Improving the quality of medical seclusion reviews on Endcliffe Ward - an Adult Psychiatric Intensive Care Unit

Background

Endcliffe Ward is a purpose built psychiatric intensive care unit (PICU) that provides care for people in a mental health crisis who require a safe environment with high intensity nursing care

As with all PICU settings, incidents of “seclusion” and subsequent medical reviews are a common occurrence on Endcliffe Seclusion is a tool used primarily to manage aggressive and disturbed behaviour that is presumed to be due to the patient's mental disorder 1

There are clear Trust and national guidelines that must be adhered to when healthcare professionals use seclusion, that are designed to maximise a patient's freedom and protect their liberty 1,2 The standards used at Sheffield Health and Social Care (SHSC) are summarised in Figure 1

This work aligns with SHSC’s Trust-wide priorities around ensuring that staff are supported to provide best practice in relation to the use and prevention of force where possible.

1: Review of service user’s physical health

2: Review of service user’s psychiatric health

3: Assessment of currently prescribed medications

4: Assessment of adverse effects of medications

Initial Assessment

5: Review of observations required

6: Assessment of risk to others posed by the service user

7: Assessment of risk to self posed by the service user

8: Assessment of the need to continue seclusion or apply less restrictive measures

The overall aim of this work was to understand and improve current medical seclusion practice by all doctors of any grade on Endcliffe Ward A service evaluation was undertaken in AugustDecember 2022 This demonstrated sub-optimal adherence to medical seclusion standards, with a mean adherence of 66 72% (Figure 3) This evaluation highlighted poor documentation, in particular, entries lacked documentation of prescribed medications, adverse effects of medications and risk to self

Stakeholder Engagement

In order to drive sustained change, we met with the Endcliffe Leadership Team, comprised of representatives from medical, nursing and support staff, psychology, ward management and the administrative department. This gave an opportunity to share established learning Each member of the team contributed to our change ideas, particularly the proforma before its pilot

A medical staff survey of 31 clinicians in 2022 provided insights into current understanding of seclusion reviews, confidence in performing, and suggestions about practical solutions (Figure 2)

36.6% felt “confident” in performing reviews when starting their job.

33.3% of doctors correctly recalled all the medical seclusion standards

SMART Aim

A “SMART” aim has been developed based on service evaluation results and colleague discussions SMART aims are Specific, Measurable, Achievable, Realistic and Timely

We aim to achieve a 90% adherence rate to seclusion guidelines within a 12-month period Greater adherence to all standards of medical seclusion reviews will enhance the quality of care provided to service users who undergo seclusion

Planned Interventions

The Driver Diagram (Figure 3) summarises the areas that are being focussed on The following change ideas are in development:

1. Creation of a proforma document for medical seclusion reviews

2. Teaching delivered at April 2023 Junior Doctor induction

3. Continuous Professional Development (CPD) slot in SHSC Psychiatry Grand Round to share good practice, and teach all clinicians about appropriate medical seclusion reviews

How will we know we are improving?

To visualise improvement a random sample of seclusion entries will be analysed monthly for 12 months, with the mean adherence to plotted onto Statistical Process Control charts Our benchmark is an increase in the overall mean adherence from 66 72%, to 90%

92.6% of medics identified that a proforma would be a “helpful” tool

74% of clinicians identified that faceto-face teaching on reviews would be “helpful”

Our process measures include overall adherence, the time taken to document medical reviews and staff experience A survey to all doctors performed on a 4-monthly basis will enable us to monitor improvement in understanding and documentation time.

Initially, this project aimed to improve seclusions trust-wide We learnt that using small scale interventions in the highest acuity area was more achievable This will enable transferrable improvement trust-wide once interventions had been consistently adopted on Endcliffe