North West Medical Student and Trainee Presentations Autumn 2014
Contents Medical Student/FY1 Poster Presentations MSP1 Roisin Ryan Dr Ross Overshott An audit and service evaluation of the use of Section 136 of the Mental Health Act 1983 MSP2 Selina Sandhar Dr Josanne Holloway Dr Caroline Hoult How bored are secure forensic psychiatric patients?
FY2/Trainee Poster Presentations Contents TP1 Dr Chun Ming Lui Dr Ruth Sanderson Dr Raghu Paranthaman Safeguarding Reporting for Vulnerable Adults: Outcomes and Recommendations TP2 Dr Malarvizhi Selvaraj Dr Nagajyothi Janapathy Use of Z-hypnotics for the short term management of insomnia among inpatients TP3 Dr Hemavathy Meeckery Ramalingam Monitoring of patients on High Dose Antipsychotic Therapy (HDAT) TP4 Dr Irum Rasool Dr Adarsh Vohra Dr Prince Ikwuagwu Dr John Lin Dr Marie Shah The use of sodium valproate in women of childbearing age. Are we following the NICE guidelines? TP5 Dr Syed Faheem Naqvi Yasmin Babiker Arifa Azmi Antipsychotic Side-Effect Monitoring on two CAMHS inpatient wards TP6 Dr Tomos Christopher Williams DXA Scans on Oaktrees Specialist Eating Disorders Unit: an Audit of Practice
Poster Presentations
Roisin Ryan MSP1 An audit and service evaluation of the use of Section 136 of the Mental Health Act 1983 Dr Ross Overshott Section 136 (S136) of the Mental Health Act allows police constables to detain a person who is found in a public place, appears to be suffering from a mental health disorder and is in need of urgent assessment. This is an audit and service evaluation of s136 assessments in Salford from April 2012 until March 2014. Standards Standards were gleaned from both local policy and guidance set out by the Royal College of Psychiatrists. Methods A data collection tool was developed and information was gathered from the paper and electronic patient records for every S136 case within this period. Areas that were assessed included the demographics of detainees, the duration and process of assessment and the quality of the environment of the Place of Safety. 197 cases were evaluated and similar to other studies, there was an overrepresentation of men and those aged in their 30s. The average duration of assessments was just over 9 hours. The sample showed that 52% of patients were under the influence of alcohol, 33% of patients didn t require specialist follow up and 11% had no other contact with mental health services. The original Place of Safety met 23 of 35 Royal College environmental standards. Conclusions The local policy was generally adhered to but there were often long delays in assessment. There has been an improvement in information recording following the introduction of a new s136 form during the period studied. The recent opening of a specific s136 assessment suite has increased the number of environmental standards met.
Selina Sandhar MSP2 How bored are secure forensic psychiatric patients? Dr Josanne Holloway, Dr Caroline Hoult Boredom in secure forensic psychiatric units is a commonly encountered problem, and arguably hinders the rehabilitative care of patients. At the Prestwich Mental Health Foundation Trust (PMHFT), the Adult Forensic Mental Health Services Directorate (AFMHSD) aims to implement the 25 hour model, for the number of hours per week patients are engaged in structured activity. Aim To investigate the levels of structured activity patients are currently engaged in, and thus reveal what may be realistic targets for amount of structured activity accessed on and off the ward. Methodology Data was collected from 16 low- and medium- secure wards (5 female, 11 male), at 4 sample times between 09:00 and 15:00, for 4 consecutive days. Where possible, patient activity was manually accounted for. For wards based at inaccessible parts of PMHFT, data was gathered by telephone communication with the ward. A varying audit sample of approximately 179 patients was assessed. Across day 1-4 of the audit the average proportion of male and female service users not engaged in structured activity were 74.9% and 69.6%, respectively. Discussion As this audit was one of the first of its kind in the service, we fulfilled an aim to highlight areas for further discussion, with the purpose of advising the setting of future guidelines.
Dr Chun Ming Lui TP1 Safeguarding Reporting for Vulnerable Adults: Outcomes and Recommendations Dr Ruth Sanderson, Dr Raghu Paranthaman Safeguarding is an important part of our practice as mental health professionals. All staff are required to report concerns regarding incidents that could cause harm to vulnerable patients. In Greater Manchester West Foundation Trust (GMW), events with a safeguarding concern should be recorded on the trust s incident reporting system, DATIX. The aims of the audit were to look at how safeguarding incidents were managed, and the level and quality of documentation involved in these cases. Methods Data was collected from all safeguarding incidents involving General Adult and Later Life patients in GMW over the period August 2013-February 2014. DATIX reports were linked to ICIS (GMW s electronic records) for further information to compare against standards of GMW safeguarding policy. Over a 6 month period there were 228 incidents recorded. The average age was 50, with a male/female ratio of 1:1. The most reported categories were physical/verbal abuse (44%), neglect/ act of omission (21%) and sexual abuse (14%). 44% of incidents were referred to the Safeguarding Unit. Community Psychiatric Nurses (31%) reported the highest number of safeguarding incidents. 63% of safeguarding incidents were discussed with a manager. 27% were recorded in a Care Programmed Approach (CPA) and 51% in a STAR-V2 risk assessment. 46% of incidents had neither a CPA nor a STAR-V2 completed. Conclusion Current safeguarding practice does not meet the standards set out in safeguarding policy. Managers are not consistently being informed neither are risk assessments completed. Staff training is recommended and a simplified and accessible flow-chart to explain safeguarding reporting.
Dr Malarvizhi Selvaraj TP2 Use of Z-hypnotics for the short term management of insomnia among inpatients Dr Nagajyothi Janapathy In Sep 2010 the prescriptions for hypnotics was 2.6 million items, an increase of 5% in the last five years. Standard: NICE guidelines 1. Hypnotic drug therapy is considered after consideration of nonpharmacological therapy for the management of severe insomnia and should be prescribed for short periods 2-4 weeks. 2. The drug with the lowest purchase cost should be prescribed 3. Switching from one of these hypnotics to another should only occur if a patient experiences adverse effects directly related to a specific agent. 4. Patients who have not responded to one of these hypnotic drugs should not be prescribed any of the others. Method Reaudit All the patients on 4 ACT wards(n=92) Proforma constructed and all medication cards reviewed Electronic database used. Survey among doctors and nurses about NICE guidelines 65% responded to survey were aware of NICE guidelines about Z-hypnotics Guideline 1 has a standard of 100%. Our performance is currently 0% (0% in previous audit) Guideline 2 has a standard of 100%. Our current performance is 50% (42% in previous audit) Guidelines 3&4 performance currently at recommended standards of 100% & 0% respectively. Recommendations Adding a review column in the PRN section of medication card. Reminder by Pharmacist on wards weekly, nursing staff in MDTs and CPNs during OPD to review Z-hypnotic. Effective communication with GPs upon discharge. Posters of Nice guidelines and audit recommendations in ward offices.
Dr Hemavathy Meeckery Ramalingam TP3 Monitoring of patients on High Dose Antipsychotic Therapy (HDAT) High dose antipsychotic therapy (HDAT) is defined as use of total daily dose of a single antipsychotic which exceeds the upper limit stated in the summary of product characteristics or BNF; or use of total daily dose of two or more antipsychotics which exceeds the summary of product characteristics or BNF maximum using the percentage method (Ref.). With HDAT, there can be serious side effects and needs close monitoring of therapy. Standards The Mental Health Trust guidelines were used as standards for this audit. The six standards audited were: 1) Therapy as per trust policy 2) Identification in notes 3) Monitoring form completion 4) ECG at specific times 5) Relevant blood tests and 6) Reviewing as required medications. Methods The case notes for all inpatients treated in the General Adult and Rehabilitation wards in the mental health hospital over a period of 18 months (August 2012 - December 2013) were reviewed. The HDAT cases were identified and the monitoring of therapy in these cases were assessed against the six standards. 33 inpatients received HDAT. The compliance rate for the six standards were 1) 72% 2) 66% 3) 42% 4) 51% 5) 66% and 6) 36%. Full compliance has not been met and monitoring needs to improve. Impact A dedicated record of patients on HDAT has been initiated in the wards. Documented communication between pharmacists and the medical team on HDAT has been recommended. We plan for a re-audit in 6 months. Reference: Royal College of Psychiatry Council Report CR138, May 2006 Institution: Psychiatry Department, Tameside Hospital, Pennine Care NHS Foundation Trust
Dr Irum Rasool TP4 The use of sodium valproate in women of childbearing age. Are we following the NICE guidelines? Dr Adarsh Vohra, Dr Prince Ikwuagwu, Dr John Lin, Dr Marie Shah : An audit was conducted between Nov 2010 to Jan 2011 about use of sodium valproate in women of childbearing age in mental health unit Blackpool. Audit results were not very encouraging and few recommendations were made. Re-audit was conducted in July 2014 to complete the loop. Standards: NICE guidelines Method: Cross sectional data was collected retrospectively from hospital records during Nov 2013 to Jan 2014. Inclusion Criteria: Women aged 18-60 who have been admitted/discharged from inpatient unit on sodium valproate. Exclusion criteria: Patients from out of area, hystrectomy, sterilised and postmenopausal. Comparison between Audit 2010 and 2014 Limitation: There was no clear documentation available in majority of patient s record about when and where sodium valproate was started. Same patients repeated admissions gave a biased result as was unable to show difference. Unable to give us clear picture of community patients being on sodium valproate. Re-audit also showed that sodium valproate NICE guidelines are not completely followed. New recommendations were made. Recommendations after re-audit: Clinical lead should give counselling to service user before starting sodium valproate. Sodium valproate NICE guidelines should be provided to the team manager, carecoordinator and ward matrons. Pharmacist to circulate emails about sodium valproate NICE guidelines every 6 months. And to alert clinical lead if consent has not been taken. Leaflets and posters about NICE guidelines should be made easily available on wards and CMHT. Arranging a consent form before starting patients on sodium valproate. Re-audit after 2 years should be conducted.
Dr Syed Faheem Naqvi TP5 Antipsychotic Side-Effect Monitoring on two CAMHS inpatient wards Yasmin Babiker, Arifa Azmi The Audit looked at antipsychotic side-effect monitoring on both the Hope and Horizon Child and Adolescent inpatient wards. Standards As per NICE clinical guideline CG155 Psychosis and Schizophrenia in Children and Young people, antipsychotic side effect monitoring should be done both systematically and regularly Method Reviewed all the case notes of patients currently on antipsychotics on both The Hope and Horizon inpatient wards (16 patients), to see if side effect monitoring is being done regularly and systematically Antipsychotic side-effect monitoring was not being done as per NICE Clinical Standards. Side effects were discussed haphazardly during ward rounds and not in a systematic manner. Only two patients were assessed using an antipsychotic side effect rating scale. The Audit Recommended 1) Need for Regular and Systematic side-effect monitoring 2) The routine use of an anti-psychotic side effect scale (Glasgow Antipsychotic Side Effect Scale recommended) 3) Re-Audit in October Impact The impact of the Audit was great, it was presented both during the CAMHS CPD day as well as in an academic teaching session and it was agreed for the Glasgow Antipsychotic Side Effect Scale to be used on both hope and horizon wards and to be completed for each ward round. This would aid compliance with NICE clinical guidance, as well as identify side effects early and help improve patient satisfaction and compliance. Re-Audit is due in October.
Dr Tomos Christopher Williams TP6 DXA Scans on Oaktrees Specialist Eating Disorders Unit: an Audit of Practice 52% of patients with Anorexia Nervosa have Osteopenia and 40% have Osteoporosis. Dual-energy X-ray Absortiometry (DXA) is important as it provides information on risk to physical health. can provide psychological motivation for recovery. Currently, staff on Oaktrees Ward decide at some point in the admission that the patient requires a scan and communicate this to the admin team, who book it. DXA should be booked for 100% of eligible patients during their inpatient stay. Standards No official guidance exists but the best available evidence (Mehler et al, 2009) suggests DXA after symptom duration of 12 months. DXA should be booked for 100% of eligible patients during their inpatient stay. Method Records of patients admitted to the ward between 01/01/14-30/06/14 (n=24) were evaluated for evidence that DXA had been booked. Patients excluded if DXA during past 12 months. The ward office communication board, the electronic case notes and the records in the DXA office were checked. 18 patients were eligible. It was documented in 55.56% of cases that DXA was booked (both office communication board and electronic notes system). 61.1% of cases actually had a scan booked, as recorded in the DXA office. Impact The current system on the ward is ineffective in ensuring that all patients eligible for DXA receive it. Suggestions for improvement include education sessions for staff, clearly defining the role of booking scans for one member of staff and/or creating a prompt system in either in the admission pack or the electronic notes system.