closing the gap paul greenwood, linda martin, dr sian bensa€¦ · •not aware of ward practises,...
TRANSCRIPT
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Closing the Gap
Paul Greenwood, Linda Martin, Dr Sian Bensa
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• The Advancing Quality Alliance (AQuA)
and the lead partner organisation; The
University of Central Lancashire
(UCLAN) were invited by the Health
Foundation (HF) to bid for a grant to
support a programme that will aim to
reduce the use of restraint.
Closing The Gap
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• reduce the incidence of harm caused to
patients and staff as the result of a 80%
reduction in physical restraint by the end of
the programme in June 2016.
• implement a robust approach to improving
quality and patient safety
Aims of CTG
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Wave 1 (6 months per wave)
• Cumbria Partnership NHS Foundation Trust
• Lancashire Care NHS Foundation Trust
Wave 2
• Merseycare NHS Trust
• Five Boroughs Partnership NHS Foundation Trust
• Cheshire and Wirral Partnership NHS Foundation Trust
Wave 3
• Manchester Mental Health and Social Care Trust
• Pennine Care NHS Foundation Trust
Participating teams
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AQuA Six Step Toolkit
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• Number of physical restraints per month
• Number of violent incidents per month
Balancing measures
• Monthly PRN medication
• Seclusion use and transfer to PICU
Measures
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• Project charter
• Improvement workshop
• Team training on 6 Core strategies©/ReSTRAIN Yourself
• On site weekly visits for 6 months.
• Ongoing PDSAs developed including coaching from Improvement Advisor on site.
• Measures and safety crosses/SPC charts
• Sign up to the Restraint Reduction Network
Implementation
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8©2015 Advancing Quality Alliance Back to Links page
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Challenges
Workforce
• Staffing levels
• Psychology not on all wards
• Activity co-ordinator not on all wards
• OT limited on some wards
• Disconnect from board to ward. Staff feel lack influence.
• Medical cover/Consultant role
• Peer support worker role
Policy and practice
• Blanket rules
• Unwritten rules
• Over cautious prescribing
• Task orientated driven by ‘to do list’.
• Them and us relationship between staff and patients.
• Data collection not standardised across trusts
• Lack of data analysis feedback.
• Legal highs
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• Low levels of restraint -1 patient can be focus.
• Focus too much on behaviour rather than ‘What is behind it’.
• Police response mixed.
• Wards have become a very task orientated culture
• Nursing office dynamics with patients “in a minute”
• Focus on permission rather than innovation
• No staff surveys done on a regular basis
• Smoking rules
• Eating with patients
• Mixed level of multi disciplinary working/tension
• Middle management – mixed messages
• Appropriate admissions – LD/Autistic spectrum
• Observations and staff interactions, particularly agency staff
• Barrier to access qualified nurses - right staff, right time and right place.
• PICU pathway – inconsistent/tensions.
Observations
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Positive practice
• Self harm pathway
• Formulation meetings
• New builds
• Meaningful activities throughout the day and evening (use of external
facilitators).
• Engaging teams
• Multi disciplinary working
• Mindfulness
• Charge and discharge
• Patients consistently positive about the staff but perception of roles
isn’t clear.
Observations
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Leadership 15 step challenge/Executive walk rounds
Data Safety Crosses/run charts
Workforce Development
Handovers/de-escalation ward sessions/least restrictive planning
Prevention tools Sensory/comfort rooms and My Safety Plan
Users/Carers Community meetings and ward mood
Debrief Formal debriefs
Improvements
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My Safety Plan
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Measures wave 1
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Measures wave 2
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Measures wave 3
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Ward example
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• PRN medication and use of
seclusion/transfer to PICU- numbers very
low and stable.
• PRN below 10 per month
• PICU/seclusion below 2 per month on all
wards. Issues with pathway.
• Common theme of concern about under
medicating
Balancing measures
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REsTRAIN Project
Weaver Ward, Brooker Centre, Halton
Linda Martin (Ward Manager)
&
Dr Sian Bensa (Clinical Psychologist)
2016
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Setting
• Weaver Ward, Halton (Runcorn and
Widnes catchment areas
• Acute Female Inpatient ward
• 14 - 16 beds
• Ward team: 33 nursing staff, 2/3
psychiatry / medical staff, 2 pharmacy
staff, 1 clinical psychologist, 1 activity
worker, 1 Team Secretary
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Interventions
Commenced February 2015…
• Safety plans (nursing)
• Least restrictive planning & team formulation (Psychologist, Sian)
• Community Meetings; “You said, We Did” (Activity Worker, Audrey)
• Low Simulation Room (nursing)
• Handover (Deputy Manager, Charlotte)
• Team debriefs (nursing)
• Patient debrief (nursing & Sian)
• Gardening (nursing)
• Principles taken from Self-injurious behaviour e.g. psychology at Wigan (nursing)
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Findings: Statistical Process Chart for Violence
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Findings: Statistical Process Chart for Restraint
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Changes in Violence & Restraints
• Restraint goes down; average was low anyway (2 per month) and not really changed over time.
• Over time where there were high levels of acuity (up to 100 per month) restraint did not rise alongside this; hence, staff response towards challenging behaviours may have changed.
• Staff’s attitude has changed from sense of personal/individual responsibility to team responsibility (i.e. shared anxiety, have a strategy and belief can deal with challenging behaviours better, which has brought the anxiety down).
• Staff not feeling as though they will be criticised and blamed for incidents or way things are managed.
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Examples
26 year old lady, diagnosis of PD
Ligaturing x3 plus per day
• Formulation, space to reflect, develop team plan of what could be done differently, let ligature, notice, encourage self-removal of ligature when ready, not over soothing or positive reinforce behaviour, boundaried one to one time at set times continued (as per self-injury ideas).
• Reduced observation levels.
• Rationale and explicit discussion re change in practise / support.
• Safety plan.
• Patient asked to remove ligatures safely on her own.
• Debrief, said she did not realise that staff did not like getting into removing ligatures and restraints.
• Staff wait outside.
• Number of ligatures reduced.
• No restraints / incidents.
• Discharge after 7 days.
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Examples59 year old lady, diagnosis of schizoaffective disorder
“Defacto seclusion”
• Staff reluctant to let patient out of low stimulation room, patient shouting, getting distressed, seemingly “paranoid”, threw drinks, threatening to harm staff.
• Staff observe what they see rather than what they are doing, monitoring as opposed to lack of active engagement by staff not helpful.
• Team reflection on how could have been managed differently, let her be distressed in ward, she was not a risk to others or self, shouting.
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Challenges for ward
• Staffing issues
• Wider system issues (within and outside trust)
• Bed management (pressure, out of area
placements, number of clients, mix of patients
not considered when admitting)
• Lack of suitable local accommodation for
some to move onto, frustrations in time taking
due to processes
• Medics (psychiatry inconsistencies,
prescribing, reviews, plans)
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Wider system issues
• Lack of IT support… white “boards”
• Inputting onto IT system, no feedback re incidents occurring.
• 2 systems for record keeping(e.g. medics write in paper notes, everyone else has to use IT).
• Safety plans are not on IT system.
• Concerns about accountability.
• Bed management & pressures
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Wider system issues: what would help?
What would help?
• Centralised case note recording.
• Place to include safety plans on shared IT system.
• Risk aversion, concerns about individuals being blamed.
• Recognition of patient mix by bed management / clinical
risk management by bed management (e.g. clinical staff,
shared acuity support across other acute wards where
necessary).
• Crisis beds in community.
• Options for accommodation in community & support e.g.
LD services, neuro, rehab services, shared homes etc.
• Adequate PICU support.
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Psychiatrists
• Turn over of locum consultants and variations in practise.
• Risk averse.
• Not aware of ward practises, e.g. management of self-harm, avoidance of restraining to medicate.
• Not working as part of the MDT or sharing responsibility.
• Unreliable, patients (plus relatives / carers and care coordinators) not seen when expected to be.
• Psychiatric treatment plans not followed through / changed / unclear.
• Not involved in team formulations and debrief.
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Psychiatrists: what would help?
What would help?
• Offer team approach to supporting psychiatrist.
• Planned review times so patients and others
know when to attend.
• Invite to formulation meetings.
• Engage in MDT discussions and decision
makings.
• Share sense of responsibility for risk taking.
• Documentation updated promptly (e.g. plans,
S17 signed, med prescribing)
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Key learning points
• Culture shift / attitude change in relation to restraints, dealing
with self-injury.
• Shared team responsibility.
• Providing interventions when someone is distressed, rather than
just monitoring.
• Reflecting what a culture shift has meant for patients / more
patient centred approach / compassion / empathy etc.
• Using debriefs with patients, have explicit and open
conversations, and discuss responsibility.
• Providing some space for reflection and developing team and
holistic support plans.
• Reflecting and learning from what helps and what does not.
• More proactive to engage medics.
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Key learning points
• Culture shift / attitude change in relation to restraints, dealing
with self-injury.
• Shared team responsibility.
• Providing interventions when someone is distressed, rather
than just monitoring.
• Reflecting what a culture shift has meant for patients / more
patient centred approach / compassion / empathy etc.
• Using debriefs with patients, have explicit and open
conversations, and discuss responsibility.
• Providing some space for reflection and developing team and
holistic support plans.
• Reflecting and learning from what helps and what does not.
• More proactive to engage medics.
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• Identified wards (5 per trust)
• Identified champions (4 per ward)
• Training
• Patient survey
• Action learning sessions
• Coaching and site visits as required.
• Supporting PMVA teams in developing corporate
training.
AQuA restraint reduction
programme
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• The AQuA restraint reduction programme is available as a
package of support to non members.
• Contact [email protected] for more information
• www.aquanw.nhs.uk
• @paul_AQuA
• Toolkit will be available on above website in October 2016
including;
www.health.org.uk
www.uclan.ac.uk
www.restraintreductionnetwork.org
Support
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Thank you