Reducing the use of Restrictive Interventions – how well are we meeting the DH Guidance?
Dr Alick BushGiselle Cope
Dr Zoe WhitakerAmy Aston
CPD Event 30th January 2015
Aims
• National and local use of Restrictive Interventions• National policy and guidance• Positive and Proactive Care DH guidance• Translating guidance in to standards• Audit of standards at Nottinghamshire• Steps to improve practice
What needs to change
• CQC inspection of 150 inpatient services- great uncertainty about use of restrictive interventions
• Many services over reliant on use of restraint instead of preventative approaches
• MIND report- Physical Restraint in Crisis (2013):– 1998 death of David Rocky Bennett (prolonged prone
restraint)– Subsequently 13 more deaths of people detained under MHA
• Winterbourne View- justified as ‘restraint’
Winterbourne View- 6 staff imprisoned
National & Local Drivers National and Local Drivers for change
National NHS Benchmarking Network
Use of restrictive interventions August 2014:
• Restraint used 8,466 times• Of these, 1,535 were prone restraints (about 20%)
• 1,459 incidents of seclusion
Census being repeated for January 2015
What about St Andrew’s?
Seclusion
• Seclusion used 200 times per month
• No changes over last 24 months.
Restraints
• 700 restraints per month
• Some reduction over last 24 months
• How many are prone?
STAH - All Sites Prone Restraint Data
Notts Prone Restraint (Oct 13 – Jan 15) [include data on actual numbers per month]
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14Jul-1
4
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
0
10
20
30
40
50
60
70
80
% of restraints being prone
% of restraints being proneExponential (% of restraints being prone)
Rapid Tranquilisation
• 140 occasions of Rapid Tranquilisation per month
• Little variation over 24 months
• Data not available on prn medication to control behaviour in absence of appropriate mental illness
Patient PMAV Injuries
• About 7 patient injuries per month
• Increased over 24 month period
Staff PMAV Injuries
• About 30 staff injuries in last 12 months
• Significant improvement over 24 months
Conclusions
• Nationally there is an over-reliance on the use of Restrictive Interventions
• Restraint, seclusion and PRN are not yet the last resort option that is expected of us
• St Andrews is moving in the right direction but we still need to be doing more
• Services are a long way off the aspiration for prone restraint to be a ‘never event’.
• Avoiding the use of RIs must remain our priority
So what should we be doing?
National Guidance to support people positively
• NICE guidance for Challenging Behaviour and learning disabilities
o Consultation until 9 February 2015o Final guidelines- 27 May 2015
• Positive and Proactive Care: reducing the need for restrictive interventions (DH, 2014)
NICE guidelines for CB & LD- draft
General principles:– Prevention– Improve support rather than change the person– Team working– All staff are trained to delver proactive strategies
to reduce likelihood of CB– Least restrictive options– Principles of PBS
Draft NICE guidelines (2)
Process is what we’d probably expect:• Functional assessment of behaviour• Formulation, that drives a Behavioural Support Plan
emphasising proactive and preventative strategies• Interventions
– Psycho-social focus– Adapt the environment– Treat co-existing physical/ mental health problems
• Evaluate against initial intervention goals & timescales
Draft NICE guidelines (3)- Medication
Only consider medication for behaviour that challenges if:• Person has co-existing mental or physical health
problem• Psychosocial, psychological or other interventions
alone do not produce change in specified time• Risk to the person or others is very severeOnly offer medication in combination with psychosocial, psychological or other interventions
Draft NICE guidelines (4)- Medication
Guidelines for prescribing anti-psychotics for CB:• Monitor effectiveness against initial aims• Single drug• Stop after 6 weeks if no response• PRN is not to exceed 4 weeks• If there is a positive response- MDT review at 3 months
then 6 monthly• Only continue to offer medication that has proven benefit
Draft NICE guidelines (5)- Reactive
• Similar to Positive & Proactive Care guidelines• Last resort and use together with proactive
interventions• Least aversive and least restrictive• Encourage person and family to be involved in
planning and reviewing• Any restrictive intervention is accompanied by a
Restrictive Intervention Reduction Programme
Reducing the use of Restrictive Interventions: how well are we meeting current guidance?
Positive and proactive care (DH 2014) indicates 4 overarching themes
• Improving care
• Leadership, assurance and accountability
• Transparency
• Monitoring and oversight
Restrictive Interventions – what do they include?
• Physical restraint
• Mechanical restraint
• Chemical restraint
• Seclusion
• Long-term segregation
Audit Aims
1. To develop appropriate set of standards to audit the care plans and documents available on RiO against the Department of Health Positive & Proactive Care guidance.
2. To recommend any actions that may improve clinical practice and ensure that care is being delivered to a high quality standard in the least restrictive methods possible, in line with Positive & Proactive Care.
Development of Standards for Care1. Person centred plan2. Multi-disciplinary formulation3. Aims of admission4. Interventions driven by formulation5. Plan addressing challenging behaviour6. Least restrictive practices used7. Service user collaboration with care plans8. Comply with MCA and MHA9. Post-incident reviews10. Learning from incidents11. Accessible data e.g. graphs12. Plan around use of physical restraint13. Discharge care plan
Audit Scoring
By checking the available information for each service user on RIO, each standard was graded as:
– Not Met/No evidence (0) – The standard has not been met in any form or there is no evidence provided.
– Some Evidence (1) – There is mention of the standard, however there is not sufficient evidence to suggest that it has been met either partially or fully.
– Almost met (2) – There is detailed information regarding the standard, however not enough evidence to suggest that it has been fully met.
– Fully met (3) – The standard has been fully met.
Each standard could achieve a maximum of 3 points (fully met) and therefore across the thirteen standards a maximum of 39 points could be achieved.
Results
Key Findings: Where we could do better
• Key finding 1: Few PMAV care plans included ideas that reflected key principles from the Mental Capacity Act and Mental Health Act [standard 8].
• Key Finding 2: Limited evidence that Post-incident reviews were held for both staff and patients. Unclear where this would/ should be documented [standard 9].
• Key Finding 3: Limited evidence of PBST care plans which derived through a collaborative formulation. Lack of evidence that formulation then led to specific interventions aims at reducing restrictive interventions [standard 2].
• Key Finding 4: The specific aims of admission were not easily identified upon RIO [standard 3].
• Key Finding 5: Limited individualised data was available that provided evidence of the effectiveness of our interventions [standard 11].
• Overall service users had strong PMAV (prevention and management of aggression and
violence) care plans.
They included;
⁻ Information about the context within which the behaviour that challenges may occur,
primary prevention strategies
⁻ Secondary prevention (de-escalation)
⁻ Tertiary strategies (including planned restrictive practices- carried out safely and as a
last resort).
• Physical health information was also commonly included to make staff aware of any
physical limitations.
Key Findings: Areas of Good Practice
Key Finding 6: Robust PMAV behaviour support plans are in place for all services users who are known to be at risk of being exposed to restrictive interventions including the most common contexts in which these behaviours occur.
Key Finding 7: Ethical care plans – All care plans were written with a strong emphasis on the principle of ‘Least Restrictive’ practice.
Key Finding 8: Good evidence of person centred, values based approach where the focus of care/ practice is on improved QoL and where support plans focus on the person, their journey and their future needs.
Implications for Practice (1)
• Overall there needs to be more collaboration with service users in the development of their individual care plans [standard 1].
• More effort is needed to capture the service users’ voice including what is important to them now and in the future [standard 1].
• All service users require a multi-disciplinary formulation that is easily identified, meaningful and accessible [standard 2].
• Pre-admission reports should provide specific details regarding the aims of the admission focussing on [standard 3].
• More effort is needed to capture the service users’ voice within the PMAV care plans to support them in using preferred de-escalation techniques [standard 7].
Implications for Practice (2)• PMAV care plans should make explicit how restrictive practices adhere to
the Mental Capacity Act and Mental Health Act (i.e. best interests, dignity, human rights) [standard 8].
• Post incident reviews should be routinely held for both staff and patients. It should be clearly documented what has been learnt from the incident in order to reduce the likelihood of it occurring again. They should then be documented chronologically to demonstrate learning [standard 9].
• It would be helpful to have access to data such as graphs to assess the effectiveness of our interventions [standard 11].
• All patients should have a discharge care plan which describes how we are supporting them to move into a less restrictive environment, or which steps are being taken to arrange discharge [standard 13].
Reduction of Restrictive Practices within Nottingham
So What?
National level
Board Level
Service Level
Individual Level
Board Level
Positive & Safe: Restrictive Intervention Reduction Programme
Led by the Chief Operating officer (Board Lead) and the Director of Nursing (Lead Director)
The 6 Core Strategies
• Leadership towards organisational change • Data to inform practice • Workforce Development • Inclusion of individuals and families • Use of reduction tools • Rigorous de-briefing
So what's happening in Nottingham? What have we done to change practice?
Service/Individual levelWhat we are aiming to achieve in Nottingham is the ability to reduce restrictive practices and to: “Foster an inclusive culture where by we can shape care effectively, raise peoples awareness, learn effectively from incidences and have the ability to evidence and change our practice. As a result ensuring patients experiences in our care is positive and safe”
But What does that look like?
Service/Individual level• Monitoring.
• Patient voice and experience to inform care planning and training.
• Examining ward climate.
• Improving relational security and meaningful engagement with patients.
How should we support People in St Andrew’s
Meaningful Conversations
Ward Climate
Service/Individual levelImplementation of:
RAID®
What next?• Monitoring• To work within the board framework-6 Core strategies• Consider the recommendations from the care plan • Embedding the correct culture around restrictive practices• Meaningful Conversations linking into handover• Consider the implications of the code of practice• Establish streamlined treatment pathways and those which
clearly articulate what needs to happen during an individuals transition.
• Being creative about how and where we utilise resources to inform practice
Final Note……..
Thank you for listening
Any Questions?
References• Department of Health (2012) Transforming care: A national response to Winterbourne
View Hospital: Department of Health Review Final Report. • Department of Health (2012) DH Winterbourne View Review Concordat: Programme of
Action: Department of Health Review Final Report. Skills for Health and Skills for Care (2014)
• A Positive and Proactive Workforce. A guide to workforce development for commissioners and employers seeking to minimise the use of restrictive practices in social care and health
• Social Care, Local Government and Care Partnership Directorate, Department of Health (2014) Positive and Proactive Care: reducing the need for restrictive interventions.
• MIND (2013) Mental Health Crisis Care: physical restraint in crisis.