8 results
Secondary Service Communications to GPs-a Regional Audit
- Tajnin Mitu, Vinila Zachariah, Jason Ray, Alberto Salmoiraghi, Ramandeep Singh, Laura Williams, Vikram Bhangu, Asmaa Elsayed, Opeyemi Ikuewumi, Wamiqur Rehman Gejdhar, Amin Rezk, Mohammad Khan, Christopher Rowley, Lopez Okhiai
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, pp. S170-S171
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Aims
The purpose of the audit was to assess the standard of communication to GPs from secondary mental health services and to ascertain whether the information included in letters to GPs was in accordance with the recommendations of RCPsych and PRSB. The audit cycle was completed by re auditing to identify how the recommendations from the first audit has improved the quality of communication to GPs.
MethodsThe audit was conducted on three psychiatric units, in three sites across Betsi Cadwaladr University Health Board and clinic letters were studied to identify whether the information was as per recommendations from: RCPsych and PRSB.
The first audit used 121 letters in total from 3 sites, with the data being collected using audit proforma over a 2 week period from 04/04/22.
The re audit looked at 69 letters with data collection using audit proforma over one week period from 19/12/22.
ResultsMajority of letters sent to GP were lacking key information like details of Care coordinators ,medical comorbidities ,non psychiatric diagnosis, and actions for GP with this data missing in 91.7%, 61.22 %,79.59% and 71.43% respectively. Fill rates for other information like patients' details was 100% , psychiatric diagnosis was 83.47%, psychiatric medications , follow-up plan were 80.17%.
The results of the re-audit most letters contained Psychiatric Diagnosis (97.1%, previous 83.5%), Psychiatric Medication (91.4%)previous 80.17%), and Follow Up Plan(98.6%, previous 80.2%). Many letters did not include information regarding Medical Comorbidity (28.6% vs 31.4% ), Non-Psychiatric Medication (65.7% vs 34.7%), Details of Care Co-ordinator (54.3% vs 8.3% ) and Action for GP (27.1%, vs 44.6%).
ConclusionThe recommendations from first audit were to create local guidelines and templates with recommended headings for clinical letters, provide formal teaching for junior doctors and to re audit to see if the implemented changes has led to an improvement.
The re-audit showed improvement since the introduction of the template in majority of headings in GP letters with decline in fill rate for 2 headings and these changes varied among three sites.
Barriers identified affecting the overall outcome of the re audit were :template not being used, lack of training to juniors, and psychiatrist workload.
In conclusion , we aim to re-distribute the template and increase awareness with informal teaching sessions, provide information on template during induction for doctors and organize training sessions on three sites.
Admission Clerking- Inpatient Adult Psychiatric Unit - a Quality Improvement Project
- Asha Dhandapani, Sathyan Soundara Rajan, Alberto Salmoiraghi, Rajvinder Sambhi, Catherine Baker, Joanne Kendrick, Sherrie Stewart
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, p. S91
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Aims
To improve the clerking proforma and physical healthcare for General Adult Psychiatric inpatients in Heddfan Psychiatric Unit, Wrexham by 100% within 18 months period with a long term goal of continuous improvement.
MethodsWe started the project with a baseline audit which showed the incompleteness of vital data when clerking a patient in adult psychiatric inpatient unit. This was compared with various standards from Core competencies for a trainee in Psychiatry, NICE guidelines and Local trust policy from our own trust BCUHB for physical health monitoring and Department of Health Guideline for VTE.
With the findings obtained, we went ahead to create a proforma encompassing all the details.
The use of various Quality improvement tools such as Fishbone diagram, Drivers diagram and PDSA cycles gave as overwhelming results
ResultsThe baseline audit, repeat audits and PDSA cycles have shown tremendous and overwhelming results in terms of completion of the proforma. This has resulted in mandatory details being inputted sufficiently in the patient's notes.
Many of the important details such as medication details, allergy status, legal and forensic status, mental state examination, risk assessment, VTE assessment, investigation details and documentation have shown to have improved during this 1 year
ConclusionThis QIP has been patient centred as this is the main goal. Following the PDSA cycle, we have identified that it has been efficient and effective. It has been safe and also reduced the chances of patient neglect. The structure of the proforma used does not discriminate or show any inequalities and is timesaving too.
The SWOT analysis has been completed, which has shown that the teamwork and support from the Consultants and other stakeholders have been a major strength. There are a few weaknesses such as unavailability of ECG machine, missing documentation of investigations despite completing them but however with timely education to the junior doctors, we are hoping for improvement further. This QIP has opened up doors for various opportunities, such as including nursing and pharmacy admission forms into this proforma. Though there are few threats in achieving 100% success, we are hoping for the best
Is Attachment Theory the Answer to a Complex Healthcare System?
- Alberto Salmoiraghi, Amy Kerti
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, pp. S111-S112
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Aims
This article proposes the need for a theoretical framework that can be applied to underpin the varied idiosyncratic mental health systems.
MethodsBowlby's Attachment Theory defines a set of values that are required for a developing child to acquire a stable base which allow for healthy psychological development into adulthood. These values and behaviours may serve as a caring and holistic framework for people using mental health services.
ResultsThe outcomes in mental health remain unsatisfactory and services are overall fragmented and increasingly specialised. Ongoing recognition of the inter-related relationship between a person's immediate and social environment and their mental health are frequently overlooked as services become ever stretched in terms of finances, capacity and limited resources including support for staff. The emphasis of treatment is on illness instead of the multifactorial humanity of the individuals using the services. A key outcome of mental health provision is recovery but instead, recovery is compromised by a reductive approach to care that may paradoxically compromise rights, autonomy, confidence and self-belief when people are at their most vulnerable. This creates feelings of mistrust, uncertainty and a limited sense of safety toward services.
Attachment theory takes into account the individual, their experiences, their social world and the significant people in their lives. The principles required for the developing child to develop a secure attachment from a stable base are similar to those required for people experiencing mental illness to facilitate recovery and develop resilience to help manage and reduce episodes of relapse.
Systems that work well, frequently exhibit values underlying models of care that include continuity, consistency, respect, safety, autonomy, human rights, freedom, supportive, trusting relationships and collaboration. The opposite of that seen in what presents as autocratic and risk-averse approaches of many mental health services.
The principles required to enable a child to develop into a psychologically well-adjusted adult are similar to those required when a person is at their most vulnerable. Episodes of mental illness can be a time for reflection and growth, with the right care and therapeutic intervention, illness can also be a time to learn and develop skills for greater resilience in future.
ConclusionThis paper outlines the implications and cultural changes that are required so that the principles of attachment theory can serve as a theoretical framework across mental health services to provide a stable base for people using the services and staff providing the care.
A Qualitative Study Exploring the Role of Hindsight Bias in the Process of Reviewing Clinical Practice Prior to Adverse Incidents
- Irene Hadjioannou, Emily Lewis, Leo Scott, Catrin Thomas, Alberto Salmoiraghi, Rajan Nathan
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, p. S76
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Aims
To explore the effect of hindsight bias on retrospective reviews of clinical decision making prior to adverse incidents to inform future approaches to incident investigations.
MethodsWe have undertaken focus groups with doctors of varying grades across the North West of England and North Wales. A vignette based on a real-life case from the publicly available NHS England Homicide Independent Investigation report database was presented to each group in one of three versions which differed in terms of the ending of the vignettes (i.e. suicide, homicide, no adverse incident). Using a semi-structured interview approach, the group participants were encouraged by the facilitators to reflect on issues relating to risk and risk management. All groups were provided with the same vignette which initially made no reference to the outcome and asked to comment on matters of risk and risk management. Halfway through the discussion, one of the three outcomes was disclosed, and further group discussion was held. The recorded interviews were transcribed and thematic analysis was undertaken using an adapted Framework Method.
ResultsPreliminary results (n = 10) indicate that participants identified the potential for significant harm, particularly to others, and identified evidence of key psychopathological and historical correlates to support assertive management of risk and admission to hospital.
Whilst knowledge of the outcome did not lead to participants changing their favoured management plans, it did alter how they appraised the case and led to participants constructing “narrative” explanations for the outcome given. The level of conviction participants held for their management plan reduced when their expectations about the outcome were confounded.
Participants presented with the suicide outcome vignette described their difficulties appraising risk to others and their over-sensitivity to that risk. Participants faced with the ‘no adverse outcome’ vignette perceived the original management plan far more favourably in hindsight. The groups that were presented with the homicide outcome vignette initially focused on both risks to self and others as well as the perceived need for further information. Following knowledge of the outcome, there was a tendency to highlight parts of the letter pertaining to risk to others which they previously had not given as much attention.
ConclusionThe initial analysis of our data confirms the findings from previous studies that hindsight colours the appraisal of adverse events. However, this study is novel in that it describes the nature of the thought processes underpinning the influence of hindsight on appraisals of risk.
Adherence to Public Health England (PHE) guidance for the use of personal protective equipment (PPE) in north Wales mental health unit- a regional audit
- Asha Dhandapani, Sathyan Soundararajan, Alberto Salmoiraghi, Shona Ginty, Tajnin Mitu, Justina Akinlua, Catrin Thomas, Rahul Malhotra, Zeenish Azhar, Haseeb Bhutta, Hanani Taib, Nikhil Gauri Shankar, Vikram Bhangu, Gathoni Kamau, Elizabeth Chamberlain, Anna Mackenzie, Henrik PAHLEN, Hannah Lock, Aniis Rymansaib, Pauline Mclean, Rodrigo Trujillo, Manjula Simiyon, Adam Chappell, Agnieszka Gross, Gaynor Gaskell
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S318
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Aims
To ensure that the PPE guidance is strictly adhered to.
To ensure that patient care is not compromised.
To help us in areas of need in order to educate the staff regarding the techniques of PPE and thus ensure patient and staff safety and care during the pandemic.
MethodNovel coronavirus 2019 was first described in December 2019 in Wuhan in China. Since those initial few cases, it has rapidly proliferated to a global pandemic, putting an inordinate amount of strain on healthcare systems around the world. We believe that the technique of donning and doffing if followed as per PHE guidelines would be of help in both preventing the infection and improve the care and safety of both patients and staff.
This Audit includes both In-patient and Out-patient units in Psychiatric services across North Wales. Data were collected from 19 units out of 39. We observed covertly 325 staff members belonging to various cadres. Apart from the Donning and Doffing techniques, we also observed the availability of designated areas for this purpose and the availability of PPE as well.
Data collection was by junior and senior doctors from various sites of the mental health unit in North Wales. A proforma was provided, the standards were based on PHE guidelines.
ResultIt was noted that just about 50% of the staff followed donning as per guidance. Amongst all three sites, the Central team showed a better adherence with 85% of them donning PPE correctly. whereas only 22% adhered to donning in the West team.
Only 21% of them managed to doff PPE as per guidance amongst all 3 centres in North Wales.
It was also noted that there are no designated areas to Don and Doff in outpatient units. Staff, in general, seem to not adhere to the guidance of utilising a mask, especially when within 2 meters distance of other staff.
ConclusionWe will be presenting the Audit at the regional meeting. After discussion with the infection prevention control team and Health and safety lead, we intend to improvise the wards with designated areas for donning and doffing. Teaching sessions for the staff in all three sites, reminders in various areas of the community mental health units and inpatient units.
We are hoping that these recommendations will help us in achieving our aim of health and safety during this pandemic.
Service evaluation of primary care mental health support services in north Wales
- Jawad Raja, Alberto Salmoiraghi, Zeenish Azhar
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S343-S344
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Aims
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
MethodCounty 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
ResultPCMHT 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
ConclusionPilot 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
Adult ADHD clinics in north Wales - case load prevalance & compliance with nice guidelines (quality evaluation project)
- Jawad Raja, Zeenish Azhar, Alberto Salmoiraghi
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S342-S343
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Aims
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.
MethodOverall, 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.
ResultPrevalence 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.
ConclusionThe 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.
Early termination of cognitive-behavioural interventions: literature review
- Alberto Salmoiraghi, Rajvinder Sambhi
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- Journal:
- The Psychiatrist / Volume 34 / Issue 12 / December 2010
- Published online by Cambridge University Press:
- 02 January 2018, pp. 529-532
- Print publication:
- December 2010
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Aims and method
The evidence of the efficacy of cognitive-behavioural interventions is well established. Despite this, clinicians often face a consistent number of not attended appointments or early treatment discontinuation rates. This paper reviews the literature to date regarding the possible causes of early termination of cognitive-behavioural interventions. A literature search was done using Medline, PsycINFO, Embase and the Cochrane Library.
ResultsWe reviewed 14 articles. Out of these, two were randomised controlled trials, one was a controlled trial and the rest were cohort studies. Drop-out was defined differently across papers. There are many factors that may affect early treatment discontinuation rates and they are described individually.
Clinical implicationsThere does not appear to be a single strong predictor of early treatment discontinuation. Specific literature relating to cognitive-behavioural therapy is scarce. However, some factors such as young age, education level and psychopathology appear to be more strongly associated with early treatment discontinuation than others.