Clinical Audits

This section summarises briefly the clinical audit activity for St. Patrick’s Mental Health Services in 2016. Clinical audit is an integral part of clinical governance. Its main purpose is to improve the quality of care provided to service users and the resulting outcomes. The clinical audit process is a cycle which involves measurement of the quality of care and services against agreed and proven standards for high quality and taking action to bring practice in line with these standards. A complete clinical audit cycle involves re-measurement of previously audited practice to confirm improvements and make further improvements if needed.

Overview of Clinical Audit Activity

The table below demonstrates the breakdown of projects by type undertaken in 2016 including those facilitated by clinical staff at local level and those carried out throughout the organization led by various committees.

No	Audit Title	Audit Lead	Status at year end
1.	Appropriate use of benzodiazepines and hypnotic drugs	Clinical Governance Committee	Re-audit completed in 2016.
	The aim of this audit is to determine if the use of benzodiazepines and night sedation (z drugs) in St. Patrick's Hospital, St. Edmundsbury Hospital and Willow Grove Unit is appropriate, provide feedback to the multidisciplinary teams and change practice if needed.
2.	The Clinical Global Impression (CGI) and Children’s Global assessment Scale (CGAS) level of change of change pre and post inpatient treatment	Clinical Governance Committee	Yearly audit completed
	To measure the CGI /CGAS outcomes for service users pre and post admission
3.	Individual Care Plan Key Worker System	Clinical Governance Committee	Three re-audit completed in 2016. Consecutive re-audit is scheduled for March 2017.
	Ensure compliance with the Mental Health Commission standards and local policies at St. Patrick’s University Hospital, St. Edmundsbury Hospital and Willow Grove Adolescent Unit.
4.	Audits of compliance with the Regulations for approved centres	Departmental Audits	Baseline audits and re-audits completed in 2016.
	To ensure compliance with the Mental Health Commission guidelines and rules of practice
5.	Use of sodium valproate	Clinical Governance Committee	Baseline audit completed.
	To ensure service users are prescribed valproate for an appropriate indication and safety of a potential unborn baby if a woman of a child bearing potential is prescribed valproate
6.	Prescribing and Monitoring of High Dose Antipsychotic Therapy (HDAT)	Clinical Governance Committee	Re-audit completed in 2016.
	To determine whether appropriate monitoring is carried out for service users who are prescribed High Dose Antipsychotic Therapy HDAT.
7.	Transfer of Residents	Clinical Governance Committee	Baseline audit completed.
	To ensure that full and complete written information regarding a service user provided to a receiving facility on a service user transfer to an approved centre or other health care facility.
8.	Admissions	Clinical Governance Committee	Baseline audit completed.
	To assess the quality of the psychiatric admission assessment record and to ensure that the documentation meets the MHC requirements of the Code of Practice on Admissions, Transfers and Discharges to and from an Approved Centre, section 15.3.
9.	Multidisciplinary Teams’ weekly review of incidents	Clinical Governance Committee	Baseline audit completed.
	To ensure that the system for clinical incidents being reviewed by the MDTs at their weekly meetings and maintaining records of same has been implemented.
10.	Prescribing for substance misuse: alcohol detoxification (audit facilitated by Prescribing Observatory for Mental Health-UK*)	Clinical Governance Committee	Baseline audit completed.
	To assess adherence to best practice standards derived from the NICE clinical guidelines on alcohol-use disorders (NICE CG100, 2010 and CG115, 2011).
11.	Prescribing antipsychotic medication for people with dementia (audit facilitated by Prescribing Observatory for Mental Health-UK*)	Clinical Governance Committee	Baseline audit completed.
	To assess adherence to best practice standards derived from the NICE-SCIE Guideline on supporting people with dementia and their careers in health and social care – CG042 (2006).
12.	Rapid tranquillisation in the context of the pharmacological management of acutely-disturbed behaviour (audit facilitated by Prescribing Observatory for Mental Health-UK*)	Clinical Governance Committee	Baseline audit completed.
	To assess adherence to best practice standards derived from the NICE Guideline on Violence and aggression: short-term management in mental health, health and community settings - NICE NG10 (2015).
13.	Adherence to the organisations protocol on falls risk prevention interventions	Falls Committee	Re-audit completed.
	Ensure that service users identified as medium or high risk of fall or with fall episode are managed appropriately to reduce any future fall incidents and to increase service users’ safety.
14.	ECT Booklet	Clinical Governance Committee	Re-audit completed.
	To assess consistency and appropriateness of the ECT documentation in accordance with the MHC guidelines.
15.	Nursing Metrics	Nursing Department	This is a monthly routine audit.
	To compare fundamental aspects of nursing practice with standards as outlined by NMBI, the MHC and best practice.
16.	Infection Control Audits	Infection Control Committee	These are yearly routine audits. Audits scheduled for 2016 were completed.
	Theses audits measure the implementation of policies and procedures relating to infection control
17.	Audit on Audio/Visual Recording	Departmental Audit	Baseline audit completed.
	To ensure current SPMHS practice on audio/visual recording is in compliance with the local policy and Data Protections Acts
18.	Follow up of abnormal laboratory test results	Departmental Audit	Baseline audit completed.
	To ensure that abnormal laboratory test results are correctly communicated, documented and reviewed.
19.	Screening rates for osteoporosis in EDP inpatients with Anorexia Nervosa and EDNOS : Completed Audit Cycle	Multidisciplinary Team	Completed.
	To determine whether all inpatients with a diagnosis of Anorexia Nervosa had an up to date DEXA scan according to the recommendations
20.	An audit of the transition of care of 18 year old patients from Adolescent mental health services	Multidisciplinary Team	Baseline audit completed.
	To establish if transfer of care between Willow Grove Adolescent Unit/Dean Clinic Lucan Adolescent Outpatient Service and the Young Adult Service is occurring in line with best practice guidelines, with a view to improving the transfer of care process.
21.	The monitoring of vital signs in a psychiatric hospital in relation to the recognition of sepsis	Multidisciplinary Team	Baseline audit completed.
	To assess the recognition of sepsis in St. Patrick’s Hospital
22.	Review compliance with documentation of last menstrual period for patients of child bearing potential on admission to SPUH	Multidisciplinary Team	Baseline audit completed.
	To review documentation on admission of LMP in clinical examination section and, if necessary, put in place measures to improve adherence to LMP documentation.
23.	Correct adherence to benzodiazepine and hypnotic withdrawal schedule	Multidisciplinary Team	Baseline audit completed.
	Measure adherence to the standard benzodiazepine and hypnotic detoxification schedules and the safety recommendations as stated in the SPMHS hospital guidelines and to implement changes to improve adherence to the guidelines.
24.	Pre-lithium commencement therapy treatments checks	Multidisciplinary Team	Baseline audit completed.
	To ensure that Lithium Therapy is efficacious and monitored effectively
25.	Audit to Assess the Practice of Prescribing Medication on medication record in Child and Adolescent Inpatient Unit (Willow Grove) of SPMHS	Multidisciplinary Team	Completed.
	To assess prescribing practices on the medication record in Willow Grove Adolescent Unit and to ensure compliance with the local protocol.
26.	Medical assessment and monitoring of adolescents with anorexia nervosa (AN)	Multidisciplinary Team	Completed.
	Ensure compliance with gold standard medical monitoring protocol

* The Prescribing Observatory for Mental Health (POMH-UK) runs national quality improvement programmes designed to the UK specialist mental health services

Key Audit Outcomes for 2016

A re-audit on the use of benzodiazepines and night sedation in St. Patrick’s Mental Health Services showed a reduction in usage of this group of medications and a significant improvement in adherence to the guidelines and local protocols.
A Clinical Audit Programme for the audits of compliance with the Regulations for approved centres has been developed and all Departments are actively involved.
The findings from the audit on prescribing for alcohol detoxification support the fact that current alcohol detoxification screening, prescribing, and monitoring provided by the specialist teams in St. Patrick’s Mental Health Services compare favourably to the levels established by other Mental Health Service Providers who participated in the POMH-UK audit.
The audits on prescribing of Sodium Valproate, on prescribing and monitoring of High Dose Antipsychotic Therapy and on the Lithium therapy initiation led the Organization to work on improving practices regarding prescribing to women of child bearing potential.
The clinical audit confirmed that abnormal laboratory test results are brought to the attention of the clinicians and acted upon by them in a timely manner.
Greater junior doctors’ involvement in clinical audit was achieved by putting in place enhanced support structures.