5 results
Improving Physical Health Monitoring on an Inpatient Dementia Assessment Unit – a Quality Improvement Project
- Ivan Shanley, Fatma Ghoneim, Nadeera Attanayake, Jennifer Ford, Alina Kutraite, Thembisa Nkungu, Elle Maccabe
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S109
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Aims
Meadowview Ward is a dementia assessment unit based at Thurrock Community Hospital as part of Essex Partnership University NHS Foundation Trust. Patients with advanced dementia are routinely admitted with significant physical comorbidities and, as such, robust physical health monitoring is required. Members of the nursing team felt that it would be helpful to formalise the approach to physical health monitoring in order to allow all members of the multidisciplinary team to be aware of the necessary requirements. It was decided to formulate a physical health monitoring prompt sheet to facilitate discussion regarding physical health during ward rounds.
MethodsA multidisciplinary discussion took place to identify the areas of monitoring which should be routinely highlighted in ward rounds. Items labelled as routine monitoring requirements were also listed. A prompt sheet was then devised which divided ward round discussion into nursing and medical feedback, with each section having specific areas for discussion (for example oral intake, recent blood results, any pending investigations). This included prompts for other staff groups including physiotherapists and occupational therapists. A section was also added regarding ongoing monitoring requirements, such as routine outpatient appointments and whether transport had been booked.
In order to assess the impact of the introduction of the prompt sheet a questionnaire was provided to members of the multidisciplinary team who regularly attend ward round. This assessed their perception of the quality of physical health monitoring both before and after the introduction of the prompt sheet, the impact of the sheet on ward rounds and whether they wished the intervention to continue.
ResultsThere was a significant increase in staff satisfaction with physical health monitoring on the ward (n=7, P = 0.0065). 100% of staff surveyed rated the introduction of the prompt sheet as “strongly helpful” and that they “strongly agree” the use of the prompt sheet should continue. An initial concern from the team had been the potential for the use of the sheet to delay ward rounds, however 57% of respondents reported no impact on ward round duration and 43% felt it strongly expedites assessments.
ConclusionThe introduction of the physical health monitoring prompt sheet has been widely perceived as a success within our multidisciplinary team. It has also demonstrated the effectiveness of a multidisciplinary approach to quality improvement projects, ensuring the wide variety of expertise within teams is utilised.
Hypercalcaemia and Primary Hyperparathyroidism – an Underappreciated Contributor to Psychiatric Presentations
- Fatma Ghoneim, Ivan Shanley, Jennifer Ford
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, pp. S6-S7
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Aims
Hypercalcaemia can lead to many neuropsychiatric symptoms from fatigue, lethargy, anxiety, irritability, and insomnia to impaired concentration and memory, depression, delirium, and psychosis. Primary hyperparathyroidism (PHPT), which is the most common cause of hypercalcaemia, is a relatively common disorder affecting 1 in 500 women and 1 in 2000 men aged over 40 years. A patient, with a diagnosis of Alzheimer's disease, subtype mixed, had hypercalcaemia on admission which wasn't corrected until 4 months of the admission had passed. Calcium correction precipitated a marked improvement in the patient's mental state. In order to learn from this incident, an audit was carried out to look at possible gaps in performing blood tests, and how abnormal calcium levels can affect patients’ mental states.
MethodsRetrospective data collection was performed to obtain blood results for all patients -aged 40 years or above- admitted to inpatient wards in South Essex within a six month period (from April 2022 to September 2022). A total number of 333 patients (173 males and 160 females) were identified.
ResultsBone Profile was checked in 248 patients (127 males and 121 females). Twelve patients were found to have hypercalcaemia on admission - mean age 65.7 years, female: male ratio of 3:1. No patients were found to have hypocalcaemia.
Hypercalcaemia was addressed in only 2 of 12 patients. Parathyroid hormone (PTH) was tested either before or during admission to mental health services in 6 patients, PTH was found to be elevated (greater than 9.3 pmol/L) in 4 patients (2 males and 2 females), below the midpoint of the reference range in one patient, and below the lower limit of the reference range in one patient.
ConclusionPatients with hypercalcemia had different diagnoses - anxiety, depression, adjustment disorder, mania, psychosis, and dementia. It was the first admission for three patients with a mean age of 76 years. Six patients were known to services but it appeared that the recent admissions were associated with hypercalcaemia. Active management of hypercalcaemia in 2 patients resulted in improvement in their mental state.
We found that risk of PHPT in mental health inpatients aged over 40 years old was increased by 1.45% (95% CI: -0.0620% to 5.6256%, P = 0.0390) in females, and was increased by 1.52% (95% CI: 0.3573% to 5.5031%, P < 0.0001) in males. Hereby, testing for bone profile should be routinely recommended for mental health patients.
The Impact of COVID-19 on the Quality of Admission Clerkings on an Old Age Psychiatry Ward – an Audit
- Ivan Shanley, Jaweria Faheem, Sandeep Bansal, Mahnur Khan, Hana Jeetun
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, pp. S174-S175
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Aims
On 11th February 2020 a novel coronavirus was named SARS-CoV-2, with the World Health Organisation announcing that the associate disease would be known as COVID-19. As doctors providing an inpatient psychiatric service, there were various changes in our daily practice secondary to the pandemic. These included reduced staffing levels due to illness, the need to wear personal protective equipment during all patient contact and high levels of anxiety surrounding transmission. We hypothesised that the resultant pressure on our service might impact the quality of admission clerkings to our ward, (a 17 bed functional Old Age Psychiatry ward), and therefore resolved to audit the data. We determined that “quality” of the clerking should be equated to completeness, i.e. the degree to which all desired information is included.
MethodsAdmission clerkings to the ward are to be completed on a pro forma built within the electronic patient record system (“Paris”). This pro forma is based on guidelines for the admission of patients to psychiatric inpatient units produced by the Royal College of Psychiatrists. The standard for the audit was set as 90% compliance with each individual section of the pro forma.
All admissions across three periods were extracted from the electronic record using the inbuilt reporting function. The periods were 1st April to 1st July in 2019 (pre-pandemic, n = 15), 2020 (early pandemic, n = 29) and 2021 (late pandemic, n = 22). Data were extracted manually from each admission clerking and recording anonymously on an excel spreadsheet, with either “yes” or “no” confirming or denying compliance with each domain (e.g. presenting complaint).
ResultsAll domains showed improved compliance from 2019 to 2021 other than recording of the mental state examination which saw a 9.09% decrease (which is not statistically significant). Comparing the pandemic years, performance was better in the early pandemic in 4 domains, better in the late pandemic in 10 domains and equal in 6 domains. 4 domains demonstrated a statistically significant improvement compared to pre-pandemic, however 9 domains still fell below the 90% standard set.
ConclusionDespite the challenges posed by the COVID-19 pandemic the quality of inpatient admission clerkings has not only remained unharmed but in some domains significantly improved. Admission numbers increased during the pandemic periods, so it may represent greater familiarity with the clerking process, or perhaps a desire to make more comprehensive notes during a time of crisis. Repetition of the study post pandemic may be of value.
Audit of methods used to contact the duty doctor - Abraham Cowley Unit
- Ivan Shanley, Jessica Thomas
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S349-S350
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Aims
The aim of this audit was to determine whether the duty doctor of a 4 ward inpatient psychiatric unit is contacted safely, effectively and in a manner that can be monitored. This is in line with trust protocol and the method stated is via switchboard. Should a deficit be found it was the aim to make an appropriate intervention.
BackgroundIn the Abraham Cowley Unit, there is a Senior House Officer ‘on-call’ duty doctor 24/7. The shifts are 2 x 12.5 hours daily and at all times the duty doctor should be contacted via switchboard. Contacting via switchboard is important to ensure there is an audit trail of calls made. Issues that arise from using other methods of contact, e.g. calling direct extensions, include miscommunication and the doctor not being reached in a timely manner. This had been identified as an issue anecdotally by junior doctors on call and also highlighted following an untoward incident.
MethodThe method by which the on call doctor was contacted was recorded in Excel for 5 consecutive 12.5 hour shifts in October 2019. The standard set for calls via switchboard was 80%. Following the initial results and the subsequent intervention, a repeat audit was performed using the same method.
ResultInitial Outcome
Initially it was found that only 25% of calls received where through the appropriate channel (5 out of 20 calls). This fell far below the 80% standard and an intervention was therefore devised.
Intervention
In order to ensure that all ward staff were aware of the trust policy posters were created and placed above all ward telephones and the telephone in the assessment suite office. This information was also handed over to the nurses in charge directly in order for it to be filtered through to other staff during handover.
Post Intervention Outcome
Following the intervention 88% of calls received where through the appropriate channels (7 out of 8 calls) and the 80% standard was achieved.
ConclusionThere has been a demonstrable improvement in the adherence to trust policy when contacting the duty doctor, with the percentage of calls made through the appropriate channel rising from 25% to 88%. This has now met the agreed standard of 80% and will improve the trust's ability to monitor contact of the duty doctor effectively.
An assessment of referrals to a liaison psychiatry team within a large district general hospital – Completing the Cycle
- Ivan Shanley, Sophie Tillman, Shruti Lodhi, Shazia Shabbir
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S102-S103
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Aims
In 2019 members of the Liaison Psychiatry Department at Frimley Park Hospital completed an audit of the referrals to the service1. The quality of referrals was found to be highly variable, for example only 28% included a risk assessment and frequently omitted both past psychiatric and past medical histories. As such an intervention was designed involving three parts;
Multidisciplinary education of staff
New and more readily available referral guidelines
New referral form
This re-audit seeks to complete the audit cycle and assess the impact of the intervention.
MethodThe first 50 referrals to the Liaison Psychiatry Department of Frimley Park Hospital during February 2021 were assessed using the following criteria:
Staff type, referral source, physically fit for assessment, physical cause ruled out, drugs / alcohol involved, appropriate reason for referral, clinical question asked, did final diagnosis match referral diagnosis, risk assessment included, information about admission included, past psychiatric history included and past medical history included.
The percentage of referrals received for each criterion (e.g. the percentage with a risk assessment completed) was then derived from the data.
ResultThere has been a marked improvement in a variety of areas. The percentage of referrals containing a risk assessment increased from 28% to 96%. This is likely due to the risk box now requiring an entry prior to being able to submit the referral form. Similarly the percentage containing past psychiatric history has risen from 38.8% to 90%. Previously 46.2% of referrals contained a working diagnosis which was not consistent with the clinical picture, but again this has improved, with 60% of initial diagnoses now matching the final outcome. There are however areas for improvement. Only 14% of referrals contained a specific clinical question, which is lower than the 20% achieved previously. This may be because the new referral form does not provide a specific free text box for this.
ConclusionThe intervention yielded a marked improvement in the quality of referrals received by the Liaison Psychiatry Department at Frimley Park Hospital, and it is the intention to continue to use the current process. Based on the new results we will look to make small adjustments, for example adding a free text box for a specific clinical question and emphasising the importance of this information.