119 results in 101 Recipes for Audit in Psychiatry
69 - Audits
- from VI - Training
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- By Mark Lovell, Oakrise Learning Disability Inpatient Unit, York, and Yorkshire Deanery
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 167-168
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Summary
Setting
This audit is relevant to all trainee psychiatrists and their trainers. It should be combined with training on the audit cycle.
Background
All doctors ‘must take part in regular and systematic audit’ (General Medical Council, 2006). Depending on where trainees are in their training, their knowledge, ability and motivation to partake in audit may vary. Demonstration of the understanding and principles of audit is one of the essential competencies that are required of an ST2 level trainee (Royal College of Psychiatrists, 2009). This audit allows a training scheme or trust to establish what proportion of its trainees are partaking in audit currently or recently, any reasons for not doing audit and the support that they have received from their trainers.
Standards
The four main audit standards for this audit were taken from the document Specialist Training in Psychiatry (Royal College of Psychiatrists, 2009):
ᐅ Trainees should undertake an audit in every placement.
ᐅ Trainees should endeavour to complete the audit cycle.
ᐅ Trainers should advise trainees about suitable audit projects or direct them to a nominated audit lead.
ᐅ Trainers should assist trainees in implementing changes suggested by audits.
Method
Data collection
Questionnaires were sent to all relevant psychiatric trainees either by post (with a return envelope) or by email. The following questions were asked:
1 Are you currently involved in audit activity?
2 If not currently, when were you last involved?
3 If not, why are you currently not involved in audit?
4 Have you ever completed the audit cycle?
5 If not, why has this not occurred?
6 Has your current trainer advised you on suitable audit projects or directed you to a nominated audit lead?
7 If you have previously completed an audit, did your trainer assist you in implementing changes suggested by your audit?
Data analysis
The replies for questions 1, 4, 6 and 7 were taken to represent the standards. This allowed a calculation of the compliance with the standard.
The replies to questions 2, 3 and 5 were qualitative and were used for discussion purposes and to guide recommendations.
1 - Forms for section 136 of the Mental Health Act
- from Appendices
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
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- 01 March 2011, pp 237-238
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13 - Eating disorders: management
- from I - Disorders
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- By Alvina Ali, Leicestershire Partnership Mental Health Trust
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 45-46
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Summary
Setting
This audit would be relevant in eating disorders services, particularly in outpatient settings. It was originally conducted for an eating disorders service within a child and adolescent mental health service (CAMHS), but it would also be appropriate in adult services.
Background
Eating disorders comprise a range of syndromes with physical, psychological and social features. The provision of psychiatric treatment by high-quality, age-appropriate, specialist eating disorder services has a clear effect on patient outcomes. The purpose of this audit was to ensure that the local service provision was in line with national standards.
Standards
According to the 2004 guideline on eating disorders produced by the National Institute for Health and Clinical Excellence (NICE):
ᐅ most patients with anorexia and bulimia nervosa should be managed on an out-patient basis
ᐅ psychological therapies should be offered to all patients who are diagnosed with an eating disorder
ᐅ psychological therapy for anorexia nervosa should last at least 6 months.
The target is that these standards are met for all patients diagnosed with specific eating disorders.
Method
Data collection
Data were collected, using a specific data tool, from all the referrals to an eating disorder service over 1 year. The data tool allowed information to be collected on the following areas:
ᐅ diagnosis at first assessment
ᐅ treatment offered (psychological, parent psycho-education, medication) and whether it was delivered on an out-patient or in-patient basis
ᐅ types of psychological therapy offered (e.g. family therapy, individual psychodynamic therapy, interpersonal therapy, cognitive–behavioural therapy or a combination)
ᐅ duration of therapy.
Data analysis
The percentage of the sample with documentation of a diagnosis in line with the ICD–10 classification was recorded. In addition, for patients who required treatment, the percentages with documentation of the following were calculated:
ᐅ type of treatment offered (psychological, others, combined)
ᐅ type of psychological therapy offered
ᐅ duration of therapy (recorded as less than or more than 6 months).
Resources required
People
The audit should be undertaken by at least two people, owing to the amount of information collected.
Time
For a service receiving 100 referrals per year it is estimated that the data collection would take around 15 hours.
89 - Hypnotics
- from VII - Treatment
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- By Josie Jenkinson, Kent, Surrey and Sussex Deanery
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
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- 01 March 2011, pp 209-210
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Summary
Setting
This audit is relevant to any in-patient setting where a significant proportion of patients may be prescribed hypnotics for the treatment of insomnia.
Background
The National Institute for Health and Clinical Excellence (NICE) (2004) has made several recommendations regarding the use of hypnotics for the treatment of insomnia. Insomnia is a symptom often experienced by those suffering from mental illness, and so hypnotics are frequently prescribed within psychiatric in-patient settings.
Standards
Standards were obtained from the audit criteria recommended by the National Institute for Health and Clinical Excellence (2004). These are as follows:
ᐅ Non-pharmacological measures are to be considered before the prescription of drug therapy for insomnia.
ᐅ When used, hypnotic drug therapy should be used for the shortest time necessary, and in strict accordance with the licensed indications.
ᐅ When hypnotic therapy is prescribed, the drug with the lowest purchase cost should be chosen. (The information on purchasing costs was obtained from the chief pharmacist.)
ᐅ Patients should not be switched from one drug to another.
The target was that these standards should be met for all in-patients prescribed hypnotics for insomnia.
Method
Data collection
Data were collected by examining the medical notes and prescription charts of all in-patients within the trust for evidence of the four standards. This was done as a snapshot audit over a pre-specified 2-week period.
Data analysis
The percentage of patients being prescribed hypnotics for insomnia for whom each of the following standards was met was calculated:
ᐅ documentation of the consideration of non-pharmacological measures
ᐅ hypnotic prescription not lasting for longer than 4 weeks
ᐅ drug with the lowest purchase cost used
ᐅ no switch from one drug to another.
The prescribing practices of different units was depicted through the use of pie charts and bar graphs.
Resources required
People
This audit would need to be completed by three or four people, depending on the size of the trust.
Time
For a trust with 250 in-patients, with approximately half of these being prescribed night sedation, it is estimated that data collection would take 20 hours.
Results
ᐅ Documentation of discussions relating to non-pharmacological measures, such as sleep hygiene, was almost universally absent.
ᐅ Compliance with length of prescription of hypnotics was good.
ᐅ Only one patient was switched from one hypnotic to another.
53 - Risk assessment: medium-secure unit
- from IV - Record-keeping
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- By Ruth Scally, Birmingham and Solihull Mental Health NHS Foundation Trust
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 131-132
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Summary
Setting
This audit is particularly relevant in forensic settings but also applies to any adult psychiatric service, both in- and out-patient.
Background
An assessment of the risks posed by patients, whether self-harm, absconding or violence to others, should be recorded in the patient's notes. In the trust audited, these assessments are based on the HCR-20 (Historical Clinical Risk),a 20-item structured clinical risk assessment tool that is widely used in forensic settings (Khiroya et al, 2009).
Standards
The National Institute for Health and Clinical Excellence (NICE) has produced a guideline (2005) on the short-term management of disturbed and violent behaviour in in-patient psychiatric settings. It states that ‘there should be an effective risk assessment and risk management plan … in the case notes of each service user at high risk and that this should be reviewed on a regular basis’. For the purposes of this audit, this was interpreted as all patients having an HCR-20 form in their notes, which had been reviewed within the past 12 months.
Method
Data collection
The medical records of all in-patients on one specific day were reviewed and the following data collected:
ᐅ whether an HCR-20 form was present in the notes
ᐅ whether it had been completed
ᐅ whether it had been reviewed in the past 12 months
ᐅ the number of disciplines involved in the risk assessment (i.e. whether it was a multidisciplinary assessment).
In addition the length of stay of each patient was noted.
This audit was conducted in combination with an audit of risk assessment documentation for the care programme approach (CPA) within the trust.
Data analysis
The percentage of sets of case notes meeting the standards was calculated for:
ᐅ those with an HCR-20 form
ᐅ those that were complete
ᐅ those that had been reviewed in the preceding 12 months.
The number (and nature) of disciplines involved was counted and displayed in a bar chart.
Resources required
People
Depending on the size of the population being studied, this audit would be suitable for one or two people, of any discipline.
Time
About 4 hours should be allowed for an audit of 90 patients.
55 - Emergency department: attendance
- from V - Service provision
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- By Jim Bolton, St Helier Hospital, South West London and St George's Mental Health NHS Trust
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 137-138
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Summary
Setting
This audit may be particularly relevant to liaison psychiatry services and other mental health services that accept referrals from emergency departments.
Background
The NHS Plan introduced an aim to reduce waiting times for patients attending emergency departments (Department of Health, 2000). This audit aimed to measure the proportion of patients referred to mental health services who remained in an emergency department for longer than 4 hours and to identify the reasons for prolonged attendance.
Standards
The standard was derived from the NHS Plan, which stipulated that, from 2004 onwards, over 98% of patients attending an emergency department should have completed their attendance episode within 4 hours (Department of Health, 2000). This time includes any assessment and management by specialist services that occurs in the emergency department. The standard set was that over 98% of referrals to liaison psychiatry should have an attendance time of under 4 hours.
Method
Data collection
Emergency department records were collected for all patients who were referred by the emergency department to the liaison psychiatry service over a 3-month period. For each attendance, the total attendance time was calculated. Where the attendance time was over 4 hours, the records were examined to identify the main reasons for a prolonged attendance.
Data analysis
Two time intervals were calculated, between:
ᐅ booking into the emergency department and assessment by a doctor
ᐅ referral to the liaison psychiatry service and psychiatric assessment.
For both intervals, an arbitrary duration of greater than 1 hour was recorded as contributing to a prolonged attendance.
Resources required
People
Cooperation is required from emergency department staff in order to collect patient records. It is suggested that the audit is undertaken by at least two people, owing to the amount information to be collected and the possible need to confer when points are uncertain. It is recommended that the auditors are clinical staff who are familiar with clinical records and emergency department care.
Time
The audit should be conducted over a long enough period to gain a representative number of cases (e.g. 3 months). It is estimated that data collection would take 15–20 hours.
4 - Bipolar depression: treatment
- from I - Disorders
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- By Jon Van Niekerk, Greater Manchester West Foundation Trust
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 27-28
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Summary
Setting
This audit will be most suitable for adult and older-adult psychiatry services. Bipolar depression is usually treated within the out-patient department. This audit can be site specific or carried out across a trust.
Background
The depressive episodes in bipolar disorder are debilitating and on the whole they last longer and occur more frequently than manic episodes. The treatment of bipolar depression is controversial and there is evidence that using antidepressants can cause switching and acceleration of cycling. The efficacy of antidepressants in bipolar depression is weak and yet they are widely used.
Standards
The following standards relating to bipolar depression were taken from the guideline on bipolar disorder produced by the National Institute for Health and Clinical Excellence (NICE) (2006):
ᐅ A patient who is prescribed antidepressant medication should also be prescribed an antimanic drug.
ᐅ A selective serotonin reuptake inhibitor (SSRI) should be used instead of a tricyclic antidepressant.
ᐅ Patients should not routinely continue on long-term antidepressant treatment.
ᐅ When initiating antidepressant treatment for patients not on antimanic medication, the risk of switching should be explained.
ᐅ Antidepressants should be avoided for patients with depressive symptoms who:
▹ have rapid-cycling bipolar disorder
▹ have had a recent hypomanic episode
▹ have recently experienced functionally impairing rapid mood fluctuations.
Method
Data collection
A retrospective case-note analysis was conducted. All patients with a diagnosis of bipolar disorder who had suffered a depressive episode were included. Those with schizoaffective disorder were excluded.
Medical/electronic notes were reviewed to see whether the following had been recorded:
ᐅ the severity of the depression – mild; moderate; severe; with or without psychosis
ᐅ any contraindications to the use of antidepressants – rapid cycling bipolar disorder, recent hypomanic episode or recent mood fluctuations
ᐅ what the baseline medications were (type and dose) and whether these had proved therapeutic/sub-therapeutic
ᐅ the treatment regimen (medication type and dose, therapy, other)
ᐅ whether the patient was on antimanic medication if an antidepressant had been started
ᐅ discussion with the patient of the risk of switching
ᐅ outcome of the treatment regimen (including adverse events such as a manic switch)
ᐅ subsequent treatment regimens (second and third).
Data analysis
Compliance with the above standards was calculated. Demographic data and site-specific data were obtained in order to allow comparisons.
62 - Prison-to-hospital transfers
- from V - Service provision
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- By Andrew Forrester, HMP Brixton
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 151-152
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Summary
Setting
This audit is relevant to general adult or forensic psychiatrists working in prison in-reach teams.
Background
Prisoners, as a group, present an excess of severe mental illness. In England and Wales, mental health in-reach teams were introduced to the prison estate to assist with high levels of need. However, prison-to-hospital transfer times have been a particular problem, which this audit sought to clarify.
Standards
No standard times for transferring acutely unwell prisoners to hospital were set until relatively recently. In 2006, the Department of Health produced agreed procedures for the transfer of prisoners to and from hospital under sections 47 and 48 of the Mental Health Act. These guidelines initially set a 7-day target for prisoner transfers, later amended to 14 days. The same 14-day target was affirmed in Lord Bradley's 2009 review of people with mental health problems and intellectual disabilities in the criminal justice system. The government later accepted that transfer delays should be reduced to a minimum, but did not confirm the application of the 14-day target. Section 47 of the Mental Health Act allows mentally disordered sentenced prisoners to be transferred to hospital from prison for treatment, while section 48 of the same Act allows the urgent transfer of mentally disordered remand prisoners. The transfer is ordered by the Secretary of State for Justice, if satisfied of the following:
ᐅ two doctors have provided written evidence (via a pro forma)
ᐅ the prisoner has a mental disorder (meaning any disorder or disability of the mind)
ᐅ the mental disorder is of a nature or degree that makes it appropriate for the individual to be detained in a hospital for medical treatment
ᐅ appropriate medical treatment is available.
Method
Data collection
The audit was designed for use by one or more prison in-reach teams. Before starting, the relevant prison was identified, along with the time period under examination.
The following information was collected from prison medical records:
ᐅ referral date
ᐅ assessment date
ᐅ acceptance date
ᐅ transfer date
ᐅ level of security of the accepting unit
ᐅ section of the Mental Health Act used.
14 - Epilepsy: management
- from I - Disorders
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- By Cameron Martin, Tees, Esk and Wear Valleys NHS Foundation Trust
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 47-48
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Summary
Setting
This audit was done in relation to out-patients served by four consultant psychiatrists specialising in intellectual disability (ID). The standards of care are the same for a non-ID population, so this audit could be adapted to any population for whom the clinician has a responsibility for managing epilepsy.
Background
Epilepsy is a chronic illness which poses a challenge in the balance between sideeffects and effective treatment. It is particularly relevant to an ID population as the prevalence is higher in this group than in the general population. The risks to the individual are high if the wrong balance is struck, leaving the patient either with frequent seizures and the increased risk of sudden unexplained death in epilepsy (SUDEP) or exposed to harmful side-effects.
Standards
The guidance on epilepsy in adults and children produced by the National Institute for Health and Clinical Excellence (NICE) (Stokes et al, 2004) presents 17 standards. All these could be audited, but key minimum standards which should be easily addressed through this type of audit would be the following:
ᐅ The records show that all individuals have had their seizures and/or epilepsy syndrome classified using a multi-axial classification scheme.
ᐅ The records show that combination anti-epileptic drug therapy, if prescribed, followed an adequate trial of monotherapy.
ᐅ The records show that all individuals with epilepsy have had a review in the previous 12 months.
ᐅ The records show that seizure frequency has been documented in the past 12 months.
Method
Data collection
A sample of the departmental case-load was systematically assessed and all cases of epilepsy were identified. Notes were examined in reverse chronological order. In all notes, the following information was sought:
ᐅ description of seizures (ictal phenomenology)
ᐅ seizure type
ᐅ syndrome
ᐅ aetiology
ᐅ reference to the number of anti-epileptic drugs taken and, where more than one drug was being taken, documentation of at least two periods of monotherapy that failed to gain adequate results
ᐅ review of epilepsy at least every 12 months
ᐅ review of seizure frequency at least every 12 months.
Data analysis
Database software was used to evaluate the proportion of patients meeting the above criteria.
47 - Confidential waste
- from IV - Record-keeping
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- By Neil Masson, NHS Greater Glasgow and Clyde
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 119-120
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Summary
Setting
This audit is relevant to all specialties in psychiatry and in all settings.
Background
Doctors have a duty to keep confidential information about their patients safe and to destroy confidential information in a safe and secure manner. Clinical notes and typed letters are often put into general waste bins instead of being shredded. This can result in sensitive information being viewed by third parties, which may have legal or disciplinary ramifications.
Standards
The Data Protection Act 1998 applies to all organisations that hold personal data on individuals. The seventh principle of the Act concerns unlawful processing and accidental loss of personal data, phrased in the Act as follows: ‘Appropriate technical and organisational measures shall be taken against unauthorised or unlawful processing of personal data and against accidental loss or destruction of, or damage to, personal data.’ The Act advocates shredding of confidential waste to reduce the risk of confidential information being made public. Compliance with the Act is mandatory: failure to comply can result in legal action and fines. The target in this audit was that no patient-identifiable information should be disposed of as general waste.
Method
Data collection
The waste bins in all rooms in a psychiatry department were checked at the end of each day for a set time period without the knowledge of the staff in that department. If confidential waste was identified, it was categorised as:
ᐅ ‘patient identifiable’ waste (i.e. that linked an individual to the department)
ᐅ ‘sensitive’ waste (i.e. that linked the individual to the department and included sensitive information, such as history, diagnosis and treatment).
Data analysis
The number of ‘patient identifiable’ and ‘sensitive’ waste items was counted. A brief description of what form they took and where they were found was recorded.
Resources required
People
This audit can be completed by a single person.
Time
This audit may involve staying behind after work for approximately 30 minutes so that waste bins can be examined at the end of the day. This would be necessary for the duration of the audit timeframe.
Results
Several items of confidential waste were identified during the data-collection period, with a few rooms being responsible for the majority. After implementation of the first suggestion below, the amount of confidential waste reduced significantly.
Contributors
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp x-xiii
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38 - Screening for breast and cervical cancer
- from III - Physical health
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- By Sofia Jaffer, Reaside Clinic, Birmingham and Solihull Mental Health NHS Foundation Trust
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 99-100
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Summary
Setting
This audit is relevant to all female patients over 25 years of age in any hospital. It will be particularly relevant in long-stay wards, such as forensic settings.
Background
Women with mental health problems may be at increased risk for developing breast and cervical cancer (Miller et al, 2007), probably because of their underutilisation of preventative services, decreased access to treatment, effects of mental illness and its treatment on the development of cancer, and risk factors common to both mental illness and cancer (Follette & Cummings, 1967; Xiong et al, 2008).
Standards
Routine screening methods are recommended by the Department of Health (2007) to detect breast cancer and to identify cervical pathology in preventing cervical cancer. The screening programmes for cervical and breast cancer run by the National Health Service (NHS) have a target standard of 100% (National Institute for Health and Clinical Excellence, 2003). The NHS breast screening programme provides free breast screening every 3 years for all women in the UK aged 50–70 (50–64 in Northern Ireland). Women between the ages of 25 and 64 are eligible for free cervical screening (25–49 years, 3 yearly; 50–64 years, 5 yearly).
Method
Data collection
All female patients aged over 25 years currently admitted to a medium-secure unit were considered for inclusion in the audit. Patients under 25 years were excluded as they were not eligible for screening for either breast cancer or cervical cancer. Information regarding the patient's age, duration of stay and cervical and breast cancer screening was collected from the medical records.
Data analysis
Data were analysed using spreadsheet software. The proportions of patients who had been screened were calculated:
ᐅ cervical screening for those aged 25–49
ᐅ breast and cervical screening for those aged 50–70
Resources required
People
Three people were involved in undertaking the audit.
Time
It took almost 3 months to complete this audit.
Results
ᐅ Of the women aged 25–49 years, 30% were not screened for cervical cancer.
ᐅ Nearly 30% of those aged over 50 were not screened for cervical cancer.
ᐅ For more than 50% of the women aged over 50, for whom breast cancer screening is essential, it was not done. In one case, a mammogram was done because an abnormality was detected by physical examination.
11 - Dementia: investigations
- from I - Disorders
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- By Amelia Orchard, Birmingham and Solihull Mental Health NHS Foundation Trust
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 41-42
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Summary
Setting
This audit is particularly relevant to psychiatrists who investigate suspected dementia, such as specialists in old age psychiatry and intellectual disability, and neuropsychiatrists.
Background
Various guidelines have been published. The National Institute for Health and Clinical Excellence (NICE) and the American Academy of Neurology recommend neuroimaging and blood tests to investigate every patient with suspected dementia. The Canadian Consensus Conference on Dementia and the Royal College of Psychiatrists recommend neuroimaging only when clinical findings point to a possibility other than Alzheimer's disease. Reasons for imaging new referrals include detecting potentially reversible causes of dementia (although the prevalence of such cases is falling) and more accurate diagnosis of dementia subtype.
Standards
The standards were obtained from the NICE guideline Dementia: Supporting People with Dementia and Their Carers in Health and Social Care (National Institute for Health and Clinical Excellence, 2006). The guideline recommends that a basic blood test should be performed at the time of presentation and should include:
ᐅ routine haematology
ᐅ biochemistry tests (electrolytes, calcium, glucose, renal and liver function)
ᐅ thyroid function tests
ᐅ serum B12 and folate levels.
The guideline also states that structural imaging should be used in the assessment of people with suspected dementia to exclude other cerebral pathologies and to help establish the subtype diagnosis. Magnetic resonance imaging (MRI) is the preferred modality but computerised tomography (CT) could be used.
The expectation is that all new referrals should receive a dementia blood screen and neuroimaging.
Method
Data collection
Data were collected in a retrospective review of medical notes. All new referrals to mental health services involving suspected dementia or memory problems were identified. Data collected were:
ᐅ age and sex
ᐅ whether each of the required blood tests had been performed
ᐅ whether the patient had a CT or MRI scan and the result of the neuroimaging (recorded in categories as Alzheimer's disease, small-vessel disease, infarct, mixed pathology, normal, awaiting scan or other).
Data analysis
The percentage of patients who had had each investigation was calculated.
Resources required
People
It is suggested that this audit is undertaken by one or two people.
Time
For approximately 50 referrals it is estimated that data collection would take around 10 hours.
66 - Transition planning in attention-deficit hyperactivity disorder
- from V - Service provision
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- By Katherine Telford, Derbyshire Mental Health Services NHS Trust
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 159-160
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Summary
Setting
This audit can take place in child and adolescent psychiatry for patients diagnosed with attention-deficit hyperactivity disorder (ADHD) where the guideline from the National Institute for Health and Clinical Excellence (NICE) (2008) recommends transition planning.
Background
Over recent years, ADHD has been re-conceptualised as a chronic disorder (Willoughby, 2003; Faraone et al, 2006). Using DSM–IV criteria for the definition of ADHD, the rate of persistence is about 15% at age 25. Using an alternative definition of impairing symptoms of ADHD that do not meet the full criteria of ADHD (partial remission) the persistence rate is 40–60% (National Institute for Health and Clinical Excellence, 2008). Young people who have had their ADHD managed by a child and adolescent mental health service (CAMHS) are likely to require ongoing treatment for ADHD from adult mental health services. This transition of care requires planning.
Standards
The following points of the NICE guideline on ADHD were audited:
ᐅ Patients with ADHD should be reassessed at school-leaving age to establish the need for continuing treatment.
ᐅ During the transition to adult services, a formal meeting involving CAMHS and/or paediatrics and adult psychiatric services should be considered.
ᐅ The young person and, when appropriate, the parent or carer should be involved in the planning and full information should be provided to the young person about adult services.
Method
Data collection
All patients of school-leaving age (i.e. in year 11 or more at UK secondary school) who had ADHD were identified. This stage was reliant on the department having some system of recording patients by diagnosis. The audit can either look only at cases still open, or can also include patients who are in the same age cohort and who have ADHD but have been discharged. This makes the audit more useful in terms of identifying unmet needs. Notes were reviewed to find evidence of transition planning documented either in letters or minutes of meetings or in written records to establish the following:
ᐅ the transition to adult services or the need for ongoing management from age 18 had been discussed with the parent(s)
ᐅ the transition to adult services or the need for ongoing management from age 18 had been discussed with the young person
ᐅ if transition was thought to be necessary, a transition planning meeting had been arranged
ᐅ the transition process had been started by contacting adult services.
I - Disorders
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 19-20
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Summary
Acute confusion: recognition
Antenatal and postnatal mental health
Attention-deficit hyperactivity disorder: provision of information
Bipolar depression: treatment
Bipolar disorder: management
Bipolar disorder: shared decision-making
Bipolar disorder: treatment
Chronic fatigue syndrome
Dementia: driving
Dementia: end-of-life care
Dementia: investigations
Depression: management in children and young people
Eating disorders: management
Epilepsy: management
Opiate dependence and pregnancy
Schizophrenia: family interventions
Schizophrenia: management
Schizophrenia: occupational achievements
Self-harm: assessment
Self-harm: assessment in children
78 - Antipsychotics: prescribing
- from VII - Treatment
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- By Madhusudan Deepak Thalitaya, Tinwoods Medical Centre, South Essex Partnership University NHS Foundation Trust, Deepthi Gunatilake, Coventry and Warwickshire Partnership NHS Trust
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 187-188
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Summary
Setting
This audit is relevant in any service where a high proportion of patients are likely to be prescribed antipsychotic medication.
Background
Guidelines on antipsychotic medication produced by the National Institute for Health and Clinical Excellence (NICE) suggests that atypical antipsychotics are preferred to typical antipsychotics because of their lesser side-effect profile and higher propensity for compliance. National Health Service trusts have an obligation to ensure that appropriate atypical drugs with the lowest purchase costs are considered before a prescription is made.
Standards
Standards were obtained from National Institute for Health and Clinical Excellence 2009 guidance on the use of atypical antipsychotic medication in schizophrenia. Of particular relevance are the following:
ᐅ The choice of antipsychotic medication should be made jointly by the prescriber and the (properly informed) patient and/or carer.
ᐅ Second-generation antipsychotics should be considered as the first-line treatment.
ᐅ Second-generation antipsychotics should be considered for patients who show or report unacceptable adverse effects caused by first-generation agents.
ᐅ Clozapine should be considered if the patient is unresponsive to two different antipsychotic medications (at least one being a second-generation antipsychotic).
ᐅ Depot medication should be used where there are grounds to suspect that a patient may be unlikely to adhere to prescribed oral therapy.
ᐅ The drug with the lowest purchase cost should be prescribed.
ᐅ Advance directives regarding patients’ preference for treatment should be developed and documented.
ᐅ A comprehensive package of care should be considered.
ᐅ Second-generation antipsychotics and first-generation antipsychotics should not be prescribed together except during a changeover of medication.
ᐅ Justify reasons for dosages outside the range given in the BNF(Joint Formulary Committee, 2009).
Method
Data collection
A retrospective review of case notes and medication cards from all in-patients was used. It was helpful to use an audit pro forma based on the above standards.
Data analysis
The total percentage compliance with all the above standards was analysed using a computerised statistical package.
Resources required
People
This audit was conducted by two people to cover the entire in-patient population as well as to minimise bias.
Time
If data are collected by two clinicians, it is anticipated that no more than 6 hours will be required for this, and a further 4 hours for analysis and presentation.
32 - Monitoring growth and blood pressure in children with attention-deficit hyperactivity disorder
- from III - Physical health
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- By Chris Pell, Carseview Centre, NHS Tayside
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
-
- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 87-88
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Summary
Setting
The audit is of particular relevance to services that manage the treatment of attention-deficit hyperactivity disorder (ADHD) in young people and which specifically use both stimulant and non-stimulant medications. Background
The medication used to treat the symptoms of ADHD can suppress appetite and so affect the growth rate of children. It can also lead to tachycardia and raised blood pressure, both of which may affect the tolerability of the medication.
Standards
Standards were obtained from two sources, the Scottish Intercollegiate Guidelines Network (SIGN) (2009) and the National Institute for Health and Clinical Excellence (NICE) (2008). The former states that:
ᐅ Psychostimulants should be considered as the first line of drug treatment for the core symptoms of confirmed ADHD/hyperkinetic disorder.
ᐅ Once an effective dose has been determined, regular review continues to be important, for checks of behavioural rating and side-effects, along with checks of height, weight and blood pressure. The NICE standards state that, for people taking methylphenidate, atomoxetine or dexamfetamine:
ᐅ Height should be measured every 6 months in children and young people.
ᐅ Weight should be measured 3 and 6 months after drug treatment has started and every 6 months thereafter in children, young people and adults.
ᐅ Height and weight in children and young people should be plotted on a growth chart and reviewed by the healthcare professional responsible for treatment.
ᐅ Heart rate and blood pressure should be monitored and recorded on a centile chart before and after each dose change and routinely every 3 months.
Method
Data collection
All case files for children in the service with a diagnosis of ADHD were located. A random sample was selected, and information collected using a pro forma. The medical notes of the selected ADHD patients were examined for documentation of the following:
ᐅ demographic data including age, gender and consultant
ᐅ whether the child has been prescribed medication for ADHD
ᐅ whether the child has been reviewed at clinic
ᐅ presence of updated growth chart in the notes
ᐅ recordings of heart rate and blood pressure.
29 - Infection control
- from III - Physical health
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- By Floriana Coccia, University of Birmingham
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
-
- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 81-82
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Summary
Setting
This audit is appropriate for all psychiatric services but may be more relevant to in-patient units.
Background
Incorporating evidence-based infection prevention and control advice into routine clinical care is believed to be important in reducing the incidence of preventable healthcare-associated infections.
Standards
There are numerous standards relating to infection control to which mental health trusts have an obligation to adhere (including National Institute for Health and Clinical Excellence, 2003; Infection Control Nurses Association, 2005; Department of Health, 2006).
Standards most relevant to the mental health trust can be selected for the audit process. Either single recommendations or combinations can be used. Four domains of care were selected for audit:
ᐅ Sharps. Sharps, needle-stick injuries, bites and splashes involving blood or other body fluids are managed in a way that reduces the risk of injury or infection (26 possible individual standards).
ᐅ Hand hygiene. Hands will be decontaminated correctly and in a timely manner using a cleansing agent, to reduce risk of cross-infection (25 possible individual standards).
ᐅ Personal protective equipment. Personal protective equipment is available and is used appropriately to reduce the risk of cross-infection (21 possible individual standards).
ᐅ Specimen handling. Specimens are handled in a way that negates the risk of cross-infection to all staff (18 possible individual standards).
The standards should be met in all areas in all domains.
Method
Data collection
The data related largely to the presence or absence of equipment on the ward. A tick-box data-collection sheet covering all relevant domains was used. This sheet contained the four main domain headings and the individual standards within each domain. For each standard the auditor indicated whether the standard was met (Yes / No / Not applicable).
Data analysis
Data were collated using spreadsheet software. Compliance with the standards was calculated for:
ᐅ the four domains described in the standards above
ᐅ the individual standards within each domain
ᐅ each trust, locality or team.
Resources required
People
This audit was coordinated by an audit facilitator; at each site at least one person collected data.
Time
Each individual required at least 1 hour to collect the data on the local ward or unit, but this depends on the size of the unit.
23 - Mental Health Act (Scotland)
- from II - Legislation
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- By Daniel M. Bennett, Royal Cornhill Hospital, Aberdeen, Sumit Sharma, Royal Cornhill Hospital, Aberdeen
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
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- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 67-68
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Summary
Setting
This audit is suitable for all areas of psychiatry where patients are detained under the Mental Health (Care and Treatment) (Scotland) Act 2003. In the original audit, a general adult psychiatry ward was the setting. It would also be possible to convert the methodology to other jurisdictions that use similar mental health legislation.
Background
The Mental Health (Care and Treatment) (Scotland) Act 2003 came into force in October 2005. It suggests that the short-term detention order is used as a ‘gateway order’. It specifies a number of principles that must be considered by any person utilising the provisions of the Act. One of these is that patients should participate in all aspects of their care, treatment and support. Patients are also given the option of preparing an advanced statement, which has to be considered when delivering their care.
Standards
Standards are taken directly from the Mental Health (Care and Treatment) (Scotland) Act 2003. Of particular relevance were the following:
ᐅ In at least two-thirds of admissions involving the Mental Health Act, a shortterm detention certificate should be used.
ᐅ All patients should have any subsequent detentions made within the specified period.
ᐅ All section papers should be present in the case notes.
ᐅ All patients should have copies of the relevant detention and letters informing them about their detention and rights.
ᐅ All named persons should receive copies.
ᐅ All documentation of suspension or revocation should be recorded in the
case notes.
Method
Data collection
Initially, the population under study was defined. In the original audit, the population included all patients detained in one general adult ward and corresponding community mental health teams (CMHTs) over 1 year. A list of detained patients was kept by the local medical records department. The medical notes were inspected to find the following:
ᐅ the type of detention certificate used at the time of admission
ᐅ the timing of subsequent detentions
ᐅ copies of relevant section papers
ᐅ copies of letters informing the patient of his or her rights
ᐅ evidence of the named person having been informed and evidence of appropriate copies having been sent to him or her
ᐅ documentation on the suspension or revocation of detention (if relevant).
VII - Treatment
- Edited by Clare Oakley, Floriana Coccia, Neil Masson, Iain McKinnon, Meinou Simmons
-
- Book:
- 101 Recipes for Audit in Psychiatry
- Published online:
- 02 January 2018
- Print publication:
- 01 March 2011, pp 175-176
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Summary
Alcohol withdrawal: management
Anticholinesterase inhibitors: monitoring of cardiac side-effects
Anticholinesterase inhibitors: prescribing
Antimuscarinic medications
Antipsychotics: combined and high dose
Antipsychotics: prescribing
Antipsychotics: use in dementia
Attention-deficit hyperactivity disorder: prescribing
Atypical antipsychotics: monitoring
Behavioural problems in adults with intellectual disabilities: medication management
Benzodiazepines in old age psychiatry
Covert administration of medication
Depot antipsychotics: side-effects
Diazepam as rescue medication in epilepsy
Electroconvulsive therapy: facilities
Electroconvulsive therapy: indications
Hypnotics
Lithium: monitoring
Medicines reconciliation
Mood stabilisers: monitoring
Nurses’ administration of medication
Prescribing: British National Formulary limits
Prescribing: Mental Capacity Act
Prescribing: p.r.n. medication
Prescription charts
Psychological therapies
Psychotherapy re-referrals
Psychotropic prescriptions in dual diagnosis
Rapid tranquillisation