@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