To improve the management of violent and aggressive patients in Critical Care

Quality Improvement Poster Download

Background & Problems

Over the last four years, we have an increasing number of incidences of violence and aggression from patients to staff in Critical Care. The severity of injury to staff has had both physical and emotional impacts. We realised that as a team we were reactive in our approach to these patients and not fully aware of the patient’s full mental and social history before planning their care.

We identified a reoccurring theme which highlighted a complex group of patients. This vulnerable group have often experienced difference kinds of abuse and socialise and grown up in a world where violence is used to express and protect themselves. These patients can suffer from mental health problems, frequent suicide attempts, recreational drug use and abuse of alcohol. Due to the difficulty of managing these patients they have experienced a prolonged stay in Critical care, often causing injuries to themselves, our staff as well as damaging equipment and the hospital environment.

Aim

Effective management:

1. The use of a patient screening tool
2. Patient risk documented and discussed at ‘TEAM SAFETY’ meetings
3. Intervention risk assessments implemented
4. Management guidelines implemented
5. Staff safe holder trained, confident and their safety maintained

We want to achieve a 75% compliance by 30th May 2018 (50).

Method

• We performed a test pilot for each of the documents implementation and gained staff feedback both verbal and written.
• The documents were then reviewed and re- tested.
• We audited the implementation of changes to check compliance
• We performed a staff questionnaire seeking their experiences of violence and aggression incidents in Critical Care. We also asked for their suggestions on solving the problem
• We trialled a bespoke ‘safe holding’ training session.

Results

We have implemented the following:

• Screening tool to assess patients ‘at risk’ of violent and aggressive outbursts within Critical care
• Critical Care ‘TEAM SAFETY’ briefing – MDT meeting each day and in each nursing handover to discuss the patients ‘at risk’ and other safety features.
• Management guidelines for the high risk patient with mental health and substance abuse
  • Contents
  • Gathering information on Mental health history and substance misuse
  • Environmental & Staff safety checklist
  • Patient management whilst sedated, before and post extubation
  • Restrain action card
  • Self-discharge decision tree
  • Discharge from DCC
  • Patient specific violence and aggression risk assessment
• Devised a training matrix and educational plan for all DCC staff.

Benefits:

• Staff feel empowered and supported in the care of these complexed patients
• The project and documentation raises awareness, promotes best practice and discussion with the whole MDT
• The project has been effective not only in improving staff safety but also improving the journey of this vulnerable patient group
• We have had no Datix from V&A since the project was implemented.

Implications

• The ‘TEAM SAFETY’ brief has already been shared within the medical, surgical and oncology nursing division with three areas implementing the tool.
• We are meeting with other areas within the trust that are having issues with violent and aggressive patients to share our work and offer support.
• We will share the project within the southwest Critical Care network.