1. Welcome
Non-Contact Physical Observations

2. Situation
There were 11 deaths ( ) within 24hrs of restraint in mental health settings in England.
There were 6 deaths within 1 hour of restraint ( ). We do not know whether restraint caused these deaths. There were 26 deaths within 24 hours of restraint ( ), 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:
Overview of where it all started …..

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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