Quality Network for In-Patient CAMHS (QNIC)

Quality Network for In-Patient CAMHS (QNIC)

Newsletter Update – Summer 2006

Welcome to the Summer 2006 QNIC Newsletter. As you will be aware, QNIC is currently starting its 6th cycle. Cycle 5 was a huge success with 85 units participating in total, including units in Ireland, Turkey, Norway and Iceland.

Staff Update

Helen Thurley will be leaving her role as QNIC Project Worker for QNIC in September to start medical school. Please join us in thanking her for all her hard work over the last year and wishing her all the best for the future.

Executive Committee

As you may be aware, Angela Sergeant and Sean Maskey have now completed their term on the QNIC Executive Committee. Angela and Sean were involved form the very early stages of QNIC and I’m sure you will join us in thanking them for all they have contributed. Following a members’ vote we are pleased to welcome Jane Claxton and Tony Livesey as our new members.

Focused Review Discussion Sessions

This cycle QNIC will be offering units who are having focused reviews, a new optional 30 minute discussion session as part of the review day. It is thought that this option will be of use to units who they feel they have particular issues or ideas to develop that would benefit from detailed discussion with the review team.

Peer-Reviewers

We have started to recruit peer-reviewers for cycle 6 QNIC reviews, which are taking place between September 2006 and April 2007. As a reviewer, you will visit another unit and meet with staff, young people and parents, looking at areas of the QNIC standards. Past reviewers have found the day a great opportunity to have a look round other units and meet other in-patient CAMHS staff to share experiences and discuss common challenges. If you are interested in reviewing a unit please contact Amber Shingleton-Smith by telephone on 0207 9776691 or by email . Reviewers need not have been on a review before, they simply have to have experience to share.

QNIC Annual Forum

This year’s QNIC annual forum in March was a great success and provided interesting workshops on a variety of issues including nutrition, therapeutic programmes, child protection and risk management. Next year’s annual forum will take place on May 9th 2007 – keep the date free in your diaries!

Thank you for your continued support of QNIC and we look forward to continuing to work with you over the coming cycle.

A Review of the QNIC Email Discussion Group – 2006

Smoking Policy

A unit approached the group regarding smoking policy for staff and young people as they were thinking about implementing such policy.

A member replied explaining that having witnessed a number of teenagers take up smoking on inpatient units he does not allow patients under his care to smoke or have cigarettes on the unit. He had not found this policy to be problematic in general. On arrival at the unit young people are offered help to manage not smoking, but this was rarely required. Young people had been threatened with discharge for breaking this rule, but it had never had to be followed through. It was noted that such policy for staff can be more problematic. Staff did not smoke on the unit, but went for breaks outside in which they could smoke.

Another member replied stating that none of their under 16’s were allowed to smoke. All of their units had designated smoking areas for patients only. Their hospital had recently introduced a new smoking policy for staff which only allowed smoking on designated breaks in an outside smoking area. This had been accompanied with a health promotion campaign to encourage and support staff to stop smoking including education and the provision of nicotine replacement products.

Another member wrote saying that their unit also had a non-smoking policy. The member pointed to evidence that smoking can have negative effects on mental health, particularly depression.

Parent/Carer Support Groups

A unit that was looking to set up a parent/carer support group approached the group for advice, suggestions and examples of well functioning groups.

Leigh House described their unit’s parent/carer support group which is run by the social worker and the clinical nurse specialist attached to the unit’s day service. It is held fortnightly for 1.5 hours.

St Georges Eating Disorder Service replied that their patient/carer support group is held on a Sunday evening, when all the patients return from leave. The parents have a group at the same time as the young people. They had tried other options during the week, all of which had been poorly attended. The group had initially been run by senior nurses, but all nurses now felt able to do this. St Georges felt that the group had been very useful and well used by the parents. The unit arranges leave so that although it varies between patients, they all return at the same time. This makes it as convenient for parents to attend as possible.

Kitty for Patient Activities

A member approached the group asking whether other units make financial provision for activities for young people to participate in, particularly during the school holidays. The unit did not have any such money set aside and were having to approach parents for this.

Fant Oast wrote in stating that they set aside money in their budget for patient activities, since they feel it is an important part of treatment. However when unexpected costs arise they are forced to cut back on this. During the holidays they ask parents to provide pocket money (usually £5 per week), so that the young people can buy things when they go on outings, but the unit funds the actual trips. The unit administers this through petty cash. They also suggested that the unit approach their hospital or Trusts League of Friends Charitable Funds, if they felt they would have difficulty finding this money within their budget.

The Newberry Centre replied that they have a budget of £2000 annually which covers all unit activities. They do not separate this out per person, but organize a unit weekly activity timetable, with the young people, that incorporates all of the young people’s individual activity plans. They tend to use more money during the school holidays than during the term time. When organizing more extravagant activities, they ask for a small donation from families, but this is not compulsory.

Veganism and Anorexia

A member approached the group as they had recently admitted a young person with anorexia nervosa who wished to be vegan. This had caused some debate amongst the team regarding her rights to make moral/lifestyle choices verses the practicalities of refeeding on such a restricted diet. The member was interested to know how other units deal with this situation.

The influence of the disorder on a young person’s ability to choose was discussed in a number of the replies. A common answer to this dilemma was to use the rule of thumb that if pre-morbidly this was a cultural/moral lifestyle choice of the young person and family the unit would respect this. However a number of members felt that refeeding on a vegan diet would be very tricky and a number of dangers were associated with this. These were outlined in nutritional guidelines offered by one member (Royal College of Psychiatrists, October 2004) (please contact QNIC for a copy ).

A unit replied that whilst they allowed freedom of choice on the issue of vegetarianism, a vegan diet was not allowed during re-feeding at their unit due to the potential physical health complications and difficulties. However a patient’s choice to be vegan would be supported in subsequent outpatient treatment at a healthy weight, unless there were individual reasons why this would be unhelpful.

Alternatively, according to one member, the Rhodes Farm service insists on first class protein being included in the refeeding process irrespective of present or prior cultural/moral belief systems. Whilst young people may avoid red meat, chicken and fish must be included in their diets.

An advocate from Orchard Lodge added that disallowing a young person to make their own choices could in their opinion be very harmful to the therapeutic relationship. In their experience staff had been able to work positively with a number of young people on vegan diets while being open with them about the impact it can have on rate of weight gain (e.g. bulk of food you need to eat). They had worked with young people who had educated themselves on the types of food that could help them gain weight on a vegan diet and had used this to gain weight.

A dietician from an adolescent mental health unit and eating disorder unit wrote that she allowed vegan diets only if they were established as vegans before the onset of the disorder. She wrote that in her opinion people with eating disorders choose a vegan diet because of the low energy density. In the eating disorder unit she uses the standard ‘5 dislikes only’ for vegetarians and each meat is a separate choice. In her experience people rapidly change their minds about a vegan diet when showed how much fat and oil they will have to take and how much fried beans, nuts, lentils and chips they will need to eat.

She continued to explain that vegan diets are nutritionally difficult to get the right balance of proteins, and other nutrients such as iron, B12, calcium and phosphate. A great deal of skill is needed to achieve this, along with the ability to eat often, and to eat good sized portions. This can be difficult for people with anorexia nervosa to manage and can also be challenging for a kitchen to produce.

Target Weights

A member wrote in enquiring about how other units calculate target weights. Their unit did not have facilities for scanning patients’ pelvises to check for ovulation. They were currently aiming for 98% of average weight for height and age, but were finding that the younger ones could look overweight.

The Huntercombe Maidenhead Hospital EDU replied that without access to pelvic ultrasound it is hard to define for an individual when they are at healthy weight. Weight itself is a pretty poor determinant of good physical health on an individual basis, as there is such a lot of individual variation. Relying on scales to measure true body weight is also dangerous as it can be influenced by water loading. However, it was suggested that if weight and height alone had to be relied upon, then in their experience most teenagers are reasonable healthy between 95% and 105% expected BMI for age, but quite a few are healthy (as measured by pelvic ultrasound) at 90% BMI for age, and a few (only a very few in my experience) need to be over 105%.

The unit added that healthy young teenagers and 11 - 12 yr olds often do look a little plumper as they gear up for their growth spurt, and this is normal and accounted for (as far as possible in amalgamated population data) in the BMI for age data tables, as raw BMI increases almost linearly from age 10 (when for girls 100% BMI = 17) to age 15 (100% BMI = 20), whereas at some point during that period their height shoots up rapidly before stabilising at adult height (with average BMIs still increasing more gradually beyond then, to 100% BMI = 22 at age 20). It is therefore expected that healthy children will look a little plumper in the year of two before their growth spurt (baring in mind that malnutrition may have delayed/prolonged this growth spurt), and a little thinner in mid teenage years, before settling into what looks normal for an adult.

Another member added that all the services they had worked for had used the weight for height database with an expected achievement of reaching 95% to 105% weight for height as guided by pelvic ultrasound.

Camera Use Policies

A member contacted the discussion group as it was in the process of reviewing its policy on the use of cameras. The use of mobile telephones with camera facility was felt to be the most contentious issue that the policy covered. Whilst the member’s units were medium secure, it was felt that some patients may leave the unit and find the use of their mobile telephone a useful way of keeping in touch. The unit was interested in how other units manage this issue and whether they might share their standards.

The Adolescent Psychiatric Unit in Oslo replied explaining that their adolescents are made aware of the issues around confidentiality and mobile phones with cameras on admission. It is also used as a group discussion theme. The adolescents are restricted to using their mobile phones in their rooms alone, as all patients have individual rooms. Mobile phones are left with staff at night times. The unit agreed that it can be useful for young people to have their mobile phones with them if they abscond. The member added that patients have a right to unrestricted access to communication with the world outside the unit. However this must not interfere with maximising the young people's security and maintaining confidentiality.

Another member replied that their unit had banned the use of mobile phones with cameras. In their experience most families have an old pre-camera phone that patients can use their SIM card in. Alternatively such basic phones are relatively cheap to buy new or second hand.

This was the line of view also offered by another member. Both units recognised that this could become more problematic as technology advances and old camera free mobile phones become less widely available.