Welcome Non-Contact Physical Observations

Situation There were 11 deaths (2008-2012) within 24hrs of restraint in mental health settings in England. There were 6 deaths within 1 hour of restraint (2004-2014). We do not know whether restraint caused these deaths. There were 26 deaths within 24 hours of restraint (2004-2014), ranging from 0-4 per year [1]. Carrying out National Early Warning System (NEWS) physical observations is often not possible on mental health inpatients as they can refuse or be too agitated for it to be safe (due to violence and aggression) for staff to carry them out. Staff need clear guidance on none contact observations that need to be carried out this then needs to be included in mandatory training, policies and cross referenced with NICE guidance. Reference: 1. National Confidental Inquiry into Suicide and Homicide by People with Mental Illness. Annual Report and 20-year review, University of Manchester, 2016: http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/2016-report.pdf] Overview of where it all started …..

Background A range of guidance exists on positive interventions to reduce the risk of self-harm, violence and aggression in healthcare settings, restrictive interventions, including seclusion, manual restraint and rapid tranquillisation are used as the last resort to manage behaviour if the patient is deemed to be a risk to themselves of others. The risk of death from positional asphyxia during restraint has been increasingly recognised, harm can also occur in the period AFTER restraint from the effect of illicit drugs, alcohol, prescribed medications and medical conditions. This project came about following a national patient safety alert and CQC inspection on Harvest. NHS/PSA/W/2015/011- Stage One: Warning The importance of vital signs during and after restrictive interventions/manual Restraint 3 December 2015 Hyperlink to alerts 26% of preventable deaths were related to failures in clinical monitoring. Patient Safety Alert NHS/PSA/RE/2016/005. Resource to support safe care of the deteriorating patient (adults and children) 2016.

Working Towards National Standards NICE (2016) NG51 Sepsis: recognition, diagnosis and early management NICE (2015) violence and aggression: short-term management in mental health, health and community settings. NICE (2014) : Rapid tranquillisation in mental health settings: promethazine hydrochloride NICE (2007) Acute illness in adults in hospital: recognising and responding to deterioration. Just recognising it links to other guidance

Benefits to Patient and Staff Patients – The safety of the patient is paramount. Non-contact observations will: Help enable swift escalation of care if vital signs are deteriorating. Reduce the risk of death after restrictive interventions and rapid tranquilisation Help to prompt further investigation for potential physical health concerns e.g. sepsis Staff – Non-contact observations will:- Ensure staff understand the importance of non-contact physical observations as the second line of action if they can not carry out NEWS physical observations. Will help ensure they are carrying out the correct level of care for patients that refuse NEWS or that have had restrictive interventions/physical restraint. Provide information for medical reviews Provide evidence of legal documentation that monitoring has occurred when the patient refuses NEWS Outline benefits

Assessment Research chart options Patient Outcomes By August 2017, Non-contact observations are carried out on 100% of mental health inpatients as required by their treatment plan when NEWS is not possible. Non-Contact Obs Chart Staff Involvement Development of Non-Obs Chart Research chart options Staff feedback on chart Training for staff Chart accessible on RiO, tick box for non-obs carried out when patient refuses NEWS Agree record keeping and storage Governance Update policies with chart Patient Outcomes Louise – process of Improvement

Measurement Spot audits showed that physical observations were taken post incident on all the audited incidents where physical restrictive interventions were used. Non-Contact Observations were recorded when NEWS was not feasible or declined by the patient. Observations were through the NEWS but this was not always feasible or declined by patient

PDSA A P S D Cycle 1E: Test on Acute Ward Cycle 1D: Test on PICU ward DATA FEEDBACK TO FRONTLINE STAFF Cycle 1E: Test on Acute Ward Cycle 1D: Test on PICU ward Cycle 1C: Review chart inc. training and Resus Cycle 1B: Review with Parity & Esteem Group Leads to link with other trials carried out in England. Final version to be ordered through central point to prevent personalised changes Challenges:- Staff to engage – showing the patient safety alert and educating them for patients best interest and safety of care RiO recording documenting – length of time, get them involved at the beginning and persist! Educating staff on correct use of documentation – face to face training Cycle 1A: Test on 1 patient on 1 ward for 8 days – feedback received

Non-Contact Physical Observations Form Version 8 of the form “I’ve found them very easy and effective to use when they've been done post rapid tranq.” Carbis Ward Staff Nurse

Update on Non-Contact Chart Feedback from staff was all positive National Sepsis triggers were added Chart has been added to the 24hour physical monitoring/NEWS monitoring page in RiO with good feedback The latest version for NEWS also includes tick box to demonstrate when physical observations or non-contact observations have been carried out post rapid tranquilisation as legally required. This is included on RiO as a tick box. Compliance reports for physical observations tool is in development for ward mangers to view overall compliance of physical health observation parameters Process of versions of forms

Spread of Non-Contact Chart The chart is used in all mental health inpatient wards Now included in Clinical Observations training sessions Non-Contact Physical Observations will be shared with two other Trusts (SW Physical Health Leads); Somerset trialling our version. Links with Plymouth University regarding students’ level of training for physical health and mental health nursing. Sharing with Parity of Esteem Leads in the South. collaboration

Implementation Training: The non-contact physical observations have been included at induction and physical observations updates. Training teams are currently working on a physical health obs pre-reading material booklet that will also need to include the observation sheet. Harvest Deputy Manager is to re-audit for post rapid tranquilisation obs to ensure that NEWS and non-contact physical obs have been documented appropriately in areas where the training has been given to evaluate the effectiveness of the training. Face to face ward-based training is given at every opportunity when meeting with staff. Training

Implementation POLICIES Policies to be reviewed and updated: Deteriorate of Physical Health Policy for Inpatients - (to be combined with Sepsis) Seclusion policy - completed Intoxication Policy Rapid Tranquilisation (Pharmacy) Links to policies

Getting the message out…. MAV Forum Internal circulation:- Taken to OAGs Ward manager’s meetings Formal communication given to teams. CASCADE (All Staff Newsletter) Nurses forum Sharing Learning Disabilities Throughout SouthWest of England NHS Trusts

Recommendations Utilise Southwest Links to develop and shared Working with local teams to test a safe standard for observations Teams have created a document that they value and use MDT involved and input into design e.g. ward secretaries to consultants, Resus team, IPC team Share across southwest Cycle of starting with Southwest links and then share back to Southwest links