An example of working towards Sustained Quality Improvement in SLAM: Audit of SLaM guidelines for Rapid Tranquillisation 13 th February 2013 HQIP Conference, London Rosie Peregrine-Jones Clinical Audit & Effectiveness Manager South London & Maudsley NHS Foundation Trust

Outline of presentation 1.Introduction ….to SLAM and our quality priorities and improvement programs 2.NHSLA Risk Management standards & Trustwide Clinical Audit Program ii) Why bother with NHSLA? 3. Rapid Tranquillisation Audit – an example of sustained improvement 4.Initial findings in Changes in Practice 6. Outcomes in RT in 2012/13 8. Conclusions

1. Introduction South London & Maudsley NHS Trust – who are we? We provide the widest range of NHS mental health services in the UK. We also provide substance misuse services for people who are addicted to drugs and / or alcohol. We work closely with the Institute of Psychiatry, King's College London, and are part of King's Health Partners Academic Health Sciences Centre. We have 4,800 staff and serve a local population of 1.1 million people. We have over 100 sites and provide support to around 39,000 in the community. We have 68 inpatient wards across four main hospital sites, and provide inpatient care for over 5,000 people each year.

1. Introduction Cont. Quality standards and priorities for sustained improvement: External requirements (e.g. CQC, NHSLA, PCT quality contract, Mental Health Act, Monitor, NICE) Internal - Quality Account /Assurance Framework/Care Pathways/CAG quality priorities Our approach to sustained quality improvement: Trustwide & CAG Clinical Audit Programs of Assurance Annual Nursing Practice Visits across all inpatient & community teams PEDIC – monitoring of service user views Productive Wards Magnet Local Improvement Projects (e.g. violence reduction)

2. i) NHSLA Risk Management standards & Trustwide Clinical Audit Program Delivery of the Trustwide Clinical Audit Program as a means to achieve sustained improvements in clinical care Since Trust achieved Level 2 NHSLA in 2008, annual clinical audit program has been focused on monitoring the key clinical policies within the 50 standards (e.g. observation, patient information, rapid tranquilisation, AWOL etc.). Annual cycle of monitoring, action planning and review Central Audit Team carried out monitoring of 25/50 (50%) of standards On 16th December 2011, after undertaking a rigorous 2-day assessment of SLaM’s performance against 50 standards, NHSLA confirmed that SLAM had passed at level 3, the highest level for acute and mental health trusts. At the time, SLaM was the only mental health trust in the NHS to be awarded Level.

2. ii) Why bother with NHSLA? Achievement of Level 3 would confirm that SLaM has successfully embedded, and is using, ‘best practice’ risk management systems and processes throughout the Trust - it would be the only Level 3 Mental Health and Learning Disability Services Trust in the country. It also serves as a quality indicator for third parties, such as commissioners, other inspecting bodies and stakeholders and how areas of risk covered by the Standards are managed within the organisation. Level 3 qualifies Trust for 30 per cent Risk Management Discount - a saving of £315,000 per year. One factor, critical to the success of the project, was being able to demonstrate annual cycles of clinical audit on the key clinical policies which have been included in the trustwide audit program since 2008

3. Rapid Tranquillisation Audit – an example of sustained improvement Rapid tranquillisation is one of several strategies commonly used in the management of severely disturbed behaviour in mental health inpatient settings. It is used when other less coercive techniques of calming a service user, such as verbal de-escalation or intensive nursing techniques, have failed. It usually involves the administration of medication over a time-limited period of minutes, in order to produce a state of calm/light sedation

4. Initial findings in 2007: Unreliable documentation of incidents in the patient record (48%) Little documentation of attempting de-escalation prior to rapid tranquillisation (10%) Common administration of Haloperidol during rapid tranquillisation (16%) Where given, Haloperidol was usually above the recommended dosage (74%) Physical observations were not recorded following rapid tranquillisation Debriefing with the patient was not recorded

5. Changes in Practice 1.Communication of critical standards to clinical teams i)Audit summary findings and recommendations issued in trustwide e-news bulletin and ed to all consultants and ward managers to be given to their teams (March 2010, December 2011). ii) Medication Incident and Error Bulletins produced by the Pharmacy Department have highlighted serious incidents involving rapid tranquillisation and reminders of the mandatory monitoring schedule (e.g. April 2012).

5. Changes in Practice iii) A poster of the rapid tranquillisation guidelines has been produced and sent to all wards in March Inpatient practice visits audit data in May 2012 demonstrated 95% inpatient areas had this poster displayed.

5. Changes in Practice 2. Training in Rapid Tranquilisation Including rapid tranquillisation in Trust mandatory 5-day PSTS training for all nursing staff Production of teaching slides for all CT1s: Treatment of Acutely Disturbed or Violent Behaviour (Rapid Tranquillisation) Teaching slides for all clinical staff: Rational Prescribing delivered by Pharmacy Department. Rapid Tranquilisation e-learning module available through Education & Training Department intranet site. The mandatory monitoring/physical observations in Rapid Tranquillisation are now included in the trustwide MEWS (Modifed Early Warning Scores) training for all staff

5. Changes in Practice

3. Documentation - Modified Early Warning Scores printed observation charts now include a prompt on the front page to record increased frequency of baseline observations due to rapid tranquillisation.

4. RT included in nursing competency frameworks (MAGNET) Requirements for physical observations in rapid tranquillisation have also been included in the SLAM Magnet Nursing Competency Framework. The purpose of this framework is to demonstrate competencies and assurance for nursing competency and capability. Rapid tranquillisation has specifically been included in the following frameworks: 1) Administration of Medications including Rapid Tranquillisation and physical monitoring 2) Physical Observation and Medical Devices Outcome record. 5. Changes in Practice

6. Outcomes in 2011 re-audit Documentation of rapid tranquillisation in the patient electronic notes improved and this was sustained (48% in 2007, up to 96% in 2010, 100% in 2011) Documented attempts to de-escalate the patient prior to rapid tranquillisation became more common (10% up to 66% in 2011) Use of Haloperidol dropped to a minimum (42% in Jan 2008 down to 3.6% in 2011) Whilst recording of at least one set of observations following rapid tranquillisation improved (0% in 2007 up to 25% in 2011), the requirement to document physical observations at the frequency required (i.e. every 5-10 minutes for one hour and then half-hourly until the patient is ambulatory) has not been met. This is now subject to a focused rapid-cycle audit project which will start in September Recorded debrief with the patient following rapid tranquillisation improved (0% to 43% in 2007)

7. RT in 2012/13 A rapid-cycle (quarterly) audit project focused on improving physical observations following rapid tranquillisation started in November draft guidance sheet and checklist to be piloted on Triage wards and PICUs from January 2013 Repeat audit planned for Feb 2013 and at 3 monthly intervals in 2013.

8. Conclusions Lessons from NHSLA program and RT audit project show: Sustained improvement is possible! It requires: Strong Leadership (from project managers & policy leads) Good project management structure Targeted investigation of barriers to compliance by asking staff Multi-faceted improvement program (e.g. communication to clinicians, training, documentation, competency assessment, regular feedback on performance to staff on ground) BUT - Need support of clinicians – in November 2012 audit it was found the greatest factor to non-compliance was disagreement over the balance of risks involved to staff with implementing the physical obs. There was a sentiment that the guidelines were out of touch with the risks to staff, exacerbating poor compliance. Ongoing support to staff to implement the guidelines is critical for success