Reducing the use of Restrictive Interventions – how well are we meeting the DH Guidance?

Dr Alick BushGiselle Cope

Dr Zoe WhitakerAmy Aston

CPD Event 30th January 2015

Aims

• National and local use of Restrictive Interventions• National policy and guidance• Positive and Proactive Care DH guidance• Translating guidance in to standards• Audit of standards at Nottinghamshire• Steps to improve practice

What needs to change

• CQC inspection of 150 inpatient services- great uncertainty about use of restrictive interventions

• Many services over reliant on use of restraint instead of preventative approaches

• MIND report- Physical Restraint in Crisis (2013):– 1998 death of David Rocky Bennett (prolonged prone

restraint)– Subsequently 13 more deaths of people detained under MHA

• Winterbourne View- justified as ‘restraint’

Winterbourne View- 6 staff imprisoned

National & Local Drivers National and Local Drivers for change

National NHS Benchmarking Network

Use of restrictive interventions August 2014:

• Restraint used 8,466 times• Of these, 1,535 were prone restraints (about 20%)

• 1,459 incidents of seclusion

Census being repeated for January 2015

What about St Andrew’s?

Seclusion

• Seclusion used 200 times per month

• No changes over last 24 months.

Restraints

• 700 restraints per month

• Some reduction over last 24 months

• How many are prone?

STAH - All Sites Prone Restraint Data

Notts Prone Restraint (Oct 13 – Jan 15) [include data on actual numbers per month]

Oct-13

Nov-13

Dec-13

Jan-14

Feb-14

Mar-14

Apr-14

May-14

Jun-14Jul-1

4

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

0

10

20

30

40

50

60

70

80

% of restraints being prone

% of restraints being proneExponential (% of restraints being prone)

Rapid Tranquilisation

• 140 occasions of Rapid Tranquilisation per month

• Little variation over 24 months

• Data not available on prn medication to control behaviour in absence of appropriate mental illness

Patient PMAV Injuries

• About 7 patient injuries per month

• Increased over 24 month period

Staff PMAV Injuries

• About 30 staff injuries in last 12 months

• Significant improvement over 24 months

Conclusions

• Nationally there is an over-reliance on the use of Restrictive Interventions

• Restraint, seclusion and PRN are not yet the last resort option that is expected of us

• St Andrews is moving in the right direction but we still need to be doing more

• Services are a long way off the aspiration for prone restraint to be a ‘never event’.

• Avoiding the use of RIs must remain our priority

So what should we be doing?

National Guidance to support people positively

• NICE guidance for Challenging Behaviour and learning disabilities

o Consultation until 9 February 2015o Final guidelines- 27 May 2015

• Positive and Proactive Care: reducing the need for restrictive interventions (DH, 2014)

NICE guidelines for CB & LD- draft

General principles:– Prevention– Improve support rather than change the person– Team working– All staff are trained to delver proactive strategies

to reduce likelihood of CB– Least restrictive options– Principles of PBS

Draft NICE guidelines (2)

Process is what we’d probably expect:• Functional assessment of behaviour• Formulation, that drives a Behavioural Support Plan

emphasising proactive and preventative strategies• Interventions

– Psycho-social focus– Adapt the environment– Treat co-existing physical/ mental health problems

• Evaluate against initial intervention goals & timescales

Draft NICE guidelines (3)- Medication

Only consider medication for behaviour that challenges if:• Person has co-existing mental or physical health

problem• Psychosocial, psychological or other interventions

alone do not produce change in specified time• Risk to the person or others is very severeOnly offer medication in combination with psychosocial, psychological or other interventions

Draft NICE guidelines (4)- Medication

Guidelines for prescribing anti-psychotics for CB:• Monitor effectiveness against initial aims• Single drug• Stop after 6 weeks if no response• PRN is not to exceed 4 weeks• If there is a positive response- MDT review at 3 months

then 6 monthly• Only continue to offer medication that has proven benefit

Draft NICE guidelines (5)- Reactive

• Similar to Positive & Proactive Care guidelines• Last resort and use together with proactive

interventions• Least aversive and least restrictive• Encourage person and family to be involved in

planning and reviewing• Any restrictive intervention is accompanied by a

Restrictive Intervention Reduction Programme

Reducing the use of Restrictive Interventions: how well are we meeting current guidance?

Positive and proactive care (DH 2014) indicates 4 overarching themes

• Improving care

• Leadership, assurance and accountability

• Transparency

• Monitoring and oversight

Restrictive Interventions – what do they include?

• Physical restraint

• Mechanical restraint

• Chemical restraint

• Seclusion

• Long-term segregation

Audit Aims

1. To develop appropriate set of standards to audit the care plans and documents available on RiO against the Department of Health Positive & Proactive Care guidance.

2. To recommend any actions that may improve clinical practice and ensure that care is being delivered to a high quality standard in the least restrictive methods possible, in line with Positive & Proactive Care.

Development of Standards for Care1. Person centred plan2. Multi-disciplinary formulation3. Aims of admission4. Interventions driven by formulation5. Plan addressing challenging behaviour6. Least restrictive practices used7. Service user collaboration with care plans8. Comply with MCA and MHA9. Post-incident reviews10. Learning from incidents11. Accessible data e.g. graphs12. Plan around use of physical restraint13. Discharge care plan

Audit Scoring

By checking the available information for each service user on RIO, each standard was graded as:

– Not Met/No evidence (0) – The standard has not been met in any form or there is no evidence provided.

– Some Evidence (1) – There is mention of the standard, however there is not sufficient evidence to suggest that it has been met either partially or fully.

– Almost met (2) – There is detailed information regarding the standard, however not enough evidence to suggest that it has been fully met.

– Fully met (3) – The standard has been fully met.

Each standard could achieve a maximum of 3 points (fully met) and therefore across the thirteen standards a maximum of 39 points could be achieved.

Results

Key Findings: Where we could do better

• Key finding 1: Few PMAV care plans included ideas that reflected key principles from the Mental Capacity Act and Mental Health Act [standard 8].

• Key Finding 2: Limited evidence that Post-incident reviews were held for both staff and patients. Unclear where this would/ should be documented [standard 9].

• Key Finding 3: Limited evidence of PBST care plans which derived through a collaborative formulation. Lack of evidence that formulation then led to specific interventions aims at reducing restrictive interventions [standard 2].

• Key Finding 4: The specific aims of admission were not easily identified upon RIO [standard 3].

• Key Finding 5: Limited individualised data was available that provided evidence of the effectiveness of our interventions [standard 11].

• Overall service users had strong PMAV (prevention and management of aggression and

violence) care plans.

They included;

⁻ Information about the context within which the behaviour that challenges may occur,

primary prevention strategies

⁻ Secondary prevention (de-escalation)

⁻ Tertiary strategies (including planned restrictive practices- carried out safely and as a

last resort).

• Physical health information was also commonly included to make staff aware of any

physical limitations.

Key Findings: Areas of Good Practice

Key Finding 6: Robust PMAV behaviour support plans are in place for all services users who are known to be at risk of being exposed to restrictive interventions including the most common contexts in which these behaviours occur.

Key Finding 7: Ethical care plans – All care plans were written with a strong emphasis on the principle of ‘Least Restrictive’ practice.

Key Finding 8: Good evidence of person centred, values based approach where the focus of care/ practice is on improved QoL and where support plans focus on the person, their journey and their future needs.

Implications for Practice (1)

• Overall there needs to be more collaboration with service users in the development of their individual care plans [standard 1].

• More effort is needed to capture the service users’ voice including what is important to them now and in the future [standard 1].

• All service users require a multi-disciplinary formulation that is easily identified, meaningful and accessible [standard 2].

• Pre-admission reports should provide specific details regarding the aims of the admission focussing on [standard 3].

• More effort is needed to capture the service users’ voice within the PMAV care plans to support them in using preferred de-escalation techniques [standard 7].

Implications for Practice (2)• PMAV care plans should make explicit how restrictive practices adhere to

the Mental Capacity Act and Mental Health Act (i.e. best interests, dignity, human rights) [standard 8].

• Post incident reviews should be routinely held for both staff and patients. It should be clearly documented what has been learnt from the incident in order to reduce the likelihood of it occurring again. They should then be documented chronologically to demonstrate learning [standard 9].

• It would be helpful to have access to data such as graphs to assess the effectiveness of our interventions [standard 11].

• All patients should have a discharge care plan which describes how we are supporting them to move into a less restrictive environment, or which steps are being taken to arrange discharge [standard 13].

Reduction of Restrictive Practices within Nottingham

So What?

National level

Board Level

Service Level

Individual Level

Board Level

Positive & Safe: Restrictive Intervention Reduction Programme

Led by the Chief Operating officer (Board Lead) and the Director of Nursing (Lead Director)

The 6 Core Strategies

• Leadership towards organisational change • Data to inform practice • Workforce Development • Inclusion of individuals and families • Use of reduction tools • Rigorous de-briefing

So what's happening in Nottingham? What have we done to change practice?

Service/Individual levelWhat we are aiming to achieve in Nottingham is the ability to reduce restrictive practices and to: “Foster an inclusive culture where by we can shape care effectively, raise peoples awareness, learn effectively from incidences and have the ability to evidence and change our practice. As a result ensuring patients experiences in our care is positive and safe”

But What does that look like?

Service/Individual level• Monitoring.

• Patient voice and experience to inform care planning and training.

• Examining ward climate.

• Improving relational security and meaningful engagement with patients.

How should we support People in St Andrew’s

Meaningful Conversations

Ward Climate

Service/Individual levelImplementation of:

RAID®

What next?• Monitoring• To work within the board framework-6 Core strategies• Consider the recommendations from the care plan • Embedding the correct culture around restrictive practices• Meaningful Conversations linking into handover• Consider the implications of the code of practice• Establish streamlined treatment pathways and those which

clearly articulate what needs to happen during an individuals transition.

• Being creative about how and where we utilise resources to inform practice

Final Note……..

Thank you for listening

Any Questions?

References• Department of Health (2012) Transforming care: A national response to Winterbourne

View Hospital: Department of Health Review Final Report. • Department of Health (2012) DH Winterbourne View Review Concordat: Programme of

Action: Department of Health Review Final Report. Skills for Health and Skills for Care (2014)

• A Positive and Proactive Workforce. A guide to workforce development for commissioners and employers seeking to minimise the use of restrictive practices in social care and health

• Social Care, Local Government and Care Partnership Directorate, Department of Health (2014) Positive and Proactive Care: reducing the need for restrictive interventions.

• MIND (2013) Mental Health Crisis Care: physical restraint in crisis.