Effects of the COVID-19 pandemic on provision of electroconvulsive therapy.

AIMS AND METHOD: COVID-19 has had a heavy impact on healthcare provision worldwide, including delivery of electroconvulsive therapy (ECT). A survey was completed in the UK and Republic of Ireland in April and July 2020 by 95 and 89 ECT clinics respectively. RESULTS: In April 2020, 53% of the clinics provided only emergency treatment and 24% had closed. Reasons included unavailability of anaesthetists, infection control measures and staff sickness. Restrictions persisted in July, with disruption to an estimated 437 individuals' treatment and poor outcomes, including clinical deterioration and readmission. CLINICAL IMPLICATIONS: Risk stratification, longer clinic sessions, improvements in ventilation, regular virus testing, pragmatic staff rostering and availability of personal protective equipment will protect against service disruption in subsequent waves of the pandemic.

Organic versus mixed specialist older adult inpatient mental health units for people with dementia.

Dementia presents a major public health challenge to healthcare providers globally. When older people with dementia need inpatient mental healthcare, they can be cared for in one of two different types of older adult ward. These patients can either be admitted to an organic inpatient ward for people with dementia or the subtypes of dementia, or they can be admitted to a mixed inpatient ward for older people who have either functional or organic conditions. Using a quality assurance pilot study, the authors aimed to investigate whether the quality of care for patients with dementia differed between mixed and organic inpatient wards in units exclusively serving older people. The quality of care on both types of ward was compared by analysing observed interactions between patients and staff, patient well-being and patient environment and mealtimes. The quality of care was measured with a specially developed instrument and against evidence-based standards of care. The ratings of both types of ward showed high levels of quality interactions between patients and staff. There were minimal differences in the quality of patient and staff interactions, patient well-being, and patient environment and mealtimes between the two types of ward. Further work on outcomes and carer experiences needs to be undertaken to establish the optimal care environment for people with dementia.

Operational Impact of a Critical Care Transport Duty Time Tool Implementation: A Quality Improvement Project to Enhance Crew and Patient Safety.

OBJECTIVE: The Commission on Accreditation of Medical Transport Systems requires transport programs to have operational risk assessment tools that must address issues such as transport acceptance with tools for assessing pilot/driver and crew alertness and fatigue, aviation decision making, and mission acceptance/medical decision making. The objective of this study was to evaluate the impact the implementation of this tool has on programmatic operations. METHODS: This hospital-based dedicated pediatric/neonatal transport team has experienced rapid increase in volume as well as an expanding response area. Data related to calls resulting in excessive on-duty time were evaluated for 2 years before and after the implementation of a formal risk assessment program that included duty time assessment. RESULTS: Since the implementation of the duty time assessment tool, there has been a 48% decrease in calls resulting in crews being held over 1 hour past their shift. Additionally, there has been no decline in transport requests, and the resultant increased safety awareness has led to a decreased risk of incidents related to crew and driver fatigue. CONCLUSION: The implementation of a risk assessment tool not only increases crew safety and subsequently patient safety, but also it has no negative impact on referral pattern or volume.

The Impact of Accreditation for 10 Years on Inpatient Units for Adults of Working Age in the United Kingdom.

Psychiatric inpatient units in the United Kingdom have been criticized for having falling bed numbers, staff shortages, and brief compulsory admissions. This column describes the impact over 10 years of a voluntary U.K. quality improvement program to provide accreditation for inpatient wards. Performance on evidence-based standards was assessed during peer review visits, and 92 of the 140 wards participating are currently accredited. Improvement was found in patient contact, access to therapies, safety, crisis planning, ability among staff to take breaks, and doctor availability. Availability of activities outside working hours needs improvement. Further work is needed to incorporate clinical outcomes in the accreditation program.

Training and service provision for people with intellectual disability and mental illness: the views of psychiatrists.

  Objectives: The objectives of this mixed methods study are to 1) investigate the knowledge and skills of mainstream psychiatrists in managing patients with Intellectual Disability (ID) and comorbid mental health disorders, 2) assess their perception of the quality and accessibility of services for this population, and 3) establish the local implementation of the Green Light Toolkit. Method: We surveyed mainstream psychiatrists in the Thames Valley region working in general adult, forensic, and older adult services, to ascertain their opinions about their knowledge and skills in managing patients with ID and comorbid mental disorder, as well as quality and accessibility of services. We compared our findings with previous UK and international research. Results: Respondents mirrored views expressed in earlier studies that inpatient care should be provided in dedicated units for people with ID, rather than general adult inpatient wards. Limited resources, training and competence, and lack of collaborative working were highlighted as key barriers to provision of effective care. Conclusion: Psychiatrists broadly support a specialist service model for people with ID. In the UK, specialist psychiatric services for people with ID have been delivered through inpatient and community services, but there is a current shift towards integrating ID with mainstream service models. Participants expressed concern that mainstream services fail to meet the mental health needs of this patient group, and lead to increased patient vulnerability. The Green Light Toolkit was not well known or used within services. A number of ways of improving collaborative care between services are suggested.

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.

Colleague and patient appraisal of consultant psychiatrists and the effects of patient detention on appraisal scores.

Aims and method This paper aims to review colleague and patient feedback from the 10-year period of the operation of the Royal College of Psychiatrists' 360-degree appraisal system, specifically: (1) examine the overall distribution of ratings; (2) examine the effect of working primarily with detained patients on patient feedback, represented by forensic psychiatrists; and (3) look for a relationship between colleague and patient ratings. Results Data were analysed for 977 participating psychiatrists. Both colleagues and patients rated psychiatrists overall with high scores. Less than 1% were identified as low scorers, although there was no relationship between those identified by colleagues or patients. Colleague and patient feedback scores varied little between subspecialties including forensic consultants. Clinical implications Psychiatrists in all subspecialties obtained high scores from colleagues and staff. Working with detained patients appeared to have little effect on patient ratings.

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.

OBJECTIVE: This study aimed to evaluate the access, experiences and outcomes of older adults receiving psychological therapies in comparison with adults of working age METHODS: Primary and secondary care providers of psychological therapy services participated in the National Audit of Psychological Therapies. The main standards of access, experience and outcomes were measured by retrospective case records audits of people who completed therapy and a service user questionnaire. Outcomes were measured pre-treatment and post-treatment on the PHQ-9 and GAD-7. RESULTS: A total of 220 services across 97 organisations took part, 137 (62%) in primary care. Service user questionnaires were received from 14 425 (20%) respondents. A total of 122 740 records were audited, of whom 7794 (6.4%) were older adults. They were under represented as 13% of the sample would have been expected to be over 65 years according to age adjusted psychiatric morbidity figures. People over 75 years had the third expected referral rate. Significantly, more older adults than working age adults completed therapy (59.6% vs 48.6%) and were assessed as having 'recovered' post-treatment (58.5% vs 45.5%). Older adults were more satisfied with waiting times and numbers of sessions, but there were no differences in self-reported experience of therapy. CONCLUSION: Although older adults are less likely to gain access to psychological therapies, they appear to have better outcomes than working age adults. Further work is needed to improve access for older people.

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.

Factors affecting care on acute hospital wards.

AIM: To identify positive and negative aspects of the quality of care for older adults admitted to acute hospital wards during the Quality Mark pilot study. METHOD: A total of 306 patients and carers and 157 ward staff from 12 wards in six hospitals participated in a pilot study by completing questionnaires about the quality of care on the ward. They stated how much they agreed with a number of statements about care and provided additional free text responses. RESULTS: Patients rated staff attitudes highly, while staff expressed confidence in their skills in providing care. Patients rated the quality of food and the availability of staff lowest. Thematic analysis identified concerns about the ward environment, staffing levels and nutrition. CONCLUSION: Attention needs to focus on improving inpatient environments, nutrition and staff availability.

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.

Adequacy of training in dementia care for acute hospital staff.

People with dementia are frequently admitted to general wards where their dementia is often unrecognised and related healthcare needs are unaddressed. This article examines how staff view the training they have received in assessing and caring for people with dementia who are admitted to hospital. It reports on the results of the National Audit of Dementia (Care in General Hospitals); staff completed questionnaires reporting the sufficiency of their training in 13 main areas related to dementia care. Responses were obtained from 270 doctors, 968 qualified nurses and 541 healthcare assistants (HCAs); 690 worked on medical wards, 677 on surgical/orthopaedic wards and 412 on care of older people wards. Doctors felt more adequately trained than nurses or HCAs. Nurses on medical and surgical/orthopaedic wards thought their training was less sufficient than their colleagues working on care of older people wards. The authors conclude that nurses and HCAs working on wards not specialising in the care of older people should receive increased training in dementia care.

Mental health services for people with intellectual disabilities.

PURPOSE OF REVIEW: This review summarizes recent research into psychiatric services for adults with intellectual disabilities, with a particular focus on inpatient care. RECENT FINDINGS: People with intellectual disability appear to be admitted with more severe problems and receive more interventions than those without intellectual disability when admitted to general psychiatric units. Qualitative research has shown poor standards of care on some general psychiatric inpatient units. Studies of supported generic inpatient units have reported successful outcomes, supported by qualitative studies of satisfaction. Length of stay for people with intellectual disability is not consistently longer on specialist than general psychiatric units. Delayed discharge and restrictive practices, however, still need addressing. The important components of community mental health services have been evaluated from the points of view of psychiatrists, patients and carers. Emergency provision of psychiatric assessment and care remains a problem in some centres. SUMMARY: There have been few randomized controlled trials in this field; however, uncontrolled comparisons and service evaluations suggest positive outcomes in specialist services. Qualitative work has made important contributions to understanding the patients' and carers' experiences. Further work should focus on the measurements of outcome and satisfaction.

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.

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.

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.

Antipsychotic medication, sedation and mental clouding: an observational study of psychiatric consultations.

Sedation and mental clouding are of concern to people on antipsychotic medication and are implicated in social withdrawal but their severity may be underestimated by psychiatrists. Existing studies of communication about adverse effects of medication are based on reports made by doctors or patients. This study is based on audiotapes of 92 outpatient consultations in two UK mental health trusts involving nine consultant psychiatrists where antipsychotic medication was discussed. When interviewed, these doctors and their colleagues had expressed a commitment to 'patient-centred' practice as well as recording concerns about the difficulties involved in the discussion of medication side effects. The study focuses on the ways in which sedation and mental clouding are presented and engaged with. Analysis of audiotape transcripts showed that patients raise these issues more often than doctors, contrasting with other adverse effects (such as blood changes) where doctors are more frequently the initiators of discussion. Sleepiness is sometimes presented by both patients and doctors as a part of normal experience and therefore to be welcomed. When presented as troublesome, patients' reports were sometimes met by doctors offering no response, changing the subject, or disagreeing with the patient's interpretation of the experience. Equally, there were some attempts by doctors to engage with patients' troubles and seek solutions. These could be unsuccessful where they involved challenges to the patients' medication-taking rationale, or more successful where they involved sympathetic and supportive listening. We speculate that the capacity to avoid addressing these problems is linked to the informal conversational style of these consultations, which means that concerns raised by one party can remain unaddressed without offending conversational norms. Doctors in these consultations are able to exercise considerable discretion over whether to define reports of sedation and mental clouding as medication-related problems.