Older Adults Division: Extra Care Suite Procedure

Lincolnshire Partnership NHS Foundation Trust (LPFT) Older Adults Division: Extra Care Suite Procedure DOCUMENT VERSION CONTROL Document Type and Title: Older Adults Division Service Protocol: Extra Care Suite Operating Procedure. Authorised Document Folder: Service Operational Protocols New or Replacing: Replacing V1.1 Document Reference: Version No: V2 Date Policy First Written: November 2016 Date Policy First Implemented: January 2017 Date Policy Last Reviewed and Updated: August 2018 Implementation Date: September 2018 Author: Approving Body: Steven Roberts Division Manager, Dawn Parker: Quality Lead. Older Adults Divisional Management team Approval Date: August 2018 Committee, Group or Individual Monitoring the Document Older Adults Divisional management team (DMT) Review Date: September 2021 O A D D e - e s c a l a t i o n P r o t o c o l Page 1

Older Adults Division Standard Operating Procedure for use of Extra-Care Suites (De-escalation Area) Steven Roberts Divisional Manager, OAD Dawn Parker Quality Lead OA Deborah Blant Service Manager Inpatient Services, OAD January 2017 O A D D e - e s c a l a t i o n P r o t o c o l Page 2

Contents 1: Introduction 2: Purpose of the Operating procedure: 2: Definition of De-escalation 4: Extra Care Suite Environment 5: Staffing 6: De-escalation Pathway 6.1: Primary Intervention 6.2: Secondary Intervention 6.3: Tertiary Intervention 6.4: Following successful de-escalation 7: Monitoring APPENDIX 1: Audit and review standards APPENDIX 2: Clinical examples to support assessment APPENDIX 3: A-B-C Chart APPENDIX 4: Proactive Care De-escalation Pathway O A D D e - e s c a l a t i o n P r o t o c o l Page 3

1: Introduction: The protocol applies to and supports practice within all Older Adult Division (OAD) in-patient wards and within the remit of broader Trust policy and protocol. To this end the guidance below supplements and should be considered within the context of the broader standards set out in: The OAD Admission and Discharge protocol. The LPFT Clinical Care Policy: with specific reference to: o Section 16: Supervision confinement o Section 17: Identification, treatment and management of people with challenging behaviour, violence and aggression. Further, with specific regards dementia care wards this protocol should also work in line with and as part of the OAD Dementia Clinical Assessment and Intervention pathway. 2: Purpose of the Operating Procedure: The primary purpose of procedure is to: To clearly define the remit and nature of de-escalation. Ensure the correct and appropriate use of the designated Extra Care Suites (ECS s) across OAD in-patient wards, by detailing the conditions and processes for its use Provide clarification on the distinction between the use of the de-escalation room and when this becomes de-facto seclusion episode. Ensure that there is a consistent approach to the use of the ECS s across the OAD. Improve staff and patient safety by providing a framework for the correct use of the Extra Care Suite. This serves to emphasise and encourage the use of the enhanced care room as less restrictive option in the management and support of disturbed / escalating behaviour. 3: Definition of De-escalation: The Code of Practice (2008) describes de-escalation as a secondary preventative strategy. It involves the gradual resolution of a potentially violent or aggressive situation where an individual begins to show signs of agitation and/or arousal that may indicate an impending episode of behavioural disturbance (See Appendix 4 for indicators to escalation of risks). De-escalation strategies promote relaxation, e.g. through the use of verbal and physical expressions of empathy and alliance. They should be tailored to individual needs and should typically involve establishing rapport and the need for mutual co-operation, demonstrating compassion, negotiating realistic options, asking open questions, demonstrating concern and attentiveness, using empathic and non-judgmental listening, distracting, redirecting the individual into alternate pleasurable activities, removing sources of excessive environmental stimulation and being sensitive to nonverbal communication. Key objectives include: O A D D e - e s c a l a t i o n P r o t o c o l Page 4

Achieve de-escalation without having to remove the patient from other patients and the communal area for any length of time; although it is recognised that in some cases this may be necessary. A patient s anger or disturbed behaviour being treated with an appropriate, measured and reasonable response. De-escalation techniques being used before other interventions and should continue to be used even if other interventions are necessary. In contrast to de-escalation, healthcare professionals must be aware that the following situations should be viewed as an incident of supervised confinement (i.e. de-facto seclusion). Placing a patient in a room with the door locked Placing a patient in a room with the door held shut Placing a patient in a room which his or her ability to leave is somehow restricted e.g. by suggesting that any attempt to leave the room will result in physical restraint or compulsory medication or other means. Separating a patient from the group although not necessarily by physical walls The older adult ECS s must not be used in a manner that equates to/meets the definition of supervised confinement (See Trust Clinical Care Policy section 16: Supervised Confinement) 4: Extra Care Suite environment As set out in the Trust Clinical Care Policy (section17.7: De-escalation rooms) each in-patient facility should have a room or area designated specifically for the purpose of reducing arousal and agitation. In the OAD these rooms are the Extra Care Suites (OCS s). The purpose of the ECS is to reduce the agitation in the client and to prevent a violent incident escalating. The environments of the ECS s is essential to ensuring that the space is fit for purpose and works as a partner in care in terms of the process of de-escalation. Herein the room environment needs to provide a safe and stimulation appropriate environment. As a minimum all ECS s should have: A settee that enables staff trained in physical interventions to perform the designated teamwork and de-escalation transfers (three seats wide and be sited against a wall). A mat in front of the sofa of suitable specification to support safe RI s. The room should remain free from clutter and ligature risk. The door furniture (lock) will enable the door to be locked from the outside when the room is not in use, but must allow those inside the room to leave without a key. The room should contain additional equipment (e.g. punch bag / bean bag/sensory equipment) that will allow staff to work therapeutically with the patient/the patient to appropriately vent their feelings. Access to and use of such equipment, will be strictly supervised by staff. O A D D e - e s c a l a t i o n P r o t o c o l Page 5

5: Staffing: The provision of staffing to support de-escalation is dynamic and will need to be determined based upon a number of considerations. Key amongst these is that: A suitable number of staff will escort the patient to the ECS the number will need to be decided based on a clinical assessment of the risks to all involved. The patient should not be left alone in the ECS (see section 3) and the clinical team should be aware of the risks of escalation and have a clear care plan to support the patient and staff members should escalation occur. For patient identified to present risks of a level that may necessitate the implementation of de-escalation and/or restrictive interventions there should be, as part of the patient careplan, a positive behaviour safety (PBS) plan (see section 6) which outlines the potential triggers and interventions that will support the patient who is distressed. This should be used to assist identify appropriate and safe staffing requirements/levels. 6: De-escalation pathway: A proactive care/de-escalation pathway algorithm is shown in Appendix 4. The algorithm illustrates the pathway for the management of an individual s distressed, disturbed or potentially harmful behaviour. The pathway consists of 4 core steps, these are; 1. Primary intervention: Early recognition. 2. Secondary intervention: De-escalation. 3. Tertiary intervention: The use of Restrictive Interventions (RI s) 4. Return to communal areas. After successful de-escalation. This stepped approach provides a framework to both support clinical practice and to inform the structure and content of patient individualised care plans. They do this by supporting understanding of the context and meaning of behaviour in order to identify appropriate therapeutic actions and interventions. The key elements of the stepped pathway include; 6.1: Primary Intervention: Early Recognition (assessment, engagement, prediction) The purpose of primary intervention is for the management of distressed, disturbed or harmful behaviour based on preventative strategies for high quality care, patient experience and the forming of therapeutic relationships. At this stage recognition, assessment, engagement and prediction early in a patient s admission is critical. Key primary actions include*: Detailed/comprehensive individual history taking at the point of admission inclusive of key biographical information. This should include the clear formulation of primary patient needs/objectives for admission as set out in the OAD Admission and Discharge Protocol (section 6) Staff should liaise with individuals and those who know their patient well, and take into account subsidiary information, formal clinical assessments, to identify individualised key triggers (see Appendix 2 and Appendix 3) and or individual/biographical/diagnosis-based factors that may trigger escalations in behaviour. O A D D e - e s c a l a t i o n P r o t o c o l Page 6

Alternate strategies/de-escalation approaches which can better meet and address the presenting individual needs identified should be recorded as preventative strategies in the individual s care plan. Patients identified as being at risk of disturbed or violent behaviour should be given the opportunity to have their views and wishes recorded in relation to these high risk behaviours as early in their admission as possible, with these clearly included in the patient care-plan. Patients and carers should be encouraged to review their wishes with staff from time to time and any changes should be recorded. *With regards patient engagement assessment of mental capacity status and associated consent should be considered in reference to engagement of the patient and/or NoK/carers. A care plan should be used to facilitate, structure, and encourage patient participation in this process. Using a care plan and taking into account a patient s wishes and views where are able will support patients and/or carers to identify as clearly as possible triggers to escalation and which interventions they find most helpful in helping them to manage their feelings of anger, frustration and their potential for aggressive behaviour. They should also be helped to identify which they would prefer to be used and at what point. This will then inform the patient s individualised care plan. In particular the patient s preferred choice of rapid tranquilisation; physical intervention should be explored and recorded at a time when the patient is able to discuss these things. It is unlikely that full and considered discussions will be possible at the time these interventions are required. NB: A hard copy of the care-plan should be printed off and kept, along with an up to date risk assessment, in the Care-Plan and Risk Assessment folder in a place accessible to all staff. All staff must be aware of the location of the folder. 6.2: Secondary Intervention: de-escalation; in communal areas or in the Extra Care Suite: If, despite the provision of primary (preventative) strategies in the plan of care the patient starts to display an initial response to identified triggers/showing common signs of distress (see Appendix 2b for examples) and/or challenging behaviours then the de-escalation techniques identified as part of the primary intervention process should be used (see Appendix 2c for examples) with reference to the care plan and risk assessment. Key requirements include: All attempts should be made to manage the situation as calmly and as discretely as possible. Staff managing de-escalation situation should be made aware of any wishes of the patient recorded in the patients care plan. Consideration should be given to which de-escalation techniques are appropriate and to the management of the immediate physical and social environment. It may be feasible for families and carers to contribute to de-escalation approaches, for example by talking to their relatives over the telephone O A D D e - e s c a l a t i o n P r o t o c o l Page 7

Where the situation is escalating consideration as to the most appropriate and therapeutic location for the individualised strategies should be considered: e.g; o Whether it is safe and appropriate for the patient to access/remain in the communal areas of the ward and if not, what are the risks? o What is the most therapeutically safe and appropriate environment to undertake positive individual strategies (i.e. stimulation levels, therapeutic milieu, required therapeutic materials and supportive equipment etc.) A clear assessment/review of any potential new triggers that may further inform primary preventative strategies should be undertaken. This process should be supported by the use of A-B-C methodology (Appendix 3). 6.3: Tertiary Intervention: Restrictive Interventions (RI s) - The patient is away from the communal area of the ward: Where a person s agitation has further escalated to a crisis where they place either themselves or others at significant risk of harm, interventions may include the use of restrictive interventions. In this context, NICE offer the following guideline for services: All [mental health] services should provide a designated area or room that staff may consider using, with the service user s agreement, specifically for the purpose of reducing arousal and/or agitation. (NICE 2005) 6.3.1: Definition of RI: As defined in the Code (2005), paragraph 26.36: RI s are deliberate acts on the part of other person(s) that restrict a patient s movement, liberty and/or freedom to act independently in order to: take immediate control of a dangerous situation where there is a real possibility of harm to the person or others if no action is undertaken, and end or reduce significantly the danger to the patient or others. 6.3.2: Application: It is understood that there will be occasions when disturbed and violent behaviour escalates and staff may be required to support the patient with an escalation in clinical holds. RI s should not be used to punish or for the sole intention of inflicting pain, suffering or humiliation. Where a person restricts a patient s movement, uses force (or warns the patient of the possibility that force may be needed) then that should be: Used for no longer than necessary to prevent harm to the person or to others A proportionate response to that harm, and The least restrictive option. Where risk assessments identify that RI s may be needed, their implementation should be planned in advance and recorded clearly within the patient care plan and are in line with Trust policy and consideration of any Advanced Directive if present. With reference to section 6.2, where the patient had remained in a communal area, if the ward communal area has become an unhelpful environment for verbal de-escalation then the patient should be supported in moving to the ECS; this is in order to protect the privacy and dignity of the individual as well as to ensure a safe and appropriate therapeutic space O A D D e - e s c a l a t i o n P r o t o c o l Page 8

where there will be greater control over patient stimulus and seated restrictive intervention de-escalation techniques may be used. Staff should be aware that the objective is always to look to reduce the level of intervention (de-escalate) as soon as it is safe to do so Staff should be aware that successful de-escalation will see a movement to primary intervention and the patient towards returning to the communal area as soon as possible. Where there is a clear agreed care plan with the patient/carer and this is not followed there should be a clear record as to why this was not possible. There may be a need to consider the use of rapid tranquilisation to support the deescalation process. If rapid tranquilisation is used this must be in-line with Trust policy. Consideration should be given to o o The level, nature and imminence of the risk of harm to others The length of time the patient has been in holds and whether de-escalation efforts have been successful rapid tranquilisation may need to be considered 6.3.3: Physical Care: Patients should have individual assessments to identify contraindications to physical interventions before they are approved. Patient assessment must be in-line with the standards set out in the Trust Clinical Care Policy (see section 17.9: Physical care of patients prior to, during and post physical interventions.) NB: A hard copy of the care-plan should be printed off and kept, along with an up to date risk assessment, in the Care-Plan and Risk Assessment folder in a place accessible to all staff. All staff must be aware of the location of the folder. 6.4: Patient returns to the communal areas of the ward following successful deescalation: Following an episode of de-escalation or use of physical intervention the following actions should be considered/completed as indicated: A post incident discussion should be held as soon as appropriate with the patient. The Care Plan should be returned to in this discussion and the warning signs, triggers and preferred coping strategies should be reviewed and evaluated (assisted by A-B-C methodology: see Appendix 3). The care plan should then be updated with the patient, thereby creating a positive feedback cycle and opportunity for reflection and growth. Where appropriate and consent has been given families should be updated on events. A Datix for the physical intervention should be completed for each de-escalation event that has required the movement of a patient from the communal area to a room used for the purpose of de-escalation with the use of restrictive intervention techniques. The time that a patient moved and then returned to the communal area will be recorded on this form. O A D D e - e s c a l a t i o n P r o t o c o l Page 9

A debrief should be undertaken with the patient and clinical team to look at triggers, lessons learnt and review of the plan of care with the patient. For the team it enables an understanding of the triggers to the patient s behaviour and contributory factors to the escalation. The patient should be reviewed by the MDT at the earliest opportunity 6.4.1: Physical Care: Patients should have individual assessments to identify contraindications to physical interventions before they are approved. Patient assessment must be in-line with the standards set out in the Trust Clinical Care Policy (see section 17.9: Physical care of patients prior to, during and post physical interventions.) 7: Monitoring (see Appendix 1) All incidences of use of de-escalation will be monitored through the monthly management meeting to monitor frequency, use of RI and DoL safeguards. Ward Managers will be responsible for bringing ward figures to the meeting for recording and discussion. Ward Managers will review each episode of restrictive intervention either with a peer/modern matron/service manager or quality lead within the division A 6 monthly audit (using audit tool in protocol) will be undertaken by Quality Lead and Modern Matron for the service. The findings will be presented to Older Adult Management meeting and through to patient safety meeting to support governance and oversight O A D D e - e s c a l a t i o n P r o t o c o l Page 10

Appendix 1: Audit and review standards DE-ESCALATION CLINICAL AUDIT STANDARDS Ref No Standard Compliance Exceptions Definitions (e.g. any interpretations, directions, or instructions on where/how to find information) DE-ESCALATION 1 Patients identified as being at risk of disturbed or violent behaviour should be given the opportunity to have their views and wishes recorded in relation to their high risk behaviours 2 Where a potential situation arises in the communal area of a ward, all attempts should be made to manage the situation as calmly, discretely and locally as possible. 3 If verbal de-escalation has not proved successful the patient should be supported in moving to a de-escalation area 4 There should be clear identification in the clinical record of staff supporting the de-escalation intervention and time spent in the room 100% None Views and wishes should include patients own triggers and interventions they find most helpful, and which they would prefer to be used. This should be recorded on the Safety Tool Care Plan. This should be used to inform the individualised care plan. 100% None Consideration should be given to which de-escalation techniques are appropriate and to the management of the immediate physical and relational environment 100% None A Datix should be completed for each deescalation and restrictive intervention event that has required the movement of a patient from the communal area to a room used for the purposes of deescalation with the use of Restrictive intervention techniques 100% None Decision to be recorded within progress notes and on datix Post Incident Review will be held within 24hrs of the use of de-escalation 100% Patient refusal/ability to engage A review supports a clinical understanding/review of the triggers, and factors that may have contributed to the escalation O A D D e - e s c a l a t i o n P r o t o c o l Page 11

Appendix 2: A: Examples of common triggers for patient distress: Not being listened to Lack of privacy Overcrowding Feeling lonely Darkness Being teased or picked on/bullied Particular time of day / night Not being able to smoke Feeling pressured to talk People yelling Arguments Being isolated Contact with family Particular time of year Anniversaries Observing others acting unsafely Feeling hot People in uniform Being touched Not having control Not being told why a treatment is being given Loud noises Being stared at Access to belongings Changes in the environment Events such as ward round B: Examples of common warning signs for client distress: Sweating Clenching teeth Wringing hands Bouncing legs Squatting Crying Not taking care of self Singing inappropriately Eating more Breathing hard Clenching fists Loud voice Rocking Cannot sit still Isolating / avoiding people Hurting myself Sleeping less Being rude Racing heart Red faced Sleeping a lot Pacing Swearing Hyper Hurting others or things Eating less Laughing loudly / giddy C: Examples of common coping skills or defusing strategies to manage patient distress: Having a cigarette outside Time out in your room Deep breathing exercises Reading a book / magazine Pacing Drawing / painting Sensory interventions Watching television Time out in a quiet room Sitting with staff Talking with peers Exercising Writing in a journal Taking a cold shower Walking in the garden / courtyard Listening to music Talking with staff Calling a friend Calling family Putting hands in cold water Taking a hot shower/bath Hugging a stuffed toy Holding a pet O A D D e - e s c a l a t i o n P r o t o c o l Page 12

Appendix 3: A-B-C Chart: A-B-C chart for:. Target behaviour: Please record any episodes of the above behaviour (day/night) Aim to record frequency and circumstances of incidents. Date and Time: What was the person doing just before the incident? (A antecedent) Where the incident occurred: Which staff were involved (initials): What did you see happen? (B actual behaviour) What did the person say at the time of the incident? How did the person appear at the time of the incident? (maybe more than one tick) Angry Frustrated Anxious Happy Bored Irritable Content Physically unwell Depressed Restless Frightened Sad Worried How was the situation resolved? (C consequences)* A Antecedents: the features happening just prior to the emergence of the behaviour that may have served to trigger or reinforce it (see also common causes of behaviours that challenge sheets). B- Behaviours: the factual acts witnessed. C Consequences: the responses of others to the behavioural disturbance. Items indicated/identified in this section may indicate ideas/direction for interventions O A D D e - e s c a l a t i o n P r o t o c o l Page 13

Appendix 4: Proactive Care De-escalation Pathway (Flow chart) 1. Primary Intervention: Prevention & Early Recognition: Prevention through high quality care, patient experience and therapeutic relationships. Facilitate Safety Tool and Care Plan involving patient, one to one time, shift names nurse, observations Complete Risk Assessments, involve patient, family/carers where possible 2. Secondary Intervention: Patient in communal areas. Initial presentation of disturbed or aggressive behaviour/identified triggers Verbal de-escalation, solution focussed and resolution techniques ; use of sensory/distraction and mindfulness techniques Is it currently safe and appropriate for the patient to access the communal areas of the ward? If no, what are the risks? 3. Tertiary Intervention: Patient away from communal areas (ECS): RETURN TO PRIMARY INTERVENTION NO RESTRICITVE PHYSICAL INTERVENTION: engaging and guiding Is it safe for the patient to return to the communal area? If not what are the risks? If yes, de-escalation interventions have been successful Successful De-escalation HIERARCHY OF HOLDS/RESTRICITVE PHYSICAL INTERVENTION Verbal and seated de-escalation techniques, team formation Is it safe for the patient to move to primary intervention? If not what are the risks? Use of De-escalation Room/ Sustained and unpredictable acutely disturbed behaviour requiring higher levels of staff engagement, support and observation Unsafe and counter therapeutic to be in general areas of ward even with staff support No immediate requirement for isolation or restraint although this remains a possibility RESTRICTIVE PHYSICAL INTERVENTION Full Restrictive intervention, 1. How long has the patient been in restraint? Position of the patient? 2. Is the patient deescalating and engaging in support? 3. Record on Datix; time; interventions used; staff involved and outcome If patient remains agitated and not responding to verbal de- escalation or supportive holds - Consider Rapid Tranquilisation. Monitor Physical health 4. Return to communal areas of ward Continue to monitor physical health Post incident review of restrictive practice/seclusion with patient and staff. Involve family/carer where possible Review Care plan and potential triggers with patient/staff Staff support, review, learning MDT review at earliest opportunity O A D D e - e s c a l a t i o n P r o t o c o l Page 14