6 results
Audit Of Psychotropic Prescribing in the Crisis Team at Fieldhead Hospital According to NICE Guidelines
- Shumaila Shahbaz, Maya Garside, Tim Rajanna
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- Journal:
- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, pp. S173-S174
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Aims
To ensure that psychotropic prescribing and monitoring in the Crisis Team is compliant with NICE guidelines and to provide excellent patient care and to practice medicine safely.
MethodsMedication prescribing should be a collaborative decision by the service user and the prescriber. This allows patients to have autonomy to decide their treatment plan. NICE provides guidelines for prescribing medication which includes baseline investigations, reviews of treatment including side effects, and physical health monitoring.
We selected 50 admitted patients for the audit from April 2021 until September 2021, who were prescribed psychotropic medications. We used medication cards and electronic patients’ records (System One). Our exclusion criteria were the 72-hour post-discharge follow-up from the inpatient ward.
The audit standards included as follows: age, gender, the indication, the start of medications, dose, within BNF limits, discussion, consent from the patient, comorbidities, physical health monitoring, response to treatment, monitoring of side effects, and other important information.
Results100% results for indication, dosage, discussion with the patient, and side effects monitoring.
We had promising results for benefits from the treatment (46 out of 50 patients responded to treatment) and 4/50 did not respond to treatment. Unfortunately, one patient died from an overdose of illicit drugs, not with prescribed medication and one was admitted, and one felt worse, and one did not have any response.
However, 22 out of 50 patients were prescribed antipsychotic medication.11 out of 22 patients had ECG and blood done by the Crisis Team and 4 done by other parties (hospital and primary care).3 had recent blood tests but no ECG.2 patients did not have physical health monitoring and the reason was not documented.2 patients were started on antipsychotic by the Crisis Team, but the dose was not changed.
In terms of side effects, 8 out of 50 reported some side effects.
6 of them were prescribed antidepressants. They reported difficulty in sleeping and palpitations with Venlafaxine, nausea with Fluoxetine, nonspecific side effects with Citalopram, and sedation with Trazadone. 2 patients felt dizziness, diarrhoea, and muscle spasms with Mirtazapine. One patient had a metallic taste with Zopiclone. For side effects with antipsychotics, only one patient reported side effects with Olanzapine.
Conclusion• The Crisis Team is working at excellent standards on most areas of psychotropic prescribing and monitoring
• The Crisis Team needs to improve physical health monitoring of their patients.
Addiction service changes due to COVID-19
- Shumaila Shahbaz, Zeeshan Hashmani, Soraya Mayet
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S349
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Aims
Addictions services had to respond rapidly to reduce COVID-19 transmission to protect patients and staff. Patients with opioid dependence are particularly vulnerable, with high risks. Our community addiction service changed practice in line with COVID-19 guidelines. For patients with opioid dependence; face-to-face contacts were initially reduce and mainly for new starts, restarts and non-attenders. Prescribing changes were completed on an individually risk assessed basis to reduce attendance at the chemist, specifically to reduce transmission, keep patients in treatment and to ensure chemists could continue to function. We document some of the service changes during the COVID-19 lockdown.
MethodService evaluation had approval from Humber Teaching NHS Foundation Trust. Data retrieved on one Hub of a community addictions service in North England, UK. Patients prescribed opioid substitution treatment for opioid dependence were assessed, with data retrieval through electronic healthcare records. Data were analysed by Microsoft Excel anonymously.
ResultIn lockdown (March 2020 to June 2020), we identified 112 patients with opioid dependence prescribed opioid substitution (OST) with methadone or buprenorphine at the Hub. All white British, mean 42 years, most male (75%) and prescribed methadone (78%). Ten were new starts and 8 restarts to OST. Attendance rates did not change: 91% before and 92% during lockdown. Appointment format changed from predominantly face-to-face (92%) to telephone (99%). Most patients (91%;n = 88) were offered take-home naloxone and overdose prevention training of which 14 refused. Supervision days at the chemist for OST reduced significantly from 75% collecting daily at the chemist, reducing to 20% during lockdown. Five patients were shielding and 7 had covid-related symptoms. There was one death during lockdown which was not attributed to covid or overdose.
ConclusionThe addictions service continued to be open and work proactively throughout lockdown, seeing new patients and continuing treatment interventions safely. Major changes were made in line with COVID-19 guidelines, to respond to the threat of transmission. Our service was flexible and able to adapt quickly to remote working. We maintained excellent attendance rates despite changes to the format of consultations. There were no related incidents e.g. overdoses linked to prescribed medications, despite a reduction in supervision, and therefore patients having extra medications. This important finding may be related to the individual risk assessments that we conducted before making changing to prescribing. This was supported by most patients were receiving naloxone to prevent overdoses. Some of the changes, such as telephone consultations, may be beneficial to continue post COVID-19.
Improving attendance in addictions - do quality improvement plans work?
- Soraya Mayet, Shumaila Shahbaz
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S206-S207
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Aims
We assessed whether a quality improvement plan initiated in 2018 had sustained benefits for improving attendance rates at addiction prescriber reviews, after 13 months.
MethodThe QIP re-audit had Humber Teaching NHSFT approval. We assessed electronic healthcare records of patients prescribed OST at a specialist addictions service, spanning a large geographical area, split into three Hubs. Data were analysed via Microsoft excel.
Baseline data for the whole addictions service were collected in April 2018 (n = 343), followed by QIP implementation. The QIP included a new appointment letter explaining the importance of the prescriber review, text message confirmation and reminder the day before, verbal reminder from keyworker and a call from the prescriber explaining the importance of attending (for persistent non-attenders). In the event of nonattendance, a medication safety review was completed. Further data were collected in December 2018 (n = 339) and a re-audit of one Hub (n = 91) was completed in Jan 2020.
ResultAt baseline in April 2018, half (50% n = 170/343) of all patients had attended an addictions prescriber review in the last 3 months; Hub 1 (55%; n = 52/95), Hub 2 (34%; n = 45/133) and Hub 3 (65%; n = 73/115). The Quality Improvement Plan was implemented. Attendance rates for subsample (Hub 1) conducted in Oct 2018 showed a reduction in attendance (51%; n = 48/92). This led to the enhanced Quality Improvement Plan.
After the enhanced Quality Improvement Plan implementation in Dec 2018, attendance rates improved for all Hubs to 76% (n = 258/339); Hub 1 (77%; n = 72/93), Hub 2 (73%; n = 97/133), Hub 3 (79%; n = 89/113). For non-attending patients, a medication review was conducted in their absence by the prescriber for most (94%; n = 74/81) patients (see table 1 and Figure 1).
In January 2020, reassessment of attendance rates for Hub 1 (subsample), in January 2020 (n = 91) which showed attendance had increased to 86% (n = 78/91). All (100% n = 13) patients who did not attend for the prescriber review in person, had a medication review in their absence. In addition, the reasons for nonattendance were discussed with the patient and their keyworker, following which they were booked for a subsequent appointment.
ConclusionNonattendance at clinical appointments causes a significant financial burden across the NHS. It was fantastic to see that the QIP improved patient attendance rates and this was sustained and improved, over a year later. Serial non-attenders may need an enhanced strategy.
QI project: Improvement in quality of Seclusion Medical Review
- Shumaila Shahbaz, Richard Ward
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S218-S219
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Aims
To establish the improvements in the quality of seclusion medical review after introducing a template to complete the review.
BackgroundThe Mental Health Act – Code of Practice outlines the standards of patient care while in seclusion. It also emphasis that supportive engagement/observation schedules should be reviewed in person and continued at the point an episode of seclusion was initiated.
Furthermore, NICE also set up standards to monitor side effect profile while prescribing psychotropic for such patients and regular management review. It also gives importance to staff training to ensure these standards.
To improve the quality of the seclusion medical review, we completed an audit in July 2019 to ascertain whether medics are following Trust Policy.
We identified good results (above 90%) in the following areas:
Time of seclusion review
Record keeping
Management plan
Good documentation of risk, mental state examination and physical health.
We also noticed that the following areas can be improved:
Prescribed Medications. (60%)
Medication side effects. (40%)
Physical Observations (40%)
We used the following audit standards for our audit after our last audit and a template was designed and after discussion with medics incorporated into the existing documentation template.
Time of review
Reason and duration for seclusion
Psychiatric diagnosis
Mental State Examination/Behaviour
Physical health (including physical observations)/Environment
Medication (prescribed, rapid tranquilisation, side effects, or adverse effects)
Risk (to self-DSH or accidental) (risks to others)
Plan :(frequency of physical obs./medical review, management, restrictions, exit plan for terminating seclusion, patient's capacity to understand it)
MethodWe considered the following aspects:
Retrospective data collection from 01.03.2020 to 30.08.2020.
Sample selection: random selection of mixture of clinicians on different times and days of the week.
Data analysis was carried out by using Microsoft Excel.
ResultWe noticed a marked improvement in the quality of seclusion medical review (between 95% and 100%) after introducing a template for it. There were no major concerns identified during the re-audit.
ConclusionTo continue to use the template for Seclusion Medical Review which has shown significant improvement in the quality of the reviews which will improve patient care.
It also helped us to deliver person centred care and safe practice.
To continue teaching and training of doctors.
This QIP project motivated nurses to do an audit on nursing seclusion review and made necessary changes.
Patient experience of telemedicine in addictions
- Soraya Mayet, Iain Mccaw, Zeeshan Hashmani, Zuzana Drozdova, Amelia Gledhill, Samreen Arshad, Shumaila Shahbaz, Thomas Phillips
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S269-S270
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Aims
Opioid dependence has high risks and opioid substitution treatment (OST) improves outcomes and reduces deaths. Attendance at addiction specialist prescribers may be limited, particularly in rural areas. Telemedicine, such as videoconferencing, can reduce travel and improve access and attendance. Pre-COVID-19, we started a telemedicine service for patients with opioid dependence, prescribed opioid substitution treatment, requiring addiction specialist prescriber consultations. We present patient experience and assess whether patients recommend telemedicine.
MethodHealth Research Authority approval for Randomized Controlled Trial of Telemedicine versus Face-to-Face (control) appointments in large semi-rural community addictions service (2500km2) using a modified Hub-and-Spoke (outreach). Adult opioid dependent patients prescribed OST and attending outreach clinics recruited. Participants received two consultations in group. Telemedicine delivered using Skype-for-business videoconferencing. Patients attended outreach clinic, where an outreach worker undertook drug testing and telemedicine conducted via the outreach workers laptop. Specialist addiction prescribers located remotely, at the Hub. Patients self-completed NHS Friends and Family Test (FFT) immediately after appointment, separate from the wider research study. Data collected Sept 2019– March 2020 (pre-COVID-19 lockdown), Microsoft Excel analysis, with qualitative thematic free-text analysis.
ResultThirty completed FFTs were received, of which all participants were ‘extremely likely’ (n = 19;67%) or ‘likely’ (n = 11;37%) to recommend the Telemedicine service to friends or family, if they needed similar care. Two themes for reasons for recommending the service were; 1. Convenience (reduced travel, reduced travel time and reduced travel costs) and 2. Supportive Staff (including listening, caring and good support). One patient mentioned ‘it is a convenient way to communicate with medical staff, saving time and effort’. Regarding Telemedicine appointments, most participants responded that the timing of telemedicine appointments was good (n = 26;87%), given enough information (n = 30;100%), enough privacy (n = 28;93%), enough time to talk (n = 30;100%), involved as much as they wanted (n = 25;83%), given advice on keeping well (n = 28;93%), and NHS staff were friendly and helpful (n = 29;97%). No participants thought they were treated unfairly. When asked what went well, patient themes were: 1. Everything and 2. Communication (including listening and explaining). One patient stated ‘Everything better, telemedicing good, heard it well, everything improved this year’. In terms of what the service could do better, there were no issues identified.
ConclusionThe Telemedicine in Addictions service was overwhelmingly highly recommended by patients. Patients recommended the service because of convenience and supportive staff. The use of telemedicine is acceptable to patients and could be considered more widely. Due to COVID-19, this technology may be beneficial access to addiction services.
Quality of seclusion medical review according to trust guidelines
- Shumaila Shahbaz, Richard Ward
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S219
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Aims
We accessed whether medics are following Trust Policy while conducting seclusion medical review and identify the strengths in quality of seclusion medical review and identify the areas which need improvements to improve our quality and standards of patient's care and safety and to reduce risks.
BackgroundThe Mental Health Act Code of Practice sets an expectation for mental health services for restrictive interventions (use of restraint, seclusion and rapid tranquilisation) by following good standards. Medical reviews provide an opportunity to evaluate and amend seclusion management plan. This clinical audit was undertaken by looking at quality of record keeping about seclusion review by junior doctors, staff grades and consultants at different times (day, night, and weekend).
MethodData analysis was carried out by using Microsoft Excel. The audit had Humber Teaching NHSFT approval. We assessed electronic healthcare records. Data collection was carried out or retrospectively in 2019(n = 40) using following parameters:
1) A review of patient's physical and psychiatric health.
2) An assessment medication prescribed and adverse effects of medication.
3) A review of observations required.
4) An assessment of the risk posed by the patient to others.
5) An assessment of any risk to the patient from deliberate or accidental self-harm.
6) An assessment of need for continuing seclusion, and whether it is possible for seclusion measures to be applied more flexibly, or in a less restrictive manner.
7) Time of Seclusion Review: Within first hour after seclusion and then every 4 hours until internal MDT. After MDT twice a day.
8) Record Keeping.
ResultKey Successes (above 80%)
Time of seclusion review (with in first hour or when required)
Record keeping (accurate time and place for clinical notes).
Plan for continuing need for seclusion.
Good documentation of Risk to self and risk to others.
Good documentation of mental state examination.
Comments on physical health although it can be improved.
Key Concerns(Less than 60%):
Prescribed Medications.
Medication side effects.
Physical Observations
ConclusionMedics are missing some important parts in seclusion medical review. We developed a template for seclusion medical review according to trust guidelines which are based on Code of Practice and to incorporate in already existing seclusion review form. We also delivered teaching and training to doctors and also showed junior doctor's an example of documentation. We will re-audit in 1 years’ time to see improvement.