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A previous audit of use of rapid tranquillisation in older adults conducted in 2019 identified high rates of use of sedation, and poor adherence to local guidelines. Following this audit, a number of quality improvement (QI) initiatives were undertaken in order to try to improve practice, including multiple teaching sessions to a variety of staff. This re-audit was conducted to study whether initiatives had been effective in line with the Plan Do Study Act cycle of Quality Improvement.
Using the same audit tool developed in 2019, six wards (2 geriatric, 3 medical and 1 surgical) were audited. Patients over 65 given oral or intramuscular sedating medications had their drug charts and notes reviewed. Data were collected on type of sedation, route prescribed, whether it was prescribed regularly or PRN, whether an indication was documented, underlying diagnosis and what monitoring took place post sedation.
297 drug charts were reviewed, and 13 patients were prescribed rapid tranquilisation (RT). The maximum daily dose was included in 63% of prescriptions similar to that of the first audit (58%). The most common route of administration was intramuscular, unlike the previous audit which was oral/intramuscular.
50% of prescriptions documented an indication, of which 25% were illegible. Whilst in the first audit the figure was 33%.
Of all the patients prescribed RT, 77% had a diagnosis of delirium, 77% had a diagnosis of dementia and about 53.8% had both. In both audits 100% of patients had a diagnosis of dementia or delirium. Most prescriptions were for lorazepam (75%). There was no evidence of observations being taken in line with post RT monitoring in the trust policy in both audits
Further work needs to be done to improve practice. Interventions to date have not been effective. Further plans for QI work include updating the RT policy to be more specific and useful for the acute trust, to fit in with a recently introduced electronic records system (ERS) and to include a clear section on older adults with signposting to the delirium and dementia policies. As well as adding prompts and protocols to the ERS to support safe prescribing and dispensing of RT. Teaching will be repeated and a poster has been developed and promoted on all the wards. The project group are planning to join the trust's ‘medication safety huddle’ regularly to include pharmacists in teaching and work. The audit will be repeated in three months time.
Differential attainment is a term used to describe variation in the achievement of groups of doctors based on certain characteristics. Evidence suggests that international medical graduates (IMGs) in the UK struggle at different stages of training in many specialties including psychiatry. This project aims to explore the experience of psychiatry trainee doctors and their trainers at SABP to understand this issue and identify areas for quality improvement.
This was an exploratory study using a mixed methods approach. Qualitative data were collected via semi-structured interviews and focus groups conducted with trainees and trainers. Interviews and focus groups were recorded and transcribed, then analysed for themes. Quantitative data were collected via an online survey sent to trainees and trainers and were analysed using descriptive statistics. Informed consent was obtained from all participants. This project received approval from the Health Education England research governance committee and was conducted in accordance with British Educational Research Association (BERA) guidelines.
The online survey had a good response rate of 60.4% for trainees (26 out of total 43 trainees) and 64.7% for trainers (22 out of total 34 trainers). Challenges identified by the participants both in qualitative and quantitative data mirrored the national picture. Five main themes that were identified from semi-structured interviews and focus groups were: 1) the impact of professional and informal support, 2) challenges faced by IMGs in adjusting to the new system, 3) communication barriers, 4) Stress and burnout impacting trainees’ performance and 5) unconscious bias during recruitment, exams, and ARCP on the training experience of IMGs.
This project was used to generate ideas for quality improvement with regard to the experience of trainees and the reduction of differential attainment within the trust. Findings from this research have guided SABP in the development of interventions to support IMGs and trainers, particularly regarding professional and non-professional support. These interventions include an induction booklet for doctors joining the trust, an IMG support network, and a mentorship scheme for all the trainees. We aim to explore the experience of IMGs trainees and trainers using a similar method in the future to evaluate the success of these interventions. Our findings will have an impact on other organisations providing postgraduate training in psychiatry and other specialties.
General hospital inpatients are routinely risk assessed for hospital associated venous thromboembolism (HAT) and given appropriate thromboprophylaxis if indicated. However, mental health trusts have not taken a similar approach in psychiatric inpatients, despite known risk factors, including some unique to psychiatric inpatients. We explored current practice of HAT prevention in English psychiatric inpatients.
A Freedom of Information Act (FOI) request was sent to all 71 English mental health trusts, asking whether there was a Venous Thromboembolism (VTE) policy, whether a VTE risk assessment tool was being used, what is looked like, and the incidence of HAT in their psychiatric inpatients i.e., VTE during admission or occurring up to 90 days post discharge.
We received 54 unique responses (76%) to the FOI. Of these, 36 (86%) shared their VTE policy, 26 (72%) of which had been adapted for this population; 38 (90%) shared their VTE risk assessment tool, of which 17 (45%) were adapted from the Department of Health VTE risk assessment tool.
Only five trusts out of 42 (12%) monitored VTE events up to 90 days post-discharge and 4 of these shared their monitoring policy. Only 18 (43%) were able to provide data on the number of psychiatric patients diagnosed with a VTE during their stay and up to 90 days post discharge between February 2016–2021, 6 (14%) said they would incur costs to collect this data and 9 (21%) were unable to access this data. Where information was provided, the number of HAT events ranged from 0–224 within each trust. Of the 18 trusts who provided data, a total of 514 events were recorded between Feb 2016-Feb 2021, but none of the trusts were able to confirm if this included VTE events up to 90 days post discharge.
Our FOI survey suggest a high incidence of VTE in psychiatric patients and indicate wide variation in HAT prevention in English hospitalised psychiatric patients. Most had a VTE Trusts had a policy in place, with 45% having a VTE risk assessment tool that listed risk factors unique to psychiatric patients, adapting VTE risk assessment tools in this way may lead to a greater use of thromboprophylaxis. The lack of access to data on HAT by mental health trusts is concerning. Further research is required to understand the rates of VTE, validate a VTE risk assessment tool and conduct trials looking at the benefit of thromboprophylaxis in psychiatric inpatients.
Our aim is to establish a network for clinicians working in or with an interest in the growing specialty of old age liaison psychiatry to provide peer support (inclusive of disciplines and geography) and access to CPD opportunities, to raise the profile of this subspecialty and enable it to continue to develop, to facilitate collaboration and integration with related disciplines and pathways and to strengthen the voice of clinicians in lobbying for improvements in mental health services for older people in the general hospital.
Old Age Liaison Psychiatry is a growing subspecialty in the UK and nationally, following widespread investment in development of liaison services in line with Department of Health strategy. With this expansion comes an increasing need for continuous professional development, networking and collaboration opportunities in order to nurture the specialty and those working in it.
Over 100 people registered for the initial webinar, and many more have watched the recording. Since the webinar the network has grown to 350 members. The webinars were received very positively, with many suggestions made for topics to be covered at future events.
The network has been established successfully and founders are now planning future events with the support of the Royal College of Psychiatrists, including a half day learning event in late 2022.
To audit VTE risk assessment compliance across psychiatric inpatient wards at three different sites within Surrey and Borders Partnership NHS Foundation Trust (SABP), and to highlight the importance of completing VTE risk assessments for psychiatric inpatient safety and care as set out by NICE guidelines (2019).
Numbers of VTE risk assessments completed (within 24 hours, and those completed any time during inpatient stay) and VTE risk assessments not completed were collected via SABP electronic mental health records. Percentage compliance for each ward and hospital involved in the study were calculated. Chi square statistical t tests were conducted using Excel to check for associations between type of ward (older adult and working age) and VTE risk assessment completion.
A total of 3004 patients were included in the study. Ages ranged from 18–82 years of age, and both males and females included in the study. A total of 2060 were working age (WA) patients (aged 18–64 years) and 944 were older adults (OA) (aged > 65 years).
Across all three sites, more than 90% of all inpatients admitted between May 2018 and October 2020 did not have a formal VTE risk assessment completed. Across all sites, less than 1% of all inpatients had a completed VTE risk assessment done within 24 hours, as recommended by the NICE guidelines. Older Adult wards showed better compliance with VTE risk assessment completion with 38% of patients on one OA ward having had a completed VTE risk assessment, and 28% on another completed OA ward. Being admitted to an OA ward was strongly associated with VTE risk assessment completion (p < 0.05).
OA wards have hosted QI programmes with regards to VTE risk assessment which may be why VTE risk assessment was more likely to have been completed on OA wards. VTE risk assessment compliance overall is inadequate across all sites included in the study. Recommendations include further education for all ward staff on how, why and when VTE risk assessment should be completed, greater accessibility of an improved VTE risk assessment form and for QI initiatives on OA wards to be rolled out on WA wards. These findings have been presented and discussed at regional Trust teaching days, and this audit will be repeated in one year.
Social isolation and living alone have been associated with increased suicidality in older adults. During the SARS-CoV-2 pandemic, older adults were advised to keep isolated and maintain social distancing. Lockdown periods in England may have led to increased isolation and loneliness in older people, possibly resulting in an increased rates of DSH and suicide. This study aimed to explore whether numbers of older adults referred to liaison services with deliberate self harm changed during the SARS-CoV-2 pandemic.
Reason for referral and total number of referrals to liaison services for older adults data were collected across 6 mental health trusts who had access to robust data sets. Data were collected prospectively for three months from the start of the UK national lockdown and for the corresponding 3 month period in 2019, via trust reporting systems. This study was registered as service evaluation within each of the participating mental health trusts.
Overall numbers of referrals to older adult liaison services went down, but the proportion of referrals for older adults with DSH increased. Across the six mental health trusts there there were a total of 2167 referrals over the first three month lockdown period in 2020, and 170 (7.84%) of these referrals were for deliberate self harm. During a corresponding time period in 2019, there were a total of 3416 referrals and 155 (4.54%) of these referrals were for deliberate self harm
Although numbers of referrals for older adults with delberate self harm appeared to stay the same, the severity of these presentations is not clear. Outcomes of referrals and severity of self harm could be explored by examining individual case records. As there have been subsequent lockdowns the data collection period should also be extended to include these. Triangulation with national and local datasets on completed suicide is planned.
We assessed venous thromboembolism (VTE) risk, barriers to prescribing VTE prophylaxis and completion of VTE risk assessment in psychiatric in-patients. This was a cross-sectional study conducted across three centres. We used the UK Department of Health VTE risk assessment tool which had been adapted for psychiatric patients.
Of the 470 patients assessed, 144 (30.6%) were at increased risk of VTE. Patients on old age wards were more likely to be at increased risk than those on general adult wards (odds ratio = 2.26, 95% CI 1.51–3.37). Of those at higher risk of VTE, auditors recorded concerns about prescribing prophylaxis in 70 patients (14.9%). Only 20 (4.3%) patients had a completed risk assessment.
Mental health in-patients are likely to be at increased risk of VTE. VTE risk assessment is not currently embedded in psychiatric in-patient care. There is a need for guidance specific to this population.
We are assuming that if you are reading this you are planning to sit the Clinical Assessment of Skills and Competencies (CASC) exam of the Royal College of Psychiatrists at some point in the future. It may be that you are currently in a training post either in or outside the UK, or working in a non-training post in psychiatry. Of course it may also be that you have interest in developing the skills required for the exam in those that you supervise or mentor.
As such, some of you may already know the details of the exam and perhaps have even sat it before. For those who are new to the exam, we will start by outlining the basics.
The CASC exam
The CASC exam has been the final membership examination of the Royal College of Psychiatrists since 2008. In its current form the exam involves two circuits of eight ‘stations’. The examination is held over the course of 1 day, with a morning and afternoon session. The morning circuit involves four paired stations of 10 min each with 90 s of reading time before each station. The afternoon circuit involves eight stand-alone stations, again with 90 s of reading time before each station.
For paired stations, information gathered in the first station is used in the following one, for example taking a history from a patient in the first station and discussing the assessment with their relative in the second.
Currently, to be eligible to sit the exam you need to have passed all written papers set by the College and have 24 months of wholetime equivalent post-foundation or internship experience in psychiatry. Detailed and up-to-date eligibility criteria can be found on the examination pages of the College's website, www.rcpsych.ac.uk/traininpsychiatry/ examinations.aspx
Structure of this book and how to use it
This book has three main sections. Part 1 describes core verbal and nonverbal communication skills, and outlines techniques for their development and practice. There are also techniques for managing time, taking control, as well as when and how to use a more structured approach. This section concludes with a chapter on the specific procedural skills that are tested in the exam, such as physical examination, cognitive assessment and interpretation of investigations.
So far we have covered various aspects of verbal and non-verbal communication as well as structured approaches to stations. Three types of station included in the CASC that can cause a lot of anxiety for candidates are physical examination, interpretation of results and cognitive assessment. Unfortunately, these are often the stations left until last when it comes to revision – but to perform well they should be included right from the start.
Many of you may have done OSCEs (Observed Structured Clinical Examination) at medical school or as part of your postgraduate training. There is little difference between these and the physical examination stations you will encounter in the CASC. You need to be able to complete an appropriate physical examination in a sensitive, efficient and confident manner in a short amount of time. When preparing for these stations, a good way to start is by devising a protocol for each of the systems you might need to examine (e.g. respiratory, cardiovascular, endocrine), with diagrams if you find these helpful. Then practise the instructions you would need to give to a patient in order for them to understand clearly what you need them to do to follow this protocol. Often during their revision people practise the examination itself but not what they will actually say as they go through it, and then find it difficult to find the right words to communicate clearly in the actual exam – this looks clumsy and feels awkward.
Once you have your protocol and instructions clear, practise. Practise again! These examinations should become fluid and natural so that during the exam you can show both competence and confidence. You should try to present the findings of your examination as you go along in lay language so that the patient can understand them. This demonstrates several skills, but perhaps the most important is your ability to convey information using non-technical, jargon-free language and help a patient feel at ease.
Great opportunities to practise these stations are while admitting a patient to a ward when on-call. See whether you can do a specific examination in 5 min, presenting the findings to the patient as you go along. Ask your patients for feedback if you feel it appropriate.
Mrs Adams has been booked into your clinic for an initial assessment. She had asked for the first appointment and has turned up 30 min early. She was referred by her general practitioner (GP) who was worried she might be having a ‘nervous breakdown’.
• You should take a history of the presenting complaint.
• You are not required to do a risk assessment.
Instructions for actor
You are very anxious, unable to sit down. You have struggled to see the doctor because of your fear of going outside. You want to leave and get back home but you realise you need help.
You have had this fear of going outside your house for 3 years. You have found it increasingly difficult to lead a normal life and spend more and more time indoors. You have arranged your life so you do not have to go out. For example you speak to your sister in America via Skype; you order your shopping via the internet.
Three years ago your partner died in a car crash. Going anywhere near a moving car is particularly difficult for you and on several occasions you have run back home having gone out.
You have been admitted to hospital before, after collapsing on the high street. You had chest pain but the doctors could not find anything wrong with your heart.
You have not been having flashbacks as you were not involved in the crash that killed your partner. Your sleep is poor and you often find it difficult to go to sleep. Your appetite is fine. You still enjoy reading and watching television but find you cannot do this for too long as your concentration has got worse. Your concentration is often disturbed by thoughts of what might happen to you (e.g. get attacked in your house or burgled).
Prior to 3 years ago you would have said you were a very conscientious person who liked to make sure things were perfect.
The aim of this station is not necessarily for the candidate to get a detailed history but to demonstrate skills at dealing with a highly anxious person.
Here are resources that will help in your quest for CASC success.
A vast array of useful leaflets on all aspects of dementia – including benefits, lasting and enduring power of attorney, and testamentary capacity (www. alzheimers.org.uk/site/scripts/documents_info.php?documentID=160).
Child and adolescent psychiatry
Useful and up-to-date information on eating disorders (www.b-eat.co.uk).
The charity dedicated to improving the mental health and well-being of children and young people as well as supporting parents and carers. The website provides well-written information sheets for both young people and their families. It is useful to read these for clear explanations of the most common disorders experienced by children and young people (www. youngminds.org.uk).
DVLA (Driver and Vehicle Licensing Agency)
The DVLA website has up-to-date and accurate information about driving with a disability or health condition and taking different psychotropics as well as advice for doctors on what to do about patients who are driving and misusing alcohol or illicit substances (www.dft.gov.uk/dvla/medical/ medical_drivers.aspx).
Provides clinical descriptions, diagnostic guidelines, and codes for all mental and behavioural disorders commonly encountered in clinical psychiatry. Available in print and online (www.who.int/classifications/icd/en/).
Mental Health Act 1983: Code of Practice
The Code of Practice provides professionals with information on how to carry out their roles and responsibilities under the Mental Health Act 1983, to ensure that all patients receive high-quality and safe care. It is also guides patients, their families and carers on their rights (www.gov. uk/government/uploads/system/uploads/attachment_data/file/396918/ Code_of_Practice.pdf).
MIND and Rethink
MIND and Rethink are two excellent large mental health charities that publish a large amount of information regarding mental health problems, which is freely accessible online. Particularly useful for revision are their leaflets on the Mental Health Act 1983 (www.mind.org.uk/informationsupport/ legal-rights/mental-health-act; www.rethink.org/living-withmental- illness/mental-health-laws/mental-health-act-1983).
National Institute for Health and Care Excellence
Look at the guidelines for major mental health conditions. You should be able to describe stepped care models in lay terms. The guidelines are available on the website or as a downloadable app (www.nice.org.uk).
Royal College of Psychiatrists
The exam pages on the College's website should be your first stop when planning for your CASC. You will find the curriculum here, a guide for candidates as well as example videos of CASC stations (www.rcpsych. ac.uk/traininpsychiatry/examinations/about/mrcpsychcasc.aspx).
A shared view of our colleagues who have passed the Clinical Assessment of Skills and Competencies (CASC) exam – the final membership exam of the Royal College of Psychiatrists – is that our day-to-day clinical practice should have gone a long way in preparing us for it. We also felt that the preparation for the exam and the intense reflective learning we undertook as a part of that made us all better clinicians. The first and most important message of this book is that practice for the CASC should begin on day 1 of your training in psychiatry so that when you come to take the exam, although a significant hurdle, you are able to see it as an opportunity to display the subtle and refined skills you have developed over the years. In our experience, real life is far more challenging than the controlled environment of the CASC.
An ability to adapt the qualities of your voice, body language, questioning technique and structure under pressure is one of the keys to passing the CASC and will help you develop into an excellent clinician. We expect that you are already using this ability, perhaps unknowingly, as a part of your everyday communication. If you are not aware you are doing this, then recognition is the first step. Mastering this ability will take preparation, whether by reviewing videos of your performance or following verbal and written feedback after mock stations. Taking the approach of realistic, honest and open self-reflection with a preparedness to challenge yourself is an important part of your preparation. We hope that this book will act as a guide for this approach.
The techniques in this chapter focus on gathering information and beginning to manage the flow of a scenario.
Unless you feel very confident, to develop the following techniques try practising them one at a time during an interaction – ideally the next time you see a patient in your clinical practice. You may well overuse them at times and find that the flow of the conversation becomes too broken up. Once through this stage you will get to a point of using them appropriately without overdoing it. By the time you get to the exam you should be blending them together to create a flowing conversational style, which you can maintain despite any distractions, derailment or frank confrontation by the patient. In this chapter we will cover the following verbal communication techniques:
• open/opening and closed/closing questions
• normalising experiences
• using and bouncing.
An open question is one to which there might be a great variety of responses. ‘What happened to bring you into hospital?’ is an open question. Starting with an open question has many advantages. It allows the patient to start with what they may find important or most upsetting. It facilitates the building of rapport as you can begin to gather useful information through the variety of responses they might give. With this in mind, it is generally a good idea to start with an open question.
The disadvantage of open questioning is the potential for you to gain irrelevant information (i.e. not relevant to the task at hand in the exam station) or for the patient to become side-tracked. So continuing to use open questions has its down sides. If you are not getting the information you need, you may need to rethink your approach.
When you want to hone in on particular details of what a patient is telling you, you may wish to ‘close’ the questioning. A closed question is one that limits the potential responses from the patient. This allows you to gain specific information and therefore to be more certain of what is going on for your patient.
We think it is very important that a large part of your CASC preparation takes place with a group of peers who are sitting the exam at the same time as you or with peers who have sat the exam recently. Here are our top ten tips.
Size of the group – four people is a good number. This allows for one person to be absent on occasion, leaving enough people to run stations usefully.
Ground rules – as you will be aware from your readings of group dynamics, ground rules are important. For a group to be mutually supportive you should be clear on what is expected from all members, such as punctuality, prior preparation, and giving constructive feedback. You all need to feel safe enough to make a fool of yourself. If you do not, perhaps this is not the group for you.
Organise and prepare – organise a schedule for covering topics/ specialties and plan sessions in advance so you can work around people's other commitments.
Membership – try and work with people you get on with, who have complementary experiences or skills in different subspecialties to ensure you can cover everything. You want to consider whether the group members are all at the same level of preparation.
Consistency – the group will work best if you are consistent in your sessions. We would suggest weekly sessions in the few months before the exam, and then you may wish to increase the frequency in the last month before the exam.
Fun – make it a rewarding experience. Plan to do something relaxing after the session (e.g. sharing a meal, going for a run, going to the pub). Each member could take it in turn to host the group and provide refreshments.
Feedback – videoing your stations and watching them back as a group can be useful in giving specific feedback. You could agree a structured way of recording feedback on a sheet. See the example structured feedback sheet on non-verbal communication skills in the Appendix. In general, be specific but not personal, honest and constructive, and think with the others how you might do something differently rather than simply criticising.
By the time you get to the CASC you will have sat all three written MRCPsych exams, so your knowledge should have become much deeper. For the CASC, you need to have much more practical knowledge at your fingertips, such as what are the steps to assess testamentary capacity or the therapeutic range for lithium levels.
We would suggest that the knowledge revision specifically for your CASC should start at least 4–6 months before the exam if it is to be done properly. You will need time to feel very secure with your level of knowledge so that you are then able to experiment with how you present in and use practice stations. Here are our top tips for developing your knowledge base.
• A useful start is to make an exhaustive list of the conditions you will need to know about for the CASC. Using the ICD-10 as a guide is useful, but remember there may be conditions which are not in there (e.g. re-feeding syndrome) that can also come up.
• Once you have your list, for each condition you need to know the main symptoms, diagnostic criteria, prognosis and management. To make sense of the management, try writing the different aspects into a 3 × 3 grid, which splits it up into short, medium and long term, and then again into biological, psychological and social areas. This formulation of the management plan will feed into the structure you develop for presenting information in a station, making it much more manageable, concise and complete.
• For every commonly used drug you need to know doses, titrations, sideeffects and contraindications. If the drug requires special monitoring through plasma levels or other blood tests, you need to know these too.
• For every form of therapy you need to understand it enough to be able to explain it.
• Use a variety of sources for your revision (e.g. standard textbooks, evidence reviews, National Institute for Health and Care Excellence (NICE) guidelines, websites, patient information leaflets). We have put together a useful list of resources at the end of the book.
You are interviewing Mr Jones, a 22-year-old man detained under Section 136 of the Mental Health Act 1983. He was detained after a member of the public reported him acting bizarrely and appearing extremely agitated and distressed. He is now calm, but still showing some bizarre behaviour and seems to be having hallucinatory experiences.
• Interview Mr Jones with a view to eliciting the underlying psychopathology.
• You are not required to undertake a risk assessment and need only ask about relevant background history necessary to undertake the task.
Instructions for actor
You are Mr Jones, a 22-year-old man. You were detained by the police earlier when a member of the public contacted them as they were worried about your behaviour. At the time this happened you were very distressed and hearing a single male voice telling you ‘The time has come’. You are not sure what this means, but have been hearing it frequently recently and recognise it as the same voice each time, although you are not sure whose voice it is. You first heard it 6 months ago and it is getting worse. The voice also tells you to ‘Make preparations for a journey. You will know what to do’ but is not overtly derogatory or threatening. You believe it but do not feel actively controlled. As a result of this you have packed a bag with belongings that you carry at all times. You are very scared that something bad will happen if you disobey the voice, but are not sure what this would be. You also sometimes feel that comments on the television or radio are signals from the voice, and have packed specific belongings you have seen in television shows as you think they will be necessary for the journey. You are not sure what the source of the voice is but believe it must be some form of higher power.
No one else around you appears to have similar experiences. Your family think you are acting oddly and tell you that you are mistaken or making it up. As a result you have stopped talking to them about your experiences as you feel that it must be a secret mission as they do not seem to understand.