1. INCIDENT SPECIFIC FACTORS
Short-term management of violence in two secure inpatient units: a cross-sectional study
Gautam Gulati1, Ingrid Parker2 and Seena Fazel1 1Oxfordshire and Buckinghamshire Partnership Mental Healthcare NHS Trust and University of Oxford, Department of Psychiatry
2Hampshire Partnership NHS Trust
The 4th National Conference of Research in Medium Secure Units, London, 16th January 2007
STUDY AIMS
To study the short-term management of violence in a Low Secure Unit (LSU) and a Medium Secure Unit (MSU) in comparison to the NICE guidelines for violence.
METHODS
NICE guidelines were reviewed to identify criteria that could be quantitatively studied.
Identified criteria were operationalised into two questionnaires.
The first questionnaire examined environmental factors and was completed by interviewing an acting ward manager for each unit.
The second questionnaire looked at incident specific factors relating to the management of violence. These were completed by studying case notes and incident reporting forms relating to 10 consecutive incidents on the LSU and 20 consecutive incidents on the MSU between June and August 2005.
RESULTS
FACTORS WITHIN THE UNIT ENVIRONMENT
Both units met most criteria for best practice in terms of environmental factors (unit setup and staff training).
The lack of immediately available parenteral antimuscarinic was identified on one of the units.
In relation to the percentage of incidents where best practice was followed, the units successfully terminated seclusion once rapid tranquilisation had taken effect (100%), documented the rationale for seclusion/rapid tranquilisation/physical intervention was used (89%), prescribed oral and IM medication separately (75%), and reviewed seclusion at least 2 hourly (71%).
Areas needing improvement included the use of de-escalation prior to other interventions (66%), the availability of doctors within 30 minutes (53%) and the monitoring of individuals within eyesight following rapid tranquilisation in seclusion (33%).
In contrast to the NICE guidelines, there was no evidence any patient had an opportunity to document their version of events after a violent incident.
CONCLUSIONS
Some of the NICE guidelines for violence can be operationalised and used for audit purposes and health services research.
A study of current practice within one UK setting showed that these guidelines were mostly implemented.
The finding that inpatients do not appear to have an opportunity to document their version of events after an incident, and the lack of within-eyesight monitoring after rapid tranquilisation in seclusion are areas where current practice was not in keeping with the NICE guidelines.
Small numbers, one setting, and the inability to evaluate all the NICE guidelines limit this study.
ACKNOWLEDGEMENTS
The staff of Oxfordshire and Buckinghamshire Mental Healthcare NHS Trust who cooperated with this study and were eager to learn from its results.
Factor studied
LSU
MSU
Is a crash bag available to the unit within 3 minutes of an incident?
Yes
Does the crash bag contain all of oxygen, suction, cannulas, bag-valve mask, AED, first line resuscitation medication?
Is the crash bag equipment checked at least weekly?
Are staff involved in seclusion trained to a minimum of Basic Life Support standard?
Are staff involved in prescription or administration of rapid tranquilisation trained to a minimum of Immediate Life Support standard?
Is an antimuscarinic (Procyclidine/ Benztropine) available on the ward for immediate oral and parenteral use? No
Does the unit regularly conduct post-incident reviews within 72 hours of a violent incident?
INCIDENT SPECIFIC FACTORS