FOI REQUEST NUMBER 316- 2015 - nsft.nhs.uk 2015.pdf · Psychiatric In-patient Settings and Emergency Departments. Code of Practice, Mental Health Act 1983. Presented to Parliament

Compliance Team – Health Records Kestrel House

Hellesdon Hospital Drayton High Road

Norwich Norfolk

NR6 5BE

Tel: 01603 421687 Fax: 01603 421411

FOI REQUEST NUMBER 316- 2015 Request & Response For period 1 January 2014 to the 31st December 2014, please provide details of all incidents of physical restraint used in relation to children receiving in-patient psychiatric care at any hospital or unit under your management or control, where possible providing a breakdown by age, gender and ethnicity:

i. The total number of incidents of physical restraintii. The total number of patients who experienced physical restraintiii. The total number of incidents where physical restraint was used to administermedicationiv. The name and location of the psychiatric hospitals and units where these incidentsoccurredv. The number of children receiving in-patient psychiatric care during this period.Please provide a copy of any written policies and/or training guidance you hold concerning the use of restraint in relation to children and details of any recording and notification system you have in place concerning the use of restraint of children in your psychiatric care.

i. The total number of incidents of physical restraint

Gender Age Other Asian

White - British

Female

13 73 3 76 14 7 7 14 16 2 233 235 17 1 3 4

83 246 329

Male

7 1 1 12 2 2 13 1 1 15 186 186 17 7 7

196 196

83 442 525

ii. The total number of patients who experienced physical restraint


White - British

Female

13 1* 1 14 1* 2 16 1** 2 17 1** 1

2 6

Male

7 1 12 1 13 1 15 1 17 1

5

2 11

* Same patient / ** Same patient

iii. The total number of incidents where physical restraint was used to administer medication


White - British

Female 13 1 1

16 1 1

1 1 2

Male 12 1 1

1 1

1 2 3

iii. Name and Location of the Psychiatric hospitals and units where these incidents occurred

5 Airey Close, Lothingland, Suffolk


White - British Grand Total

Female

13 3 3 16 2 2 4 14 2 2 17 1 1

3 7 10


Gender Age Other Asian White - British Grand Total

Female 13 73 73 16 231 231 14 7 5 12

80 236 316

Male

13 1 1

15 186 186

187 187

80 423 503



Male 7 1 1

1 1

Poppy Ward, Woodlands, Suffolk


Male 17 7 7

7 7

Southgate Ward, Wedgewood House, Suffolk


Male 12 1 1

1 1

Yarmouth Acute Services, Northgate Hospital


Female 17 3 3

3 3

TOTAL

83 442 525

iv. The name and location of the psychiatric hospitals and units where these incidents occurred. Details of locations provided above. v. The number of children receiving in-patient psychiatric care during this period I confirm for the period 1st January 2014 to 31st December 2014 the following number of children receiving inpatient care was as follows:- Row Labels Count of FacilityID Acute Services Centre Yarmouth 2 AMH Northgate Ward (NORTHW) 1 AMH Southgate Ward (SOUTHW) 4 Churchill - Fermoy Unit 1 Five Airey Close CAMHS 28 LD 6 Airey Close (6ACW) 3 Nor 6 Airey Close Ward 2 Poppy Ward (POPW) 1 Grand Total 42 Please find attached the various policies requested. The Trust provides a complaints procedure to deal with complaints about the Trust's handling of requests for information. If you feel you need to make a complaint, in the first instance, you should contact a Non-Executive Director via the Chair of the Trust. If you feel you have exhausted our internal complaints procedure, you also have the right and may feel you wish to write to the Information Commissioner who can be contacted on telephone number 01625 545740 or at www.ico.gov.uk.

http://www.ico.gov.uk/

Norfolk and Suffolk NHS Foundation Trust C08: Prevention and Management of Violence and Aggression. Version 01 Page 1 of 23

Title: Prevention and Management of Violence and Aggression (including the

use of physical intervention)

Outcome Statement: A safe and therapeutic culture will be provided for all service users including those who may present with behavioural disturbance

Written By: Helen Oatham – Governance Practitioner Chris Platten – PMA Lead Practitioner

Reviewed By: N/A – first version In Consultation With: Michael Lozano – Patient Safety and Complaints Lead

Jane Sayer – Director of Nursing, Quality and Patient Safety Emma Townsend – Clinical Team Leader/AHP Lead Modern Matrons PMA Practitioners

Approved By and Date:

Clinical Effectiveness and Policy Group – April 2015

With Reference To: Code of Practice for Minimising the Use of Restrictive Interventions: Planning, Developing and Delivering Training. British Institute of Learning Disabilities (BILD) (2014) National Institute for Health and Clinical Excellence (2005).Clinical Guideline 25: Violence – The Short-term Management of Disturbed/Violent Behaviour in Psychiatric In-patient Settings and Emergency Departments. Code of Practice, Mental Health Act 1983. Presented to Parliament pursuant to section 118 of the Mental Health Act 1983. Department of Health (2015). Skills for health; A Positive and Proactive Workforce. Department of Health (2014) Positive and Proactive Care: reducing the need for restrictive interventions. Department of Health (2014) Developing Positive Practice to Support the Safe and Therapeutic Management of Aggression and Violence in Mental Health In-Patient Settings. National Institute of Mental Health in England (2004) Meeting the Needs and Reducing Distress, Guidance on the Prevention and Management of Clinically related Challenging Behaviour in NHS Settings. NHS Protect (2014), Price, O. et al. Key components of de-escalation techniques: A thematic synthesis. (2012) Restraining, Holding Still and Containing Children and Young People. Royal College of Nursing (2003) Safewards Model. Institute of Psychiatry. http://www.safewards.net/

Associated Trust Policies and Documents:

C07: Mental Capacity Act and Deprivation of Liberty Safeguards C82: Clinical Risk Assessment and Management C98: Care Programme Approach C107: Seclusion and Long-term Segregation Q11: Serious Incidents Requiring Investigation Q15: Corporate Induction Q16a: Management Supervision Q17: Lone Working Q19: Stress Management Q20: Accident and Incident Reporting Q32: Being Open Promoting Safer and Therapeutic Services. Course content , including positive and proactive care and reducing the need for restrictive intervention

Applicable To: Trust wide (In-patient Areas) For Use By: All staff Reference Number: C08


(NB: this policy replaces C30: Physical Intervention and C66: Prevention and Management of Violence and Aggression)

Version: 01 Published Date: April 2015 Review Date: April 2016 Equality Assessment: April/August 2013 (C30 and C66) – to be reviewed Implementation Practical implementation through PMA training

Routine distribution procedures (publication on the Trust intranet, email notification to identified senior staff for distribution throughout the team and inclusion in the Trust Update e-bulletin).

Review and Amendment Log Version Number

Reasons for Development/Review

Date Description of Change(s)

01 Planned review to merge previous policies and to reflect national changes

01 C30: Physical Intervention and C66: Prevention and Management of Violence and Aggression merged into this policy and discontinued. Reflection of restraint reduction drivers Introduction of Behaviour Support Plan terminology Publication of the revised MHA Code of Practice Reflection of restraint reduction and restrictive interventions guidance Terminology updated to introduce care-plans as behaviour support plans Clear reference to the fact that physical/practical safety and service specific interventions are delivered via PMA Training and are set out in the course syllabus (CQC) Reference that restrictive interventions must be compliant with the Human Rights Act (CQC/CofP) Reference to Debrief Record Form if a SIRI - now being introduced into Q11: SIRI policy


Contents 1.0 Introduction 4

2.0 Purpose 4

3.0 Definitions 4-5

4.0 Roles and Responsibilities 5-7

5.0 Prevention and Management of Violence and Aggression – Summary of Key Points 8

6.0 Communication, Personal Safety and Lone Working 9

7.0 Risk Assessment 9-10

8.0 Care-plan (Behaviour Support Plan) 10

9.0 Prevention 10-11

10.0 Low Stimulus Environment 11-12

11.0 Breakaway Techniques 12

12.0 Restrictive Interventions 13

13.0 Physical Intervention 13-14

14.0 Legal Aspects 14

15.0 Gender Mix 14

16.0 Review of Physical Intervention 15

17.0 Physiological Observations 15

18.0 Reporting 16

19.0 Support for Staff 16-17

20.0 Support for Service Users 17

21.0 Post-incident MDT Review 17

22.0 Monitoring Statement 18

Appendices

1 Physical Intervention for Personal Care 19-21

2 Prevention and Management of Violence and Aggression (PMA) Department 22-13

NB: If a service user is assaulted this should be referred to the Patient Safety and Complaints Lead. The Practitioner in-Charge should arrange for the service user to be examined by medical staff or transferred to Accident and Emergency as clinically indicated. They should also ensure the provision of immediate and ongoing support. If another individual (e.g. a visitor) is assaulted on Trust premises they should be advised to see their GP, report to police etc as appropriate. If they require immediate medical attention an ambulance should be called and staff should offer support as appropriate. They should also be offered the opportunity to make a complaint


1.0 Introduction It is inherent to the nature of Trust services that we will be supporting people whose needs and histories mean that, based on risk assessment, they can reasonably be predicted to present with behaviours that place themselves and/or others at risk of harm. However the effects of a physical restraint on an individual can have a marked impact on the recovery process and invoke distress thus should be perceived as a treatment failure Nationally, there is increased emphasis on health and social care organisations developing a culture that is committed to developing therapeutic interventions/environments where restrictive interventions are only used as a last resort. Norfolk and Suffolk Foundation Trust (NSFT) is an advocate for the reduction in restraint and restrictive practice thus it is the expectation of employees to take the time to understand the constituents of restrictive practice and validate this understand with changes in practice to support the patient through the recover process In order to take this forward in practice there will need to be a focus on continual development of the knowledge and skills of clinical staff to enable the recovery process. 2.0 Purpose This policy aims to:

• Help promote best practice principles across a range of health and social care settings

• Ensure that restrictive interventions are used in a transparent, legal and ethical manner.

• Encourage a culture across health and social care organisations that is committed to developing therapeutic environments where physical interventions are only used as a last resort

3.0 Definitions Restrictive Interventions/Restrictive Practice (see Section 12.0 for details)

• ‘Deliberate acts on the part of other person(s) that restrict an individual’s movement, liberty and/or freedom to act independently in order to:

o Take immediate control of a dangerous situation where there is a real possibility of harm to the person or others if no action is undertaken;

o End or reduce significantly the danger to the person or others;

DH (2014) Behaviour Support Plan (see Section 8.0 for details) An individualised care-plan which includes

• Primary preventative strategies – these aim to enhance a patient’s quality of life and meet their unique needs, thereby reducing the likelihood of behavioural disturbances

• Secondary preventative strategies – these focus on recognition of early signs of impending behavioural disturbance and how to respond to them in order to encourage the patient to be calm

• Tertiary strategies – these guide the responses of staff and carers when there is a behavioural disturbance.

Code of Practice (2015) Physical Restraint

• “Any direct physical contact where the intervener’s intention is to prevent, restrict, or subdue movement of the body, or part of the body of another person”.

DH (2014) Positive and Proactive Care

• The use of threat or force where a person who lacks capacity resists, and any restriction of liberty or movement whether or not the person resists. Restraint is only permitted if the person using it reasonably believes it is necessary to prevent harm to the person who lacks capacity, and if the restraint used is proportionate to the likelihood and seriousness of the harm (Mental Capacity Act, Section 6

Immediately

• The requirement for the ‘immediate’ review by medical staff means that they should attend the area as a priority as soon as they are informed that physical intervention has taken place


• In exceptional circumstances (e.g. if they are prescribing medication for a highly disturbed service user) they should complete this and then attend the area as their next priority.

Work-related violence:

• Any incident in which a person is abused, threatened or assaulted in circumstances related to their work

Non-physical Assault:

• The use of inappropriate words or behaviour causing distress and/or constituting harassment (Secretary of State Directions, (2003)

Physical Assault:

• The intentional application of force to the person of another without lawful justification, resulting in physical injury or personal discomfort

• If a staff member is injured during the restraint of a service user, either deliberately or accidentally, it is considered a physical assault

Low Stimulus Environment (LSE)

• A room or area where there are few bright lights and a low noise level so the person is away from others/stimuli and has their own space.

• Areas used as low stimulus may include o The service user’s own room o Quiet rooms (including interview, group and therapy rooms when not in use) o Courtyards o Multi-faith rooms

Lone Working/Lone Worker

• Any situation or location in which someone works without a colleague nearby, or when someone is working out of sight or earshot of another colleague. Lone working is not unique to any particular group of staff, working environment or time of day.

(NHS SMS, 2009) 4.0 Roles and Responsibilities Statutory Responsibilities

• As specified in the Health and Safety at Work Act 1974, the employer has a responsibility to ensure as far as reasonably practicable the health, safety and welfare of their employees. Employees are also tasked with the responsibility to maintain a safe working environment by complying with measures put in place by the employer. Thus accountability for attendance on Prevention and Management of Aggression training rests with both the manager and staff

Trust Board

• Ensuring that there are arrangements for identifying, evaluating and managing risk associated with violence and aggression at work

• Providing resources for putting the policy into practice

• Ensuring that there are arrangements for monitoring incidents of violence and aggression

• Appointing a Security Management Director and Non Executive Director Local Security Management Specialist (LSMS) The Local Security Management Specialist overall objectives are to work on behalf of NHS bodies to deliver an environment that is safe and secure so that the highest standards of clinical care can be made available to service users. This includes:

• Working closely with the PMA Department/Workforce Development to ensure that PMA training is compliant with Security Management Service guidance

• Maintaining an overview of all Prevention and Management of Aggression and Personal Safety training

• To work with the PMA department to audit and complete returns on training, assault statistics and sanctions that are taken against perpetrators


• Ensuring that any member of staff who is assaulted is appropriately supported

• Co-operating with the police to ensure that appropriate sanctions are taken against the perpetrator (subject to assessment of capacity) and monitoring police actions following an assault

• Acting as liaison between the Trust and the Business Authority

• Issuing ‘Acknowledgement of Responsibilities Agreements’ letters, Final Warning letters and ‘Withholding of Treatment’

Prevention and Management of Aggression (PMA) Lead Practitioner

• Implementing and providing Prevention and Management of Aggression training throughout the Trust and to external care providers and agencies affiliated to the Trust.

• Providing clinical links across the Trust and working closely with all areas to ensure best practice is maintained

• Working closely with the Risk Management Department and LSMS to ensure training is in line with service needs, meets with current risk trends and is up to date with current local and national guidance

• Co-ordinating the departments involvement with national groups, networking and information sharing

• Disseminating findings from national guidance, internal and external investigations to inform best practice

• Providing support and guidance to locality and service managers and keeping them up to date on any PMA/risk issues

Clinical Team Leaders/Team Managers

• Risk assessing roles and identifying training needs both for the clinical area as a whole and for staff as individuals through appraisal

• Ensuring that clinical risk assessments have been completed/reviewed and are up-to-date and comprehensive through line management supervision

• Carrying out environmental risk assessments with the LSMS/Patient Safety and carrying out any actions required as a result of this

• Putting procedures, safeguards and safe systems of work into practice to eliminate or reduce the likelihood of violence and aggression

• Maintaining an awareness of incidents within the area and ensuring that actions to reduce/prevent recurrence are taken.

• Ensuring that staff workplace induction includes this policy, Q17: Lone Working and the site of the area’s resuscitation equipment and how to summon urgent assistance

• Ensuring that resuscitation equipment is available in the area and that there are systems for checking this in place (See C46: Cardiopulmonary Resuscitation policy)

• Ensuring appropriate support has been offered/given to all persons involved in/witnessing any incident of violence and aggression.

• Ensuring that planned duty rotas include adequate numbers of PMA trained staff to manage incidents

• Issuing verbal warnings (in consultation with the Local Security Management Specialist) to service users

All Staff

• Ensuring that themselves/others do not expose themselves to unnecessary risk

• Participating in required mandatory training (as set out on their LARA template) within the required timeframe

• Following policies and procedures designed for safe working (e.g. Q17 Lone Working)

• Reporting all incidents involving verbal abuse, threats and physical assaults (via Datix)

• Reporting any concerns they may have regarding potentially violent situations or the environment in which they work to an appropriate person

• Maintaining (as far as possible) the health, safety and welfare of all people involved in/witnessing an incident and providing support

• Attending areas where an incident has occurred to assist/support the team/service users etc


• Instigating the ‘Serious Incident’ procedure (when required) (See Q11: Serious Incidents Requiring Investigation).

Clinical Staff (in addition to above)

• Carrying out risk assessments relating to violence and aggression and using this information to develop a care/management plan

• Ensuring that risk assessments and care-plans are reviewed at planned intervals or sooner if the service user’s presentation/behaviour changes

• Ensuring that service users are routinely monitored and that any indication of increasing risk factors is dealt with as early as possible

• Ensuring that physical intervention is only used as a last resort, when all other interventions have been attempted and that use is always appropriate, reasonable, proportionate and justifiable to the individual (Care Quality Commission)

• Ensuring that all interventions are carried out in a way that respects dignity, protects human rights and wherever possible respects the preferences of the service user (Care Quality Commission)

• Comprehensively documenting a violent or aggressive incident in the health record

• Ensuring that service users involved in a violent incident are reviewed by their Responsible Clinician/Consultant (or nominated deputy)

• Seeking advice/guidance from the PMA department (as required) using the Referral to PMA Department Form

• Attending PMA training/refresher within the required timeframe/as set out in the Trust’s mandatory and statutory training list

• Reporting any concerns regarding the use and/or practice of physical intervention to their Clinical Team Leader/Charge Nurse), PMA Lead Trainer or PMA Lead Practitioner

Medical staff:

• Carrying out physical health and mental state reviews

• Documenting the review or any refusal by the service user

• Attending within agreed time limits


5.0 Prevention and Management of Violence and Aggression – Summary of Key Points


6.0 Communication, Personal Safety and Lone Working The Health and Safety Executive places a legal responsibility on the Trust to assess all risks to the health and safety of its staff, including the risk of lone working. However staff also have a responsibility to maximise their own safety and that of colleagues. Communication is not only integral to reducing distress for service users and supporting recovery, put is also important in maintaining the safety of all and all new team members, clinicians visiting the service user etc must be provided with information (as appropriate). This should include

• An individuals previous risk history

• Changes in behaviour over the last 24 hours

• The role and purpose of observations

• What interventions have been tried and to what degree of success

• Antecedents to aggression (physiological, psychological, sociological and environmental) Information should be reiterated during the handover process and it is the clinical areas responsibility to make sure that new /existing individuals have access to this information for review and/or update In addition to this staff unfamiliar with the clinical area must receive an induction to ensure that they are familiar with emergency procedures and the environment as well as being given patient information (see Q15: Corporate Induction policy). They should also be made aware of Q17: Lone Working policy as although lone workers are often seen as community-based clinical staff, all Trust staff (domestic and support staff, those working in in-patient areas etc.) may potentially be a lone worker and the clinical area should have systems in place to reduce the risks associated with this 7.0 Risk Assessment Risk assessment is key in identifying the likelihood and consequences of violent and/or aggressive behaviour and those interventions that avoid, mitigate or control the risks. Proactive factors such as greater collaboration should also be emphasised, Good practice would indicate that the risk assessment is carried out by the MDT and includes collaboration with other professionals involved in the service user’s care and also discussion with the service user as part of a risk sharing partnership, and/or their family/carer/friends (as appropriate) in line with Q32: Being Open policy The risk assessment should be holistic and must take into account any physical, psychological, cultural/religious issues or other needs such as sensory impairment or learning disability that would impact/influence the service user’s behaviour. Physical risks may include

• Reduced cardiac and respiratory function

• Specific breathing difficulties that could be caused by asthma, allergies, hay fever, smoking, bronchitis, etc

• General physical ill-health – coughs, colds, flu etc

• Being overweight, large in stature or having a distended stomach

• Ageing process factors – papery skin, rheumatism, arthritis, hypertension, sensory and cognitive

• Alcohol consumption and/or substance misuse

• Prescribed medication

• Physical deformity/previous injuries The PMA Training team can offer advice/support in managing individuals with physical health issues. The service user’s age should also be considered as seclusion can be a traumatic experience for anybody, but can have particularly adverse implications for the emotional development of a child or young person, especially those with a history of trauma and/or abuse. This should be taken into consideration in any decision to seclude a child or young person.


Historical risks must always be included/remain (regardless of time lapse) although staff should not assume that a previous risk of behavioural disturbance means that they will behave in this way in the future All risk assessments should have the next planned review date recorded on them. The risk assessment should be reviewed at planned intervals or sooner if the service user’s presentation (physical and/or mental health) changes and as part of post-incident review. Consideration should also be given to review if there is a significant life event for the service user (E.g. bereavement) The quality (up-to-date, comprehensive etc) of risk assessments will be monitored through staff’s management supervision (see Q16a: Management Supervision ‘Audit of Record Keeping’). NB: See also C82: Clinical Risk Assessment and Management policy 8.0 Care-plan (behaviour support plan – see Section 3.0 Definitions) Where a risk of violent and/or aggressive behaviour is identified a risk management/care-plan must be developed. This should focus on prevention (primary prevention strategies) and specify interventions that would reduce the risk of violent/aggressive behaviour occurring and de-escalation strategies (secondary prevention strategies) Where there is the possibility of physical intervention being necessary, a specific care-plan should be written (tertiary strategies), where this has not been possible, it should be completed as soon as possible after the event. The care-plan should address both prevention/de-escalation interventions and physical interventions. The PMA Department can be contacted for advice if required (NB: this does not constitute ‘planned restraint’ as the situation of use is still an emergency) The care-plan should take account of disabilities, a patient’s level of cognitive functioning, the impact of age in terms of physiological and emotional maturity, the patient’s ethnicity, culture, religion or belief, gender, gender identity and sexual identity and they should maximise privacy and dignity. Behaviour support plans must include the specific details of individualised reactive management strategies including any required restrictive practices, this must take account of the individual’s unique circumstances (BILD 2014) As with risk assessment, the service user, their family, carer and friends should be involved wherever possible. Good communication will improve the information that is available to professionals for the development and review of risk assessments and care-plans. Sharing information with the service user’s carer/family and friends (as appropriate) will also enable them to support the service user and alert staff early where they have a concern. A copy of the care plan must be offered/given to the service user and, with their consent, to their family/carer. In exceptional circumstances the care-plan may not be shared and this should be clearly documented on the care-plan. As with the risk assessment, care-plans should be reviewed at planned intervals or sooner if the service user’s behaviour and/or presentation changes and monitored through line management supervision 9.0 Prevention The prevention of aggression requires an understanding of the violent/aggressive behaviour within the service user, including the service user in assessment, care-plans and decision-making and basing care on individualised needs The use of restrictive intervention(s) can often be an antecedent to aggression and the MDT, in consultation with the service user and their family/carer (as appropriate) should decide individually on the need for restriction. If restrictions are imposed this must be for the minimum amount of time and continually reviewed according to the presentation of risk. All discussion, the decision and rationale must be documented in the health record


The management of aggression will vary on an individual basis; it is important to acknowledge this individuality and thus the need to tailor interaction to the individual to gain a reduction in aggression, however there are a few common factors that need to be acknowledged when de-escalating an individual:

Restraint reduction is a key concept in promoting the recovery process; to reduce restraint the service user must be at the centre of all interventions this could include;

• Clear mutual expectation

• Soft words

• Talk down/De-escalation

• Positive words

• Bad news mitigation

• Know each other

• Mutual help meetings

• Clam down methods

• Discharge messages

• Trauma informed care

• Open office

• Self awareness in interaction

• Risk sharing Safewards (2014)

Early identification of when a service user’s behaviour may be escalating (based on individual risk assessment) and intervention to ‘defuse’/de-escalate a situation may mean that the use of physical intervention is avoided. This may include strategies such as:

• Distraction

• Provision of and/or support to engage in suitable activity

• Use of a low stimulus environment

• Orientation to environment

• Removal of triggering factors or people

• Offering time to discuss feeling/concerns

• Change of environment Clinicians must be also have an awareness of

• Control self

• Delimit

• Clarify

• Resolve

• Respect and empathy

• Personal control

• Verbal and non verbal skills

• Engagement (when and how)

• Safe conditions

• Strategies of de-escalation

• Shared problem solving

• Facilitation of expression

• Alternatives to aggression Safewards (2014) and Price, O. et al (2012)

10.0 Low Stimulus Environment Service users may at times become distressed and/or aroused due to their mental health problems. At these times staff must provide interventions to minimise the increase in risk factors and this may include the use of a low stimulus environment, in conjunction with other de-escalation techniques –distraction, diversion, relaxation etc. A low stimulus environment is one that is not locked and may include


• The service user’s own room

• Quiet rooms

• Group/Interview/Therapy rooms when not in use

• Multi-faith rooms

The low stimulus environment can only be used if the service user consents to go to and remain in the quiet area; any use of coercion/physical intervention or of locking the door would constitute seclusion. The service user should also be involved in deciding how long they remain there and how return to the main ward areas can best be managed. Where the use of a low stimulus environment has been identified as a possible/actual intervention this should form part of the service user’s care/management plan. The service user and/or their family/carer (as appropriate) should have the rationale for the use of the low stimulus environment explained to them and be involved in developing the care/management plan. The professional-in-charge of the ward at the time the intervention is used should:

• Consider the need to review the service user’s level of observation and ensure that record sheets are fully completed (See C36: Observation and Engagement of Service Users)

• Allocate a member of staff to support the service user. They must be aware of the service user’s care-plan and completed relevant training (E.g. Additional Observations Competency Assessment, Prevention and Management of Aggression)

• Ensure that any physiological observations indicated by the service user’s presentation are carried out

• Monitor/review the effectiveness of the low stimulus environment

• Consider how the return to the main ward environment should be managed

• Consider if an escalation to seclusion is required (See C107: Seclusion and Long-term Segregation policy)

• Review the care/management plan

• Ensure a comprehensive account of the intervention is documented in the health record The service user’s Keyworker should:

• Ensure that any episodes of LSE are discussed/reviewed at the next MDT meeting

• The risk assessment and care-plan are reviewed as indicated following the meeting If staff have any doubts/concerns about the use of a low stimulus environment, seclusion procedures should be followed to ensure that the rights of the service user are maintained. NB: The use of a low stimulus environment may be considered as ‘time away’ but must not be confused with time out which is a specific behavioural intervention 11.0 Breakaway Techniques Breakaway techniques are designed to be instinctual and easy to recall, but also consider care and compassion towards individuals within our care. The use of breakaway technique is deemed to be as a last resort following failure of all other clinical skills including de-escalation, environmental awareness, situational awareness etc The use of a breakaway technique is not a planned intervention and must always be considered in application under Common Law of reasonable, necessary and proportionate response to the threat being faced. Inappropriate use of a breakaway technique not following the guidance under law can be deemed as an assault If a breakaway technique has been used this must be documented (including the circumstances of use) in the health record and an incident report submitted (Datix). The service user must be offered support and follow-up so as to understand why the action taken was and be able to work with staff to develop coping strategies collaboratively.


12.0 Restrictive Interventions Restrictive interventions are deliberate acts on the part of other person(s) that restrict a patient’s movement, liberty and/or freedom to act independently in order to take immediate control of a dangerous situation where there is a real possibility of harm to the person or others if no action is undertaken and/or reduce significantly the danger to the patient or others.

Skills for Care (2014) Restrictive interventions may be a requirement for those whose clinical presentation indicates that a marked amount of damage and distress will occur if restrictive interventions are not forthcoming. These are designed to support and protect the patient and must not be used to punish or for the sole intention of inflicting pain, suffering or humiliation. Restrictive practice is not just about restraint (physical, mechanical and chemical), it can include (this list is not exhaustive):

• Coercion

• Ward routines/blanket rules

• Technological

• Seclusion

• Additional observations

• Restrictions in movement/access

• Locked wards

• Rapid tranquilisation Where a restrictive intervention is used, the patient and/or their family/carer (as appropriate) should be involved in the decision making process and have the rationale as to why these interventions are to take place explained to them. All options should be considered and explored to maximise independence and empowerment thus facilitating inclusivity The use of a restrictive intervention should be:

• Used for no longer than necessary to prevent harm to the person or to others

• A proportionate response to that harm

• The least restrictive option

• Continually reviewed considering whether there is a necessity to maintain the restriction

• Compliant with the Human Rights Act (1998) (e.g. interventions that are not medically necessary may breach Article 3 which prohibits inhuman or degrading treatment and/or Deprivation of Liberty Safeguards (see C07: Mental Capacity Act and Deprivation of Liberty Safeguards policy)

Decision to use restrictive intervention should be transparent and establish clear lines of accountability; many decisions will involve assessment of whether the person involved has mental capacity (see Section 14.)

13.0 Physical Intervention Physical intervention is likely to be reactive with the intervention being necessary at that time to maintain the immediate safety of the service user, staff or others and a proportionate response to the likelihood and seriousness of the likely harm.

When considering the use of physical intervention in Children, the following must be acknowledged:

• The young person has a full assessment of their target behaviour and that a support plan has been developed for and with them

• There is an up to date risk assessment for the young person

• A restrictive physical intervention reduction plan has been developed and will be implemented in line with specific review dates and plans

• There is a record of everyone who has been trained in techniques and that training is reviewed and refreshed as regularly as is required to comply with Health and Safety legislation

BILD (2014)


Any physical intervention (restraint) must always be used as a last resort and be reasonable, necessary, proportionate and must be justifiable. In all circumstances (planned or reactive restraint) clinicians should make every attempt to engage the service user in the delivery of their care. This should include the early identification, prevention and de-escalation of disturbed/violent behaviour or the consideration of the ‘best interests’ for those who lack capacity. Physical intervention in any position has risks including positional (postural) asphyxiation, cardiac/respiratory distress, and it should be avoided wherever possible. It should not be used for prolonged periods, and should be brought to an end as soon as possible. Other management options such as seclusion or rapid tranquilisation should be considered as alternatives to continued physical intervention in an emergency (see C107: Seclusion and C111: Rapid Tranquilisation policies) Physical interventions should only be carried out by staff who have completed their Trust Physical Intervention (PI) training and refreshers as set out in their LARA template. However, untrained staff may occasionally need to act in defence of themselves or under their duty of care (Donoghue vs Stevenson 1932) to prevent injury to others. In these circumstances a member of staff with current training should always take over as soon as is practicable. Techniques used should not usually involve the deliberate application of pain. The deliberate application of pain has no therapeutic value and could only be justified for the immediate rescue of staff, service users and/or others

(National Institute for Health and Clinical Excellence, 2005). The risk to both the patient and others must be continually monitored and a decision not to physically intervene due to the heightened level of risk can be made to and the situation managed environmentally with the option to call police NB: Safe management of prone positions and service specific needs (e.g. children and young people or those with a learning disability) is covered in PMA practical guidance/instruction on the safe use of positions, airway monitoring etc (as per MHA Code of Practice, 2015). Advice on specific situations can be sought at any time from the PMA Team 14.0 Legal Aspects Any action taken must account for the parameters set out in common law, the action taken must be reasonable, necessary and proportionate. It is permissible to come to defence of another or act in the prevention of a crime under Section 3 Criminal Law Act 1967 Physical interventions can be utilised under the Mental Capacity Act (MCA) as a means of responding to an immediate risk (e.g. to prevent a service user walking in front of traffic). However this is only permissible once and correct multidisciplinary action must follow any event of this nature (e.g. reconsider MCA/MHA status, review risk assessment and care-plan). Due care must be taken that this doesn’t result in unnecessary restriction i.e. if a patient presents as a risk in a certain situation the action should be taken to assist through this situation rather than prevent access. The use of physical interventions may also be permissible under the MCA as a planned intervention following a best interest’s assessment (see C07: Mental Capacity Act including Deprivation of Liberty Safeguards policy) Individuals detained under the Mental Health Act (MHA) may be considered for the use of physical intervention – this however remains a last resort and all other options should be considered/attempted before physical intervention is deemed necessary. 15.0 Gender Mix Good practice would be that a member of staff the same gender as the service user was there at the commencement of the physical intervention (either participating or as a chaperone). Where this was not the case (e.g. in an emergency) a member of the same sex as the service user should be present as soon as possible (NHS Executive, 1999).


16.0 Review of Physical Intervention During any physical intervention, the team must constantly review;

• Rationale for the continued use of physical intervention

• De-escalation techniques used

• Other interventions considered to manage the situation and why these were not suitable and/or effective

Medical Review Service users who have been restrained in a prone or supine position should be reviewed immediately (see Section 3.0 Definitions) by a member of medical staff.

(Blofield Report 2003, NICE 2005)

Whenever restrictive interventions are being used there should be timely attendance of a doctor in response to staffs requests concerning a psychiatric emergency whether in relation to medication, restraint or seclusion (see Section 3.0 Definitions)

Code of Practice (2015) A physical and mental health examination must be carried out by a member of medical staff. Where this is not possible at the time of review attempts to complete this must continue. If a person has been restrained but taken to seated position without going into a prone or supine position, then medical review necessity will be decided by risk assessment and NEWS/PEWS as well as acknowledging the patients request. Support and consideration given to observation must still be offered to a person following this circumstance due to risk of psychological trauma (please see post incident support) Concerns regarding the physical well-being of the service user must be taken account in deciding the appropriate timeframe for review/course of action. The examination or any refusal should be documented in the health record. 17.0 Physical Observations A service user who has been restrained in a prone or supine position must have their physiological observations monitored at regular intervals – a minimum of 2-hourly for a minimum period of 24-hours. Where rapid tranquilisation has been used staff must follow the guidance set out in the Trust’s C111: Rapid Tranquilisation policy (C111 and summary available in Psychotropic drug Information and Protocols manual (PIP)) Interventions/observations that should be made include:

• Ensuring care in the recovery position (especially where medication has been administered)

• Level of consciousness

• Respiration rate

• Pulse rate

• Blood pressure

• Temperature

• Food and fluid intake and output Observations should be recorded on a physiological observations chart (NEWS/PEWS) and action taken as indicated of if there are any concerns (see C22: Physiological Observations policy) If staff are unable to gain consent/cooperation from the service user to carry out these observations, the Practitioner in-Charge should ensure that a suitable alternative plan of observation/monitoring is put in place (e.g. the Agitation-Calmness Evaluation Scale; ACES). The reason why the physical observations could not be carried out and the alternative actions taken should be clearly documented in the service user’s health record.


18.0 Reporting All incidents of violent and/or aggressive behaviour must be reported via the Trust’s incident reporting system (Datix) (see also Q20: Accident and Incident Reporting). Incidents should be graded using the Trust’s ‘Defining Level of Risk, 5x5 matrix’ (available on the Trust intranet). If staff are unsure of how to grade an incident they should seek advise from a more senior colleague or the Datix team. All service user related violent incidents are checked daily (Mon-Fri) by the Datix team. This information is shared with the National Patient Safety Agency and any other parties who we are legally required to inform. Reporting incidents supports the Trust’s approach to its duty of care to service users and staff, and to improve quality through learning from incidents. Incidents are collated and reported as part of the quarterly Risk Report to the Quality Governance Committee where this information is discussed and any learning required from incidents disseminated through the Trust. Where a member of staff sustains an injury during physical intervention an additional/separate incident report for ‘physical assault’ (cross-referenced to the original incident/web number) must be submitted, as whilst the injury may not have been inflicted deliberately, it would not have been sustained had the physical intervention not taken place. NHS Protect classes this as physical assault and therefore requires additional information. 19.0 Support for Staff Initial/Immediate Support Wherever possible a senior person who has not been involved in the incident should lead the support. If this is not possible a senior member of staff who was involved may lead (if they feel able), but should also consider seeking assistance from other clinical areas. Staff should be aware that the effects and behaviours following an assault will vary and therefore different types/levels of support will be required. Actions that should be considered in providing support include:

• Provision of reassurance

• Provision of emotional and physical time and space (some people may prefer not to talk about what happened at his point)

• Initial defusing (to all involved) In an emergency situation (the person is unconscious) their Next-of-Kin should be contacted as soon as possible and offered support. Physical Wellbeing

• Is First Aid, medical help or hospital treatment needed?

• If required, the person should be offered the opportunity to attend A&E and/or encouraged to see their GP.

• If a person is going off duty/going home, see Attendance and Ill Health Management policy for reporting requirements.

• If they are driving, a registered practitioner must make an assessment of whether they seem fit to do so or whether other transport arrangements are required If other arrangements are required (a taxi, in these circumstances, this should be paid from the ward budget, a family member/friend could collect them etc).

• Consideration should also be given to checking whether they will be alone or have someone with them at home. Whilst the person may state that they feel able to drive, it is not good practice to base the decision on this as people may prefer to have their own car, don’t want to appear “weak”, may be in shock, etc

• Offer the opportunity to talk through the incident before going off duty (or at the earliest possible opportunity). This should identify good practices and what was done well during the incident

Later Support

• The Clinical Team Leader/Service Manager should ensure that they (or an appropriate deputy)


consider any ongoing support needs, especially if the staff member is experiencing difficulties associated with the event.

More serious incidents may require a Critical Incident Debrief/Root Cause Analysis; these are likely to have been managed as a serious incident and for these, the Debrief Attendance Record should be completed (see Q11: Serious Incidents Requiring Investigation policy) Staff who are involved in or who witness physical intervention should ensure that they are engaging in regular clinical supervision and use this to address any issues/concerns that they may have. If staff observe practice which causes them concerns they should discuss this with their Line Manager/senior staff (Band 6 or above). Advice and support can also be obtained from the PMA Lead Trainer/Team. NB: Staff should also ensure that people (visitors, non-clinical staff) involved in/witnessing the incident and/or the physical intervention are also offered appropriate post-incident support. 20.0 Support for Service Users Following an episode where the service user has been aggressive/violent they should also be offered support and the opportunity for a post incident review. If the service user wishes to discuss the incident which led to the use of a restrictive intervention, their understanding and experience of the incident should be explored as it is important that service users are helped to understand what has happened and why and identify what helped, didn’t help and what might be done differently in future. Where a service user is not able to/does not wish to discuss the incident, staff should assess the effects of any intervention on their behaviour, emotions and clinical presentation In both instances the care-plan/ behaviour support plan should be reviewed and consideration be given to supporting the service user to develop an Advanced Statement 21.0 Post Incident MDT Review There should be an MDT review following an incident. Good practice would be that this is held within 72 hours of the incident and (wherever possible) is lead by someone who was not directly involved. (NICE 2005). The Clinical Team Leader (or nominated deputy if they are unavailable) should co-ordinate this review but if possible, a person not directly involved in the incident should lead the review. The review should consider:

• What happened during the incident

• Any trigger factors and how these may be managed in the future

• Each person’s role in the incident and subsequent seclusion

• Their feelings at the time of the incident, at the review and how they may feel in the near future

• What can be done to address their concerns

• Where seclusion has occurred in a room not designated as a seclusion room this issue must be specifically addressed in the review

• Review of the risk assessment and care/management plan The service user and/or their carer (if appropriate) should be involved in the review and the care and management planning.


22.0 Monitoring Statement Aspects of the policy to be monitored

Monitoring method

Individual/Team responsible for monitoring

Frequency Findings: Group/Committee that will receive the findings/monitoring report

Action: Group/Committee responsible for ensuring actions are completed

Use of physical intervention – trends in numbers

Figures of restraint incidents (via Datix)

Patient Safety Group

Monthly Patient Safety Group Trust Board


Appendix 1 Physical Intervention for Personal Care

This section should be used in conjunction with the main guidance on physical intervention and may only be used if the need for physical intervention for personal care is in the individuals’ best interests and has been agreed by the MDT and consent and capacity has been checked

• For the purposes of physical/personal care (E.g. toilet, washing, dressing etc) and

• This is required at least once daily because of the service user’s refusal/inability to engage is persistent

The use of pain compliance is not appropriate in these situations. MDT Meeting – Identification and assessment of clinical need Where there is a possibility of planning physical intervention for personal care, the following must be taken into account:

• Clinical need /risk assessment

• Advance Statements or crisis plans (see main guidance)

• Mental Health Act status

• Assessment of capacity • A combined PMA or physiotherapy and manual handling assessment may be considered.

Psychological assessment should also be considered. Where physical intervention is deemed to be necessary in order for staff to be able to carry out necessary physical care interventions the factors considered must be clearly documented in the health record and reflected in the care-plan Personal Care Physical Intervention Care Plan The care plan must be specific to the personal care intervention for which physical intervention has been agreed by the MDT. It does not apply for any other intervention where physical intervention is required. These instances should be reported as set out in the main section of this policy. The care-plan should be explained to the service user and/or their carer/relative (as appropriate) and them given the opportunity to comment and/or sign it.

The care plan should clearly set out:

• The aim of and rational for the physical intervention

• The circumstances in which it will be used (I.e. as a last resort and what interventions should be employed beforehand)

• Any identified physical health risks and how these should be managed

• The gender of staff for the physical intervention. Wherever possible and based on risk assessment the service user’s choice of the gender mix of staff who would carry out the personal care

• Any cultural and/or religious needs that would influence the personal care and/or the physical intervention

Incident Reporting Incident reporting will be used as part of the physical intervention for personal care review process. An incident report will be submitted for the following:

• An initial report on the agreement by the MDT (and service user/carer as appropriate) that physical intervention for a personal care activity is appropriate. The report will state the identified intervention and the rationale, and the estimated frequency that the physical intervention will be needed

• A minimum of weekly for a period of 8-weeks and monthly thereafter. Reports should reflect care plan reviews and any changes in capacity. The incident report must be submitted sooner if there is change in service user’s MHA status/capacity or presentation. Reports should be cross-referenced (Web or form number) to the initial report


• When there is a change in the care plan

• Where there is an adverse event related to the intervention (E.g. the service user sustains bruising)

• When the planned physical intervention care plan is discontinued An entry should be made in the health record confirming that the incident report has been completed and in the ward diary/equivalent for the date next due. If anyone is injured during the physical intervention an additional incident report must be submitted – see main policy guidance for details. Physical Intervention for Personal Care On each occasion staff should consider:

• Is there a clinical need for the physical intervention and/or personal care at this time?

• The amount and type of assistance or supervision required as this may vary from day-to-day and the service user should have as much autonomy as possible.

• Capacity at this time Should the intervention have any adverse outcomes (E.g. the service user sustains bruising) they must be examined by a member of medical staff immediately (see definitions) and an additional incident report completed.

Physical Intervention – Personal Care P

ost-

resra

int

Eve

nt

of

Pers

on

al C

are

Ph

ysic

al In

terv

en

tio

nA

sse

ssm

ent

Personal care need identified that may indicate a need for physical intervention

(see guidance)

Formulate personal care physical intervention care plan (this must

be intervention specific and consider Advance Decisions

See guidance)

Does the service user have

capacity?

Is physical intervention appropriate?

Detained under the Mental

Health Act?

No further action. Review as required

No physical intervention for personal care possible. Seek

advice if concerns

MDT meeting with service user/nearest relative/carer (as

appropriate). Make ‘Best Interests Decision’

Yes No Yes

No

Initial Incident report (Datix)

Resubmit datix report weekly for 8 weeks and monthly thereafter to account for

changes in capacity and/or if care plan changes

Reassess capacity

SU has capacity?

Personal care required

Offer support to service

user.

Medical staff to review

Complete risk assessment to

determine necessity of clinical need

Yes

Decision to use physical

intervention for personal care?

Yes

No

No

Agrees to intervention?

Carry out personal care using physical

intervention

No

Carry out personal care without physical

intervention

Yes

YesNo

Service user sustained

injury ?

Document in health record (to include evaluation of intervention,

other strategies used)No

Yes

If staff member injured during Physical

intervention, complete Accident Book and

submit incident report for a physical assault

Norfolk and Suffolk NHS Foundation Trust C08: Prevention and Management of Violence and Aggression (including the use of physical intervention). Version 01 Page 22 of 23

Appendix 2

Prevention and Management of Violence and Aggression (PMA) Department Education and training are central to promoting and supporting change. Staff whom may be required to use restrictive interventions must have specialised training The focus of the department is to promote greater awareness, understanding and knowledge of the important issues and factors that should be considered in the prevention of aggression. Emphasis is on the prevention of violence and/or aggression, reducing risk and the safe management of aggressive incidents. This includes:

• The importance of comprehensive assessment of the service user and situation

• The use of non-physical intervention/de-escalation skills to prevent and manage aggressive Incidents

• Looking at behaviours that may lead to assaultive behaviour and the triggers for individual service users

• Looking at how the environment, communication, mental health, medication etc may affect the individual’s ability to cope with situations

• Using scenarios to explore ways of managing the risks of violence and/or aggression two person visits to a high risk community service user, or in-patient areas having increased staffing if service user requires increased observations etc.

• Emphasising the importance of reflective practice/clinical supervision The PMA Department is committed to the following principles:

• Reducing the need for restrictive intervention

• Enhancing de-escalation skills

• Acting as a Trust resource/advisory service for all staff in clinical and non-clinical areas, providing support and advice via the referral procedure

• Working with all departments/services and statutory bodies affiliated to the Trust to provide a consistent and professional service

• Providing high quality education and training programmes which are monitored, evaluated, reviewed and modified

• Monitoring the service provided against other educational establishments and the national arena

• Maintaining and disseminating knowledge of current research, legislation and best practice guidance

• Respecting the privacy, safety and dignity needs of staff, service users and their family/carers, whilst seeking their views and active involvement.

• Staff practice in the prevention and management of violence and aggression, should always be guided by the following principles:

o Showing respect and concern for the privacy, safety and dignity of service users o Support for colleagues and others who may have been involved in/witnessed an incident o Using positive/therapeutic risk management skills (based on risk assessment), knowledge

and safe working practices o Following the relevant policies and procedures. o Following legal frameworks, including the use of Common Law and reasonable force.

The Common Law principles of duty of care, service user’s best interests and necessity of need underpin best practice and these principles work in conjunction with the law relating to the use of reasonable force. Reasonable force is defined within the Criminal Law Act (1967) as being the amount of force necessary to use and proportionate to the level of threat perceived: ‘…the test to be applied for self defence is that a person may use such force as is reasonable in the circumstances s/he honestly believed them to be in defence of themselves or another…’

Criminal Law Act (1967)

Norfolk and Suffolk NHS Foundation Trust C08: Prevention and Management of Violence and Aggression (including the use of physical intervention). Version 01 Page 23 of 23

All training courses are based upon a core syllabus, structured around the Security Management Service’s, ‘Promoting Safer and Therapeutic Services’ (2003) and adopt the principles based in Meeting Needs and Reducing Distress (2014)

During training it is emphasised that physical techniques must only be used as a last resort, with the minimum amount of force necessary, when all other methods have failed and communication has broken down. Theory is related to practice. Practical techniques include breakaway techniques (taught during personal safety courses) which are designed to be a quick and effective way of disengaging from physical contact after de-escalation and awareness have all failed, the application maintains a focus on reasonable,necessary and proportionate making reference to not all physical contact requires the same degree of force respective of the nursing profession and client presentation. Physical intervention techniques incorporating teamwork are designed to safely manage aggressive incidents that may occur when working with service users in an inpatient setting. Courses are delivered by PMA instructors who are Registered Nurses and Support Instructors. All instructors have or are working towards accredited teaching qualifications. Following induction staff will be expected to book onto Personal Safety training at the earliest available opportunity. In-patient clinical staff will go on to complete the Full Physical Interventions course with subsequent 3 day refreshers at maximum interval of 18 months. All staff attending full physical interventions training must also ensure that they attend Intermediate Life Support training (ILS) which includes airway management and defibrillation training. As part of Trust induction all staff who will have direct service user contact complete a Personal Safety training session (See Q15: Induction policy) Thereafter all in-patient non-clinical staff and community based clinical staff (others based on locally assessed need) are required to complete Personal Safety training on an annual basis.

Norfolk and Suffolk NHS Foundation Trust C107: Seclusion and Long Term Segregation. Version 07 Page 1 of 19

Title: Seclusion and Long Term Segregation Purpose: To provide practice guidance based on the Mental Health Act Code of Practice

(2015) and other national best practice guidance To ensure that the patient receives the care and support necessary with regard to their physical and emotional safety and wellbeing (MHA Code of Practice, 2015)

Introduction A safe and therapeutic culture should be provided for all patients including those who present with behavioural disturbance. The focus of care and treatment should be on preventing behavioural disturbance, early recognition and de-escalation (Code of Practice, 2015) Most patients showing disturbed behaviour will be managed without the need for seclusion but when this is required, it should be carried out lawfully, in the patient’s interests, proportionately and with consideration of the patient’s dignity Staff must always use the least restrictive intervention necessary and be aware that use of any restrictive interventions must be compliant with the Human Rights Act (1998), particularly Articles 3 and 8 which prohibit humane/degrading treatment and provide the right to liberty

Approved By & Date:

Quality Governance Committee – 26th May 2015

For Use By (Area/Staff):

Trust-wide (In-patient areas) – all clinical staff

Reference No: C107 Version: 07 Published Date: September 2015 Review Date: September 2017 Equality Assessment:

April 2013

Review and Amendment Log

05 Addition of guidance for use of Earlham Ward (Norvic Clinic)

March 2014

See Appendix 2

06 Early review June 2014

Clarification on secluding detained patients or informal service users

07 Early review May 2015 July 2015

Amendments as required by the Mental Health Act Code of Practice Section on children and young people added Section on designing seclusion environments removed Specialist Commissioning information added – as no change to clinical content/procedures current version number maintained.


Seclusion – Summary of Key Points (PTO for additional guidance on documentation)


Guidance on documentation: Document/Form Location Guidance Seclusion record (Starting and Terminating Seclusion – Part 1)

All available in Lorenzo as clinical notes in the In-patient Chart – observations tab

Complete electronically within Lorenzo Should staff wish to print this, it should be for reference only and reviews/amendments must be recorded directly into Lorenzo.

Seclusion record (During Seclusion – Part 2)

Print, attach securely to Part 1. Complete by hand and scan into Lorenzo when complete

Seclusion 72 Hour Review Form

Electronically by practitioner collating discussions at review

Seclusion/Long Term Segregation Care Planning Tool

This is an optional tool to support good practice/ support meeting MHA requirements. It should be completed electronically although a copy may be printed for reference alongside the Seclusion Records.

Contents

1.0 Definitions 4-5

2.0 Duties 5

3.0 Commencing Seclusion 5-6

4.0 Observation During Seclusion 6

5.0 Care During Seclusion 6-7

6.0 Children and Young People 7-8

7.0 Seclusion Reviews – Frequency and Staff Required 8-9

8.0 Seclusion Reviews – Areas to Consider 9-10

9.0 Ending Seclusion 10

10.0 Post-incident Review 10-11

11.0 Long Term Segregation 12

Appendix 1 Agitation-Calmness Evaluation Scale 13

Appendix 2 Earlham Ward (Norvic Clinic) 14-18

Monitoring Statement 19

Supporting Information 19


1.0 Definitions Responsible Clinician

• The Approved Clinician with overall responsibility for the patient’s case Approved Clinician

• A mental health professional approved by the Secretary of State or a person or body exercising the approval function of the Secretary of State to act as an approved clinician for the purposes of the Act.

Suitably Skilled/Competent

• A member of Trust staff who has satisfactorily completed: o Prevention and Management of Aggression (PMA) training and updates o Intermediate Life Support training o The Physiological Observations Workbook (where a learning need has been identified at

appraisal) o The Assessment of Competence in Additional Observations (C36: Observation and

Engagement of Service Users policy) o Rapid tranquilisation training

• NHS Professionals (NHSP) flexible workers o NSFT PMA training and updates o Basic life support/CPR (annual - NHSP) o Clinical observations module (TPR & BP) where professional development need identified

(NHSP) o The Assessment of Competence in Additional Observations (C36: Observation and

Engagement of Service Users policy) Time Away

• When a patient agrees, or requests, to be alone in a room or other separate area. It may be formally identified as part of the care-plan, or may be an informal strategy, suggested and used in order to help reduce tension in a situation or individual. .

Time Out

• A behaviour modification technique, which removes positive reinforcement from a patient for a period of no more than 15 minutes

• This should only be used as part of a care planned approach to the management of an individual’s disturbed behaviour and at no time should it be used as a spontaneous reaction to a particular type of behaviour

• It may involve spending time alone in a quiet room or bedroom, which must not be locked Low Stimulus Environment

• When a patient is not locked in a room on their own and can leave/move around freely as they wish. This could be in a designated low stimulus area or other appropriate environment (e.g. their bedroom, quiet room etc).

Seclusion

• The supervised confinement and isolation of a patient, away from other patients, in an area from which the patient is prevented from leaving, where it is of immediate necessity for the purpose of the containment of severe behavioural disturbance which is likely to cause harm to others.

• If a patient is confined in any way that meets the definition above, even if they have agreed to or requested such confinement, they have been secluded and it is essential that they are afforded the procedural safeguards of the Code of Practice. i.e. seclusion covers circumstances where a patient is prevented from leaving and is isolated from others where they are not in a room with the door shut

Long Term Segregation (LTS)

• A situation where, in order to reduce a sustained risk of harm posed by the patient to others,


which is a constant feature of their presentation, a multi-disciplinary review and a representative from the responsible commissioning authority determines that a patient should not be allowed to mix freely with other patients on the ward or unit on a long-term basis

• In contrast to seclusion it is not an emergency response to an acute incident, but a planned restriction introduced in response to a chronic presentation of risk of harm to others

• NB: Seclusion does not automatically become LTS after 72 hours 2.0 Duties All clinical staff:

• Ensuring that the patient receives the care and support necessary both during and after seclusion

• Ensuring that they are familiar with the environment, including how to lock and unlock the seclusion room door (NB: Seclusion may occur without a locked)

• Carrying out activities relevant to their role as identified throughout this policy

• Raising any concerns regarding the use of seclusion or long term segregation with their Line Manager or the PMA department

• Attending training and updates (as required) 3.0 Commencing Seclusion Seclusion should only be used in hospitals and in relation to patients detained under the Act. If an emergency situation arises involving an informal patient and, as a last resort, seclusion is necessary to prevent harm to others, then an assessment for an emergency application for detention under the Act should be undertaken immediately. Seclusion should:

• Only be used in an emergency situation and where other measures to reduce the disturbed behaviour have been tried

• Be used as little as possible and for the shortest possible time

• Not be used as a punishment or threat

• Not be used because of staff shortages, or because the environment is being damaged, unless the welfare of others is compromised

• Never be used solely as a means of managing self-harming behaviour

• Not form part of a treatment plan Seclusion may be appropriate if it can be used to avoid a prolonged (longer than 10 minutes) physical restraint (NICE, 2015) Seclusion may be authorised by:

A psychiatrist If the psychiatrist who authorises seclusion is neither the patient’s Responsible Clinician (RC) nor an Approved Clinician (AC), the RC or duty doctor (or equivalent) should be informed of seclusion as soon as practicable.

An Approved Clinician who is not a doctor The patient’s Responsible Clinician or the On-call Consultant should be informed of seclusion as soon as practicable

The Practitioner-in-Charge

As above

NB: the person authorising the seclusion should have seen the patient immediately prior to it commencing. Where seclusion has not been authorised by a psychiatrist there must be a medical review:

• Within one hour or

• Without delay if the patient is not known or there has been a significant change from their usual presentation

If the decision to commence seclusion is made by someone other than those who can authorise


seclusion, a psychiatrist or approved clinician must be informed (see table above) Informing the patient’s family/carer would usually have been identified as part of the care-plan (also called a Behaviour Support Plan where the possibility of seclusion as an intervention had been identified (see C08: Prevention and Management of Violence and Aggression policy). In an emergency staff should try and ascertain the patient’s wishes, either at the time (as appropriate) or after the episode in case of further periods of seclusion. The following should be completed:

• Comprehensive entry in the health record

• Seclusion Record – Starting and Terminating Seclusion.

• Incident report (Datix): to include details of the incident which lead to the patient being secluded

• If the patient was on additional observations, record that seclusion has commenced and the time on the additional observations form. This does not then need to be completed until seclusion ends.

• Risk assessment review

• Care-plan review 7.0 Observation during Seclusion A suitably skilled/competent (see Section 3.0 Definitions) staff member will be allocated to carry out ‘within eyesight’ (constant) observation of the secluded patient (see C36: Observation and Engagement of Service Users policy). They must remain within arm’s length of the seclusion room at all times (including areas with CCTV) so as to ensure that they can hear (e.g. if the patient is clearly agitated or shouting) and/or see the patient and respond immediately if required. This level of observation must not be reviewed until seclusion is ended and the patient is awake and alert At all times the staff member observing should be assessing and monitoring the patient’s physical and mental state. Levels of consciousness/alertness and respiratory rate must be assessed and recorded at 5 minute intervals. Particular attention should be paid to this when the patient appears to be asleep in seclusion and/or they have received rapid tranquilisation (see Seclusion Record for guidance, ACES – Appendix 1, Psychotropic Drug Information and Protocols Manual) and C111: Rapid Tranquilisation policy for guidance) The staff member observing must be aware of the patient’s risk assessment and care/management plans and there should be a brief handover between staff rotating on to and off the observation. Consideration should always be given to the patient’s privacy and dignity needs (based on risk assessment) but may also need to be given to the gender of the person carrying out the observations depending on the patient’s history Any re-entry into the room used for seclusion must be by a minimum of three staff. A visual check of the room should be made prior to opening the door and entry should be in a planned and organised manner using NSFT PMA techniques NB: Where a service user is secluded and is being observed by 3 people (or more) staff, see C36: Observation and Engagement of Service Users policy for guidance on claiming additional costs. Claim forms are available on the intranet and must be completed promptly if costs are to be recouped http://intranet.nsft.nhs.uk/corporate/finance/Pages/home.aspx 8.0 Care during Seclusion Where a risk of violent and/or aggressive behaviour is identified a risk management/care-plan must be developed. This should focus on prevention (primary prevention strategies) and specify interventions that would reduce the risk of violent/aggressive behaviour occurring and de-escalation strategies (secondary prevention strategies)


Where there is the possibility of physical intervention being necessary, a specific care-plan should be written (tertiary strategies), where this has not been possible, it should be completed as soon as possible after the event. The care-plan should address both prevention/de-escalation interventions and physical interventions. The PMA Department can be contacted for advice if required (NB: this does not constitute ‘planned restraint’ as the situation of use is still an emergency) NB: see C08: Prevention and Management of Violence and Aggression (including the use of physical interventions policy for further guidance A seclusion care-plan must be developed. This should identify how the patient’s presenting and ongoing needs can continue to be met whilst they are secluded and the steps that should be taken in order to bring the need for seclusion to an end as soon as possible (care-planning tool available in Lorenzo if required) As a minimum the care-plan should include

• Clinical needs (physical or mental health), risks and treatment objectives. Any existing care-plans regarding physical health must be taken into account and continued wherever possible.

• How de-escalation attempts will continue and how risks will be managed

• Details of bedding and clothing to be provided*

• Details as to how the patient’s dietary needs are to be provided for (use of cutlery, finger foods etc.)

• Hygiene needs (use of toilet or provision of disposable equipment, shower/wash etc.) and consideration how the patient’s privacy and dignity will be maintained

• Details as to how religious/cultural/diversity needs will be provided for

• Details of any family/carer contact/communication which will be maintained during the period of seclusion

*The seclusion room/area should be safe and secure and staff may decide what a patient can take into it. Patients should never be deprived of clothing or other aids necessary for their daily living when in seclusion, although items that may potentially be used for self-harm should be removed (e.g. belts, shoes/laces). Wherever possible, patients should keep their own clothing and any personal items, including those of religious or cultural significance (such as some items of jewellery). This should be based on risk assessment and should not compromise their safety or the safety of others. Tear-proof clothing should not be routinely used and such a decision should be proportionate to the risk posed and authorised by the patient’s Responsible Clinician (see Code of Practice Sections 26.161 – 26.166: Deprivation of Access to Normal Daytime Clothing). It is acknowledged that sometimes, based on the level of risk patient safety may have to take priority The Seclusion Record – During Seclusion must be used to document all observations/interventions e.g. physical care and hygiene, details of food and fluid (offered and amount consumed) as well as what the patient is doing, saying, mood, level of awareness etc. Respirations should be recorded as high, normal or low (see ACES Appendix 1) Wherever possible, the care-plan should be developed in conjunction with the patient and staff should ensure that (as far as possible) the patient is aware of what they need to do for the seclusion to come to an end and what support they will receive at that time. 9.0 Children and Young People Staff should always ensure that restrictive interventions are used only after having due regard to the individual’s age and having taken full account of their physical, emotional and psychological maturity Seclusion can be a traumatic experience for any individual but can have particularly adverse implications for the emotional development of a child or young person. This should be taken into consideration in any decision to seclude a child or young person. Careful assessment of the potential effects of seclusion by a


Child and Adolescent clinician is required, especially for those children and adolescents with histories of trauma and abuse, where other strategies to de-escalate behaviours may be more appropriate than the use of seclusion. Where Children and Young People’s services use ‘time-out’ as a specific behaviour change strategy, delivered as part of a programme they must ensure that if these processes have the features of seclusion, this should be treated as seclusion and comply with the requirements of this policy/Code of Practice.

(see Code of Practice Sections 26.55 – 26.61) 10.0 Seclusion Reviews – Frequency and Staff Required All reviews should provide an opportunity to determine whether seclusion needs to continue or should be stopped, as well as to review the patient’s mental and physical state. These should be carried out as follows: Nursing Review Every two hours for the duration of the seclusion

These should be undertaken by two registered nurses, at least one of whom should not have been involved directly in the decision to seclude Any concerns regarding the patient’s condition (physical or mental health) must be brought to the attention of medical staff immediately they are identified (see ACES, Appendix 1 and NEWS/PEWS, C22: Physiological Observations policy)

Medical Review

Where seclusion has not been authorised by a Consultant Psychiatrist

• Within one hour or

• Without delay if the patient is not known or there has been a significant change from their usual presentation

Where seclusion has been authorised by a Consultant Psychiatrist the review they undertook before authorising seclusion can be classed as the first medical review Every four hours by either the Ward/Duty Doctor (outside of regular working hours) until the first MDT Review (internal) has taken place. Any concerns should be discussed with the Responsible Clinician/Approved Clinician/On-call Consultant When the MDT Review has taken place, at least twice in every 24-hour period (one by the Responsible Clinician)

MDT Review (internal)

As soon as is practicable by Responsible Clinician/Approved Clinician (outside of regular working hours) and senior nurse (band 6 and above) and staff from other disciplines At weekend and nights this may be limited to nursing and medical staff in which case the on-site manager/bleep holder should be invited to attend (where possible) MDT review to continue every 24 hours Good practice would be that ongoing reviews are planned for regular working hours and a plan put in place for weekends and bank holidays.

Independent MDT Review

When seclusion has lasted for eight hours consecutively or intermittently for a total of 12 hours within a 48 hour period by an Approved Clinician and other professionals not involved in the incident/decision to seclude

Secure Services Notify NHS England (Specialist Commissioning) of all new episodes of seclusion


and CAMHS Tier 4 only

or long-term segregation within 1 working day of commencement. A copy of the seclusion record (part 1) should also be sent for information Regional Specialised Commissioning Group (East), [email protected] 07920252094

At 48 hours the clinical area should notify the Medical Director and the Director of Nursing, Quality and Patient Safety via email ([email protected] [email protected])

As a minimum this must state the patients name, NHS no and Lorenzo number, ward and the date and

time seclusion commenced. The email should be copied to [email protected]

Staff should also contact the relevant CCG (details below) and invite them to attend the 72 hour review meeting (see 72 hour review form for guidance):

• Regional Specialised Commissioning Group (East), Jim Beck [email protected] 07920252094 and [email protected]

• Great Yarmouth and Waveney, Kim Arber [email protected] GY&W CCG 01502 719500

• Suffolk, Richard Cracknell 01473 770061 [email protected] or Chris Hooper 01473 770077 [email protected]

• South Norfolk, South Norfolk CCG Quality & Patient Safety Team 01603 257179 email [email protected]

• North Norfolk, Jackie Schneider 01263 738100 (07795 470847)

• West Norfolk, Pallavi Devulpalli [email protected] West Norfolk CCG 01553 666900

• Norwich, Sheila Glenn [email protected] Norwich CCG 01603 613325

• Tier 4 CAMHS, David Wright [email protected] 72 hour Review Review at 72 hours by MDT and a representative from the responsible

commissioning authority. Where the patient has an IMHA they should also be invited. Review must consider whether:

• Seclusion can end (see Section 12.0)

• Seclusion needs to continue (continue observation, reviews etc.)

• The patient can be managed under the provisions of long term segregation (see Section 14.)

The review should be recorded on the Seclusion 72 Hour Review Form All reviews must record:

• Who undertook them

• Their assessment

• The patient’s condition

• Recommendations NB: When the patient is sleeping, based on risk assessment and recent presentation (physical and mental health) the review may be carried out without waking them. The decision and the rationale must be documented as part of the seclusion review record 11.0 Seclusion Reviews – Areas to Consider The review should be carried out in person and consider:

• The patient’s physical and mental health

• What has been done to ensure basic welfare, privacy and dignity needs have been met (e.g. physical care, hygiene, food/fluid (offered and amount consumed) etc.)

• Any adverse effects of medication and reassessment of medication prescribed

• Review of physiological observations (see C22: Physiological Observations policy)

• Risk posed by the patient to others

• Risk to the patient from deliberate or accidental self-harm

• Risks of using seclusion (e.g. increasing agitation) and how to address these

• Care-plan review (including strategies that prevent seclusion being required in the future)


• Need for continuing seclusion, and whether it is/has been possible for seclusion measures to be applied more flexibly or in a less restrictive manner*

• The indicators for ending seclusion *In order to ensure that seclusion measures have a minimal impact on a patient’s autonomy, where seclusion is used for prolonged periods, it should (subject to risk assessment) be applied flexibly and in the least restrictive manner possible. This may include allowing patients to receive visitors, brief periods of access to secure outside areas or allowing meals to be taken in general areas of the ward. This may help to provide a means of evaluating the patient’s mood and degree of agitation under a lesser degree of restriction, without terminating the seclusion episode and help inform the decision to end seclusion. The patient and their family/carer (this would usually have been identified as part of the care-plan (also called a Behaviour Support Plan – see C08: Prevention and Management of Violence and Aggression policy) should also be involved in the review(s) Reviews should be documented on the Seclusion Record – During Seclusion and a brief entry made in the health record that the review has occurred. 12.0 Ending Seclusion Seclusion ends when a patient is allowed free and unrestricted access to the normal ward environment or is to be cared for under the provisions of long term segregation. Opening a door for toilet and food breaks or medical review does not constitute the end of a period of seclusion Seclusion should immediately end when a MDT review, a medical review or the independent MDT review determines it is no longer warranted. Where the Practitioner-in-Charge feels that seclusion is no longer warranted, seclusion may end following consultation with the patient’s Responsible Clinician or On-call Consultant. This consultation may take place in person or by telephone. The following should be completed:

• Comprehensive entry in the health record incident

• Seclusion Record – Starting and Terminating Seclusion

• Consider recommencing additional observations and at what level as there is the potential for either a re-escalation of behaviour or for the patient to experience feelings of hopelessness and/or guilt in the period after seclusion which may place them at increased risk. If a patient is to be placed on routine/headcount observations following seclusion the decision and the rationale must be clearly documented in the health record

• Risk assessment review

• Care-plan review to manage the return to the ward environment 13.0 Post-incident Review Following an episode of acute behavioural disturbance that has led to the use of seclusion a post-incident review should take place a soon as possible (within 72 hours) so that involved parties, including patients, have appropriate support and there is opportunity for organisational learning. The Clinical Team Leader (or nominated deputy if they are unavailable) should co-ordinate this review but if possible, a person not directly involved in the incident should lead the review. The review should consider:

• What happened during the incident that led to seclusion

• Any trigger factors

• Each person’s role in the incident and subsequent seclusion

• Their feelings at the time of the incident, at the review and how they may feel in the near future

• What can be done to address their concerns

• Where seclusion has occurred in a room not designated as a seclusion room this issue must be specifically addressed in the review.

• If there is any dispute about the decision to use seclusion, the matter should be referred to the


Service Manager and Lead Clinician Where there has been a serious incident the Clinical Team Leader (or nominated deputy if they are unavailable) should ensure that post-incident support/debrief is offered and recorded on the Debrief Attendance Record (Q11: Serious Incidents Requiring Investigation policy)


Long-term Segregation – Summary of Key Points


Appendix 1 Agitation-Calmness Evaluation Scale (Eli Lilly and Co.©)

Score Alertness Level

Description Guide to Respiration Rate

1 Marked Agitation

• High levels of physical activity

• May demonstrate markedly increased levels of verbal expression

• May be physically violent

• Cannot control signs of agitation if requested to do so

HIGH An accurate respiratory rate may be difficult to assess, however it is likely to be

increased.

Likely to be greater than 18 per minute

2 Moderate Agitation

• Moderately increased levels of physical activity

• Demonstrates increased levels of verbal expression and may be verbally threatening

• Is not physically violent

• Can partly control signs of agitation if requested to do so 3 Mild

Agitation • Slightly increased levels of physical activity

• May demonstrate slightly increased levels of verbal expression (e.g. raised voice volume)

• Is not threatening or violent

• Can control signs of agitation if requested to do so 4 Normal • Awake and alert

• Normal levels of physical activity

• Normal levels of verbal expression

• Awake with eyes continuously open

• Respiration rate normal (for service user)

NORMAL 9-18 per minute

(normal respiration rate)

5 Mild Calmness

• Slightly reduced levels of verbal and physical activity

• Eyes continuously open

• Remains aware of and responsive to the environment 6 Moderate

Calmness • Moderately reduced levels of verbal and physical activity

• Eyes may be intermittently open

• Easily aroused/responsive to mild verbal (calling name) or physical stimulation (gentle touch)

• Remains awake when stimulus as (above) removed 7 Marked

Calmness • Greatly reduced verbal or physical activity

• Sleeping lightly

• Aroused by mild to moderate verbal or physical stimulation 8 Deep Sleep • No verbal or physical activity

• Sleeping deeply

• Awakened only with great difficulty by vigorous verbal (loud repeated calling of name) and/or physical stimulation (vigorous shaking of shoulders)

• Returns to sleep immediately when stimulus removed

LOW

8 or less per minute and not increasing if roused

EMERGENCY RESPONSE

9 Unrousable • Sleeping deeply

• Cannot be roused by either vigorous verbal (loud repeated calling of name) and/or physical stimulation (vigorous shaking of shoulders)


Appendix 2

Earlham Ward (Norvic Clinic)

1.0 Introduction Earlham Ward consists of a large open area, a nursing station, bathroom and toilet facilities, a storeroom and two seclusion rooms. It is a Norvic Clinic wide resource and the operational management is therefore a collective one with the co-operation of all areas/staff vital to the safe and effective running of the area. It is important to note that a patient on Earlham is secluded (even if they are not in one of the seclusion rooms) if they are isolated from other patients and not free to leave (where a patient is using Earlham for de-escalation/low stimulus or time away and, if they asked, would be escorted back to the ward this would not class as seclusion) Whilst patients should be supported to manage periods of crisis within their usual environment, there may be occasions when their level of arousal/distress indicates that a different environment best meets their privacy and dignity needs – and the safety needs of patients and staff. NB: there must never be more than 2 patients being care for on Earlham at any one time, whether in or out of seclusion. 2.0 Staffing

• Earlham ward is not staffed unless in use

• All staff working on the ward must have successfully completed their PMA training and updates within required timeframes

• The Professional in-Charge will be a substantive Band 5 or above and will have completed their preceptorship and/or Trust and Secure Services Security Induction. This would usually be a Registered Nurse

• The Professional in-Charge, and wherever possible, one other member of staff should be from the patient’s ward

• Initially the Professional in-Charge is responsible for arranging staffing, but must receive assistance and cooperation from other areas. Staffing on an on-going basis should be arranged by those with day-to-day responsibility for staffing (i.e. Charge Nurse or above supported by Ward Administrators/Clerks, and out-of-hours Clinical Advisors)

• The host ward retain responsibility for staffing – if 2 wards require use of Earlham they should work together to provide staffing

• Staffing should continually be reviewed by the Professional in-Charge in liaison with those with day-to-day responsibility for staffing (as above) to ensure staff are able to take their breaks and a suitable gender and skill mix are maintained

• In an emergency the Professional in-Charge of Earlham may utilise the responding staff/Bleepholders from other areas to assist in the opening and initial staffing of Earlham Ward. These staff should be released to return to their wards as soon as possible once the initial situation has been dealt with

Recommended staffing levels – NB: these numbers must always include 1 registered professional (usually a nurse) One patient – not in seclusion room/door shut 4 staff

One patient – in seclusion room/door shut 2 staff

Increase to 4 when opening seclusion room door

Two patients – one not in seclusion room/door shut one in seclusion room/door shut

5 staff

Two patients – both in seclusion room/door shut 3 staff

Two patients – neither in seclusion room/doors shut 6 staff


In exceptional/specific circumstances these staffing levels may be reviewed. The decision and rationale must be based on risk assessment and individual needs and clearly recorded in the risk assessment and care-plan. 3.0 Equipment and Maintenance

• 2 mattresses (1 in each seclusion room)

• Spare mattress (in locked store room)

• 3 armless easy chairs (main day area)

• Secure clothing (if required, kept in locked store room)

• Locked medicine cabinet (in office) containing oral and intra-muscular medication (as required) and a selection of syringes and needles

• Locked medicine fridge (in office) containing oral and intra-muscular medication (as required)

• Emergency Treatment (Section 62) forms available

• Landline telephone (in office)

• Defibrillator, ambi-mask(wall mounted) and ligature cutters (in office)

• Fire equipment extinguisher, fire policy and plan of evacuation areas

• 2 x sets plastic cutlery, disposable plates/bowls and melamine mugs (kept in locked store room)

The Modern Matron (or nominated deputy) is responsible for the maintenance/checking of the defibrillator and medication supplies. When not in use Earlham Ward will be inspected daily by Unit Security Officers and any problems reported to the Security Lead or Clinical Advisor. Earlham Ward will be cleaned daily by the ISS team (in liaison with the Practitioner in-Charge if open) 4.0 Use of Earlham Ward The use of Earlham ward would usually be for the minimum period of time required for the initial management of a crisis period. However, based on risk assessment and for a specific purpose agreed by the MDT there may be occasions when the ward is used for longer periods of time. This should be included in the patient’s care-plan When Earlham ward is vacant, it is the preferred area for receiving new admissions to the Norvic Clinic and carrying out the admission process. Based on risk assessment it may also be the preferred route for taking patients outside of the Norvic Clinic (e.g. to Court, Hospital).


5.0 Transfer To and From Earlham Ward

NB: If the patient is being brought to Earlham Ward from outside of the Clinic (e.g. from Highlands, or the community, safe transportation plans, based on risk assessment should be put in place prior to transfer.

Possibility of patient needing transfer to Earlham (from within the Norvic Clinic. If from Highlands/external see

Section 5.0 of this Appendix))

Wherever possible the decision to transfer a patient to Earlham Ward should be made by the MDT (Responsible

Clinician/medical staff, Care Coordinator/Practitioner in-Charge, Occupational Therapist, Physiotherapist etc)

however it is acknowledged that in an emergency this may not always be possible.

Outside of office hours staff should consult the Clinical Advisor and/or On-call medical staff

The patient (where possible) should also be involved in the discussion/decision.

Ensure ongoing reviews and delivery of care (see Section 6.0 of main policy ‘Summary Flowchart’

Transfer patient and ensure that their health record, medication chart (if paper) and medication (if

not Earlham stock) are made available.

Commence seclusion record (Appendices 1 & 2)/record segregation in health record (Appendix 4)

When seclusion/segregation terminated (see Section 13.0 of main policy ‘Termination of Seclusion’) arrange transfer of patient to main ward area

The patient must not be transferred during handover periods and liaise with other areas (e.g. suspending

activities/escorting around the building)

Inform reception and Unit Security Officer so that radio and lighter can be returned to reception

Inform MDT (as for opening Earlham)

Ensure the flask (if used is emptied and left to air

Replace any equipment, medication etc that has been used

Ward to inform Norvic reception that Earlham is to be opened

Liaise with other areas regarding opening Earlham (e.g. suspending activities/escorting around the building)

Unit Security Officer (or nominated other) to check safety and preparedness of environment and take a radio to Earlham

(A lighter can be brought later by the USO if required)


Considerations should include:

• Number of escorts (all PMA trained)

• Skill and gender mix of the staff

• Entry should be via the main airlock gates

• Transfer route

• The leave that other patients have at that time

• Choice of vehicle

• The ability of the patient to communicate effectively

• Possible Police assistance

• Is the transfer being conducted under physical intervention? 6.0 Care whilst on Earlham Ward Clothing, Bedding and Personal Items

• The clothing and bedding used and access to personal item should be based on continuous risk assessment and adjusted as indicated

• Any personal items removed should be recorded and stored as set out in C108: Service User Property policy

Food and Fluids

• Cool and warm drinks are allowed (not those made with boiling water). A flask can be used to bring water for making tea/coffee

• Cool water should always be available and kept in the fridge in the office

• Drinks should be made in the office and served in a plastic/unbreakable mug

• Food will be brought from the servery. Wherever possible the patient will be given a choice of food (from the usual menu). This should be served using plastic/unbreakable plates/bowls etc.

• Plastic cutlery should be used and counted out and in as per the usual process by a nominated security officer (from the staff on Earlham).

Medication

• If the patient is not secluded they should receive their medication at the door of the office

• If the patient is secluded medication should be delivered to and administered in the seclusion room (as per Trust PMA training on entering seclusion)

Use of Telephone and Visits

• The office phone (cordless taken outside of the office) may be used for official calls (e.g. solicitor) or at the discretion of the Professional in-Charge. The rationale for the decision must be documented in the health record as well as the effect on the patient so as to evaluate any benefit received or increased distress caused. This should inform future decisions and risk assessment.

• No visits will take place on Earlham Ward unless agreed by the MDT. These should only be from officials such as the Care Quality Commission, CQC, legal representatives, advocacy or chaplaincy services (including, based on risk assessment, faith leaders/religious representatives from outside of the Trust). See also Long Term Segregation guidance for

Use of the Courtyard

• This should only be used o During daylight hours o Based on risk assessment (if there are 2 patients on Earlham, consider risks/effects to

both) o In agreement with the Practitioner in-Charge. o With 3 x PMA staff in attendance


7.0 Escorting Patients on Earlham outside of the Norvic Clinic and Returning them to Earlham All wards at the clinic may be required to escort patients to other areas (e.g. Acute Hospital, Court etc). In these circumstances – based on risk assessment and/or leave status, the patient and the escorts will depart via Earlham Ward as follows.

Minibus to be driven into the secure perimeter and parked outside the emergency door of Earlham.

USO to ensure perimeter is re-secured

Escorting staff, accompanied by the Unit Security Officer (USO) go to reception and

exchange keys/alarms for their ID badges and collect a mobile telephone

Completed clothing description form for the patient to be handed to reception staff

Staff and escorts leave Earlham via emergency door and into vehicle

USO ensures secure perimeter is unlocked and locked again accordingly

On return (assuming patient is also returning) the escorts notify reception when their arrival is imminent

Escorting staff, accompanied by the USO go to patient’s ward, collect the patients and return to Earlham

Reception inform USO

USO ensures that vehicle removed from secure perimeter and that this is secured

USO goes to main airlock gates to allow vehicle passage into the secure perimeter

Patient, escorts and USO return to Earlham via the emergency door and then escort the patient to their ward

USO escorts staff to reception to obtain Keys/alarms and hand-in badges/mobile telephone


Monitoring Statement Aspects of the policy to be monitored

Monitoring method


Frequency Findings: Group / Committee that will receive the findings / monitoring report

Action: Group / Committee responsible for ensuring actions are completed

Seclusion records

Frequency of seclusion. The electronic completion of the Seclusion Record (Starting and Terminating Seclusion – Part 1) within Lorenzo

Clinical Audit Team

Ongoing Assurance and Clinical Effectiveness Manager’s quarterly report to the Quality Governance Committee

Quality Governance Committee

Use of seclusion – trends in numbers

Figures of seclusion (via Datix)

Patient Safety Group

Monthly Patient Safety Group

Trust Board

Supporting Information With reference to: From Positive and Proactive Care: reducing the need for restrictive

interventions. Department of Health (2014) NG10: Violence and Aggression: short-term management in mental health, health and community settings. National Institute for Health and Care Excellence (2015) Code of Practice, Mental Health Act 1983. Presented to Parliament pursuant to section 118 of the Mental Health Act 1983. Department of Health (2015). Human Rights Act (1998) Agitated-Calmness Evaluation Scale (ACES). Eli Lilly and Co.© (1998)

Associated trust policies and documents

C08: Prevention and Management of Violence and Aggression (including the use of physical intervention C22: Physiological Observations C36: Observation and Engagement of Service Users C54: Privacy, Safety and Dignity C111: Rapid Tranquilisation Psychotropic Drug Information and Protocols Manual Spirituality Strategy (2013-2016)

Written by: Helen Oatham – Governance Practitioner Reviewed by: Helen Oatham – Governance Practitioner In consultation with: Karen Clements – Service Manager

Maria Short – Contracts Manager

Norfolk and Suffolk NHS Foundation Trust C111: Version 04 Page 1 of 15

Title: Rapid Tranquilisation Policy

Purpose: To set out the process of rapid tranquillisation, including management of problems resulting from the intervention and to provide an overview of the Mental Health Act/Mental Capacity Act in relation to rapid tranquillisation.

Introduction There are significant changes in guidance given about rapid tranquilisation (National Institute for Health and Care Excellence (NICE), 2015) including that it only applies to medication given via the parenteral route (usually intramuscular or, exceptionally, intravenous). However oral medication must continue to be offered/administered as part of the de-escalation process prior to using IM medication.

Rapid tranquillisation is a potentially restrictive intervention and must only be used based on clinical need (e.g. where the service user is highly aroused, agitated, overactive, aggressive or making serious threats or gestures towards others or is being destructive to their surroundings and is therefore placing their safety or that of others at risk) and only when de-escalation and other preventive strategies, including PRN medication, have failed and attempts at de-escalation must continue throughout a restrictive intervention (NICE, 2015). Staff involved must understand the indications and risks of rapid tranquilisation and take into account:

• Mental Health Act and the Code of Practice

• Mental Capacity Act including Advanced Decisions to Refuse Treatment

• Human Rights Act

• Children Act Approved By & Date:

Clinical Effectiveness and Policy Group – October 2015

For Use By (Area/Staff):

Trust-wide (in-patient areas) – all clinical staff

Reference No: C111 Version: 05 Published Date: November 2015 Review Date: October 2016 Equality Assessment:

July 2013

Review and Amendment Log Version Number

Reasons for Development/Review

Date Description of Changes

03 Early review July 2014 Updated to reflect change in national guidance on haloperidol dosage

04 Early review Sept 2015 Updated to reflect the publication of NICE guideline NG10

05 Early review November 2015

Minor amendments required


Rapid Tranquilisation: Acutely Disturbed Adults – Summary of Key Points

De-escalation procedures (including the use of oral medication) unsuccessful

See C08: Prevention and Management of Violence and Aggression policy

If there is a partial response, consider a further

dose after 30-60minutes and monitor patient.

If there is no response to, consider IM haloperidol

combined with IM promethazine (on their own).

If rapid tranquilisation is necessary:

- Discontinue any potentially unhelpful drugs & simplify regimen including any therapeutic duplication

- Review physical health and drug status, if young, thin, frail or suffering cardiac or respiratory disease seek advice from

senior colleagues as lower doses may be required

- Note total medicines taken in the last 24 hours – include any PRN doses

- If total dose >BNF limits contact the (on-call) Consultant and implement high dose antipsychotics therapy guideline (C112)

Oral medication must be tried as a part of de-escalation process prior to prescribing RT

Drugs must never be mixed in the same syringe

Write the initial prescription as a single dose – do not repeat it until the effect of the initial dose has been reviewed

When deciding which medication to use, take into account:

- The service user's preferences or advance statements and decisions

- Pre-existing physical health problems, pregnancy or possible intoxication

- Previous response to these medications, including adverse effects and potential for interactions with other

medications

- If there is insufficient information to guide the choice of medication for rapid tranquillisation, or the service user has

not taken antipsychotic medication before, use intramuscular lorazepam

IM Haloperidol 2–5 mg (max. 12mg/ day)

(with ECG, see Section 6.0) with IM

promethazine 25-50mg (max. 100mg/day)

IM Lorazepam 1-2mg (max 4mg/day) (IM

Promethazine 25-50mg, max 100mg/day may

be an alternative)

Observation and monitoring:

After rapid tranquillisation, monitor:

- Side effects

- TPR&BP, level of hydration and level of consciousness at least every hour for 4 hours and until there are no

further concerns (see Agitated-Calmness Evaluation Scale (ACES) in C36 and C107 policies)

- Monitor the above every 15 minutes if the BNF maximum dose has been exceeded or the service user:

- Appears to be asleep or sedated

- Has taken illicit drugs or alcohol

- Has a pre-existing physical health problem

- Has experienced any harm as a result of the restrictive intervention

Document all actions, decisions and rationale in the health record (see Section 8.0) and submit Datix report

for incident (ensure this records that rapid tranquilisation was used)

Possible alternatives may include aripiprazole IM (5.25-15mg), olanzapine IM (5-10mg)

(see also Appendix 1)

Treatment failure/contraindication with the above

If partial response, consider a further dose.

If no response, consider IM lorazepam(on its own) if

this hasn't been used already during this episode. If

IM lorazepam has already been used, arrange an

urgent team meeting to carry out a review and seek a

second opinion if needed.

Consider either (see Also Appendix 1)

Plan for next 24 hours and afterwards:

- Review physical health status

- Continue to monitor patient

- Seek advice from/discuss with Consultant

- Review MHA status (especially if an in-patient for longer than 3 months)

- Review PRN. medication

- Consider increase/start regular (oral) antipsychotics

- Options for ‘treatment resistant’ cases should be discussed with Pharmacy


Rapid Tranquilisation: Acutely Disturbed Children and Young People (12-18 years) – Summary of Key Points


Contents 1.0 Definitions 4

2.0 Duties 5

3.0 PRN Medication 5-6

4.0 Assessment and Review – all service users 6

5.0 Assessment and Review – service users with particular risks/needs 6-7

6.0 Physical Health Monitoring and Emergency 7-8

7.0 Additional Observations 8

8.0 Documentation 8

Appendices

1 Pharmacotherapy Facts and Prescribing Guidance – Adults 9-10

2 Pharmacotherapy Facts and Prescribing Guidance – Children and Young People 11

3 Haloperidol Administration – Oral and IM Equivalent Doses 12

4 Management of Problems Occurring during Rapid Tranquilisation 13

5 Stage-Specific Interventions – Children and Young People (Aged 12-18 years) 14

Monitoring Statement 15

Supporting Information 15

1.0 Definitions Rapid Tranquilisation

• “The use of medication by the parenteral route (usually intramuscular or, exceptionally, intravenous) if oral medication is not possible or appropriate and urgent sedation with medication is needed” (NICE, 2015).

• The aims of rapid tranquillisation are: o To reduce suffering for the patient: psychological or physical (through self-harm or

accidents) o To reduce risk of harm to others by maintaining a safe environment o To do no harm by prescribing safe regimens and monitoring physical health

• The goal is not to induce sleep or unconsciousness but to sedate the service user whilst enabling them to still be able to participate in further assessment and treatment.

Advance Decision to Refuse Treatment

• A written statement made by a person aged 18 or over that is legally binding and conveys a person's decision to refuse specific treatments and interventions in the future (see C07: Mental Capacity Act policy).

Advance Statement

• A written statement that conveys a person's preferences, wishes, beliefs and values about their future treatment and care. An advance statement is not legally binding and a completed crisis plan should perform this function.

De-escalation

• The use of techniques (including verbal and non-verbal communication skills) aimed at defusing

anger and averting aggression. PRN (pro re nata) medication can be used as part of a de-

escalation strategy but PRN medication used alone is not de-escalation.

Psychiatric Emergency The service user’s condition is such that it presents a severe risk to themselves or others, e.g. suicidal or


violent, and requires immediate intervention to lessen that risk. 2.0 Duties Pharmacist

• Ensuring prescriptions are checked for clinical appropriateness and accuracy Pharmacy Technician

• Regularly checking medication (including flumazenil) and replenishing where needed

Medical Staff

• Carrying out a detailed medical history/assessment to determine the appropriateness of rapid

tranquilisation as a potential intervention

• Following the appropriate rapid tranquillisation pathway

• Writing the initial prescription for rapid tranquillisation as a single dose

• Ensuring that future prescriptions details:

o What medication is to be used for rapid tranquillisation

o oral and IM prescriptions must be prescribed as separate prescriptions

o Indication or target symptoms

o Dose range

o Dose frequency

o Minimum time between doses

o Maximum dose to be administered in a specified period

• Undertaking mandatory rapid tranquilisation training and related training as set out in staff pathways

NB: if rapid tranquilisation is used, a senior doctor should review medication a minimum of once a day. Practitioner-in-Charge (See also Registered Nursing Staff)

• Ensuring that all other de-escalation strategies have been tried including oral medication prior to utilising rapid tranquillisation and satisfying themselves that rapid tranquilisation is an appropriate intervention

• Carrying out physiological observations and physical health monitoring (see C22: Physiological Observations and the Agitation-Calmness Evaluation Scale © (ACES)

• Ensuring the service user is placed on an appropriate level of additional observations so as to maintain their safety (see Section 7.0)

• Ensuring that documentation is completed (See Section 8.0)

Registered Nursing Staff

• Following the appropriate rapid tranquillisation pathway

• Checking the accuracy of the medication against the prescription

• Ensuring adequate stocks of medications, including flumazenil, are maintained

• Ensuring flumazenil is available on the ward prior to carrying out rapid tranquilisation

• Undertaking mandatory rapid tranquilisation training and related training as set out in staff pathways

All Clinical Staff

• Carrying out physiological observations (if deemed competent to do so) and taking appropriate action (see C22: Physiological Observations policy, including (P)EWS)

3.0 PRN Medication De-escalation techniques (e.g. talking, distraction, time away or use of a low stimulus environment) must always be used prior to any physical/pharmacological intervention (see C08: Prevention and Management of Violence and Aggression (including the use of physical intervention) policy.


The MDT (including a psychiatrist and a specialist pharmacist) should develop and document an

individualised plan for using routine and PRN medication to calm, relax, tranquillise or sedate service

users who are at risk of violence and aggression as soon as possible after admission to an inpatient

psychiatric unit. This should be reviewed (see Section 4.0) a minimum of once a week or more frequently

if the service user’s presentation is escalating and restrictive interventions are being considered / used.

Consideration should be given to stopping medication that has not been used.

Wherever possible this should include the service user and their family/carer (as appropriate).

When prescribing PRN medication consider the following: • Do not prescribe routinely or automatically on admission

• Tailor to individual need

• Ensure there is clarity about the rationale and circumstances in which it may be used and

document in the care-plan and as an ‘Indication’ on the prescription

• Specify the maximum daily dose and ensure that this and any regular prescription does not

inadvertently exceed the maximum daily (as per BNF). If this is to be exceeded in order to

achieve an agreed therapeutic goal, this must be carried out as per High Dose Antipsychotics

Therapy Guideline (C112 Appendix 5)

• Specify the interval between doses

4.0 Assessment and Review – all service users There should be a multi-disciplinary Team (MDT) assessment and review of the individual service user’s risk factors associated with rapid tranquillisation and medication a minimum of once a week or more frequently if the situation is escalating. Wherever possible this should include the service user and their family/carer (as appropriate) and include discussion about the risks, benefits and alternatives of rapid tranquilisation. Assessment and reviews should consider the following as they may affect dose requirements and side effects:

• Likely diagnoses

• Known physical illnesses and medication

• General physical state (e.g. pregnancy, exhaustion, dehydration)

• Current psychiatric medication (oral, depot and PRN) (including total daily dose of medication, prescribed and administered, any missed doses and the reason, likely timescale for response to medication and/or therapeutic response thus far and side/unwanted effects)

• Alcohol and substance misuse

• Target symptoms NB: if rapid tranquilisation is used, a senior doctor should review medication a minimum of once a day. Staff should take into account any Advance Decisions to Refuse Treatment (MCA) or Advance Statements/Crisis-plans. 5.0 Assessment and Review – service users with particular risks/needs Children and Young People – including those with a learning disability

• The assessment should also include consideration of severe impulsivity problems, conduct disorder, oppositional defiant disorder, pervasive developmental disorders and learning disabilities as these may all contribute to poor frustration tolerance and therefore aggressive presentation.

• Many children who have been severely abused or traumatised may present with disorganised or violent behaviour.

• Use of rapid tranquillisation in under-18s must be discussed with their Consultant/CAMHS On-call Consultant prior to treatment and lower doses considered (see Appendix 2).


• Avoid benzodiazepines in children/adolescents who are physically unwell, delirious or who have significant respiratory impairment. Low dose oral haloperidol and risperidone have been used for treatment of delirium that produces aggression and mental state changes.

• Use benzodiazepines in preference to antipsychotics in patients with cardiac disease, as these are safer, but beware of accumulation.

• In an intoxicated patient conservative management may be adequate. Lorazepam is preferable to antipsychotic agents but small doses of haloperidol may be required until the patient is stabilised.

Pregnant service users

• Special care must be taken when administering rapid tranquillisation to a service user during any stage of pregnancy

• Medical advice may be required due to the possible complications that may arise Elderly (>65 years) and frail service users

• Use of rapid tranquillisation should be infrequent and only in extreme emergency

• The service user’s Consultant should be consulted prior to prescribing any IM medication for rapid tranquillisation

• All other options, including non-pharmacological and oral medication such as lorazepam or promethazine and/or antipsychotics (haloperidol, risperidone, olanzapine) should have been exhausted prior to prescribing for rapid tranquillisation

• Consider dementia and physical frailty; look for causes of confusion that may be affecting behaviour

• Consider that older people may: o Require smaller doses of medication

o Have altered levels of metabolism and may be more frail

o Have pre-existing general medical illnesses and taking several medications (check

medical history up to date)

o Be more likely to develop extrapyramidal side effects and other adverse effects

o If suffering from dementia, be more likely to develop increased cognitive impairment with

high doses of medication

o Be naïve to antipsychotics and/or benzodiazepines

Lorazepam 0.5-1mg (max 4mg/day) or promethazine 10-25mg (max 100mg/day) and/or haloperidol 1-2.5mg or olanzapine 2.5-5mg, aripiprazole 5.25mg (all IM) may be considered for rapid tranquilisation in older people. Midazolam may also be an option but may be significantly more sedative. 6.0 Physical Health Monitoring and Emergency ECG

• Carry out at the earliest opportunity (usually on admission/ideally pre-treatment for haloperidol) particularly if any other QT-prolonging drug is prescribed and/or the service user has a history of cardiovascular problems

• If there is evidence of cardiovascular disease, including a prolonged QT interval, or no electrocardiogram has been carried out, avoid IM haloperidol combined with IM promethazine and use IM lorazepam instead

• If an ECG is not available the prescriber should consider the risks and benefits of using IM haloperidol plus IM promethazine and be able to justify their prescribing decision, because it may be considered an ‘off-label’ use (NICE, 2015)

• Consult with Acute hospital for advice on interpretation if required Plasma glucose

• See C67: Capillary Blood Glucose Monitoring and Self-Administration of Insulin policy

Electrolytes

• Assess if not done in previous 3-4 days, repeat daily if emergency persists

• Ensure adequate fluid intake, toilet visits


Pressure areas

• Ensure these remain dry and clean. See C33: Pressure Ulcer: Assessment and Prevention policy.

Emergency equipment/medication

• All areas using rapid tranquilisation must have quick access to resuscitation equipment (automatic external defibrillator (AED), bag, valve mask, oxygen, cannulas, fluids, suction and first-line resuscitation medications) (see C46: Cardio-pulmonary Resuscitation policy).

• Procyclidine (for dystonic reaction) must be available where antipsychotics are used.

• Flumazenil injections, and cannula must be available in all areas where lorazepam is used. NB: Monitor physical health post-rapid tranquilisation as set out in ‘Summary of Key Points’ (see C22: Physiological Observations policy). 7.0 Additional Observations Additional Observations (see C36: Observation and Engagement of Service Users policy)

• The service user should be placed on ‘within eyesight observations’ and monitored closely until they are ambulatory

• If seclusion is used the staff member must remain within arm’s length of the seclusion room at all times (see C107: Seclusion and Long Term Segregation policy)

• Record observations on the Additional Observation of Service Users at Risk (Parts 1 and 2) (NB: if seclusion used record on seclusion record until seclusion terminated)

• The on-going level of observation should then be determined by MDT risk assessment 8.0 Documentation The Practitioner-in-Charge must ensure that a comprehensive account of the incident is made in the health record. This should include:

• Antecedents/events leading up to the incident

• De-escalation techniques used

• Legal basis for use of rapid tranquillisation (e.g. capacity to consent, consented or not, Advanced Statements/crisis plans, Advanced Decisions to Refuse Treatment, Mental Health Act status etc.)

• Drugs and doses administered (including if above BNF or NICE recommended doses)

• Reasons for use of alternative medication (if necessary)

• Physiological observations and time of monitoring

• The response of the service user

• All physical care interventions (e.g. food/fluids offered and intake, toilet/washing etc.) The Practitioner-in-Charge must also ensure that:

• An incident report (Datix) is completed (use of rapid tranquilisation must be recorded)

• Physiological observations are recorded and the reason why not documented in the health record if unable to do so (see C22: Physiological Observations policy)

• Additional observations are implemented and recorded on the additional observations chart (see C36: Observation and Engagement of Service Users)

• The medicine card has been completed and signed

• The risk assessment and care-plan are reviewed

• The service user and/or their family/carer (as appropriate) is given the opportunity to talk to a member of staff about the event and this documented in the health record


Appendix 1 Pharmacotherapy Facts and Prescribing Guidance – Adults

Oral medication which may be used as PRN as a part of de-escalation strategy Drug Route BNF max Onset Peak Duration Repeat Problems Lorazepam Oral 4mg/day* 30-45 mins 1-3 hrs 4-6 hrs 4 hourly Respiratory

depression Haloperidol Oral 20mg/day

1 hr 2-6 hrs 20 hrs 4-6

hourly Can accumulate

Promethazine Oral 100mg/day 30 mins 2-3 hrs 4-6 hrs BD Prolonged sedation, Seizures

Quetiapine Oral 750mg/day** 1 hr 1.5 hrs 6 hrs 12 hourly

Postural hypotension

Risperidone Oral 16mg/day*** 1 hr 1 hr 20 hrs 24 hourly


*The maximum oral BNF dose for lorazepam (anxiety) is 4mg/day. The Trust acknowledges that in some

instances lorazepam dose may go above BNF maximum daily dose provided that:

• A risk/benefit analysis has been carried out and documented in the health record

• The rationale has been recorded in the care plan

• Flumazenil is available

• The service user’s physiological observations are monitored (see Summary of Key Points)

• Trust’s protocol on high dose lorazepam has been followed

** Max daily dose in schizophrenia ***In general max dose of 6mg/day should suffice IM medication recommended for rapid tranquillisation (NICE, 2015) Drug Route BNF max Onset Peak Duration Repeat Problems

Lorazepam*

IM 25-30 microgram/kg Repeat 6 hourly if needed.

30-45 minutes

1-3 hrs 4-6 hrs 6 hourly

Haloperidol IM 12mg/day 30 minutes

30 mins 4-6 hrs 4-8 hourly

Can accumulate

Promethazine IM 100mg/day 15-30 minutes

15-30 minutes

1hr BD/TDS Can be very sedative

*Lorazepam injection is stored in the refrigerator. It should be mixed in a 1:1 ratio with water for injections before administration but check product leaflet to confirm as it may vary with brands. If lorazepam IM injection is not available (e.g. during a manufacturer shortage), contact pharmacy for advice. Separate Trust guidance exists in the event of lorazepam unavailability and can be obtained from Pharmacy. NICE states that despite a lack of high-quality evidence to guide the choice of medication, the use of IM

lorazepam as a first choice option is supported because of its favourable benefit/harm profile. The use of

IM haloperidol in combination with IM promethazine is moderated to a certain extent by practicalities of

administering a combination of medication during an episode of violence.


Recommendations do not preclude the use of alternative treatment options; however, their use should be tailored to the individual in line with the recommendations for rapid tranquillisation (NICE, 2015). Possible alternative IM drugs for Rapid Tranquillisation There was insufficient evidence to make a judgement about the relative risk/benefits of other antipsychotic drugs (NICE, 2015). Some of the other benzodiazepines and antipsychotics that have been used include: Drug (see below for details)

Route BNF max Onset Peak Duration Minimum dose interval

Problems

Olanzapine IM 20mg/day 15 minutes

1 hour 6-8 hour 2 hours Maximum 3 days course

Aripiprazole IM 30mg/day 1hr 1-3 hourrs

24 hours 2 hours Maximum 3 injection/day

Midazolam IM 15mg/day 6-20 minutes

30 minutes

2 hours 20 minutes

Olanzapine IM

• Don’t confuse olanzapine IM injection with olanzapine embonate depot injection.

• The dose in renal or hepatic impairment is 5mg

• Efficacy has only been established in schizophrenia and mania

• Observe closely for postural hypotension, bradyarrhythmia and/or hypoventilation, particularly for

2 to 4 hours after injection

• Use with IM benzodiazepines has not been studied and is therefore not recommended. IM

benzodiazepines should not be given within 1 hour after IM olanzapine or vice versa.

Aripiprazole IM

• It is indicated for the rapid control of agitation and disturbed behaviours in schizophrenia or manic

episodes in Bipolar I Disorder, when oral therapy is not appropriate

• Treatment with aripiprazole solution for injection should be discontinued as soon as clinically

possible

Zuclopenthixol acetate (Clopixol Acuphase®)

• This is not recommended (by the Trust and NICE) for rapid tranquillisation due to the slow onset

of action (peaks at around 24hrs) and long duration of action (3 days)

• It may be used in exceptional circumstances (e.g. a history of timely response in the past or if

need of repeated injection)

• If it has to be used, the maximum dose is 400mg in 2 weeks (not 3x150mg)

• The request should be accompanied with a non-formulary drug request form agreed/signed by

Locality/Service Pharmacist and be approved by Drugs and Therapeutics Committee member

before use


Appendix 2

Pharmacotherapy Facts and Prescribing– Children and Young People Oral medication which may be used as PRN as a part of de-escalation strategy Drug Route BNF max Onset Peak Duration Repeat Problems

Lorazepam Oral 4mg/day 30-45 minutes

1-3 hours

4-6 hours 4 hour hourly

Respiratory depression

Haloperidol Oral 10mg/day 1 hour 2-6 hours

20 hours 4-6 hourly

Accumulation, ECG

Quetiapine Oral 750mg/day* 1 hour 1.5 hours

6 hours 12 hourly


Risperidone Oral 16mg/day** 1 hour 1 hour 20 hours 24 hourly


Promethazine Oral 50mg/day 30 minutes 2-3 hour 4-6 hours BD Prolonged sedation, Seizures

* in general max 200mg/day should suffice ** in general max 2-4mg/day should suffice IM medication which has been used for rapid tranquillisation Drug Route BNF max Onset Peak Duration Repeat Problems

Aripiprazole IM 30mg/day 1 hour 1-3 hours

24 hours 2 hours Max. 3 inj./day

Lorazepam

IM 4mg/day 20-40 minutes

1-1.5 hours

4-6 hours 6 hourly Respiratory depression

Haloperidol IM 10mg/day 20-30 minutes

30 minutes

4-6 hours 4-8 hourly

EPSEs, Postural hypotension, QTc, Seizures

Olanzapine

IM 20mg/day 15-30 minutes

1 hours 6-8 hours Wait at least an hour

3 days maximum as IM

Promethazine IM 50mg/day 30 minutes 1-2 hours

BD Prolonged sedation, Seizures

*Benzodiazepines are used frequently in emergencies with young people because of their relative safety, as well as their sedative properties however the person may develop paradoxical effects of disinhibition. Lorazepam is most frequently used because of its short half-life (12 – 16 hours) and rapid onset of action However avoid in children/adolescents who are physically unwell, delirious or who have significant respiratory impairment. NB: Most of these are not licensed for use in people under the age of 18. NICE does not make recommendations on any other drug except lorazepam IM for rapid tranquillisation in children and adolescents.


Appendix 3 HALOPERIDOL ADMINISTRATION – ORAL & INTRAMUSCULAR EQUIVALENT DOSES The maximum recommended daily dose for each route of administration is different, because parenteral doses generally have a greater bioavailability than oral doses.

Maximum dose in 24 hours: If only oral form prescribed: 20mg If only IM form prescribed: 12mg

If oral & IM forms prescribed in combination, refer to table below for total daily dose Please use the conversion chart below if a patient has received both haloperidol IM and oral in the last 24 hours, to calculate how much the patient had received in total: Route APPROXIMATE EQUIVALENT DOSES (mg) Oral 0.5 1 1.5 2 2.5 5 7.5 10 12.5 15 17.5 20 IM 0.3 0.6 0.9 1.2 1.5 3 4.5 6 7.5 9 10.5 12

For example:

Patient has been given 1 x 5mg haloperidol IM, followed 30 minutes later by 5mg orally, then 30 minutes later by another 5mg orally.

Convert to all oral doses, i.e. 8.3mg + 5mg + 5mg = 18.3mg oral equivalent

Or Convert to all IM doses, i.e. 5mg + 3mg + 3mg = 11mg IM equivalent

NOTE: Each route of administration should be prescribed as a separate entry on the prescription

chart.


Appendix 4

Management of Problems Occurring during Rapid Tranquillisation

Problem Remedial Measures – Adults Remedial Measures – Children and Young People

Acute dystonias (including oculogyric crisis) and Parkinsonism

Procyclidine 5-10mg IM (usually effective in 5-10minutes but may need 30 minutes for relief repeat after 30 minutes if necessary)

Procyclidine 2.5 mg PO (TDS) or 5-10 mg IM (usually effective in 5-10 minutes, repeat after 10 min’s if necessary).

Increased temperature or marked muscular rigidity (risk of neuroleptic malignant syndrome (NMS) and possible arrhythmias)

Withhold antipsychotics Monitor closely – send bloods to acute hospital for CK level Cool service user Seek urgent medical advice and refer to intensive care (ambulance via emergency number) if continued or further signs of NMS e.g. sweating, hypertension or fluctuating BP, tachycardia, incontinence, retention or obstruction, muscular rigidity (may be confined to head and neck) or confusion, agitation/altered consciousness

Withhold antipsychotics Monitor closely Cool patient Seek urgent medical advice AND refer to ITU if continued or any other signs of NMS such as sweating, hypertension or fluctuating BP, tachycardia, incontinence, retention or obstruction, muscular rigidity (may be confined to head and neck) or confusion, agitation/altered consciousness.

Reduced respiratory rate (<10/minute after lorazepam or if oxygen saturation <90% or in other respiratory distress e.g. fast shallow breathing)

Give flumazenil (a benzodiazepine antagonist) if benzodiazepine induced respiratory depression. Initially 200mcg IV over 15 seconds then 100mcg over 10 sec repeated every 60 seconds until level of consciousness obtained. Maximum dose 1mg (1000mcg) in 24-hours (1 initial dose and 8 subsequent doses). Patient may become agitated, anxious or fearful on awakening. Monitor respiration rate continuously until rate returns to baseline level (monitoring must continue beyond initial recovery of respiration as flumazenil has a short half-life. If respiratory depression induced by other agent the service user will require mechanical ventilation – arrange transfer to an intensive care unit immediately (ambulance via emergency number, see C32a: Transfer To and From Acute Hospital) Flumazenil is best avoided in epileptic patients; start mechanical ventilation instead.

Give flumazenil (a benzodiazepine antagonist) if benzodiazepine-induced respiratory depression: Initially 10mcg/kg (max 200mcg) IV over 15 seconds then repeated every 60 seconds until level of consciousness obtained. Maximum dose 50mcg/kg (if less than 20kg) or 1mg in 24 hours Monitor respiratory rate continuously until rate returns to baseline level (monitoring must continue beyond initial recovery as flumazenil has a short half-life). If induced by other agent, the patient will require mechanical ventilation (ambulance via emergency number, see C32a: transfer To and From Acute Hospital policy). . Use pulse oximetry if available or consider as medical emergency

Irregular/slow pulse (<50 minute)

Refer to specialist medical care immediately (ambulance via emergency number)

Fall in blood pressure (>30mmHg orthostatic or <50mmHg diastolic)

Lie service user flat and raise legs if possible. Monitor closely. Seek medical assistance if no improvement.


Appendix 5

Stage-Specific Interventions – Children and Young People (Aged 12-18 years)

Management of the aggressive paediatric patient should be based on the application of an appropriate level of intervention (see table) based on target symptoms, severity and the risk of violence. The appropriate level of intervention must be determined based on the severity and progression of the violent behaviour. Behaviour/Presentation Example Interventions Stage Specific Use of

Medication 1 The child/adolescent may show early signs of agitation,

such as oppositional behaviour or talking loudly, using inappropriate or abusive language and non-specific threats. The symptoms are not considered dangerous and the goal of intervention is to help the young person maintain autonomy.

Behaviour management including offering choices, removing upsetting stimuli, providing a quiet space, clear communication and limit setting.

N/A

2 The child/adolescent becomes more agitated and oppositional, and there is a potential for imminent danger. The young person may be severely agitated and anxious with pacing. There may be verbal threats and actual property damage. The patient is not yet believed to be an imminent danger to self and others. The goal with intervention is to reduce target symptoms and reduce agitation.

Interventions include a less stimulating environment and the provision of symptom specific medication.

Offer oral medication such as benzodiazepines but may require IM if danger to patient or others persist.

3 Immediate interventions are required to maintain the safety of the youth or staff. The child/adolescent is believed to pose an imminent danger to themselves and/or others. They are either at risk of attacking staff or injuring themselves or others. The aim of level 3 intervention is to maintain safety.

Examples of interventions include physical restraint and the administration of medication either orally or intramuscularly.Preparations such as benzodiazepines and antipsychotics are used. At all times, patient rights should be preserved and patient preferences considered wherever possible.

Give IM Lorazepam if oral is refused or inappropriate.

4 Patient still agitated, endangering self/others despite level 3 intervention.

After seeking advice from relevant Consultant/on Call CAMHS Consultant

IM Haloperidol + Promethazine, IM aripiprazole or IM olanzapine may be considered in discussion with consultant.

Staff must select the least restrictive interventions needed to maintain safety while attempting to maintain autonomy and treat target symptoms.


Monitoring Statement Aspects of the policy to be monitored

Monitoring method


Frequency Findings: Group/Committee that will receive the findings/monitoring report

Action: Group/Committee responsible for ensuring actions are completed

Aspects as identified by Prescribing Observatory for Mental Health (POMH-UK) audit

Participation in the national POMH-UK audit

Pharmacy Department

2016/17 (as per POMH-UK timeframes

Clinical Cabinet As identified based on report/results

Supporting Information With reference to: Code of Practice Mental Health Act (1983). Presented to Parliament

pursuant to Section 118 of the Act. Department of Health (2015) Mental Capacity Act (2005) Human Rights Act (1998)/European Convention on Human Rights – Articles 2, 3, 5 and 8 NG10: Violence and Aggression: short-term management in mental health, health and community settings. National Institute for Health and Care Excellence (2015) CG155: Psychosis and Schizophrenia in Children and Young People. National Institute for Health and Clinical Excellence (2013) Positive and Proactive Care: reducing the need for restrictive interventions. Department of Health (2014) Health and Safety at Work Act (1974) Management of Health and Safety at Work Regulations (1992)

Associated trust policies and documents

C22: Physiological Observations (including (P)EWS) C08: Prevention and Management of Violence and Aggression C32a: Transfer To and From Acute Hospital C36: Observation and Engagement of Service Users C40: Intramuscular Injections C46: Cardiopulmonary Resuscitation C48: Management of Medication Error C67: Capillary Blood Glucose Monitoring and Self-administration of Insulin C107: Seclusion and Long term Segregation C112: Management of Medicines Q11: Serious Incidents Requiring Investigation Q16b: Clinical Supervision Q18 Risk Management Strategy and Policy Q20: Accident and Incident Reporting Multidisciplinary Physical Examination Sheet Advance Decision to Refuse Treatment – Form and Guidance Agitated-Calmness Evaluation Scale (ACES). Eli Lilly and Co.© (1998)

Written by: John Hunter – Clinical Pharmacy Manager Reviewed by: Asta Prajapati – Clinical Pharmacy Manager (Norfolk) In consultation with: Clinical Pharmacists

Medical Staffing Committee Clinical Cabinet Drug and Therapeutics Committee