Monitoring patients in crisis

Transcription

1 Monitoring patients in crisis Lessons from dynamic symptom profiles Roland van de Sande

2 Framework of reference Training: Inservice psychiatric nursing training Community psychiatric nursing training Advanced crisis response training Master of science in nursing Higher education teaching qualification PhD trajectory 3 years 3 years 1 year 3 years 1 year 7 years Practice: Thousands of emergency assessments Senior lecturer clinical decision making Clinical supervisor Secretary General European Psychiatric Nurses

3 Crisis monitoring research informed practice Tailor made practice development Solid implementation strategies

4 Critical debates Ineffective traditions and myths? What can we do to improve safety more consistently? How can we analyse challenging situations more effectively? Implementation of relevant research recommandations? Options to maximize the outcome of learning communities? WARNING! This lecture will not provide solutions and even may confuse you but may hopefully inspire to consider joint actions

5 Some myths in violence management Less coercion results in more aggression More medication results in less aggression More staff results in less aggression What really matters is the therapeutic competences of staff

6 Nijman model (2002) AGGRESIVE INCIDENTS COERCION RISK ASSESSMENT STAFF PATIENT Frequent and systematic riskassessment REFLECTION INTERACTION RIK COMMUNICATION DISCUSSION INTERVENTIONS BEHAVIOUR STAFF BEHAVIOUR PATIENT Reconstruction and analysis crisis episode STAFF CHARACTERISTICS - EXPRIENCE -SEX -ATTIDUDE- -STRESS / COPING - TEAM COHESION WARD -NUMBER OF PATIENTS - ARCHITECTUURE - LOCKED / OPEN - THERAPEUTIC ENVIORMENT - STAF / PATIENT RATIO PATIENT - SEX - AGE -PSYCHOPATHOLOGY - LEGAL STATUS - BACKGROND -- MENTAL STATE Evaluation working diagnosis Refined crisisplan

7 Community mental health teams since 1950 Located in the city to assess and to provide short term intensive care 160 different cultures Case finding and early intervention teams Current national trends: Involuntary admissions have doubled in the last 15 years However the length of admissions have decreased signicantly

8 Estimated risk in mental health care Suicide (2-10%) Aggression (15-25%) Exposure to trauma (30-50%)

9 Around 70% of the patients are involuntary admitted

10 60% were violent just before admission

11 All acute psychiatric wards are locked

12 Identified risk factors at admission (Baseline measurement in 4 acute wards, 183 patients) Suicidal History of self-harm Recent aggressive incident Recent substance abuse History of violence Medication non compliance % Lack of insight Psychotic episode

13 Target of aggression Self harm Objects Visitor Fellow patient Nurses 0% 10% 20% 30% 40% 50% 60% 70%

14 Psychiatric Intensive Care Units very few legal issues

15 Six Core Strategies Kevin Huckshorn: The use of seclusion and restraint (S/R) are high risk, problem prone interventions for both consumers and staff and are to be avoided whenever possible. S/R shall only be used in the face of imminent danger and when unavoidable. Preventing the use of seclusion and restraint is the organizational goal. For all types of managers and clinicians

16

17 Six core strategies 1. Leadership towards organizational change 2. Use of data to inform practice 3. Workforce / practice development 4. Use of Seclusion and restraint prevention tools 5. Genuine service user involvement 6. Structured debriefing techniques (Huckshorn,2004) Readiness to change checklist (Colton,2006) can be an additional support tool

18 Pennsylvania USA study outcomes in (Smith et al,2005) Seclusion episodes reduced fom 4.2 to 0.3 episodes per 1,000 patient days Restraint episodes reduced from 3,5 to 1.2 episodes per 100 patient days. Reduction of the duration of restraint reduced from 11.9 hours to 1.9 hours

19 National requirement to measure coercion in a more refined and consistent way at national level. Janssen,W, Sande van de,r, Noorthoorn,E, Nijman,H, Mulder,CL, Widderhoven,G, Bowers,L, Steinert,T (2011) Monitoring the use of restrictive measures; methodological issues in data collecting, analysis and outcome, International Journal of Law and Psychiatry, 34 (2011)

20 Type of innovations change of attitude therapeutic engagement early recognition intensive care verbal deescalation external consultation risk assessment clinical supervision crisisplans comfort rooms

21 Psychiatric Nursing Research Center Expertise data base Evidence apraisal Expert groups Sharing expertise Forum

22 Areas for practice development Early recognition and harm prevention Safety on the the wards Level of expertise Therapeutic environment

23 Risk assessment modalities Long term Short term History of violence Patientrecords analysis Escalation paterns Mental state Level of agitation Social context Indication and frequency?

24 Risk management principles Under or overestimation of risk can be harmfull for patients and staff Main challenges Combat false positive risk jugdements (Sharkey & Sharples,2003; O Rourke & Bailes, 2006; Doyle & Dolan, 2002; Hawley e.a., 2006) Combat false negative risk jugdements (Kapur e.a., 2000; Simon & Petch, 2002).

25 Maximum benefit of risk assessment Incorparation of risk assessment in clinical practice Dynamic debates led by local clincal leaders Followed by proportionals riskmanagement strategies Consistent linls with (relapse) preventive strategies Contribute to therapeutic value of recovery based care

26

27 Monitoring process Every patient is monitored at the same way from day one until the last day of their admission stay 1. Activities of the patient (program) 2. Psychological functioning 3. Medication (adherence, side effects) 4. ADL (hygienne, nutricion issues) 5. Somatic issues 6. Coercive aspects 7. Family involvement 8. Specific interventions today

28 Scale Kennedy As V BVC BPRS Danger Scale SDAS Focus Global functioning in 8 different domains Assessment of agitation and imminent risk of violence (4 to 16 uur) Severity and compound of psychiatric symptoms Refined asessessment of dangerous criteria acoording the mental health act Assessment of behavioral problems. Clinical relevance To synthesize the strength and waekness in current patient functioning Pro-active support at a day to day level Short term assessemnt of the risk of imminent escalations Evaluation of the treatment provided to combat the severity of speciific psychiatric symptoms. Compare psychiatric problems with current behavioral problems Refine discharge planning and risk taking during the admission To identify the relationship of psychopathologiy and behavioral problems.

29 Problem categorization of the Kennedy Axis V Psychological Impairment Social Skills Violence ADL- Occupational Substance Abuse Medical Impairment Ancillary Impairment Every sub-scale should be rated regularly by nurses Score profiles used to identify recovery and relapse patterns Kennedy, J.A (2003) Mastering the Kennedy Axis V: A New Psychiatric Assessment of Patient Functioning Fundamentals of Psychiatric Treatment Planning, Second Edition Washington, D.C., American Psychiatric Publishing, Inc., 2003, Faay, M, van de Sande, R, Gooskens,F, Hafsteinsdottir, T (2012) The Kennedy Axis V: clinical properties assessed by mental health nurses, accepted for publication, International Journal of Mental Health Nursing

30 This approach raises the awareness on symptom changes and different needs for care levels

31 Research design CrisisMonitor project Baseline measurement (10 weeks) Cluster randomization Experimental wards Controle units Risk assessment training CrisisMonitor Outcome: Seclusion hours Violent incidents Clinical jugdement

32 SDAS (Wistedt, et al,1990) 1. Verbal aggression 2. Directed verbal aggression 3. Agitation SDAS assessment every week 4. Negativism 5. Anger Severity scores 0 >4 6. Social disturbing behavior 7. Physical violence to staff 8. Physical violence to others 9. Self Harm 10. Psychical violence to objects 11. Suicidal thoughts or tendency to suicidal behavior

33

34 Validation study BVC / Kennedy Axis V Sample: 7403 risk assessments during admission days (72% full data coverage) in 301 acute patients during a 12 month research period (66% was involuntary admitted and 28% experienced seclusion). Methods: Multi-level logistic regression analysis (stepwise forward and backwards procedure,stata software version 12) Conclusion: dysfunctional scores regarding confusion, psychological problems and social skills are at risk of seclusion within a few hours. Both instruments support pro-active riskmanagement. Result of replication multicenter research are expected soon.

35 Next steps After tested the Crisis Monitor approach and tried to minimize the bias of other intervention we needed to take care of the risk that the intervention would loose it s clinical relevance. Therefore nurses were invited to come up with smart options to maximize the use of the Crisis Monitor approach.

36 Indirect project concequences No new ideas when the teams are only surviving violence and get burned out. Reduction of violence and coercion made room for a culture shift from containment focus towards engagement and therapeutic values Nurses gained more recogntion for their work and were invited to experience international exchange initiatives with other acute psychiatric care New vision of care and care programmes were developed Contious education and clinical supervision program was implemented

37 Towards integrated care Frequent and systematic risk assessment Pattern analysis and crisis reconstruction Evaluation of the working diagnosis Seemless crisisplans

38 Consolidation challenges If you use scales just to score, better leave it Better use them as a common language If clinical leaders ignore the ratings, start serious talking Use them to evaluate your actions and incidents Translate scores into clinical relevant language Human beings are unique so is the meaning of risk profiles Discuss monthly coercion figures in relation to risk profiles Involve every new collegue in the risk management system Apoint clinical supervisors and external auditors Continious education and critical reflections are mandatory

39 Decreased number of seclusion rooms Reduction of the number of seclusion rooms (above 50 %) in the last 5 years ) 2011 compared with % seclusion time reducation.. Seclusion immidiate at admission is getting rare and in some days there is no seclusion room occupied at all.

40 Severe verbal aggression Engagement by two nurses Risk appraisal 1 De-escalation actions Check the stress of the nurses Agression : affective or instrumental? Current BVC en Kennedy ratings? Move to save position Choose who will take the lead Garantee savety of others Positive instructions toward the patient. Limit setting challenging behavior. senior nurse can overrule current strategy Stable now? 2 escalation Physical aggression Verbal aggression continious Follow scheme: Physical aggression Crisis plan Phase 1 or 2 Use crisisplan Phase 3 or 4 Restoring contact CrisisMonitor assessment again Inform other disciplines about the outcome. Evaluatiion of the risk factors Discuss the findings with the patient Change or validate the treatment plan Close observation Limit setting External consultation Multi-disciplinairy rapid response policy

41 Towards therapeutic engagement Some alternatives explored

42 Comfort rooms Research from the USA and the Netherlands reveals that comfort rooms (self management) can be important stress reduction aids and can lead to less conflicts and aggressive behavior (Champagne & Stromberg, 2004, de Veen, et al, 2009, Noorthoorn et al, 2010, Cummings et al,2010, Sivak et al,2012). However USA studies also report that comfort rooms are not really helpful for 10% of the acute psychiatric ward patients. Comfort rooms should always be unlocked and are never used to have stressfull conversations.

43

44 Area to have privacy with family

45 Occupational therapy for everyone

46

47 10% patients need intensive care Several psychiatric intensive care experts in Europe argue that realistically the space to experiment with some high risk profile patient is limited. Therefore frequent riskassessment is need to refine treatment planning. (Pereirra et al, 2006). Most PICU studies look promising but are mostly small scale studies and in majority purely descriptive and lack until now RCT findings (Bowers et al,2008). The aim of some Dutch hospitals is to develop evidence informed intensive care and to avoid excluding patients in civil psychiatric settings. This will mean education, research and long term practice development

48 Final reflections ( ) Risk profiles can change rapidely in acute psychiatric wards Short term risk assessment can enhance safe practice Supports risk taking and risk control in the acute phase Can help to evaluate new ward policies empirically Can be a support care planning Scales can never totally replace clinical jugdement Teams need consistent and prolonged clinical supervision Trauma informed practice is getting more structured Intensive Psychiatric Care programs are under development More solid research projects are still needed!

49 THANK YOU! Contact: