This audit evaluates the adherence of nursing and medical staff to local protocols for managing distress in older adults (aged >65 years) using non-pharmacological approaches and rapid tranquilisation (RT) in a psychiatric hospital's dementia ward, an acute medical unit, and a geriatric ward in a general hospital. We hypothesize that operational differences between these wards significantly influence the management of older adult patients.

Conducted from September 17 to October 8, 2022, in hospitals in Inverness, Scotland, this study reviewed 322 case notes and drug charts from patients who underwent RT in three wards: the Old Age Psychiatric Ward, Acute Medical Unit (AMU), and Geriatric Ward. Focus groups and informal discussions with ward nurses and junior doctors were organized to understand their perspectives on handling distress in dementia patients, with an emphasis on de-escalation techniques.

Data focused on key parameters:

• • Patient Diagnosis and Legal Status.

• • Administration Details: including initiation time, de-escalation techniques, consultation with senior doctors, and details of drugs administered (route, drug, and dosage).

Staff nurses in all wards prioritized non-pharmacological de-escalation techniques, such as recognizing early signs of agitation, employing distraction and calming tactics, and acknowledging the importance of personal space, even in the face of staffing challenges and high patient loads. These measures were consistently employed prior to considering RT, adhering to the local protocol. Physical restraint was employed only in scenarios where there was a risk to the patient or others, executed by personnel trained in managing violence and aggression.

Conversations with junior doctors, particularly in the AMU, revealed a limited understanding of the RT protocol, suggesting a need for enhanced training and awareness. Overall, the study indicates that while RT is regarded as a last resort after the failure of psychological and behavioral approaches, there is a clear necessity for further education and training to ensure the safe and effective administration of RT.

This audit demonstrates that despite the varying environments and pressures in the three wards, adherence to the local protocol for managing distress in older adults is largely effective, with a strong preference for non-pharmacological methods. The findings highlight the need for ongoing education and reinforcement of RT protocols, particularly among junior doctors, to ensure patient safety and adherence to best practices. The results suggest that with proper support and training, the use of RT can be a carefully controlled and beneficial tool in managing distress in older adult patients.

Anxiety in pregnancy and after giving birth (the perinatal period) is highly prevalent but under-recognised. Robust methods of assessing perinatal anxiety are essential for services to identify and treat women appropriately.

To determine which assessment measures are most psychometrically robust and effective at identifying women with perinatal anxiety (primary objective) and depression (secondary objective).

We conducted a prospective longitudinal cohort study of 2243 women who completed five measures of anxiety and depression (Generalized Anxiety Disorder scale (GAD) two- and seven-item versions; Whooley questions; Clinical Outcomes in Routine Evaluation (CORE-10); and Stirling Antenatal Anxiety Scale (SAAS)) during pregnancy (15 weeks, 22 weeks and 31 weeks) and after birth (6 weeks). To assess diagnostic accuracy a sample of 403 participants completed modules of the Mini-International Neuropsychiatric Interview (MINI).

The best diagnostic accuracy for anxiety was shown by the CORE-10 and SAAS. The best diagnostic accuracy for depression was shown by the CORE-10, SAAS and Whooley questions, although the SAAS had lower specificity. The same cut-off scores for each measure were optimal for identifying anxiety or depression (SAAS ≥9; CORE-10 ≥9; Whooley ≥1). All measures were psychometrically robust, with good internal consistency, convergent validity and unidimensional factor structure.

This study identified robust and effective methods of assessing perinatal anxiety and depression. We recommend using the CORE-10 or SAAS to assess perinatal anxiety and the CORE-10 or Whooley questions to assess depression. The GAD-2 and GAD-7 did not perform as well as other measures and optimal cut-offs were lower than currently recommended.

Trauma is prevalent amongst early psychosis patients and associated with adverse outcomes. Past trials of trauma-focused therapy have focused on chronic patients with psychosis/schizophrenia and comorbid Post-Traumatic Stress Disorder (PTSD). We aimed to determine the feasibility of a large-scale randomized controlled trial (RCT) of an Eye Movement Desensitization and Reprocessing for psychosis (EMDRp) intervention for early psychosis service users.

A single-blind RCT comparing 16 sessions of EMDRp + TAU v. TAU only was conducted. Participants completed baseline, 6-month and 12-month post-randomization assessments. EMDRp and trial assessments were delivered both in-person and remotely due to COVID-19 restrictions. Feasibility outcomes were recruitment and retention, therapy attendance/engagement, adherence to EMDRp treatment protocol, and the ‘promise of efficacy’ of EMDRp on relevant clinical outcomes.

Sixty participants (100% of the recruitment target) received TAU or EMDR + TAU. 83% completed at least one follow-up assessment, with 74% at 6-month and 70% at 12-month. 74% of EMDRp + TAU participants received at least eight therapy sessions and 97% rated therapy sessions demonstrated good treatment fidelity. At 6-month, there were signals of promise of efficacy of EMDRp + TAU v. TAU for total psychotic symptoms (PANSS), subjective recovery from psychosis, PTSD symptoms, depression, anxiety, and general health status. Signals of efficacy at 12-month were less pronounced but remained robust for PTSD symptoms and general health status.

The trial feasibility criteria were fully met, and EMDRp was associated with promising signals of efficacy on a range of valuable clinical outcomes. A larger-scale, multi-center trial of EMDRp is feasible and warranted.

Children and young people with CHD benefit from regular physical activity. Parents are reported as facilitators and barriers to their children’s physical activity. The aim of this study was to explore parental factors, child factors, and their clinical experience on physical activity participation in young people with CHD.

An online questionnaire was co-developed with parents (n = 3) who have children with CHD. The survey was then distributed in the United Kingdom by social media and CHD networks, between October 2021 and February 2022. Data were analysed using mixed methods.

Eighty-three parents/guardians responded (94% mothers). Young people with CHD were 7.3 ± 5.0 years old (range 0–20 years; 53% female) and 84% performed activity. Parental participation in activity (X2(1) = 6.9, P < 0.05) and perceiving activity as important for their child were positively associated with activity (Fisher’s Exact, P < 0.05). Some parents (∼15%) were unsure of the safety of activity, and most (∼70%) were unsure where to access further information about activity. Fifty-two parents (72%) had never received activity advice in clinic, and of the 20 who received advice, 10 said it was inconsistent. Qualitative analysis produced the theme “Knowledge is power and comfort.” Parents described not knowing what activity was appropriate or the impact of it on their child.

Parental participation and attitudes towards activity potentially influence their child’s activity. A large proportion of young people performed activity despite a lack and inconsistency of activity advice offered by CHD clinics. Young people with CHD would benefit from activity advice with their families in clinics.

There are few data on the profile of those with serious mental illness (SMI) admitted to hospital for physical health reasons.

To compare outcomes for patients with and without an SMI admitted to hospital in England where the primary reason for admission was chronic obstructive pulmonary disease (COPD).

This was a retrospective, observational analysis of the English Hospital Episodes Statistics data-set for the period from 1 April 2018 to 31 March 2019, for patients aged 18–74 years with COPD as the dominant reason for admission. Patient with an SMI (psychosis spectrum disorder, bipolar disorder) were identified.

Data were available for 54 578 patients, of whom 2096 (3.8%) had an SMI. Patients with an SMI were younger, more likely to be female and more likely to live in deprived areas than those without an SMI. The burden of comorbidity was similar between the two groups. After adjusting for covariates, SMI was associated with significantly greater risk of length of stay than the median (odds ratio 1.24, 95% CI 1.12–1.37, P ≤ 0.001) and with 30-day emergency readmission (odds ratio 1.51, 95% confidence interval 1.34–1.69, P ≤ 0.001) but not with in-hospital mortality.

Clinicians should be aware of the potential for poorer outcomes in patients with an SMI even when the SMI is not the primary reason for admission. Collaborative working across mental and physical healthcare provision may facilitate improved outcomes for people with SMI.

To undertake a healthcare-based multimodal evaluation of the combination of filtering facepiece respirator (FFR) with the elastic-band beard cover technique, including quantitative fit test (QNFT) results, skills assessment, and usability assessment.

We conducted a prospective study through the Respiratory Protection Program at the Royal Melbourne Hospital from May 2022 to January 2023.

Healthcare workers who required respiratory protection and could not shave for religious, cultural, or medical reasons.

Online education and personal face-to-face training on the use of FFR with the elastic-band beard cover technique.

Among 87 participants (median beard length 38 mm; interquartile range [IQR], 20–80), 86 (99%) passed 3 QNFTs consecutively with the elastic-band beard cover under a Trident P2 respirator and 68 (78%) passed 3 QNFTs consecutively with a 3M 1870+ Aura respirator. The first QNFT pass rate and the overall fit factors were significantly higher when using the technique than without the elastic-band beard cover. Most participants displayed a high skill level in their donning, doffing, and user seal-check techniques. Of 87 participants, 83 (95%) completed the usability assessment. The overall ease of use, comfort, and overall assessment were rated highly.

The elastic-band beard cover technique can provide safe and effective respiratory protection for bearded healthcare workers. The technique was easily taught, comfortable, well tolerated and accepted by healthcare workers, potentially allowing them full participation in the workforce during pandemics with airborne transmission. We recommend further research and evaluation of this technique in a broader health workforce.

To investigate if current practices by nursing and medical staff in the dementia ward (New Craigs Psychiatric Hospital), acute medical unit and geriatric ward (Raigmore General Hospital) followed the local protocol for managing distress of non-pharmalogical approach and rapid tranquilisation (RT) in older adults (aged >65years). We believe the split between the general and psychiatric hospitals and the different time pressures experienced in these 3 wards will influence the management and RT of their older adult patients.

Data were collected from 17/09/2022 to 8/10/2022 from case notes and drug charts of older adult patients that received rapid tranquilisation from 3 wards:

1. 1. Ruthven Ward, New Craigs Psychiatric Hospital

2. 2. Acute Medical Unit (AMU), Raigmore Hospital

3. 3. Ward 2C (Geriatrics), Raigmore Hospital

Focus groups and informal discussions were made with the ward nurses and junior doctors to understand their point of view on managing distressing behaviours in patients with dementia using de-escalation techniques.

A table was collated using Microsoft Excel. The parameters used were:

1. 1. Patient Diagnosis and Legal status

2. 2. Administration

3. • Date and time started

4. • If de-escalation techniques were used

5. • If discussed with a senior doctor

6. • 1st and/or 2nd line of drugs administered (route, drug and dosage)

7. • If Haloperidol given and if ECG was done

Data collection showed the following:

1. 1. Ruthven Ward- all 32 patients did not receive RT.

2. 2. AMU- only 1 out of 280 patients received 4 subsequent RT in 5 hours including 3x haloperidol (total 3mg) and 2mg of Midazolam despite an ECG showing prolonged QT interval. The latter prescribed after consultation with a senior doctor.

3. 3. Geriatric Ward – all 10 patients did not receive RT.

Focus groups and informal discussions with staff nurses from all three wards concluded that in spite of the stressful environment posed by issues of understaffing and high patient load, de-escalation techniques (recognition of early signs of agitation, distraction and calming techniques, recognising the importance of personal space) were prioritised before moving on to RT as per local protocol. Restraining was often used if patient was at risk to self or others by staff trained in violence and aggression management.

Informal discussions with junior doctors rotating in and out of AMU showed limited awareness of the RT protocol. In general, it was evident that RT was a last resort when psychological and behavioural approaches failed but that further education was required to administer RT safely.

Many male prisoners have significant mental health problems, including anxiety and depression. High proportions struggle with homelessness and substance misuse.

This study aims to evaluate whether the Engager intervention improves mental health outcomes following release.

The design is a parallel randomised superiority trial that was conducted in the North West and South West of England (ISRCTN11707331). Men serving a prison sentence of 2 years or less were individually allocated 1:1 to either the intervention (Engager plus usual care) or usual care alone. Engager included psychological and practical support in prison, on release and for 3–5 months in the community. The primary outcome was the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), 6 months after release. Primary analysis compared groups based on intention-to-treat (ITT).

In total, 280 men were randomised out of the 396 who were potentially eligible and agreed to participate; 105 did not meet the mental health inclusion criteria. There was no mean difference in the ITT complete case analysis between groups (92 in each arm) for change in the CORE-OM score (1.1, 95% CI –1.1 to 3.2, P = 0.325) or secondary analyses. There were no consistent clinically significant between-group differences for secondary outcomes. Full delivery was not achieved, with 77% (108/140) receiving community-based contact.

Engager is the first trial of a collaborative care intervention adapted for prison leavers. The intervention was not shown to be effective using standard outcome measures. Further testing of different support strategies for prison with mental health problems is needed.

Patients with mental health disorders are known to have worse physical health outcomes. ‘Consultant Connect’ (CC) is an app-based communication platform which aims to improve patient outcomes and experience, by offering clinicians direct access to consultants working in a partnership acute Trust, so they can seek advice and guidance for their patients’ physical health problems. This creates whole system efficiencies by avoiding unnecessary referrals to an Emergency Department or outpatient clinics. This poster describes the implementation of CC in a large UK Mental Health Trust. Initially designed for GPs, this is the first time a UK Mental Health Trust has used CC.

Consultant Connect was launched in the Mental Health Trust's inpatient services in June 2020 as part of a Trust-wide programme of work aiming to improve the physical healthcare of mental health patients. In July 2021 it was rolled out across all services, including all community services. All platform activity was monitored and the implementation team collected data to determine: a) origin of call, b) which specialty was required, c) numbers of calls successfully connected, and in a subset of calls d) outcome of call. In addition, 183 call recordings were analysed, to identify clinical training needs and inform further development of the platform.

In the period June 2020 – December 2021, there were 1422 use episodes of the CC platform by Mental Health Trust clinicians. There were 401 Trust registered downloads of the CC App by the Trust clinicians. 53 different clinical specialties were contacted, with cardiology (414 calls), diabetes and endocrinology (243 calls), and haematology (124 calls) the most frequently called. 68% of queries received a response. 48% of calls had an outcome recorded, with 70% of these resulting in the physical healthcare being delivered by the mental health team, following the advice received (i.e. referral or admission avoided, or the patient treated out of hospital).

CC is being progressively embedded into clinical practice and has become a well-used pathway for mental health clinicians seeking immediate clinical advice from acute hospital Consultant colleagues. Further qualitative and quantitative work is planned with mental health clinicians, patients and carers to better understand their experience and determine if it improves care from both the clinicians’ and patients’ perspective.

Some manufacturers provide information on similar-fit model pairings of filtering facepiece respirators (FFRs), suggesting that fit-test outcome of one model helps predict the other. This guidance may be useful during crisis capacity when FFR supplies and/or fit tests are constrained. The purpose of this study was to compare quantitative fit-test (QNFT) results and concordance between a pair of similar-fit 3M Aura FFRs: the 3M 9320A+ and 3M 1870+.

All participants completed online training and a QNFT with both respirators. The order of the respirator being examined first was randomly allocated. The outcomes included QNFT pass rate, concordance between the 2 models, overall and individual fit factors, and percentage of male and female participants who passed or failed the QNFT.

We recruited 1,000 participants (668 females and 332 males). The QNFT pass rate, overall fit factors, and individual fit factors were significantly higher for the 3M 9320A+ than the 3M 1870+ FFR. The concordance between the models was “fair” (κ coefficient, 0.38). Male participants who passed a QNFT with either of the FFRs had 96% chance of passing the QNFT for the alternate model. Female participants who passed the 3M 1870+ had 97% chance of passing the QNFT for the 3M 9320A+ model. However, ∼1 in 12 females who passed the QNFT for the 3M 9320A+ failed the QNFT for the 3M 1870+ FFR.

Similar-fit paired FFR models may provide a consequentially different level of respiratory protection, especially for women. Our findings are important for FFR stockpiling and fit-testing strategies, especially during crisis capacity.

Discomfort and device-related pressure injury (DRPI) caused by N95 filtering facepiece respirators (FFRs) are common. The use of prophylactic hydrocolloid dressings is one of the strategies that may improve comfort and reduce DRPI. In this study, we investigated the impact of these dressings on N95 respirator fit.

We performed a repeat quantitative fit testing through the Respiratory Protection Program on 134 healthcare workers (HCWs), who applied hydrocolloid dressings on the bridge of their nose under the N95 FFRs that they passed the initial fit test with, but reported discomfort with the FFR.

With the hydrocolloid dressings in place, the fit-test pass rate for the semirigid cup style (3M 1860) was 94% (108 of 115); for the the vertical flat-fold style (BYD), the pass rate was 85% (44 of 52); for the duckbill style (BSN medical ProShield and Halyard Fluidshield), the pass rate was 81% (87 of 108); and for the 3-panel flat-fold style (3M Aura) N95 FFRs, the pass rate was 100% (3 of 3). There was a statistically significant reduction in the overall fit factors for both the vertical flat-fold and duckbill type N95 respirators after the application of hydrocolloid dressings.

Hydrocolloid dressings are likely to disturb the mask seal for nonrigid-style N95 FFRs, particularly the vertical flat-fold style and the duckbill style N95 FFRs. Given the risk of mask seal disturbance of N95 respirators as shown in this study, we advocate that any HCW requiring the use of prophylactic dressings should undergo repeat quantitative fit testing with the dressing in place prior to using the dressing and mask in combination.

To determine the effect of the COVID-19 pandemic on referrals to mental health and physical health services.

We analysed referral data from three psychiatric services in the boroughs of Camden and Islington across 2018-2020: Early Intervention Services (for patients with a 1st episode of psychosis), Crisis Resolution Teams and inpatient admissions. We also analysed GP referral data to Cancer Services (two-week wait referrals) to Whittington Hospital, Royal Free Hospital and University College Hospital (all of North Central London). We examined the impact of the COVID-19 pandemic on these referrals and compared the findings between physical and mental health. We chose to use EIS and Cancer services as comparable services since they both operate with the two-week target of achieving diagnosis of psychosis and cancer respectively.

The number of referrals to EIS and CRT both decreased to 61% in April 2020 with respect to their baseline; EIS referrals continued to decrease to 48% in May before starting to recover. Inpatient admissions saw a smaller reduction to 87% in April 2020. The number of cancer two-week wait referrals similarly decreased and reached a trough of 37% in April 2020. The rate of recovery back to the baseline number of referrals and admissions relative to previous years differed between services, with acute care recovering faster. Referrals to CRT and inpatient admissions recovered by 98% and 115% respectively by June 2020; comparatively, referrals to EIS recovered to 102% by December 2020. In contrast, cancer two-week wait referrals returned to 106% by September 2020, a rate faster than EIS, but slower than CRT and inpatient admissions.

The reduction in the number of referrals across all examined services correlated with the first wave of the COVID-19 pandemic. The rate of decrease was similar across all services, coinciding with the peak of COVID-19 infections. However, the ultimate degree of decrease and following rate of recovery in numbers differed across both psychiatric and non-psychiatric services. These differences likely have multifactorial origins. The authors discuss contributing factors, such as changes in health seeking behaviours observed during the pandemic, potential impact of reduction in face to face consultations in primary care, as well as temporary changes in the population demographic of Camden and Islington resulting in absent target groups (i.e. students who make up a large proportion of referrals to EIS opting to return home). It remains important to not neglect mental health and face a hidden epidemic once COVID-19 pandemic settles.

During the Randomized Assessment of Rapid Endovascular Treatment (EVT) of Ischemic Stroke (ESCAPE) trial, patient-level micro-costing data were collected. We report a cost-effectiveness analysis of EVT, using ESCAPE trial data and Markov simulation, from a universal, single-payer system using a societal perspective over a patient’s lifetime.

Primary data collection alongside the ESCAPE trial provided a 3-month trial-specific, non-model, based cost per quality-adjusted life year (QALY). A Markov model utilizing ongoing lifetime costs and life expectancy from the literature was built to simulate the cost per QALY adopting a lifetime horizon. Health states were defined using the modified Rankin Scale (mRS) scores. Uncertainty was explored using scenario analysis and probabilistic sensitivity analysis.

The 3-month trial-based analysis resulted in a cost per QALY of $201,243 of EVT compared to the best standard of care. In the model-based analysis, using a societal perspective and a lifetime horizon, EVT dominated the standard of care; EVT was both more effective and less costly than the standard of care (−$91). When the time horizon was shortened to 1 year, EVT remains cost savings compared to standard of care (∼$15,376 per QALY gained with EVT). However, if the estimate of clinical effectiveness is 4% less than that demonstrated in ESCAPE, EVT is no longer cost savings compared to standard of care.

Results support the adoption of EVT as a treatment option for acute ischemic stroke, as the increase in costs associated with caring for EVT patients was recouped within the first year of stroke, and continued to provide cost savings over a patient’s lifetime.

Clinical Trial Registration: NCT01778335