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AimsThere is a well-known bidirectional relationship between mental and physical health. A thorough mental and physical health assessment of new inpatients on admission is crucial to assess possible organic causes of psychiatric presentations and enable appropriate treatment to be commenced in a timely manner. We noted a pattern of incomplete clerking, leading to delays in commencing treatment and increased workload pressure on the ward medical team. Our audit aims to assess how thoroughly and in what time frame patients' admission assessments are being completed on an acute psychiatric inpatient unit.MethodsA sample of 20 patients was used for each cycle. Eight components were identified from the Trust clerking procedure. These were a full psychiatric history, capacity assessment, prescription chart, physical health systems review, physical examination, blood tests, ECG and VTE assessment. The expected standard was completion of all of the above at the point of admission or, if applicable, adequate documentation of patient refusal with documented reattempt within 24 hours.Electronic patient records were retrospectively reviewed to identify whether each component was completed, the number of days from admission to completion and if completed by the clerking doctor. Evidence of documented patient refusals and the number of incomplete draft entries were noted.ResultsInitial results showed only 20% of patients (n = 4) had the full expected clerking procedure completed at admission. Physical health assessments (ECG, blood test, physical examination) had the lowest completion rates. When components were not completed by the clerking doctor, there was often a delay of several days from admission to completion of by the ward day team. For 50% of patients, some assessments were never completed (without adequate refusal documented). Eight patients did not have a completed VTE assessment by the point of discharge.ConclusionReasons were identified for the poor completion rates of clerking assessments. These included a lack of understanding by on-call doctors about the importance of completing all assessments, unfamiliarity with ward equipment, lack of adequate handover to the ward medical team and staffing pressures. A new handover checklist was introduced for clerking doctors to use and enable better communication with the ward team. Clerking procedure summaries were displayed in on-call rooms and additional teaching was organised.

Abstract Objective To evaluate the effectiveness of a crisis resolution team. Design Randomised controlled trial. Participants 260 residents of the inner London Borough of Islington who were experiencing crises severe enough for hospital admission to be considered. Interventions Acute care including a 24 hour crisis resolution team (experimental group), compared with standard care from inpatient services and community mental health teams (control group). Main outcome measures Hospital admission and patients' satisfaction. Results Patients in the experimental group were less likely to be admitted to hospital in the eight weeks after the crisis (odds ratio 0.19, 95% confidence interval 0.11 to 0.32), though compulsory admission was not significantly reduced. A difference of 1.6 points in the mean score on the client satisfaction questionnaire (CSQ-8) was not quite significant (P = 0.07), although it became so after adjustment for baseline characteristics (P = 0.002). Conclusion Crisis resolution teams can reduce hospital admissions in mental health crises. They may also increase satisfaction in patients, but this was an equivocal finding.

Crisis resolution teams (CRTs) are being introduced throughout England, but their evidence base is limited. To compare outcomes of crises before and after introduction of a CRT. A new methodology was developed for identification and operational definition of crises. A quasi-experimental design was used to compare cohorts presenting just before and just after a CRT was established. Following introduction of the CRT, the admission rate in the 6 weeks after a crisis fell from 71% to 49% (OR 0.38, 95% CI 0.21-0.70). A difference of 5.6 points (95% CI 2.0-8.3) on mean Client Satisfaction Questionnaire (CSQ-8) score favoured the CRT. These findings remained significant after adjustment for baseline differences. No clear difference emerged in involuntary hospitalisations, symptoms, social functioning or quality of life. CRTs may prevent some admissions and patients prefer them, although other outcomes appear unchanged in the short term.

Identification of comorbid substance misuse may be crucial in managing this group, given the increased attendant risks and the strong association between first episode schizophrenia and substance misuse. 3 Substance misuse is likely to be related to suicidal ideation and warrants early attention. 4 5 Regrettably, little systematic study has been done of people with first episode psychosis, but the development of a positive trusting relationship with a single mental health key worker as early as possible is advisable.

The vast majority of workers understand their company's goals (83 percent) and their own job responsibilities (87 percent), but few are given the skills (43 percent) and information (38 percent) needed to achieve those goals, reports a major new study released today by Watson Wyatt Worldwide, a leading global management consulting firm. The study did find that most workers (61 percent) are satisfied or very satisfied with their jobs, and 73 percent indicated that they cooperate well with their immediate co-workers. Unfortunately, the respondents were not so positive when asked their feelings about management or the company as a whole. Less than one in three (32 percent) feel that management makes good and timely decisions. And barely over half (52 percent) reported satisfaction with their companies. Half of all workers (50 percent) are satisfied with their level of pay, the highest response ever to this question in the last ten years. However, few workers (30 percent) see a clear link between pay and performance, a mere 2 percentage points higher than reported in the 1987 study. Only 34 percent say they are rewarded for taking risks and being successful.

The history of the physician's legal duties has been traced from the first recorded writings of the Babylonian era to the present day. There has been a transition from the days of absolute liability to the modern idea of liability based on culpability. The doctrine of stare decisis developed in early English law forms the very backbone of our own jurisprudence. Broadly, if a physician renders reasonable care and skill, he is absolved from liability. Some of the more important legal duties and proscriptions applying to physicians are discussed in particular in this presentation.

Soils used for prehistoric agricultural terracing between 1000 and 1150 A.D. in a semiarid mountainous area of southwest New Mexico were studied. Terracing involved construction of small rock dams across gentle hillslopes and drainageways with subsequent natural sedimentation upslope of each dam. Sources of water for terrace crops were rainfall and runoff from summer thunderstorms. Corn was probably the principal crop. Aims of the study were to (1) characterize soils and geomorphic settings associated with terracing sites in order to infer criteria for site location and (2) explore possible long-term effects of this land use on soil properties. Sites occur primarily within a narrow range of possible locations, implying deliberate placement with respect to climatic, topographic, and soil factors. Locational characteristics commonly include elevations of 1800 to 2000 m, 3 to 10% slopes, < 1 to 8 ha drainage areas, and soils with strongly-developed argillic horizons (claypans). These soils, Paleustolls and Argiustolls, are developed in middle to late Pleistocene rhyolitic or mixed volcanic alluvium. The slowly permeable claypan probably served to confine moisture within the crop rooting zone. Functions of the terracing were to reduce runoff velocity, increase soil moisture, and thicken a naturally thin sandy loam to loam A horizon overlying the claypan. Besides the preserved terraced topography, landscape changes persisting at some sites include gully erosion within and between sets of terraces and sparser grass cover, the latter probably due to the difficulty of blue grama re-establishment from seed under present climatic conditions. Changes in soil properties, mainly limited to A and BAt horizons, were inferred by comparing terraced soils with nearby, similarly-developed, unterraced soils. Although A horizon texture was not appreciably altered, terraced A horizons were thickened to varying degrees at the expense of nearby upslope soils. Most soil changes were degradative, including bulk density increase and reductions in organic carbon, total nitrogen, and total as well as certain inorganic fractions of phosphorus. A greenhouse pot test with corn and barley indicated that the A and BAt horizons of unterraced soils are more fertile than those of terrace soils, although response to nitrogen fertilization in both soils was dramatic.