A New Way Forward: How Brain SPECT Imaging Can Improve Outcomes and Transform Mental Health Care Into Brain Health Care

In the past three decades, brain single-photon-emission-computed-tomography (SPECT) imaging has garnered a significant, evidence-based foundation for a wide array of indications relevant to the field of clinical psychiatry, including dementia, traumatic brain injuries, seizures, cerebrovascular disease, complex neuropsychiatric presentations, and treatment-resistant disorders. In clinical psychiatric practice, however, SPECT remains underutilized. Only a small percentage of psychiatric clinicians use brain imaging technology. In this article, the authors provide a rationale for shifting the paradigm to one that includes broader use of SPECT in the clinical psychiatric setting, primarily for patients with complex conditions. This paper will outline seven specific clinical applications. Adding neuroimaging tools like SPECT to day-to-day clinical practice can help move psychiatry forward by transforming mental health care, which can be stigmatizing and often shunned by the general public, to brain health care, which the authors argue will be more likely to be embraced by a larger group of people in need.

Implementation of treatment escalation plans in an old age psychiatry inpatient hospital

A treatment escalation plan (TEP) enables timely and appropriate decision making in the management of deteriorating patients. The COVID-19 pandemic precipitated the widespread use of TEPs in acute care settings throughout the National Health Service (NHS) to facilitate safe and effective decision making. TEP proformas have not been developed for the inpatient psychiatric setting. This is particularly concerning in old age psychiatry inpatient wards where patients often have multiple compounding comorbidities and complex decisions regarding capacity are often made. Our aim for this quality improvement project was to pilot a novel TEP proforma within a UK old age psychiatry inpatient hospital. We first adapted a TEP proforma used in our partner acute tertiary hospital and implemented it on our old age psychiatry wards. We then further refined the form and gathered data about uptake, length of time to complete a TEP and the ceiling of care documented in the TEP. We also explored staff, patient and family views on the usefulness of TEP proformas using questionaries. TEP decisions were documented in 54% of patient records at baseline. Following revision and implementation of a TEP proforma this increased to 100% on our two wards. The mean time taken to complete a TEP was reduced from 7.1 days to 3.2 days following inclusion of the TEP proforma in admission packs. Feedback from staff showed improvements in understanding about TEP and improved knowledge of where these decisions were documented. We advocate the use of TEP proformas on all old age psychiatry inpatient wards to offer clear guidance to relatives and treating clinicians about the ceilings of care for patients. There are potentially wider benefits to healthcare systems by reducing inappropriate transfers between psychiatry and acute NHS hospitals.

554 - Evaluation of CPR Decisions on an Older Adult Psychiatric Ward, A Quality Improvement Project

BackgroundThe National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) stated that CPR status must be considered and recorded for all acute hospital admissions. Compliance with this recommendation and with Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form documentation in an inpatient psychiatric hospital was assessed. Multidisciplinary team (MDT) opinions surrounding DNACPR were also explored with an aim to educate staff, improving frequency and quality of future discussions.Research ObjectiveEnsure patient suitability for CPR is discussed at admission, that discussions are documented and forms completed in line with Trust policy and national guidelines.MethodResuscitation Council UK guidelines were used as a standard, namely recommendations for clear and full documentation of CPR decisions triggered by a new admission to hospital. A retrospective study of admissions to the older adult psychiatric ward over a four-month period was carried out, identifying 25 patients fulfilling the inclusion criteria. Demographics and CPR consideration at the initial consultant ward round were documented. Completed DNACPR forms were audited for compliance with Trust guidance. Following data collection, 14 staff interviews using standardised questions were completed to gauge understanding of DNACPR. Answers were analysed and education was identified as key. Bite-sized teaching for MDT staff on DNACPR was carried out and response to the intervention assessed using these same standardised questions.Preliminary Results of the Ongoing Study1 patient out of 25 had a CPR discussion documented from their initial consultant review. 12% had documentation of DNACPR consideration throughout the entirety of admission. The 1 DNACPR form subsequently completed had 91% compliance with Trust policy. Qualitative results from staff interviews were insightful with 50% knowing where DNACPR forms werekept, 29% feeling confident discussing DNACPR and 93% feeling able to contribute to team decisions.Following a bite-sized education session these figures increased to 100% having awareness and confidence discussing CPR suitability.ConclusionDNACPR considerations are infrequent and staff interviews suggest this may be due to lack of confidence and knowledge surrounding CPR. Bite-sized education may play a significant role in informing the MDT and ensuring vital DNACPR considerations are not forgotten about in the psychiatric setting.

Quality improvement project: improving the confidence of junior doctors to manage emergencies; Drs abc in an acute psychiatric setting

AimsTo improve the confidence and preparedness of junior doctors in managing medical or psychiatric emergencies when on call at an inpatient psychiatric unit.BackgroundFacilities for emergency care differ between acute medical and psychiatric units. Protocols for managing acutely deteriorating patients and those requiring immediate resuscitation differ across these organisations.Managing medical emergencies can be stressful for all involved. Junior doctors rotate between services where the level of support varies depending on specialty and setting. For doctors who have worked in a setting where the minimum emergency response includes a Resuscitation team, moving to an environment with less support available is a challenge.In our unit, the protocol following an urgent call is for the on-call doctor (who has access to basic resuscitation equipment) to attend and assess the need for paramedics and transfer to local hospital. Stress can be worsened by change of environment, change of expectation and concern about best management in new settings.MethodA cohort of junior doctors were recruited. Baseline assessment included rating their confidence level (scale 1- 10), listing common medical and psychiatric scenarios they had experienced and those they felt least confident managing. Over a period of 10 weeks, follow-up data was obtained. Interventions to improve confidence were assessed during this period, including a handbook and a teaching session on emergency medications. At the end of the project a wordcloud was created in response to the request to “choose 5 words to describe your feelings when called to an emergency”. Identified themes have been fed back to relevant senior staff and will form the basis of future projects.ResultThe initial average confidence score improved from 4.9 to 9.2 and was sustained out to 14 weeks. According the word cloud the most commonly used words were “morale” and “education”.ConclusionPrior to the study, confidence levels amongst the Junior Doctors was low. Introduction of the handbook and teaching session led to an improvement which was sustained. Key themes identified using a word cloud were “morale” and “education”.For junior doctors moving from between services, different expectations and protocol for management of emergencies can influence confidence levels. Psychiatric units should be cognisant of these concerns and implement evidence-based intervention to support junior doctor confidence and improve quality of working experience.

Responding to a pandemic with Simulation Based Education (SBE)? Sharing lessons learned from Sussex Partnership Foundation Trust (SPFT)

AimsIn March 2020 SPFT was preparing for the first wave of the COVID-19 pandemic. Senior medical leadership supported the rapid development and delivery of SBE workshop for assessment and management of physically unwell patients in a psychiatric setting in the context of COVID-19. The training was delivered to 102 psychiatrists across 10 sessions over 4 weeks.A learning review was completed to identify lessons learned from the delivery of this SBE workshop.MethodThe intervention was reviewed using open-space feedback from attendees, interviews with facilitators and medical leadership, and SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis.ResultOverall, the simulation project met its pre-determined objectives of increasing confidence and competence in the medical workforce in the context of COVID-19 and physical health. Development and delivery of the workshop was rapid, with request to delivery taking 4 days.A summary of the key lessons include:An existing simulation faculty within the trust was essential, allowing for rapid identification of key stakeholders and those able to deliver the project.A “direct-line” relationship to senior leadership enabled the project to be dynamic and responsive to changing demands as COVID-19 guidelines and objectives evolved.Redeploying higher trainees with SBE experience to develop the project as a focussed team allowed for rapid delivery which was resource-effective.The workforce found reassurance from understanding what was not expected of them, as much as what was. For example, making clear that Arterial Blood Gases would not be introduced to the psychiatric setting.There is an ongoing learning need for physical health training through SBE in non-covid scenarios.SBE can be an effective intervention for a range of medical grades and covering a large geographical area.There are opportunities for developing multi-disciplinary training on physical health in psychiatry.ConclusionWe have outlined some of the key learning outcomes from a successfully implemented SBE project during the first COVID-19 wave in spring 2020. The project has cemented the role of the relatively new simulation faculty within the trust and highlighted the effectiveness of close collaboration between leadership and a small, dedicated group of facilitators. The project has continued to be used for training new staff members and the resources have been widely shared, used by other NHS trusts and also internationally.