Case Note Audit Research Articles

Borderline personality disorder and parenting capacity: Understanding child protection population characteristics

Objective This paper describes an audit of borderline symptoms, risk factors for maltreatment and types of abuse among parents who completed a parenting capacity assessment at a South Australian health-based child protection service. Method A retrospective case note audit within a 28-month period was conducted and included parents ( n = 107) who had completed a Mclean’s screening instrument for borderline personality disorder and/or had a psychiatric review with a formal diagnosis. Parents who had a borderline personality disorder diagnosis or endorsed five or more symptoms were categorised into the ‘high’ borderline symptom group. Rates of parental risk factors for maltreatment and type of abuse were compared between parents with low or high borderline symptoms. Results Forty percent of parents endorsed at least five borderline symptoms on the screening tool. On average, parents high in borderline symptoms had a greater number of parental risk factors. Conclusions These findings highlight the importance of screening for personality pathology among parents presenting to child protection services. Foundational training for staff and making evidence-based interventions available should be considered in such settings.

Suppression head impulse test in children-experiences in a tertiary paediatric vestibular centre.

The suppression head impulse paradigm (SHIMP) involves suppression of the vestibulo-ocular reflex (VOR) and anticompensatory saccades generated thereof. SHIMP is gaining importance to understand vestibular compensation with its different parameters (VOR gain/peak saccadic velocity PSV/latency of saccades). SHIMP studies are emerging in adults, but pediatric studies have hardly been performed. This study is a retrospective case note audit over a period of 2 months in a tertiary pediatric vestibular center in the United Kingdom to investigate whether SHIMP is safe/robust to be used in children conforming to existing standards/norms in normal children and whether it yields any meaningful inferences in pediatric vestibular hypofunction. This is the largest pediatric SHIMP study to date. A total of 44 referred children (6-18 years, female children>male children) with a range of complaints from dizziness, imbalance, motor incoordination, postural instability, and hearing loss were included, and their SHIMP parameters were measured. All children underwent comprehensive functional/objective audiovestibular assessments. Two groups were defined-Group A with normal vestibular function and Group B with abnormal vestibular function. The normal population showed an average SHIMP VOR gain of 0.98+/-0.08 and latency of overt saccades at 215.68+/-46.16 milliseconds agreeing with published evidence. The PSV of overt saccades was 315.39+/-56.30/s, and there was a gain asymmetry of 7.42+/-4.68 between the sides. Statistically significant differences with moderate/large effect sizes were observed between the groups in terms of VOR gain and PSV but not in saccade latencies. Covert saccades were rare in SHIMP, while overt saccades were observed in 100% of children. VOR gain difference between the head impulse paradigm (HIMP) and the SHIMP was significant as well. We observed statistically significant differences in side asymmetry of VOR gain between the groups. Furthermore, we identified a group of children with cerebellar lesions where overt saccades in SHIMP were rather low in number. Further research is recommended to investigate pediatric PSV, asymmetry, and inability to generate overt saccades that may suggest useful means to assess compensation and central function. We conclude that SHIMP yields valuable information and is a safe, easy to perform, and a reliable test that should be used in children to supplement HIMP.

Interpretation services used for non-English language speaking patients with head and neck cancer: Findings from a tertiary London cancer centre

BackgroundTreatment for head and neck cancer (HNC) can lead to profound changes in swallowing function and nutrition. UK HNC standards recommend informational counselling is provided pre-treatment by the dietitian and speech and language therapist (SLT). Non-english speaking patients treated in English speaking countries have poorer treatment outcomes. UK guidance recommends all patients should have access to interpretation services where required. This audit aimed to investigate the language needs and utilisation of interpretation services for patients with HNC attending pre-treatment clinics. MethodsA retrospective casenote audit over two-years (2021–2023) of all patients attending pre-treatment clinics in a centralised London cancer centre. Information was collected from electronic hospital records on demographics, disease/treatment characteristics, first language; categorised as English primary language (EPL), non-English primary language (NEPL) and interpretation requirements; formal (professional interpreters) or informal (patients friends/relatives). Data was processed and collated using Microsoft Excel (Version 2308). Descriptive statistics were conducted using Excel Analysis ToolPak. Results408 patients were included. Most patients were male (67%), aged 61 ± 13 years. 18% (n = 74) had NEPL; 58 required interpretation services. Formal interpretation service was provided in 43% (n = 25), informal services in 33% (n = 19), and no service in 24% (n = 14). Non-adherence to formal services included lack of/inaccurate documentation of language needs, patient preference and lack of available interpreters. ConclusionThis audit indicated that barriers exist in utilising formal interpretation services. Future research should investigate how this can be optimised to ensure necessary language support is provided consistent with guidelines that promote equality, diversity, and inclusion.

Improving the quality of antenatal screening and early intervention for alcohol and other drug use: protocol for a multi-stage approach to systems reform

BackgroundAlcohol, tobacco and illicit drug use during pregnancy can cause significant harm to women and their developing fetuses. Despite recommendations for abstinence during pregnancy, some women continue to use, making screening for substance use during antenatal clinic attendances an important strategy for reducing risk. This study aims to improve the rates of screening and intervention for substance use among pregnant women, including appropriate referral for those who may be substance-dependent. The protocol outlined here focuses on a multi-stage implementation study.MethodsThis study will occur in four phases. Phase 1 will identify a baseline rate of screening and subsequent care at the antenatal clinics of two, South Australian hospital-based maternity services, through a retrospective case note audit. Rates of self-reported substance use identified in the case notes will also be compared against representative data from Adelaide Primary Health Network to establish rates of over or underreporting. Phase 2 will involve an online Training Needs Analysis of midwifery staff working at those services, to assess their knowledge, attitudes, beliefs, and commitment to the care of women who use substances during pregnancy. Phase 3 will involve a training package for all midwifery staff at those services, focused on routine screening for substance use, and how to provide appropriate care. Outcome measures from phase 2 will be reassessed during phase 3 and any changes since training will be evaluated. Phase 4 will then repeat phase 1 to compare the changes in rates of both screening and any associated intervention before and after training.DiscussionFrom a public health perspective, this project has the potential to make a significant impact on reducing risk of harm from substance use disorders among pregnant women, and contribute to better health outcomes for their children.Trial registration: This trial has been pre-registered under the Open Science Framework. Registration: https://doi.org/10.17605/OSF.IO/73FDZ.

Embedding the rehabilitation treatment specification system (RTSS) into clinical practice: an evaluation of a pilot teaching programme

BackgroundDeficiency in the provision and quality of treatment specification by rehabilitation clinicians impairs the ability to differentiate effective from ineffective elements of treatment. The standardised language of the rehabilitation treatment specification system (RTSS) has been proposed as a countermeasure. To date, there is no evidence of its use in clinical practice and what effect it may have. This study aimed to assess the ability of a pilot teaching programme to embed the RTSS into the clinical practice of an inpatient oncology physiotherapy team. The objectives were to evaluate the teaching programme’s effect on; participants’ familiarity and perceived benefit of the RTSS, its uptake, participants’ clinical reasoning, and their feelings and attitudes towards adopting the RTSS. This study provides an evaluation of the pilot teaching programme which will subsequently inform a larger iteration in an ongoing Health Education England (HEE) project aiming to disseminate and embed the RTSS into physiotherapy practice to improve physiotherapists’ treatment specification.MethodsA 6-week, multi-modal RTSS pilot teaching programme based upon socio-constructivist theory was delivered to 10 inpatient oncology physiotherapists at a large urban UK trust in 2021. Self-reported measures and clinical case note audits were assessed before and after the RTSS teaching programme to evaluate its effect on RTSS familiarity and perceived benefit, uptake, and clinical reasoning. A post-teaching focus group was undertaken. It was qualitatively analysed using an inductive, independent thematic approach to evaluate clinicians’ reflection and adoption.ResultsTen participants (8F, 29.4(±3.5) years) with variable clinical experience completed the RTSS teaching programme (six 1-hour lecture/case-based-learning sessions weekly) with 85% mean attendance. Nine yielded complete data for analyses, and 7 participated in the focus group. There was significant improvements in self-reported familiarity and confidence using the RTSS. Furthermore, there was a significant effect of the teaching on self-reported clinical reasoning overall and specifically in knowledge and theory application. But this was not reflected in clinicians’ uptake of RTSS language, nor in the quality of clinical reasoning emergent in their case notes. Qualitative analyses revealed that while clinicians’ conceptual understanding and the relative advantage of using the RTSS in practice was pervasive, they articulated that translating its perceived academic disposition into their clinical practice a challenge.ConclusionsThe RTSS teaching programme was shown to be effective in improving self-reported measures of clinical reasoning, despite clinical uptake of the RTSS remaining low. Future iterations should be tested across physiotherapy specialisms and in a larger sample with consideration of pedagogical and cultural measures to support the clinical diffusion of the RTSS.

The Efficacy of Same Day Plerixafor Dosing on CD34+ Haematopoietic Stem Cell Collection: A Single Centre Australian Experience

Introduction: Haematopoietic stem cell (HSC) transplantation is an important therapeutic option for many haematological conditions, as well as, some solid organ cancers. Plerixafor (a selective inhibitor of CXCR4) can be used in patients for primary stem cell mobilisation; those who have previously failed stem cell mobilisation ("rescue" or "Planned"); or in patients with a poor peripheral CD34+ response to GCSF and/or chemotherapy mobilisation ("on demand", "just in time" or "pre-emptive"). In Australia, Plerixafor is funded for patients with CD34+ count <10 cells/µl on day of collection or if first apheresis has yielded CD34+ <1 x 106cells/kg. In these patients, Plerixafor is administered the evening prior to the planned morning collection but this presents logistical issues as it has to be given after hours. Therefore, it was proposed to administer Plerixafor followed by same day HSC collection to improve the logistics of these "just in time" collections. Methods: A retrospective case note audit identified 96 patients who received Plerixafor for HSC collection between 03/2017 and 06/2021. Patients were categorised into PM (late afternoon/evening dosing) and AM (morning dosing). Transplant HSC dose target was >2 x 106/kg. Results: Of the 96 patients, 17 received 2 doses of plerixafor with 4 of these patients receiving both an AM and PM dose. These 4 patients were excluded from the final analysis. Of the 92 patients remaining, 57% (n=52) of patients received PM and 43% (n=40) AM dosing. Median age was 64 years (range 23 to 78). 58% were male (n=53) and 42% female (n=39). Underlying malignancy included Myeloma (n=51), Lymphoma (n=37) and Solid malignancy (n=4). Median pre plerixafor blood CD34+ count was 8.7x10^6/kg (range 0.3-35.5) in the PM group and 9.2 (range 1.6-38.2) in AM group prior to collection. Median number of HSCs collected post-plerixafor administration was 4.97 x106/kg (range 0.91-34.97) for PM group vs 4.16 x106/kg (range 0.71-9.52) AM group. Total median HSC number collected for patients in the PM group was 6.6x106cells/kg (range 3.14-8.18) vs 5.16x106/kg (range = 2.46-6.45) in the AM group. The AM group had an increased median HSC collected post plerixafor of 83% vs PM median of 75%. A transplantable HSC dose was collected in 97% of those in the AM group and 96% in the PM group. Median number of apheresis procedures with PM dosing was 2 (range 1-5) vs 2.4 with AM dosing (range 1-4). Conclusion: While post plerixafor HSC collection doses were higher with PM dosing this is countered by the total median HSC collection being higher in the AM group. These findings show that same day plerixafor dosing is a feasible option with similar numbers of patients achieving their target HSC collection.

Telehealth delivery of paediatric rehabilitation for children with neurodisability: A mixed methods realist evaluation of contexts, mechanisms and outcomes.

Teledelivery of rehabilitation services has been proposed as a cost-effective option for supporting children with neurodisability and their families. However, little is understood of the conditions that support uptake of telehealth in paediatric rehabilitation, what is delivered during telehealth or perceptions of its outcomes. The aim of this study was to identify the context, process and outcomes of telehealth for children with neurodisability and their families. A secondary objective was to identify if variations in these aspects of telehealth occurred for Māori, the indigenous people of New Zealand. A mixed-methods, three phase, realist evaluation identified context-mechanism-outcome configurations (CMOcs) of telehealth. In Phase 1, the Determinants of Implementation Behaviour Questionnaire indicated factors affecting practitioner uptake of telehealth (Context). In Phase 2, a casenote audit identified 'practitioner input' during telehealth (Mechanism). Phase 3 interviews with practitioners and parents explored 'parent response' to telehealth and practitioner and parent perceptions of its value (Mechanism and Outcomes). Subgroup analyses for Māori were planned. From Phase 1, practitioners (29/37, 78%) intended to use telehealth; however, few did so regularly (7/37, 22%). Positive experiences of telehealth were described by all practitioners (n = 5) and families (n = 7) in Phase 3. CMOcs explained that practitioners' offering of telehealth occurred when practitioners were confident, valued access to therapy over the familiarity of in-person delivery, and when practitioners used coaching-style communication. Parents were receptive to telehealth when they trusted practitioners, felt listened to and were offered telehealth as a choice. When telehealth occurred, access to therapy was timely and more consistent than in-person delivery. Child outcomes appeared to be positive. Confidence in offering telehealth to Māori was low. Initiatives to improve uptake of telehealth in paediatric rehabilitation should focus on creating conditions for practitioner implementation. Training in telehealth should include engagement with Māori. Adequate workspace and workplace culture change are required if telehealth is to be offered beyond the current 'early adopters'.

2019 British Association of Sexual Health and HIV National Clinical Audit of timelines to be seen, test results and treatment for Chlamydia trachomatis

BASHH/MEDFASH (Medical Foundation for HIV and Sexual Health) Standards for the Management of Sexual Health Services 20141 set out a number of recommendations regarding time between contacting a service to being seen, time to receiving results, and time to treatment. This audit investigated if UK practice is compliant with BASHH standards of care in terms of: Time to patient being seen after contacting sexual health services, time to chlamydia (CT) NAAT (nucleic acid amplification test) results and time from positive CT result to treatment. All UK level 2 (non-specialist) and level 3 (specialist) sexual health clinics were invited to take part. Data were collected via a survey of sexual health clinics and a retrospective case-note review of the last 40 people aged 16 or over per service seen with chlamydia but not syphilis or gonorrhoea. Cases were identified using the SHHAPT (Sexual Health and HIV Activity Types) National STI Surveillance code for chlamydia (C4). There were responses from 221 sites. 67% of sites reported offering both appointment and walk-in access, 26.2% appointment-only, 6.8% walk-in only. The mean turn-away rate of individuals seeking walk-in access on the last open day was 6.1%. There were variations in local service specification turnaround times for chlamydia nucleic acid amplification test results; 32% of sites reported no specified turnaround time. Case note audit of individuals seen with chlamydia showed 74.1% of individuals were tested for chlamydia at a level 3 clinic, 11.8% at a level 2 sexual health clinic, 7.3% used a self-sampling kit requested online and 3.9% tested at a different setting. 92.1% of individuals who initially tested at a sexual health service had an attempted notification within 10 working days of a positive chlamydia test. 95% of individuals were treated within a sexual health service. Overall, 94.0% of individuals were treated within 15 working days of the test result. When missing data were excluded, patient initiated GUM/level 3 attenders seen within 2 working days met the audit standard as did patient access to results within 10-working days for those whose initial CT NAAT sample was taken at a GUM/level 3 clinic and treatment within 3 weeks for GUM/level 3 attenders. Patients offered to be seen/assessed within 2 working days and lab report within 5 working days did not meet the audit standard. Recommendations include ensuring that laboratory turn-around times are included in contracts or service level agreements for clinical services, and local monitoring of these. Dates when individuals first seek to access sexual health services should also be recorded and used to monitor performance in comparison with access standards.

Early mobilisation in critically ill children: Does routine patient screening reduce time to commencing mobilisation?

ObjectiveThe objective of this study was to investigate the impact of daily screening for medical readiness to participate in early mobilisation in the paediatric intensive care unit (PICU), on reducing time to mobilisation and to explore the safety-, feasibility-, and patient-level barriers to the practice. MethodsAn interventional study with a historical control group was conducted in a PICU in a tertiary teaching hospital in Australia. The Early Mobilisation Screening Checklist was applied at 24–48 h of PICU stay with the aim to reduce time to commencing mobilisation. All patients aged term to 18 years admitted to the PICU for >48 h were included in this study. Data on time to mobilisation and patient characteristics were collected by an unblinded case note audit of children admitted to the PICU over 5 months in 2018 for the baseline group and over a corresponding period in 2019 for the intervention group. Measurements and main resultsA total of 71 children were enrolled. Survival analysis was used to compare time to mobilisation between groups, and a cox regression model found that children in the intervention group were 1.26 times more likely to participate in mobility, but this was not statistically significant (P = 0.391, log rank test for equality of survival functions). Early mobilisation was safe, with no adverse events reported in 177 participant mobilisation days. Feasibility was demonstrated by 62% of participants mobilising within 72 h of admission. Mechanical ventilation during stay (P = 0.043) and days receiving sedation infusion (% of days) (P = 0.042) were associated with a decreased likelihood of participating in mobility. ConclusionsImplementation of routine screening alone does not significantly reduce time to commencing mobility in the PICU. Early mobilisation in the PICU is safe and feasible and resulted in no adverse events during mobilisation. Patient characteristics influencing participation in mobility warrant further exploration.

Validation of a post operative complication risk prediction algorithm in a non-head and neck squamous cell carcinoma cohort

Risk-adjusted algorithms in surgical audit attempt to adjust for patient case mix and complexity in order that published outcomes fairly reflect surgical performance and quality of care. Such risk-adjustment models have applied to head and neck squamous cell carcinoma (HNSCC). We test one algorithm, currently embedded in the oncology and reconstruction dataset within the Quality and Outcomes in Oral and Maxillofacial (QOMS) Audit, which is an artificial neural network, for its predictive accuracy on a surgical cohort receiving curative surgery for non-HNSCC pathology. A single centre retrospective case note audit of post operative complications between 2010 and 2020 was conducted on patients having curative surgery for non-HNSCC pathology. The observed complication rate was compared to the predicted probability of complications in order to test the performance of the complication risk-adjustment model. Of 1591 non-HNSCC patients, 58 met the inclusion criteria with a 30-day complication rate of 8/58 (13%). The artificial neural network predicted a complication rate of 20/58 (27%). Sensitivity (0.75), specificity (0.72) and overall accuracy (0.72) suggest acceptable discrimination. Hosmer-Lemershow Goodness of Fit test was good (p = 0.55) suggesting acceptable calibration though over-prediction of complication rate in the highest risk patents was observed. This external validation series suggests the algorithm can be applied to the non-HNSCC cohort, though some refinement of the algorithm is required to account for over-prediction of complications for higher-risk patients. With further analysis a robust means of risk adjusting for the non-HNSCC cohort should be possible.

Hospital in the Home Delivery of Supportive Care for Autologous Stem Cell Transplantation: A Novel Single Centre Patient Focused Approach

Hospital in the Home Delivery of Supportive Care for Autologous Stem Cell Transplantation: A Novel Single Centre Patient Focused Approach

SP2.2.11Improving the quality of the documented weekend surgical handover: Implementation of a handover sticker within an urban teaching hospital

Abstract Aim Effective, high-quality patient handovers between the surgical team are essential for safe transfer of responsibility for patient care whilst ensuring continued patient-safety and supporting good clinical governance. Weekend handovers provide a particular challenge, with error potential, when patients are cared for by multiple different healthcare professionals. This project aimed to improve the documentation of the weekend handover for the surgical inpatients of a busy UK teaching hospital. Method Quality Improvement project performed within a single General Surgical department between August and October 2020. An initial casenote audit on 3 consecutive Fridays compared available handover information against RCS guidance. A comprehensive surgical weekend handover sticker was designed and all members of the surgical team educated in its use. Following sticker introduction, handover quality was similarly re-audited. **=p&amp;lt;0.00001 using Chi-squared/Fisher exact. Results 138 inpatient records were evaluated in cycle 1 and 135 in cycle 2, with the proportion containing a weekend handover increased post-intervention (96 vs. 82%,p=0.0004). Handover quality improved following sticker introduction with more frequent documentation of: diagnosis (96 vs. 21%**); need for imaging review (94 vs. 29%**); intravenous fluid plan (84 vs. 21%**); blood test requirements (94 vs. 24%**); mode of nutrition (90 vs. 24%**); antibiotics (90 vs. 30%**); drug monitoring (90 vs. 1%**); discharge planning (94 vs. 44%**) and escalation plan (87 vs. 0%**). Conclusion Introduction of a sticker has significantly improved the quality of documented handover available to the responsible on-call team. Future work will assess sticker impact on quality of care and clinical outcomes.

Hospital in the Home Delivery of Conditioning Therapy for Allogeneic Haematopoietic Stem Cell Transplantation: A Novel Single Centre Patient Focused Approach

Introduction: High dose therapy with Allogeneic Haematopoietic Stem Cell Transplantation (AlloHSCT) has traditionally been performed as an inpatient procedure. However, with improvements in supportive care and patient selection it is possible to safely deliver conditioning chemotherapy in an outpatient setting (Subirà M et al., 2003). While deemed an “outpatient procedure” this method is currently delivered on large day units which requires the patient to attend daily, often only spending the night at home.To reduce these daily visits The Royal Melbourne Hospital (RMH) Bone Marrow Transplant department in collaboration with the Hospital in the Home (HIH) department developed an innovative program to safely deliver Fludarabine chemotherapy as part of conditioning for AlloHSCT in the patient's home. This process involved a daily patient review by a HIH Doctor as well as twice daily visits by a HIH nurse to administer chemotherapy and supportive care in the comfort of the patient's home. Here we report on the safety outcomes of HIH AlloHSCT vs inpatient (IP) care, specifically complications and outcomes.Methods: A retrospective case note audit identified 395 consecutive AlloHSCT patients who received Fludarabine based conditioning between 2011 and 2017 at the RMH. Of these 130 received Fludarabine as part of the HIH Program and 265 as a traditional IP.Results: Of those treated as HIH patients, median age was 51 years (range 18-69). 59% patients were male (n=77) and 41% Female (n=53). Underlying disease groups included Leukaemia (n=53; 40%), Lymphoma (n=35; 27%), Myelodysplatic/Myeloproliferative (n=28; 21%), Myeloma (n=11; 9%) and Non-malignant (n=3; 3%). 2% of patients had myeloablative conditioning (n=2) and 98% received Reduced Intensity Conditioning (n=128). 57% (n=73) received stem cells from a sibling (Sib), 41% (n=54) from Voluntary Unrelated Donors (VUD) and 2% (n=3) from Umbilical Cord Donors.Median total Length of Stay (LOS) for HIH patients was 27 days (Range 10-97) with a median of 5 days (range 2-8) at home as part of this. The LOS for those receiving fludarabine as an IP was not significantly different at 26 days (range 5-174; p=0.209). Total number of IP Bed days saved through the HIH program was 682. There was no significant difference in median time to neutrophil engraftment (HIH 20 vs IP 17 days; p =0.95) or platelet engraftment (HIH 23 vs IP 20 days; p=0.99). Having chemotherapy as a HIH patient had no effect on outcome (HR 1.01). There is no difference in Overall Survival (OS) between the two groups (HIH 17 vs IP 16 months - see Figure 1) while Median OS was not reached.Of the 130 patients who were treated in the HIH Program only 11 had an unplanned admission before Day 0 of their AlloHSCT. Reasons for readmission included suspected infection (n=8; only one culture positive), vasovagal (n=1) and anxiety (n=2). Of note, four of these admissions arose in the first three months of the program with the other seven readmissions occurring over the following six years, with a readmission rate of approximately 5% (7/126 patients).Conclusion: The HIH delivery of chemotherapy and supportive care as part of conditioning for AlloHSCT in the patient's home is both safe and effective. It resulted in a median of five bed days saved per patient (Total number of bed days saved = 682), allowing the department to increase bed capacity without the costs associated with building a new ward. Additionally, the risk of complications was low (approximately 5%) and those that did occur were safely managed.Figure 1 - Comparison of Survival Between HIH and IP AlloHSCT Patients [Display omitted] DisclosuresRoutledge:Celgene: Honoraria; Gilead: Honoraria; Bristol-Myers Squibb: Honoraria. Ritchie:Amgen Inc.: Honoraria.

Improving the safety of rapid tranquilisation in older people

AimsTo identify intramuscular rapid tranquilisation (IMRT) events in all &gt;65 years inpatients in Sussex Partnership NHS Foundation Trust (SPFT) and to establish whether accompanying documentation meets SPFT guidelines. This is a re-audit, initial data were collected in 2016. Multimodal intervention has been implemented since initial data collection. In psychiatric inpatients IMRT should be administered as a last resort to calm acutely disturbed patients after verbal de-escalation and an offer of oral medication has failed. IMRT can cause physical health complications and impact therapeutic relationships. Quality improvements made since initial data collection were: an IMRT treatment algorithm for &gt;65s, a teaching package for staff, IMRT prescription area on medicine cards and post IMRT physical monitoring forms – in line with updates to trust IMRT policy.MethodRetrospective case note audit cycle of 119 patients. Electronic and paper records were reviewed for inpatients &gt;65 years on 1/9/2019. Records were examined for instances of IMRT– the following features were noted: diagnosis; verbal de-escalation; oral medication offered prior to IMRT; IMRT prescription location; and post-IMRT monitoring. Descriptive statistics were performed. This audit was approved by the trust audit committee.ResultThere were 34 RT events in 17 patients, reduced from 83 RT events in 20 patients in 2016. De-escalation was attempted in 62% versus 34% in 2016, oral medication offered first in 71% versus 59% in 2016. Physical monitoring was fully completed in 50% of instances in 2019, an improvement from 23% in 2016.ConclusionEducation, a new treatment algorithm, medicine card changes, and IMRT physical monitoring forms have improved adherence to trust standards. There was a 49% reduction in IMRT events in 2019 versus 2016. De-escalation is being performed more frequently, and oral sedation offered in more cases. The physical monitoring of patients has improved.

Urine drug screening in women's forensic mental health services: is current practice meeting guidelines?

AimsTo investigate adherence to Trust guidelines for urine drug screening amongst female forensic psychiatric inpatients.BackgroundThe use of illicit substances is an important risk factor which needs to be considered in the management and treatment of forensic psychiatric patients. Research has demonstrated that a high proportion of women admitted within secure services in the UK have a history of substance use. Substance misuse amongst this population can lead to an increased risk of violence, re-offending and mental health relapse; which can pose a significant threat to the safety of other patients, staff and the public. It is therefore important that regular drug screening is carried out to minimise such risks. Ardenleigh is a blended female secure unit in Birmingham. The service has established specific substance use guidelines, outlining the need for each patient to have a personalised drug screen care plan in place. Here we present the findings of an audit completed in 2019.MethodA six month retrospective electronic case note audit for female inpatients admitted to Ardenleigh as of 1st September 2019 (n = 27). We compared drug screen care plans and frequency of urine drug screens over 6 months with the recommendations of the current service-specific Trust guidelines. Care plans should include: information regarding random drug screening; frequency of random drug screening; triggers for increased risk of substance misuse; and consequences for a positive test result to be contained within inpatient care plans.ResultPatient aged between 20 and 56 years old (median age 31). Fewer than half of inpatients (41%) had a documented random drug screen completed within the review period. In terms of care-planning, only 52% of patients had random drug screening mentioned in their care plan. 22% of patient care plans reported the actions/consequences for a positive test result. Not a single care plan mentioned how frequently patients should be being tested or potential triggers for increased risk of drug misuse amongst inpatients.ConclusionCurrent practice and recording of drug screening amongst female forensic psychiatric patients is poor compared to expected standards. The lack of consistency in drug screening raises concerns regarding whether potential substance misuse amongst inpatients may be going undetected, and therefore impacting the recovery of patients. Improvements to drug screening practice should be considered in order to ensure optimal recovery and safety to patients and others.

Is pregnancy status being assessed within women's secure services?

AimsTo establish rates of pregnancy testing on admission of women within a blended secure service.BackgroundWomen with psychiatric illness are known to be at increased risk of pregnancy, often due to engagement in risky sexual behaviours such as having a higher numbers of sexual partners and engaging in sexual activity whilst under the influence of drugs or alcohol. Awareness of pregnancy at the point of admission to psychiatric hospital would inform ongoing care plans to manage the pregnancy in the safest, least restrictive environment and inform future prescribing decisions, to minimise the risk of teratogenicity associated with some psychotropic medications. Ardenleigh in Birmingham is a blended female secure unit. No pregnancy screening guidelines for this population currently exist. This audit sought to establish current rates of pregnancy testing at the point of admission with a view to developing future guidelines.MethodA retrospective case note audit of electronic records of all patients admitted to Ardenleigh blended women's service as of 1st September 2019 (n = 26). The expected standard for pregnancy testing within one month of admission was set as 100%.ResultKey results include: The majority of patients (67%) were aged under 35 years (range 20–56). The most common ethnicities were Caucasian (42%) and African-Caribbean (38%). Almost half (46%) had a primary diagnosis of paranoid schizophrenia.Two women were known to be pregnant at the point of admission. Only 54% of women with an unknown pregnancy status were screened for pregnancy within one month of admission.Rates of screening were particularly poor in women aged under 25 years (43%) and between 36 and 45 (0%).Women not screened for pregnancy were typically admitted from other hospital settings, including AWA services (27%) or other medium secure units (55%). 2 women admitted from prison were not tested (29%)Of those tested, the majority were checked using urine hCG (92%).None of the women tested were found to be pregnant.ConclusionOverall pregnancy testing on admission to the unit was poor, with only 54% of service users screened. Less than 100% compliance could result in serious consequences for both the woman and unborn baby if a pregnancy is not discovered. Updating the admission checklist for Ardenleigh to include pregnancy testing may prove beneficial. It is recommended that a re-audit is completed 6 months following checklist introduction.

Stillbirth rates, service outcomes and costs of implementing NHS England's Saving Babies' Lives care bundle in maternity units in England: A cohort study.

To assess implementation of the Saving Babies Lives (SBL) Care Bundle, a collection of practice recommendations in four key areas, to reduce stillbirth in England. A retrospective cohort study of 463,630 births in 19 NHS Trusts in England using routinely collected electronic data supplemented with case note audit (n = 1,658), and surveys of service users (n = 2,085) and health care professionals (n = 1,064). The primary outcome was stillbirth rate. Outcome rates two years before and after the nominal SBL implementation date were derived as a measure of change over the implementation period. Data were collected on secondary outcomes and process outcomes which reflected implementation of the SBL care bundle. The total stillbirth rate, declined from 4.2 to 3.4 per 1,000 births between the two time points (adjusted Relative Risk (aRR) 0.80, 95% Confidence Interval (95% CI) 0.70 to 0.91, P<0.001). There was a contemporaneous increase in induction of labour (aRR 1.20 (95%CI 1.18-1.21), p<0.001) and emergency Caesarean section (aRR 1.10 (95%CI 1.07-1.12), p<0.001). The number of ultrasound scans performed (aRR 1.25 (95%CI 1.21-1.28), p<0.001) and the proportion of small for gestational age infants detected (aRR 1.59 (95%CI 1.32-1.92), p<0.001) also increased. Organisations reporting higher levels of implementation had improvements in process measures in all elements of the care bundle. An economic analysis estimated the cost of implementing the care bundle at ~£140 per birth. However, neither the costs nor changes in outcomes could be definitively attributed to implementation of the SBL care bundle. Implementation of the SBL care bundle increased over time in the majority of sites. Implementation was associated with improvements in process outcomes. The reduction in stillbirth rates in participating sites exceeded that reported nationally in the same timeframe. The intervention should be refined to identify women who are most likely to benefit and minimise unwarranted intervention. The study was registered on (NCT03231007); www.clinicaltrials.gov.

Lurasidone for Adolescents With Complex Mental Disorders: A Case Series

Objectives: Lurasidone is a new second generation (atypical) antipsychotic agent with unique receptor affinity and side-effect profiles, but limited literature is available on its use in adolescent populations. Contrasting with research treatment trials which typically recruit patients by stringent selection criteria, this case series examined the effects and tolerability of using lurasidone in adolescents within real-life clinical settings in treating complex cases who had not responded to other therapy options. Methods: We conducted a retrospective case-note audit of 6 adolescents aged 14 to 17 years old attending community child and adolescent mental health services (CAMHS) who were prescribed lurasidone. Results: Lurasidone had been prescribed for a range of “hard-to-manage” conditions with complex comorbidities, in adolescents in relation to specific use of lurasidone on the basis of clinical and pharmacological indications after exhausting more conventional treatment options. Case-note review suggested response to lurasidone was clinically positive in 3 cases, equivocal/marginal in 2 cases, and ineffective in 1 case. There were no cases of poor tolerance or adverse effects. Notably, positive responses for depressive and irritable mood symptoms were specifically recorded by prescribing clinicians, indicative of benefits on symptom improvement. No lurasidone attributed weight gain, galactorrhoea, metabolic abnormalities, sexual dysfunction or intolerance were reported. Pro-cognitive effects were not detected; but our findings were constrained by the non-systematic and incomplete information ascertainment, typical in retrospective case-note review. Conclusion: This case series provides preliminary data supporting lurasidone’s potential use in adolescents of complex clinical needs (but without a clinical diagnosis of bipolar disorder) within real-life clinical settings. Lurasidone appears to show a weight-sparing effect, in addition to improving mood symptoms in some cases. Lurasidone deserves further study for its use in the adolescent population (outside the remit of FDA) given its potential more favorable risk-benefit profile in young people. The favorable tolerability appear to be borne out by the pharmacodynamic predictions in our complex patients who would be excluded in formal clinical trial studies.

Postoperative systemic antibiotic usage in elective eyelid surgery: is it really necessary?

ABSTRACT Purpose The use of prophylactic antibiotics for oculoplastic procedures varies because of a lack of specific guidelines or literature. Comparable studies in clean orbital surgery have shown no proven benefit and its indiscriminate use has been linked to individual harm and rising levels of resistance. We investigated whether avoidance of systemic prophylactic antibiotics in elective lid surgeries increased surgical site infections (SSI). Methods We conducted a case-note audit of consecutive anterior ptosis repair and lateral tarsal strip (LTS) surgeries performed with post-operative oral antibiotics (co-amoxiclav or clarithromycin) and topical chloramphenicol ointment, compared to only topical antibiotics. Data on American Society of Anesthesiologists (ASA) status, age and incidence of surgical site infection at 2 weeks follow-up were collected. Results Of a cohort of 232 patients, 99 patients had combined systemic and topical antibiotics (ptosis n = 49, LTS n = 50) and 133 had topical antibiotics (ptosis n = 83, LTS n = 50). The groups were not significantly different for age (p = .6, t-test) or ASA status (p = .7, chi2 test). Three patients from the combined group required further treatment for SSI compared with two patients from the topical antibiotic group (p = .7 Fisher’s exact test). Conclusions Avoidance of systemic antibiotic prophylaxis for LTS and anterior ptosis repair procedures was not associated with increased SSI rates. Given that prescriptions of antibiotics carry the risk of side-effects and growing antimicrobial resistance, we feel that our study shows that its routine use in this setting is of no benefit.

73 Using the Gold Standards Framework to Identify Opportunities for Advance Care Planning

Abstract Introduction Departmental discharge data (January 2017–January 2018) suggested a high number of “Day 1 Deaths” i.e. an individual who was readmitted 24 hours after discharge, and subsequently died during their readmission. We wondered if this was due to a lack of Advance Care Planning (ACP). Methods We undertook a retrospective case note audit of 50 cases from the “readmissions who died” (total 176/7421) subgroup, to understand whether or not they were predictably within the last days, weeks or months of life and whether there was ACP in place. We reviewed all Day 1 Deaths (16/50), and a random selection of cases across the Day 2–30 (34/50) data set. We used the Gold Standards Framework (GSF) as a prognostic tool, by use of the intuitive “surprise question” (“would you be surprised if this person died within the next days, weeks, months?”) and the disease-specific Prognostic Indictors (PI). Results Using the GSF we (retrospectively) predicted death in 94% of the Day 1 deaths and 63% of the Day 2–30 deaths. There was evidence of ACP in 32/50 patients (64%), predominantly in the form of a DNAR CPR (61%). There was very little evidence of other forms of ACP. Readmissions were justified on the basis of a medical condition in 100% of cases; this was infective in 60% (30/50). There were few interactions with secondary care in the 12 months prior to death (mode was 2 admissions in the month prior to death, 4 in the 12 months prior to death). Conclusions We must consider our discharge processes and medical decision making at the front door. A Prognostic indicator Tool would be useful to focus medical decision making. We must recognise infections as end stage disease in advanced ill health, including advanced frailty. We need to consider how we facilitate meaningful involvement of older people in their medical care towards the end of life.