Scottish Patient Safety Programme – Mental Health Trauma Informed

Scottish Patient Safety Programme – Mental Health

Trauma Informed care, Seclusion and Restraint Scottish Patient Safety Programme – Mental Health

Trauma Informed care, Seclusion and Restraint

Johnathan MacLennan Improvement Advisor and Programme Lead SPSP-MH Healthcare Improvement Scotland

‘...why wouldn’t they be safe?’ Scottish Patient Safety Programme – Mental Health

Restraint – Opening Pandora’s Box

Carolyn Little Project Manager User and Carer Involvement Dumfries

Scottish Patient Safety Programme – Mental Health

Improving practice in restraint and seclusion

Dr David Hall National Clinical Lead SPSP-MH Consultant Psychiatrist and Clinical Director NHS Dumfries and Galloway First .....

Do No Harm

HARM

16 ‘The Scottish Patient Safety Programme is, without doubt, one of the most ambitious patient safety initiatives in the world – national in scale, bold in aims, and disciplined in science. It harnesses the energies and wisdom of Scotland's healthcare leaders – all aligned toward a common vision, making Scotland the safest nation on earth from the viewpoint of healthcare.’

Don Berwick, former President and Chief Executive for the Institute for Healthcare Improvement

Acute Maternity Adult and Children

SPSP

Mental Primary Health Care Overall Aim: Reduction in harm experienced by individuals receiving care from mental health services Types of Harm Social Sexual Physical Psychological

Treatment Accidents Self Aggression Suicide Sexual Self – Medication including falls Harm and Violence Harm Neglect – Interventions

Can result from one causal factor or a combination of factors Complex interaction between patient factors, environment, staff factors, illness and treatment and far more prevalent in mental health services Category A Harm Incidents Harm caused to person resulting from interaction with service Category B Harm Incidents Harm behaviours of service user to self and others Overall Aim: Reduction in harm experienced by individuals receiving care from mental health services Types of Harm Social Sexual Physical Psychological

Treatment Accidents Self Aggression Suicide Sexual Self – Medication including falls Harm and Violence Harm Neglect – Interventions

Can result from one causal factor or a combination of factors Complex interaction between patient factors, environment, staff factors, illness and treatment and far more prevalent in mental health services Category A Harm Incidents Harm caused to person resulting from interaction with service Category B Harm Incidents Harm behaviours of service user to self and others What is distinctive about harm in mental health care?

Physical Psychological e.g. harm resulting from e.g. due to conduct or medication errors, harm experiences which cause fear, resulting from restraint alarm or distress

Social Sexual e.g. harm caused to social e.g. adults at risk due to sexual relationships or financial harm disinhibition or the resulting from the person’s manipulation of an individuals vulnerabilities vulnerabilities

To include: Forensic inpatient units To exclude: Inpatient units caring for people with dementia Older adult functional illness units.

Phase One Preparation Pre-work Phase Two Phase Phase (Testing) Sep 13 – May 16 Jan 12 – May 12 May 12 – Aug 12 Aug 12 – Sep 13

The value of “failed tests”

“I did not fail one thousand times; I have found one thousand ways how not to make a light bulb.”

Thomas Edison Programme Objective

(1) To systematically (2) Reduce harm experienced by people using mental health services in Scotland (3) By empowering staff to work with service users and carers (4) To identify opportunities for improvement (5) To test and (6) reliably implement interventions (7) And to then spread successful changes across NHS Board areas Programme Workstreams

Safer Medicines Management Risk Assessment and Safety Planning

Leadership and Culture

Restraint and Seclusion Communication at Transitions Scottish Patient Safety Programme- Mental Health Outcome Measures

• Rate of violence and aggression per ward • Percentage of patients engaged in violent and aggressive behaviour • Rate of patients being restrained per ward • Percentage of patients being restrained per ward • Percentage of patients who experience one or more episodes of seclusion • Percentage of patients who experience self harm • Days between inpatient suicide • Percentage of patients who have emergency detention or use of nurse holding power

Scottish Patient Safety Programme- Mental Health Outcome Measures

Acute Admission Rate of incidents of physical violence NHS Scotland

7.00

6.00 Start of phase 1

5.00

4.00 Start of phase 2

3.00 rate per 1000 per 1000 rate beddays 2.00 17 Acute wards from 10 Boards 1.00 Learning Session 2 Learning Session 3

0.00

Jul 13 Jul

Jan 13 Jan

Jun 13 Jun

Oct 12 Oct

Apr 13 Apr

Sep 12 Sep 13 Feb 13 Sep

Dec 12 Dec

Aug 13 Aug

Nov 12 Nov

Mar 13 Mar May 13 May Acute Admission Rate of incidents of restraint NHS Scotland

4 Start of phase 1 Start of phase 2 3

2 rate per 1000 per 1000 rate beddays

1 17 Acute wards from 10 Learning Session 2 Boards Learning Session 3

Jul 13 Jul

Jan 13 Jan

Jun 13 Jun

Oct 12 Oct

Apr 13 Apr

Sep 12 Sep 13 Feb 13 Sep

Dec 12 Dec

Aug 13 Aug

Nov 12 Nov

Mar 13 Mar May 13 May Culture / climate

PDSA • Please • Do • Something • ANYTHING!! May 2013 Leadership report

NHS Grampian - WARD 4 Time taken for Risk Assessment Time taken from Admission for Risk Assessment December 2012-to date Median 14:00

Baseline data of when RSI were completed from time of admission 12:00

Aim achieved. Admissions have RSI completed within 2 hours of admission since January 2013 10:00

PDSA 3 - 2 1/2 hrs to 08:00 complete RSI

PDSA 4 - complete RSI 06:00 within 2 hrs o/a

29/1/13 Agreement with staff standard for documentation 04:00 No times recorded

02:00

00:00 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65 67 69 71 73 Median Staff Meeting in IPCU REH Safety Brief Compliance 100% IPCU to discuss Version 3 issues and introduced

90%

First Re-audited 80% Completion and left audit carried Included in

induction pack

70% Version 4 introduced Influx of new with added staff who were

Compliance 60% unfamiliar with process.

50% Version 2 introduced, now 1 bundle and 3 safety briefs per day Introduced

40%

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35

Week As Required Psychotropic Monitoring

% Compliance ORAL/IM PRN MONITORING COMPLIANCE IN IPCU REH Median

100

50 Highlighted on safety brief 40

20 Changed to coloured 10 stickers

13 13

- -

Jul

Jun

Aug Sep May Sticker Use 100 SPSP-MH recruited the NHS Lothian co-ordinator 90

Ran out of stickers 70

60 Ran out of stickers

30 Percent compliance Percent 20

------

14 14 14

- - -

Feb Feb Feb Feb Mar Mar Mar Mar Mar

14 14 14 14 14 14 14 14 14

------

Apr Apr Apr

Jan

- - -

24 03 10 17 03 10 17 24 31

07 14 21 27 Enabling patients to share the way they feel about their experiences forms a powerful message that will help to:

•Understand complex experience •Take another look at practice •Provides concrete real examples that cannot be disputed •Develop a service that is more responsive to the experiences of those who give and receive the service •Recognise and reinforce good practice

Improvement Participate

Safety Climate Survey Learning Results

Feed- back Looking into an unknown future...... Phase 1 Phase 2

Total number of Year 1 eligible wards in Scotland – Total of 59% of 123 eligible wards are involved as Percentage of today involved in pilot stage – 24% Predicted to have 93% involved by September 2014

So what? • Debriefs or is it review? • Trauma informed care • Medication • Data • Feedback

For more information:

• www.knowledge.scot.nhs.uk/spspmh.aspx • www.scottishpatientsafetyprogramme.scot.nhs.uk

• @SPSP_MH

• [email protected] • [email protected]

Scottish Patient Safety Programme – Mental Health

Trauma Informed care, Seclusion and Restraint

Scottish Patient Safety Programme – Mental Health

Trauma Informed care, Seclusion and Restraint James Boyle RESTRAINT MONITORING TRAINING, TIMING, TECHNIQUES Alyssa Bell SPSP-MH Project Manager, NHS Fife Neil Gallacher SPSP-MH Senior Charge Nurse / Clinical Lead, NHS Fife

Background

• Original monitoring forms • Original GSA training • Why was there a need to change? • What did we do with regards to monitoring restraint? • What was the training? • What techniques were used? The Original Monitoring Form Starting To Change

• New trainer • Vision changed to a new mindset • Emphasis on reducing harm and patient safety • Research carried out into restraint techniques • Research related to patient centred approaches

Discussing The Vision The Vision • Reducing the number of restraints • Reducing the time restraining • Emphasis on de-escalation • Wherever possible avoiding floor restraints • Seated restraints preferred • Proper post-incident reviews • Awareness through accurate reporting • More appropriate training First Adaptation of the Monitoring Form Training Overview

• GSA training – the original training

• 120+ complicated fine motor skill movements

• NFPS training – the current training

• 7 breakaway and 7 intervention techniques – all use gross motor skills.

Current Form

Post Incident Reviews

NHS Fife % of Restraint episodes resulting in a Staff incident review 100

60 50 40

0 2012 2013 2014 Physical Interventions Training

NHS Fife % of Staff involved in restraint that have been trained May 2013-May 2014 100 no trainer 90 training resumes 80 70

60 50

% of of staff % 40 30 20 10

13 14

May May

Jul 13 Jul

Jan 14 Jan

Jun 13 Jun

Oct 13 Oct

Apr 14 Apr

Sep 13 Sep 14 Feb

Dec 13 Dec

Aug 13 Aug

Nov 13 Nov Mar 14 Mar Types Of Restraint

NHS Fife Type of Restraint Used (%) 100 90 80 70

% 50 40 30 20 10 0 2011 2012 2013 2014

Upper body Seated Kneeling Full Floor Missing Restraint Duration

NHS Fife Length of restraints

8 Time (minutes) Time 6

0 2007 2008 2009 2010 2011 2012 2013 2014 Number Of Restraints

NHS Fife Number of incidents of restraint

30 Number 20

Jul 13 Jul

Jan 13 Jan 14 Jan

Jun 13 Jun

Oct 13 Oct

Apr 13 Apr 14 Apr

Feb 13 Feb 13 Sep 14 Feb

Dec 13 Dec

Aug 13 Aug

Nov 13 Nov

Mar 13 Mar 14 Mar

May 13 May 14 May Mental Health Quality Improvement Conclusion

• Through ongoing hard work of our Quality Improvement department, one dedicated trainer with a vision, and the willingness of frontline staff to embrace change in the pursuit of harm reduction, we have seen change take place. In some instances not much, and in others new trends have emerged.

• There are plans to develop the training further, with more service user and carer involvement, greater communication to make any physical intervention as safe as it possibly can be. Contact Details

Alyssa Bell Neil Gallacher Project Manager SCN / Clinical Lead Mental Health Quality Improvement Mental Health Quality Improvement Kinnaird Kinnaird Stratheden Hospital Stratheden Hospital Cupar Cupar Fife Fife

01334 696241 01334 696034

The State Hospitals Board for Scotland

Restraint & Seclusion Statistics

Nicola Watt Risk Management Team Leader

The State Hospital THE STATE HOSPITAL

Situated in Lanarkshire midway between Glasgow and Edinburgh

The State Hospital Carstairs Lanark ML11 8RP

The State Hospital ABOUT US

The State Hospital is one of four high secure hospitals in the UK.

It is part of the NHS in Scotland (since 1994) and provides a national service for Scotland and Northern Ireland.

The State Hospital ABOUT US

The State Hospital employs around 700 staff.

As a Special Health Board is accountable to Scottish Ministers through the Scottish Government.

There are 140 high-secure beds for male patients requiring maximum secure care: 12 specifically for patients with a learning disability.

The State Hospital SECURITY PROCEDURES

All visitors must adhere to security procedures.

The State Hospital ADMISSIONS

Scotland and Northern Ireland’s most disturbed and dangerous patients are sent to The State Hospital under the provisions of The Criminal Procedures (Scotland) Act 1995, The Mental Health (Care and Treatment) (Scotland) Act 2003, and other related legislation because of their dangerous, violent or criminal propensities.

The State Hospital PRIOR TO ADMISSION

• Homicide • Breach of the peace • Attempted homicide • Escape • Armed robbery • Absconding • Assault with weapon • Self injury • Fire raising • Attempted suicide • Indecent assault • Drug abuse • Explosives • Hostage taking • Rape

The State Hospital ABOUT PATIENTS 2013/14

77% of the patients are ‘restricted’ and are under direct jurisdiction of Scottish Ministers. In other words, a patient who has committed a crime but who has a major mental illness that was in part or fully the cause of the offence.

Not all patients have been convicted of an offence, but those without formal convictions will have displayed seriously aggressive behaviours, including physical and sexual aggression.

The State Hospital PATIENTS 2013/14 42 admissions 44 discharges • 17 courts • 5 courts • 15 prisons • 3 prisons • 9 NHS hospitals • 34 NHS hospitals • 1 community • 1 community • 1 patient died

The majority have a primary diagnosis of schizophrenia.

The average length of stay is eight years, ranging from around two months to over 40 years. The State Hospital ABOUT PATIENTS

All patients are male - The women’s service closed in 2007/08 in line with the national plan for no high secure provision for females.

The average age is 42 years.

A large proportion are overweight or obese.

The State Hospital CARE & TREATMENT

Each patient is cared for by a multi-disciplinary clinical team.

The State Hospital CARE & TREATMENT

Patient dining room, day room and bedroom

The State Hospital 60 ACRE CAMPUS

The State Hospital Total Reported Incidents by Month

200

180

160

140

120

100

Jul-08 Jul-09 Jul-10 Jul-11 Jul-12 Jul-13

Jan-09 Jan-10 Jan-11 Jan-12 Jan-13 Jan-14

Nov-08 Nov-09 Nov-10 Nov-11 Nov-12 Nov-13

Mar-08 Sep-08 Mar-09 Sep-09 Mar-10 Sep-10 Mar-11 Sep-11 Mar-12 Sep-12 Mar-13 Sep-13 Mar-14

May-08 May-09 May-10 May-11 May-12 May-13

The State Hospital Assaults (all types) 50

Jul-08 Jul-09 Jul-10 Jul-11 Jul-12 Jul-13

Jan-08 Jan-09 Jan-10 Jan-11 Jan-12 Jan-13 Jan-14

Mar-08 Mar-09 Mar-10 Mar-11 Mar-12 Mar-13 Mar-14

Sep-08 Nov-08 Sep-09 Nov-09 Sep-10 Nov-10 Sep-11 Nov-11 Sep-12 Nov-12 Sep-13 Nov-13

May-08 May-09 May-10 May-11 May-12 May-13

The State Hospital 08/09 09/10 10/11 11/12 12/13 13/14 Total Number of 336 179 144 191 116 84 Assaults Average bed 168 144.5 133.5 133.5 134.25 131 complement Assaults per patient 2.00 1.24 1.08 1.43 0.86 0.64

The State Hospital 1361 Incidents

700

600

500

400 Medium Low High 300

200

100

0 Assault Behaviour Sexual Verbal aggression/abuse

The State Hospital Breakaway Techniques used from Sept 2012 (22 incidents)

0 Defence Rail removal Defence Defence Other PAA activation against against kicks against wrist punches grab

The State Hospital Non-secure holds from Sept 2012 (204 incidents)

140

120

100

0 Wrist/lower arm Used to escort away Upper arm Other (without flexion) from incident/area

The State Hospital Secure holds from Sept 2012 (236 incidents)

120

100

Other

locks

Gooseneck

(faceup) sitting

Leg controls Leg Patient

(facedown)

Floor restraint Floor restraint Floor

Full thumb wrist thumb Full

Controlled t/d in t/d Controlled

In transport In full

Clothing removal Clothing

straight arm hold arm straight

Restrained whilst Restrained

thumb wrist locks thumb

Straight arm holds arm Straight

thumb wrist locks thumb removal/relocation Controlled t/d in full in t/d Controlled The State Hospital 90

50 40

30 20

0 2011/2012 2012/13 2011/2012 2012/13 2011/2012 2012/13 2011/2012 2012/13

Ashworth Broadmoor Carstairs Rampton

2012/13 Total number of Violence & Riddors Aggression Total per 100 Hospital Riddors Patients patients Ashworth 24 211 11 Broadmoor 22 200 11 Carstairs 11 130 8 Rampton 40 324 12

The State Hospital Seclusion

44 seclusions since Sept 2012 10 – one patient Longest 18 months Shortest 1 hr 40m

The State Hospital Training

Level One Trained is the successful completion of training in personal safety and breakaway techniques. (refresher every two years)

Level Two Trained is the successful completion of training in non secure and secure holds. (refresher every two years)

The State Hospital FURTHER INFORMATION

The State Hospital • [email protected] • Web: http://www.tsh.scot.nhs.uk

The State Hospital Nicola Watt Scottish Patient Safety Programme – Mental Health

Trauma Informed care, Seclusion and Restraint