21 results
Teaching, assessment and best practice in undergraduate psychiatry education in the UK: cross-sectional survey
- Deepika Sharma, Thomas Hewson, Sridevi Sira Mahalingappa, James Fallon, Declan Hyland, Seri Abraham, Alexa Sidwell, Subodh Dave
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- Journal:
- BJPsych Bulletin , FirstView
- Published online by Cambridge University Press:
- 13 February 2024, pp. 1-7
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Aims and method
We conducted a cross-sectional survey to examine how undergraduate psychiatry is taught and assessed across medical schools in the UK that have at least one cohort of graduated students.
ResultsIn total, 27 medical schools completed the survey. Curriculum coverage of common mental disorders, assessment skills and mental health law was broadly consistent, although exposure to psychiatric subspecialties varied. Significant variation existed regarding the duration of psychiatry placements and availability of enrichment activities. Small-group teaching, lectures and e-learning were the most frequent teaching modalities and various professionals and lived experience educators (patient and/or carers) contributed to teaching. Objective structured clinical examinations and multiple-choice questions dominated assessments.
Clinical implicationsMedical schools should consider increasing students’ exposure to different psychiatric subspecialties and integrating physical and mental health training to address comorbidity and promote holistic care. Future research should explore whether specific undergraduate experiences promote greater career interest and skills in psychiatry.
A Re-Audit of ECG Monitoring in Patients Admitted to the General Adult Inpatient Wards at Clock View Hospital, Liverpool, Mersey Care NHS Foundation Trust
- Yasmine Elagamy, Cherian John, Adetokunbo Dacosta, Declan Hyland, Nesma Hassan, Ryaz Nankoo
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S155
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The aim of this re-audit was to analyse current practice following a previous audit of ECG monitoring in patients admitted to the general adult wards at Clock View Hospital in 2020 and determine whether recommendations made from the original audit have improved performance.The objectives of this re-audit were: screen for recording of the admission ECG; ensure clear documentation of the ECG report; identify any reason why the ECG was not performed within 24 hours of admission and identify whether inpatients with an abnormal ECG on admission had any further investigation(s) done.
Methods92 inpatients discharged from the three general adult wards at Clock View Hospital between 1st of January 2022 and 31st of March 2022 was obtained. The same audit tool designed and used in the original audit in 2020 was used for this re-audit. Each inpatient's electronic record was reviewed to determine whether an ECG was performed within 24 hours of admission. In those patients who didn't have an ECG done, the reason why was recorded (if documented) and whether those patients who had an abnormal ECG were referred for further investigation. The quality of documentation of ECG reports was analysed.
ResultsOf the 92 inpatients, 57 (62%) had an ECG within 24 hours of admission and 16 (17%) had one done more than 24 hours after admission. 19 (21%) inpatients never had an ECG done at any point during their admission. The reason for not performing an ECG was documented for 32 (91%) of affected inpatients. Of the 73 inpatients who had an ECG done, 16 (22%) had an abnormal ECG, but only nine had further investigation (56% vs 23% in the original audit).
ConclusionThe findings from this re-audit showed that completion of an ECG within 24 hours of admission to the general adult inpatient wards at Clock View Hospital has improved from 52% to 62%. There has been improvement in quality of documentation of ECG reports. There was no documentation of the ECG report in 13% of cases compared to 35% in the original audit. In almost all affected cases, the reason for not performing an ECG was documented. The authors recommend creating an alert on the electronic record system if an ECG is not performed within 24 hours of admission and asking the ECG reporting service to copy the ECG report to the ward clerk and / or Consultant PA to ensure the report is reviewed promptly.
A Re-Audit of the Assessment and Management of Patients With Alcohol Use Disorders Following Admission to the General Adult Inpatient Wards in Mersey Care NHS Foundation Trust
- Declan Hyland, Ranjan Baruah, Mohammed Hussain, Hollie Buchan
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- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, p. S162
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This re-audit aimed to determine the level of performance in the assessment and management of patients with alcohol use disorders following admission to one of the general adult inpatient wards in Mersey Care NHS Foundation Trust and to determine whether the level of performance has improved compared to the original audit done in 2021 and whether recommendations that were implemented following the original audit have been effective.
MethodsA list of all inpatients on each of the eight general adult inpatient wards in the Trust was obtained. The electronic patient record (on RiO) and electronic prescription card (on EPMA) for each inpatient was scrutinised to obtain the required data. All data were collected retrospectively.
ResultsA total of 149 inpatients were identified on the eight general adult inpatient wards. Using specific inclusion and exclusion criteria, 56 of the 149 inpatients formed the final sample. Of the 56 inpatients, 58% were male, 42% were female. An alcohol history was documented in 81% of the 56 inpatients, representing an improvement on the 45% in the original audit in 2021. An average weekly quantity of alcohol for the inpatient was documented in only 8% of cases, a drop from 22% in the original audit in 2021. There was minor improvement in documentation of a CIWA-R score for the inpatient on admission to the ward - an increase from 0.7% in 2021 to 4.0% in 2022. There were improvements on gamma GT and serum Magnesium level being checked on admission for the 2022 audit cohort compared with the 2021 audit cohort. There was also an improvement on referral of the inpatient to community alcohol services - 3% in the 2021 audit vs 7% in the 2022 audit.
ConclusionThe findings from this re-audit indicate an improved level of performance in assessment and management of patients with alcohol use disorders following admission to the general adult inpatient ward since the original audit in 2021. Recommendations from this re-audit are: ensuring that taking and documenting a thorough alcohol history is included in the induction for junior trainees, the provision of education and training to both medical and nursing staff on the wards in using the CIWA-R to assess level of alcohol withdrawal and producing a flow chart on the assessment and management of alcohol use in patients following admission to the ward that can be displayed in the Treatment Room on each ward and in the Junior Doctors’ office.
An Evaluation of the Prescribing of High Dose Antipsychotic Therapy and Combination Antipsychotic Therapy to Inpatients on the General Adult Wards of Mersey Care NHS Foundation Trust
- Louise Campbell, Harry Holmes, Declan Hyland
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- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, pp. S135-S136
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High dose antipsychotic therapy (HDAT) is defined as “a total daily dose of a single antipsychotic which exceeds the upper limit stated in the SPC or BNF or a total daily dose of two or more antipsychotics exceeding the SPC or BNF maximum using the percentage method. Previous audits have looked at HDAT on both a national level (the Prescribing Observatory for Mental Health) and within Mersey Care NHS Foundation Trust. This audit aimed to identify the proportion of patients subject to HDAT and review combination antipsychotic strategies and consideration of Clozapine in patients subject to HDAT.
MethodsIn August 2021, data were collected from the eight inpatient wards in Mersey Care NHS Foundation Trust. This involved using the Electronic Prescription and Administration system to identify those prescribed antipsychotics. Following this, the patient's electronic record was scrutinised for documentation of the rationale for HDAT, combination antipsychotics and consideration of Clozapine.
Results129 inpatients were identified as being prescribed antipsychotic medication. 21 (16.3%) patients were prescribed combination antipsychotic therapy, with four of these patients (3.1%) being prescribed HDAT. For these four HDAT patients, there was no recorded documentation of discussion of the option of Clozapine. The most common antipsychotic combination was Paliperidone depot with oral Risperidone. 38 out of 129 (29.5%) patients had been considered for Clozapine. Reasons for Clozapine being refused included the patient declining, concerns about non-concordance with oral medication, patients having had a neutropenia on an FBC, the patient being reluctant to have regular blood tests and a patient's comorbidities.
ConclusionWhen comparing the proportion of patients subject to HDAT (3.1%) to the previous Trust audit in December 2020 (9.1%), there is a recurrent theme that antipsychotic prescribing practice in Mersey Care is safe, with minimal HDAT. Of note, the figure is significantly lower than the proportion of HDAT patients identified in the 2012 national study (28%). In this audit, none of the patients on HDAT had documented consideration of Clozapine. Three of the four patients were soon to be no longer subject to HDAT which may explain this result. Compared to the Trust's HDAT audit in 2020, the percentage of patients on combination antipsychotic therapy has stayed largely the same - 16.3% compared to 17.4%. The Trust needs to strive to continue minimal HDAT prescriptions and ensure that, in those patients subject to HDAT, there is consideration of and documentation of Clozapine being considered.
Documentation of Driving Status and of Fitness to Drive Following Admission of Patients to Clock View Hospital - How Are We Doing?
- Azmeralda Abraheem, Enrica Barnes, Ryan Hendry, Cameron Martin, Declan Hyland
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- BJPsych Open / Volume 8 / Issue S1 / June 2022
- Published online by Cambridge University Press:
- 20 June 2022, p. S98
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Developing a mental illness and being commenced on psychotropic medication are factors that may interfere with the ability of an individual to drive safely as both can impact information processing, psychomotor actions and social interpretation. The Driver and Vehicle Licensing Agency (DVLA) suggests that certain medical conditions require driving licence holders to notify them for further assessment of their ability to drive. DVLA notifiable mental disorders include psychosis, schizophrenia, bipolar disorder, dementia and personality disorders. The doctor's legal duty is to assess the patient for any relevant diagnosis, inform the patient of their duty to report their medical condition to the DVLA and for the doctor to comply with the legal duty to inform the DVLA of any patient who won't or can't notify the DVLA of their medical condition. The authors conducted a quality improvement project to evaluate and improve the number of fitness to drive assessments completed for patients admitted to the five wards (three general adult, one older adult and the Psychiatric Intensive Care Unit) at Clock View Hospital.
MethodsThe electronic (RiO) record for each inpatient on the five wards was scrutinised for: whether the patient's driving status was established on admission; whether the patient was notified of the DVLA rules if they did drive; whether the patient agreed to fulfil their duty of notification and, in instances where they were not, whether the medical professional had taken appropriate steps to address this.
Results74 patients on the five wards were included in the sample. Only nine of the 74 patients had driving status documented on admission. Three of these nine patients were noted to be driving or learning to drive and were not notified of the DVLA rules. Four of the nine patients were no longer driving and so discussion about DVLA guidance was unnecessary. The remaining two patients were confirmed to be driving and informed of the DVLA regulations. Both patients agreed to comply and therefore no further action was indicated.
ConclusionA review of current practice indicates a deficit in incorporating driving status and fitness to drive assessment into the clerking proforma following admission to Clock View Hospital. The second half of this cycle will implement change and raise awareness amongst inpatient medical and nursing staff of the need to consider this important issue prior to discharge. A re-assessment of the effectiveness of these changes will be carried out in the future.
An audit to assess the measurement of Body Mass Index (BMI) and referral to the dietetics service following admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust
- Declan Hyland, Millie Prime, Rabia Khaliq
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S83
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This audit aims to establish whether patients have their BMI measured and recorded following admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust and whether, in those with a BMI >30 kg/m2, or >28 kg/m2 in those with weight-related comorbidities, they are referred to the dietetics service for input.
BackgroundObesity has an increased prevalence in those with mental disorder. There are many factors that influence this, e.g. sedentary lifestyle and poor dietary intake. Medication prescribed to treat mental disorders may increase risk of weight gain. Patients with severe mental illness are at increased likelihood of developing weight-related comorbidities, particularly type II diabetes mellitus.
Many patients with severe and enduring mental illness do not regularly access primary care services. Admission to the psychiatric ward therefore provides an opportunity to address, not only the patient's mental health issues, but also any physical health issues.
MethodA list of all inpatients on the eight general adult wards was obtained on 3rd of December 2020. Inpatients on the Psychiatric Intensive Care Unit were also incorporated, providing a final sample of 148 inpatients.
An audit tool was designed, to collect demographic data for each inpatient – gender, age, ethnicity, psychiatric diagnosis, as well as BMI on admission and, if applicable, whether a referral to the dietetics service was made.
ResultOf the 148 inpatients, 91 were male, 57 female. Patient age ranged from 19 to 71 years. The majority were of “white British” ethnicity. The most common mental disorder diagnosis was schizophrenia (35 patients). For 14 of the 148 inpatients, no BMI was measured on admission. In the 134 inpatients that had BMI measured, 74 were in one of the “overweight”, “obese”, “very obese” and “morbidly obese” categories. Thirty-four patients met the criteria for requiring referral to the dietetics service. Of these, four were not referred, five were offered referral but declined, 17 referrals were made for other reasons, e.g. BMI <18 kg/m2, and one patient was referred despite no BMI being recorded.
ConclusionCurrent practice across the general adult inpatient wards in the trust indicates a proportion of patients do not have BMI recorded following admission. This may result in a valuable opportunity to address obesity being lost. There is a need to emphasise to ward staff the importance of recording BMI as part of the admission physical health screen and of the criteria for referring an inpatient to the dietetics service.
An audit to assess physical health monitoring of patients following their admission to the general adult psychiatric inpatient wards in Mersey Care NHS Foundation Trust
- Declan Hyland, Agatha Milner, Ellen Carter
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, p. S84
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This audit aimed to establish whether patients undergo physical health monitoring within 24 hours of admission to one of the general adult inpatient wards in Mersey Care NHS Foundation Trust, as per Trust policy.
BackgroundMean life expectancy in individuals with severe and enduring mental illness (SMI) is 15-20 years shorter than that of the general population. A significant proportion of excess mortality in patients with SMI is due to natural causes, e.g. cardiovascular disease and type II diabetes mellitus. Although SMI patients are at greater risk of developing chronic physical health problems, they often receive worse health care than the general population. Shared care of SMI patients between primary and secondary healthcare professionals causes uncertainty over who is responsible for monitoring the physical health of these patients.
MethodA list of all inpatients on the eight general adult wards in the Trust was obtained in September 2020, producing a sample of 135 inpatients.
An audit tool was designed, capturing demographic data – gender, age, ethnicity. The patient's psychiatric diagnosis was recorded. The tool captured whether each of the following were measured following admission – body mass index (BMI), blood pressure (B.P), serum cholesterol level, QRISK score and HbA1c level, and, if so, whether this was done within 24 hours of admission. For those patients who were smokers, being offered nicotine replacement therapy was documented.
ResultOf the 135 inpatients, 10 didn't have any physical health monitoring completed and were excluded from the sample, making the final sample 125 inpatients. 68 of the inpatients were male, 57 were female. 98 had a diagnosis of an SMI, 27 did not. Most inpatients were of “white British” ethnicity. 91% of the sample had a BMI measured within 24 hours of admission, but only 62% had a B.P done, 59% had a serum cholesterol level done and 58% had an HbA1c level done within 24 hours of admission. 78% of eligible patients had a QRISK score calculated. 97% of inpatients who were smokers were offered nicotine replacement therapy, but only 13% accepted it.
ConclusionThe majority of patients admitted to the general adult inpatient wards have an SMI. The audit findings show need for improvement in physical health monitoring following admission. Creation and implementation of a checklist of physical health parameters to be measured within 24 hours of admission could help improve performance. Use of motivational interviewing may help increase uptake of nicotine replacement therapy in smokers.
A literature review of whether communication skills specific to psychiatry are being taught to medical undergraduates around the world
- Sarah Winfield, Declan Hyland
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S301-S302
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The ability to communicate effectively is an imperative skill for clinicians to master as doctor-patient communication is one of the most essential dynamics in health care. Patients with a mental disorder present a unique challenge for doctors with regards to effective communication due to the nature of their illness.
This literature review aimed to determine whether medical undergraduates around the world are taught psychiatric communication skills.
MethodIn January 2021, the following electronic databases were searched for articles relating to medical undergraduates, the concept of psychiatric communication skills and the teaching and support of such skill development: ERIC, MEDLINE, PsycINFO, SAGE and Web of Science. Combinations of keywords focussed the content of papers and truncation obtained alternative word endings. Generated articles were appraised iteratively for suitability against pre-defined inclusion criteria. The bibliographies of eligible articles were then examined to capture any further relevant studies. Ethical approval was not required.
Result1040 citations of potential relevance were initially identified. Following an iterative screening process, 10 articles (from seven different countries) were eligible for inclusion. 70% of papers used the modality of simulated patients to teach psychiatric communication skills and Technology Enhanced Learning (TEL) was used to create “virtual patients” for undergraduates to engage with. Discussing sensitive and emotive topics, such as suicide attempts or substance misuse, was less commonly taught compared to conditions such as anxiety and depression. Only 10% of papers explicitly taught medical undergraduates empathy or written communication skills and the importance placed on psychiatric teaching differed between countries.
ConclusionThis literature review showed that some medical undergraduates receive psychiatric communication skills teaching, but the format and content of this varies. Increased consideration of incorporating TEL into psychiatric communications skills teaching is pertinent given undergraduates’ reduced face-to-face patient contact during the COVID-19 pandemic, but further work is needed to validate such technology. Written communication skills are rarely taught but are imperative given the high volume of written correspondence in clinical practice. Delivering such teaching is feasible and should be incorporated into undergraduate curricula. Medical educators need to consider cultural differences when developing psychiatric communication skills teaching. Cultural influences not only affect undergraduate perceptions of psychiatry and mental illness, but also a patient's understanding and interpretation of their illness experience. Medical undergraduates may come from various cultural backgrounds, so actively discussing these differences opportunistically may augment the ability of medical undergraduates to be empathetic and establish therapeutic rapport with patients with mental illness.
An evaluation of the prevalence of weight-related comorbidities in patients following admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust
- Declan Hyland, Millie Prime, Rabia Khaliq
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S83-S84
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This audit aims to evaluate the prevalence of any weight-related comorbidities in patients following their admission to the general adult inpatient wards in Mersey Care NHS Foundation Trust.
BackgroundObesity has an increased prevalence in those with mental disorder. There are many factors that influence this, e.g. sedentary lifestyle and poor dietary intake. Medication prescribed to treat mental disorders may increase risk of weight gain, particularly most of the second generation antipsychotics. Patients with severe mental illness are at increased likelihood of developing weight-related comorbidities - essential hypertension, ischaemic heart disease, hyperlipidaemia and type II diabetes mellitus.
Many patients with severe and enduring mental illness do not readily or regularly access primary care services. Admission to the psychiatric ward therefore provides an ideal opportunity to address, not only the patient's mental health issues, but also any physical health issues.
MethodA list of all inpatients on the eight general adult wards was obtained on 3rd of December 2020. Inpatients on the Psychiatric Intensive Care Unit were also incorporated, providing a final sample of 148 inpatients.
An audit tool was designed, to collect demographic data for each inpatient – gender, age, ethnicity, psychiatric diagnosis, as well as the presence of any cardiovascular comorbidities and, if so, what were they and how many were present.
ResultOf the 148 inpatients, 91 were male, 57 female. Patient age ranged from 19 to 71 years. The majority were of “white British” ethnicity. The most common mental disorder diagnosis was schizophrenia (35 inpatients), followed by schizoaffective disorder (22 inpatients). Twenty-one of the 148 patients had at least one weight-related comorbidity recorded. Only 2 of the 21 inpatients with a diagnosis of one or more weight-related comorbidity had a recorded BMI in the “healthy” range. The gender split for the presence of weight-related comorbidities was almost equal. The most common comorbidity recorded was type II diabetes mellitus. Most patients with a weight-related comorbidity had only one recorded, but three patients had two comorbidities recorded, and one patient had three recorded.
ConclusionA significant proportion of patients admitted to the general adult inpatient wards in the trust have a weight-related comorbidity. Admission to hospital provides an ideal opportunity to review the management of any such comorbidity and optimise this as required. There is a need to ensure there is a strong focus on, not only the patient's mental health issues, but also his / her physical health status.
A survey of the level of knowledge and understanding of members of the inpatient team on the role of the physician associate on the general adult psychiatric wards
- Declan Hyland, Mohammed Uddin
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S140
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Physician Associates (PAs) are healthcare professionals with a general medical education background, having completed a two-year postgraduate degree. Whilst the number of PAs employed in healthcare trusts continues to increase, the number working in mental health settings remains small.
Mersey Care NHS Foundation Trust employed two PAs two years ago. In August 2019, a third PA was recruited to work at Clock View Hospital, a general adult inpatient unit.
This survey aims to establish what level of understanding different members of the inpatient teams across the inpatient wards have of the tasks PAs are permitted to undertake and those they are not.
MethodA survey was designed, listing 37 tasks, e.g. completing an admission clerking. For each task, the participant was asked whether a PA is allowed to complete it or not, with three options provided – “can carry out the task”, “cannot carry out the task” and “do not know.” A score of + 1 was awarded if the correct answer was provided, –1 for an incorrect answer and 0 if the respondent didn't know. The highest possible score for a completed survey was + 37 points; the lowest possible score was –37 points.
A sample of survey respondents was identified from the three general adult inpatient wards at Clock View Hospital and the Psychiatric Intensive Care Unit (PICU), comprising: senior doctors, junior trainees, Ward Manager, Deputy Ward Manager, Band 5 nurse and Assistant Practitioner.
ResultTwenty-four members of staff completed the survey – 3 senior doctors, 4 junior trainees, 4 Ward Managers, 4 Deputy Ward Managers, 5 Band 5 nurses and 4 Assistant Practitioners. The respondents were distributed equally across the three general adult wards and the PICU. The highest survey score was 36 out of 37 (a Consultant); the lowest was 18 (a junior trainee). The lowest mean score was variable across the different grades of staff, with Consultants scoring highest at 29 and Assistant Practitioners and Ward Managers both scoring lowest at 25. There was little variability in mean score (only 2 points) across the three wards and PICU.
ConclusionThe results from this survey demonstrate that different members of the inpatient team have a good understanding of what tasks PAs are and are not permitted to. There is still a need to provide further education to inpatient staff to ensure they utilise the PA at Clock View Hospital appropriately and that the PA is able to develop his skill set.
An analysis of the views of different members of the inpatient team on the role of the physician associate on the general adult psychiatric wards
- Declan Hyland, Mohammed Uddin
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S140-S141
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Physician Associates (PAs) are healthcare professionals who have a general medical education background, having completed a two-year postgraduate degree. Whilst the number of PAs employed in healthcare trusts continues to increase, the number working in mental health settings remains small.
Mersey Care NHS Foundation Trust employed two PAs two years ago. In August 2019, a third PA was recruited to work at Clock View Hospital, a general adult inpatient unit.
This analysis aimed to establish the views of different members of the team across the three general adult wards and the Psychiatric Care Unit (PICU) at Clock View Hospital on the role of the PA.
MethodA sample of members of staff was identified from across the three general adult inpatient wards at and the PICU, comprising: senior doctors (Consultants and Specialty Doctor), junior trainees (Core Trainee and Foundation Trainees), Ward Manager, Deputy Ward Manager, Band 5 nurse and Assistant Practitioner. Each member of staff was asked to answer the question “On a scale of 1 to 10 (with “1” being completely unhappy, “10” being completely happy), how happy are you to have a PA working on your ward?” Each staff member was then asked to provide comments on their views on the role of the PA.
ResultTwenty-three members of staff participated – 3 x senior doctors, 4 x junior trainees, 4 Ward Managers, 4 Deputy Ward Managers, 4 x Band 5 nurses and 4 x Assistant Practitioners. The respondents were distributed equally across the three general adult wards and the PICU. All 23 members of staff provided a score of 10 out 10 to the question about how happy they were to have a PA working on the ward. Many of the staff members provided some very positive comments on their respective views about the role of the PA at Clock View Hospital. No negative comments were provided by any members of staff.
ConclusionIt is clear from the large sample of members of staff of different grade at Clock View Hospital that were surveyed that the PA has been a warmly received and welcome addition to the inpatient team and that the PA is viewed as having become an important and valued member of the inpatient team. This provides a strong argument for both Mersey Care NHS Foundation Trust, and other mental health trusts across the U.K., to consider employing more PAs to work in their inpatient units.
An audit of high-dose and combination antipsychotic prescribing across the general adult inpatient wards in Mersey Care NHS Foundation Trust
- Declan Hyland, Beth Hemmings, Yasmine Elagamy
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, pp. S82-S83
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To review the number of prescriptions of regular high-dose antipsychotics and combination antipsychotic therapy across the eight general adult inpatient wards in Mersey Care NHS Foundation Trust and examine whether these prescriptions followed Trust recommendations for high-dose antipsychotic therapy (HDAT).
BackgroundThe two main rationales behind prescribing HDAT are pharmacokinetics differ in individuals and so insufficient amounts of antipsychotic may reach the effect site at maximum dose in some patients and variations in the effect site between patients may mean higher doses are required to achieve therapeutic effect.
MethodThe electronic prescription records for all patients on the eight general adult inpatient wards were scrutinised. 121 patients were prescribed antipsychotic medication. Any patients on a combination of regular antipsychotic medication or on HDAT were identified. Any patient on combination therapy or HDAT was studied to determine if Clozapine had been considered. The electronic notes of HDAT patients were analysed to ascertain whether tests recommended by Trust guidelines – BMI, blood pressure (B.P), pulse rate, ECG, FBC, U and Es, LFTs, serum prolactin, serum cholesterol and HbA1c level had been performed prior to initiation and following any dose increase.
Result21 of 121 patients prescribed antipsychotic medication were on combination therapy. 11 were subject to HDAT. 8 of the 11 HDAT patients were on combination therapy. Clozapine was considered before initiating HDAT in 9 of the HDAT patients. Clozapine was considered in 13 of the 21 patients on combination antipsychotic therapy, but only two were initiated on Clozapine (combined with Olanzapine or Risperidone).
100% of HDAT patients had an ECG prior to initiation of HDAT; only 36% had one after dose increases above BNF maximum. 100% of HDAT patients had their BMI measured before initiation. 91% had baseline B.P and heart rate checked. Of the recommended blood tests, 100% of HDAT patients had baseline FBC, U and Es, LFTs and serum cholesterol. Fewer patients had a baseline HbA1c level (91%) or serum prolactin (46%) measured.
ConclusionPrevalence of HDAT across the general adult inpatient wards in the Trust was 9%, much lower than the 28% reported in the HDAT audit completed by the Prescribing Observatory for Mental Health in 2012. Patients within Mersey Care are more likely to be prescribed combination therapy than HDAT. Not every HDAT patient has been considered for Clozapine. There is a need to ensure Trust monitoring guidelines for HDAT patients are being strictly adhered to.
A literature review for the introduction of psychiatric simulation to University of Liverpool Medical School
- Alexander Challinor, Declan Hyland
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, p. S129
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The aim of this review is to systematically investigate simulation in psychiatry to enable the evidence based introduction of psychiatry simulation into the undergraduate curriculum at the University of Liverpool.
BackgroundTransformations in the structure of psychiatric delivery and reductions in funding to mental health care have limited the availability of direct patient clinical experiences for medical students. Experiential learning through simulation can be utilised as a powerful pedagogical tool and provide exposure to a broad range of psychopathology.
Although psychiatric skills and knowledge are gained from the current University of Liverpool undergraduate curriculum, there is no specific well-designed psychiatry simulation.
MethodThe author searched MEDLINE, EMBASE and PsycINFO databases for studies that met the inclusion criteria. Search terms included ‘simulation (psychiatry or ‘mental health’). Studies were also searched using snowballing via citation tracking within the databases.
Inclusion criteria comprised studies of an educational intervention that involved simulation. The intervention had to be utilised within the field of psychiatric teaching.
ResultThe literature review illustrated the dearth of studies analysing role-playing (RP) and/or simulated patients (SP) in psychiatry with it typically encountered as part of the more general communication skills curriculum. Studies analysing SP and RPs demonstrate how they build on the social context of learning alongside drawing on a range of educational theories, including experiential learning. However, studies show that well-designed simulation training should encompass more facets of learning to be transformative, specifically reflecting upon ones experiences alongside understanding and interpreting this new knowledge, allowing it to guide future actions and change practice.
Studies analysing virtual-reality in psychiatry are limited but demonstrate significant improvements in students’ acquisition of key psychiatric skills and exposure to psychopathology. More studies are needed to evaluate the efficiency and cost-effectiveness of virtual-reality over more traditional methods.
Despite the increase in simulation teaching within psychiatry, and the expansion of innovative simulation approaches in other specialties, there was limited use of novel approaches found within the studies analysing psychiatric simulation. There were studies evaluating novel approaches to psychiatry simulation outside of the undergraduate curriculum.
ConclusionWhilst there are barriers to overcome in simulation training, these are primarily logistical and are clearly outweighed by the educational gain demonstrated throughout this review. Simulation training in psychiatry has often remained limited to traditional communication-oriented scenarios using RP or SP. A greater emphasis on furthering the advancement and integration of more innovative approaches into psychiatric undergraduate teaching is needed.
An evaluation of the Royal College of Psychiatrists' “Psych Star” scheme
- India Lunn, Declan Hyland
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- BJPsych Open / Volume 7 / Issue S1 / June 2021
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- 18 June 2021, pp. S145-S146
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Aims
In 2019, the Royal College of Psychiatrists (RCPsych) launched the “Psych Star” scheme for medical students with an interest in psychiatry. The one-year scheme provides Psych Stars with a matched mentor, free registration at the RCPsych's International Congress, financial support for psychiatry-related activities, journal subscriptions and access to two online learning platforms. This project aimed to evaluate the effectiveness of the scheme in supporting Psych Stars to explore their interest in psychiatry and in promoting psychiatry as a career choice, through use of a survey for both Psych Stars and mentors.
MethodSurveys were sent to all Psych Stars and mentors from the first cohort of the scheme. The mentor and student surveys contained a mixture of ranking, multiple choice, closed-ended and open-ended questions. Questions examined: clarity of the scheme's aims and objectives; benefits of each aspect of the scheme; impact of the scheme on application to Core Training; benefits and barriers to successful mentorship; adequacy of mentor support from the RCPsych and suggestions to improve the scheme.
ResultSix Psych Stars and nine mentors completed the respective surveys. All Psych Stars stated the scheme was enjoyable. Five Psych Stars were more likely to apply for Core Training because of the scheme. All Psych Stars identified the most beneficial aspect of the scheme being the funded place at the RCPsych International Congress. Other aspects highly ranked included: funding to explore areas of psychiatry of interest and the opportunity to be an ambassador for psychiatry. All Psych Stars found the mentorship useful.
Mentors supported Psych Stars by providing career advice, suggesting relevant conferences to attend and assisting Psych Stars make decisions on how to use their allocated funding. Barriers to mentorship that were identified included: geographical separation, limitations related to the COVID-19 pandemic and lack of time. For mentors, areas for improvement included clearer aims and objectives and more support from the RCPsych.
Both mentors and Psych Stars suggested forming a network of Psych Stars and mentors would be useful to share ideas and experiences.
ConclusionThis evaluation shows that the Psych Star scheme successfully supports Psych Stars to explore their interest in psychiatry, and promotes psychiatry as a career choice. This survey has been helpful in identifying what aspects of the scheme are particularly attractive, and also, importantly, how the Psych Stars scheme can be improved for future cohorts. The survey will be delivered to all future annual cohorts of Psych Stars and mentors.
An audit of ECG monitoring in patients admitted to the general adult wards at clock view hospital
- Declan Hyland, Unmol Thandi, Udani Mahamithawa, Yasmine Elagamy, Mohammed Uddin
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S82
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Aims
To identify whether patients admitted to the general adult inpatient wards at Clock View Hospital, an inpatient unit in Mersey Care NHS Foundation Trust, have an ECG performed following admission and whether, if this done, the ECG report is properly documented in the patient's electronic record, and whether those patients with an abnormal ECG have any further investigations requested.
BackgroundAn important risk factor for development of cardiac disease is use of psychotropic medications. Antipsychotics can increase the QTc interval.
NICE guidelines recommend that, before starting antipsychotic medication, an ECG should be offered if physical examination identifies cardiovascular risk factors, there is personal history of cardiac disease or if the individual is being admitted to hospital. The Royal College of Physicians states all patients should be assessed for cardiovascular disease, including having a routine ECG. Mersey Care's physical health policy recommends all new admissions to inpatient wards have an ECG performed within 24 hours of admission as part of their admission physical examination and investigation.
MethodA sample of 60 patients discharged from the general adult wards at Clock View Hospital between 16th of July 2019 and 30th of September 2019 was obtained. An audit tool was designed and each patient's electronic record scrutinised to determine whether an ECG was performed within 24 hours of admission; in those patients who didn't, whether the reason why was recorded; and whether those patients who had an abnormal ECG were referred for further investigation. The quality of documentation of ECG reports was also analysed.
ResultAge range of patients was 19–66 years. Only 31 patients had an ECG performed within 24 hours of admission. Of the remaining 29, there was documentation of why an ECG was not performed in only 16 cases. Thirteen patients had an abnormal ECG, but only three were referred for further investigation. Of the ECG reports that were analysed, only a minority met the required standard for “good”, with there being no documentation of the ECG report in one third of cases.
ConclusionThere is significant room for improvement in performance of ECG monitoring and documentation of the ECG report. The importance of the ECG as part of the admission process needs to be highlighted in the induction of junior doctors. Training nursing staff on the wards to perform ECGs would reduce the likelihood of unnecessary delay to a patient having an ECG done following admission.
An audit to look at the prescribing of psychotropic medication in the general adult inpatient setting in patients with emotionally unstable personality disorder
- Declan Hyland, Charlie Daniels, Iulian Ionescu, Christina Houghton, Katie Goodier, Simon Graham
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S31
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Aims
To assess the frequency of prescription of psychotropic medication in patients with a primary diagnosis of emotionally unstable personality disorder (EUPD) following admission to Clock View Hospital, an inpatient unit in Mersey Care NHS Foundation Trust.
MethodA retrospective analysis of the electronic (RiO) record of 50 patients discharged from Clock View Hospital between 1 January 2020 and 1 November 2020 was performed to assess prescribing practice.
Twenty-five patients with a diagnosis of EUPD and no associated psychiatric comorbidities were included in the sample, as well as 25 patients with a diagnosis of EUPD and associated psychiatric comorbidities.
Result80% of the 25 patients with EUPD and associated psychiatric comorbidities were prescribed psychotropic medication prior to admission to hospital (56% an antidepressant, 24% a mood stabiliser, 60% an antipsychotic and 8% a benzodiazepine). 64% of patients were prescribed two or more psychotropic medications. 28% were initiated on new psychotropic medications following admission. For four of the seven prescriptions commenced on psychotropic medication, prescribing practice was as advised in Mersey Care's EUPD guidelines.
Of the 25 patients with EUPD and no associated psychiatric comorbidities, 96% of the patients were prescribed psychotropic medication prior to admission to hospital (56% an antidepressant, 20% a mood stabiliser, 72% an antipsychotic and 12% a benzodiazepine). 68% of patients were prescribed two or more psychotropic medications. Following admission, 28% of patients were initiated on new regular psychotropic medications. For five of the eight prescriptions for new psychotropic medication, prescribing practice was as advised in Mersey Care's EUPD guidelines.
78% of the 50 patients were prescribed as required (PRN) psychotropic medication. In 21 patients, PRN medication was prescribed for longer than one week.
ConclusionThere is a higher rate of prescribing of antipsychotic prescription in those EUPD patients with no psychiatric comorbidities compared to associated psychiatric comorbidities (72% vs 60%). Surprisingly, there was a lower rate of psychotropic polypharmacy in those with psychiatric comorbidities.
Use of PRN psychotropic medication for longer than a week was higher in those patients with psychiatric comorbidities compared to those without psychiatric comorbidities (58% vs 50%). Benzodiazepines were overwhelmingly the most consistently prescribed PRN medication for patients with EUPD.
One action to consider would be highlighting the importance of trialling psychologically-minded interventions and supportive psychotherapy prior to initiation of psychotropic medication. There also needs to be consideration to use of the sedative antihistamine promethazine as a first-line PRN medication for acute agitation.
Off-licence use of clozapine in patients with emotionally unstable personality disorder: a case series analysis
- Declan Hyland, Alex Walmsley, Victoria Simpson
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S116
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Objective
This retrospective case series followed emotionally unstable personality disorder (EUPD) patients following initiation of clozapine on an off-licence basis, aiming to examine tolerance by determining side effect prevalence and treatment cessation frequency, as well as examining efficacy, by investigating number of hospital re-admissions and symptom control.
Case reportThis case series captured the experiences of 11 EUPD patients under the care of Mersey Care NHS Foundation Trust, all of whom had, at some time in the past five years, been initiated on clozapine. All patients were white British females, with a median age of 31. The median daily dose of clozapine was 300 mg. Most patients had significant psychiatric comorbidities, as well as illicit substance and / or alcohol misuse.
Whilst prescribed clozapine, patients were only admitted to hospital once on average and this was commonly for clozapine re-titration. Whilst in hospital, rates of self-harm were low, but ligaturing and suicide attempts showed higher prevalence. Patients still demonstrated self-harming behaviour out of hospital leading to A and E presentations. In the community, contacts with the police were minimal, with only two patients undergoing Section 136 assessments or arrests.
All patients reported side effects from clozapine - usually hypersalivation, over-sedation and constipation. All 11 patients experienced sinus tachycardia. Eight patients temporarily ceased taking clozapine at some point. In three patients, discontinuation of clozapine was as a result of intolerable side effects. Three patients experienced neutropenia, which subsequently resolved. Only two patients had a body mass index within healthy range.
DiscussionDespite patients reporting clozapine to provide symptomatic benefit for their EUPD, and improved their engagement with mental health services, prevalence of self-harm and of A and E presentations remained high, indicating the importance of community support and concomitant psychotherapeutic treatment. Patients with more robust community support showed greater adherence to clozapine.
High prevalence of side effects and obesity in these patients, in addition to risk of developing neutropenia, highlights the importance of rigorous monitoring after initiating clozapine. It is reassuring that, despite development of neutropenia in some patients, this recovered quickly, and clozapine treatment could resume.
ConclusionClozapine may be an effective pharmacological treatment for enabling EUPD patients to engage more therapeutically with services. Clozapine may be of greater benefit to those with more stable, less chaotic lives. Although diminished, patients still show self-harming behaviour and need for A and E admissions and re-hospitalisation. Side effects of clozapine are common and regular monitoring is required.
An evaluation of the prevalence of physical health comorbidities in patients with severe and enduring mental illness following admission to the general adult psychiatric inpatient wards in Mersey Care NHS Foundation Trust
- Declan Hyland, Millie Prime, Ellen Carter
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S84-S85
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This evaluation aimed to establish the prevalence of physical health comorbidities in SMI patients admitted to the general adult wards in Mersey Care NHS Foundation Trust.
BackgroundMean life expectancy in individuals with severe and enduring mental illness (SMI) is 15-20 years shorter than that of the general population. A significant proportion of excess mortality in patients with SMI is due to natural causes, e.g. cardiovascular disease and type II diabetes mellitus. Although SMI patients are at greater risk of developing chronic physical health problems, they often receive worse health care than the general population. SMI patients more likely to engage in unhealthy lifestyle behaviours, such as poor dietary choices, smoking and physical inactivity; Antipsychotic medication prescribed to these patients can cause adverse metabolic side effects.
MethodA list of all inpatients on the eight general adult wards in the Trust was obtained in September 2020, producing a sample of 135 inpatients.
An audit tool was designed, capturing demographic data – gender, age, ethnicity, and also recording whether the patient had a diagnosis of an SMI (e.g. schizophrenia, bipolar affective disorder). The presence of any physical health comorbidities and whether the inpatient was a smoker was also recorded.
ResultOf the 135 inpatients, 10 didn't have any physical health monitoring completed and were excluded from the sample, making the final sample 125 inpatients. 68 of the inpatients were male, 57 were female. 98 had a diagnosis of an SMI, 27 did not. Most inpatients were of “white British” ethnicity. Of the 98 SMI patients, 14 had type II diabetes mellitus, 11 had essential hypertension, 12 had chronic obstructive pulmonary disease and 22 were obese (i.e. a BMI > 30 kg/m2). 70 of the 98 patients with an SMI were smokers.
ConclusionAs expected, a significant proportion of patients with SMI admitted to the general adult inpatient wards are smokers. Whilst admission to hospital may not be considered an ideal time to get patients to consider quitting smoking, admission does at least provide an opportunity to educate patients on the negative effects on physical health that smoking has. This evaluation has highlighted that physical health comorbidities are common in this patient group. Admission to the psychiatric ward provides a golden opportunity to provide education to patients on the importance of making healthy lifestyle choices and also to assess any physical health comorbidities and ensure the management of any such comorbidities is optimised prior to discharge.
An evaluation of barriers to the initiation of clozapine in patients with treatment-resistant schizophrenia
- Declan Hyland, Seth Jamieson
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S30-S31
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Aims
This evaluation aimed to identify patient, practitioner and infrastructural barriers to initiation of clozapine treatment in patients with treatment-resistant schizophrenia (TRS). In response to recent research supporting use of clozapine as the most effective treatment for patients with TRS, concerted efforts have been made to establish why clozapine is underutilised in the NHS. Following a study conducted by South London and Maudsley NHS Foundation Trust, which identified barriers and made recommendations, this evaluation aimed to identify barriers to initiation of clozapine in patients under the care of Mersey Care NHS Foundation Trust.
This evaluation also aimed to make further recommendations to increase use of clozapine in Mersey Care's TRS patients and assess whether there have been any differences to concerns about clozapine initiation compared to previous evaluations.
MethodAn online questionnaire containing a series of Likert scales was e-mailed to all Consultant Psychiatrists in Mersey Care NHS Foundation Trust. The questionnaire asked Consultants to rate how often they felt a range of barriers interfered with successful initiation of Clozapine treatment. The barriers chosen were based on the 2019 systematic review “Barriers to using clozapine in treatment-resistant schizophrenia.”
ResultNineteen consultant psychiatrists completed the online questionnaire. All 19 indicated they either “agreed” (16%) or “strongly agreed” (84%) that they were confident in diagnosing TRS. This was a significant increase compared to the South London and Maudsley evaluation, with only 81% of participants in that study being “fairly familar” or “very familiar” with clozapine guidelines.
Furthermore, concerns about inadequate blood testing facilities appear to have been addressed, with no participants in this evaluation staing there were insufficient blood testing facilities. However, 53% of Consultants who completed this evaluation stated they “often” (37%) or “very often” (16%) have patients who refuse clozapine because of the requirement for regular blood testing. Refusal to agree to required blood testing was the commonest reason identified for failure to initiate clozapine in TRS patients. This was consistent with the results from the South London and Maudsley study.
ConclusionThose Mersey Care consultants surveyed identified that providing patients with further information about clozapine would be the most valuable intervention to increase likelihood of uptake of clozapine in the treatment of TRS. Significant progress has been made in improving the likelihood that clozapine can be successfully initiated, especially in the removal of practitioner barriers. This evaluation suggests interventions should now be aimed at reducing patient barriers to initiation of treatment.
An evaluation of the incorporation of psychological interventions into the care of patients with a diagnosis of emotionally unstable personality disorder following admission to the general adult inpatient setting
- Declan Hyland, Charlie Daniels, Iulian Ionescu, Katie Goodier, Simon Graham
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, p. S327
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Aims
To assess incorporation of and access to psychological therapies for patients with a diagnosis of emotionally unstable personality (EUPD) who were discharged from the inpatient wards at Clock View Hospital, an inpatient unit in Mersey Care NHS Foundation Trust.
MethodA retrospective analysis of the electronic record of 50 patients discharged from Clock View Hospital between 1st of January 2020 and 1st of November 2020 was performed to assess whether patients were engaged with psychotherapy and whether they had an extended care plan in place.
25 patients with EUPD and no associated psychiatric comorbidities were included in the sample, as well as 25 patients with EUPD and associated psychiatric comorbidities.
ResultThose EUPD patients with no psychiatric comorbidities were more likely to be under the care of the Liverpool Personality Disorder (PD) Hub compared to those with psychiatric comorbidities (12 vs seven patients). Of the 19 patients under the PD Hub, 11 had a Case Manager, four were engaged with the PD Hub's day services / safe service and one with a PD Hub readiness group. Six of the 50 patients had a documented refusal to engage with the PD Hub.
Only 27 of the patients had either received psychological intervention, were on a waiting list, or had a referral in place. 16% of patients refused a psychotherapy referral. Of the 20 patients who received psychological treatment, eight completed a form of psychotherapy (cognitive analytic therapy, dialectical behaviour therapy, cognitive behavioural therapy, eye movement desensitisation and reprocessing) and 12 psychological intervention (either structured case management, psychoeducation or emotional coping skills).
Only 28 of 50 patients had an extended care plan and 28 had a collaborative risk management plan in place.
ConclusionThere was no obvious correlation between previous completion of psychological therapy and degree of polypharmacy. Median admission time was reduced for patients under the PD Hub (six vs 14 days). This was also reduced for patients who accessed psychotherapy or psychotherapeutic interventions (nine vs 10 days).
This audit coincided with the COVID-19 pandemic and subsequent reduced access to the PD Hub and psychotherapy service. There is a need to consider barriers to EUPD patients receiving psychotherapy.
EUPD patients may have numerous hospital admissions and frequently present in crisis. Given the iatrogenic harm from prolonged hospital admission, there is a need to consider incorporating a collaborative extended care plan and risk management plan as part of discharge planning, following admission to hospital.