Delivering physical health care on a PICU following a serious adverse incident 1 year on: lessons learned and future plans

Background Haven Ward is a 12 bed mixed sex PICU in Dorset Female ward opened Jan 2017 Many issues during first few months of opening such as staff vacancies including Ward Manager position We had a serious adverse incident on the ward April 2017 Subsequent investigation highlighted issues regarding management of physical health complaints on the ward 1

Key issues Very high co-morbid physical health problems, especially with females, and in some cases the physical health symptoms required greater input than the mental health symptoms Staff did not have the required training to meet this demand and many had only a basic understanding of physical health problems and how to assess, treat and manage. Staff were misdiagnosing physical health issues as behavioural. CQUINS: we were inputting the information but not always doing anything with it Patients being transferred to local general hospital for fairly routine problems Poor links with primary and secondary care 2

What we did in the first 6 months… Tried not to panic Began process of identifying areas where there was deficit in knowledge and developed a training programme (using QI methodology) Implemented staff training, attempted to match skill set of HCAs in general hospitals Began process of changing ward culture around physical health Started a physical health clinic, initially twice a week Made sure information from CQUIN audit was being followed up Hired RGN to help run clinic and to help asses, treat and manage issues Attended conferences and looked to learn from other organisations 2

Initial problems we encountered... People panicked Very high acuity on the ward, short staffed and a lot of agency staff, no consistency in care delivery We had a plan but weren’t able to fully implement Clinic for 2 days a week was not enough RGN struggled to develop and integrate role on the ward. Role of RGN on the ward de-skilled staff Difficult to shift prevailing attitudes and ward culture 1

Where we are now Staff are now confident in taking physical observations and assessing physical health complaints Physical health clinic run 5 days a week, CQUIIN outcomes are monitored and followed up The ward has a physical health team, who take the lead in ensuring any learning from incidents is shared and training implemented Staff are able to take blood, do ECGs, manage wounds, use NG tubes, and know when to refer to primary & secondary care services All patients have individualised physical health care plans which includes escalation plans in case of deterioration. These are co-produced and have input from specialists where applicable Ward has access to a GP, as well diabetic and asthma nurses, every week We are now able to manage some physical health incidents without having to transfer to a general hospital 2

What next? 2

Admission to a mental health inpatient ward should be seen as an opportunity to improve that person’s mental AND physical health. Our vision on Haven Ward is to provide evidence based treatments for people with complex mental and physical health problems who also require a safe and secure environment. 2

Document Name What next? Pivot the ward away from being solely about the management of violence and aggression to the management of complex physical and mental health problems Ensure there is a member of the physical health team on duty 24/7 so we can provide a physical health ‘clinic’ day or night Change the title of Mental Health Support Workers to Nursing Assistants / Health Care Assistants Continue with ensuring majority of staff can take blood, do ECGs etc Carry on learning from mistakes 1

Lessons learned: Don’t panic Make sure you are doing the basics right each and every time Have a plan and be ready to change and adapt as you go along Ward culture is as important as its knowledge base Hiring an RGN is not the answer to all your problems It is better to have lots of people able to deliver single individual interventions than one person who can do them all Physical health emergencies don’t always occur Monday to Friday, 9 to 5 and they don’t occur in a vacuum It takes time Attending the Safety Collaborative can save lives… 2

Any Questions? …. 1