Robert Chaplin

Behavioural antecedents to pro re nata psychotropic medication administration on acute psychiatric wards

This study examined the antecedents to administration of pro re nata (PRN) psychotropic medication on acute psychiatric wards, with a particular focus on its use in response to patient aggression and other conflict behaviours. A sample of 522 adult in-patients was recruited from 84 acute psychiatric wards in England. Data were collected from nursing and medical records for the first 2  weeks of admission. Two-thirds of patients received PRN medication during this period, but only 30% of administrations were preceded by patient conflict (usually aggression). Instead, it was typically administered to prevent escalation of patient behaviour and to help patients sleep. Overall, no conflict behaviours or further staff intervention occurred after 61% of PRN administrations. However, a successful outcome was less likely when medication was administered in response to patient aggression. The study concludes that improved monitoring, review procedures, training for nursing staff, and guidelines for the administration of PRN medications are needed.

How does an accreditation programme drive improvement on acute inpatient mental health wards? An exploration of members' views

Background: Concerns have been raised about inpatient mental health care. An accreditation model can improve compliance with standards associated with improved quality of health care. Aims: To explore the effects of a standards-based, peer review, accreditation model on standards of care in acute inpatient wards and explore how staff achieved change. Method: Quality of care was assessed by independent peer review against evidence-based standards in an accreditation process. Staff from the 11 wards receiving subsequent accreditation were interviewed to find out what processes had enabled accreditation. Results: Sixteen wards enrolled: four achieved immediate and 11 subsequent accreditation. The most common reasons for initial failure of accreditation were lack of psychological therapies or 1:1 time for patients, and presence of ligature points. Ward staff perceived the accreditation process improved communication, gave power to negotiate for resources, clear guidance how to practice, rewarded good practice and led to additional unrelated improvements in care. Conclusions: Acute wards need to attend to basic safety and provide talking treatments (both formal psychotherapy and basic time spent with patients). An accreditation, peer-reviewed, standards-based process can enable staff to feel confident about improvements in the quality of care.

Violence, alcohol and drugs: The views of nurses and patients on psychiatric intensive care units, acute adult wards and forensic wards

Aims and method : To measure the numbers of staff and patients experiencing physical assault, and identify the perception of staff and patients regarding alcohol and drug related violence on Psychiatric Intensive Care wards (PICUs), acute adult wards and forensic wards. Postal questionnaires were received from 2761 individuals. They yielded quantitative and qualitative data. Further information arose from discussion groups of staff at feedback events. Results : Nurses on PICUs (61%) were more likely to report assault than those on acute wards (45%) or forensic wards (33%). Patients on PICUs (25%) were significantly more likely to report assault than those on acute wards (14%) but not forensic wards (23%). Nurses were more likely than patients to report that drugs and alcohol had caused violence on their ward. Nurses on PICUs and forensic wards thought drug use was more likely to cause violence than alcohol. Compared with PICUs, more nurses considered that violence was due to alcohol and drugs on acute wards but not on forensic wards. Many nurses on PICUs carried out personal searches but few had received training in this. Conclusion : Nurses on PICUs appear to be at particularly high risk of violence. Reducing the availability of illegal drugs on PICUs and improvement of staff training could be important means of reducing violence.

Aggression on psychiatric inpatient units for older adults and adults of working age

Staff and patients on acute psychiatric wards report high rates of exposure to violence (Chaplin et al., 2006). Aggressive behaviour by older people with mental illness is associated with dementia, frequently directed at staff providing personal care and other patients, and does not generally result in severe injury. The National Audit of Violence (Healthcare Commission, 2005) revealed comparable rates of staff and patients experiencing aggression on older adult (OA) wards and wards for adults of working age (WAA wards). This study aims to compare numbers of staff and patients experiencing physical assault on OA wards with those working on WAA wards and document the severity of aggression against nursing staff working on OA wards.

Electroconvulsive therapy: the practice and training needs of referring psychiatrists in the United Kingdom and Republic of Ireland.

This study aims to gain a greater understanding of the clinical practice and training needs of psychiatrists who prescribe electroconvulsive therapy (ECT), including knowledge about ECT, obtaining informed consent, and the monitoring of patients after ECT. Four hundred ninety psychiatrists who refer patients for ECT were sent questionnaires as part of reviews conducted by the ECT Accreditation Service, and 56% responded. Data were analyzed using descriptive statistics and thematic analysis. Nearly all felt that they had adequate knowledge about ECT with 35% recognizing further training needs. Psychiatrists were likely to find difficulty explaining to patients more about how ECT works and the possibility of long-term cognitive side effects than the benefits of ECT. The main areas of training need are the obtaining of informed consent, including the choice between unilateral and bilateral ECT, and the assessment of cognitive function during and after the course. The study also reveals the need for further research into long-term cognitive side effects of ECT and the need for a reliable cognitive assessment tool for measuring persistent or autobiographical memory deficits.

An audit of the quality of inpatient care for adults with learning disability in the UK

Objectives To audit patient hospital records to evaluate the performance of acute general and mental health services in delivering inpatient care to people with learning disability and explore the influence of organisational factors on the quality of care they deliver. Setting Nine acute general hospital Trusts and six mental health services. Participants Adults with learning disability who received inpatient hospital care between May 2013 and April 2014. Primary and secondary outcome measures Data on seven key indicators of high-quality care were collected from 176 patients. These covered physical health/monitoring, communication and meeting needs, capacity and decision-making, discharge planning and carer involvement. The impact of services having an electronic system for flagging patients with learning disability and employing a learning disability liaison nurse was assessed. Results Indicators of physical healthcare (body mass index, swallowing assessment, epilepsy risk assessment) were poorly recorded in acute general and mental health inpatient settings. Overall, only 34 (19.3%) patients received any assessment of swallowing and 12 of the 57 with epilepsy (21.1%) had an epilepsy risk assessment. For most quality indicators, there was a non-statistically significant trend for improved performance in services with a learning disability liaison nurse. The presence of an electronic flagging system showed less evidence of benefit. Conclusions Inpatient care for people with learning disability needs to be improved. The work gives tentative support to the role of a learning disability liaison nurse in acute general and mental health services, but further work is needed to confirm these benefits and to trial other interventions that might improve the quality and safety of care for this high-need group.

Comparison of access, outcomes and experiences of older adults and working age adults in psychological therapy

This study aimed to evaluate the access, experiences and outcomes of older adults receiving psychological therapies in comparison with adults of working age

Quality of care for people with dementia in general hospitals: national cross-sectional audit of patient assessment

There have been recent reports of poor quality care in the National Health Service in the UK, and older people with dementia are particularly vulnerable. This study aims to examine the quality of assessment of people with dementia admitted to hospital. Cross-sectional case-note audit of key physical and psychosocial assessments was carried out in 7,934 people with dementia who were discharged from 206 general hospitals. Most people had no record of a standardised assessment of their cognitive state (56.8%, 95% confidence interval [CI] = 55.8-58.0) or functioning (74.2%, 95% CI = 73.2-75.1). Information from carers was documented in 39.0% of cases (95% CI = 37.9-40.1). There was considerable variation across hospital sites. Key assessments were less likely when people were admitted to surgical wards. Assessments fall well below recommended standards especially with regard to social and cognitive functioning. Problems are particularly marked on surgical wards.

Use of continuation and maintenance electroconvulsive therapy: UK national trends.

Background: Continuation and maintenance electroconvulsive therapy (ECT) have been used for prophylactic treatment of recurrent depression but are poorly researched and not recommended by the National Institute of Health and Clinical Excellence, UK. Aims: To document the demographic, clinical, and legal characteristics of patients receiving continuation or maintenance ECT, trends in their use, and whether the 2 types could be distinguished by duration and frequency of application. Method: Electroconvulsive therapy specialist psychiatrists completed postal questionnaires about its current use and retrospective use over the past decade. Results: Thirty-five (34%) clinics responded, with 26% currently treating patients with either treatment. Its use has declined over a 5-year period after restrictive guidance by the National Institute for Clinic Excellence. The mean age of patients was 60 years, and more women are treated. Maintenance ECT was given for a longer duration and less frequently than continuation ECT. Conclusions: Use has declined since 2001-2002. Continuation and maintenance ECT can be differentiated according to the frequency and duration of treatment.

A Further Decrease in the Rates of Administration of Electroconvulsive Therapy in England.

Objectives Electroconvulsive therapy (ECT) is an effective treatment of major depression, and there have been consistent improvements in the administration of ECT in the past decade. However, studies have reported a steady decline in the rates of use of ECT in the United Kingdom and Ireland. Despite this, there has been no consistent record of how much ECT is being given or to whom it is given, for more than 20 years. The purpose of this study is to estimate the change in frequency of ECT use, the length of courses, patient demographics, and clinical outcomes between 2006 and 2 periods of 2012/2013 and 2014/2015. Methods In 2012/2013, clinics were asked to complete an online survey giving details of every patient who started a course of ECT between April 1, 2012, and March 31, 2013. This was repeated for the same period in 2014/2015. Results There continues to be a striking decline in the number of courses of ECT prescribed. Course length has increased. Women are twice as likely to be prescribed ECT as men. Modal age is 60 to 80 years, and the most common diagnosis is depression. Most courses were rated as clinically effective, especially for people with severe illnesses. Maintenance ECT is used at half the clinics surveyed. Conclusions The use of ECT in England continues to decline. The reasons for this are unclear and need investigation.