Reduction of Disruptive,
Aggressive Behaviour
Registered charity no. 252892. Scottish charity no. SC039245.
On the Older
Persons Ward
Who is involved?
•
Chris Cudlip – Patient Safety Lead
•
Karen Williams – Ward Manager
•
Sam Snell – Occupational Therapist
•
Jonathan Speed – Deputy Ward Manager
•
Louise Crane – Patient Safety Administrator
Registered charity no. 252892. Scottish charity no. SC039245.
Situation
Project
Initiated
Registered charity no. 252892. Scottish charity no. SC039245.
Background
• Programme started September 2015
• High level of Disruptive and Aggressive behaviour on the
wards
• Staff unable to quickly identify a person’s needs
• Patients remained on enhanced observations longer than
clinically required
• Recording processes needed a meaningful person centred
approach to reflect patients needs for a more rounded
assessment on the ward
Registered charity no. 252892. Scottish charity no. SC039245.
Benefits to the patient and staff
•
Patient safety
•
Patients experience
•
Staff safety
•
Staff experience
•
Better ward environment
•
Increased staff retention
•
Reducing staff sickness levels
Registered charity no. 252892. Scottish charity no. SC039245.
Assessment
Aim/Primary Outcome:
Primary Drivers:
Patients
Reduction in
Disruptive Abusive
Behaviour (DAB)
on Garner Ward by
40% in 12 months.
Environment
Staff
Secondary Drivers:
•
•
•
•
Person centred care / Cornwall Supporting Behaviour Pathway
Physical health
Medication
Communication
•
•
•
•
Communal areas
Noise / temperature
Doors
Number of occupied beds
•
•
•
•
•
Communication
Weekly Patient Safety Huddle
Training / involvement
Support / supervision
Open and just culture
Culture
• Engaged and committed leadership
Registered charity no. 252892. Scottish charity no. SC039245.
Measuring the effects of changes
Safeguard
Huddles initiated
Level 2&3 Obs
Chart initiated
Project
Initiated
Registered charity no. 252892. Scottish charity no. SC039245.
Measuring the effect of change
34%
Registered charity no. 252892. Scottish charity no. SC039245.
reduction in DABs incidents
in the first 12 months.
Rolling Year Data
Registered charity no. 252892. Scottish charity no. SC039245.
25
Number of patients involved in the DAB incidents
20
15
10
Number of
Patients involved
in the DAB
incidents
Number of DAB
Incidents
5
0
Registered charity no. 252892. Scottish charity no. SC039245.
Behaviour Support Plan for:
Escalation & Crisis Phase
Level 3 observation
Initiated on admission and discharge.
On file with care plans.
Used from level 3 obs.
Behaviours
*Emergency alarm to be called
He will pick up items as weapons and use them to
smash glass.
He will hit out unprovoked and shout.
He will make direct threats.
He will follow who he perceives as his antagonise
increasing the risk to them.
Anyone near him is now in immediate risk.
Triggering Phase
Triggers:
Noise. His space being invaded. When he
needs the toilet( looks for small spaces to
urinate, even when there are peers around ,
putting himself between them. When prevented
from doing something. Personal care.
*Move anyone at risk out of the way
*Remove potential weapons
*If no others are at risk withdraw and hope he deescalates on his own accord (which he
does do at times)
*If any risk evident and MAPA required, minimum 3 staff using high level holds and
*relocate to nearest sofa and safe area. He will bite headbutt kick and punch.
*Level 3 to observe at this stage from a distance consider 2 – 1 staffing.
Level 3 observations
*Alert staff nurse and colleagues of change as risks to others are now increasing.
*Encourage him to a quiet low stimulus environment this may be sufficient for him to
return to baseline. This may not always be easily done as …. doesn’t like ‘hands on’
direction.
*Offer pet dog Morris
Behaviour: Walk faster, mutters, pointing,
swearing, dismissive, voice tone more angry
sounding. Clenches his fist. Push or over turn
furniture. Gather items.
*Consider prn medication may need to be given as per covert medication plan.
Baseline
(when calm and relaxed
This is the time when you can offer and try new activities
Offer activities –.
*Offer food and drink
*personal care
*enjoys a laugh and banter with staff.
*offer pet dog Morris
Level 3 observations by day but staff who are on line of sight with him are not to be too
invasive as he can become easily irritated even when he appears in a good frame of
mind.
* level 2 observation by night when in his bedroom.
What does that look like?
Walks around the ward. Smiling. Cheeky
banter.
Pet dog under his arm. Eating and drinking.
Engages in very limited conversation.
Registered charity no. 252892. Scottish charity no. SC039245.
*Move other people away.
*Do not attempt personal care as this will increase his irritability.
*Limited conversation/ interaction with him.
Care Plan
Challenges and Needs Detail: A Safety and Risk Management Care Plan: TRAFFIC LIGHT AND LEVEL OF
OBSERVATIONS
Mr A is a 79 year old man with known Vascular Dementia who has been re-admitted to Garner Ward,
Challenges and Needs Challenges and Needs currently under Section 3 MHA. Mr A was initially discharged home after his first admission to Garner
Category: CC&D InSub Category:
- where he was relatively settled at home with a few episodes of being paranoid and angry. He
Patient Care Plan
Activities of Living
believed his wife was having an affair, this is an on-going belief. At times he was becoming angry and
suspicious.
You are currently on level 2 (10 minute checks) but this may be increased at the discretion of the
shift nurse if you appear anxious or agitated.
Intervention Category: AOP Safety & risk
Intervention Type: Prescribed observation (observation
Client Agreed:
Section 117:
management
levels)
No
No
Planned /
Anticipated
Main Person Actual
Goals
Activities
Client's View
End
Responsible
Start
Date
Date
To maintain baseline presentation (calm,
relaxed and settled) and level 2 observations.
Mr A baseline presentation - Generally sat
quietly or sat singing Irish songs Smiley and
polite during engagement with staff and peers
Well kempt (shaved and smartly dressed).
Level 2 Observations in the
communal area and
bedroom
Staff will offer activities for
you engage with.
Staff will engage in
conversation or sing with
you.
Well will offer you a cup of
coffee, hot chocolate or
juice
Encourage you to quieter
environment to relax,
watch television (football,
cricket,golf)
Staff to offer you personal
care (bath or shower if
required).
Registered charity no. 252892. Scottish charity no. SC039245.
Mr A is unable to directly participate in care planning
SHIFT NURSE
process. Care plan is informed by information gathered
via the patient profile/lifestory work (see core
assessment), family views and observations of carers.
Care plans to be shared with family
20 Feb
2016,
01:03
Intervention Category: AOP Safety & risk
management
Goals
Intervention Type: Prescribed observation (observation
levels)
Activities
Triggering Phase (escalating agitation) To return Staff to consider increasing level of
you to baseline presentation.
observation to level 3 (LOS) during this
When in escalation phase He will- Be invasive of time.
others, Start to rhyme his words, Be dissmisive Staff to encourage Noel to a quieter area
of staff and peers during conversation, He will of the ward away from potential triggers.
pace the communal areas, Will be demanding of Staff to offer reassurance
staff, May rasie his voice, Can be sexually
Staff to monitor for signs of further
inappropriate with females
escalation in mood and behaviour and
Triggers: Busy environments – high stimuli
report to nurse in charge.
Noises- Loud-environment, banging Seeing
Consider use of PRN medication and
other people agitated
encourage acceptance of this.
Consider use of MAPA as a last resort
only, to prevent harm to self or others
and staff to be aware of physical health
needs - MAV to be used only in
intervening in high risk situations for the
absolute minimal period necessary
Registered charity no. 252892. Scottish charity no. SC039245.
Client's View
Client Agreed:
No
Section 117:
No
Planned
/
Anticipated
Main Person
Actual
End
Responsible
Start
Date
Date
Mr A is unable to directly participate in
SHIFT NURSE
care planning process. Care plan is
informed by information gathered via the
patient profile/lifestory work (see core
assessment), family views and
observations of carers.
Care plans to be shared with family
20 Feb
2016,
01:04
Intervention Category: AOP Safety & risk
management
Intervention Type: Prescribed observation (observation
levels)
Client Agreed:
Section 117:
No
No
Planned
/
Anticipated
Main Person
Actual
End
Responsible
Start
Date
Date
Goals
Activities
Client's View
Escalation & Crisis Phase (agitated, aggressive or
distressed)
To return to baseline presentation.
Maintain safety
In escalation phase He will - Become physically and
verbally abusive. Punch, kick and grab at staff and
peers (Generally their wrists) Verbally threatening
Shout loudly Verbal communication becomes
nonsensical sexually inappropriate with female
staff
You level of observation will
increase to level 3 (LOS)
Observations during this time.
Staff will call for assistance, move
others away, remain Calm, give
you simple and clear instructions
and move you away from busy
areas if necessary
Male staff will be involved when
possible
Monitor mood and behaviour record in progress notes and
review at least weekly at MDTM.
Female staff to attend in pairs.
PRN medication to be offered orally at first but if refused IM.
If IM medication is used staff will
follow the Rapid tranquilisation
policy to monitor your physical
health once settled.
Mr A is unable to directly participate in care SHIFT NURSE
planning process. Care plan is informed by
information gathered via the patient
profile/lifestory work (see core assessment),
family views and observations of carers.
Care plans to be shared with family
Registered charity no. 252892. Scottish charity no. SC039245.
28 Feb
2016,
22:05
Behavioural Chart (Edition 3)
Date:
Patient:
Obs level:
Asleep
Y/N
Baseline
Triggering
Esculation
Location
EHE/Com/
Bed/Corridor
Each box indicates 10 minutes within given hour.
Example
07.00 AM
08.00 AM
09.00 AM
10.00 AM
11.00 AM
12.00 PM
13.00 PM
14.00 PM
15.00 PM
16.00 PM
17.00 PM
18.00 PM
19.00 PM
20.00 PM
21.00 PM
22.00 PM
23.00 PM
00.00 AM
01.00 AM
02.00 AM
03.00 AM
04.00 AM
05.00 AM
06.00 AM
N
X
X
X
X
X
X
Cor
Addition comments
This is a chart that
had been trialled and
altered following
feedback given
Note – Use with patient traffic light template to identify behavioural phase during checks
Registered charity no. 252892. Scottish charity no. SC039245.
Near miss incidents
during your period
of observation?
Y/N
Y
* Colour box when patient is asleep
Staff
Initials
cc
This is the reviewed
and altered Level 2 and
3 Observations Chart
now adopted on the
ward.
Registered charity no. 252892. Scottish charity no. SC039245.
Relative Feedback received
“I have noticed that non regular staff appear
more aware of John’s* needs. One lady was
able to engage in appropriate ‘banter’, but
knew exactly what to do when he started to
shows signs of agitation. I’m sure John*
would have become aggressive if she didn’t
know to stop engaging and give him space”.
AW * (patient family member)
*names have been changed.
Registered charity no. 252892. Scottish charity no. SC039245.
Completed PDSAs
Library Care Plan will incorporate traffic light care
Behavioural traffic light passports have been adopted into main
practice with good results and feedback.
Some families are aware of the traffic light passport and are
encouraged to contribute.
Planned weekly huddles held with Deputy Ward Manager, HCAs
and Psychologist.
Registered charity no. 252892. Scottish charity no. SC039245.
Update
•
Started using Level 2&3 Obs Chart beginning Dec 2016. Which incorporated
a sleep chart therefore reducing the number of forms needed to complete per
patient.
•
Safeguard Huddles initiated every Tuesday morning
(protected time) since November 2016.
–
–
–
–
Discuss incidents raised over past 7 days
Review and update care plans and risk assessments to reflect identified
reports raised within the past 7 days
Review observations charts for patients on level 2 and 3 with the view of checking
and subsequently decreasing the level of observation for patients not presenting
at triggering or escalation phase behaviour
Linking with incidents reflecting the observation charts and discuss amongst
wider team to encourage open and just culture
Registered charity no. 252892. Scottish charity no. SC039245.
Next Steps
•
Further development of traffic light passport for nutrition,
moving and handling and personal care. Good feedback
received from HCAs.
•
Electronic application funding is being sought by Medical
Director so that the data can be analysed from ten minute
observations.
•
Embed Safety Huddles into weekly practice
Registered charity no. 252892. Scottish charity no. SC039245.
Recommendations
•
Keep talking to staff about what we are trying to achieve
•
Continue to foster family involvement and awareness of the Patient’s Traffic
Light Passports.
•
Continue to keep all members of the ward team actively involved in all
processes and decisions.
•
Allocate protected time to keep moving forward
•
Report back to safety champions
Registered charity no. 252892. Scottish charity no. SC039245.
Barriers
•
Time alongside frontline role
•
Staffing levels within the ward
Positive Outcomes
•
Increased awareness and compliance of reviewing and utilising the traffic
light system
•
Eradicated needless duplication of paperwork
•
Meaningful Person Centre Approach
Registered charity no. 252892. Scottish charity no. SC039245.
Key improvement message
“Everyone has a part to play in the
planning and implementation of the
project.”
Registered charity no. 252892. Scottish charity no. SC039245.