The audit was carried out to determine the frequency of off label prescribing of quetiapine and compliance with standards within Trust Policy (UHM PGN 02 PPT PGN 08) – Physical Health Monitoring of Patients Prescribed Antipsychotics and other Psychotropic Medicines, NICE CG178, General Medical Council Ethical Standards and Royal College of Psychiatrists – College Report CR210.

The main objectives of the audit were to determine if:

Patients have been appropriately informed of off-label status and consent recorded.

Alternative licensed treatment first used/ruled out.

Appropriate communication on transfer of care.

Appropriate physical health monitoring completed.

Quetiapine is associated with various physical side effects. Patients should be fully informed of the expected risks and benefits of treatment, and the limited evidence base for off-label prescribing.

There are additional issues around the transfer of prescribing to primary care.

The sample consisted of 50 consecutive patients selected from the crisis team caseload in the month of December 2018.

Data reviewed in this audit were taken from six months period.

Records audited were obtained from RiO (electronic records) and prescription charts.

Data collection was started in January 2019 and completed in March 2019

The audit tool was a dichotomous scale questionnaire based on NICE guidelines.

4 patients from the sample (8%) were prescribed off-label quetiapine.

100% had physical health monitoring completed as per Trust policy.

100% off-label indication been clearly documented in notes.

100% Consent to treatment was documented.

100% had medication reviewed in the previous 6 months.

75% had licensed medication used or ruled out before considering off-label quetiapine use

25% risks/benefits of treatment were documented as part of a patient discussion.

25% had documented evidence that alternative treatment options were discussed.

25% had documented evidence of Community consultant/GP consent/agreement was obtained before transfer of prescribing

75% had a documented plan for review of quetiapine for treatment efficacy and side effects

50% had a documented plan in place for ongoing physical health monitoring

Suggested a wider audit may be required with greater patient numbers and which specifically filters for patients prescribed quetiapine.

Audit result has been shared with Crisis team members, Medicines Optimisation Committee and South Locality Quality Standards Committee in the trust.

To ensure close monitoring of physical health parameters when antipsychotics are prescribed and to liaise with primary care to ensure appropriate interventions are implemented.

Antipsychotics are the most frequently prescribed psychotropic medication for PwID. Treatment with antipsychotic agent is associated with cardio-metabolic risks such as obesity, diabetes, and dyslipidemia. A strong association is well documented between antipsychotic use and the risk of stroke in schizophrenia although the magnitude of this association has yet to be studied in PwID.

PwID have an increased risk of premature death. Cardio-metabolic monitoring and appropriate intervention to this vulnerable cohort will improve the preventable cardio-metabolic multi-morbidity. The NICE guideline (CG11) recommends antipsychotic medication should only be initially prescribed and monitored by the secondary care professionals for at least 12 months. They also should work together with primary care to ensure appropriate interventions are arranged where necessary.

A retrospective audit was performed for 40 service users, taking antipsychotic medication. Quota sampling was used to identify 10 cases each from the caseload of 4 consultant psychiatrists, within the Intellectual Disability community setting, between September 2019 and October 2019.

An audit tool was designed, in accordance with cardio-metabolic measures (smoking status, height, weight, Blood Pressure, HbA1c, Lipid profile), based on physical health CQUIN targets and the Lester adaptation tool. Collection of data was performed from electronic case records and electronic blood results service. The work was performed with the approval of local clinical audit team and analysed by using Microsoft Excel.

Baseline cardio-metabolic assessment was observed in over a half of the sample population (50–65%) whilst only less than 15% was noted at 3–6 months. Documentation Evaluation of physical health assessments for new admissions to the Oleaster during the first wave of COVID-19 on body weight and blood pressure was seen only in 15% and 2.5% of population respectively at 3–6 months. Collaboration with GP for annual health check was observed in 78–100% of population.

Intriguingly, our finding indicates a significant improvement in all required compliance when nursing team is involved.

Improving physical healthcare is essential to reduce the cardio metabolic outcome in PwID taking antipsychotic medication. Better involvement of community nurses as well as availability of Sphygmomanometers at every outpatient clinic will determine the successful implementation of cardio metabolic monitoring and effective collaboration with primary care clinicians.

Once the action plan is disseminated to the teams, the impact of change will be reassessed by a re-audit in one year's time.

Physical health of psychiatric inpatients is worse than the general population. Physical health monitoring of these patients can have positive effects on outcomes. Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) states that a physical health assessment (PHA) should be completed within 72 hours of admission. This comprises a physical health form (PHF) and minimum data set (MDS): BP, BMI, TB and BBV status, alcohol and drug screen, smoking status, Hba1c and lipids. In a 2017 audit, compliance was shown to need improvement, with 28.3% of admissions not having a PHF documented.

To assess whether PHAs for new admissions to the Oleaster, Birmingham during the first wave of COVID-19 were completed in line with trust policy

To compare findings with a previous audit

To make recommendations to improve inpatient physical health and compliance with trust policy

A retrospective audit was conducted, with PHA details accessed via the electronic medical records system RiO. Admissions from 16/03/2020-30/06/2020 were accessed and 158 admissions (155 patients) were included. 21 admissions were excluded as they were internal transfers; only data from the initial admission were included. Data were collected by 2 medical students and a psychiatry trainee using a data collection tool. Data were recorded and analysed on Excel.

Of 158 admissions, 81 had PHFs (51.3%). 59 were completed within 72 hours of admission (34.3%); 39 were completed fully (24.7%). Of incomplete PHFs, 2 explicitly stated incompletion due to COVID-19. 22 PHFs were created but not completed within 72 hours. 15 gave a deferral reason e.g., refusal to consent or agitation. For 77 admissions (47.3%), no assessment was documented, with no reason given.

2 admissions (1.3%) recorded the full MDS within 72 hours of admission.

2 admissions (1.3%) had fully complete PHAs (PHF and MDS) within 72 hours of admission, fulfilling trust policy.

51.3% of admissions had a PHF, with 34.3% documented within 72 hours of admission. However, only 1.3% of admissions fulfilled trust policy of both a completed PHF and MDS within 72 hours of admission. There were more admissions without a PHF than in the previous 2017 audit; 47.33% compared to 28.3% previously. Given trust targets that a PHA should be fully completed for 100% of admissions, it was found that the Oleaster did not meet these guidelines during this period and improvements must be made to maintain integrity of patient care.

To determine the effect of the COVID-19 pandemic on referrals to mental health and physical health services.

We analysed referral data from three psychiatric services in the boroughs of Camden and Islington across 2018-2020: Early Intervention Services (for patients with a 1st episode of psychosis), Crisis Resolution Teams and inpatient admissions. We also analysed GP referral data to Cancer Services (two-week wait referrals) to Whittington Hospital, Royal Free Hospital and University College Hospital (all of North Central London). We examined the impact of the COVID-19 pandemic on these referrals and compared the findings between physical and mental health. We chose to use EIS and Cancer services as comparable services since they both operate with the two-week target of achieving diagnosis of psychosis and cancer respectively.

The number of referrals to EIS and CRT both decreased to 61% in April 2020 with respect to their baseline; EIS referrals continued to decrease to 48% in May before starting to recover. Inpatient admissions saw a smaller reduction to 87% in April 2020. The number of cancer two-week wait referrals similarly decreased and reached a trough of 37% in April 2020. The rate of recovery back to the baseline number of referrals and admissions relative to previous years differed between services, with acute care recovering faster. Referrals to CRT and inpatient admissions recovered by 98% and 115% respectively by June 2020; comparatively, referrals to EIS recovered to 102% by December 2020. In contrast, cancer two-week wait referrals returned to 106% by September 2020, a rate faster than EIS, but slower than CRT and inpatient admissions.

The reduction in the number of referrals across all examined services correlated with the first wave of the COVID-19 pandemic. The rate of decrease was similar across all services, coinciding with the peak of COVID-19 infections. However, the ultimate degree of decrease and following rate of recovery in numbers differed across both psychiatric and non-psychiatric services. These differences likely have multifactorial origins. The authors discuss contributing factors, such as changes in health seeking behaviours observed during the pandemic, potential impact of reduction in face to face consultations in primary care, as well as temporary changes in the population demographic of Camden and Islington resulting in absent target groups (i.e. students who make up a large proportion of referrals to EIS opting to return home). It remains important to not neglect mental health and face a hidden epidemic once COVID-19 pandemic settles.

Over 5 million adults in England are living with depression, with the highest prevalence rates recorded in the North West and North East of England, 12.88% and 11.53%, respectively (NHS Digital, 2019). Depression is also associated with the highest rates of self-harm and suicide (SH&S) (Singhal, Ross, Seminog, Hawton, & Goldarce, 2014). The impact of SH&S on a family ranges from shock and horror to, blame, secrecy and shame. Survivors may also be negatively judged or self-stigmatise (Cerel, Jordan, & Duberstein, 2008). Managing self-harm episodes has a significant financial implication for the NHS (Tsiachristas, et al., 2017). If high-risk individuals are identified and intervened early, it would not only save lives but also potentially reduce financial strains. The aim of the audit is to evaluate the performance of risk assessment and management of self-harm and suicide at the Reedyford Healthcare Group, Nelson, England, and to determine whether the primary care practice is meeting the standards of the National Institute for Health and Care Excellence (NICE) guidelines for adults with depression.

A retrospective audit of 62 patients presenting with depressive symptoms over 3 months was performed at the Reedyford Healthcare Group.

Two criteria from the NICE guidelines for adults with depression were included with associated standards of 100%:

All patients with depression should be assessed for suicidal ideation and intent by asking direct questions.

A patient presenting with significant risk to self/others should be referred to specialist mental health services the same day, as soon as possible.

42 patients were asked direct questions about SH&S. 2 patients presenting with immediate risk were urgently referred to specialist services. Nonetheless, all those patients at increased risk of suicide were given an increased level of support by the practice. The results indicated that the practice could improve, and a quality improvement approach has been planned.

The assessment of risk in patients presenting with depression is vital. This audit shows that it is not always done in practice. The author has not found other published audits on this topic and suggests that this may be appropriate for a national audit. This is particularly prudent with the current concern regarding mental health in the COVID-19 pandemic.

‘All cause’ mortality is higher among patients with serious mental illness than the general population and a significant contributor from this is cardiovascular disease. Mean triglyceride levels have been shown to double and cholesterol levels to increase by at least 10% after 5 years’ treatment with clozapine. NICE guidelines state all patients should have their lipids measured at baseline, 3 months after starting treatment with a new antipsychotic, and then annually.

The first aim of our audit was to identify whether patients who had been on clozapine for at least 3 months from our community mental health team (CMHT) who were not taking cholesterol lowering medication are having their lipid profile checked annually. The second aim was to see whether these patients have high total cholesterol levels and whether they had had a documented discussion about exercise, diet or lifestyle and a QRISK3 assessment.

We constructed a list of 56 patients who were taking clozapine from the CMHT. We excluded 17 patients who were on cholesterol lowering medication and would have excluded any patients who had been on clozapine for less than 3 months. We then looked at whether the patients had had a lipid profile and identified patients with a cholesterol level >5.0 to indicate a ‘high cholesterol level.’ We then searched through the last year of each of the patient's case notes to see whether they had had a QRISK assessment or lifestyle advice by searching for the words ‘diet, exercise, lifestyle and QRISK’.

36 of the 39 (92%) patients had lipid levels checked in the last 12 months. 21 of the 39 (54%) patients had a cholesterol over 5.0. 9 of the 39 (23%) patients had a documented discussion regarding lifestyle, diet or exercise in the last year. 0 of the 39 (0%) patients had a documented QRISK3 assessment.

Most (92%) patients from the CMHT had their lipid profile checked in the last year. 54% had total cholesterol level over 5.0. Only a small proportion (23%) had documented lifestyle discussion and none of the patients had a QRISK3 assessment. The results will be presented to the CMHT and we will organise teaching on giving lifestyle advice and QRISK3 assessments.

Clozapine is associated with a risk of severe adverse events for which there are current monitoring systems are in place; however, there are no established regimens for monitoring of clozapine plasma levels. Recent Medicines and Healthcare products Regulatory Agency (MHRA) guidance advises clozapine levels should be monitored in certain clinical situations where toxicity may be suspected. This audit aimed to evaluate current practice of clozapine level monitoring within one Local Mental Health Team (LMHT).

Electronic (RiO) records of 41 patients (33 male, 8 female; aged from 27 to 76 years; mean age 45 years) registered to the ZTAS system within the Nottingham City Central LMHT were reviewed. 46% had been on clozapine for over 16 years. 73.3% of patients were within clusters 12 and 13; 25.4% of patients were in cluster 11, with one patient in cluster 8. Dates of clozapine plasma level tests for each patient between 2006 and 2020 were found on the electronic NoTIS system, along with clozapine, norclozapine and total clozapine levels. Concurrent clozapine dose and regimens were obtained from pharmacy records from 2018 onwards.

273 clozapine plasma levels were conducted between 2006 and 2020. The average interval between levels taken was 10 months, 2 weeks but had a wide range, the shortest interval being 2 days, the longest being 13 years. 88 levels taken were >600 ug/L, suggesting increased toxicity risk. 108 levels were <350 ug/L, suggesting possible sub-optimal dosing or non-compliance. Statistical tests on correlation coefficient, although statistically non-significant (R = 0.37), showed a positive trend between total clozapine dose and the plasma level between all 3 parameters (i.e. clozapine, norclozapine and total clozapine).

There does not appear to be any routine plasma clozapine level monitoring throughout the LMHT with an average interval between tests of 10 months. There was a non-significant but positive trend between total daily dose of clozapine and clozapine level. 32% of clozapine levels returned were higher than the recommended level. We would recommend as suggested in the guidelines from MHRA, clozapine plasma levels should be monitored in certain clinical situations with increased toxicity risk. Trough levels should be taken with records of time of previous dose taken. Limitations of this study included a small sample size (41 patients) with data collection reliant on electronic systems. It was unclear if these results represent trough levels, making values difficult to interpret. Multifactorial impact on clozapine metabolism causes wide patient variability in plasma levels.

Attention deficit hyperactivity disorder (ADHD) is a highly prevalent disorder in young adult prisoners. This audit aimed to identify how many residents are prescribed medication treatment for ADHD in HMP Elmley and whether those seen by the prison psychiatrists have been managed in line with NICE guidelines. We also audited waiting times and time to follow-up appointments. This was done with the overall aim to identify potential areas for development.

We performed a spot audit of all residents in HMP Elmley who were prescribed ADHD medication on 4th November 2019, using their electronic patient records. Appointments with the psychiatrists were then subdivided into initial assessments and follow-up appointments for the purpose of analysis. Performance was measured against NICE Guideline [NG87]: Attention deficit hyperactivity disorder: diagnosis and management. We also calculated the waiting times for initial appointment and follow-up appointment.

We found that 33 of residents were on ADHD medication at the time of the audit, approximately 3% of the prison population. 64% of those had a pre-existing diagnosis and 36% had been given a new diagnosis at HMP Elmley. Of those newly diagnosed 100% had undergone a Diagnostic Interview for Adults in ADHD (DIVA) assessment for diagnosis.

Baseline physical health checks had been performed in 68% of patients prior to starting medication and a cardiovascular examination had occurred in 9%. At follow-up 100% of patients had their physical observations and weight checked and their symptoms reviewed.

91% of patients were started on methylphenidate or lisdexamfetamine as first line treatment, with the rest started on atomoxetine and the reason for this documented.

100% patients were offered general psychological support.

There was a mean 22 day wait for an initial appointment (range 0-65) and a mean 20 day wait from starting medication to a psychiatric follow-up appointment (range 8-37)

The number of residents treated for ADHD in HMP Elmley is relatively low (3%) compared to the estimated prevalence in prison population.

The key areas for improvement are in baseline cardiovascular examinations and physical health evaluations. The waiting time between initial psychiatric appointment and follow-up is another area where improvement is needed and this will form the basis of a quality improvement project.

Future steps include setting up a specific ADHD clinic with an allocated nurse practitioner to support, producing a template for ADHD assessments and follow-ups, producing a local policy on ADHD and developing specific resources for ADHD psychoeducation.

Initial planning during the first wave of the COVID-19 pandemic involved difficult decision making for many clinicians. The Older Adult Mental Health Wards in Bridgend were relocated from the district general hospital (Princess of Wales) and merged at Angelton Clinic, an off site separate unit. It was therefore essential that patients had clear escalation of care plans as access to medical input was limited and transfer to hospital potentially not appropriate in the later stages of chronic illness such as dementia.

The initial aim of the PDSA cycle was to assess the level of compliance with Do Not Attempt Resuscitation (DNAR) discussions and if appropriate, DNAR documentation. The other aim was to assess the utilisation of Escalation of Care plans.

An audit of patients MDT medical notes on 38 admitted to Angelton clinic was carrired out in March. It was documented if the patient had a clear DNAR or Escalation plan that was easily accessible in the front of the notes. The guidelines compared to were the GMC recommendations that patients 12 months of should have a discussion about risks and benefits associated with Cardiopulmonary Resuscitation. If the patient lacks capacity a best interest decision should be made with nearest relatives. Discussions should also be had with patients and family in in regards to and transfer to a medical ward.

Upon completion of the initial PDSA cycle, views were sought from the wider MDT a new escalation of care proforma was designed. This was implemented by education and communication with members of the medical team. This was to be clearly placed in the notes, with the DNAR form if that was appropriate.

All inpatient notes were audited at Angelton Clinic in March 2020. It was found that only 18% of patients had Escalation of Care plans in comparison to 84% of notes which had DNAR forms. Previous escalation of care forms were not being utilised appropriately.

Upon implementation of the Escalation of Care proforma, a re-audit of the audit cyle was completed. In July 2020 it was found that 78% of notes had completed Escalation of Care forms with 83% had completed DNAR forms.

To enable ongoing sustained improvement, the unit Nurse Practitioner will champion its completion. The audit findings have been shared with the newly rotated junior doctors and proformas were made available on all inpatient wards.

To evaluate if patients referred to Ealing Liaison Psychiatry Service (ELPS) with co-existing substance use are being appropriately identified as per NICE guidelines.

Patients with co-existing substance misuse have greater morbidity and mortality and it is therefore important to identify these patients to optimise their management. NICE recommends that all patients are asked about their substance use.

Anecdotally, our team felt we were doing a good job of identifying and managing such patients but we had no objective evidence of this.

Completed a retrospective audit looking at a sample of patients referred to ELPS over two weeks in December 2019.

A training session for ELPS was then held to highlight the initial audit results and NICE guideline recommendations.

We then repeated the audit over two weeks in March 2020.

Initial audit (100 patients):

Only 69% of patients asked about substance use. From those asked, 50-65.2% were using a substance, most commonly alcohol.

None of the patients over the age of 80 were asked about substance use vs 79.5% of patients aged 20–40 years.

55% of females vs 81% of males were asked about illicit substances.

33.3% of ward referrals vs 74.2% of Emergency Department referrals asked about substance use

Re-audit (53 patients):

Significant improvement across all areas

93% now asked about substance use

60% of over 80s, 96% of females and 85% of ward referrals were now being correctly asked about substance use

We were surprised to find that we were initially not meeting NICE standards regarding asking patients about their substance use.

Acknowledging this problem during our training session proved to be effective.

This knowledge will help us develop our care pathways with our Acute colleagues and the Drug and Alcohol Liaison Service.

The majority of people with dementia will develop one or more behavioural or psychological symptoms of dementia (BPSD) as the illness progresses. Treating these symptoms in diverse residential environments is a challenge, with frequent prescribing of antipsychotic medications. The risks and limited benefits of antipsychotic use in this context are well recognised, prompting national guidelines in Ireland to improve prescribing patterns.

1) Assess the frequency and appropriateness of prescribing of antipsychotic medication in older adults with BPSD referred to Psychiatry of Old Age service in the West of Ireland (Sligo) by comparing with best practice guidelines.

2) Address identified deficits via quality improvement initiatives within department.

Audit standards were set using draft National Clinical Guidelines and NICE guidelines for prescribing in dementia to develop a study specific audit tool.

Items assessed included: the frequency of review of antipsychotic use, whether or not non-pharmacological methods were trialled, if there was an assessment of benefit of the antipsychotic and discussion or risks, if a reduction/discontinuation of antipsychotic was considered, if metabolic monitoring was achieved.

Clinical records for all patients actively under the care of the clinical team with a diagnosis of BPSD were assessed using this tool at the time of the study.

49 patients with BPSD were attending the service in this time period. 58% (n = 29) of the entire cohort were prescribed an antipsychotic, most commonly quetiapine. Patients cared for at home showed the lowest levels of antipsychotic use at 50% (n = 18), while those who were in nursing home (80%, n = 8) and hospital care (100%, n = 3) showed higher rates, though this sample size was too small to demonstrate statistical significance, χ2 = 5.12 p = 0.077.

Exploration of non pharmacological management of BPSD, documentation of discussion of risks of AP medication (metabolic, cardiovascular, falls, sedation, extrapyramidal), attempt at dose reduction or antipsychotic withdrawal were all achieved in less than 45% of cases (range 33–45%).

This audit revealed higher than expected rates of antipsychotic prescribing in our BPSD cohort. It also revealed suboptimal documentation around the use of antipsychotics in this population during clinical interactions.

A subsequent intervention to the proforma assessment tool to prompt these discussions improved these behaviours, there was no impact on the rates of antipsychotic prescribing.

Despite increased attention regarding the limited benefits of antipsychotic medication in BPSD their use remains widespread. Due attention must be given to changing this practice in order to protect this vulnerable patient group.

This project was designed to evaluate the use of PRN medication and PRN monitoring charts on an adult learning disability ward. These charts had been designed by the trust to provide us with a way of monitoring the use of psychotropic PRN medication to ensure monitoring of treatment response, physical health and side effects.

The data were collected from PRN monitoring charts, electronic case notes and electronic prescribing chart records for all patients on an adult learning disability inpatient unit. The sample consisted of 7 patients who had been prescribed and/or received PRN psychotropic medication over a five week period. Quantitative data were derived by simple calculation for the total amount of PRN medication used and number of PRN monitoring charts completed. Qualitative data were collected of prescription charts and PRN protocols which is supposed to guide treatment.

Out of all the incidences where PRN medication was administered, only 64% of monitoring charts were completed. Out of the 7 patients on the ward, 6 had PRN protocol charts and for only 5 patients these were followed.

Clinical practice must be improved. The results were presented to ward staff and doctors to discuss the implications for patient care and ways to improve clinical practice by ensuring full monitoring of the use of PRN medication to help reduce the overmedication of people with learning disability by improving the use of the PRN charts. NICE guidelines and The Royal College of Psychiatrists have published guidelines on the prescription of psychotropic drugs for people with learning disabilities. NHS England have also published an article to discourage over-medication of people with learning disabilities. There is a risk that doctors are prescribing medication to treat behaviour that is an expression of distress or a mode of communication rather than a mental disorder. Doctors have a responsibility to ensure they have fully assessed the person's potential to benefit from medication before they prescribe. The audit would serve to provide a baseline for this team prior to any audits in the future.

NICE guidelines suggest baseline physical health monitoring be performed prior to commencing antipsychotics, in addition to follow-up monitoring for adverse effects for at least 12 months. ‘Shared Care Guidelines’ were adapted from NICE guidance for local use in North East Lincolnshire. Nevertheless, a local audit published in 2018 reported low compliance with baseline monitoring in community mental health teams (CMHTs) compared to inpatient teams. The parameter most infrequently performed overall was the Glasgow Antipsychotic Side Effect Scale (GASS) questionnaire.

This study aimed to assess whether compliance with baseline physical health monitoring had improved in line with the previous audit's recommendations. Additionally, it aimed to expand on previous findings by adding compliance data for follow-up physical health checks and produce further recommendations to optimise performance.

A retrospective re-audit was performed in NAViGO Health and Social Care to assess compliance with the guidelines for physical health monitoring when commencing antipsychotics in previously antipsychotic-naïve patients. Patient records were examined for which recommended physical health checks were performed at baseline, and at 1-, 3- and 6- months from commencing antipsychotics.

15 eligible patients were identified to have been commenced on antipsychotics, 8 patients under a CMHT and 7 under an inpatient team. The average overall compliance at baseline for checking 16 parameters was 50%. For the CMHT, compliance was 60%, compared to 38% for the inpatient team. Across both teams, baseline compliance was highest for renal function tests, liver function tests, and blood pressure and pulse (80%). For 1-, 3-, and 6- month checks, overall compliance for checking recommended parameters were 33%, 29% and 29% respectively. GASS monitoring compliance was 7% at baseline, 0% at 1- and 3-months, 7% at 6-months.

The CMHT performed better than the inpatient team at baseline monitoring. This may reflect action on the previous audit's recommendations to increase provision of community ‘Wellbeing Health Improvement Service’ (WHISe) clinics. However, performance of the GASS questionnaire at baseline was consistent with the previous audit, with similar performance at follow-up extending these findings.

In response, the first recommendation is for Quality Improvement Activities to help improve compliance with the ‘Shared Care Guidelines’. This may include CQUINs and further provision of community clinics to improve compliance with both baseline and follow-up checks. Secondly, it is proposed that GASS questionnaires be sent to patients prior to appointments to be completed in advance to avoid further risk of GASS being incomplete.

Audit carried out to assess whether or not patients had been asked about their smoking status during admission onto an acute adult mental health ward, as well as if they had received any smoking cessation advice or offered nicotine replacement therapy.

• • Physical health outcomes in patients with serious mental illness (SMI) are consisitently worse than the general public This is due to multiple factors; adverse effects of medication (including metabolic syndromes with psychotropics) as well as poor lifestyle factors such as smoking status

• • Patients with an SMI are 3–6 times more likely to die due to coronary artery disease. 70% of patients in inpatient psychiatric units are smokers, a strong independent risk factor for cardiovascular disease.

• • Smoking cessation is a potent modifiable risk factor that can prevent mortality and reduce morbidity.

A cross-sectional review of all 34 inpatients across four general adult acute psychiatric wards.

Patient records were explored using the Aneuran Bevan Health Board admission proformas to identify evidence of smoking status and whether advice was offered.

Smoker but not given cessation advice n = 13 (38%)

Not asked about smoking n = 11 (32%)

Smoker and given cessation advice n = 4 (12%)

Non-smoker n = 6 (18%)

Patients were asked about their smoking status the majority of the time (68%) but provision of advice or nicotine replacement therapy was only done in 14% of potential smokers (identified smokers and patients not asked about smoking status).

A consideration to be taken into account is that on admission, a patient's physical health status may be unknown, with the additional difficulty of a patient's acute distress complicating the physical examination, smoking status and modification of patient's smoking status may not be the highest priory in that context.

Data regarding asking about smoking were different amongst wards, potentially signifying differences between assessors willingness to ask about smoking status.

There is a lack of smoking cessation literature available on the wards and patients are often unaware of what options are available to quit smoking.

The audit simply determined whether or not assessors were documenting smoking status, it does not measure the quantity or quality of smoking cessation advice provided.

Further quality improvement projects should be launched, with focus groups as the intial step at further investigating inpatient smoking rates, as well as attempting to reduce them in a more systemic way.

This audit was carried out in response to the Coronavirus pandemic. The COVID-19 pandemic has forced many teams to review how they provide care to their patients. Due to attempting to reduce the spead of COVID-19, the Child and Adolescent Mental Health Service within the Northern Health and Social Care Trust largely switched to telephone reviews instead of face-to-face reviews for non-urgent outpatient appointments from March 2020 onwards. The aim of this audit was to establish whether or not service users found telephone reviews to be as useful and therapeutic as the previous standard face-to-face reviews.

A questionnaire was used to assess opinions on telephone reviews. Those who were answering the questions were asked to rate their answers on the following scale: “not at all”, “a little”, “somewhat” or “a great deal”. There was an “any other comments” section at the end where service users could give detailed opinions on how successful they thought telephone reviews were. A sample of twenty patients was involved. This cohort of twenty patients was a mixture of ten ADHD reviews and ten medication reviews. The audit was conducted by one person and this was done via the telephone.

For questions one to four (which will be fully outlined in the poster), the most popular category chosen was “somewhat” and this indicates that the majority of patients found telephone reviews somewhat better than face-to-face appointments. For question five (which was- “Overall, was the help you received good?”), 80% of service users stated that the help that they received was “a great deal” better than the help that they had received at previous face-to-face appointments. Lastly, for question six (which was- “If a friend or family member needed similar help, would you recommend that they are phoned by our service?”), 80% of service users said that they would recommend our service “a great deal” to family members or friends.

Generally the feedback was positive for the telephone reviews. However, some still outlined a preference for face-to-face reviews. There may have been bias in this audit as it was the same doctor who did the telephone reviews as conducted the audit. To conclude, telemedicine is likely to become more popular in the future especially as the Coronavirus pandemic is still currently a worldwide problem therefore it is important to explore how service users feel about this as a way of communicating with the clinicians who are treating them.

The release of the Cumberlege Report in 2020 served as a reminder of the importance of informed consent for women when they are started on treatment that may affect their fertility or future pregnancies.

Our aim was to evaluate current performance with regards to advice given to women of childbearing age around contraception, impacts of psychotropic medication on fertility and future pregnancies, and availability of preconception counselling.

Standard identified as NICE Guideline 192 (Antenatal and Postnatal Mental Health), sections 1.2 and 1.4.

60 female inpatients were selected by looking at the most recent discharges prior to 03/11/2020 from 3 local acute adult wards. All females aged between 18 and 48 years were included.

Electronic notes were reviewed for each patient. The discharge summary and last four ward round entries were reviewed, then key-word search of the patients’ records was performed using the terms “pregnan*”, “conception”, “contraception”, and “fertility”.

The following information for each patient was documented in a spreadsheet:

Discharge medication

Is there any discussion or advice around contraception?

Have women taking antipsychotic medication been given advice regarding the possible impact on fertility?

Has the potential impact of psychotropic medication on a future pregnancy been discussed?

Has advice been given about the availability of preconception counselling should they plan a pregnancy in future?

On discharge, a total of 33 women were taking one or more antipsychotics and 14 were prescribed a benzodiazepine. 24 women were discharged with antidepressants and 10 women were using a mood stabilising agent. 8 women were discharged without any psychotropic medication.

Overall, 4 women received advice about contraception, and a further 8 women were already using contraception. The impact of taking an antipsychotic on fertility was not discussed with any patient. No women were advised about pre-conception counselling. The impact of taking psychotropic medication on a future pregnancy was discussed with one woman.

Current practice falls well below the standard set by NICE. Opportunities to inform women are being missed, and this has implications for the wellbeing of the patient and, potentially, future children.

Action plan;

Present findings at teaching.

Deliver local teaching covering preconception counselling and the role of adult mental health teams when managing women of childbearing age.

Produce a poster for inpatients wards and an information leaflet for women of childbearing age to aid with discussions.

Create a poster for doctors’ offices to remind about NICE standards and documentation.

Re-audit in 6 months.

We aimed to reduce the number of patients absent without leave (AWOL) by carrying out an audit of processes around granting leave for those patients and the action taken when they absconded. We also wanted to determine factors which might be associated with patients absconding.

Nile ward is a 14-bedded male psychiatric intensive care unit (PICU). All patients admitted to the ward are under section 2 or 3 of the Mental Health Act. Patients who are AWOL may pose a risk of harm to themselves or others. The Royal College of Psychiatrists’ Quality Network for PICUs has developed applicable standards, which include criteria on developing a leave plan, actions to take when patients are AWOL and involvement of carers.

Patients who went AWOL during a six month period in 2019 from ward records. The electronic medical records for identified patients were reviewed to assess whether the following eight criteria were met: risk assessment documented; leave conditions specified; consultation with the multi-disciplinary team; crisis card provided to patients or families; risk management plan enacted when AWOL; relevant authorities informed; incident form completed; relatives/carers involved in patient's care if they consented. In reviewing the notes, factors that might have been associated with an increased risk of AWOL were also assessed in order to inform risk assessment.

Six patients were identified who went AWOL during the six month period in question. For six of the criteria, all of patients' cases met the audit standards. Five patients' did have involvement of relaties/carers if they consented, but in one case no details were available for making contact. All patients lacked documented details of crisis numbers being provided before they went on leave. Preliminary findings that might be associated with an increased risk of AWOL are differing views between the patient and the treating team on the care plan and concerns about mental state.

The audit showed many of the standards are met. However, a quality improvement intervention is planned to ensure all audit standards are met, in particular around providing a crisis card to patients and these findings will be presented on the poster, if accepted. Further research is needed into factors which might be associated with an increased risk of absconsion in PICU.

To ascertain if CTOs ensure that patients are effectively treated in the community and maintain stability in their mental health.

If a patient requires recall(+/- revocation) that this is done in a timely fashion in according to the 1983 Mental Health Act.

A number of studies have been inconclusive in determining the benefits of CTOs in reducing the re-admissions of “revolving door” patients In Assertive Outreach (AO). It is felt that CTOs have reduced readmission of patients due to the intensive input from community teams, decreased recall and subsequent revocation. Those admitted are thought to require fewer inpatient days. It is clear that many patients who require recall following non-engagement, non-compliance, will accept medication following RC review. However at present in BSMHFT patients can only be recalled if they are allocated a bed. Due to the national bed shortage, this has resulted in delays following decision to recall and thus early and effective treatment for patients. In this aspect it defeats the role of the CTO as per the 2007 MHA.

CTO data from 1st April 2018 to 31st March 2019 was obtained from all 6 AOT's in BSMHFT. The following factors were considered;

1. 1. Time between decision to recall by RC and recall to inpatient facility

2. 2. Number of recalls converted to revocations

3. 3. Number of inpatient bed days if revoked

4. 4. Number of admissions on CTO

5. 5. Patient/family agreement of CTO

98 CTO patients were recorded over this period. 19 out of 26 recalls had recall dates documented. 10 recalls were revoked due to relapse of mental illness. Average days from RC recall decision to actual recall or cancellation was 63.89 days. Main reasons for delay were bed unavailability and execution of warrant.

Following revocation, average inpatient bed days was 103.71. 41% of families agreed with CTOs, 36% of patients contested their CTO.

Over a quarter of patients on CTO were recalled to hospital however, less than half of these had their CTO revoked. The remainder accepted treatment following urgent community review whilst on the bed list. Evidently the majority of patients didn't need admission. With the ongoing bed crisis, alternative avenues need to be sought to ensure prompt treatment and prevent relapse.

A CTO suite designed for recall could be the solution for the future.

This audit aimed to analyse the patient population coming into East Surrey Hospital's Intensive Care Unit from 1993 to 2019.

The Office for National Statistics (ONS) published a report in August 2019 on ages most likely to die by suicide and drug poisoning. Their data showed that Generation X were dying by this method in greater numbers than other age groups. This is in contrast with data from 1990s for England and Wales which showed people in their 20s were most likely to die by suicide or poisoning. This audit set out to look at admission data from an intensive care unit (ICU) in a district general hospital in Surrey over a similar period of time.

Patient records from 1993 to September 2019 were accessed using the WardWatcher database. To access the maxim number of admissions qualifying under the aims, the database was accessed by searching under “admission comments” for: overdose, self-harm, poison, suicide. These reports were downloaded and the lists were checked against each other to delete duplicates. This gave a total of 331 patients. The data were analysed by year, according to age, gender, season, psychiatric diagnoses and previous overdose attempts. Their outcomes were checked against recorded deaths. There was not enough information to investigate method of overdose.

A total of 331 patient records were accessed. The youngest patient was 15 years old, the oldest was 84 years old. The age dataset was non-parametrically distributed with the median age of 43 years (IQR 33-51 years). The age distributions for each year appeared symmetrical but total numbers for each year were small. The population was split as 191 female (58%) and 141 male (42%). 16 patients died on the ICU on admission with an overdose, 5% of total numbers, of which 19% had a previous overdose attempts and 44% had a psychiatric diagnosis. The youngest death was 22 and the oldest was 81 years old. The average age was 47 years, with the spread consistent in the 2000s and 2010s.

The results from East Surrey Hospital's ICU do not reflect the analysis from the ONS. The mean age for each year has remained similar. Numbers for the audit were small and admission criteria to the ICU prescribe that the patient be critically unwell and may not be indicative of the total admissions to a district general hospital.

This audit aimed to analyse the use of neuroimaging and its effect on treatment in an older adult inpatient psychiatry unit over the period of one year.

Brain imaging can be used as a diagnostic tool in psychiatry. According to NICE guidelines, structural imaging, such as magnetic resonance imaging (MRI) or computed topography (CT), can be used in the workup for dementia diagnosis in order to exclude non-dementia pathology and identify dementia subtype. This is important in the geriatric population where evidence of small vessel disease has an impact on treatment options and management of polypharmacy.

A list of patients from the past year (January to December 2019) was accessed. Patient records were then analysed to see if neuroimaging had been accessed during their admission at The Meadows Hospital, Surrey and Borders Partnership. This included imaging from prior to admission. Analysis was divided into type of imaging, comments and impact on diagnosis.

Overall numbers for the audit were small. A total of 74 patients were admitted onto the unit, of which 3 were readmissions. There was missing information for 8 patients, giving a total of 63 patients. CT scans were accessed for 35 patients (56% of total); 3 of these were done during the admission. MRI scans were completed for 21 patients (33%), with one requested during admission. A total of 9 patients (14%) had both CT and MRI scans. Neuroimaging results led to a change in diagnosis for 6 patients (10%). In all cases this reflected the finding of small vessel disease and a change of diagnosis to either vascular dementia or mixed dementia.

Diagnoses were also analysed. The Meadows Hospital has 2 dementia wards (male and female) and 1 functional ward (for females). A total of 36 patients (57%) were diagnosed with dementia, of which the biggest groups were: Alzheimer's dementia (13 patients, 36%) and Vascular dementia (11 patients, 31%).

The majority of the patients were admitted with established diagnoses and so only a small number had changes made following review of imaging. Good imaging results and reports help to differentiate types of dementia. Although neuroimaging is not gold standard in diagnosing dementia syndromes, it is now an important aspect in the diagnostic pathway. Getting the diagnosis correct will help with treating individuals appropriately and avoid unnecessary prescribing.