To audit the investigation, identification and treatment of Vitamin D deficiency within Men's Secure Services.

Vitamin D and/or vitamin D deficiency has been suggested to play a role in the pathogenesis of mental illness. There is evidence that Vitamin D inadequacy is pandemic among rehabilitation patients in inpatient settings. Patients within secure hospitals are similarly considered to be at high risk, due to their limited solar exposure during often lengthy admissions. It has been suggested that these patients should be considered an ‘at-risk’ cohort, for whom Vitamin D supplementation should be routine. Men's secure services in Birmingham comprise of two medium secure units and a low secure rehabilitation unit. Here we present an audit of Vitamin D monitoring and treatment completed in 2019.

A three year retrospective review of electronic patient records, for all inpatients admitted within men's secure services as of 1 September 2019 (n = 188). Standards were based on the Trust accepted guidelines for management of Vitamin D deficiency.

Key findings included:-

• The majority of inpatients were Caucasian (43%) and African-Caribbean (24%). Ages ranged from 18 to 70, with a mean age of 39.

• Approximately two-thirds (65%) had been in hospital for over a year, of which 44% had been admitted for more than 3 years. The average length of admission was 885 days.

• Only 47% of patients had their Vitamin D level checked within the study period.

• Of those checked, 24% were tested within 1 month of admission. The mean duration between admission and Vitamin D testing was 464 days.

• Results ranged from 10.3 to 118.5nmol/L. A high rate of Vitamin D deficiency was identified (54%), whilst a further 16% had ‘inadequate’ levels.

• 23% of those identified as requiring treatment did not receive any supplementation, whilst 59% of those with sufficient Vitamin D were prescribed treatment.

• Only 48% had their levels rechecked following treatment; of these, only 59% now had an adequate Vitamin D status.

This audit demonstrates limited Vitamin D monitoring within male forensic inpatients. There was a high prevalence of Vitamin D insufficiency in this population, yet a substantial proportion of patients with identified deficiency were not prescribed any treatment. Ongoing monitoring and review of treatment effectiveness was poor. We argue that more consideration should be given to this population, with robust guidelines introduced for the treatment of this specific ‘at-risk group’.

Recently, there has been a greater focus on how mental health in young people (YP) can be improved. Up to 10% of YP in Scotland have a diagnosable mental health condition1 and half of all adults with mental ill-health have had symptoms from their mid-teens2. Poverty is an important factor associated with poorer mental well-being from an early age which worsens if left untreated3. The aim of this audit was to answer the question: Are more YP referred from the least deprived areas, and are they more likely to require medication intervention or high intensity (tier 4) care? The results of which could help identify possible avenues for intervention to help improve retention of those most at risk of negative outcomes.

NHS Grampian CAMHS provides service to Aberdeen City, Aberdeenshire, and Moray. Pre-collected data over 15 months from these areas were analysed using the Scottish Index of Multiple Deprivation (SIMD) deciles to distinguish any differences between referrals made. In addition, this audit evaluated the data to define any trends of deprivation linking YP to medication intervention or tier 4 care.

Results showed that more referrals were made for YP in low-ranking areas (3.19% of decile one compared to 1.74% of decile ten). The referrals were also more likely to be rejected based on the referral criteria, 33% in decile one versus 21% in decile ten. The increased rejection of referrals is most likely a reflection of the health inequalities faced by communities in more deprived areas. In terms of service provision, the patients from the most deprived areas are 3 times more like to require tier 4 care while the least deprived are 1.5 times more likely as compared to percentage of population. With regards to medication intervention patients from deciles one, five, six and seven have significantly higher numbers.

This project set out to look at the current service provided by CAMHS and found that despite best efforts deprivation has had an impact on the acceptance of referrals. Going forward this data will be shared with multiagency stakeholders to develop service provisions, in particular the issues identified with the rejection of referrals in more deprived areas. Higher level of medication use in more deprived population is not unexpected but highlights the need to share the findings with a multiagency network.

The Central and North West London NHS Foundation Trust ADHD clinic offers diagnosis and medication stabilisation for adults with ADHD, in preparation for discharge back to GP for continued prescribing and monitoring. Referral waiting time is shortened by efficiently managing the service and soon transfer of care to GP whilst referrals have been increasingly accepted years on years. A snap shot service evaluation was made to understand characteristics of service exploring its strength and areas to improve.

All 115 patients offered in March and April 2019 for an ADHD specialist assessment were sampled from the new electronic patient record SystmOne in use since 1st March 2019.

Data were collected for

Male & Female ratio

Age range distribution

Clinical Commissioning Group referral source

Clinic attendance characteristics

ADHD diagnosis, sub-types and psychiatric comorbidity

ADHD Medication prescribed

FP10 Prescription duration by prescribers

Patient data were anonymously encoded into Microsoft Excel Sheet for sorting, counting, summating and illustrating into tables and pie charts.

The male & female ratio of the sample was 6:5 and nearly half were in age range 20-29 years. Majority were referred from Westminster and West London Clinical Commissioning Groups.

107 patients completed the assessment, of which 106 were diagnosed as having an adult ADHD.

22% of follow-up clinics were cancelled or not attended (DNA) by patients. The majority of the patients (62%) required 1-2 follow-ups before transfer to GP, whilst 8% did not require or want follow-ups either already being on ADHD medication, not wanting medication or having lost to reviews. Only 3% require six or more follow-ups.

Majority were reviewed after two- to five-week prescription, the peak being four-weekly.

91% of completion to GP were discharged on ADHD medication, majority being singly on Elvanse (48%) and Concerta XL (25%). Discharge without ADHD medication was due to concerns for its addiction, preference on non-medication treatment, intolerance of medication adverse effect or mental health priority treatment.

Collaboration with GPs for their pre-treatment physical health screening facilitated prompt prescribing initiation on assessment with most discharges taken place after 1-2 follow-ups, enabling service turn-over with short waiting time (6-9 months in 2018/2019). Service expansion for increasing referral uptake is probably feasible from this baseline by appointing additional sessional clinicians and further efficiency management on clinic scheduling & DNA with a target majority likely requiring 1-2 follow-ups with average four-weekly prescribing.

This study aimed to assess the level of satisfaction patients feel towards their experience of attending for psychotherapy, in order to inform local management on the service being offered by the department.

This survey was conducted as part of routine service provision analysis by the psychotherapy department. It aimed to assess the level of satisfaction patients feel towards their experience of attending for psychotherapy, in order to inform local management on the service being offered by the department. Ethics committee confirmed this fulfilled “Service evaluation” criterion and the project was registered with the local NHS quality improvement register.

Patients who completed an episode of therapy were invited to complete a survey form. This consisted of a Client Satisfaction Questionnaire (CSQ-8) as well as four additional questions pertaining to patient satisfaction. The patient's therapist would inform administration staff of the patient's final appointment; administration staff would then issue the patient with a questionnaire which they were invited to complete and return in their own time. The questionnaires were completed anonymously and no reward was offered for completing the questionnaire. The therapies included group analysis, psychodynamic individual and Cognitive Analytic Therapy.

22 patients who had completed psychotherapy in 2018–2019 returned a completed questionnaire. The average and range responses were examined.

The average response was “4: Excellent” for the overall rating of the service received, and for 5 other questions on the CSQ-8 the average score was the highest possible. The average response was slightly lower on the question about whether the service met their needs “3: Mostly”, and on the question: Has the service you received helped you to deal more effectively with your problems? (3 yes, somewhat). The additional questions highlighted how important the setting and administration role played in the experience of therapy. The questionnaire also included a free text box giving the patient the opportunity to offer any other comments. Many of these included messages of gratitude and remarks on the impact therapy has had on their general wellbeing.

In general it is encouraging to see that feedback provided through this survey was extremely positive. This was reflected both in the Likert scale questions and the free text box. Patients are described themselves as very satisfied with their experience within therapy and reflected a positive experience of the holding environment provided by the department as a whole.

(NO Funding received)

Telephone consultations have been in clinical use since the early 1960s and are increasing in frequency and importance in many areas of medicine. With the advent of the COVID-19 pandemic in 2020, the use of telemedicine consultations increased dramatically alongside utilization of other digital technologies. Despite promise and potential advantages for clinicians (including remote working, improved time management and safety) there are known drawbacks to telephone consultations for psychiatrists. This includes limitations to assessments of mental state and risk, with loss of non-verbal communication often cited as a point in favour of more sophisticated technologies such as video calling. By adopting telephone consultations to a greater extent during the initial months of the COVID-19 pandemic in the Coventry Crisis Resolution and Home Treatment Team (CRHTT), we aimed to assess the patient experience in telehealth, through a patient survey.

After an initial assessment or follow-up consultation with a medical practitioner from the crisis team, patients were invited to take part in a short questionnaire with a member of the administration staff. This consisted of eight questions on a Likert scale and three open questions for comments. Results were collated and analyzed via Microsoft Excel.

Most patients found the telephone consultations satisfactory, with more than 90% returning positive scores in understanding, convenience and overall satisfaction. All patients felt listened to and that their confidentiality was maintained; with all but one respondent willing to engage in further consultations via the telephone. Negative scores were typically returned for practical telephonic problems including poor signal, interference and background noise. In their comments patients expressed largely positive views about their experience with their clinician; analysis revealed key insights into the patient experience, demonstrating the convenience, comfort and flexibility possible with ‘telepsychiatry’.

Patient experience of telemedicine in a UK psychiatric crisis team is mostly positive, with clear advantages for both patients and clinicians. Our results show telephone consultations can be expanded to new patient assessments alongside follow-ups, enabling the team to reach a greater number of service users. This includes service users who are housebound due to infirmity, required to shield or have significant anxiety about the pandemic.

The number of patients presenting to Emergency Departments (EDs) in the UK with acute psychiatric issues is a major concern. This project aimed to explore the outcome of patients assessed by Mental Health Liaison Services (MHLS) in a large district general hospital ED in the UK, with a focus on patients with self-harm or suicidality.

Data were extracted from electronic patient records on 100 consecutive attendees to MHLS in July 2020. Data were collected on demographics, index of multiple deprivation (IMD) by postcode, time and reason for attendance, known ICD-10 diagnoses, self-harm history, alcohol/substance misuse at time of presentation, recent psychosocial stressors and outcome of MHLS assessment. Assessments by MHLS in the preceding 12 months and reattendance to the service within 3 months following this assessment were also recorded.

The sample included 44 male and 56 female patients, with a mean age of 35.3 years. 80.0% of patients were Caucasian. 67.0% lived in areas classed within the top 30% most deprived in the country, whilst 2.0% had no fixed abode. The majority (79.0%) of patients self-presented; outside of normal working hours (70.0%). The most common reasons for attendance were thoughts/intent of self-harm/suicide (50.0%), overdose (29.0%) and self-harm by laceration (7.0%).

The majority (73.0%) of patients had a known psychiatric diagnosis, with the most frequent being depressive disorder (36.0%) and emotionally unstable personality disorder (15.0%). Almost half (48.0%) had a history of self-harm, and 40.0% were under the influence of alcohol/illicit substances upon presentation to ED. The most common psychosocial triggers were conflict with partner (26.0%) and stress due to the COVID-19 pandemic (19.0%).

Following assessment, 24.0% of patients were discharged to their General Practitioner, 18.0% to the community mental health team; and 17.0% to the Crisis & Home Treatment Team. A minority (13.0%) were admitted to a psychiatric hospital (10.0% informally, 3.0% under the Mental Health Act 1983).

Approximately one in five (21.0%) patients re-attended to MHLS within 3 months. Out of 37 patients that had previously been assessed by MHLS in the preceding 12 months; 37.8% were reassessed within 3 months (p < 0.01).

In the studied sample, most (90%) of psychiatric patients attended ED for self-harm or suicide, and a significant proportion had repeat attendance. Socioeconomic deprivation, substance misuse, relationship difficulties and stress due to the COVID-19 pandemic were major issues, alongside diagnosed depression and personality disorder. Focussed support for these issues may decrease ED attendance due to self-harm/suicidality.

Adherence with antipsychotic medication is an important factor in the prevention of relapse in psychotic disorders such as schizophrenia. Long acting antipsychotic injections promote improved adherence. In recent years, second generation antipsychotic long-acting injections have become increasingly popular, and little has been written about the use of the older depot medications. Here, we explore the current use of one of the first-generation antipsychotic long acting injections in Birmingham and Solihull Mental Health NHS Foundation Trust.

An 18-month retrospective case-note review of all patients who started zuclopenthixol decanoate during the first 6 months of 2018 (n = 45)

Key findings included: -

• ⋅ 71% were male

• ⋅ The mean age was 37 (range 19-65)

• ⋅ The most common diagnoses were: schizophrenia (51%), bipolar affective disorder (18%) and schizoaffective disorder (13%). We noted that 2 individuals (4%) had a primary diagnosis of recurrent depressive disorder, 2 (4%) had a primary diagnosis of emotionally unstable personality disorder.

• ⋅ 60% of those who were prescribed zuclopenthixol decanoate discontinued it within the 18-month follow-up period.

• ⋅ The vast majority of discontinuation occurred within the first 6 months, and after this, few individuals stopped treatment.

• ⋅ The most common reason for discontinuation was side effects (57%), with other reasons including patient choice (7%), non-compliance (7%), pregnancy (4%), or needle phobia (4%).

Zuclopenthixol decanoate has been used for individuals with both schizophrenia and paranoid psychosis (where it is licenced) and also occasionally for other indications. A high proportion discontinued the zuclopenthixol within 6 months, this generally being attributed to adverse effects. Those who were still receiving this medication at 6 months were very likely to continue to take it throughout the 18 months. We would therefore recommend robust monitoring for and management of adverse effects in the early phases of treatment.

To describe the changes in complexity and management of individuals with schizophrenia in a community mental health team (CMHT) over a three year period.

It is often believed that individuals receiving care from CMHTs are those with low levels of complexity and risk, and are relatively stable, with more complex individuals being managed by assertive outreach or other specialist teams. Here, we describe changes in the complexity, comorbidity, service-usage and management, of patients with a diagnosis of schizophrenia in a CMHT between 2016 and 2019.

Data were collected from an electronic patient record system (RiO) for all individuals with schizophrenia in a CMHT in Birmingham (n = 84 in 2016, n = 71 in 2019), examining demographic variables, comorbidity, use of mental health services and current management.

Key findings included: -

• • 63% were managed through care programme approach (CPA) in 2016, compared to only 31% in 2019.

• • 21% had required home treatment or inpatient care in the preceding 12 months in 2016; this had improved to 8.5% in 2019.

• • Significant levels of psychiatric comorbidity, including addictions with almost half of patients (46.5%) having a known history of substance use in 2019, compared to only 15.5% noted in 2016.

• • Pharmacological management has remained broadly similar; in 2016 21% patients were taking a combination of 2 antipsychotics compared to only 10% in 2019 and 25% were taking clozapine in 2016 (21% in 2019). 39% were prescribed a long acting antipsychotic injection in 2016, compared to 32% in 2019.

• • In 2016, medication was being prescribed in the majority of cases within secondary care (55%) patients and in primary care in only 21%. GPs have now taken on greater prescribing responsibility in 2019, prescribing in 44% of cases, with 47% being prescribed by the CMHT.

The acuity and management of individuals with a diagnosis of schizophrenia under the care of a CMHT has changed over a 3 year period. It is positive to note the reduced use of crisis services and lower rates of polypharmacy. There is a reduction in the proportion of patients receiving management through CPA, and a move towards more medication being prescribed in primary care. The reasons for this change are however unclear and may reflect change in available resources, given that more than half of this group receive clozapine or long acting injections, and have high levels of comorbidity.

To evaluate the use of antipsychotics, and high dose antipsychotic treatment (HDAT) in psychiatric inpatient units

The Royal College of Psychiatrists published a consensus statement on high dose antipsychotic medication in October 1993. Such treatment carries an increased risk of adverse effects including towards ventricular tachycardia and sudden death.

A retrospective case note review of all male patients on acute adult inpatient units in a psychiatric hospital in South Birmingham on a date in June 2018 (n = 45) including review of electronic patient records and prescriptions. This was compared with the results of an earlier study, with identical methods, undertaken in June 2015.

• • In both 2015 and 2018, only a minority of patients (20% and 11% respectively) were informal.

• • In both 2015 and 2018, the majority of inpatients had a diagnosis of schizophrenia (54% and 67%)

• • In both 2015 and 2018, 93% inpatients were prescribed antipsychotic medication.

• • In 2015, 56% patients were prescribed HDAT. This reduced in 2018 to 16%.

• • This reduction in use of HDAT was almost entirely due to a reduction in the prescription of PRN antipsychotic medication.

• • In terms of regularly prescribed antipsychotic medication, in both years, the most commonly prescribed drug was flupentixol, with a range of other second generation oral and long acting medications being prescribed, usually at doses within BNF limits.

The vast majority of psychiatric inpatients were being prescribed antipsychotic medication. Prescription of high dose antipsychotic medication was common in 2015, and this was largely attributable to high levels of prescribing of PRN antipsychotics. Following an educational programme for junior doctors and ward nurses, and the introduction of electronic prescribing, we achieved a significant change in practice, particularly in the prescribing of PRN antipsychotics, which has reduced our patients’ risk of receiving high dose antipsychotic medication.

This complete cycle consists of an audit assessing compliance with the evidence based person-centred pathway of care for Depression in Children and Young People across the Trust, completion of an action plan and re-audit of progress, aiming to improve patient care. The pathway was derived from NICE Quality Standard 48/Clinical Guideline 28, updated for NICE Guideline 134 (2019) and includes comprehensive assessment considering comorbidities, social, educational and family context, parent/carer Mental Health assessment and plan for treatment including psychological therapies as first line treatment in mild depression.

The Audit tool was compiled from the above evidence based pathway and NICE guidance. Each of the 26 community teams were requested to select 5 cases on the pathway who had completed a minimum of 6 treatment sessions (final sample size n = 61). The results were analysed for compliance against the pathway and compared with previous results by the clinical audit team.

The results showed areas of good practice, maintained and improved on re-audit, with over 90% compliance in key evidence based areas regarding consideration of comorbidity, social and educational context and 100% compliance in offering psychological interventions.

Improvement was obtained in some areas highlighted in the previous audit e.g. poor recording of ICD 10 diagnosis in medical records, 19%, improved to 30%, and less than 40% recording of symptom tracking via the RCADS (Revised Children's Anxiety and Depression Scale) monitoring improved to over 50%. There had been a failure to record identification or referral to other pathways/services for mild depression in the 16-18 age group with 0% compliance; this improved to 82% and 100% respectively.

Areas still needing improvement were highlighted including recording of weekly monitoring of medication side-effects for first 4 weeks (43%) and a referral of parent/carers to mental health services after identifying issues (40%).

Response to the audit also improved significantly from 29% of teams not responding in the initial audit to a limitation of only 1 of 26 (4%) at re-audit.

This audit cycle has demonstrated that use of an evidence based approach has been instrumental in improving patient care. The Audit evidenced areas of good practice in holistic assessment and use of psychological therapies and importantly highlighted areas of significant improvement needed including initial monitoring of medication response and referral onwards of parents/carers with mental health issues. Continuous improvement in patient care is planned via a targeted action plan, and further re-audit.

The SARS-CoV-2 pandemic has led to core changes in the healthcare systems worldwide in terms of access, resources and patient's management. Patients admitted to a general hospital with COVID-19 are at a higher risk for developing or exacerbating various psychiatric disorders, due to the virus brain tropism and associated psychosocial factors. However, there are still limited data regarding the psychiatric needs and mental health care of these patients. The present study seeks to evaluate the changes in liaison psychiatry, patients’ characteristics and outcomes, brought on by SARS-CoV-2.

We retrospectively analyzed liaison psychiatry patients’ characteristics during the second wave of COVID-19 pandemic, between October and December 2020, in comparison with the same trimester pre-COVID-19 in 2019.

At admission to hospital, we found no differences between liaison psychiatry pre-COVID-19 (n = 96) and COVID-19 period (n = 114) groups, for age (p = 0.35), gender (p = 0.96), or hospital resource utilization in the previous year : number of hospital admissions (p = .40), Accident and Emergency presentations (p = 0.61), outpatients clinics (p = 0.20). There was, however, a significant association between pre-COVID-19 vs COVID-19 period groups and psychiatric diagnosis during hospitalization (Χ2(5) = 11.56, p = 0.04), influencing overall respective rates of delirium/dementias (29.2 vs 42.1 %), mood disorders (18.8 vs 26.3 %), anxiety and stress related disorders (22.9 vs 14.0 %), psychoactive substance use disorders (12.5 Vs 9.6 %) and psychotic disorders (10.4 vs 2.6 %). Mortality rate in pre-COVID-19 Vs COVID-19 period increased from 5.2 % to 15.8 % (Χ2(1) = 5.98, p = 0.01), mostly due to increased mortality in COVID-19 patients (7.3 vs 30.3 %, p < 0.001). Referrals to liaison psychiatry increased by 18.8 % during the COVID-19 period, 28.8 % of referred patients were positive for SARS-CoV-2 and time to referral was positively correlated with hospital length of stay (ρ = 0.60, p < 0.001). In the COVID-19 period, fewer patients were referred to outpatient psychiatric follow-up after discharge from hospital (p < 0.001), and delayed discharges for social reasons were of shorter duration (p = 0.001).

Our findings are consistent with emerging data on comorbid or superimposed mental illness in hospitalized patients with COVID-19, showing a strong impact in neuropsychiatric mani-festations, clinical prognosis and mortality, as well as clinical management. Consideration should also be given to adequate staffing of psychiatry liaison services during the pandemic, in order to attend and safely manage general hospital inpatients mental health needs.

The aim of the project was to get a baseline of the number of patients who have had blood tests, ECG and physical health observations completed in the past 12 months.

There are 30 patients under Early Intervention in Psychosis team at Bassetlaw Hospital , Nottinghamshire. The elctronic notes and blood reporting system were checked for each of the patients, to get the data on blood test results , ECG reports and Physical health (Blood pressure, heart rate and weight) .

It was noted that 19/30 patients had Blood tests completed, 14/30 had ECG completed and 19/30 had physical health checks completed. All these patients except one were on antipsychotic medications.

Further work is still required in getting 100% results for all these different variables. This may include the need to review the process of how we engage the patients for physical healthcare checks. With the inclusion of a physical healthcare worker now, we might be able to improve results. Hence this evaluation would be redone in a years' time.

To evaluate feedback from Balint style case based discussion groups and to reflect on learning points.

We have three medical students from Sheffield University on six week psychiatry placements at Bassetlaw Hospital and we get eighteen students in a year. In order to further develop their approach towards reflection and their understanding towards the doctor patient relationship we developed the Balint style case based discussion group, and each group of students attend three sessions during their placement.

The groups are held on a weekly basis and consist of the three medical students and 1-2 facilitators. As the group is small one of the facilitators may participate with the students for the Balint process and to help encourage the students. Following completion of the third session of the discussion group we gain written feedback from the students. A total of 17 feedbacks have been reviewed over the period of November 2018 -November 2019.

16 students stated that this was their first experience at Balint Group and all except one student felt that they were given a good introduction about Balint groups before starting. When asked about the most significant thing that they have learnt in the group, the majority of students marked reflecting feelings to improve relationships with patients, exploring why they feel a certain way with patients and that the doctor patient relationship can affect the consultation.

One student stated that they would not recommend it to colleagues as they felt it was relevant more to doctors rather than medical students. Another student recommended having more people in a group.

Overall, it has been a positive experience with the medical students during the groups and with feedbacks. We have reflected on difficult topics like bereavement, fantasized about the purpose of a patient's delusion and shared the joy of a patient who was discharged after a long stay. While we think we have been able to teach the students some tips on reflection, we ourselves have been able to reflect on certain topics we would not have if not raised by the students. Some medical students have contacted the larger Balint Group in Sheffield for further sessions. Considering our experience, we will continue with the sessions at Bassetlaw Hospital.

Measure compliance with National Institute for Health and Care Excellence (NICE) recommendations in four Adult CMHT's

Guide further service development.

We audited the case notes of 20 patients each currently under care of 9 General Adult Consultants across 6 CMHT's in East side of North Wales against NICE standards using an adapted version of the ADHD audit support tool.

My role in the Project & How does this represent my practice?

I was the audit and overall lead for this project

I formulated the audit tool and registered my project with Audit Registration Team.

I lead data collection and compilation of results.

Overall, this is the first audit of Adult ADHD Services in East side of North Wales.

It established good compliance with NICE guidance for assessment and treatment.

NICE has expressed the need for full mental health and social assessment including full history and physical examination prior to the drug treatment.

Good compliance was observed in using & documenting Diagnostic Criteria (DSM-IV and/or ICD-10).

There were deficiencies in conducting or arranging recommended physical examination & side effect monitoring.

Drug treatment was the first line of treatment in the majority of cases.

Antipsychotics were used in some patients referred for ADHD assessment, despite the fact that NICE has ruled out the use of antipsychotic drugs in treatment of core symptoms of ADHD.

Prevalence of Adult ADHD clinician case load in Wrexham and Fintshire Counties.

Diagnosis of Adult ADHD according to ICD 10 & DSM IV Guidelines.

Pre treatment screening of physical health for ADHD patients.

Side effects monitoring of patients on stimulant medications.

The finding highlights the need for more effort in educating clinicians about safety and effectiveness of antipsychotics in ADHD.

Comprehensive treatment programmes that address psychological, behavioural, educational and occupational needs should be established.

Development of local ADHD Clinics, support groups and in partnership with the voluntary sector should be encouraged.

It is important that mental health professionals receive appropriate training in assessment, management & monitoring of ADHD patients with co morbid substance use disorder and other mental illnesses.

BETSI Health Board to participate in national Prescribing Observatory for Mental Health (POMH-UK) Quality Improvement Programme (QIP) focusing on prescribing for ADHD in children, adolescents & adults.

1. 1. Quality of clozapine clinic appointment

2. 2. Effectiveness of clozapine clinic servive

3. 3. Compliance with BCUHB guidelines for physical health monitoring in clozapine clinics

4. 4. We retrospectively audited 40 case notes 10 each from 4 differtent CMHT clozapine clinics

1. 1. I was the audit and overall lead for this project

2. 2. I formulated the audit tool and registered my project with Audit Registration Team

3. 3. I lead data collection and compilation of results

1. 1. This audit followed up from a Coroner's investigation for a clozapine clinic patient

2. 2. Clozapine is used for Treatment Resistant Schizophrenia but needs close monitoring due to potentially fatal side effects

3. 3. NICE recommends annual monitoring of weight, blood pressure, waist measurement, blood glucose and plasma lipid levels

1. 1. Has the patient been seen in the past year by clinician to monitor response to clozapine treatment?

2. 2. Has the clozapine plasma level been measured during the last year of treatment?

3. 3. Is brief MSE & Risk assessment documented during review?

4. 4. Has Life style modification advice been provided?

5. 5. Has annual physical health been completed?

6. 6. Has Annual CTP/CPA been completed and documented?

7. 7. Has the patient been allocated a named care coordinator?

8. 8. Has clozapine side effects monitoring been documented?

1. 1. Clozapine is a superior medication for the treatment of refractory schizophrenia and is also be effective for other conditions

2. 2. Clozapine is underused due to a variety of barriers related to the drug and its properties, the health care system & regulatory requirements

3. 3. This service evaluation/quality improvement project provides the framework for clozapine clinics evaluation and recommends strategies for improvement

Bringing specialist psychiatrist into PCMHT

Undertaking initial assessments for people Referred by G.P's

Working According to the principle of “Prescribing Interventions”

Decrease number of assessments carried out within secondary Care

County of Wrexham is situated between the lower Dee Valley and the Welsh mountains. It is the largest town in North Wales (140,000)

Since 2013, the total new patient referrals to be seen by Wrexham county consultant psychiatrists has consistently risen

This issue has been dealt with in different ways across North Wales and indeed the whole of Wales

Following a review of services in Wrexham during 2017, it was identified that there was an opportunity to pilot a new model which would allocate a designated Consultant to the local Primary Care Mental Health Team (PCMHT)

The Consultant would work entirely within Part 1 of the Mental Health Measure and would offer specialist opinions to Tier 1 Services

PCMHT team members are maintaining open cases for a significant amount of time rather than the 8–10 sessions that was originally predicted during the implementation of the Mental Health Measures

In order to sustain the service, the minimum number of direct clinical patient contact sessions to be offered by the psychiatrist was up to 4 a week.

During the review period, total number of clinics offered were 51 and a total of 139 patients were offered appointments

Consultants in secondary care covering the same area received exactly 100 less referrals in the first 6 months of the pilot

Main source of referrals to the Tier 1 Consultant came from G.P.'s and the local PCMHT itself

Pilot demonstrated that bringing specialist consultant psychiatrist dedicated to the PCMHT improved the care offered to patients referred by G.P's

Scope of PCMHT needs to extend in order to absorb mild to moderate mental illness and thus avoid patients going into secondary care

This model should be supported, and further resources should be inputted into PCMHT

We should move from a categorical diagnostic referral system to a needs-based intervention where only the most complex cases requiring lengthy interventions shall progress to secondary care

Risk should not be classed as criteria to move patients into secondary care and PCMHT should be able to absorb moderately risky cases

To establish rates of pregnancy testing on admission of women within a blended secure service.

Women with psychiatric illness are known to be at increased risk of pregnancy, often due to engagement in risky sexual behaviours such as having a higher numbers of sexual partners and engaging in sexual activity whilst under the influence of drugs or alcohol. Awareness of pregnancy at the point of admission to psychiatric hospital would inform ongoing care plans to manage the pregnancy in the safest, least restrictive environment and inform future prescribing decisions, to minimise the risk of teratogenicity associated with some psychotropic medications. Ardenleigh in Birmingham is a blended female secure unit. No pregnancy screening guidelines for this population currently exist. This audit sought to establish current rates of pregnancy testing at the point of admission with a view to developing future guidelines.

A retrospective case note audit of electronic records of all patients admitted to Ardenleigh blended women's service as of 1st September 2019 (n = 26). The expected standard for pregnancy testing within one month of admission was set as 100%.

Key results include:

• The majority of patients (67%) were aged under 35 years (range 20–56). The most common ethnicities were Caucasian (42%) and African-Caribbean (38%). Almost half (46%) had a primary diagnosis of paranoid schizophrenia.

• Two women were known to be pregnant at the point of admission. Only 54% of women with an unknown pregnancy status were screened for pregnancy within one month of admission.

• Rates of screening were particularly poor in women aged under 25 years (43%) and between 36 and 45 (0%).

• Women not screened for pregnancy were typically admitted from other hospital settings, including AWA services (27%) or other medium secure units (55%). 2 women admitted from prison were not tested (29%)

• Of those tested, the majority were checked using urine hCG (92%).

Overall pregnancy testing on admission to the unit was poor, with only 54% of service users screened. Less than 100% compliance could result in serious consequences for both the woman and unborn baby if a pregnancy is not discovered. Updating the admission checklist for Ardenleigh to include pregnancy testing may prove beneficial. It is recommended that a re-audit is completed 6 months following checklist introduction.

To investigate adherence to Trust guidelines for urine drug screening amongst female forensic psychiatric inpatients.

The use of illicit substances is an important risk factor which needs to be considered in the management and treatment of forensic psychiatric patients. Research has demonstrated that a high proportion of women admitted within secure services in the UK have a history of substance use. Substance misuse amongst this population can lead to an increased risk of violence, re-offending and mental health relapse; which can pose a significant threat to the safety of other patients, staff and the public. It is therefore important that regular drug screening is carried out to minimise such risks. Ardenleigh is a blended female secure unit in Birmingham. The service has established specific substance use guidelines, outlining the need for each patient to have a personalised drug screen care plan in place. Here we present the findings of an audit completed in 2019.

A six month retrospective electronic case note audit for female inpatients admitted to Ardenleigh as of 1st September 2019 (n = 27). We compared drug screen care plans and frequency of urine drug screens over 6 months with the recommendations of the current service-specific Trust guidelines. Care plans should include: information regarding random drug screening; frequency of random drug screening; triggers for increased risk of substance misuse; and consequences for a positive test result to be contained within inpatient care plans.

Patient aged between 20 and 56 years old (median age 31). Fewer than half of inpatients (41%) had a documented random drug screen completed within the review period. In terms of care-planning, only 52% of patients had random drug screening mentioned in their care plan. 22% of patient care plans reported the actions/consequences for a positive test result. Not a single care plan mentioned how frequently patients should be being tested or potential triggers for increased risk of drug misuse amongst inpatients.

Current practice and recording of drug screening amongst female forensic psychiatric patients is poor compared to expected standards. The lack of consistency in drug screening raises concerns regarding whether potential substance misuse amongst inpatients may be going undetected, and therefore impacting the recovery of patients. Improvements to drug screening practice should be considered in order to ensure optimal recovery and safety to patients and others.

To complete the audit cycle on compliance of MHA documentation (including MCA1 form at admission and 3 months, T2 form, SOAD request and T3 form authorization) on patients on section 3 staying 90 days and over in adult wards at Roseberry park hospital

In the initial audit, we collected data from all inpatients on section 3 staying 90 days and over, in Adult acute and rehab wards on Roseberry park hospital between the time period 28/10/19–04/11/19. Using a designated audit data collection tool, information was gathered from each patient's electronic record pertaining to the standards. The same method was used in re-audit where data were collected from all inpatients on section 3 staying 90 days and over in Adult acute wards on Roseberry park hospital between the time period 04/11/20–11/11/20. To note, the rehab ward at Roseberry park hospital was closed in Feb 2020. The data were analysed by the project lead.

In the initial audit, 16 patients records were identified as meeting criteria,out of these 7 (44%) patients were on acute wards and 9 (56%) at rehab ward. Where as in re-audit 5 patients records were identified as meeting criteria and all were on acute wards. Days in Hospital - Ranged from 120 days to 664 days, average being 295 days and median of 186 days in the initial audit compared to121 days to 290 days, average being 170 days and median of 150 days in the reaudit. Percentage of patients records with documented capacity assessment at admission and 3 months were same at 80% and 60% respectively in both audits.T2 form was completed in all consenting patients in both audits. SOAD request sent was recorded in only 1 (25%) patient in the reaudit, which was lower than the initial audit, where in SOAD request was sent in 7 (78%) patients but recorded in 5 (56%) of them. For patients lacking capacity, T3 form was documented only in 4 (45%) patients but T3 form authorisation was discussed with patient and evidenced in case notes in only 1(11%) case in the initial audit, where as in reaudit T3 form was not documented or discussed for any patient.

There needs to be improvement in MHA documentation for detained patients.

The aim of the audit was to identify patients at risk of developing Metabolic Syndrome who are on Clozapine in the community. Anyone who has three of following attributes has Metabolic Syndrome. A large waist size (greater than 40 inches in men or 35 inches in women) ,high blood pressure (130/85 mm Hg or higher) ,high triglycerides — a form of fat in the blood (150 mg/dL or higher) ,high blood sugar (a fasting level of 100 mg/dL or higher).Patients receiving should be regularly monitored under clinical review particularly in relation to side effects of the drug and maintain minimum standards of review both physically and clinical investigations once a year .

To measure the screening of central obesity, Blood Pressure, serum glucose levels and lipid profile in last one year.

Data were collected from Blood results and electronic entries of patients who are on Clozapine in South Ceredigion Community Mental Team. There were 31 patients of which 20 were male and 11 were female patients. The age range was 31–66 years and average was 46 years.

52% of the patients had obesity,34 % with Hypertension,50 %Dyslipidaemia and 43 % had Increased glucose tolerance. 80 % were only on clozapine,3% were on combined Amisulpride, 10% on combined on Ariprazole, 3 % on combined Quetiapine.

Treatment of causes like making changing lifestyle changes, weigh reduction using health diet and to include regular physical activity. Reduce Abdominal Obesity and in possible provide nutritional intervention.