Monitoring patients in crisis

Lessons from dynamic symptom profiles

Roland van de Sande

http://www.horatio-web.eu/

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

Practice:

• Thousands of emergency assessments

• Senior lecturer clinical decision making

• Clinical supervisor

• Secretary General European Psychiatric Nurses

• 3 years

• 3 years

• 1 year

• 3 years

• 1 year

• 7 years

Crisis monitoring research informed practice

Tailor made practice development

Solid implementation strategies

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

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

RISK ASSESSMENT

COERCION

STAFF CHARACTERISTICS

- EXPRIENCE -SEX -ATTIDUDE- -STRESS / COPING - TEAM COHESION

PATIENT

- SEX - AGE -PSYCHOPATHOLOGY - LEGAL STATUS - BACKGROND -- MENTAL STATE

WARD

-NUMBER OF PATIENTS - ARCHITECTUURE - LOCKED / OPEN - THERAPEUTIC ENVIORMENT - STAF / PATIENT RATIO

BEHAVIOUR PATIENT

STAFF – PATIENT

INTERACTION

BEHAVIOUR STAFF

AGGRESIVE

INCIDENTS

REFLECTION

DISCUSSION INTERVENTIONS

RIK COMMUNICATION

Nijman model (2002)

Frequent and

systematic

riskassessment

Reconstruction

and analysis crisis

episode

Evaluation

working diagnosis

Refined crisisplan

Located in the city to assess and

to provide short term intensive care

Community mental health teams

since 1950

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

160 different cultures

Estimated risk in mental health care

Suicide (2-10%)

Aggression (15-25%)

Exposure to trauma (30-50%)

Around 70% of the patients are involuntary admitted

60% were violent just before admission

All acute psychiatric wards are locked

Identified risk factors at admission (Baseline measurement in 4 acute wards, 183 patients)

0 10 20 30 40 50 60 70 80 90

Psychotic episode

Lack of insight

Medication non compliance

History of violence

Recent substance abuse

Recent aggressive incident

History of self-harm

Suicidal

%

Target of aggression

0% 10% 20% 30% 40% 50% 60% 70%

Nurses

Fellow patient

Visitor

Objects

Self harm

Psychiatric

Intensive

Care

Units

legal

issues

very few

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

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)

Six core strategies

Readiness to

change checklist

(Colton,2006) can

be an additional

support tool

Pennsylvania USA study outcomes in 1990–2000 (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

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) 429-438

Type of innovations

change of

attitude

early

recognition

risk

assessment

comfort

rooms crisisplans

therapeutic

engagement

clinical

supervision

external

consultation

intensive

care

verbal

deescalation

Expertise data base

Evidence apraisal

Expert groups

Sharing expertise

Forum

Psychiatric Nursing Research Center

Areas for practice development

Safety on the

the wards

Early recognition

and

harm prevention

Therapeutic

environment Level of

expertise

Risk assessment modalities

Long term

• History of violence

• Patientrecords analysis

• Escalation paterns

Short term

• Mental state

• Level of agitation

• Social context

Indication and frequency ?

Risk management principles

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).

Under or overestimation of risk can

be harmfull for patients and staff

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

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

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.

Medical

Impairment

Psychological

Impairment

Social Skills Violence ADL-

Occupational

Substance

Abuse

Ancillary

Impairment

Problem categorization of the Kennedy Axis V

100-95-90-85-80-75-70-65-60-55-50-45-40-35-30-25-20-15-10-0

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

This approach raises the awareness on symptom

changes and different needs for care levels

Experimental

wards Controle

units

CrisisMonitor Clinical jugdement

Outcome: Seclusion hours

Violent incidents

Baseline measurement

(10 weeks)

Cluster randomization

Risk assessment

training

Research design CrisisMonitor project

SDAS (Wistedt, et al,1990)

1. Verbal aggression

2. Directed verbal aggression

3. Agitation

4. Negativism

5. Anger

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

SDAS assessment every week

Severity scores 0 >4

Validation study BVC / Kennedy Axis V

• Sample: 7403 risk assessments during 10725 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 multi-

center research are expected soon.

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.

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

Towards integrated care

Frequent and systematic risk assessment

Pattern analysis and crisis reconstruction

Evaluation of the working diagnosis

Seemless crisisplans

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

Decreased number of seclusion rooms

Reduction of the number of seclusion rooms

(above 50 %) in the last 5 years )

2011 compared with 2010 25% seclusion time

reducation..

Seclusion immidiate at admission is getting

rare and in some days there is no seclusion

room occupied at all.

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.

Severe verbal aggression

Engagement by two nurses

Risk appraisal 1

De-escalation actions

Stable now ?

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

senior nurse

can overrule

current strategy

Crisis plan

Phase 1 or 2 Use crisisplan

Phase 3 or 4

Close observation

Limit setting

External consultation

2 escalation Verbal aggression

continious

Multi-disciplinairy

rapid response policy

Physical aggression Follow scheme:

Physical aggression

Towards therapeutic engagement

Some alternatives explored

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.

Area to have privacy with family

Occupational therapy for everyone

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

Final reflections (2007-2012)

• 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 !

Contact: roland.vandesande@hu.nl

r.vandesande@parnassiabavogroep.nl

THANK YOU !