Improving the management of menopause in women with serious mental illness

Aims To improve the diagnosis and management of menopause in women with a serious mental illness in psychiatric services. This will be achieved by developing a questionnaire to systematically assess symptoms related to the menopause, based on NICE guidelines. Women will be offered information and advice, according to these guidelines. Barriers to the assessment or management of the menopause will be identified by piloting the questionnaire on an inpatient female ward. Method Women aged 40 years and over, admitted to an acute female in-patient ward in South London and Maudsley NHS Foundation Trust, were interviewed using a structured questionnaire. Result In total, 23 eligible women were approached of whom 17 (74%) agreed to take part with mean age 53 years (range 40–67 years). Nine women reported that they had undergone the menopause and four women reported experiencing perimenopausal symptoms. Fifteen women had not previously received information about the menopause. Of the 13 women who had undergone the menopause or were experiencing irregular periods, 7 reported experiencing hot flushes, night sweats and a general change in physical and mental health and four reported a change in mood. Seven women reported that the changes noted may have been related to the menopause over the previous 12 months. Eight women requested further information either in written format or in the form of an information group about the menopause. Conclusion We identified women who were admitted to a psychiatric ward who had experienced symptoms related to the menopause that had impacted on their mental and physical health. It was evident that the majority of these women with severe mental illness had not had the opportunity to discuss their symptoms with a healthcare professional in the past and a significant proportion welcomed further information to help make sense of their symptoms. We intend to implement the questionnaire trust-wide with the eventual aim of developing a local guideline to inform the assessment and management of the menopause within our services.

Aims. To improve the diagnosis and management of menopause in women with a serious mental illness in psychiatric services. This will be achieved by developing a questionnaire to systematically assess symptoms related to the menopause, based on NICE guidelines. Women will be offered information and advice, according to these guidelines. Barriers to the assessment or management of the menopause will be identified by piloting the questionnaire on an inpatient female ward. Method. Women aged 40 years and over, admitted to an acute female in-patient ward in South London and Maudsley NHS Foundation Trust, were interviewed using a structured questionnaire. Result. In total, 23 eligible women were approached of whom 17 (74%) agreed to take part with mean age 53 years (range 40-67 years). Nine women reported that they had undergone the menopause and four women reported experiencing perimenopausal symptoms. Fifteen women had not previously received information about the menopause. Of the 13 women who had undergone the menopause or were experiencing irregular periods, 7 reported experiencing hot flushes, night sweats and a general change in physical and mental health and four reported a change in mood. Seven women reported that the changes noted may have been related to the menopause over the previous 12 months. Eight women requested further information either in written format or in the form of an information group about the menopause. Conclusion. We identified women who were admitted to a psychiatric ward who had experienced symptoms related to the menopause that had impacted on their mental and physical health. It was evident that the majority of these women with severe mental illness had not had the opportunity to discuss their symptoms with a healthcare professional in the past and a significant proportion welcomed further information to help make sense of their symptoms. We intend to implement the questionnaire trust-wide with the eventual aim of developing a local guideline to inform the assessment and management of the menopause within our services.
Physical health monitoring before commencing regular antipsychotics in a Psychiatric Intensive Care Unit (PICU) -A Quality Improvement project Aims. To compare the practice in a PICU setting against the standard practicing guidelines before commencing antipsychotics with regards to: 1. Physical examination 2. ECG 3. Baseline blood investigations 4. Physical health conditions 5. Family history of medical conditions.
Method. Data were collected from the PICU, Black Country Healthcare NHS Foundation Trust which covers four different hospital sites. 37 patients were admitted in PICU from 1st March 2020 to 30th September 2020, out of which 30 were included. 6 case notes were not available and one patient was admitted twice, thus case notes for only one admission was included in data collection.The standard guidelines for PICU outline that each admitted patient should have physical examination, vitals monitoring and baseline investigations including routine blood tests and ECG within first 24 hours. The data were collected as per standards retrospectively within two weeks from case notes in health records. Investigations were accessed through electronic information system for current inpatient admission and 12 months prior to the admission to the PICU. Result. Mean age of the sample (n = 30) was 34.26 years. 37% of patients had physical comorbidities and a family history of medical conditions was documented for only 3% of cases. A large proportion of inpatients (53%) refused to have blood investigations before treatment and only 13% of blood investigations were completed before commencing treatment. Only 7% of patients consented to an ECG prior to commencing treatment. 27% of patients had a physical examination, including vitals, before starting treatment, a further 37% had just their vitals taken within 24 hours of admission and 20% refused any form of physical examination during their inpatient admission. 7% of cases had complications due to a lack of investigation. Conclusion. Although there are standard guidelines for the PICU setting, it has been noted that these guidelines aren't always implemented. Multiple factors have a role to play such as: nonconsenting patients, inaccessibility of previous records, initial assessment forms being incomplete including assessment of mental capacity and lack of follow-up with physical investigations by both primary care and secondary mental health services. As per findings, a few recommendations were proposed to meet the standards.
A quality improvement (QI) project to ensure females on valproate in a CMHT outpatient clinic, eput are registered on the valproate pregnancy prevention programme Aims. Recent MHRA guidelines, state that Valproate medicines must no longer be used in women or girls of childbearing potential due to its highly teratogenic effects unless a Pregnancy Prevention Programme is in place. We carried out a service evaluation to determine if there was any way of identifying such patients with the aim of setting one up if required. Background. Valproate is highly teratogenic and evidence supports that use in pregnancy leads to physical birth defects in 10 in every 100 babies (compared with a background rate of 2 to 3 in 100) and neurodevelopmental disorders in approximately 30 to 40 in every 100 children born to mothers taking Valproate. Data from a previous inpatient audit identified 35 females of childbearing age and none was on a pregnancy prevention plan. Audits done thereafter confirmed there was no system available for identifying such patients. Availability and accessibility to a synchronised IT system, which alerts when the yearly review is due is consistently identified as a contributory factor. Method. A request via the Medicines management team was sent to the GP surgeries within the catchment area to assist in identifying female patients on their records on Valproate registered on the Pregnancy Prevention Programme.
The Plan-Do-Study-Act (PDSA) Quality Improvement (QI) model was used to bring about change. The target set to achieve was a 50% reduction in the prescriptions of Valproate in such patient groups. Result. We had 10 out of the 50 GP surgeries contacted responded with a list of female patients on Valproate, a total of 25 patients' altogether. In total, 4 patients out of the 25 were registered on the Pregnancy Prevention Programme and the overall non-compliance rate was 86%. . Factors believed to contribute to the low numbers include a lack of a system for registering women of childbearing age on the pregnancy protection plan and the recent introduction of GDPR regulation. Conclusion. There are ongoing discussions with various stakeholders like the Medicines management team, Pharmacists, electronic records team (IT) and other clinicians regarding inserting an alert in the electronic system that reminds clinicians to register all such women on the Pregnancy Prevention Programme, while automatically creating a yearly reminder for completion of the annual risk acknowledgement form. Aims. This project aimed to improve the knowledge and confidence of doctors at all levels when managing patients with eating disorders while on call. Background. A recent survey found just 1% of doctors have the opportunity for clinical experience on eating disorders. Anecdotally, a number of junior doctors within our trust had mentioned that they felt unsure when asked to manage patients with eating disorders during their out of hours shifts. Method. This project aimed to ascertain levels of confidence with managing patients with eating disorders, and to collect suggestions to improve this. This was achieved using a survey sent out to 97 doctors working in a Mental Health Trust.

Improving knowledge and confidence in the acute management of eating disorders and resulting complications
We then utilised two of the suggestions to improve the identified areas of concern. The first method involved direct lectures. This was followed up with the creation of a poster highlighting the pertinent information which was displayed in key clinical areas. The second avenue was the creation of an information booklet covering key clinical information that is available to all on call doctors. Result. The response rate for the survey was 37.11%. The survey found that doctors lacked confidence in the management of common conditions that arise in patients admitted with eating disorders. Refeeding syndrome was identified as the greatest area of concern by responding doctors.
To assess the impact of the lectures, MCQs were given out before and after the presentation. The results were compared, and showed a clear improvement in overall knowledge, with results going from an average score of 56.6% to 80%. Conclusion. By using multiple methods to improve doctors confidence, (lectures, written information and visual posters), this quality improvement project achieved its aims in improving doctors knowledge, and through having easy access to important information, will have long term positive effects on patient care.
Evaluation of tobacco use and willingness to accept nicotine replacement therapy during stay in an acute inpatient psychiatric ward Aims. To evaluate tobacco smoking and willingness to try and to accept prescription of nicotine replacement therapy during psychiatric acute inpatient stay. When free to choose and use as desired (without imposing smoking cessation) patients may be open to nicotine replacement therapy. Background. Tobacco smoking interventions are increasingly in demand especially for difficult to treat patient populations, as are those with severe mental illness. Implementing totally smokefree psychiatric inpatient units is challenging. Imposing smoking cessation and use of nicotine substitutes may or not be the best of strategies for smoking reduction and cessation in the mid and long term. Allowing the patient free choice as to trying and learning to use nicotine replacement therapy with supervision may constitute a more acceptable approach. Method. From 1/1/2020 to 28/1/2020 (four weeks), 40 of the 44 patients in a general adult psychiatric inpatient unit (4 patients were too sedated or too agitated to be evaluated), with smoking restricted to a designated area and only during the day, were briefly evaluated as to their tobacco smoking habits (cigarettes/ day) and willingness to accept nicotine lozenges and patches and were invited to participate in a smoking cessation programme during or after discharge. Result. Of the 40 patients evaluated, 26 were male and 14 were female, average age was 34 years (age range from 19 to 79 years). Diagnostic hypotheses for patients at admission were: schizophrenic disorder/schizoaffective disorder 9, bipolar disorder 7, psychosis not otherwise specified 19, depressive disorder 1 and other 4. 20(50%) were current smokers and 20 (50%) were non or ex-smokers. The smokers reported smoking an average of 14 cigarettes/day. Only one patient refused to try nicotine lozenges and all other smokers accepted regular prescription of nicotine lozenges during inpatient stay. 5 patients (25% of smokers) asked for or accepted suggestion to try nicotine patches in