BackgroundLength of stay and bed occupancy are important indicators of quality of care. Admissions are longer on older adult psychiatric wards as a result of physical comorbidity and complex care needs. The recommended bed occupancy is 85%; levels of 95% or higher are associated with violent incidents on inpatient wards.MethodsWe aimed to reduce length of stay and bed occupancy on Leadenhall ward, a functional older adult psychiatric ward serving a population of just under 40 000 older adults in two of the most deprived areas of the UK.At baseline in October 2015, the average length of stay was 47 days, and bed occupancy was at 77%. We approached the problem using quality improvement methods, established a project team and proceeded to test a number of changes over time in line with the driver diagram we produced.ResultsIn 12 months, length of stay was reduced from an average 47 to an average 30 days and bed occupancy from 77% to 54%.At the end of 2016, the closure of some beds effected this calculation and we added an additional outcome measure of occupied bed days (OBD) better to assess the impact of the work. OBD data show a decrease over the course of the project from 251 to 194 bed days (a reduction of 23%).ConclusionThe most effective interventions to address length of stay and bed occupancy on an older adult functional mental health ward were the daily management round and the high-level management focus on longer-stay patients. The work depended on an effective community team and on the support of the quality improvement programme in the trust, which have led to sustained improvements.

As exam season is now under way, Laura Ralph looks at how schools can support pupils who are feeling the pressure around their assessments

Objectives: It is well established that current measures of pregnancy intentions fail to capture the complexity of couples' experiences. Despite its limitations, the dichotomous framework of intended versus unintended pregnancy guides public health programs, policy and clinical practice. We describe the construct of pregnancy acceptability, which captures whether individuals anticipate that an unexpected pregnancy will be considered welcomed or okay. Methods: Individual qualitative interviews were conducted with 50 young women aged 18-24 and their male partners (n=100) to elucidate prospective pregnancy desires and perspectives on pregnancy planning. Results: Nearly all couples were not currently trying to become pregnant; thus, if they were to become pregnant, traditional measures would classify these pregnancies as unintended. Yet, a surprising number of participants indicated they would consider an unexpected pregnancy okay, welcomed or even a very positive outcome. For some participants, the acceptability of an unplanned pregnancy reflected pregnancy desires not considered normatively appropriate or captured by traditional measures (e.g., being open to a pregnancy "just happening" or not having an expectation of active pregnancy planning). In reflecting on their retrospective pregnancy intentions, parents described pregnancies as not planned but very much wantedthough they were unintended, they were considered acceptable. Conclusions: Acceptability captures a more nuanced view of pregnancy experience and what it means for young people's lives in a way that current intentions language and framing neglect. In addition, acceptability may be a construct that resonates with the perspectives and lives of young people for whom the notion of active pregnancy planning is not salient.

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Background: Current quality improvement models in obstetrics focus on prevention of adverse perinatal outcomes. The development of these metrics was based on expert opinion that did not account for patients' values. The ultimate aim of our research is to develop performance indicators for labour and birth that reflect the patient perspective. Methods: A qualitative interview design was used to engage a convenience sample, of recent (<1 year) postpartum patients, in semi-structured interviews, where they shared their experiences of their recent birth. Patients were also asked to assess descriptions of adverse perinatal outcomes for readability and comprehension, towards developing accurate unbiased descriptions for a subsequent survey of patients to weight complications. Responses were recorded, transcribed, coded and analyzed using thematic analysis. thematic analysis. Results: Five themes emerged during the analysis: (1) desire for patient-centred care, (2) improved communication, (3) labour/birth, expectations and outcomes, (4) care team support during labour and birth, (5) continuing emotional and physical postpartum care. Conclusions: Patient-centred care and good health outcomes were the major values expressed by the patients in this study. Good communication and shared decision making led to patients describing their labour and birth as a satisfying experience. This study lays the foundation for developing a quality tool to measure the outcomes of birth and adverse outcomes from the patients' perspective.