@JInnesMpharm

A Pharmacist and Quality Lead’s journey through PICU: A case of the past, present

and future

@JInnesMpharm

The past….

• Violence

• RT and associated monitoring

Two problems…

• Agitated & violent behaviour constitutes 10% of all emergency psychiatric admissions1

• In 1998/1999, 65,000 pt on staff violent incidents reported in NHS2

• Led to Zero Tolerance Campaign

Violence

1. Raveendran N et al. BMJ. 2007. 335:8652. NHS Protect website/., http://www.nhsbsa.nhs.uk/3645.aspx3. /.,.,/,/. ,/ /,/ .,/ /.,

4.

2004-2005 2005-2006 2008-2009 2009-2010 2010-2011 2011-2012 2012-2013 2013-20140

10000

20000

30000

40000

50000

60000

70000

80000

Number of Pt on Staff Violent Incidents, Year on Year, Reported in the NHS

Num

ber

of in

cide

nts

Three times as many violent incidents occur in MH services than other NHS services

Violence levels over the last few years…

1. NHS Protect website/., /.,. http://www.nhsbsa.nhs.uk/3645.aspx2. ,/,/. ,/ /,/ .,/ /.,

Local Repercussions

• Violence

• RT and associated monitoring

Two problems…

What is RT?

• In the UK (2012);

• ‘the use of medication to calm/lightly sedate the service user and reduce the risk to self and/or others. The aim is to achieve an optimal reduction in agitation and aggression, thereby allowing a thorough psychiatric evaluation to take place, whilst allowing comprehension and response to spoken messages throughout.’ 3

• TREC studies 1, 4 (India and Brazil) Tranquill or asleep

• Unclear definition of the agitated state and therapeutic goals of RT 5

3. Violence. NICE 2005. Clinical Guideline 254. Huf et al. BMC Psychiatry. 2002. 2:115. De Fruyt et al. European Psychiatry. 2004. 19 (5) 243-249

Risks Associated with RT?

• Arguably one of the highest risk clinical processes currently undertaken in MH

• Risks can be both drug and non drug related.

• Physical monitoring forms an essential backbone to this practice ensuring the patient remains safe

• Our own internal audits indicated that post RT monitoring was a particular issue

1. Innes J, Iyeke L. (2011) A review of the practice and position of monitoring in today's rapid tranquillisation protocols.

2. Innes J, Sethi F (2012) Current Rapid Tranquillisation documents in the UK; A review of the drugs recommended, their routes of administration and clinical parameters influencing their use.

3. Loynes B, Innes J, Dye S (2012) Assessment of physical monitoring following RT: A national survey

4. Innes J, Curtis D (2013) Medication patient safety incidents linked to RT: one year’s data from the NRLS

A Series of 4 Review Articles…

Drugs recommended (PO)

Dia

zepa

m

Lora

zepa

m

Arip

ipra

zole

Chlo

rpro

maz

ine

Hal

oper

idol

Levo

mep

rom

azin

e

Ola

nzap

ine

Que

tiapi

ne

Risp

erid

one

Lith

ium

Prom

etha

zine

Valp

roat

e

Benzos Antipsychotics Other

0

10

20

30

40

50

5

40

3 2

37

3

32

9

29

1

8

1

Drugs recommended (IM)

Clon

azep

am

Lora

zepa

m

Mid

azol

am

Arip

ipra

zole

Hal

oper

idol

Levo

mep

rom

azin

e

Ola

nzap

ine

Zucl

open

thix

ol a

ceta

te

Para

ldeh

yde

Prom

etha

zine

Benzos Antipsychotics Other

0

10

20

30

40

50

1

44

15 15

43

3

44

32

1

20

Clinical Decision Making Parameters

AlcoholHistory of NMS

Illicit DrugsUse in Pregnancy

EPSEsCardiovascular Disease

Neuroleptic NaivetyMental State

Safe Use of BenzosUse of HaloperidolCurrent Treatment

45

614

1520

2728

2936

44

• Wide variation in advice across different RT documents within the same clinical decision making parameters

• In some cases, information is conflicting

When should monitoring be initiated?

50%46%

2% 2%

After any route

After parenteral

Optional after PO, but mandatory after parenteral

Mandatory after high dose therapy and parenteral

What should be monitored?

Blood Pressure

Temperature

Level of Consciousness

Oxygen Saturation

EPSE

Urea and Electrolytes

Electrolytes

0 10 20 30 40 50 60 70 80 90 1009595

9193

5234

18

22

7

22

22

52

255

5075

7111111 Mandatory

Conditional

Frequency?

5 mins

10mins

15 mins

30 mins

Depends on monitoring parameter

Regular interval

Duration?

1 hour2 hours4 hoursPt ambulatoryNot stated

How were Trusts doing with post RT Monitoring?

Only 38% (18/47) of Trusts were auditing post RT monitoring

@JInnesMpharm

The present….

@JInnesMpharm

S + P = OStructure + Process = Outcomes

Source: Donabedian, A. Explorations in Quality Assessment and Monitoring. Volume I: The Definition of Quality and Approaches To Its Assessment. Ann Arbor,

MI, Health Administration Press, 1980.

Dr. Avedis Donabedian(1919-2000)

A classic approach to delivering outcomes

Key Ingredients for Success

Success

Form a team

Agree the quality issue to

be tackled

Ensure patient (and carer)

involvementFind time to meet

A P

DS

Plan

DoStudy

Act

AIM: What are we trying to accomplish?

MEASURES: How will we know if achange is an improvement?

CHANGE: What changes can we makethat will result in improvement?

The Model for Improvement

A P

DS

Rapid cycle testing

Develop a strategyPrioritise and pick

change ideas

Observe the resultsImplement,

adapt or abandon

Structured, systematic approach to tackling problems…

• Violence

• RT and associated monitoring

Two problems…

1. Create a structure

2. Make all aware of the evidence base

• Contributory factors to violence– Patient factors– Staff factors– Environmental factors

• Violence prediction– Static (acturial)– Dynamic (clinical prediction models)

3. Create a strategy…

4. Test change ideas in parallel

Personal support plan

Pt property

Ward round

Mindfulness

Reducing violence

OU

TCO

ME

MEA

SURE

STrust-wide dataTower Hamlets data

Combined wards dataIndividual ward data

Key

05-J

an-1

4

13-J

an-1

4

29-J

an-1

4

29-J

an-1

4

12-F

eb-1

4

07-M

ar-1

4

30-M

ar-1

4

05-A

pr-1

4

19-A

pr-1

4

19-A

pr-1

4

22-A

pr-1

4

30-A

pr-1

4

01-M

ay-1

4

02-J

un-1

4

20-J

un-1

4

21-J

un-1

4

26-J

un-1

4

02-J

ul-1

4

09-A

ug-1

4

21-N

ov-1

4

08-M

ar-1

5

20-A

pr-1

5

06-M

ay-1

5

16-M

ay-1

5

0

50

100

150

UCLLCL

Days between incidents resulting in staff injury (Acute wards only) - T Chart

Tim

e be

twee

n ev

ents

/

days

06-J

an-1

420

-Jan

-14

03-F

eb-1

417

-Feb

-14

03-M

ar-1

417

-Mar

-14

31-M

ar-1

414

-Apr

-14

28-A

pr-1

412

-May

-14

26-M

ay-1

409

-Jun

-14

23-J

un-1

407

-Jul

-14

21-J

ul-1

404

-Aug

-14

18-A

ug-1

401

-Sep

-14

15-S

ep-1

429

-Sep

-14

13-O

ct-1

427

-Oct

-14

10-N

ov-1

424

-Nov

-14

08-D

ec-1

422

-Dec

-14

05-J

an-1

519

-Jan

-15

02-F

eb-1

516

-Feb

-15

02-M

ar-1

516

-Mar

-15

30-M

ar-1

513

-Apr

-15

27-A

pr-1

511

-May

-15

25-M

ay-1

508

-Jun

-15

22-J

un-1

506

-Jul

-15

20-J

ul-1

5

0

5

10

15

20

25

30

UCL

LCL

Incidents resulting in Physical Violenceper 1000 occupied bed days (OBD) - U Chart

No.

of

Inci

dent

s pe

r 10

00 O

BD

06-J

an-1

420

-Jan

-14

03-F

eb-1

417

-Feb

-14

03-M

ar-1

417

-Mar

-14

31-M

ar-1

414

-Apr

-14

28-A

pr-1

412

-May

-14

26-M

ay-1

409

-Jun

-14

23-J

un-1

407

-Jul

-14

21-J

ul-1

404

-Aug

-14

18-A

ug-1

401

-Sep

-14

15-S

ep-1

429

-Sep

-14

13-O

ct-1

427

-Oct

-14

10-N

ov-1

424

-Nov

-14

08-D

ec-1

422

-Dec

-14

05-J

an-1

519

-Jan

-15

02-F

eb-1

516

-Feb

-15

02-M

ar-1

516

-Mar

-15

30-M

ar-1

513

-Apr

-15

27-A

pr-1

511

-May

-15

25-M

ay-1

508

-Jun

-15

22-J

un-1

506

-Jul

-15

20-J

ul-1

5

02468

10121416

UCL

LCL

Incidents of Physical Violence (Acute wards only) per 1000 occupied bed days (OBD) - U Chart

No.

of

Inci

dent

s pe

r 10

00 O

BD

06-J

an-1

420

-Jan

-14

03-F

eb-1

417

-Feb

-14

03-M

ar-1

417

-Mar

-14

31-M

ar-1

414

-Apr

-14

28-A

pr-1

412

-May

-14

26-M

ay-1

409

-Jun

-14

23-J

un-1

407

-Jul

-14

21-J

ul-1

404

-Aug

-14

18-A

ug-1

401

-Sep

-14

15-S

ep-1

429

-Sep

-14

13-O

ct-1

427

-Oct

-14

10-N

ov-1

424

-Nov

-14

08-D

ec-1

422

-Dec

-14

05-J

an-1

519

-Jan

-15

02-F

eb-1

516

-Feb

-15

02-M

ar-1

516

-Mar

-15

30-M

ar-1

513

-Apr

-15

27-A

pr-1

511

-May

-15

25-M

ay-1

508

-Jun

-15

22-J

un-1

506

-Jul

-15

20-J

ul-1

5

0

20

40

60

80

100

UCL

LCL

Incidents of Physical Violence (PICU's only)per 1000 occupied bed days (OBD) - U Chart

No.

of

Inci

dent

s pe

r 10

00 O

BD

06-J

an-1

420

-Jan

-14

03-F

eb-1

417

-Feb

-14

03-M

ar-1

417

-Mar

-14

31-M

ar-1

414

-Apr

-14

28-A

pr-1

412

-May

-14

26-M

ay-1

409

-Jun

-14

23-J

un-1

407

-Jul

-14

21-J

ul-1

404

-Aug

-14

18-A

ug-1

401

-Sep

-14

15-S

ep-1

429

-Sep

-14

13-O

ct-1

427

-Oct

-14

10-N

ov-1

424

-Nov

-14

08-D

ec-1

422

-Dec

-14

05-J

an-1

519

-Jan

-15

02-F

eb-1

516

-Feb

-15

02-M

ar-1

516

-Mar

-15

30-M

ar-1

513

-Apr

-15

27-A

pr-1

511

-May

-15

25-M

ay-1

508

-Jun

-15

22-J

un-1

506

-Jul

-15

20-J

ul-1

5

0

1

2

3

4

5

6

7

UCL

LCL

Incidents resulting in staff injuryper 1000 occupied bed days (OBD) - U Chart

No.

of

Inci

dent

s pe

r 10

00 O

BD

10-J

an-1

4

21-M

ar-1

4

27-M

ar-1

4

22-A

pr-1

4

26-J

un-1

4

20-J

ul-1

4

06-A

ug-1

4

25-A

ug-1

4

29-S

ep-1

4

30-O

ct-1

4

12-N

ov-1

4

20-N

ov-1

4

29-N

ov-1

4

20-D

ec-1

4

21-D

ec-1

4

07-J

an-1

5

11-J

an-1

5

13-J

an-1

5

03-F

eb-1

5

14-F

eb-1

5

23-F

eb-1

5

21-M

ar-1

5

23-M

ar-1

5

27-M

ar-1

5

17-J

un-1

5

29-J

ul-1

5

0

20

40

60

UCLLCL

Days between incidents resulting in staff injury (PICU's only) - T Chart

Tim

e be

twee

n ev

ents

/

days

5. Make the results visible to all…

57% reduction

• Violence

• RT and associated monitoring

Two problems…

1. Create a structure

• Bevan ward tasked with reducing medication errors as part of Harm Free Care initiative.

• In 2011, an audit showed that the trust was at 50% compliance of which Bevan ward was at 10%

To have 100% of patients’ who received psychotropic PRN/RT will have their physical health monitored and we aim to do this by September 2014

Primary Drivers Secondary drivers Change ideas

Review policy to simplify

Clinical governance

Staff training and knowledge

Patient safety

ELFT RT guidelines and policy

ELFT Prescription chart

Knowledge on rapid tranquilisation

Physical health observations

Review prescription chart

Staff questionnaire to assess policy

Staff training on RT

Clarify differences between PRN and RT

administration

Knowledge on physical health monitoring

ELFT RT monitoring form

Review observations form

2. Create a strategy…

The Bevan ward RT/PRN monitoring

Tool

3. Test change ideas…

wee

k 1

wee

k 3

wee

k 5

wee

k 7

wee

k 9

wee

k 47

wee

k 49

wee

k 51

wee

k 53

wee

k 55

wee

k 58

wee

k 60

wee

k 62

wee

k 64

wee

k 6

6

wee

k 68

wee

k 70

wee

k 72

wee

k 74

wee

k 76

wee

k 78

wee

k80

wee

k 82

wee

k 84

Wee

k 86

Wee

k 88

Wee

k 90

Wee

k 92

Wee

k 94

Wee

k 96

Wee

k 98

Wee

k 10

0

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

UCL

LCL

P Chart Showing number of Bevan ward scales completed as a percentage of number of RT doses adminstered

Team Health Sipho effect

4. Make the results visible to all…

@JInnesMpharm

The future….

Top down

Bottom up

Improvement

A P

DS

1. Top down/bottom up approach

NICE 2005 NICE 2015

RT Definition Use of medication to calm/lightly sedate the service user and reduce the risk to self and/or others. The aim is to achieve an optimal reduction in agitation and aggression, thereby allowing a thorough psychiatric evaluation to take place, whilst allowing comprehension and response to spoken messages throughout

Use of medication by the parenteral route if oral medication is not possible or appropriate and urgent sedationwith medication is needed.

RT Monitoring Pulse, BP, RR, temp, level of hydration,.

At regular intervals until service user active. Monitoring should occur more frequently if other concerns.

Pulse, BP, RR, Temp, level of hydration, level of consciousness

At least every hour, or every 15 minutes if HDA or other concerns, until pt active

Policy, Guidelines, Research

Policy, Guidelines, Research

Efficacy vs Effectiveness

Focus on outcomes, not tasks

Front line staff able to use systematic

method

Learning system, where it is ok to fail

Performance is visible for all to see

Focus on continuous improvement

• CQUINs and KPIs• Outcomes rather

than processes• Incentivise

approach?

Importance of Commissioning

2. Scale up and spread of ‘change bundles’

• Stop reinventing the wheel

• Bundle of interventions proven to work

• Use ‘bottom up’ approach to implement these interventions reliably