Assessment of mental capacity provides an ethical and legal framework for care which values patients' autonomy whilst recognising the instances where it is appropriate to act in patients' best interests.Existing medical literature indicates that mental capacity is poorly documented in psychiatric inpatient settings. The aim of the project was to examine the frequency of capacity and consent to treatment documentation with a view to creating changes in practice by raising awareness about the importance of assessing and documenting mental capacity.A multi-centre quality improvement project was conducted in September 2014 across all general adult psychiatric inpatient wards in the North Central London Training Scheme. The frequency of documentation of capacity and consent to treatment for all adult psychiatric inpatient wards across North Central London was measured.Electronic patient notes were audited retrospectively to ascertain whether capacity and consent to treatment on admission, and within the preceding seven days of data collection, was recorded. Data was collected across three successive time points during a 12 month period following the implementation of changes. A total of 232 patients were included in the baseline measurements. The results highlighted a deficiency in the recording of capacity and consent to treatment for adult psychiatric inpatients. The results showed that, of the patients audited, 49.8% had their capacity and consent to treatment assessed on admission, 61.9% had a capacity assessment in the previous 7 days and 60.5% had consent recorded in the previous 7 days. These findings were presented at local hospital teaching sessions at each of the audited sites. These sessions also gave teaching on mental capacity. Audit cycle 1 was conducted 6 months later, this included 213 patients and showed a 30% improvement in the frequency of documentation across all measures. The results showed that 77% of patients audited had their capacity and consent assessed on admission to the ward, 87.3% had a capacity assessment in the previous 7 days and 85.5% had consent recorded in the previous 7 days. After feedback from the teaching sessions, a clerking proforma was produced that had a prompt to assess to capacity. Audit cycle 2 was conducted 12 months after the initial baseline measurements, had a sample size of 229 patients and a sustained improvement in documentation of 26% from baseline was demonstrated across all measures.This project demonstrated that capacity and consent to treatment was not routinely recorded but that the frequency of recording improved through the use of teaching sessions on mental capacity and the introduction of admission clerking proformas with capacity prompts.
AimsHealthcare triage for those subject to section 136 powers (MHA 1983/2007) remains challenging. Camden and Islington NHS Foundation Trust opened a dedicated Health-Based Place of Safety (HBPOS) in 2020, situated separately from an emergency department (ED). There was concern that this may lead to physical health problems going unrecognised. We aimed to design a simple, efficient algorithm to be used by non-medically-trained staff to identify those who are subject to s.136 powers who would benefit from medical clearance before being admitted to the HBPOSMethodWe chaired a consensus meeting with nursing staff, police and emergency medicine consultants when designing the algorithm. Case notes of those presenting under s.136 to the POS over 1 calendar-month in 2019 were reviewed, and the proportion of those who the algorithm would have diverted for medical clearance was calculated. We then reviewed the proportion of cases sent for medical clearance during a single calendar month in 2020, after the HBPOS had opened, to see whether there was a significant difference.Result37 patients were admitted to the ED-based POS in July 2019, of which 36 records were analysed. 9 patients (25%) were referred for medical clearance, with 2 (6%) requiring medical admission. 8.6% were identified as needing medical clearance when the algorithm was applied retrospectively (positive predictive value 66%, negative predictive value = 79%).Review of records over 1 calendar-month after the HBPOS was established showed 30.6% of patients had been diverted for medical clearance prior to entering the HBPOS. Of the 65 patients, 1 (2%) required transfer to ED within 48 hours of entry. No statistical difference in the proportion of patients sent for medical clearance was observed since the formation of the HBPOS away from the ED (Chi-squared = 0.549, p = 0.458), suggesting the algorithm successfully identified those patients who needed medical clearance prior to admission.We observed high rates of intoxication amongst those admitted (30–40%).ConclusionThe algorithm showed high specificity and negative predictive value, allowing for a degree of confidence when admitting those deemed at low-risk of physical deterioration, though it does not eliminate the need for clinical judgement. Interpretation of the results is complicated by the COVID19 pandemic in 2020, which was not accounted for in the algorithm, which possibly led to deviations from the algorithm in real-world clinical practice.
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