An audit of admission clerking of patients in Heddfan, Adult Mental Health Unit in BCUHB - north Wales

Aims To ensure admission clerking includes salient features needed for the management of both physical and mental health of the patient and also to aid in administrative purposes. Method The audit included a team of doctors reviewing the admission clerking notes for 50 patients in the General Adult Psychiatric unit in-patient ward. We created a standard questionnaire-based on Intended learning outcome of core training in psychiatry CT1-CT3 from Royal College of Psychiatry and standard textbooks. Our aim is to achieve 100 % compliance in clerking Result It was noted that only 30% wrote their GMC number, 4% added route of admission of the patient and a mere 8% filled the Consultants name. Though almost everyone had written the presenting complaints, the other aspects such as history of presenting illness, medical and family history, Allergy status and substance misuse history were missing in many clerking notes. None of them had filled in details of personal history and very few did a risk assessment. Further lacuna was noted with Mental state examination. Physical examination was also noted to be incomplete. While more than 50% had completed the Blood investigations and ECG, half of them had not documented it and that meant searching in the entire file. A mere 20% filled the nursing observation level whilst none had completed the formulation in the notes. Conclusion Admission clerking is a vital source of information that would be needed for the formulation of patients diagnosis and future management. Apart from this, it also is needed for further continuity of care. Hence this vital source of information will need to be shared with the junior doctors who will be clerking the patient and seeing them in the first instance. We, therefore, intend to create a complete clerking proforma along with physical health proforma to aid us in this respect. We will audit initially in the first round and then plan to introduce a proforma for Clerking and physical examination based on the findings. We will re-audit to see if the standards are achieved after using the proforma and will consider a Quality improvement project based on this topic

Frequent empty on-call slots meant some doctors being asked to hold the bleep between 9-5 in-order to cover the vacancy.
Some felt this added to the existing workload and that it was unfair and unsafe.
This issue was raised during a supervision session with the Educational supervisor, North Wales and an initial data collection was suggested.
Method. Data were collected over 2 week period to look at the Daytime bleep duties between 9 am to 5 pm We hoped the data would demonstrate certain patterns of the task being asked to perform. Result. The total number of bleeps were noted to be 249 Discharge notification and prescription writing was noted to be the commonest reason for bleep in East and Central while Routine review and Discharge notification was the reason to be bleeped major number of times in the West Nearly 70% and 90% of the bleeps were found to be appropriate by the East and West respectively, while only a mere 15% were reported so in Central.
While 30% of these bleeps in the West were considered to be deferred, 70% bleeps were deferrable in the East and almost 95% in Central.
The general trend in all 3 centres was as follows: All three centres have high numbers of bleeps for discharge, prescribing tasks and routine patient reviews Most think planned discharge paperwork could be done in advance and jobs can be deferred if there is a ward/team doctor available Conclusion. A simple solution could be some jobs being planned ahead (e.g TTO/Discharge Summaries, Re-write charts) and done by the team/ward doctor. ECG could be arranged to be done by nurses/ECG technicians. Some nurses/HCAs are trained in phlebotomy, however, they have not been utilising the skills. That needed to be reinforced in safety huddles meeting.
Apart from these suggestions, we were also wondering about the impact of the service models and how the juniors placed in the community mental health unit could stay involved in their team inpatients Audit on use of PRN (pro re nata) psychotropic medication for behavioural disturbance in individuals with intellectual disability in the community Aims. Psychotropic medication is commonly used in people with Intellectual disabilities (ID). This may be attributed in part to an increased prevalence of mental illness in this population and the presence of challenging behaviour which has been shown to increase rates of prescribing. Whilst there are a number of studies looking at regularly prescribed medication there are few studies on "as and when" required (PRN) medication.
Psychotropic medication continues to be used to manage behavioural disturbances in people with ID. Where there is no clear cut psychiatric illness, the role of psychotropic medication is an adjunct to a comprehensive multimodal treatment plan.
The aim is to find out if prn psychotropic medication for behavioural disturbance is being used appropriately and safely in these individuals. Method. Files and PRN protocols of individuals known to be using prn psychotropic medications for the management of acute episodes of agitation and behavioural problems and supported by professional staff teams was studied.
We collected the data by contacting the residential homes, carers, Collecting details from case notes, from the Staff nurse who made the protocol for their patients A questionnaire based on the standards mentioned above was developed and files and prn protocols were marked against these standards.
Result. The standards from the medical file were 100 % achieved. Thus indicating the importance of the psychotropic prn medication and documentation of the same.
However, the protocol that needs to be with the patient/carers had some lacuna/deficits. Overall only in 53% of the case, standards were achieved. This needs to be highlighted to the team.
The Audit gave an insight into what needs to be improved. THE FOLLOWING AREAS NEEDED IMPROVEMENT 1. There should be a prn protocol/ similar instruction to the staff about the use of prn medication(written by appropriately trained professional) 2. Prn protocol should be accessible to direct care staff 3. There should be a description of when to use the prn medication 4. There should be a description of what non-pharmacological de-escalation methods ought to be tried before using prn/ is there a detailed behaviour support plan available 5. Protocol should describe what the medication is expected to do 6. Protocol should describe the minimum time between doses if the first dose has not worked 7. Protocol should state the maximum dose in 24 hour period 8. Use of prn should be recorded Conclusion. I hope this audit will help in improving the patient care with the right psychotropic prn medication, with correct doses and further details as mentioned in the standards of the protocol.
We also hope to ensure that in our area, prn psychotropic medication used for agitation and behavioural disturbance is used safely, appropriately and consistently by staff teams. This would be in accordance with the guidelines. Hergest and Heddfan both have their own templates which are then sent to the GP and filed in the case notes. Data were collected from both sources. The first audit cycle used 25 discharges selected at random from the male and female open wards in each site (n = 75 summaries). Data were collected over 3 months time using the audit proforma. Result. All mandatory headings are automatically inputted into the WCP summary used in Ablett therefore documentation was 100% for information such as patient name, DOB, and GP Details.

Audit of the quality and content of discharge summaries from mental health inpatient units across Betsi Cadwaladr University Health Board
Documentation of allergies was poor across 3 sites, particularly in Hergest, in which there was no mention of allergy status in 96% of summaries. Only 13% of Ablett summaries and 0% of Hergest summaries reach the GP on the day of discharge, however, 100% of summaries from Heddfan do, possibly due to their method of 'discharge notification'. The date and location of discharge were documented in 84% of Heddfan summaries, 100% of Hergest summaries, and 100% of Ablett summaries. This implies that this heading is already incorporated into the templates for the 2 sites which scored 100%. In the Ablett, medication was documented in 88%, but we found that in 49% of discharge summaries, the medication was the only field filled in! In these cases, the GP may not even know why the patient had been admitted. This is clearly unacceptable. Risk history is poorly documented across the sites, with 0% in Hergest and Heddfan, and 12% in Ablett. 0% of summaries across the Health Board mentioned crisis contacts. 0% of summaries in Heddfan and Ablett contained details of the patient's care coordinator. Conclusion. Our audit has identified a lack of psychiatry-relevant headings in the discharge summaries, particularly for those working in Ablett. Aims. Our aim was to evaluate psychotropic prescribing practices in adults with intellectual disability (ID) and autism spectrum disorder (ASD) across the Richmond Neurodevelopmental Service (NDS).

Psychotropic prescribing practices in adults with intellectual disability and autism spectrum disorder in Richmond Neurodevelpmental Services
Stopping over-medication of people with a learning disability, autism or both with psychotropics (STOMP) aims to reduce the potential harm of inappropriate use of psychotropic medications. We aimed to evaluate our prescribing practices in keeping with STOMP and the NICE guidelines. Method. We collected information from our clinical records on patients that met the inclusion criteria (≥18 years + diagnosis of ID and autism) from October-November 2019. We gathered the following: age, sex, severity of ID, psychiatric diagnoses, psychotropic medication, presence of challenging behaviours, involvement of positive behaviour support (PBS) and documentation of a PBS plan. Result. 32 patients met our criteria (3:1 Male-Female ratio with an age range of 20-74 (Median 33 years old)). All 32 patients showed evidence of challenging behaviours. In the cohort, mild ID represented 18.8% (n = 6), moderate ID 40.6% (n = 13) and severe ID 40.6% (n = 13).
17 patients (53%) had a PBS plan in place. For those without a PBS plan (47%, n = 15), a referral to behavioural analysis had been considered/requested in 67% (n = 10). 31 patients were on psychotropic medication and 84% (n = 26) had an indication documented in the notes although every patient had had a medication review in the last 6 months. 67.7% (n = 21) of the prescriptions were for challenging behaviours.
The average number of medications prescribed was 2 (median 2, mean 2.41) but this was reduced to 1 (median 1, mean 1.76) when additional psychiatric diagnoses and epilepsy were excluded. Conclusion. Prescriptions are regularly reviewed in keeping with STOMP guidance but there is more scope for utilising behaviour analysis input as well as the need to improve documentation of the rationale for psychotropic medications.