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
Treatment
– Medication
– Interventions
Can result from one causal factor
or a combination of factors
Sexual
Accidents
including falls
Physical
Self
Harm
Aggression
and Violence
Psychological
Suicide
Sexual
Harm
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
Self
Neglect
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
Treatment
– Medication
– Interventions
Can result from one causal factor
or a combination of factors
Sexual
Accidents
including falls
Physical
Self
Harm
Aggression
and Violence
Psychological
Suicide
Sexual
Harm
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
Self
Neglect
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
medication errors, harm
resulting from restraint
e.g. due to conduct or
experiences which cause fear,
alarm or distress
Social
Sexual
e.g. harm caused to social
relationships or financial harm
resulting from the person’s
vulnerabilities
e.g. adults at risk due to sexual
disinhibition or the
manipulation of an individuals
vulnerabilities
To include:
To exclude:
Forensic inpatient units
Inpatient units caring for people with dementia
Older adult functional illness units.
Preparation
Phase
Pre-work
Phase
Jan 12 – May 12
May 12 – Aug 12
Phase One
(Testing)
Aug 12 – Sep 13
Phase Two
Sep 13 – May 16
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
•
•
•
•
•
•
•
•
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
Acute Admission
Rate of incidents of physical violence
NHS Scotland
7.00
Start of phase 1
5.00
Start of phase 2
4.00
3.00
2.00
17 Acute wards from 10
Boards
1.00
Learning Session 3
Learning Session 2
Sep 13
Aug 13
Jul 13
Jun 13
May 13
Apr 13
Mar 13
Feb 13
Jan 13
Dec 12
Nov 12
Oct 12
0.00
Sep 12
rate per 1000 bed days
6.00
Acute Admission
Rate of incidents of restraint
NHS Scotland
6
4
Start of phase 1
Start of phase 2
3
2
1
17 Acute wards from 10
Boards
Learning Session 2
Learning Session 3
Sep 13
Aug 13
Jul 13
Jun 13
May 13
Apr 13
Mar 13
Feb 13
Jan 13
Dec 12
Nov 12
Oct 12
0
Sep 12
rate per 1000 bed days
5
Culture / climate
PDSA
• Please
• Do
• Something
• ANYTHING!!
May 2013 Leadership report
NHS Grampian - WARD 4
Time taken from Admission for Risk Assessment
December 2012-to date
Time taken for Risk Assessment
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
complete RSI
08:00
PDSA 4 complete RSI
within 2 hrs o/a
06:00
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
Staff Meeting in
IPCU to discuss
issues and
100%
Version 3
introduced
Median
IPCU REH Safety Brief Compliance
90%
First
Completion
audit carried
Re-audited
and left
Included in
induction pack
70%
Version 4
introduced
with added
Influx of new
staff who were
unfamiliar with
process.
60%
Version 2 introduced,
now 1 bundle and 3
safety briefs per day
50%
Introduced
Week
35
34
33
32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
40%
1
Compliance
80%
As Required Psychotropic Monitoring
% Compliance
ORAL/IM PRN MONITORING COMPLIANCE IN IPCU REH
Median
100
90
80
70
60
50
Highlighted on safety brief
40
30
20
Changed to coloured
stickers
10
Sep-13
Aug-13
Jul-13
Jun-13
May-13
0
0
21-Apr-14
14-Apr-14
07-Apr-14
31-Mar14
70
24-Mar14
17-Mar14
10-Mar14
03-Mar14
24-Feb14
17-Feb14
60
10-Feb14
90
03-Feb14
27-Jan-14
Percent compliance
100
Sticker Use
SPSP-MH recruited the NHS
Lothian co-ordinator
80
Ran out of stickers
Ran out of stickers
50
40
30
20
10
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
Learning
Participate
Safety
Climate
Survey
Feedback
Results
Looking into an unknown future.......
Phase 1
Total number of
eligible wards in
Scotland –
123
Percentage
involved in pilot
stage – 24%
Phase 2
Year 1
Total of 59% of
eligible wards
are involved as
of today
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
• dhall2@nhs.net
• Spsp_mentalhealthteam.hcis@nhs.net
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
90
80
70
60
50
40
30
20
10
0
2012
2013
2014
Physical Interventions Training
NHS Fife
% of Staff involved in restraint that have been trained
May 2013-May 2014
no trainer
100
training resumes
90
80
60
50
40
30
20
10
May
14
Apr 14
Mar 14
Feb 14
Jan 14
Dec 13
Nov 13
Oct 13
Sep 13
Aug 13
Jul 13
Jun 13
0
May
13
% of staff
70
Types Of Restraint
NHS Fife
Type of Restraint Used (%)
100
90
80
70
%
60
50
40
30
20
10
0
2011
2012
Upper body
Seated
2013
Kneeling
Full Floor
Missing
2014
Restraint Duration
NHS Fife
Length of restraints
18
16
14
Time (minutes)
12
10
8
6
4
2
0
2007
2008
2009
2010
2011
2012
2013
2014
0
May 14
Apr 14
Mar 14
Feb 14
Jan 14
Dec 13
Nov 13
Oct 13
Sep 13
Aug 13
Jul 13
NHS Fife
Jun 13
May 13
Apr 13
Mar 13
Feb 13
Jan 13
Number
Number Of Restraints
Number of incidents of restraint
60
50
40
30
20
10
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
Project Manager
Neil Gallacher
SCN / Clinical Lead
Mental Health Quality Improvement
Kinnaird
Stratheden Hospital
Cupar
Fife
Mental Health Quality Improvement
Kinnaird
Stratheden Hospital
Cupar
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
Attempted homicide
Armed robbery
Assault with weapon
Fire raising
Indecent assault
Explosives
Rape
The State Hospital
•
•
•
•
•
•
•
Breach of the peace
Escape
Absconding
Self injury
Attempted suicide
Drug abuse
Hostage taking
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
• 17 courts
• 15 prisons
• 9 NHS hospitals
• 1 community
44 discharges
• 5 courts
• 3 prisons
• 34 NHS hospitals
• 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
Mar-08
May-08
Jul-08
Sep-08
Nov-08
Jan-09
Mar-09
May-09
Jul-09
Sep-09
Nov-09
Jan-10
Mar-10
May-10
Jul-10
Sep-10
Nov-10
Jan-11
Mar-11
May-11
Jul-11
Sep-11
Nov-11
Jan-12
Mar-12
May-12
Jul-12
Sep-12
Nov-12
Jan-13
Mar-13
May-13
Jul-13
Sep-13
Nov-13
Jan-14
Mar-14
Total Reported Incidents by Month
200
180
160
140
120
100
80
60
40
20
0
The State Hospital
Jan-08
Mar-08
May-08
Jul-08
Sep-08
Nov-08
Jan-09
Mar-09
May-09
Jul-09
Sep-09
Nov-09
Jan-10
Mar-10
May-10
Jul-10
Sep-10
Nov-10
Jan-11
Mar-11
May-11
Jul-11
Sep-11
Nov-11
Jan-12
Mar-12
May-12
Jul-12
Sep-12
Nov-12
Jan-13
Mar-13
May-13
Jul-13
Sep-13
Nov-13
Jan-14
Mar-14
Assaults (all types)
50
45
40
35
30
25
20
15
10
5
0
The State Hospital
Total Number of
Assaults
Average bed
complement
Assaults per patient
08/09
09/10
10/11
11/12
12/13
13/14
336
179
144
191
116
84
168
144.5
133.5
133.5
134.25
131
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
The State Hospital
Sexual
Verbal aggression/abuse
Breakaway Techniques used from Sept 2012
(22 incidents)
12
10
8
6
4
2
0
Defence
against
punches
Rail removal
The State Hospital
Defence
against kicks
Defence
against wrist
grab
Other
PAA activation
Non-secure holds from Sept 2012
(204 incidents)
140
120
100
80
60
40
20
0
Wrist/lower arm
(without flexion)
Used to escort away
from incident/area
The State Hospital
Upper arm
Other
0
The State Hospital
In transport full
thumb wrist locks
Full thumb wrist
locks
Straight arm holds
Restrained whilst
sitting
Patient
removal/relocation
Other
Leg controls
Gooseneck
Floor restraint
(face up)
Floor restraint
(face down)
Controlled t/d in full
thumb wrist locks
Clothing removal
Controlled t/d in
straight arm hold
Secure holds from Sept 2012
(236 incidents)
120
100
80
60
40
20
90
80
70
60
50
40
30
20
10
0
2011/2012
2012/13
2011/2012
Ashworth
2012/13
2011/2012
Broadmoor
2012/13
2011/2012
Carstairs
Rampton
2012/13
Total number of
Violence &
Aggression
Riddors
Total
Patients
Riddors
per 100
patients
Ashworth
24
211
11
Broadmoor
22
200
11
Carstairs
11
130
8
Rampton
40
324
12
Hospital
The State Hospital
2012/13
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
• n.watt@nhs.net
• Web: http://www.tsh.scot.nhs.uk
The State Hospital
Nicola Watt
Scottish Patient Safety
Programme –
Mental Health
Trauma Informed care,
Seclusion and Restraint