1. @JInnesMpharm A Pharmacist and Quality Lead’s journey through PICU: A case of the past, present and future

2. @JInnesMpharm The past….

5. Violence RT and associated monitoring Two problems…

6. Agitated & violent behaviour constitutes 10% of all emergency psychiatric admissions 1 In 1998/1999, 65,000 pt on staff violent incidents reported in NHS 2 Led to Zero Tolerance Campaign Violence 1.Raveendran N et al. BMJ. 2007. 335:865 2.NHS Protect website/., http://www.nhsbsa.nhs.uk/3645.aspxhttp://www.nhsbsa.nhs.uk/3645.aspx 3. /.,.,/,/.,/ /,/.,/ /., 4.

8. Three times as many violent incidents occur in MH services than other NHS services Violence levels over the last few years… 1.NHS Protect website/., /.,. http://www.nhsbsa.nhs.uk/3645.aspxhttp://www.nhsbsa.nhs.uk/3645.aspx 2.,/,/.,/ /,/.,/ /.,

9. Local Repercussions

10. Violence RT and associated monitoring Two problems…

11. What is RT? In the UK (2012); ‘the use of medication to calm/lightly sedate the service user and reduce the risk to self and/or others. The aim is to achieve an optimal reduction in agitation and aggression, thereby allowing a thorough psychiatric evaluation to take place, whilst allowing comprehension and response to spoken messages throughout.’ 3 TREC studies 1, 4 (India and Brazil) Tranquill or asleep Unclear definition of the agitated state and therapeutic goals of RT 5 3. Violence. NICE 2005. Clinical Guideline 25 4. Huf et al. BMC Psychiatry. 2002. 2:11 5. De Fruyt et al. European Psychiatry. 2004. 19 (5) 243-249

12. Risks Associated with RT? Arguably one of the highest risk clinical processes currently undertaken in MH Risks can be both drug and non drug related. Physical monitoring forms an essential backbone to this practice ensuring the patient remains safe Our own internal audits indicated that post RT monitoring was a particular issue

13. 1.Innes J, Iyeke L. (2011) A review of the practice and position of monitoring in today's rapid tranquillisation protocols. 2.Innes J, Sethi F (2012) Current Rapid Tranquillisation documents in the UK; A review of the drugs recommended, their routes of administration and clinical parameters influencing their use. 3.Loynes B, Innes J, Dye S (2012) Assessment of physical monitoring following RT: A national survey 4.Innes J, Curtis D (2013) Medication patient safety incidents linked to RT: one year’s data from the NRLS A Series of 4 Review Articles…

14. Drugs recommended (PO)

15. Drugs recommended (IM)

16. Clinical Decision Making Parameters Wide variation in advice across different RT documents within the same clinical decision making parameters In some cases, information is conflicting

17. When should monitoring be initiated?

18. What should be monitored?

19. Frequency?

20. Duration?

21. How were Trusts doing with post RT Monitoring? Only 38% (18/47) of Trusts were auditing post RT monitoring

22. @JInnesMpharm The present….

23. @JInnesMpharm

25. S + P = O Structure + Process = Outcomes Source: Donabedian, A. Explorations in Quality Assessment and Monitoring. Volume I: The Definition of Quality and Approaches To Its Assessment. Ann Arbor, MI, Health Administration Press, 1980. Dr. Avedis Donabedian (1919-2000) A classic approach to delivering outcomes

26. Key Ingredients for Success Success Form a team Agree the quality issue to be tackled Ensure patient (and carer) involvement Find time to meet

27. The Model for Improvement

28. Rapid cycle testing Develop a strategy Prioritise and pick change ideas Observe the results Implement, adapt or abandon Structured, systematic approach to tackling problems…

29. Violence RT and associated monitoring Two problems…

30. 1. Create a structure

31. 2. Make all aware of the evidence base Contributory factors to violence – Patient factors – Staff factors – Environmental factors Violence prediction – Static (acturial) – Dynamic (clinical prediction models)

32. 3. Create a strategy…

33. 4. Test change ideas in parallel Personal support plan Pt property Ward round Mindfulness Reducing violence

34. OUTCOME MEASURES Trust-wide data Tower Hamlets data Combined wards data Individual ward data Key 5. Make the results visible to all…

35. 57% reduction

36. Violence RT and associated monitoring Two problems…

37. 1. Create a structure Bevan ward tasked with reducing medication errors as part of Harm Free Care initiative. In 2011, an audit showed that the trust was at 50% compliance of which Bevan ward was at 10%

38. To have 100% of patients’ who received psychotropic PRN/RT will have their physical health monitored and we aim to do this by September 2014 Primary DriversSecondary driversChange ideas Review policy to simplify Clinical governance Staff training and knowledge Patient safety ELFT RT guidelines and policy ELFT Prescription chart Knowledge on rapid tranquilisation Physical health observations Review prescription chart Staff questionnaire to assess policy Staff training on RT Clarify differences between PRN and RT administration Knowledge on physical health monitoring ELFT RT monitoring form Review observations form 2. Create a strategy…

39. The Bevan ward RT/PRN monitoring Tool 3. Test change ideas…

40. 4. Make the results visible to all…

41. @JInnesMpharm The future….

42. Top down Bottom up Improvement 1. Top down/bottom up approach

43. NICE 2005NICE 2015 RT Definition Use of medication to calm/lightly sedate the service user and reduce the risk to self and/or others. The aim is to achieve an optimal reduction in agitation and aggression, thereby allowing a thorough psychiatric evaluation to take place, whilst allowing comprehension and response to spoken messages throughout Use of medication by the parenteral route if oral medication is not possible or appropriate and urgent sedation with medication is needed. RT Monitoring Pulse, BP, RR, temp, level of hydration,. At regular intervals until service user active. Monitoring should occur more frequently if other concerns. Pulse, BP, RR, Temp, level of hydration, level of consciousness At least every hour, or every 15 minutes if HDA or other concerns, until pt active Policy, Guidelines, Research

45. Efficacy vs Effectiveness

46. Focus on outcomes, not tasks Front line staff able to use systematic method Learning system, where it is ok to fail Performance is visible for all to see Focus on continuous improvement

47. CQUINs and KPIs Outcomes rather than processes Incentivise approach? Importance of Commissioning

48. 2. Scale up and spread of ‘change bundles’ Stop reinventing the wheel Bundle of interventions proven to work Use ‘bottom up’ approach to implement these interventions reliably