Compliance with Driver and Vehicle Licensing Agency guidance in a psychiatric inpatient setting

Aims Driving is complex, requiring adequate: attention and concentration, memory, insight and understanding, judgement, planning and the ability to self-monitor1. Psychiatric illness, and associated medications, may affect patients’ ability to drive safely. The DVLA is responsible for determining individuals’ safety to drive and produces guidance specific to psychiatric disorders. Patients must comply with relevant guidance and clinicians must determine patients’ driving status and offer appropriate advice about medications and any need to inform the DVLA. This audit aimed to determine the compliance with DVLA guidance on a single inpatient psychiatric ward within Merseycare NHS Foundation Trust, UK. Method A retrospective review of electronic patient records was completed. Clerical staff identified all patients admitted to Windsor House from 1/8/20–30/11/20 (n = 42). Data relating to driving status and driving advice were collected onto individual patient audit proformas, and uploaded to the online Audit Management and Tracking (AMaT) system. Result 100% of patients had diagnoses that would require the DVLA to be informed and 100% were prescribed medication with potential side effects that could impair ones’ ability to drive safely such as dizziness, drowsiness or impaired concentration2. Driving status was only documented for 12 patients (29%) and type of vehicle driven for only 6 patients (1 of whom had an HGV licence). Discussion of DVLA guidance within the last 3/12 by the mental health team was documented in 17% patients. Of these patients, appropriate driving advice was given to 86%. All patients advised to cease driving were willing to. No patients were advised about side effects of medications on driving. No notes evidenced if the DVLA had been informed of patients’ admission, diagnosis or medication regimes. Conclusion Discussing diving status and DVLA advice with psychiatric patients is important but may not always happen in inpatient settings, despite most patients having a relevant diagnosis. Failure to determine driving status may mean some patients are not being given appropriate guidance as required. Counselling on medication side effects in relation to driving should be encouraged as the majority of patients are taking prescribed medication that can potentially impair driving. Recommendations to improve compliance include: adding “driving status” to admission clerking and ward review proformas, educating staff to actively discuss driving with inpatients and create discharge checklists which prompt discussing driving status, medications and driving advice, and to re-audit in 6 months time.

Aims. Driving is complex, requiring adequate: attention and concentration, memory, insight and understanding, judgement, planning and the ability to self-monitor1. Psychiatric illness, and associated medications, may affect patients' ability to drive safely. The DVLA is responsible for determining individuals' safety to drive and produces guidance specific to psychiatric disorders. Patients must comply with relevant guidance and clinicians must determine patients' driving status and offer appropriate advice about medications and any need to inform the DVLA. This audit aimed to determine the compliance with DVLA guidance on a single inpatient psychiatric ward within Merseycare NHS Foundation Trust, UK. Method. A retrospective review of electronic patient records was completed. Clerical staff identified all patients admitted to Windsor House from 1/8/20-30/11/20 (n = 42). Data relating to driving status and driving advice were collected onto individual patient audit proformas, and uploaded to the online Audit Management and Tracking (AMaT) system. Result. 100% of patients had diagnoses that would require the DVLA to be informed and 100% were prescribed medication with potential side effects that could impair ones' ability to drive safely such as dizziness, drowsiness or impaired concentra-tion2. Driving status was only documented for 12 patients (29%) and type of vehicle driven for only 6 patients (1 of whom had an HGV licence).
Discussion of DVLA guidance within the last 3/12 by the mental health team was documented in 17% patients. Of these patients, appropriate driving advice was given to 86%. All patients advised to cease driving were willing to. No patients were advised about side effects of medications on driving. No notes evidenced if the DVLA had been informed of patients' admission, diagnosis or medication regimes. Conclusion. Discussing diving status and DVLA advice with psychiatric patients is important but may not always happen in inpatient settings, despite most patients having a relevant diagnosis. Failure to determine driving status may mean some patients are not being given appropriate guidance as required. Counselling on medication side effects in relation to driving should be encouraged as the majority of patients are taking prescribed medication that can potentially impair driving. Recommendations to improve compliance include: adding "driving status" to admission clerking and ward review proformas, educating staff to actively discuss driving with inpatients and create discharge checklists which prompt discussing driving status, medications and driving advice, and to re-audit in 6 months time.
Audit on prolactin monitoring for patients on oral risperidone, intramuscular risperidone, and intramuscular paliperidone Aims. The aim of this audit was to investigate whether sufficient Prolactin monitoring was completed in a patient sample in the Torfaen area of Aneurin Bevan University Health Board. This audit targetted patients an oral or intra-muscular formulation of Risperidone in the year 2018 with the hypothesis that Prolactin monitoring is done less frequently than recommended. Background. Risperidone is the anti-psychotic drug most frequently associated with hyperprolactinemia which is often asymptomatic but can present with symptoms of oligomenorrhea, amenorrhea, galactorrhea, decreased libido, infertility, and decreased bone mass in women. Men with hyperprolactinemia may present with erectile dysfunction, decreased libido, infertility, gynecomastia, decreased bone mass, and rarely galactorrhea. The BNF advises monitoring of Prolactin at baseline, after 6 months, and then annually. Method. Retrospective review of 150 patients' clinical letters to identify if they are on the above medications, using the local digital records system EPEX. Emails were also sent to community psychiatric nurses asking them if they could highlight any patients they were caseholding on the above medication. Depot clinic lists were also examined. Patients identified as being on the above medication had their blood tests reviewed on the online system Clinical Workstation (CWS) to determine whether they had their Prolactin level tested. A single spot sample of all patients on Talygarn ward in January 2019 was also included. Result. 1. 28 Risperidone 2. 23 of 28 never had any Prolactin measurements 3. 2 of 28 patients had the appropriate level of monitoring done for the year of 2018 a. One patient complained of Galacotorrhea b. Another patient had baseline done while on the ward and isn't due for any further monitoring at the time of writing. Conclusion. The above results identify that Prolactin monitoring is not being routinely completed for patients on the studied medication at an acceptable compliance level. Limitations around utitlity of prolactin monitoring may be the contributing factors; eg. Prolactin levels or medication dose may not be positively associated with adverse effects.. Further efforts were made to highlight the importance of baseline prolactin monitoring, as well as including a baseline Prolactin as an admission blood test for patients presenting with psychotic symptoms or on an antipsychotic. A complete audit of metabolic monitoring and Prolactin levels for all patients on anti-psychotics would be an appropriate next step. Aims. Co-existing mental illness and substance misuse is highly prevalent within the UK, with approximately 40% of people diagnosed with psychosis having a history of substance misuse. However, in Redbridge we currently do not have access to a dual diagnosis team or integrated care.
This audit aims to assess the health and social implications of fragmented care, plus the effectiveness of mental health services in assessing patients with dual diagnosis and referring to specialist misuse teams. We used the NICE guidelines on co-existing severe mental illness and substance misuse [CG120] to help guide our recommendations.
Method. We identified 50 out of 359 patients within our service who were admitted to psychiatric hospital over a one year period (between 01/11/2019-01/11/2020).
We looked at medication compliance, use of the Mental Health Act and accommodation status to compare between those with and without known dual diagnosis. We used frequency and length of admission as indicators of how successfully patients were being managed in the community and the cost to the hospital trust. Urine drug screening and referral to substance misuse services were chosen as markers of whether patients were being appropriately managed on admission. Result. A higher percentage of patients with dual diagnosis were detained under the Mental Health Act compared to those without substance misuse (89% versus 72%). They were more likely to have no fixed abode (28% versus 13%) and be non-compliant with treatment pre-admission (83% versus 56%). Patients with dual diagnosis also had a higher number of hospital admissions, with a greater proportion having 3 admissions that year (11% versus 3%).
Only 50% of patients with known dual diagnosis had a urine drug screen performed on admission and just 25% of patients who were currently misusing substances were referred to specialist services by the inpatient team. Conclusion. Our audit found that there are overall poorer outcomes for patients with dual diagnosis versus a psychiatric illness only. It is evident that integration of services will improve the care we are able to provide and reduce costs associated with multiple admissions to hospital.
We identified three key areas for improvement. Firstly, we advised on the need to improve documentation. Additionally, we recommend ensuring assessment of current drug misuse is done on admission, including performing simple tests such as urine drug screening. Finally, we highlighted the need to improve discussions about substance misuse with patients, within teams and between services, aiming for integrated and holistic care. Aims. Studies have shown that people with intellectual disability (ID) show a greater severity of attention deficit hyperactivity disorder (ADHD) symptoms and atypical presentation, as well as having a greater risk of developing comorbidities, such as challenging behaviour, anxiety, tic disorders and sleep problems. It is estimated that 1.5% of patients with ID will have a clinical diagnosis of ADHD.

Audit of ADHD medication prescription and monitoring in intellectual disability services, Greater Glasgow & Clyde
The aim of this audit was to find whether individuals with ID and ADHD, who are prescribed medication for ADHD are adequately monitored and reviewed in accordance with the ADHD medication prescription guidance by NICE and the Royal College of Psychiatrists (RCPsych).
Method. This audit looked at ADHD medication prescription for the ID population within Greater Glasgow & Clyde NHS. This is the 6th audit cycle where electronic records (EMIS) were analysed between 28/9/19 to 09/10/20. (The 5th cycle data collection period ended on 28/9/19). We collected data on all patients aged over 18 years.
An audit tool was developed to find whether the following were documented; patient demographics, physical health monitoring, symptom severity, medication dosage, side effects, need for ongoing treatment and frequency of review. 100% of patients should have all components on the ADHD audit tool documented, as per NICE/ RCPsych prescription guidance. Result. 32 patients were identified as being diagnosed with ADHD prescribed medication. One patient was impacted by the COVID-19 pandemic which meant that the required monitoring was not fully carried out. The age ranged from 18 to 56 years. 75% had mild intellectual disability, 19% had moderate and 6% had severe, with no cases of profound intellectual disability. Blood Pressure/pulse was recorded in 84% of patients. Height/weight/ BMI was recorded in 81% of patients. 97% of patients had ADHD symptom severity, medication dosage, side effects, need for ongoing treatment and frequency of review recorded. Conclusion. There is further scope for improvement in the monitoring and documentation of physical health observations, however there was a significant improvement compared to the previous cycle of the audit. Other aspects of monitoring and documentation appear to be recorded in almost 100% of patients. This finding emphasises the challenges of physical health monitoring and compliance in psychiatry as a whole. We need to continue to encourage awareness and education around the physical health risks to our patients, not only due to their comorbidities but also as a result of the psychotropic medications we prescribe them.
Are patients self-referring to Lewisham Community Wellbeing (LCW) when advised to do so by the assessment and liaison psychiatry team? Aims. It is well-recognised by the RCPsych that mental illness is both a cause and consequence of social exclusion, and thus social inclusion is an important part of recovery and leads to better outcomes for patients.
The Lewisham Assessment and Liaison team Neighbourhood 4 (A&L N4) is a CMHT service that acts as an intake team for all referrals into secondary care mental health services, with the purpose of assessment and brief intervention. Currently, if a patient is assessed to potentially benefit from our local social inclusion service, Lewisham Community Wellbeing (LCW), they are advised to self-refer. However, there is no follow-up as to whether patients go on to do this.
Therefore, this audit aimed to calculate: How many patients are advised to self-refer to LCW (advised referral) How many of these patients make the self-referral to LCW (completed referral) Method. The electronic notes for patients who were accepted by the A&L N4 team from July to September 2020 were retrospectively analysed to see if an LCW self-referral was advised. A list of these patients was then given to LCW to check whether they had self-referred. Result. A&L N4 worked with 82 patients during the study period. 16 patients were advised to self-refer to LCW-an advised referral rate of 19.5%. There was notable month-to-month variation in the advised referral rate-29.6% in July vs. 9.4% in September.