on the importance of VTE prophylaxis. The statistics were rechecked two months later for further improvement.

At the start of the QI, it was found that the service was underperforming in reaching its target of 100% of the VTE prophylaxis data entry for all service users in older adult inpatient wards. After implementing the first PDSA cycle, the data increased to 84% compliance (October 2023 data). After implementing the second PDSA cycle, the data increased to 100% compliance (December 2023 data). The data showed both implementations had a significant impact on the data input and the target being reached. The new strategy has now been firmly placed into the team working pattern as a routine measurement and continues to be actively utilised.

In an older adult inpatient ward setting with service users who have co-morbidities, reduced mobility and risk of dehydration from self neglect, it is vital they are assessed appropriately for VTE risk factors and prescribed the appropriate prophylaxis. Once this was highlighted to the ward staff and an easy system of the PDSAs were implemented, the team are now able to actively input the data and provide optimal care for the service users.