Shared learning database
Type and Title of Submission
The Acute Medical Challenge Facing Mental Health Care: an audit of resuscitation training in a psychiatric settingDescription:
Traditionally mental health units have relied on the acute medical team to provide resuscitation but increasingly psychiatric wards are geographically separated from general hospitals. Cardiac arrests remain comparatively rare on mental health wards and attrition of resuscitation skills through disuse seems to have led to a low sense of urgency amongst some psychiatrists to address the issue. We have conducted a repeat audit highlighting these issues that has led to a re-invigoration with regard to resuscitation training in mental health service provision in relation to CG25.Category:
2010 Shared Learning examplesDoes the submission relate to the general implementation of all NICE guidance?
NoDoes the submission relate to the implementation of a specific piece of NICE guidance?
YesFull title of NICE guidance:
CG25 - Violence: the short term management of disturbed/violent behaviour in psychiatric in-patient settings and emergency departmentsCategory(s) that most closely reflects the nature of the submission:
Is the submission industry-sponsored in any way?
Description of submission
For psychiatric inpatient areas, the NICE Guidance on Violence states that: "All staff involved in rapid tranquillization should receive training to a minimum of Immediate Life Support. Staff who employ physical intervention or seclusion should, as a minimum, be trained in Basic Life Support." Anecdotal evidence suggested that psychiatric trainee staff felt that provision of resuscitation training within the organisation was inadequate. A baseline audit revealed that that this was indeed the case and a programme was launched to raise the profile and provision of training in this area.Objectives
Following a baseline audit, the intention of the project was to improve the skill base in 10 areas. Of these, three were considered to be a priority. 1] Increase the numbers of medical staff receiving training in resuscitation. 2] Increase the confidence of medical staff in using Automated External Defibrillators. 3] Increase the ability of medical staff to administer IV adrenaline without nursing assistance.Context
There was concern amongst psychiatric trainees in Sheffield that provision of resuscitation training was inadequate. An audit was conducted by questionnaire to establish the facts. Only 56% of junior doctors were current with training and 8% had never received training during the course of their career. None of the training had been provided by Sheffield's mental health trust. The outcome was only 43% of respondents were confident to use an Automated External Defibrillator and only 51% were confident to administer IV adrenaline without nursing assistance (psychiatric nurses are not routinely trained to administer IV injections). This identified a clear need for improved training and/or access to training in resuscitation skills.Methods
The audits were conducted as an online survey to ALL trainees. These were a mixture of General Practice trainees (GPVTS), Foundation level trainees (F1-2) and rotational Psychiatry SHOs. The survey requested information on 10 items. In 2007/8 the initial audit results were presented at a Trust Wide audit meeting. Following this, it was proposed that the appropriate forum group develop and implement a system to train medical staff in resuscitation. Immediate recognition was given to the importance of the results; particularly in the light of this statement by the Resuscitation Council. "Failure to provide an effective (resuscitation training) service is a failure in duty of care that is a clinical risk, contravenes the principles of clinical governance, and has implications for clinical negligence premiums." Furthermore, in 2009/10 the Care Quality Commission (CQC) introduced a new system of regulation where practice in accordance with CG25 is specifically referred to as a requirement within CQC regulations. It was highlighted that medical expertise was being eroded and that the Trust was losing a skill base that if retained would benefit patient care. Attention was given to the different role doctors have in a resuscitation attempt. It was suggested that doctors required a higher training level to other staff to reflect this. It was agreed Advanced Life Support (ALS) training was not indicated although it was strongly agreed that individuals should be able to access this level of training if they desired it. To monitor progress following these recommendations, a re-audit was undertaken in 2009/10. The same doctor distributed the same audit tool with an equivalent group to that audited in 2007 but expanded to include consultant and middle grade staff.Results and evaluation
Results from the first and second audits were analysed for differences in proportions in responses to analogous questions using StatsDirectİ. Statistical differences are reported as probability values using appropriate tests for differences in proportions responding to questions in the two audits(table1). The main results focus on training in basic life support, confidence in applying this training and the use of automated defibrillators. Table 1 Junior Grades 2007/8 vs 2009/10 Significant improvement? Have your received training in Basic Life Support (BLS)in the last year? 2007/8 = 34/37 2009/10 = 39/39 Difference P=0.002 Are you confident in using BLS skills? 2007/8 19/37 2009/10 29/39 Difference P=0.035 Have you been trained in the use of Automated Electronic Defibrillators (AED)? 2007/8 20/37 2009/10 32/39 The results indicated that the intervention produced significant improvements in uptake of training, skills and confidence in resuscitation techniques and the use of equipment. Despite these improvements, staff felt training may still be inadequate. The audit also identified that the numbers of staff who ideally should receive training far exceed availability. Psychiatrists must now take the clinical lead and help trusts to focus on their responsibility to the physical, as well as the mental health of their patients. In Sheffield a business case for radical restructuring and investment in resuscitation training is currently being discussed. In addition this also demonstrates that trainee audit has the ability to cause structural change at the highest level within an organisation.Key learning points
Identification of audits that relate to national agendas and safety issues suggested by clinical staff help complete the audit cycle and improve practice. Resuscitation issues within CG25 may be overlooked in Mental Health organisations as a priority. Do not attempt to audit whole guidelines at once. We restricted this audit to 10 questions in relation to a specific aspect of the guideline. The audit was promoted by a (then) junior doctor within the ward environment. For junior doctors 99% contributed to the audit and this was largely due to the promotion by a clinical champion. References 1. Winston T, Drybala G. Improving resuscitation skills in psychiatric hospitals: A multidimensional problem. Psychiatric Bulletin (1997). 21, 557-560. 2. Osbourne DPJ et al. Physical activity, dietary habits and Coronary Heart Disease risk factor knowledge amongst people with severe mental illness: A cross sectional comparative study in primary care. Social Psychiatry and Psychiatric Epidemiology. Vol 42, No 10. 787-793. 3. Harris EC, Barraclough B. Excess mortality of mental disorder. The British Journal of Psychiatry (1998) 173: 11-53. 4. Violence: The short-term management of disturbed/violent behaviour in in-patient psychiatric settings and emergency departments. NICE CG25. Feb 2005. 5. Care Quality Commission. July 2009. 6. Rapid Response Report NPSA/2008/RRR010: Resuscitation in Mental Health and Learning Disability Settings. Nov 2008. 7. NHS Litigation Authority Risk Management Standards for Mental Health & Learning Disability Trusts. NHSLA. Jan 2010. 8. Cardiopulmonary Resuscitation-Standards for Clinical Practice and Training.
View the supporting material
|Name:||Amanda Clements* and Brian Hockley|
|Job Title:||Consultant Psychiatrist* and Projects Manager|
|Organisation:||Sheffield Health and Social Care NHS Foundation Trust|
|Address:||Old Fulwood Road|
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This page was last updated: 07 January 2011