Clinical coding (CC) is the translation of medical terminology into a coded format that is recognised both nationally and internationally. NHS trusts must record the clinical care given to inpatients and the resources used for inpatients while they are in hospital care. CC ensures accurate patient records, communication and data exchange between providers and can aid in epidemiological research, healthcare planning and quality as well as cost control. An audit was carried out in a mental health inpatient unit to assess whether CC was completed as per the local and national CC guidelines, followed by an intervention to improve compliance.

2 inpatient wards were identified, 1 male and 1 female, and 10 patients from each ward were selected at random on the 15th of December 2023. Their notes were assessed to determine whether: the CC has been updated during their current admission, CC has been updated if new diagnosis, CC had been completed on last discharge, physical health conditions were included in the CC and the number of physical health diagnosis changes and their documentation. Intervention was carried out and a re-audit completed on the 31st of January 2024.

Out of 20 patients: 5 (25%) had a completed CC during their admission and 4 had a diagnosis change but only 1 (25%) CC was updated. 9 had a physical health diagnosis but only 3 (33%) were included on CC. 16 (89%) had a completed CC on last discharge and 2 were admitted for the first time.

Doctors on the wards were informed about CC, how to access the form on the system and the importance of updating CC. This was communicated in teaching sessions and doctor communication groups.

The re-audit showed some improvement. Out of 20 patients: 10 (50%) had a completed CC during their admission, 4 had a diagnosis change and 3 (75%) CC were updated. 7 had a physical health condition and only 2 (29%) were included on CC. 12 (75%) had a completed CC on last discharge and 4 were admitted for the first time.

The audit showed a lack of awareness of CC and its importance. The intervention helped to improve compliance of CC in current inpatients. Further intervention and improvement is required for physical health CC and can be attempted with posters in the doctor's rooms and regular reminding during group sessions.

There remains stigma surrounding electroconvulsive therapy (ECT) amongst junior doctors, as well as gaps in knowledge, recent studies have shown. The aim of this study is to reduce stigma and negative biases towards ECT among junior doctors in Hertfordshire.

This research strives to improve clinical knowledge regarding ECT amongst the same population of junior doctors.

After highlighting stigma and gaps in clinical knowledge amongst junior doctors, we aimed to implement an educational intervention to reduce these and assess the impact it made.

Over 80 doctors ranging from foundation year 1 doctors to consultants attended a weekly academic teaching for doctors working in Psychiatry. A 50-minute slot was set aside for a teaching session on ECT.

This included a pre- and post-teaching anonymous questionnaire, with open and closed questions, asking junior doctors about their previous exposure to ECT, and asking them to list three words they associated with ECT.

The teaching session included: what ECT is, indications, side effects, a short video explaining the procedure, an open discussion about stigma and ECT, a brief overview about the future of neuromodulation, and a consultant psychiatrist who is part of the ECT team talking through the before, during, after, and answering questions from the participants.

31 participants answered the pre-intervention questionnaire. Of the 31 respondents, 70% reported learning about ECT during medical school. However, 40% reported little teaching and only 13% had observed ECT. From thematic analysis of free text responses, 54% of respondents expressed detailed understanding of ECT, with 71% agreeing that ECT is a humane treatment. 80% expressed that ECT should be part of NICE guidelines. 50% of respondents conveyed that stigmatised portrayals of ECT in popular culture have influenced their negative opinion of ECT.

Of the 10 responses to the post-teaching questionnaire, 100% agreed that ECT is a humane treatment and that ECT should be part of NICE guidelines for treatment of severe/treatment-resistant depression. From thematic analysis, when asked to name 3 words they associated with ECT, 60% of participants described ECT as effective or successful and 40% described ECT as safe. 72% of the words used were positive descriptors.

ECT is not covered thoroughly during medical school. Before this teaching, about half of the trainees expressed a negative opinion of ECT due to popular culture. Post-teaching, positive opinions had increased, and more trainees (100%) agreed that ECT is a humane treatment and should be part of NICE guidelines.

The Royal College of Psychiatrists sets out ‘Education and Training’ as one of the High Level Outcomes (HLOs) in its GMC approved curriculum for higher speciality trainees in Psychiatry. The West Midlands (WM) School of Psychiatry runs a well-established 3-day Training the Trainer (TTT) course to support acquisition of teaching skills and key capabilities to help prepare trainees to become trainers as Consultants.

We aim to explore the views and attitudes held by WM Psychiatry higher trainees towards the current TTT course and other teaching opportunities available across the region.

An anonymous online scoping survey was sent to all WM Psychiatry higher trainees, via Microsoft Forms, in January 2023. This comprehensive survey included questions on the trainees’ awareness of the TTT course and available teaching opportunities, as well as support and barriers in accessing these. We designed dichotomous, rating and free text questions to generate both quantitative and qualitative data.

Key findings of the survey included:

• • 27 out of 40 trainees responded. All subspecialty training programmes were represented.

• • Many trainees were aware of the WM TTT course (81%). No trainees had accessed private TTT courses.

• • Most trainees felt the current available opportunities allowed them to meet the curriculum requirements (82%) and felt their supervisor could provide support in gaining teaching experiences (93%).

• • Only two-thirds of trainees felt the current opportunities prepared them to be an effective Consultant trainer (67%). Some were also uncertain of teaching opportunities available in the deanery (41%).

• • Trainees expressed a preference of learning through small group tutorials, interactive workshops and experiential learning.

• • Trainees requested incorporating content around innovative technology in medical education including artificial intelligence and simulation as well as formal qualifications in medical education.

The project has shown that the current TTT course is effective in supporting Psychiatry higher trainees meet their curriculum requirements, however there is a scope to adjust the content to meet their changing needs and align with digital advancements in medical education. We suggest the course should be delivered in a more interactive and engaging manner for example using breakout rooms and workshops. To ensure all trainees are aware of the course and teaching opportunities available, an information leaflet outlining the TTT course will be sent out as part of the induction process. It is hoped that with these improvements, the needs of Psychiatry higher trainees will be better met as they move forwards in their careers and become Consultant trainers.

King Edward Memorial Hospital (KEMH) is the largest tertiary women's hospital in Western Australia and a tertiary referral center for complex pregnancies, for example, adolescent pregnancies (12–19 yr olds), pregnancies with obstetric complications or fetal anomalies, statewide drug and alcohol antenatal service and preterm births. With 6000 births annually, this women's hospital does not only provide obstetric care, but also looks after gynecology, oncology and chronic pain patients. We would like to share the model of care for our women's mental health service which provides statewide Childbirth and Mental illness (CAMI) service looking after women with chronic enduring mental illness, statewide drug and alcohol antenatal service (WANDAS), adolescent model of care and our service for all other women attending this tertiary hospital within a unique consultation liaison model.

Our team comprises 3.0 full time consultant psychiatrists, 2 Psychiatry trainee registrars, 5 clinical psychologists, 2 triage nurses and administrative staff. In total, we had 1959 referrals to our service in 2022–23 financial year. These women had varying amount of input from our service during their treatment in hospital: one assessment with advice and signposting to brief therapy, up to a fully comprehensive Multidisciplinary Team (MDT) care as provided by an adult community mental health service. In addition to comprehensive assessment, MDT interventions include risk assessment, pharmacological interventions, psychological interventions, working alongside child protection services, infant mental health and attachment work.

Our most common diagnostic categories included post-traumatic stress disorder (10%), adjustment disorders (10%) followed by Generalized anxiety disorder and recurrent depressive disorder (6% each). Our key performance indicators include: number of consumers (541 in 2022–23) that received comprehensive intervention from us in last 12 mths, consumer and carers’ feedback and rate of completion of outcome scale at point of admission and discharge from service. These figures have remained consistent for the last 5 yrs.

Our hybrid model of care is unique as it incorporates a consultation liaison and a community mental health care model for women attending our hospital. This allows us to provide a safe, specialized, timely service to women in their most vulnerable period of life.

Opioid use disorder (OUD) is a global burden with significant morbidity and mortality. Standard of care often includes integrated treatment programs combining psychosocial interventions and Medication Assisted Therapy (MAT) which includes methadone, Buprenorphine (BUP) and Naltrexone. BUP, a partial u-opioid receptor agonist, has shown to increase patient treatment retention, reduce relapse, and improve quality of life. BUP Oral formulations can be associated with misuse, diversion, and non-adherence. Despite availability, many individuals don't receive adequate MAT treatment or discontinue medications prematurely, substantially increasing their relapse risk. Subcutaneous Long-Acting BUP (SC LABUP) injectable formulations have been associated with improved access, less burden of adherence, and greater abstinence in OUD patients. From this perspective, the OUD program at Erada Center maintains affected individuals on weekly or monthly SC LABUP injections. Our study aims to evaluate abstinence and treatment retention in Erada Center patients who are maintained on LABUP injections.

We conducted a retrospective cohort study of all individuals following at Erada Center from January 2023 until January 2024, who were maintained on weekly or monthly LABUP injection. 174 individuals were identified, with diagnosis of OUD as per ICD–10 criteria, and receiving LABUP injection during inpatient admission or outpatient follow up. Primary outcomes were abstinence period (defined as negative urine drugs test apart from q-BUP), and retention in treatment (defined as compliance with attendance with OUD program). These were assessed at three time intervals: 24, 36, and 48 weeks from taking the first LABUP injection.

174 individuals were maintained on LABUP injection. Participants were all males, aged 18–65 years old, and polysubstance users with opioids being their drug of choice.

70 patients completed at least 24 weeks and received at least 2 doses of LABUP. Out of those, 53 achieved full abstinence and retention in 24 weeks (75.71%), 32 patients achieved the same for 36 weeks (45.71%), 25 patients achieved the same through 48 weeks (35.71%). Reasons for being lost to follow-up included relapse, incarceration (military service or custodial sentence), or drop out for no identifiable reasons.

To the best of our knowledge, this is the first study in the UAE and Arab world looking at the outcomes of individuals with OUD maintained on LABUP injection. Results highlight a notable abstinence and retention rates as above. Further studies should look at reasons for relapse and loss for follow-up.

The audit aims to check compliance of prescribers to the following National Institute of Clinical Excellence (NICE) guidelines:

• • NG134, CG31: Antidepressants are prescribed in conjunction with psychological therapy.

• • NG134: A risk-benefit discussion took place.

• • NG134 Written information was given.

• • NG134, CG31: First-line medication was prescribed in the first instance.

• • NG134: An off-licence medication is only prescribed after a review.

• • NG134: A consent form is signed if an off-licence is prescribed.

All patients under CAMHS and receiving antidepressant therapy was considered. People on the caseload currently an inpatient were excluded. The audit was performed in October 2023. 86 eligible patients were randomised; 30 were selected for case review. Clinic letters and internal case notes were reviewed to check compliance.

Areas of good compliance: antidepressants prescribed with psychological therapy, risk-benefit discussions took place, first-line medications prescribed in the first instance, off-licence medications prescribed only afer review.

Areas of moderate compliance: written information given with prescriptions.

Areas of no compliance: consent form does not form part of standard practice or local guidelines.

The local CAMHS service showed good compliance to NICE guidelines around antidepressant prescribing. Presentation to the local team is required to remind clinicians of the need to document parts of the consultation such as giving written information. A discussion with the regional consultant body yielded the outcome that the service will adhere to local Trust guidelines of internal case notes documenting consent rather than a signed form. The standards for the re-audit in 6 months will reflect this.

To assess the quality of General Practitioner (GP) referrals to a Local Memory Service in South Sefton – a reaudit.

The quality of GP referrals received from primary care to the Memory Clinic at South Sefton Neighbourhood Centre (SSNC), Mersey Care NHS Foundation Trust, was assessed over three months. This reaudit was based on an initial similar audit conducted in 2019 of 106 GP referrals to SSNC.

The GP’s documented history and duration of memory loss, collateral history, and the impact of the patient's memory loss on activities of daily living (ADLs) were analysed. Also explored were the cognitive tests, physical examination, and completeness of blood investigations.

The expected standard for completeness was set at 100%. Achieved compliance for each parameter was graded 95% and above (green), 75% to 94% (yellow), and below 75% (red).

106 GP referrals were received in the SSNC Memory Service between June and August 2022. About 86% of the referrals had a history of memory loss noted by the referring GPs, while only 46% commented on the duration of memory loss. We observed increased documentation regarding the patient's history of memory loss, physical health status and cognitive testing. On the other hand, there was an 8% reduction in the referrals regarding the impact of memory loss on activities of daily living in comparison to the initial audit done in 2019.

About a quarter of all the GP referrals were accepted based on the information the GP provided on the first referral letter sent to the service. On the contrary, 70 referrals were either considered inappropriate or declined outright. Alternative diagnostic advice was given to the referring GPs in 12, and the GP asked to provide additional information in 9 of these 70 referrals. After the GP offered further details, 17 initially rejected referrals were accepted for assessment.

Even though there were some observed improvements in the information GPs provided on referrals made to the local memory service in 2022 compared with 2019, this still fell drastically below the expected standard. The finding from this re-audit process brings to the fore the need for improved partnerships between memory services professionals and GP colleagues.

A new referral proforma has been designed in collaboration with the local Integrated Care Board (ICB), detailing essential information that needs to be documented by the GP before a referral is sent to memory services

Suicide poses a significant public health issue, and the presence of suicidal thoughts stands out as a prominent risk factor, highlighting the importance of addressing this aspect for early intervention and prevention efforts. While older adults face an elevated risk of attempted suicide, research in this domain is currently constrained. This study aims to enhance and evaluate the efficacy of an E-CMAP (Culturally Manual Assisted psychological intervention for Elderly) in mitigating suicidal ideation among individuals aged 55 years and older in Pakistan.

The study will be carried out in 2 phases. Phase 1 is cultural adaptation and refinement of the intervention and phase 2 is exploratory randomised control trial. In Phase 1, focus groups were conducted (N = 2) with Health professionals and service users and carers for adaptation of CMAP manual for suicidal ideation. In Phase 2 randomized exploratory trial will be conducted with 192 older adults with suicidal ideation randomized either to 1) E-CMAP added to Treatment As Usual (TAU) or TAU arm. ECMAP is a problem solving intervention comprising 6 sessions delivered one to one over 3 months by trained therapists. All participants will be assessed at baseline and after intervention (i.e. 3 months) for suicidal ideation, hopelessness, depression, health-related quality of life, coping resources, satisfaction with intervention, and episodes of self-harm.

Thematic Analysis of focus group discussions indicates that participants expressed a preference for incorporating a religious element into distraction techniques, delivering information about the significance of medical treatment, showcasing recorded sessions illustrating problem-solving techniques, and involving family throughout the intervention period.

A culturally tailored psychosocial intervention that incorporates problem-solving and cognitive components has the potential to decrease the risk of suicide among older adults.

We would like to report a case of pseudo bulbar affect during recovery from locked in syndrome due to brainstem stroke.

We present a lady in her early 60s who developed pseudobulbar affect during recovery from locked in syndrome. MRI brain confirmed brain stem infarct. No personal or family history of mental illnesses was noted. Neurological examination on our rehabilitation unit confirmed dense weakness in all four limbs. She would cry even when family gave her good news or made jokes with her. This appeared to be the only method of expressing her emotions she had; however, it was unclear if this was aligned to her internal emotional experience.

Through clinical observation and using the Testing Emotionalism After Recent Stroke-Questionnaire (TEARS-Q) measure of emotionalism we identified that pseudobulbar affect was present, and intervention should be considered. The patient also stated that her crying was not always aligned with her emotional experience, but laughter was. The Clinical Outcome Routine Evaluation (CORE-10) was also used to screen out other potential psychological difficulties including depression. The assessment indicated she was experiencing low levels of psychological distress.

We initiated fluoxetine and clonazepam was given to help with spasticity and sleep. Our non-pharmacological measures included sitting with the emotional expression and not asking her to stop, encouraging her to take deep breaths and modelling this and when she presented as calmer supporting her to identify if her emotional expression was in line with her internal emotional experience and using different communication strategies to explore this and support her to have her needs met. If the crying persisted mid communication, staff supporting her would reorientate her to what she had been attempting to communicate and encourage her to continue, which she would be able to do. All staff were asked to do this during their interactions with the patient to support identification of emotional alignment. Significant reduction in emotional misalignment was noted following the implementation and increased use of external communication aids. Within a few months her distressing crying episodes reduced and neurologically she improved.

Pseudo bulbar affect is a distressing condition that can occur during recovery from locked in syndrome. Diagnosis can be confirmed by ruling out other common conditions like anxiety or depression. Treatment includes both non-pharmacological and pharmacological measures best provided by a specialist multidisciplinary team.

To evaluate whether a comprehensive biopsychosocial assessment is performed for patients presenting with self-harm or suicidal ideation in clinical practice, following National Institute for Health and Clinical Excellence guidelines 225 (NG225). We assessed Dorset Healthcare Liaison Psychiatry practitioners' compliance with a standardized biopsychosocial assessment template.

A standardized biopsychosocial assessment template, aligned with NG225, is utilised in all Dorset Healthcare Liaison Psychiatry services for conducting initial assessments. Included data were the initial assessments of adult patients presenting from 01/08/2023 to 30/09/2023 for the following indications: 1) a suicide attempt, 2) a self-harm incident, or 3) suicidal ideation. Any initial assessment that did not use the standardised template was excluded. Retrospective analysis of Rio records assessed compliance with each heading on the biopsychosocial assessment template.

A total of 60 records were included from Dorset Healthcare Psychiatry Liaison Services. Only one heading, the “Presenting Situation”, was documented in all assessments (100%). Psychiatric headings on the template showed high compliance: “Mental State Examination” and “Risk Summary” were each documented in 98% of assessments, and “Psychiatric Formulation” in 92%. The “Carer/Parent's Understanding of the Assessment” was the least assessed (40%). Other significant headings that showed moderate compliance were, “Safeguarding Concerns” (71%), “Physical Health History” (75%) and “Social Situation” (81%).

Our findings emphasize the need for more comprehensive biopsychosocial assessments in Dorset Healthcare Liaison Psychiatry services. While Liaison Psychiatry practitioners exhibit proficiency in evaluating psychiatric aspects, there is reduced compliance in assessing social aspects, notably in assessing family understanding. Future qualitative analyses will evaluate practical barriers and human factors affecting compliance with specific headings. Moreover, data collection can expand to encompass additional Mental Health services in a wider catchment area, including settings such as community and inpatient facilities.

To ensure smooth running of Multidisciplinary team (MDT) in Community mental health team (CMHT) and reviewing MDT structure for better functioning at Parkview Mental health Resource centre.

On a Friday two Multidisciplinary teams (MDTs) were running online on Microsoft teams simultaneously. The same staff was running the two MDTs, so staff input could be limited at times and staff would dip in and out of MDTs. Discussion around ways of improving this so that both MDTs run smoothly. Also, there was no formal structure to MDT meetings. It was decided that improvement in Quality of MDT needs to be addressed.

Initially numerous discussions held online with Parkview team, nursing colleagues.

CMHT Quality improvement group was set up and a meeting was arranged where everyone's ideas were considered.

A pilot project was first introduced in March 2022 and audited in July 2022. Plan, do, study, act (PDSA) cycle was carried out.

Plan

Two nursing teams to be setup which will feed back into the two MDTs on alternate weeks. This will reduce nursing teams having to come in and out of one MDT to join other MDT, hence increasing the efficacy of the MDT.

Devise a new template to provide formal structure for the MDT presentation.

Do

Trial the new setup of two nursing teams.

Study

Ask all MDT staff members for feedback on the working of MDT.

Act

Reformat the Structured template and distribute to all staff members.

100% staff felt that new structure of MDT was useful.

84% staff satisfied with the new way of running of MDT.

84% staff satisfied with having designated teams for MDT.

Having Designated MDT teams and a structured format helped in robust functioning of the MDT in the CMHT.

The aim of this project is to improve the monitoring of patients on lithium under the South Gloucestershire Later Life Community Mental Health Team and to clarify the process for this monitoring with the aim of improving patient care and safety. We aim to try to achieve 100% compliance with agreed standards based on NICE and Trust guidelines.

Following a meeting with team medics we agreed a series of nine standards derived from local and national guidelines. We then used a locally held database of patients on the later life CMHT caseload on lithium therapy to identify our sample and devised a simple audit tool to collate the information. We used Rio electronic health records and ICE blood results to obtain baseline data from June 2022 to December 2022.

We used the plan-do-study-act (PDSA) cycle model for quality improvement. Following analysis of the baseline data, we planned and implemented key changes of the physical health nursing team taking over investigations from primary care and utilising a bespoke database. We also completed an education session for staff. Following these changes, data was collected and analysed from June until November 2023. From the analysis of these results, a further change was planned for PDSA cycle 2 and further data collection is planned.

Results from baseline data showed that six out of eight standards had compliance of < 60%, which included the time-sensitive investigations such as lithium levels every 3 months; kidney function tests every 3–6 months; calcium level every 6 months. Weight/BMI monitoring and documentation of side effects also had poor results. Average compliance across all standards was 57%.

Following the agreed steps to improve compliance, PDSA cycle 1 results showed improvement across the board, with average compliance increasing to 94%. Time-sensitive investigations now had 100% compliance (lithium level, kidney function, calcium level). Areas for improvement remain, namely in weight/BMI monitoring every 6 months and clear action plans for results falling out of range being clearly documented in patient notes.

By working closely with the physical health nursing team to devise a bespoke local database of information and taking over the investigations from primary care, we have shown an improvement across all standards, therefore improving the quality of care and patient safety.

Women with severe mental illness are at higher risk of sexually transmitted infections (STIs), unplanned pregnancies and poor engagement with cervical and breast screening. Despite current national guidance, these issues are poorly addressed during psychiatric admissions.

We aimed to improve the provision of women's sexual and reproductive healthcare on psychiatric wards using a quality improvement framework.

Female psychiatric inpatients aged over 18 were included. A baseline audit was performed in October 2022 on a female psychiatric ward, followed by six PDSA cycles from August 2022–January 2024 (n = 108).

We introduced women's health assessments (WHAs), offering counselling on: (1) contraception, (2) cervical and breast screening, and (3) STI screening. We arranged treatment and follow-up.

Changes were made at each PDSA cycle: ensuring provision of emergency contraception and STI swabs; establishing a protocol for referring to the sexual health clinic; creating dedicated clinic time to offer counselling; developing a poster and educational leaflet; and creating a proforma to record outcomes. The interventions were then extended to a neighbouring ward.

We reviewed electronic notes and recorded the percentage of patients offered counselling at baseline and after each cycle, later also recording the percentage of patients accepting interventions.

At baseline, 12.5% of inpatients had been offered at least one of: contraceptive counselling, cervical and breast screening or STI screening. This improved to 87.7% offered a leaflet and 63.1% offered counselling by the final cycle. Of these patients, 48.8% accepted at least one intervention. On the neighbouring ward, offers of counselling increased from 28.6% to 63.6%.

Introduction of dedicated clinic time increased offers of interventions the most, to 94.1% (cycle 3). Compliance was lowest in cycle 4 (54.2% offered any intervention) which coincided with junior doctor changeover. Provision of an educational leaflet did not increase acceptance of interventions (cycle 5).

Introduction of WHAs led to detection and treatment of STIs in seven patients. Absent contraception was identified and started for a patient taking sodium valproate. Five patients were administered emergency contraception and two commenced long-term contraceptives. A case of female genital mutilation was identified, and a case of cervical neoplasia (CIN 3) was detected.

Provision of WHAs improved women's healthcare in inpatient psychiatric settings, with clinician contact being the most valuable resource in achieving this. There were several barriers, importantly clinician availability and awareness during junior doctor changeover. We will establish our interventions trust-wide, protocolising WHAs in the junior doctors’ handbook, and collect patient feedback.

Additional authors: Dr Terteel Elawad, Dr Judith Stellman.

Optimal management of Behavioural and Psychological symptoms of Dementia (BPSD) remains challenging. This report describes using nabilone, a synthetic cannabinoid, in a 61-year-old woman with Alzheimer's dementia (AD) experiencing progressive BPSDs.

AM was diagnosed with AD in February 2019 and prescribed donepezil and mirtazapine. In August 2021, her behaviour deteriorated, becoming paranoid, repeatedly pacing and developing expressive aphasia. Behaviours further declined leading to an admission to our dementia ward under the Mental Health Act 2007 in January 2022. AM showed limited response to medications including risperidone and mirtazapine which were switched to olanzapine and citalopram. “Controlled falls” were observed, during which AM placed herself suddenly onto the floor. In February 2022, she was witnessed having a self-terminating generalised tonic clonic seizure (GTCS) lasting 3 minutes and later witnessed having three more seizures. Computed tomography excluded acute intracranial pathology. She had no previous history of seizures. An electroencephalogram displayed focal slowing over the frontal region greater on the right and presence of sharp, transient, sharpened slow wave, triphasic waves and reported that epileptiform discharges can be seen in AD in the absence of epilepsy.

Behavioural charts, Cohen Mansfield Agitation Inventory (CMAI) and Neuropsychiatric inventory (NPI) questionnaires were used to monitor response. Decision was made to trial Nabilone in April 2022 due to minimal improvement. Nabilone was started at 0.25 mg daily and up-titrated by 0.25 mg fortnightly based on the response. Over the subsequent month there was a measurable improvement. This was temporarily halted due to issues with nabilone supply, together with cessation of lorazepam, showing worsening in behaviours. Nabilone was eventually restarted and increased to 1 mg once daily with promising effect.

There was a notable qualitative improvement in AM's engagement and communication with family and staff. Prior to treatment the frequency of aggressive incidents ranged from 25–35, reducing to five to ten incidents per day. Controlled falls largely ceased. The NPI Caregiver distress score dropped from 21 to 8 over three months; Frequency and severity scores dropped from 73 to 40 during the same period. CMAI scores dropped from 86 to 64 over two months.

We describe a measurable improvement in BPSDs and quality of life in a patient with severe AD. Reduction in irritability, agitation and improvements in sleep were observed after initiating nabilone. The mechanism of nabilone via CB1 agonism has shown to be neuroprotective and anti-inflammatory. This indicates a promising treatment for BPSDs.

Research has found that having a mental health condition is associated with smoking, and difficulties remaining abstinent. It is also evidenced that there is desire to reduce the amount smoked and cease smoking altogether by those with mental health conditions. Smoking can also affect some medications used to treat mental health conditions.

To assess nicotine replacement management in inpatients at Rathbone Rehabilitation Centre (RRC) against Mersey Care NHS foundation Trust (MCFT) Nicotine Management Guidelines (SA20).

Data of all discharged patients from RRC over a 12-month period was collected following a standardised process and assessed for 6 parameters.

A total of 51 discharges were identified and the whole sample of 51 patients were audited.

47 (92%) were asked and recorded of their smoking status and 4 (8%) were not at the point of first contact on patient electronic records (Rio).

Of the 28 smokers who were identified on admission, 26 (93%) were offered support to stop smoking at that point. 3 other patients started smoking during admission.

Of the 31 patients who were identified as smokers (including 3 who began smoking during admission), 24 (77%) were offered support to stop smoking at regular intervals throughout their admission and 7(23%) were not.

Of the 28 smokers who did not wish to permanently stop smoking, there was documented evidence that 20 (71%) of these individuals were offered nicotine replacement treatment (NRT) in some form to manage temporary abstinence from smoking.

5 out of 31 smokers were referred to a Nicotine Dependence Treatment Advisor for counselling and support during their inpatient stay.

Below action plan was designed to improve compliance with MCFT Nicotine Management Guidelines (SA20):

Audit leads to communicate with every team member at RRC (Team meetings and emails) to remind them of the following:

1. ◦ To offer smokers support to stop smoking at regular intervals and document on Rio; via named nurse sessions or opportunistically.

2. ◦ To offer NRT where appropriate and document on Rio if accepted or declined during MDT reviews/named nurse session.

3. ◦ Ensure Physical Health Nursing Proforma is always completed on Rio, and if the service user is a smoker, to ensure referral status (referred/declined) to Nicotine management team is documented.

4. ◦ Increase awareness of referral pathway by putting up posters in relevant clinical areas.

Aim:

80% of Central and North West London NHS Foundation Trust (CNWL) QI projects will have meaningful Service User & Carer involvement by August 2023 (baseline was 46%).

Background:

Service user and carer (SU&C) involvement is increasingly recognised as integral to healthcare improvement efforts. However, despite its many benefits, the meaningful involvement of service users and carers remains a challenge.

Thus, it is necessary to get an in-depth understanding of the barriers and enablers to embedding involvement in improvement practice at the individual, service and organisational levels. With this understanding and staff can then co-produce evidence-informed behaviour change interventions to improve SU&C involvement.

Patient representation and lived experience

This improvement work embraces a full and continuous partnership with SU&Cs.

SU&C worked with CNWL staff in the conception, execution, delivery and dissemination of this work including EbE Improvement Forum.

They, thus, serve as integral members of the project team where they provide valuable input based on their lived experiences and perspectives to help shape the direction of the work. As equal partners, it also helps foster a culture of mutual respect, collaboration, and trust between all the parties involved.

This work adopts the COM-B model. The approach to conduct semi-structured interviews (interview questions were based on COM-B model and behavioural change wheel) with frontline healthcare staff and SU&Cs. The interviews gave insights on the barriers and facilitators to SU&C involvement in healthcare improvement work.

This then generated operational-level and actionable change ideas to guide tailored strategies for enhancing involvement capabilities, widening involvement opportunities and enabling motivations using the model for Improvement. These change ideas were then co-tested with SU&C using the Model for Improvement approach.

This systematic approach enabled a cultural shift towards collaborative partnerships between healthcare staff and SU&C to contribute to the service improvement.

Measurement of improvement

1. 1. Qualitative data to understand enablers and barriers to involvement in improvement work.

2. 2. Percentage of all QI projects (registered on Life QI and scoring 1 or more on IHI Project Score) that have a SU&C involvement.

Effects of changes

Staff and SU&C interviews identified the key barriers as inadequate capability (lack of understanding and skills), limited opportunities (leadership, resources, access) and insufficient motivation (discomfort, inability, time limitations). Enablers included appreciating diverse perspectives, leadership support and buy-in, established processes, valuing insights and patient empowerment.

The outcome measure also showed an increase in the number of improvement projects at CNWL that have SU&C involvement from 46% to 80%.

Lesson Learnt:

This work has shown that by bringing multi-disciplinary staff and SU&Cs together generates cognitive diversity to the learning to drive improvement and sustain the gains. Furthermore, partnership working helped to create and establish learning culture within the healthcare service.

Message to others:

1. 1. Strong executive sponsorship helps to drive involvement across the organisation.

2. 2. By bringing staff and SU&Cs together generates cognitive diversity to the learning to drive improvement.

3. 3. Using well-known and established behavioural change model, such as COM-B model, helped to identify, design and synthesize behaviour change interventions.

Whether focusing on clinical or non-clinical roles, activity within organizations (and, by extension, outcomes) depends on decision-making. The conscious experience of decision-making (as if it is the outcome of an objective and explicit appraisal of pertinent information) belies the complex nexus of influences on this process. Whilst extensive research has been undertaken on both organizational and clinical decision-making, these literatures have largely remained separate. The authors contend that, when account is taken not only of the interplay between decisions that are deemed either ‘organizational’ or ‘clinical’, but also that this dichotomy itself is invalid, there is an imperative to take a whole system approach to decision-making in health organizations.

The aim of this study was to develop a framework for understanding decision-making that has applicability across a complex mental health system.

• • Step 1: Define the domain of discourse (i.e. decision-making in a complex adaptive mental health system including clinical and non-clinical settings);

• • Step 2: Generate a dataset of domain-relevant statements by iterative reflection on the respective areas of practice (clinical and non-clinical);

• • Step 3: Thematically analyse the dataset to identify a thematic structure.

A hierarchical thematic structure was identified. At the highest order, this structure comprises a dichotomy between embodied and disembodied conceptualizations. The embodied theme is further divisible by perspectives that are intra- or inter-personal. The former includes ways of thinking, assumptions, approximations, uncertainty, holding the model, and epistemic humility; and the latter includes relationships, trust/resentment, and disagreeing well. The disembodied theme incorporates both broad-brush characteristics of the system (such as holistic, connections, relata and complexity) and those characteristics with explanatory power (such as nonlinear, fuzziness and nondeterministic).

The framework defined by this analysis has the potential to facilitate the examination of facets of, and influences on, decision-making across a mental health organization. With further empirical testing and revision, such a framework can be used to inform the improvement of approaches to making decisions.

Children and young people (CYP) with intellectual and developmental disabilities (IDD) of known genetic origin experience complex physical and mental health problems; IMAGINE-ID has followed a national UK cohort from childhood to early adulthood. Parents completed structured online psychiatric assessments on repeated occasions. From these assessments, semi-automated personalised reports were generated summarising each child's strengths and difficulties, in collaboration with IMAGINE ID participants and the charity UNIQUE.

We aimed to discover whether providing a structured summary of our mental health and behavioural assessments would be beneficial to families of children with rare genetic conditions and IDD.

574 of the CYP's caregivers completed an online ‘impact’ survey, five years after receiving their initial report, comprising four areas of potential benefit: Quality of Care (whether the report led to an improvement in the child's quality of mental and/or physical health care); Social Impact (whether the report was used as evidence to support an EHCP, disability benefits etc.), Psychological Impact (whether it led to any change in understanding of the child's condition), and Referrals (whether the report led to a referral for Autism/ADHD etc.). We also invited qualitative feedback.

82% of respondents rated the reports as helpful. 35% reported they had led to an improvement in their CYP's quality of care, 24% reported social impact using the report as supporting evidence, 99% reported a psychological impact – a change in their understanding of the child, and 17% used the report to initiate a referral for an assessment of ADHD and/or autism. In our qualitative analysis, families who found the report helpful mentioned it led to ‘reflection’ on their child's condition and that it provided ‘access to benefits’. For those who did not find the report helpful, issues such as ‘it lacked professional input’ and ‘forgetting the contents’ of the report were identified.

Personalised summary reports, based on a structured assessment of their child's behavioural, social and emotional adjustment, are valued by families of children with rare genetic conditions and IDD and can bring about tangible benefits to the child and the family's access to resources.