Trust Policy and Procedure Document ref. no: PP (17)220 Restrictive Physical Intervention and Breakaway procedure & Guidance Policy For use in: For use by: For use for: Document owner: Status: WSFT All Staff Management of Violence and Aggression Health Safety and Environmental Committee Approved Contents Page Introduction 2 Policy Statement 2 Policy Aim 2 Scope and Application 2 Definition 2 Restrictive Physical Intervention 2 Responsibilities 3 Principles of Physical Intervention 4-5 Prevention and Management 5 The Environment 5 Behaviour and Underlying Condition (Clinical Cause) 5-6 Mental Capacity 6 Duty of Care 6-7 The Use of Restrictive Physical Intervention 7 Planned Physical Interventions 7 Unplanned or Emergency Physical Interventions 7 Restrictive Physical Intervention Team (RPI Team) 7-8 Violent/Aggressive Patients and the Use of Physical Intervention 8 Prolonged Intervention 8 The Wandering Patient 8-9 Recording and Monitoring 9-10 Post Incident Management 10 Training 10 Reference and Further Guidance 11 Appendix A Switchboard Action Card 12 Appendix B Incident Flow Chart 13 Appendix C Crisis / Physical Intervention Record 14-15 Appendix D Clinically Confused Flow Chart 16 Appendix E 5 Principles Which Underpin the Mental Capacity Act 17 Source: Security Manager Status: Approved Page 1 of 17
1. Introduction 1.2 Policy Statement Policy: Restrictive Physical Intervention and Breakaway Physical Intervention should be seen as one in a range of strategies and actions to help staff to address the needs of individuals whose behaviour poses a serious challenge to provided services. The West Suffolk NHS Foundation Trust recognises that due to clinical cause patients may at times and in certain circumstances behave in a violent and aggressive manner. Where prevention has not been successful, physical intervention may be necessary to protect the safety of the patient or other parties involved. Restrictive physical intervention inevitably affects the personal freedom and choice of the individual. It should be used as infrequently as possible and in the best interests of the patient. Where it is used everything should be done to prevent injury and maintain the individual s sense of dignity. 1.3 Policy Aim The Policy is designed to ensure individuals with challenging behaviours are treated with respect, care and dignity: especially when they are behaving in ways, which might be harmful to themselves or others and as a result require physical intervention from staff. By using this policy assistance will be given to staff to act appropriately and in a safe manner, so ensuring effective responses to difficult situations. It also provides clear guidance of the role of physical intervention and its appropriate use and the circumstances in which the trust will facilitate its use. 1.4 Scope and Application This policy applies to all employees of the Trust, and all personnel working on Trust premises, permanently or otherwise. 1.5 Definition This guidance is specifically concerned with: Restrictive Physical Interventions: a skilled hands-on method of physical restraint involving trained designated healthcare professionals to prevent individuals from harming themselves, endangering others or seriously compromising the therapeutic environment. Its purpose is to safely immobilise or restrict the individual involved. 1.6 Restrictive Physical Intervention can be employed to achieve a number of different outcomes: To prevent a patient from causing themselves or others physical harm To breakaway or disengage from dangerous or harmful physical contact initiated by a patient without inflicting pain or injury. To separate an individual from a possible trigger. To protect a patient from a dangerous situation for example, a busy road. Source: Security Manager Status: Approved Page 2 of 17
2. Responsibilities As the accountable officer, the Chief Executive has the ultimate responsibility for ensuring compliance with the Health and Safety at Work Act 1974 and the Management of Health and Safety at Work Regulations 1999. In line with the Secretary of States Directions, the Trusts Security Management Director (SMD) will lead on all security management work. The Trusts Local Security Management Specialist (LSMS) is responsible for ensuring compliance with the policy and the day-to-day implementation of its use. Reviewing the policy and amending when required. The LSMS is responsible for overseeing the implementation and attendance of all RPI Team members, to all training and subsequent refresher courses 2.1 Ward Managers / Senior ward Staff are responsible for ensuring that Patients and their relatives or carers are fully informed of the Trusts policy on physical intervention, and in particular how it relates to the individual concerned. The possibility of using restrictive physical intervention should be discussed, where ever possible, by the patients medical team and the patients relatives / care home, with a view to obtaining approval for said intervention, and this should be recorded in the patient s documentation. 2.2 All Ward Staff Pre / Post RPI Call Out 2.2.1 Ward Staff need to consider if all efforts to establish control of the situation have been made. 2.2.2 Once the decision to call the RPI Team has been made the ward staff need to identify the qualified nurse who will receive the team and conduct a handover to the RPI Team on their arrival. 2.2.3 A member of the ward staff is required to remain throughout the RPI Team s attendance to ensure the patient has consistent access to the clinical team and communication is maintained. Where possible these people should be known to the patient and have the ability to engage effectively with the individual. 2.2.4 The clinical team maintain a duty of care to the patient and established rapport is paramount when situations have escalated and that staff are trying to assist the patient in gaining control of their behaviours and immediate situation. The identified member of the ward staff should attempt to maintain a rapport where possible as long as this is having a positive effect on the de-escalation process. 2.2.5 The clinical team will be responsible for recording any RPI actions in the patients records / notes. 2.2.6 The Clinical team MUST continue to monitor the patient s vital signs, after the RPI team has been stood down. Making sure that no deterioration to the patient health occurs due to the intervention of the RPI team. Source: Security Manager Status: Approved Page 3 of 17
2.3 All ward Staff on RPI Attendance The RPI Team will require a handover from a qualified nurse on arrival. The following standard information is required; 2.3.1 Nurse name and role that will remain with the situation to support the RPI Team and the patient. In situations where physical intervention might be used and in the event of injury or physical distress arising, the designated nurse will be required to monitor the patients health. 2.3.2 Patients preferred name. 2.3.3 What is the relevant background to the current situation. 2.3.4 What is the immediate situation and what has been tried previously to contain or prevent the situation. 2.3.5 Are there any immediate issues and or risks to consider e.g. a history of aggression. 2.3.6 Does the patient have any known vulnerabilities for example; a mental health condition, dementia, a heart or chest condition. 2.3.7 Does the person have any sensory deficits for example hearing or sight reduction. 2.4 RPI Team s Responsibilities upon Arrival The first team member to arrive at the scene will assume the role of team leader and ask for a handover via a qualified nurse. The Team leader will ask for the name and role of the nurse who will remain with the situation to support the RPI team and Patient as per 2.3.1. The team will then undertake a dynamic risk assessment and take the appropriate action. 2.5 Occupational Health Are to ensure that all staff who participates within the team are fit to complete the training and carry out the role. All those who experience the use of physical intervention should if appropriate be offered the opportunity to influence the development of management strategies. They should also be offered the opportunity to discuss the way staff have responded to the particular behaviours, and to express their concerns and preferences about future management. 3. Principles of Physical Intervention The inappropriate use of physical intervention may give rise to criminal charges or action under civil law or prosecution under health and safety legislation. Restrictive interventions should only be used when other strategies have been tried and found to Source: Security Manager Status: Approved Page 4 of 17
be unsuccessful or, in an emergency, when risks of not employing a restrictive intervention are outweighed by the risks of using force. The decision to use a restrictive physical intervention (RPI) must take account of the circumstances and be based upon an assessment of risks of not employing a restrictive physical intervention. An RPI must also employ a reasonable amount of force that is needed to avert injury, or damage to property, applied for the shortest amount of time. The scale and nature of any physical intervention must be proportionate to both the behaviour of the individual patient to be controlled and the nature of the harm they might cause. These judgements have to be made at the time, taking due account of all the circumstances, including any known history of other events involving the individuals to be controlled. The minimum necessary force should be used and the techniques deployed should be those with which staff involved are familiar and able to use safely from training provided. Only staff trained in the use of physical intervention should use these techniques, except in an emergency situation where it may be necessary to protect the safety of staff and service users. RPI should only be used to achieve outcomes that reflect the best interests of the patient and others affected by the behaviour requiring intervention. 4. Prevention and Management Before the use of physical intervention all patients should be subject to a regular updated comprehensive risk assessment that considers the risk of challenging behaviour and documents preventative strategies and, wherever it is foreseeable that the use of RPI might be required, said assessment would be an integral part of the patients Care Plan, thus reducing the risk to themselves, other patients and staff. This should consider: The environment Patients behaviour Underlying condition and treatment Patients mental capacity Duty of care 5. The Environment The care environment can have either a positive or negative effect on patients. Every effort should be made to reduce the negative impact of the environment where possible. Examples could include staffing shortages impacting on quality care or levels of supervision, restricted observation in patient areas, high levels of noise or disruption, boredom or lack of stimulation for patients and negative attitudes/poor communication skills of staff. 6. Behaviour and Underlying Condition (Clinical Cause) Understanding a patient s behaviour and responding to an individual s needs should be at the centre of patient care. Identifying the underlying clinical cause of behaviour (agitation, wandering etc.) and deciding whether the behaviour needs to be prevented is essential. Possible Clinical causes to consider are: Source: Security Manager Status: Approved Page 5 of 17
Hypoxia Hypotension Pyrexia Need to empty bowel or bladder Pain or discomfort Electrolyte or metabolic imbalance Anxiety or distress Mental illness e.g. dementia Other form of memory impairment Drug / Alcohol dependency or withdrawal Brain injury or cerebral irritation Reaction/side effect of medication Intoxication (due to alcohol, drug overdose or drug abuse) If a mental health patient has an underlying physical illness then this may require treatment within an acute general environment. This is not always ideal for a patient with mental health issues. The challenge is always to get a timely Psychiatric review, however if the patient has required sedation this process may be delayed. This category of patient may require a Police presence to deal with any ensuing problems. The confused elderly patient, who may be abusive and or violent, may benefit from the early intervention of the Pyschogeriatricians and the establishment of a tailored RPI plan to suit the individual patient. Although behaviour e.g. wandering can be problematic with staff, this does not necessarily mean that preventing the behaviour is in the best interests of the patient concerned. Having identified the reason for the behaviour a decision should be made on the appropriate preventative strategies. Preventative strategies should be fully documented in risk assessments, Care Plans etc. and agreed with the patient, relevant departments/agencies and relatives where appropriate. They should include strategies for preventing the occurrence of behaviours, which precipitate the use of physical intervention. All staff must be aware of these strategies. (See Policy: Management of violence and aggression, item 2.0 Prevention) 7. Mental Capacity It is necessary to consider the patients mental capacity, and when the patient lacks capacity to consent, the use of physical intervention techniques must, wherever possible, be discussed with the patient s relatives or carers and their agreement gained. Staff must always act in the best interests of the patient and the least restrictive means used to keep the patient safe (See Mental Capacity and the use of IMCAs Trust policy) A mental capacity issue relates to a single point in time and to a specific decision. Individual patients cannot simply be described as lacking capacity. A patient s capacity may fluctuate. (See appendix E & F) Source: Security Manager Status: Approved Page 6 of 17
8. Duty of Care All Health care staff have a duty of care for patients. This means acting in their best interests. In relation to a patient who is at immediate risk of harm, physical intervention may be part of the duty of care. The Trust also has a duty of care to its employees who must be conscious of their own personal safety within their working environment and of their responsibility to avoid placing themselves or others in a vulnerable position. 9. The Use of Restrictive Physical Intervention Wherever possible restrictive physical interventions should be used in a way that is sensitive to, and respects the cultural expectations of customers and their attitude to physical contact. Any restrictive physical interventions should avoid contact that might be misinterpreted as sexual. Patients must not be deliberately restrained in a way that impacts on their airway, breathing or circulation. The mouth and/or nose must never be covered and techniques should not incur pressure to the neck region, rib cage and/or abdomen. There must be no planned or intentional restraint of a person in a prone/face down position on any surface, not just the floor. If a person is restrained unintentionally in a prone/face down position, staff should either release their holds or reposition into a safer alternative as soon as possible. This policy makes clear that face down restraint, or other restraint which blocks breathing or circulation, is not acceptable and should never be used deliberately. 10. Planned Physical Interventions The plans should detail Strategies for preventing the occurrence of behaviours, which precipitate the use of physical intervention. Strategies for de-escalation or diffusion, which can avert the need for physical intervention. Any specific techniques, which it would normally be appropriate to use. Incorrect practices that might expose customers or staff to risk of injury or psychological distress. Procedures for post incident support and de-briefing for staff, patients and their relatives. Situations in which it is reasonable to use physical intervention as the least intrusive method, which is consistent with the safety of staff and patients. 11. Unplanned or Emergency Physical Interventions Unplanned or emergency physical interventions should only be used in response to unforeseen events. Source: Security Manager Status: Approved Page 7 of 17
12. Restrictive Physical Intervention Team (RPI team) The Trusts RPI team will comprise of bleep holders to form a rapid response unit, which will operate 24/7 (24 hours a day, seven days per week) The team will consist of a minimum of three persons. All nominated members will be trained in conflict resolution, breakaway skills and restrictive physical intervention techniques The team members will be volunteers from all staff groups. The team will elect a leader for each call out, and in line with the approved training module, it will be their responsibility to direct the team s response when dealing with the incident. The Team leader will also be responsible for ensuring that a RPI record form (see appendix C), is completed in detail. Those call outs requiring no action will be recorded with the patients` details and annotated with a No Action Required comment. 13. Violent/Aggressive Patients and the Use of Physical Intervention If staff are confronted by a patient/relative/member of public who is using or threatening violent and aggressive behaviour they should, if safe to do so, attempt to use conflict resolution skills and call 2222 and request assistance. If staff, patients or other members of the public are at risk immediate police attendance should be requested. Any relevant details and circumstances should be provided with the call. (See SWB Action Card Appendix A) If a patient, who is violent and or aggressive, confronts staff they should attempt to contain and defuse the patient using conflict resolution skills and knowledge gained from the initial risk assessment. The RPI team should be called as an additional option to resolve the matter and assist with physical skills if appropriate. (See Flow Chart Appendix B) 14. Prolonged Intervention When a patient s condition results in long periods of sustained aggression; one-to-one Specialist intervention may be considered. (See appendix D for procedure). The following links may be required should the ward not have a DoLS form. Adult Safeguarding Micro-site - http://staff.wsha.local/intranet/microsites/safeguarding/safeguarding.aspx DoLS Forms - http://staff.wsha.local/intranet/microsites/safeguarding/adults/safeguardingadultsforms/safeguarding VulnerableAdult.aspx Observation of patient: One to Onehttp://staff.wsha.local/Extranet/ClinicalGuidelinesandProtocols/CG10280-Observation-of-Patients,one-to-oneobservation.pdf Source: Security Manager Status: Approved Page 8 of 17
15. The Wandering Patient There are several reasons, why a confused patient may wander from their clinical care area. (Guidelines for the assessment and /Management of said patients can be seen in annex F of the Management of Violence and Aggression policy and Nursing Guideline B33). Attempting to achieve the safe return, of said wandering patients, back to their clinical care area may induce an aggressive/ violent reaction and the following guidelines have been developed to facilitate this procedure. Should the location of the patient not be known, the Missing Person policy should be employed (PP131). When the location of the confused, wandering, patient is known, two staff members, from their clinical care area, should be dispatched to the location. If possible the attending staff should be familiar to the patient. The Portering Supervisor should be contacted, via ext. 3522- Pager 959, and asked to arrange for a wheelchair to be dispatched to the patient s location. (If an emergency situation please use 2222) The attending staff should then endeavour to persuade the patient to return to their ward, either on foot or via the wheelchair. During this process a sympathetic and understanding demeanour should be employed, however not all patients will respond to this approach and further assistance may be required. Failure to get the patient to co-operate and return to the ward, one staff member should stay with the patient, whilst the other contacts Switchboard via 2222 and gives a brief scenario of the problem asking the operator to contact the Restrictive Physical Intervention (RPI) Team. This will activate the attendance of a three-person team who will assist the medical staff, using trained physical intervention techniques to return the patient back to their clinical area. Should there be only one member of the ward staff, attending the patient, and the patient becomes aggressive and refuses to cooperate, the attending staff should endeavour to attract the attention of other Trust employees and ask them to phone 2222 and summon help on their behalf. If possible, without endangering the patient or attending staff, it would be good practice to contact relatives, or care home staff members, who may be familiar to the patient (living relatively close to the hospital) and request that they attend the hospital with a view to defusing any possible volatile situation. 16. Recording and Monitoring The use of restrictive physical interventions must always be recorded on the restrictive physical intervention record form (Appendix C). The report must include: The names of staff The patient involved, including their CRN number, DOB and address. Source: Security Manager Status: Approved Page 9 of 17
The reason for using physical intervention rather than another strategy. The type of physical intervention employed. The date and duration of the physical intervention. Whether the patient or anyone else experienced injury or distress and, if they did, what action was taken? The views of the patient involved and family, where appropriate. Staff have a responsibility for the recording, monitoring and review of local physical intervention. This should be done in partnership with managers, using the Trust incident reporting form and the Restrictive Physical Intervention Team (RPI) debrief form to assess performance and identify ways of improving the overall response. Unlawful offences should be reported to police via usual channels (see Management of V & A policy) 17. Post Incident Management The use of physical interventions can be both physically and emotionally demanding for both patient and staff. Following an incident both staff and patient s welfare should be imperative. Both parties should be given separate opportunities to talk about what happened in a calm and safe environment. Post incident interviews/debriefs should be used to determine exactly what happened, the effects on the participants and their support needs. Said debriefs to be conducted by the relevant Manager, the Physical Intervention Team Lead, and a representative from Occupational Health. 18. Training Under the Health and Safety at Work Act etc 1974, the Trust is responsible for the health, safety and welfare of all those present on the premises. This requires employers to assess risks to both employees and others from work activities, including physical interventions. Employers should also establish and monitor safe systems of work (Standard Operating Procedures) and ensure that employees are adequately trained. Training must be provided for staff members that are regularly required to use physical interventions. It is the Local Security Management Specialist s responsibility to ensure employees are suitably selected, trained and familiar with intervention techniques. Staff must be competent in the following and have been passed as fit by Occupational Health, prior to using physical interventions. Policy on Management of Violence and Aggression Conflict Resolution skills Breakaway skills Emergency First Aid skills (Resuscitation, Recognition of Possible Symptoms, and how to place a patient in the Recovery Position). Occupational Health to provide said training. The purpose and principles of using only the minimum physical intervention necessary to protect patients, staff and others The means of achieving this without unnecessary injury The physical intervention techniques identified for use with individual patients and the situations where these are likely to be applied Source: Security Manager Status: Approved Page 10 of 17
It is imperative that an audit trail is maintained of who has attended training. After Initial training, six monthly refresher training must be provided and all selected staff attends to maintain practical competency and up to date knowledge in relation to policy and legislation. References and Further Guidance Author(s): Darren Cooksey LSMS Other contributors: WSFT Lead Nurses Approval and endorsements: Health and Safety Committee Consultation: Issue no: 6 File name: PP(17) 220 Restrictive Physical Intervention and Breakaway procedure & Guidance Policy Supersedes: PP(16)220 Equality assessed: Yes Implementation: Distribution to all Managers, Published on Intranet Monitoring: (give brief details The implementation of the policy will be on an ongoing, constant basis by the LSMS. Trust incident how this will be done) forms will create audit trail along with RPI activation debrief hard copy. All incidents to be reported to the Trusts V&A Panel, which will be monitored, by the Security Group with the expectation of a year on year Other relevant policies/documents and references: Additional information: reduction in assaults against staff. Management of violence aggression policy PP 082; Department of Health Guidance for Restrictive Physical Interventions; Physical Interventions: A policy Framework (BILD1996); Physical Interventions With People With Intellectual Disabilities: Staff Training and Policy Frameworks (Jan 2003); N.I.C.E Clinical Practice Guidelines; Violence: The short-term management of disturbed/ violent behaviour in Psychiatric inpatient settings and emergency departments (Feb 2005). Source: Security Manager Status: Approved Page 11 of 17
Appendix A SWITCHBOARD ACTION CARD Receive and Log Time Name of Caller Location of Caller Incident Details, why RPI is required Patient s Name Patient s CRN No. Ward No. Last Known Location Name of Staff Member with Patient Time of RPI Call out Activated Source: Security Manager Status: Approved Page 12 of 17
Appendix B INCIDENT FLOW CHART Commencement of Incident Call 2222 Request RPI Attendance And give Concise Details of Problem Switchboard Call Out of RPI RPI Arrive at Incident Point Assess and Deal Incident Debrief Complete debrief Form Submit to RPI team manager for signing off Source: Security Manager Status: Approved Page 13 of 17
West Suffolk Hospital NHS Trust Appendix C RECORD of RESTRICTIVE PHYSICAL INTERVENTION One form to be completed in full for each Restrictive Physical Intervention Incidents Date: Patients Addressograph Time From:..To... Ward / location :.. Names of RPI team attending: / / / / / Name of Medical Staff Present: Clinical Duty Manager Attended: YES / NO - Name: About the patient (complete all sections) Patient Condition: Dementia, Detox, Mental Health, Confusion, UTI, Learning Disability Other (please state) Intervention required: None, Talk Down, Guided Escort, Light Restraint, Full Restraint Restraint started at: Restraint ended at: or Not applicable Was medication given during the RPI intervention: YES / NO Is the Patient subject to the Mental Capacity Assessment (MCA): YES / NO Is the Patient subject to a Deprivation of Liberty Safeguards (DoLS): YES / NO Has a One to One request been made: YES / NO Reason for RPI team Attendance:. About the intervention used: (must be complete for any form of hands on) If Guided Escort, Light or Full restraint was required please identify which team member was assigned to : Left hand side (Arm).. Right hand side (Arm) Left leg Right leg... Head... Source: Security Manager Status: Approved Page 14 of 17
West Suffolk Hospital NHS Trust As a consequence of the intervention: As a result of any restraint was there any injury, bruising or reddening of the skin sustained to the patient Yes / No / Not Applicable If YES provide Details:..... Did a member of the medical staff examine the injury: Yes / No / Not Applicable Staff Members Name: Details of incident: Please continue on separate page if required. This document could form part of an internal or external investigation, all information contained MUST be an accurate reflection of what happened. By signing this document you confirm that all details contained within are accurate to the best of your knowledge. Name: Signature:.. Security Manager: Darren Cooksey, LSMS Source: Security Manager Status: Approved Page 15 of 17
West Suffolk Hospital NHS Trust Appendix D SECURITY SPECIALIST ONE-TO-ONE ASSESSMENT ASSESS PATIENTS LEVEL OF AGGRESSION IS THERE AN ONGOING RISK TO STAFF AND PATIENT SAFETY? IS THE PATIENTS AGGRESSION LIKLEY TO BE SUSTAINED? CONTACT THE PATIENTS DOCTOR/ REGISTRAR/ CONSULTANT AND ASK FOR HIS ADVICE RE THE PATIENTS MEDICAL/ MENTAL CONDITION AND THE POSSIBILITY OF SPECIALIST SUPERVSION NEEDS? CAN THE SITUATION BE RESOLVED BY CONFLICT RESOLUTIO/ SEDATION/ RPI INTERVENTION? IF THE ANSWER IS NO IMMEDIATLEY REQUEST THAT A DEPREVATION OF LIBERTY FORM IS COMPLETED. DOES THE COMPLETED FORM INDICATE THE NECESSITY FOR SPECIALIST HANDS ON ONE-TO ONE SUPERVISION? CONTACT THE CLINICAL DUTY MANGER (PAGER 888) AND ENSURE THAT CORRECT PROCEDURE HAS BEEN FOLLOWED AND THAT ONE TO-ONE SPECIALIST SUPERVISION IS REQUIRED IMPORTANT TO NOTE THE SPECIALIST TEAM WILL TAKE TWO HOURS TO ARRIVE FROM INITIAL POINT OF CONTACT. SPECIALIST SUPERVISION REQUIRED; TAKE THE FOLLOWING ACTIONS. IN HOURS CONTACT THE SECURITY MANAGER (PAGER 320) /ASSISTANT MANAGER (PAGER 321) AND REQUEST THE SPECIALIST TEAM OUT OF HOURS CONTACT DUTY SHIFT PORTERING SUPERVISOR (PAGER 959) TO REQUEST THE SPECIALIST TEAM STAND DOWN CONTACT THE SECURITY MANAGER (PAGER 320) /ASSISTANT MANAGER (PAGER 321) AND REQUEST THE SPECIALIST TEAM TO STAND DOWN STAND DOWN CONTACT DUTY SHIFT PORTERING SUPERVISOR (PAGER 959) TO REQUEST THE SPECIALIST TEAM STAND DOWN Source: Security Manager Status: Approved Page 16 of 17
West Suffolk Hospital NHS Trust Appendix E Source: Security Manager Status: Approved Page 17 of 17