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Transition as a topic in psychiatry training throughout Europe: trainees' perspectives.The majority of adolescents with mental health problems do not experience continuity of care when they reach the transition boundary of their child and adolescent mental health service. One of the obstacles for a smooth transition to adult mental health services concerns the lack of training for health-care professionals involved in the transition process. This study aims to seek psychiatric trainees' opinions regarding training on transition and the knowledge and skills required for managing transition. A survey was distributed to trainees residing in European countries. Trainees from 36 countries completed the questionnaire, of which 63% reported that they came into contact with youth and young adults (16-26 years) during their clinical practice. Twenty-seven percent of trainees stated they have good to very good knowledge about the transition process. Theoretical training about transition was reported in only 17% of the countries, and practical training in 28% of the countries. Ninety-four percent of trainees indicated that further training about transition is necessary. The content of subsequent transition-related training can be guided by the findings of the MILESTONE project.
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Practical Guidance on the Use of Lurasidone for the Treatment of Adults with SchizophreniaIntroduction: Lurasidone is an atypical antipsychotic that was approved in Europe in 2014 for the treatment of schizophrenia in adults aged ≥ 18 years. Clinical experience with lurasidone in Europe is currently limited, and there is therefore a need to provide practical guidance on using lurasidone for the treatment of adults with schizophrenia. Methods: A panel of European psychiatrists with extensive experience of prescribing lurasidone was convened to provide recommendations on using lurasidone to treat adults with schizophrenia. Results: Extensive evidence from clinical trials and the panel's clinical experience suggest that lurasidone is as effective as other atypical agents, with the possible exception of clozapine. Lurasidone is associated with a lower propensity for metabolic side effects (in particular, weight gain) and hyperprolactinaemia than most other atypical antipsychotics and has a relatively benign neurocognitive side effect profile. Patients switching to lurasidone from another antipsychotic may experience weight reduction and/or improvements in the ability to focus/concentrate. Most side effects with lurasidone (such as somnolence) are transitory, easily managed and/or ameliorated by dose adjustment. Akathisia and extrapyramidal symptoms may occur in a minority of patients, but these can be managed effectively with dose adjustment, adjunctive therapy and/or psychosocial intervention. Conclusions: Given the crucial importance of addressing the physical as well as mental healthcare needs of patients, lurasidone is a rational therapeutic choice for adults with schizophrenia, both in the acute setting and over the long term.
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Training of adult psychiatrists and child and adolescent psychiatrists in europe: a systematic review of training characteristics and transition from child/adolescent to adult mental health services.Background: Profound clinical, conceptual and ideological differences between child and adult mental health service models contribute to transition-related discontinuity of care. Many of these may be related to psychiatry training. Methods: A systematic review on General Adult Psychiatry (GAP) and Child and Adult Psychiatry (CAP) training in Europe, with a particular focus on transition as a theme in GAP and CAP training. Results: Thirty-four full-papers, six abstracts and seven additional full text documents were identified. Important variations between countries were found across several domains including assessment of trainees, clinical and educational supervision, psychotherapy training and continuing medical education. Three models of training were identified: i) a generalist common training programme; ii) totally separate training programmes; iii) mixed types. Only two national training programs (UK and Ireland) were identified to have addressed transition as a topic, both involving CAP exclusively. Conclusion: Three models of training in GAP and CAP across Europe are identified, suggesting that the harmonization is not yet realised and a possible barrier to improving transitional care. Training in transition has only recently been considered. It is timely, topical and important to develop evidence-based training approaches on transitional care across Europe into both CAP and GAP training.
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Clozapine induced neutropenia, onset after 6 years of treatment: a case reportNo abstract available.
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Can orexin receptor antagonist offer a future option in pharmacological management of insomnia in older adults?Insomnia is a sleep condition in the general population including older adults. Pharmacological treatments may have limited efficacy and unacceptable side effects profile for the older population. Daridorexant, a dual orexin receptor antagonist has shown promise in improving some sleep parameters. We discuss its clinical application and efficacy in this article. Methods: We searched databases including PubMed and Science Direct and checked clinical trials that determined its efficacy using parameters such as wake time after sleep onset (WASO), latency to persistent sleep (LPS) and total sleep time (TST), at different doses. Results: Small doses such as 5 and 10 mg did not show clinical efficacy, while 25mg and 50mg were superior in improving the efficacy outcomes with mild adverse reactions. Daridorexant reduced wake time after sleep onset (WASO), latency to persistent sleep (LPS), whilst increasing total sleep time (sTST). It was associated with a mild risk of headache and fatigue but did not cause other adverse associated with traditional therapies, such as withdrawal or rebound insomnia. This review supports clinicians such as psychiatrists, physicians and pharmacists in choosing the best treatment options taking into consideration patients’ conditions and preferences. The authors do not recommend prescribing before more longitudinal and larger studies.
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A visual antiretroviral regimen based tool to support cost-effective prescribing in treatment-naive individuals : defining the baselinePoster abstract P146 from the 23rd Annual Conference of the British HIV Association (BHIVA), Liverpool, UK, 4–7 April 2017.
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The importance of clinical observation: A case of subtle tardive dyskinesia with paliperidone palmitateNo abstract is available.
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What are the attitudes toward patients with substance use disorders (SUD) among medical students in the UK: a systematic reviewBackground Patients accessing treatment for substance use disorders (SUD) are often met with negative attitudes from healthcare professionals. Identifying how future doctors perceive these patients is central to tackling stigmatized attitudes, which deter patients from utilizing services. This systematic review explores UK medical students’ prevailing attitudes toward SUD patients. Methods This PROSPERO-registered review is guided by the PRISMA checklist. Database and citation searches identified 1688 papers for screening, of which seven met the inclusion criteria and were quality assessed, extracted and synthesized. Results We found some students held negative attitudes, assigning SUD patients blame for their conditions and considering them more dangerous than other patients. Students also lacked confidence in addressing these patients’ needs. They felt SUD teaching was low priority on their curricula, despite identifying doctors as responsible for overall SUD management. Progression through training appeared to correlate with improved attitudes within the included studies’ limitations, and diverse methods such as expert patients further enhanced student perceptions and knowledge. Conclusion Stigmatizing views of SUD patients remain present among UK medical students. Time and resources allocated to SUD education should better reflect the public health challenge it represents. Further work is needed to explore the effectiveness of stigma-reducing interventions.
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Neuroleptic Malignant Syndrome: The Value of Diagnostic CriteriaNeuroleptic malignant syndrome (NMS) is a rare but potentially serious reaction to antipsychotic medications. The incidence of NMS is around 0.9%,1 with an estimated mortality of 5.6%–12%.2,3 Early recognition is key and a low index of suspicion is required as the presentation shares symptoms with other disorders,1,4,5 which is further compounded by a lack of definitive diagnostic criteria.
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Phelan-McDermid syndrome, bipolar disorder and treatment with lithiumBackground Phelan-McDermid syndrome is caused by a deletion at chromosome 22q13.3, and results in a phenotype characterised by intellectual disability, features of autism, physical and mental health conditions. It is becoming increasingly recognised that bipolar disorder represents part of this phenotype. Materials and methods This case study describes 2 patients with Phelan-McDermid syndrome presenting with bipolar mania at inpatient unit for adults with intellectual disability. Both patients presented with severe disturbance of their behaviour, at times exhibiting aggression, disinhibition and hypersexuality. Results Despite treatment with a number of atypical antipsychotics and anticonvulsant mood stabilising agents, both patients showed the greatest improvement when started on lithium, and were successfully treated with this medication. Conclusions This adds further support to the growing evidence of bipolar disorder contributing to the phenotype of Phelan-McDermid syndrome, and clinicians should have a low threshold for considering the use of lithium in these patients.
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QI 1279 Reducing Waits for Review in Children’s Speech and Language Therapy MainstreamAim: To reduce length of wait for follow up review assessment within school age caseload (mainstream schools, non-EHCP service) by 30%. This project was carried out to address the waiting time for follow up (review) assessment in the Mainstream schools (non-EHCP) caseload in Children’s SLT. The project started in June 2023 when the wait for a follow up assessment was beginning to increase, the longest wait being 28 weeks. 1.5 days per week clinical time was taken up by band 6 SLTs managing 6 separate Mainstream caseloads (11hrs per week). A number of change ideas were tested and implemented to streamline the caseload and caseload management system, introduce an opt in system for parent/carers, consider the use of diary sheets for admin staff to book directly into, and considering how both SLTs and SLTAs worked within the sessions. These changes overall helped maintain and then reduce the wait time for a follow up assessment. It is important to note that other changes within the service (external to this project) have also had a positive influence on the wait times and overall size of the caseload, these included the introduction of a language package of care (throughput model) and an unusually low opt in rate over summer 2024. Monitoring of the data has allowed for the impact of these changes to be observed. Having one overall shared database for the entire Children’s SLT caseload helped with data collection and oversight of the caseload. Tools Used: Process Map - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-conventional-process-mapping.pdf; Understanding the problem; Stakeholder Engagement - www.aqua.nhs.uk/wp-content/uploads/2023/07/qsir-stakeholder-analysis.pdf; PDSA - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf; Measurement - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-measurement-for-improvement-overview.pdf. Project Impact: A more consistent and standardised approach in dealing with queries from schools and parents. Reduction in unnecessary appointments for children who don’t require one. Aligns the process with the rest of the service. Caseload size has reduced and then remained fairly static (even over the month of September when there is usually a large influx of preschool transfers).
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QI 1189 Delivering Family Intervention (FI) Across Early Intervention in Psychosis ServiceAim: To increase the number of families being offered family intervention (FI) by 30% and to increase the number of families receiving FI by 30% across the Early Intervention Service. Family Intervention (FI) is an intervention that NICE state should be offered to all families on the Early Intervention (EI) caseload. CWPT’s offer of FI is BFT. The National Clinical Audit of Psychosis (NCAP) measures how well each service delivers this, historically we have scored poorly in comparison to other Trusts. We have previously trained staff in BFT, expected them to deliver this as part of their role, offered ad hoc supervision, put BFT leads into teams, and told staff they needed to provide BFT. These approaches did not improve our score. Using the learning from the North Warwickshire QI project which improved the uptake of BFT, a different approach has been tried. There is now a dedicated FI team and Clinical Lead. They have used QI methodology to understand where the barriers are for delivering BFT, used this information to create different approaches to deliver, worked with staff to challenge professional bias and change to the culture around FI and carers support. Numbers of families being offered BFT has increased across all the service but the number of families receiving BFT has not significantly increased. When it is being declined it is the families making an informed choice rather than staff making the decision on their behalf. The feedback is that BFT is being offered too early (within 12 weeks) therefore this is now being offered again later.
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QI 1214 Improving Staff Confidence and Competence in Delivering End of Life Care on Acute Dementia Wards (Stanley and Pembleton)Aim: Improve staff's confidence and abilities to care for patients on end-of-life (EOL) pathways. This project ran across Stanley and Pembleton the acute dementia wards. During reflective meetings, staff identified a need around improving confidence in working with people at end of life (EOL). Staff voiced wanting to feel they had done the right thing, despite not being a specialist EOL ward. Staff’s views regarding what they needed to help improve their confidence in working with people at end of life were used to develop training, information and support around the following topics: -Increasing Knowledge and Skills around EOL -MDT Working and a ‘joined up approach’. Providing an appropriate environment and tools to guide interventions (i.e. SOP, pain identification). Tools Used: Staff discussions and feedback. Questionnaires with quantitative and qualitative responses. QI Driver Diagram - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf. Staff report feeling more confident in their abilities to care for patients at end of life (EOL). Service level agreement in place: Mary Ann Evans hospice to offer rapid response to support ward with EOL concerns. Staff report feeling better able to access support from services during/following identifying a patient as approaching EOL. Importance of the need for a SOP identified and development has begun.
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QI 1209 Accurately Reporting on Capacity, Demand and Waiting Times for the Dysphagia Service within Adult Speech & LanguageAim: To accurately report on the Waiting List in order to see a reduction in Actual Waiting Time data from 54 days in December 2022 to a target of 30 days by 30 June 2023 All referrals are received and triaged at ISPA. The service were cold calling patients from the waiting list and triaging the patient and then, if appropriate, booking a face to face appointment. The report was not counting the triage cold call as their first appointment, which showed the waiting times as 50 days for patients to be seen. The service planned to identify the triage calls as New Patient Telephone Slots where the first contact is made with the patient. Admin are able to book these appointments in advance, removing the cold calling and it was hoped that the service would be able to accurately record the data and by doing so would show a reduction in waiting time data. Tools Used: PDSA Cycles - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf; SPC Charts - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-statistical-process-control.pdf; Process Mapping - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-conventional-process-mapping.pdf. Project Impact: • Waiting time data for the First Patient Contact have decreased from 54 to 30 days (a 24 day reduction) since December 2022. • Decrease in "unable to contact" telephone consultations from 40% in January 2023 to 19% in May 2023. • A more streamlined process for first appointments has been implemented. This has been simplified from 21 steps to 12 steps.
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QI 1221 Reducing Urgent Community Response (UCR) Service RejectionsAim: To achieve a 25% reduction in senior clinical reviews from an average of 52 per month in Q1 2023 to a target of 39 in Q3 2023. A clinical audit was undertaken in December 2022 by the Advanced Consultant Clinical Practitioner in the UCR service; SQ1132 Urgent and Emergency Care Clinical Audit Toolkit. The audit highlighted significant discrepancies in the use of the UCR follow-up clinical review process, which allows UCR clinicians to keep patients on the acute medical caseload for up to 72 hours. Consequently, an improvement project was proposed to reduce the burden of clinical reviews with the UCR senior clinicians’ cohort. Tools Used: PDSA Cycles - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf; Driver Diagrams - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf Project Impact: The average number of senior clinical reviews decreased from 52 in quarter 1 to 26 in quarter 3. A reduction of 50%. 780 minutes of senior clinician patient facing time were freed up each month - 156 hours per year. Cost savings of £290.68 per month and £3488.16 per year.
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QI 104 Implementation of MOSAIC (Multi-disciplinary One Stop Assessment and Intervention Clinic) within a Home Treatment TeamAim: To reduce the: 1.Proportion of people referred to the Home Treatment Team (HTT) following their initial assessment with the Mental Health Access Hub (MHAH) by 10% 2.Length of stay (LoS) for those patients referred to the Home Treatment Team (90% referrals <42 day length of stay) 3.Waiting time for an initial medical review following referral to the Home Treatment Team by 50%. The initial assessment of patients referred to the HTT should include multi-disciplinary team (MDT) assessment of needs, but involving different professionals often occurs over days to weeks. MOSAIC was introduced as a one stop MDT clinic set up to review newly referred patients who required an urgent assessment. Prior to MOSAIC patients were seen by the MHAH where there was no immediate access to an MDT. The assessment was undertaken by one clinician who determined if the patient required the HTT or another community team. This could lead to delays in the assessment process. Tools Used: Clinical Audit; SPC Charts; Patient/Survey Feedback. Aim Target Achieved Reduce number patients referred to HTT 10% 34% Reduction in LoS (to <42 days) 90% 86% Reduce time to initial medical review 50% 95% Project Impact: Aim - Reduce number of patients referred to HTT - Target 10% - Achieved 34%; Aim - Reduction in LoS (to <42 days) - Target 90% - Achieved 86%; Aim - Reduce time to initial medical review - Target 50% - Achieved 95%.
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QI 1259 Improving Awareness Documentation and Care of Bowel Movements in Learning Disability and Autism (Inpatients, Respite and Community)Aim: To identify constipation at an early stage or any changes to bowel habits that could indicate a physical health condition. To empower patients and staff alike to have healthy and open conversations regarding their bowel movement and urine output health and when to act upon it. Historically, conversation and awareness of healthy bowel movements (BM) has been a taboo topic amongst both staff and patients in Learning Disabilities. Patients in particular can find the topic uncomfortable to talk about which can lead to gaps in healthcare; making it harder for staff and patients to understand their physical healthcare needs. Constipation is also a contributor to death with those of a learning disability (LeDeR reports), with a high use of laxatives for LD&A patients. Initially, a project was proposed to look at physical healthcare as a whole, however it was quickly understood that the topic was extremely broad and a few different projects were initiated, including this one. Tools Used: Stakeholder Analysis - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-stakeholder-analysis.pdf; Process Mapping - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-mapping-the-process.pdf Project Impact: • A Physical Health Group and Patient Forum has been started in LD&A to foster open conversations. • Patients have been taught to self-report with a user-friendly chart. • Vinyl stickers are now in all toilets to help patients identify good vs bad bowel movements. • Standardised chart to help staff monitor bowel movements in a standard way. • Staff and patients feel more empowered to talk about bowel movements. Staff Feedback; “We have a patient on the ward who is very independent and doesn’t talk about bowel movements. We used the self-reporting chart and they thought it was great! They wrote down their BM and were happy to show us the chart. They said they don’t like to talk about it, which is why they’d never told us before.”
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QI 110 To Improve Access for Families to Family Intervention in the North Warwickshire Early Intervention Team (EIT)Aim: To increase the number of families offered family interventions (FI) in North Warwickshire EIT by 10% by September 2022. FI should be offered to all families who receive an EIT service. Data from the 2020/21 National Clinical Audit of Psychosis (NCAP) showed we were underperforming (14%) and were identified as an outlier for this audit standard. Quality improvement methodology was used to scope the available data to understand the current process by mapping referrals and the last 10 patients. A driver diagram was developed to identify change ideas which could be implemented within the North Warwickshire EIT service. Using Plan, Do, Study, Act (PDSA) cycles we were able to see whether the change had been effective. The statistical process control (SPC) chart (left) illustrates the number of people being offered FI and whether the change has been sustainable. Driver Diagram - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf; PDSA Cycles - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf; SPC Charts - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-statistical-process-control.pdf. Project Impact: The project aim has been exceeded-Number of families being offered FI has increased by a mean of 262% . Other identified benefits: •Clearer pathways in place for clinicians to identify families. •Stepped care approach embedded into EIT practice. •Robust supervision in place. •New Family Intervention Team being appointed.
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QI 111 Improving the Equipment Ordering Process in Children's Therapy ServicesAim: To understand the length of time from assessment to handover of equipment for orders placed by the Children’s Community Physiotherapy and Occupational Therapy Service between 06/02/2019 and 13/03/2020. The Children's Community and Physiotherapy and OT Service perceived that children were experiencing significant waits for their equipment. They used a SPC chart to look at how long children were waiting from their assessment to the handover of their equipment and to identify where improvements could be made. Changes to local ordering processes were made and PDSA cycles were used to monitor and develop the change ideas. Tools Used: Driver Diagram - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf; PDSA Cycles - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf; SPC Charts - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-statistical-process-control.pdf. Project Impact: The team gained an understanding of their equipment ordering processes and introduced a streamlined process which reduced the time children spent waiting for equipment from an average of 207 days prior to November 2019 to 60 days from November 2019 onwards. A 71% reduction in waiting times.
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QI 117 Improving Physical Health Care Provided by Coventry 11-17 (Psychosis Pathway) TeamAim: By 9 July 2022 for patients open to medical staff only in the Coventry Recovery Team (N=96): 1. 30% will have been offered an appointment to complete the lifestyle screening tool. 2. 20% will have had a physical health and lifestyle screening tool completed. The trust requires that all patients open to the service with psychotic disorders have an annual physical health screening assessment. Prior to this project there was a nurse and health care led process in place which was unable to meet these requirements. Baseline data showed that of those patients only open to the medical team 13.5% had been offered a physical health screen and only 12.5% had a completed assessment over the past 3 years. Tools Used: PDSA - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-pdsa-cycles-model-for-improvement.pdf; Driver Diagram - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-driver-diagrams.pdf; SPC - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-statistical-process-control.pdf; Process Mapping - https://aqua.nhs.uk/wp-content/uploads/2023/07/qsir-mapping-the-process.pdf; Project Impact: Completed physical health assessments increased from baseline by 20% up to 32.5% at week 16. Cycle 2: aimed at non-attendance. Providing generic information improved this by 3.6% but a personalised letter to non-attenders at a 1st appointment (n=3) resulted in them all attending a 2nd appointment.
