Setting

The setting for this audit was a psychiatric high-dependency area in a general adult psychiatric in-patient unit. However, the audit could be replicated on any psychiatric in-patient facility.

Background

Acts of violence by patients, including assaults on staff, constitute a major management problem in psychiatric services. In 1999, the National Health Service (NHS) launched a zero tolerance campaign to reduce violence against its staff. However, violent incidents are still frequent in treatment settings and there is evidence that the incidence is increasing, particularly within mental health. Violence has significant physical, psychological and financial consequences – reportedly, violent incidents cost the NHS around £69 million a year, excluding the human cost. Safe and effective management of violence is important and is the topic of a guideline produced in 2005 by the National Institute for Health and Clinical Excellence (NICE).

Standards

The standards for the audit were derived from NICE guideline on the short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments. The guidance is detailed and it would not be feasible to audit against all of the standards. The following were selected:

ᐅ There should be a comprehensive (and up-to-date) risk assessment/ management plan.

ᐅ There should be evidence of the early use of de-escalation.

ᐅ Observations should be used to engage the patient positively.

ᐅ The use of physical interventions should occur only after de-escalation fails.

ᐅ Where physical restraint is used, vital signs should be monitored.

ᐅ There should be evidence of reassessment of the care plan after physical interventions.

ᐅ Incidents should be reported contemporaneously.

Method

Data collection

A data-collection tool (pro forma) was used to collect the following information:

ᐅ patient details – age, gender, ethnicity, date of admission, Mental Health Act status, diagnosis

ᐅ incident details – date, time, location, involvement of alcohol/drugs, observation levels, type of incident, presence of injury

ᐅ preventative measures – up-to-date risk assessment and management plan

ᐅ immediate management – use of de-escalation, rapid tranquillisation and physical restraint

ᐅ short-term management – incident reporting, clinical risk review, use of relevant resources.