An example of working towards
Sustained Quality Improvement in
SLAM: Audit of SLaM guidelines
for Rapid Tranquillisation
13th February 2013
HQIP Conference, London
Rosie Peregrine-Jones
Clinical Audit & Effectiveness Manager
South London & Maudsley NHS Foundation Trust
Outline of presentation
1. Introduction ….to SLAM and our quality priorities and
improvement programs
2. NHSLA Risk Management standards & Trustwide Clinical
Audit Program
ii) Why bother with NHSLA?
3. Rapid Tranquillisation Audit – an example of sustained
improvement
4. Initial findings in 2007
5. Changes in Practice
6. Outcomes in 2011
7. RT in 2012/13
8. Conclusions
1. Introduction
South London & Maudsley NHS Trust – who are we?
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We provide the widest range of NHS mental health services in the UK. We
also provide substance misuse services for people who are addicted to
drugs and / or alcohol. We work closely with the Institute of Psychiatry,
King's College London, and are part of King's Health Partners Academic
Health Sciences Centre.
We have 4,800 staff and serve a local population of 1.1 million people. We
have over 100 sites and provide support to around 39,000 in the
community. We have 68 inpatient wards across four main hospital sites, and
provide inpatient care for over 5,000 people each year.
1. Introduction Cont.
Quality standards and priorities for sustained
improvement:
• External requirements (e.g. CQC, NHSLA, PCT quality contract, Mental
Health Act, Monitor, NICE)
• Internal - Quality Account /Assurance Framework/Care Pathways/CAG
quality priorities
Our approach to sustained quality improvement:
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Trustwide & CAG Clinical Audit Programs of Assurance
Annual Nursing Practice Visits across all inpatient & community teams
PEDIC – monitoring of service user views
Productive Wards
Magnet
Local Improvement Projects (e.g. violence reduction)
2. i) NHSLA Risk Management
standards & Trustwide Clinical
Audit Program
• Delivery of the Trustwide Clinical Audit Program as a means to achieve
sustained improvements in clinical care
• Since Trust achieved Level 2 NHSLA in 2008, annual clinical audit
program has been focused on monitoring the key clinical policies within
the 50 standards (e.g. observation, patient information, rapid
tranquilisation, AWOL etc.).
• Annual cycle of monitoring, action planning and review
• Central Audit Team carried out monitoring of 25/50 (50%) of standards
• On 16th December 2011, after undertaking a rigorous 2-day
assessment of SLaM’s performance against 50 standards, NHSLA
confirmed that SLAM had passed at level 3, the highest level for acute
and mental health trusts.
• At the time, SLaM was the only mental health trust in the NHS to be
awarded Level.
2. ii) Why bother with NHSLA?
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Achievement of Level 3 would confirm that SLaM has successfully
embedded, and is using, ‘best practice’ risk management systems and
processes throughout the Trust - it would be the only Level 3 Mental
Health and Learning Disability Services Trust in the country.
•
It also serves as a quality indicator for third parties, such as
commissioners, other inspecting bodies and stakeholders and how
areas of risk covered by the Standards are managed within the
organisation.
• Level 3 qualifies Trust for 30 per cent Risk Management Discount - a
saving of £315,000 per year.
• One factor, critical to the success of the project, was being able to
demonstrate annual cycles of clinical audit on the key clinical policies
which have been included in the trustwide audit program since 2008
3. Rapid Tranquillisation Audit –
an example of sustained
improvement
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Rapid tranquillisation is one of several strategies commonly used in the
management of severely disturbed behaviour in mental health inpatient settings.
It is used when other less coercive techniques of calming a service user, such
as verbal de-escalation or intensive nursing techniques, have failed. It usually
involves the administration of medication over a time-limited period of 30-60
minutes, in order to produce a state of calm/light sedation
4. Initial findings in 2007:
• Unreliable documentation of incidents in the patient
record (48%)
• Little documentation of attempting de-escalation prior to
rapid tranquillisation (10%)
• Common administration of Haloperidol during rapid
tranquillisation (16%)
• Where given, Haloperidol was usually above the
recommended dosage (74%)
• Physical observations were not recorded following rapid
tranquillisation
• Debriefing with the patient was not recorded
5. Changes in Practice
1. Communication of critical standards to clinical
teams
i) Audit summary findings and recommendations issued
in trustwide e-news bulletin and e-mailed to all
consultants and ward managers to be given to their
teams (March 2010, December 2011).
ii) Medication Incident and Error Bulletins produced by the
Pharmacy Department have highlighted serious
incidents involving rapid tranquillisation and reminders
of the mandatory monitoring schedule (e.g. April 2012).
5. Changes in Practice
iii) A poster of the rapid tranquillisation guidelines has been produced
and sent to all wards in March 2011. Inpatient practice visits audit
data in May 2012 demonstrated 95% inpatient areas had this poster
displayed.
5. Changes in Practice
2. Training in Rapid Tranquilisation
• Including rapid tranquillisation in Trust mandatory 5-day PSTS
training for all nursing staff
• Production of teaching slides for all CT1s: Treatment of Acutely
Disturbed or Violent Behaviour (Rapid Tranquillisation)
• Teaching slides for all clinical staff: Rational Prescribing
delivered by Pharmacy Department.
• Rapid Tranquilisation e-learning module available through
Education & Training Department intranet site.
• The mandatory monitoring/physical observations in Rapid
Tranquillisation are now included in the trustwide MEWS
(Modifed Early Warning Scores) training for all staff
5. Changes in Practice
5. Changes in Practice
3. Documentation Modified Early Warning
Scores printed observation
charts now include a
prompt on the front page to
record increased
frequency of baseline
observations due to rapid
tranquillisation.
5. Changes in Practice
4. RT included in nursing competency frameworks
(MAGNET)
• Requirements for physical observations in rapid
tranquillisation have also been included in the SLAM
Magnet Nursing Competency Framework. The purpose
of this framework is to demonstrate competencies and
assurance for nursing competency and capability.
• Rapid tranquillisation has specifically been included in
the following frameworks: 1) Administration of
Medications including Rapid Tranquillisation and
physical monitoring 2) Physical Observation and Medical
Devices Outcome record.
6. Outcomes in 2011 re-audit
•Documentation of rapid tranquillisation in the patient electronic
notes improved and this was sustained (48% in 2007, up to 96% in
2010, 100% in 2011)
•Documented attempts to de-escalate the patient prior to rapid
tranquillisation became more common (10% up to 66% in 2011)
•Use of Haloperidol dropped to a minimum (42% in Jan 2008 down
to 3.6% in 2011)
•Whilst recording of at least one set of observations following rapid
tranquillisation improved (0% in 2007 up to 25% in 2011), the
requirement to document physical observations at the frequency
required (i.e. every 5-10 minutes for one hour and then half-hourly
until the patient is ambulatory) has not been met. This is now
subject to a focused rapid-cycle audit project which will start in
September 2012.
•Recorded debrief with the patient following rapid tranquillisation
improved (0% to 43% in 2007)
7. RT in 2012/13
•A rapid-cycle (quarterly) audit
project focused on improving
physical observations
following rapid tranquillisation
started in November 2012.
•draft guidance sheet and
checklist to be piloted on Triage
wards and PICUs from January
2013
•Repeat audit planned for Feb
2013 and at 3 monthly intervals
in 2013.
8. Conclusions
•Lessons from NHSLA program and RT audit project show:
•Sustained improvement is possible! It requires:
•Strong Leadership (from project managers & policy leads)
•Good project management structure
•Targeted investigation of barriers to compliance by asking
staff
•Multi-faceted improvement program (e.g. communication to
clinicians, training, documentation, competency
assessment, regular feedback on performance to staff on
ground)
•BUT - Need support of clinicians – in November 2012 audit it
was found the greatest factor to non-compliance was
disagreement over the balance of risks involved to staff with
implementing the physical obs. There was a sentiment that the
guidelines were out of touch with the risks to staff, exacerbating
poor compliance. Ongoing support to staff to implement the
guidelines is critical for success