Clinical message of the week – Monday 11 June 2018

This week is Carers’ Week

Evidence:  People providing high levels of care to someone are twice as likely to be permanently unwell and are at risk of suffering mental ill health.

Key messages:

Ask patients if they have someone who cares for them and how they would like that person involved in their care Listen to carers’ insights and involve them, where the patient agrees and in line with Trust policy on confidentiality    Offer or signpost carers to a carer’s assessment and tell them about the Recovery and Wellbeing College, where they can learn with other

carers Tell staff who are carers about the staff carers ’ network

For further information please: Contact Lucy Palmer, Head of Patient and Carer Involvement at Lucy.Palmer7@nhs.net See the Trust Carer’s leaflet For working carers and staff who are carers please visit the Employers for Carers website.

Clinical Message of the Week – Wednesday 30 May 2018

Monitoring of patients on LithiumEvidence: Lithium is a highly effective and recommended medicine used for bipolar affective disorder and depression. Due to its narrow therapeutic index patients prescribed it need to be monitored for signs and symptoms of toxicity and the dose adjusted carefully.Between April 2015 and December 2017 across the Trust there were 15 incidents relating to lithium use, two were of moderate harm to the patient (for example, the patient was lithium toxic).

It is everybody’s  responsibility to monitor patients and help check lithium levels  Both patients and involved healthcare professionals must know the signs and symptoms lithium toxicity: - Coarse tremors and muscle weakness    - Abdominal pain and gastrointestinal disturbances (e.g. nausea)- CNS disturbances (confusion and drowsiness increasing to lack of coordination, restlessness, stupor) - Visual disturbances - Abnormal reflexes 

Common causes of increasing lithium levels are: o Dehydration: advise patient to keep hydrated, especially in hot weathero Changes in salt level: advise patient to not go onto any low salt diet without prior consultationo Other medications: obtain a full medication history and advise patient to consult with pharmacist or doctor before starting any new medicines. 

Prior to and ongoing monitoring: Check the patient's BMI, renal, thyroid function and ECG. In the first few weeks of initiation, measure lithium level (12 hours post-dose) weekly until a target range of 0.4 - 1.0mmol/L is achieved. Repeat levels usually three monthly thereafter.

For further information: Lithium therapy information booklet available for patients however staff are also encouraged to read The “Prescribing and monitoring of lithium therapy” SOP can be found here on Trustnet (If the link does not work for you, or you’re based

in Surrey please use this link). To order supplies of the purple “Lithium Therapy” packs for patients email pharmacy.cnwl@nhs.net

Clinical message of the week – Monday 21 May 2018

Safer care for people with personality disorderEvidence: 153 people with a personality disorder diagnosis died by suicide in 2013 and 40% of these deaths were by overdose. (National Confidential Inquiry into Suicides and Homicides by people with mental illness 2018).

The inquiry found that there were often no clear pathways for people with personality disorder to access care. The majority had not received care in line with NICE guidance (psychological interventions, short term prescribing only, avoiding inpatient care wherever possible).

CNWL have co-designed a pathway for people with Personality Disorder.  Services will be supported to plan local implementation. For more information please contact Marcus.maguire@nhs.net

While this is in process, some Key Actions can help keep people with personality disorders safe: Make sure patients know how to access help – for example emergency numbers, out-of-hours Single Point of Access number, relevant

staff and services numbers Take a non-judgmental, open, curious approach, maintain this even if faced with hostility and ambivalence about treatment – builds

trust and reduces stigma Explore and aim to understand traumatic experiences – when people feel heard it builds a relationship which can support them in

times of crisis. Prescribe safely - to reduce risk of fatal overdose Always assess alcohol and substance use - and refer to appropriate services

For further information please refer to:o Safer Care for People with Personality Disorder, please click on this link o NICE Guidelines: Borderline Personality Disorder, please click on this link

 

Clinical message of the week –Monday 14 May 2018 Getting it Right for Insulin patients – 5 Rs Evidence: 

In general, using insulin is safe but there is potential for serious harm if not administered and handled properly (NPSA Rapid Response Alert 2010).There has

been a significant rise in insulin use due to an increase in the incidence of type 2 diabetes and longer survival of such patients. Death and severe

harm incidents have resulted from administration errors with insulin products and as such insulin is included in the list of top 10 high-alert

medicines worldwide.  All staff involved with insulin patients should be aware of the following safety concerns: 

The right insulin should be prescribed Administered to the right patient At the right dose Using the right device At the right time Not changing injection sites can result in lumpy areas called lipohypertrophy. Injecting in to lipohypertrophic areas causes erratic insulin absorption resulting in potential hypo- or hyperglycaemia. For correct injection

technique   visit the ‘Fit 4 Diabetes’ website. For further information please refer toNational diabetes inpatient audit (NADIA) Insulin wall chart

Clinical message of the week –Tuesday 8 May

How to make Clinical handover safe and effective (Checkout the revised Trust Policy!)

Evidence:  Handover is the transfer of responsibility for the care of an individual or group to another person or professional group on a temporary or permanent basis.   Effective handover reduces the risk of error and harm to patients. (from NPSA, 2009)

Make sureo There is a designated leader who takes charge of handover and encourages multidisciplinary handover when practicableo Handover time is protected; remember handover must happen at the change of shifts, transfer of care between teams, or clinical

settings, when patient presentation or needs change and on discharge o The location for handover facilitates discussion and protects patient confidentiality. If this is away from patient areas allocate staff to

monitor patients.o Use the  Situation, Background, Assessment, Recommendation (SBAR) framework, to structure handover o Use the patient notes to give handover so that you are factual and accurateo Don’t use jargon, acronyms or terms that criticise patients, o Record and document in line with Trust policy.

For further information

Please refer to the new Clinical Handover policy, which includes specific considerations for handover in mental health and community settings. (If the link does not work for you, or you’re based in Surrey please use this link).

Clinical message of the week – Monday 30 April 2018

Clean hands save lives!

Evidence: Effective hand decontamination, even after wearing gloves, results in the significant reduction in the transmission of potential germs on the hands and decreases the incidences of preventable healthcare associated infections (NICE 2014).

To minimise the risk of cross infection and to ensure effective decontamination, make sure you do the following:

Be Bare Below the Elbow (BBE)o Do wear short sleeved garments or those that allow you to push your sleeves upo Don’t wear nail polish, false nails, wrist watch or rings with stones

Decontaminate hands following the WHO 5 moments of hand hygiene (please see image)

Know the correct Hand Hygiene Technique ALWAYS use soap and water when hands are:

o Visibly dirtyo Exposed to blood and body fluidso In the presence of vomiting and diarrhoea as alcohol gel is ineffective against

spores Carry Alcohol Hand Rub (AHR) for point of care hand decontamination

For further information please refer to the Trust Hand Hygiene Policy (if the link does not work for you, or you’re based in Surrey please use this link)

Clinical message of the week – Tuesday 24 April 2018

Minimising the risks with Insulin

Insulin is a high risk medicine and is frequently included in the list of top ten high alert medicines worldwide.

Insulin prescription and administration errors are a recurring problem within healthcare, yet are easily preventable. That is why some incidents are classified as Never Events. Nationally, incidents related to insulin have been reported at all stages of the medication process

The most common errors are: Wrong dose Wrong insulin product Omitted or delayed insulin

All clinical staff must:

Always write ‘units’ in full; Insulin is a critical medicine hence all preventable dose omissions should be avoided. The use of abbreviations that result in misinterpretation and administration of the incorrect dose is reportable as a Never Event

Always use an insulin syringe or pen device to administer insulin. Do not withdraw insulin using a syringe from prefilled pens or cartridges. This is also reportable as a Never Event

Always prescribe insulins by brand name, strength and device Advise patients to carry an up-to-date insulin passport

For further information Trust Guideline for the safe use of insulin is available on Trustnet (if the link does not work for you, or you’re based in Surrey please use

this link) Patient Safety Alert – Risk of severe harm and death due to withdrawing insulin from pen devices (2016).

NHS improvement – Never Events List 2018 (January 2018)

Clinical message of the week – Monday 16 April 2018

Managing ligature points saves lives

Evidence: Following extensive work on all our mental health inpatient wards; we have not had an inpatient suicide involving a ligature point for the last three years but we recognise this requires constant attention; therefore regular ligature point reviews, assessment and management is essential to maintaining patient safety.

All staff on inpatient mental health wards should: Know what their Ligature Point Risk Assessment plans are Where the plans are located and if a ligature point has been identified Know the management plans for the ligature points.

Make sure Ligature Point Risk Assessments are conducted locally at least once a year or sooner if an incident occurs highlighting a ligature point risk.

Ligature Point Risk Plans must be updated if there are changes to: The environment, for example new furniture The patient group, for example change from adults to older adults  The use of the ward for example from a rehabilitation ward to a PICU

There are four ways to manage ligature points:1. Remove the ligature point for example solid bathroom doors 2. Remove and replace (with an anti-ligature or ligature free version) for example shower curtain rails3. Protect for example do not leave pipes exposed4. Manage locally, for example restrict access to an area unless supervised

Please visit Trustnet to read the Management Ligature Suspension Point Risks policy (if the link does not work for you, or you’re based in Milton Keynes please use this link)

Clinical message of the week – Monday 9 April 2018

Substance use in mental health – Screen, Identify, Risks, Act

Evidence: People with mental health problems have increased physical morbidity and premature mortality (15 to 20 years lost). People who use alcohol or drugs lose 9 to 17 years of life compared to national norms.

When combining substance use with a mental illness, healthy life years are reduced even further.

All service users presenting to us must be asked about their smoking, alcohol and drug use

SUFARI (Substance Use Frequency Amount Risk Identification) is the Trustwide screening tool used to record drug and alcohol use of people accessing mental health services, it is available on JADE and SystmOne

When substance or alcohol use is indicated, appropriate actions, support and referral must then be taken, please read the updated Substance Use in Mental Health (SUMH) Policy for latest guidance on Trustnet. If the link does not work for you, or you’re based in Surrey please use this link.  It outlines practice for all clinical staff who provide care to people with coexisting mental health and substance use needs.

Further information:o The Trust’s Dual Diagnosis policy has been updated and renamed as the Substance Use in Mental Health (SUMH) Policyo For further training in working with patients who have mental health and substance use problems, a two-day Physical Health in Mental

Health training is available on the Learning and Development Zone (LDZ)

o Foundations in Physical Health: Day 1 - Foundations in physical health for mental health staffo Making Every Contact Count: Day 2  - Physical healthcare for mental health staff

o For national guidance please see the resources on the NICE website NICE guideline [NG58] and [CG120], and the GOV.UK website.

For further queries, please email the SUMH Operations Group at cnw-tr.sufari@nhs.net

Clinical message of the week – Monday 26 March 2018 Emergency life support oxygen cylinders – Instructions for use

Evidence: Staff not being familiar with how to use these cylinders resulted in some patients not receiving oxygen and sometimes becoming critically ill. A National Patient Safety alert recently highlighted over 400 incidents in a three year period.

Familiarise yourself with the Six Steps for correct use so that patients receive oxygen.

Check contents gauge, make sure needle is not in the red zoneRemove tamper seal if unopened or presentAttach oxygen tubing to firtree (metal pin) outletTurn on the cylinder by rotating the hand wheel in the open directionSet the prescribed flow for 12 or 15 litresListen and feel  to confirm oxygen is flowing.

Watch this video showing how to use the cylinder  (Open in Google Chrome)

You can also watch a film showing how to help if someone is having breathing problems. (Open in Google Chrome)

For further information use these step by step picture instructions and print and display them locally. If the link doesn’t work for you or you’re based in Surrey, please use this link.

Clinical message of the week – Tuesday 20 March 2018Use the SBAR communication tool for safer and reliable care

Evidence: Analysis of incidents and serious incidents shows that communication issues between clinicians and/or services are a common contributory factor. Our QI partner, the Institute for Healthcare Improvement, say the SBAR technique has been used successfully in healthcare to improve patient safety. It was created by clinical staff at Kaiser Permanente in Colorado and uses a systematic approach so that relevant information is provided accurately.

Situation – Identify yourself, your team, who you are speaking about. Give a brief outline of the problem

Background – Give a concise overview of what has led to this situation. This may include trauma suffered, medical history, dates, medical information, or names of clinicians involved. Basically, anything that’s relevant

Assessment – Summarise what you think is going on. If you can’t create a clear assessment, just say that

Recommendations – Clearly state what you’re requesting. Be specific about suggested action and time frame. In verbal communication, ask the person receiving the information to repeat any instruction for greatest accuracy. Making a recommendation can be as simple as saying, “I’d like you to check on this patient.”

What next?For more information and practical guidance see the resources on NHS Improvement:

Choose a situation when you and your team would like to try SBAR, handover is a good place to start. Monitor the progress – how well it is being used, has communication improved, are you saving time. If it is proving successful, the next step is to embed the tool into people’s everyday habits, so that it becomes ‘the way things are done around here’.

If you want to set up a Quality Improvement project in this area contact cnw-tr.improvementsupport@nhs.net

Clinical message of the week – Tuesday 13 March 2018 Stop Smoking! No Smoking Day – Wednesday 14 March  Smoking is the biggest cause of preventable deaths in England (more than 80,000 each year). One in two smokers will die from a smoking-related disease. Below are just some of the causes:         An increased risk of cancer of lips, tongue, throat, voice box and oesophagus. More than 93% of throat cancers are caused by smoking         Increasing the risk of heart disease, heart attack, stroke, peripheral vascular disease, pneumonia and emphysema           Smoking causes 84% of deaths from lung cancer and 83% of deaths from chronic obstructive pulmonary disease (COPD)         People with serious mental illness have shorter  life expectancy than the general population, in part due to smoking 

What can we do as staff to help people quit?   Discuss a person’s smoking status regularly and encourage them to quit  Encourage the use of NRT and make sure they use enough of it and use it correctly  Varenicline (Champix, Chantix®) is effective to stop smoking and does not significantly worsen mental health. Don’t use Varenicline in

combination with NRT  Service users on wards are able to use e-cigarettes (disposable non- rechargeable types); many people find them helpful as a nicotine

substitute  Training: Level 2 training in smoking cessation (essential to role for front-line clinicians) is available on LDZ and Level 1 for all other staff.  Further resources to inform and assist service users and/or staff, are available from the Communications Team to order. Please email

communications.cnwl@nhs.net

Clinical message of the week -  Monday 5 March 2018

Key learning from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness 2017

While patient deaths from suicide is down overall, the downward trend for this is decreasing – from 2005 to 2010 it had reduced by 39%, but from 2010 to 2015 it had only reduced by 10%.

People in highest risk groups for suicide are those with a primary diagnosis of an Affective Disorder (Depression and Bi-polar).  o Careful management of leave, minimising risk of AWOL, and ensuring post discharge follow up processes are robust are of primary

importance for people in these diagnostic groups.

Staff need to be vigilant as the first week post-discharge from wards remains a time of heightened risk

Most inpatients deaths from suicide occur outside of the ward environment – either whilst on leave or being absent without leave (AWOL)

The report found that suicide risk is also higher for: o people who have been diagnosed with an eating disorder for more than five yearso people on the autistic spectrum who have a history of self-harmo people within the first year of being diagnosed with dementia

Opiates and opiate containing analgesics are the most frequent type of drug used in fatal overdoseo Safer prescribing helps reduce the rate of suicide by overdose

For more information please refer to the National Confidential Inquiry 2017 (Lead: Jo Majithia, Author: Chrissy Reeves at Chrissy.reeves@nhs.net)  

Clinical message of the week – Monday 26 February 2018

Potential risks of suicide with benzodiazepine prescribing and withdrawal

Evidence: A Coroner Regulation 28 report has been issued to prevent future deaths associated with the above; whilst general risks associated with benzodiazepines are well known, all prescribers and pharmacists working in any care setting need to be mindful of this added risk when prescribing these medicines. 

Clinical staff are requested:

To make sure that patients receiving benzodiazepines for extended periods of time are regularly reviewed for their suitability for long term use

To make sure regular and close monitoring of patients who are withdrawing from benzodiazepines

To consider the particular risks associated with shorter acting benzodiazepines as part of the decision making process

To be aware of the existence and continued relevance of national guidance from the National Institute of Health and Care Excellence (NICE) and the British Association of Psychopharmacology (BAP) on prescribing/withdrawal of benzodiazepines

For further informationo NICE Clinical Knowledge Summaries: Best practice advice in the management of benzodiazepine and ‘z’ medicines withdrawal

o BAP comment paper – ‘Benzodiazepines: Risks and Benefits - A reconsideration’ published in the Journal of Psychopharmacology (2013: 27(11) 967–971) also contains useful guidance for prescribers

Clinical message of the week – Monday 19 February 2018

Nasogastric tube misplacement: risk of death and severe harm

Evidence: Misplaced nasogastric and orogastric tubes are a recognised national patient safety issue. Over the last five years 95 incidents were reported nationally where fluids or medication were introduced into the lungs via a misplaced nasogastric or orogastric tube. While this is a very rare event, incident analyses show that risks to patient safety persist.

If you are a healthcare professional who inserts nasogastric tubes and/or support feeding or administration of medication via nasogastric tubes whilst caring for adults or children, please make sure you follow the new Nasogastric Tube Insertion and Management Policy, now available on Trustnet. If the link does not work for you, or you’re based in Surrey please use this link

The policy provides guidance in relation to caring for adults and children who are malnourished or at risk of malnutrition in hospital. It outlines how nasogastric tube feeding support should be started, administered and stopped

For further information:

o For further national guidance please see the resources on the NHS Improvement website

Please contact your clinical education lead or speak to your team manager for more details on training:

o Goodall – Sarah Wilson sarah.wilson88@nhs.net o Diggory – Davina Culley Davina.culley@nhs.net

If you have any further queries please don’t hesitate to contact the Safety Team on 020 3214 5780.

Clinical message of the week – Monday 12 February 2018

Controlled drugs prescriptions: Regular review needed

Evidence: Recommendations from the latest CQC Controlled Drugs annual report emphasises the need for prescribers to regularly review patients receiving controlled drugs, benzodiazepines and ‘z’ drugs, such as zopiclone. These are all within the top five most commonly abused prescription medicines.

All clinical staff should: Regularly review patients taking controlled drugs, benzodiazepines and ‘z’ drugs, depending on their clinical need. Make sure all prescribed controlled drugs, benzodiazepines and ‘z’ drugs and length of treatment continues to be the most appropriate

for the patient’s clinical condition. Regularly assess the patient’s adherence to their prescribed regime. Work with patients and carers to review the patient’s medicines and have a collaborative approach to medicines review. De-prescribe where appropriate and reduce opportunities for over-prescribing, misuse and diversion where possible.

For further information please refer to:

o NICE guidelines on Controlled Drugs (2016) o General Medical Council – Good practice in prescribing and managing medicines and devices

Clinical message of the week – Monday 5 February 2018

Falls – What you can do to reduce them

Evidence:Falls are everybody’s business; they can happen to anyone, in any of our adult services. There is a lot we can all do to check the risks faced by the people we work with – and then do something about them.

The new Falls Policy is a very practical guide to how we should deal with falls risk in every adult service user.

Everyone who comes into our services should:

1. Be asked if they have fallen more than once in the past year, and also observed to check whether they are unsteady.2. If either of those is a problem, we should carry out a more comprehensive assessment which focuses on the person’s overall health as

well as their environment.3. Where we pick up a specific problem, there is now clear guidance on what to do about it there and then.4. Every team can either use one of the recommended assessment tools, or else carry on using their own tool as long as it covers all the

items set out in the Falls Policy.

For more information, please contact Paul Hopper, Falls Policy Lead at phopper@nhs.net or Jason Leung, Falls Board Administrator at jason.leung@nhs.net.

Clinical message of the week – Monday 29 January 2018

Do you know your Emergency Grab-Bag?

Evidence: o Prompt use of emergency equipment saves lives. o Recent grab-bag audits have highlighted the importance for all clinical staff to be familiar with its contents. o Treating a patient who is very unwell may require the use of emergency equipment - knowing your grab bag means that we can all play

our part in responding to emergencies.

How can we be prepared? There will be existing daily equipment/grab bag checks but you can also check the contents at any time and use team meetings and other

learning opportunities to ensure that you all know what equipment is available, what it looks like and what it is used for.

In addition to a defibrillator, all in-patient sites and the vast majority of community sites have a grab bag containing oxygen and masks, suction, ligature cutters and airways including I-Gels. Familiarise yourself with these when checking the contents of the bag.

Being familiar with the equipment will improve the way in which the team responds collaboratively and confidently – talk about this within

your team and consider arranging a simulation exercise in partnership with the Resus training team.

For further information please visit the Learning and Development Zone and visit resuscitation guidance.

Clinical message of the week – Monday 22 January 2018

Resources to support discussions with patients about their medicines

Evidence: Almost half of our patients say they are not provided with sufficient information about their medication in formats that they could understand. All patients who are prescribed medication should be given information on those medicines. Information should be offered in both verbal and written formats so that they have a chance to ask any questions, and can also refer to the information after the consultation.

Resources to assist you: Choice and Medication has a range of leaflets on mental health medicines and conditions in a variety of formats including different

languages, large or basic print www.choiceandmedication.org/cnwl/ MAPPs®, provides very brief information on medicines and can be used to provide reminder charts to help patients remember to take

their medicines, you can access the portal and download a user guide from Trustnet. If the link does not work for you, or you’re based in Surrey please use this link.

NHS Choices provides guides to patients on conditions and the questions to ask about their medicines, medicines leaflets are in development. Visit the NHS Choices website – Making sense of your medicines page

Patient.co.uk provides medicines leaflets for many medicines providing the most important information in a patient friendly way. Visit the Patient.co.uk website

The Medicines Helpline is available to all CNWL patients who have questions about their medicines. It can be accessed Monday to Friday 9am to 5pm on 020 8206 7270 or medinfo.cnwl@nhs.net

Patient information leaflets (PILs) from the manufacturers are available from www.medicines.org.uk these can be long and contain lots of complex information. Pharmacy staff are legally obliged to provide these with all medicines.

Clinical message of the week – Monday 15 January 2018

Are you encouraging people to complete their own Health and Wellbeing plan?

Health and wellbeing plans can be helpful for those who access our services, and for staff to support them. The plan aims to help people think about the things they can do to support their overall health and wellbeing in order to get the most out of life and help them to become experts in themselves. Read the Health and Wellbeing Plan (Second edition) on CNWL Recovery and Wellbeing website.

The Advance Statement part of the booklet is designed to help people plan in advance what they would prefer to happen in future when they might need additional healthcare support.

o It helps quickly identify an individual’s preferences and wishes about what help they would prefer during times of distress. The use of Advance Statements is known to reduce the level of restrictive interventions and promote safety for all. Read the Advance Statement booklet on the CNWL Recovery and Wellbeing website.

Copies of the Health and wellbeing plans are also available from Miriam Peck at the Recovery and Wellbeing College, please email Miriam.peck@nhs.net

A six week course is also available at the Recovery and Wellbeing College which covers the Health and Wellbeing plan called ‘Exploring what works for me’. Open to both staff and service users.

Clinical message of the week – Monday 8 January 2018

Flu – NHS urges staff to get the flu vaccine

Evidence: National statistics show that 4.5 million people have symptoms; 3,750 people are in hospital; last week 24 people died with a 70% increase in intensive therapy unit use. At CNWL a number of inpatients in Milton Keynes contracted Influenza Type A at Windsor Intermediate Care Unit. It reopened on Friday and all Infection Prevention and Control measures are in place with medical treatment administered to patients. One staff member was affected.

Don’t forget flu can kill. The annual flu immunisation programme helps to reduce GP consultations, unplanned hospital admissions and pressure on A&E.

You are still at risk of getting the flu, so make sure you avoid spreading it to family, friends and patients.

Wash your hands often with warm water and soap Use tissues when you cough and sneeze Throw away tissues in the bin as soon as possible.

Five reasons why healthcare workers should have their flu vaccine:1. The flu vaccine is given to healthcare workers for free to protect themselves and patients2. Research has found that people catch the flu approximately once every five years.  It may just be a mild case that feels like a heavy cold

but it’s enough to infect other people like patients!3. The flu vaccine is most effective in fit healthy young people, people like our healthcare workers.  4. The flu vaccine is less effective in the elderly and people with reduced immunity i.e. many of our patients 5. People most likely to die from flu are people with underlying health conditions - people most likely to come into contact with

healthcare workers

For further information please visit the Flu Trustnet page. (If the link does not work for you, or you’re based in Surrey please use this link).

Clinical message of the week – Monday 18 December 2017

Managing the intoxicated inpatient

Evidence: 

Alcohol intoxication has the potential to be life-threatening.

Intoxicated patients may present considerable risks to themselves in terms of their physical and/or mental health and through increased risk of self-harm and suicide.

Providing best care to intoxicated patients can be challenging.Some guidance to help improve your practice:

There is no blanket rule that an intoxicated patient cannot have their mental state assessed. If you are unable to carry out an adequate assessment of risk because of the level of intoxication, you still have a duty of care towards the

patient. An alcometer reading will usually inform the decision making process. However, this does not take into account the patient’s tolerance * to

alcohol and therefore has limited value. *After continued regular drinking, a person becomes tolerant to the effects of alcohol, which means that they need to drink more to get a similar effect.

You should quickly recognise the features of alcohol intoxication so that appropriate assessment and physical health monitoring can take place.

In cases where care is being provided for an intoxicated patient, it is essential that all clinical decisions are based on the actual presentation of the patient.

For further information please refer to CNWL’s Management of Alcohol Intoxicated MH and LD Patients Policy available on Trustnet which explains the key concepts and should guide your management. If the link does not work for you, or you’re based in Surrey please use this link.

Clinical message of the week – Monday 11 December 2017

Prompt action on complaints can prevent harm

Evidence: Sometimes complaints are raised by a family member, friend or carer. We know from our data that for most complaints requiring patient consent, investigations are delayed and we take longer than 25 days to respond. This means we could miss opportunities to act in the best interests of our patients. We also know that when we engage promptly with patients and complainants we are more likely to make immediate improvements resulting in safer services.

Key messages:

If you’ve received a complaint log it onto Datix straight away. This gets the process started: the Patient Support Service can then acknowledge the complaint and request consent within three days.

While awaiting consent the appointed investigator should start their investigation, unless there is good reason not to. This needs to be discussed with the manager of the service.

Where possible, the investigator should contact the complainant as soon as possible to understand the complaint issues, discuss consent and alert the service manager to any action that requires immediate attention.

If patient consent is not given the investigator should let the complainant know, but also assure them that appropriate action has been taken.

For further information please: o Contact the Patient Support Service on 0300 013 4799o Refer to the Complaints, Compliments and Concerns procedure available on Trustnet. If the link does not work for you, or you’re based in

Surrey please use this link.

All previous editions of the Clinical Message of the Week are available on Trustnet. Take a look to see what you’ve missed. If the link does not work for you, or you’re based in Surrey please use this link.

Clinical message of the week – Monday 4 December 2017

Are you ready for changes to sections 135 and 136 of the Mental Health Act 1983?

Evidence: The government has formally announced that changes in law to sections 135 and 136 of the Mental Health Act 1983 will come into effect on 11 December 2017. These changes will commence at 00.00am on 11 December, anyone brought in up to 11.59pm on 10 December will be under the old detention period.

The most significant changes are highlighted below: 

The previous maximum detention period of up to 72 hours will be reduced to 24 hours (unless a doctor certifies that an extension of up to 12 hours is necessary) 

Section 136 powers may be exercised anywhere other than in a private dwelling;  It is unlawful to use a police station as a place of safety for anyone under the age of 18 in any circumstances  A police station can only be used as a place of safety for adults in specific circumstances Before exercising a section 136 power police officers must, where practicable, consult a health professional For section 135, a person may be kept at their home for the purposes of an assessment rather than being removed to another place of

safety A new search power will allow police officers to search persons subject to section 135 or 136 powers for protective purposes. 

The government has also published guidance to support local partners’ interpretation of these changes. You can view this guidance online

To make sure the Trust is fully prepared and ready to implement these important changes, local Health Based Places of Safety Leads have been attending a Trust Task and Finish Group. The Group is led by Karen Cook, Head of Social Work and Social Care, and if you have any queries you can contact her at karencook@nhs.net . Alternatively you can contact Anthony Beschizza, Head of Mental Health Law at anthony.beschizza@nhs.net

Clinical message of the week – Monday 27 November 2017

Urinary Catheterisation: new CNWL policy for catheter insertion and aftercare

Evidence: Urinary Catheterisation is an invasive procedure which must only be undertaken if indicated after a full clinical assessment as the risk of complications is significant and indwelling catheterisation carries a very high risk of infection. All catheterisation and associated procedures must therefore follow the principles for safe practice outlined in the new policy. (EUAN; RCN; NICE – 2012)

What to consider when carrying out Urinary Catheterisation and all associated care.

Indications; contraindications and risks - Is catheterisation in the patient’s best interests? Can the procedure be done safely in your service, or should he/she be referred for specialist treatment?

Consent, patient information and dignity - Does the person have enough information to give informed consent? Does he/she have the capacity to consent?

Infection Prevention and Control (IPC), and safe use of antibiotics; Use correct IPC procedures at all stages of catheterisation and care and be alert to the risk of catheter-acquired UTI (symptomatic bacteriuria proven on culture). Change the catheter before antibiotics are given where possible.

Training and delegation - staff may only undertake catheterisation and associated procedures if deemed competent.

Record-keeping - include details of the catheter, consent, the procedure, and outcome.

Equipment and supplies - ensure all ordering, storage, use and disposal of equipment and supplies is carried out correctly, in line with Trust policy

For further information please refer to Urinary Catheterisation Policy on Trustnet and/or contact the Bladder and Bowel specialist in your area. (If the link does not work for you, or you’re based in Surrey please use this link).

Clinical message of the week – Monday 20 November 2017

Management of a Cardiac Arrest

Evidence:A patient may go into cardiac arrest for a wide number of reasons including coronary heart disease or Sepsis. When this happens staff must react quickly and use the acronym ‘DRSAB’ (Danger, Response, Shout, Airway, Breathing) to make sure a safe and prompt response and the best possible chance of survival for the patient.

In a recent unexpected cardiac arrest on a trust inpatient ward staff responded well by providing:

Prompt recognition and intervention: This included quickly calling for help, assessing him, calling the ambulance and duty doctor, moving him to the floor and starting chest compressions

Good chest compressions being delivered throughout with changes in the deliverer

The defibrillator was quickly brought to the scene and when opened the pads quickly attached to the patient and a shock quickly and safely delivered (58 seconds after defibrillator opened). The patient was shocked a number of times

Good team work with clear communication and staff getting quickly and practically involved

For further information please log on and visit resuscitation guidance on Learning and Development Zone.

Clinical message of the week – Monday 13 November 2017

Flu – What you need to know about the flu vaccine

Evidence: Australia has endured one of its worst flu seasons in more than a decade with at least 170,000 confirmed influenza cases, almost two-and-a-half times more than in 2016; a total of 52 deaths associated with influenza have been reported compared with 27 this time last year.

Flu is a key factor in NHS winter pressures, especially for vulnerable people. Don’t forget flu can kill. The annual flu immunisation programme helps to reduce GP consultations, unplanned hospital admissions and pressure on A&E.

Five reasons why healthcare workers should have their flu vaccine:6. The flu vaccine is given to healthcare workers for free to protect themselves and patients7. Research has found that people catch the flu approximately once every five years.  It may just be a mild case that feels like a heavy cold

but its enough to infect other people like patients!8. The flu vaccine is most effective in fit healthy young people, people like our healthcare workers.  9. The flu vaccine is less effective in the elderly and people with reduced immunity i.e many of our patients 10. People most likely to die from flu are people with underlying health conditions - people most likely to come into contact with

healthcare workers

Finally, don’t forget your manners! Good respiratory hygiene is another good way to stop the spread of flu! Cover your mouth when you cough or sneeze using a tissue or into your upper sleeve Throw away any used tissues into the bin – don’t leave them lying around! Wash your hands regularly

For further information please visit the Flu Trustnet page. (If the link does not work for you, or you’re based in Surrey please use this link).

Clinical message of the week – Monday 6 November 2017

Use of Chaperones for Intimate Procedures: New Policy

Evidence:  A Chaperone accompanies and/or supervises another person to provide a safeguard for all parties (patients and practitioners), as a witness to a procedure. It is essential for clinicians to offer a Formal Chaperone when performing intimate procedures.

What to consider when undertaking an intimate procedure: An Informal Chaperone is someone in a position to give reassurance and emotional comfort to the patient leading up to the procedure

and who may assist with personal care A Formal Chaperone is a clinician or a specifically trained non-clinical staff member who has had sufficient guidance to enable him/her to

act as a witness for the patient and clinician during an intimate procedure.

The patient has the right to decline a chaperone; however chaperones must be used for: Children, or adults considered vulnerable* Intimate procedures* People with unpredictable behaviour towards healthcare staff

*Except in specific circumstances defined in the policy:

Special circumstances - the policy provides additional guidance for: Community/lone working Children and young people Adults considered vulnerable

For further information please refer to the Chaperone Policy on Trustnet (If the link does not work for you, or you’re based in Surrey please use this link) and/or contact the Safeguarding specialist in your area.

Clinical message of the week – Monday 30 October 2017

Report Illicit Drug Reactions (RIDR)

Evidence: Public Health  England (PHE) and Medicines & Healthcare Products Regulatory Agency (MHRA) are running a pilot project for reporting the effects of New Psychoactive substances (NPS), similar to the yellow card scheme. The aim to increase understanding NPS harms and establish treatment methods.

The RIDR form enables health professionals to report the effects of NPS that they either witness, or that patients report to them. It is intended to be used by health professionals who work in emergency departments, general practice, drug treatment services, sexual

health services, mental health services and any other services where staff are coming into contact with people who have developed acute or chronic problems with NPS.

Website for healthcare professionals to report cases of suspected harm with illicit drug reactions here.

If you need further information on the clinical management of a patient visit please see below:

o Neptune website http://neptune-clinical-guidance.co.uk/

o Toxbase https://www.toxbase.org/

For further information on New Psychoactive Substances please visit:o Talk to Frank http://www.talktofrank.com/

o Know the Score http://knowthescore.info/

o Dan 24/7 http://www.dan247.org.uk/

Clinical message of the week – Monday 23 October 2017Antimicrobial Resistance (AMR)Evidence: In 2014, the World Health Organisation (WHO) warned we could be moving into a post-antibiotic era where even minor injuries could lead to life-threatening infections. Currently 700,000 deaths a year can be linked with Antimicrobial Resistance (AMR). Using antimicrobials (antibiotic, antiviral, antifungal medicines) when they are not needed is a major cause of antimicrobial resistance and reducing the threat is about appropriate prescribing as well as reducing the amount of prescribing.

Good Practice Guidance for initiating an antimicrobial:

Only prescribe if it is clinically indicated

Do not offer a prescription for acute self-limiting infections or for simple coughs, colds and sore throats

Take appropriate microbiology specimens before starting antibiotics where possible but do not delay therapy

Use antimicrobial prescribing guidelines to help you select an appropriate antibiotic and course length for each indication

Antimicrobials are critical medicines and should not be delayed in terms of supply and administration

Review the clinical diagnosis and continuing need for the antimicrobial 48-72 hours after initiation.

Document fully on the prescription and in the patient medical record including clinical indication, antimicrobial choice and intended duration (course length)

For further information please refer to:o CNWL Antimicrobial Stewardship Policy available on Trustnet. (If the link does not work for you, or you’re based in Surrey click here)o Antimicrobial Prescribing Guidelines available on Trustnet. (If the link does not work for you, or you’re based in Surrey please click here)o CNWL List of Critical Medicines available on Trustnet. (If the link does not work for you, or you’re based in Surrey please use this link).o Royal College of General Practitioners TARGET Antimicrobial Stewardship Toolkit for Primary Care o Public Health England, Start Smart Then Focus Antimicrobial Stewardship Toolkit

Clinical message of the week – Monday 16 October

Safety of girls and women being treated with Valproate

Evidence (from Patient Safety Alert NHS/PSA/RE/2017/002): Unborn babies exposed to valproate during pregnancy are at very high risk (30 - 40%) of neurodevelopment disability - such as lower

intelligence and autistic spectrum disorders, and also at risk (10%) of other birth defects A recent survey of women found that of those taking valproate (n=624) 20% were not aware of any of the risks of valproate in pregnancy

and less than 20% had received any of the educational materials.

Key messages:o A national Patient Safety Alert was published on the use of valproate in girls and women of childbearing ageo The resources signposted in the alert should be used to support fully informed decisions on the use of valproate by girls and women of

childbearing age, including a checklist for prescribers and patientso Staff should be aware of the MHRA valproate toolkit and use this to document a thorough risk assessment and consent process prior to

prescribing valproate in girls and women of child bearing ageo Patients should be issued with a patient card and a valproate leaflet for information upon prescribing or receiving a prescription for

valproate.

For further information please refer to: The patient safety alert – resources to support the safety of girls and women on valproate (NHS/PSA/RE/2017/002) The MHRA toolkit patient and prescriber checklist

Clinical message of the week – Monday 9 October

Use the Royal Marsden Manual!

Evidence:  When undertaking clinical duties approved procedures should be adhered to.  The Marsden Manual is the best evidence-based source of adult nursing procedures and guidance.

The Marsden Manual publishes evidence-based clinical skills procedures related to essential aspects of care. Content is updated every three years to include new research evidence, NICE guidelines and RCN recommendations. It is our Trust’s policy that the Marsden Manual should be used by CNWL nurses as main reference on any clinical procedure for which

there is no CNWL policy or local guidance; and it should be used as the evidence base for developing CNWL local procedures. Click here to read the Marsden Manual of Clinical Procedure. (If the link does not work for you, or you’re based in Surrey please use this link).

Whenever CNWL guidance is available, this should override Marsden Manual’s procedures. For ease of access, all appropriate CNWL guidance documents are uploaded and regularly maintained on the Royal Marsden Manual Online (RMMO)

Access: the RMMO is available here (http://www.rmmonline.co.uk/), login is not required. For access via own PCs and mobile devices, login is via individual OpenAthens accounts.

Clinical message of the week – Monday 2 October

Fire Safety – Keeping Patients and Staff Safe

Evidence: The main causes of fire nationally are arson, faulty electrical equipment and smoking materials. As part of our ongoing work, we are committed to going ‘Smoke free’ on all sites.

We all have a responsibility to manage the fire safety agenda:

Make sure you are familiar with the fire evacuation procedure at your site, including how patients are to be evacuated. Mobility impaired patients and staff require a Personal Emergency Evacuation Plan (PEEP) to be in place, to clarify their safe evacuation Matches and lighters are not generally permitted at inpatient unit sites-be vigilant in line with the ‘Smoke free’ policy Participate in your local fire evacuation drills/table top exercises Attend the mandatory fire safety training courses which are advertised on LDZ. Ensure the fire brigade is called if a fire breaks out (but not if it’s false alarm) Record fire outbreaks via the Trust’s incident reporting system (DATIX).

For further information please refer to the Trust Fire Safety Strategy available on Trustnet. If the link does not work for you, or you’re based in Surrey please click here

Clinical message of the week – 25 September 2017

Smoking cessation medication in severe mental ill health: what works?

Evidence:Bupropion and Varenicline have been shown to be effective in the general population in helping people give up smoking.  A systematic review of 26 randomised control trials concluded that they also work for people with severe mental ill health.  (Severe mental health was defined as schizophrenia or other psychotic disorders, bipolar disorder and depression with psychotic features.)

Importantly, the review did not find any significant worsening of psychiatric symptoms.  This is a particularly helpful finding given the BNF ‘Important safety information for Varenicline: Patients with a history of psychiatrist illness should be monitored closely when taking Varenicline’.

Take home message for the attention of all prescribing clinicians:

People with serious mental ill health can quit smoking  The interventions that work for people in the general population work for people with serious mental ill health Nicotine Replacement Therapy (first choice) Varenicline Bupropion (note: not on the NWL formulary, so GP may not agree to prescribe)

For further information:

For any queries please contact Dr Frances Klemperer, Consultant Psychiatrist on frances.klemperer@nhs.net

Peckham et al. BMC Psychiatry (2017) 17:252 DOI 10.1186/s12888-017-1419-7. Smoking cessation in severe mental ill health: what works? An updated systematic review and meta-analysis

Clinical message of the week – 18 September 2017

Let’s get physical – again!Evidence:

Life expectancy of people with serious mental illness is reduced by up to 20 years because of poor physical healthcare Internal audits and mortality reviews show that we need to do more for patients in this area Wide use of the Lester positive cardiometabolic health resource leads to better care and outcomes The imminent National Clinical Audit of Psychosis (NCAP) is an opportunity to demonstrate high quality care.

Clinical staff in adult, older adult and learning disabilities services should assess and then treat or refer patients (as necessary) for the following measures:

Blood pressure Body mass index Smoking status Blood cholesterol Blood glucose Alcohol misuse Substance misuse

Remember to document this on the electronic patient record (SystemOne or JADE); staff using JADE should use the new JADE Physical Health Assessment form (SHINE Physical Health Assessment). Remember to document any ‘refusals’ as well.

This can be done in partnership with primary care – it shouldn’t be necessary to repeat all tests if they’ve been done elsewhere already, but it is essential to check it is done, and complete it if not.

For further information please refer to:The Trust has Minimum Standards for Physical Health Monitoring in our Adult Mental Health Services which are available on the Trustnet physical health page If the link does not work for you, or you’re based in Surrey please use this link You should also refer to the Lester Cardiometabolic Resource

Clinical message of the week – 11 September 2017Catheter associated urinary tract infections Evidence:Catheters bypass the body’s natural defences and make it easier for microorganisms (bacteria, viruses, and fungi) to reach the bladder and cause a Catheter Associated Urinary Tract Infection (CAUTI). The risk of developing a CAUTI increases by 3 to 10% each day the catheter is in situ. 

Only treat symptomatic CAUTI – defined as :o the presence of fever >38°C or 1.5°C above baseline on two occasions during 12 hourso symptoms including suprapubic pain or tenderness (lower abdominal pain or tenderness), costovertebral angle tenderness (Pain

and tenderness in the kidney area), rigorso and/or otherwise unexplained systemic symptoms such as altered mental status, hypotensiono and/or evidence of a systemic inflammatory response syndromeo together with a proven bacteriuria on culture.

Cloudy or offensive smelling urine do not always indicate infection Collect the urine sample from the catheter sampling port using a needle and syringe – don’t take a urine sample from the drainage

bag! Do not use dipstick urinalysis to diagnose CAUTI – The presence of bacteria in the urine of catheterised patients is common and does

not always mean infection, especially if the patient is asymptomatic Change the catheter first then start antimicrobials. This is associated with improved treatment outcomes for patients. If, however,

there is going to be a delay in changing the catheter then start antibiotics first Antimicrobials are critical medicines and should be started without undue delay Always consult antimicrobial prescribing guidelines for appropriate antimicrobial treatment choice.

For further information please refer to:SIGN 88: Click here for clinical guidelines on the management of suspected bacterial urinary tract infection in adults; Local Antimicrobial Prescribing Guidelines; CNWL Antimicrobial Stewardship Policy and CNWL Critical Medicines List (on Trustnet).

Clinical message of the week – 4 September 2017

Ensuring a safe transition from CAMHS to adult mental health services

Evidence: Adolescence is a period of high risk for the development of mental health disorders and is also a period of transitions. 75% of adult mental disorders develop in adolescences and young adulthood. A successful transition from Child and Adolescent Mental Health Service (CAMHS) to Adult Mental Health Service (AMHS) is very important for the further engagement in services and overall prognosis for young people.

This is a shared responsibility for clinicians in CAMHS and AMHS.

The main principles of good transition:

Collaborate - professionals, the young person and carers/parents Start early and plan Good communication and consistency of support Transition is a process, not a one-off event

What do we need to know from the new transition policy?- Transition discussion starts when a young person is 17 and a half years old- Adult mental health services should start their involvement before eighteenth birthday- Joint working and transition meetings are recommended - By eighteenth birthday young people should complete transition and be discharged from CAMHS

For further information please refer to: CNWL Transition Policy if the link does not work for you, or you’re based in Surrey please use this link. NICE Guidelines – Transition

Clinical message of the week – 29 August 2017Mental Capacity Act (MCA) – Best InterestsEvidence: If you have assessed your service user as lacking the mental capacity to make a particular decision, then – in line with the fourth of the key principles described in the first MCA Clinical Message of the Week – you must act in accordance with the service user’s best interests. 

Points to consider before making a Best Interests decision:

Remember that you are trying to find out what the individual would want to do if they had capacity.  This means you must take into account any known previous decisions or statements and any legal arrangements they may have around advance decisions

Consult as far as is necessary and appropriate with people who know and/or are involved in the care and life of the individual.  This could include family members, friends, or anybody important to the service user, as well as staff members and other service providers, but it must involve anyone who has the relevant Power of Attorney or Guardianship order, and you must involve the service user as far as possible. 

Where no friends or family can be identified and the decision to be made is major/serious you should involve an Independent Mental Capacity Advocate (IMCA)

Keep a full record of the steps you have taken to reach a decision. It is essential that you record:      a) Your belief that the service user does not have mental capacity for the decision, and how you made that judgement and

b) The steps you took, and who you involved, in reaching a best interest decision, and – of course – what the decision was. A template for recording these decisions is available.

Finally, always remember to allow for unwise decisions. If the individual has mental capacity then neither you nor their family/friends can make a best interests decision for them. People with capacity are entitled to make what others may regard as foolish or unwise decisions.

For further information please refer to the Capacity Consent and Best Interests Assessment for Health and Social Care Interventions Policy available on Trustnet. If the link does not work for you, or you’re based in Surrey please use this link .

Clinical message of the week – 21 August 2017 Stay safe with sharpsEvidence: Injuries from contaminated sharps pose a significant risk to the physical and mental wellbeing of healthcare workers (HCW’s). Over the past year there have been 64 sharps injuries reported to OHS from CNWL - an increase of 18% from the previous year. Contaminated needles can transmit more than 20 blood-borne pathogens, including hepatitis B, hepatitis C and human immunodeficiency virus (HIV). 

If you follow these simple rules you will minimise the risk of a sharps injury

Use approved safety devices -  Make sure you are trained to use the device, do not adapt the device Dispose of sharps at the point of use – Carry a sharps bin if necessary Do not overfill the sharps bin and make sure the temporary closure mechanism is in place when the bin is not in use Make sure your sharps bin is stored at worktop height.  Do not store on the floor or high up. 

If you do sustain a sharps injury or are exposed to blood or body fluids through broken skin, a bite or scratch or an eye splash then act promptly!

Encourage bleeding and wash the area under running water Report to your manager or supervisor and complete a Datix form Contact Occupational Health (Monday to Friday 9am to 5pm) on 020 3317 3350 or your local Accident and Emergency Department

outside of these hours as soon as possible after the injury has occurred.

For further information please refer to the Safe Use and Disposal of Sharps Policy on Trustnet or contact the Infection Prevention and Control Team. If the link does not work for you, or you’re based in Surrey please use this link

Guidelines for message of the week

Spend no more than 2-3 mins on the given message highlighting why it is so important

Do this at every handover, night and day shifts for one week and staff briefings

The aim is to capture as many staff as possible and share learning

Clinical message of the week – 14 August 2017

Mental Capacity Act (MCA) – Making an assessment

Evidence:Bearing in mind the five key principles of the Mental Capacity Act (MCA) described in last week’s clinical message, the following points must be considered when carrying out an assessment of a patient’s ability to make a decision.  These points remain the same independent of the seriousness of the decision.

What to consider when carrying out a MCA assessment Is the individual able to understand information relevant to the decision you want them to make?  This means that you also need

to consider how best to give the information to help the person understand it more easily. Can the individual retain the information for long enough to make a decision?   The length of time can be as long as is available in

the circumstances. Particularly with complex and important decisions, the individual might want to fully consider their options. Can the individual weigh up their options?  Part of making a decision involves thinking through the options available, so make sure

where it is appropriate that these are discussed while bearing in mind that sometimes too much choice can also confuse people. Can the individual communicate their decision?  Here, the communication can be in any appropriate way, such as speaking, writing,

and even – with necessary checks – blinking or using hand pressure, for example.

If you can genuinely say that you feel the individual has failed in any one of these four measures, then you have assessed that they do not have the mental capacity to make the decision.  If they do not fail in any of the measures then, whatever the outcome and whatever you think of it, you must accept that the individual has the right to make that decision. Your record of the assessment should then be recorded appropriately in the care record.

For further information please refer to the Capacity, Consent and best interests assessment for health and social care interventions Policy on Trustnet If the link doesn’t work, or you’re based in Surrey use this link

Clinical message of the week – 7 August 2017

Mental Capacity Act (MCA) – Principles

Evidence: People must be given every opportunity to make their own decisions about their care and treatment and we should support them to make those decisions while they can, or act in their best interests if they are unable to decide for themselves. This is the essence of the MCA and explains why we have a  Mental Capacity as opposed to a Mental Incapacity Act.

The MCA is based on five key principles:

Always assume the individual has mental capacity: Don’t pre-judge their ability to decide because you know they have a particular condition

Take reasonable steps to help in decision making: If the individual is struggling to decide, think about whether you could change how you give information – such as writing things down, or using shorter sentences

Allow for unwise decisions: The individual might disagree with what you think is sensible decision, but if they understand what they are doing then it is up to them

Act in the service user’s best interests: If you believe the individual does not have mental capacity to make a particular decision, try to find out what they would have decided if they could

Act in a proportionate way: A lack of mental capacity for one decision does not necessarily mean a lack for others - each decision must be assessed separately

For further information please refer to the Capacity Consent and Best Interests Assessment for Health and Social Care Interventions Policy available on Trustnet. (If the link does not work for you, or you’re based in Surrey please click here).

Clinical message of the week – 31 July 2017 Management of deteriorating patient!  Evidence:

A patient may deteriorate at any time for a wide number of reasons such as developing coronary heart disease or Sepsis that may be

undiagnosed. Evidence suggests that patients who are, or become, acutely unwell in hospital may receive suboptimal care for reasons including

their deterioration is not recognised or, despite indications of clinical deterioration, is not appreciated, adequately communicated or rapidly acted

upon.

Management of deteriorating patient should include:

         Record and complete the vital signs chart and early warning scoring (NEWS/MEWS) which may prompt intervention – MEWS score

above 5 means a call to 999/2222 immediately.

         Call for help early – being familiar with local procedure regarding calling of duty doctor and using a structured communication tool such

as SBAR.

         Consideration of oxygen therapy particularly with saturations below 95 and other emergency medications held on the ward or unit.

For further information please refer to the Recognition and Management of the Deteriorating Patient Policy available on Trustnet. (Staff in Milton

Keynes and Surrey please use this link).

Clinical message of the week – 24 July 2017

Recognition of deteriorating patient

Evidence:A patient may deteriorate at any time for a wide number of reasons, such as developing coronary heart disease or Sepsis that may be undiagnosed. Evidence suggests that patients who are, or become, acutely unwell in hospital may receive suboptimal care. It may be that deterioration is not recognised or – despite indications of clinical deterioration – it may be not appreciated, adequately communicated or rapidly acted upon.

To assist in the recognition of a deteriorating patient:

Check vital signs – A patient with a deteriorating condition may show changes in vital signs away from the ‘normal ranges’ such as

changes in respiratory rate, pulse rate, blood pressure. They may also have changes in their body temperature and skin colour.

Record and complete vital signs chart and early warning scoring (NEWS/MEWS) which may prompt intervention - MEWS score above

5 means a call to 999/2222 immediately.

Know your patient – the better you know someone, the more likely you are to recognise deterioration.

Guidelines for message of the week

Spend no more than 2-3 mins on the given message highlighting why it is so important

Do this at every handover, night and day shifts for one week and staff briefings

The aim is to capture as many staff as possible and share learning

Clinical message of the week – 17 July 2017

Duty of candour - being open when mistakes happen

Evidence:The Berwick patient safety report, 2013, said all organisations should be transparent about their standards of care particularly when they fail. Evidence suggests that patients respond to treatment better when they have trust in staff; when a mistake has been made most people just want to be sure we have taken action to stop it happening again.

As soon as possible, after a mistake has been made talk to the patient and/or their carer(s); explain what happened, apologise and explain what will be done to avoid a repeat

Say sorry in a way that shows you mean it

The legal duty of candour only applies when there has been ‘significant harm’ but we should be open with patients at all times

Follow-up the conversation in writing - always inform patients and carers about the outcome and the actions we have taken

For further information please refer to the Openness/Duty of Candour Policy available on Trustnet. (Staff based in Milton Keynes and Surrey please click here).

Clinical message of the week – 10 July 2017

Supporting people with personal care using NICE guidance

Evidence:When physically or mentally unwell, some people will require more help with personal care and activities of daily living.  This can be very distressing, particularly if there is a cognitive impairment. To keep both the patient and the staff member safe we may need to use an appropriate hold, a type of restraint (NICE 2006, updated 2016).

It is important to complete some key actions if someone is going to require restraint as part of their personal care intervention:

A capacity assessment – Can the person comprehend, retain, weigh up and communicate a decision? Have you consulted family, the MDT and significant others? Is it in the person’s best interests?

Risk assessment and management plan – What are the risks if this intervention is not carried out? What does the person think about their personal care?

A detailed care plan – This should include how many people may need to be involved to keep the person safe and what types of holds may need to be used.

For further information please refer to:

Therapeutic Management of Violence and Aggression policy on Trustnet (Staff based in Milton Keynes and Surrey please click here) Capacity, Consent and Best Interest Guidance on Trustnet (Staff based in Milton Keynes and Surrey please  click here) NICE Guidance click here

Clinical message of the week – 3 July 2017Five moments for Hand Hygiene at the point of careEvidence:‘My five moments for Hand Hygiene’ at the point of care approach defines the key moments when health care workers should perform hand hygiene. ‘To protect the patient from colonisation or infection and to protect the health care environment against germs carried on your hands. To protect you from colonisation or infection from a patients germs.’ WHO (2009)

Moment one: Before touching a patient                                                                  Moment two: Before a clean / aseptic procedure (for example, before management of a wound or an invasive medical

device)                                Moment three: After body fluid exposure risk  (for example, after contact with  non-intact skin , body fluids, or cleaning any

contaminated surface) Moment four: After touching a patient: (for example, after shaking hands or  after performing a physical non-invasive examination: like

taking  a pulse) Moment five: After touching patient surroundings (for example, after an activity involving physical contact with the patient’s immediate

environment: like moving chairs)

o For further information please refer to the Hand Hygiene Policy available on Trustnet. (Staff based in Milton Keynes and Surrey please use this link).

o You can read more about the five moments of Hand Hygiene on the World Health Organisation website.

Clinical message of the week – 27 June 2017Shut that door!

Evidence: Last year 87 detained patients went AWOL from CNWL mental health and learning disability. This often led to harm to the patient and great stress to their families.

The majority of these incidents are as a result of ‘tailgating’, where the person follows a member of staff or visitor through the door before it has been able to close and lock. There are three simple steps to ensure that we reduce the likelihood of these incidents happening.

Before opening the door, make sure it is safe to do so. Make sure when leaving the ward you close the door behind you. After closing the door, make sure that it has secured behind you.

For further information please refer to:

o The Missing Informal Mental Health and Learning Disability Inpatient Policy, please click here. (Staff based in Milton Keynes and Surrey please click here).

o Section 17 Leave Policy, please click here. (Staff based in Milton Keynes and Surrey please click here).

Clinical message of the week – 19 June 2017

Safe Administration of Emergency Oxygen!

Evidence:

Recent incidents within CNWL where patients for whom a 999 emergency call was made were not given oxygen therapy - although it was available and may well have been beneficial.

Medical oxygen is located within the Lifeline Grab Bags. These should be readily available in all inpatient units and community teams.

How to administer oxygen therapy:

o Check the cylinder is in date, and the contents gauge is in the green zone. This indicates the cylinder is FULL.  Turn the cylinder on by twisting the hand wheel anti-clockwise to open.

o Attach the oxygen therapy tubing from mask to the valve outleto Turn the flow gauge to 12. This delivers 12 litres per minute. Check the gas is flowing.o Ensure the reservoir bag is inflated, and attach oxygen therapy mask to patiento Check the oxygen contents gauge, and replace the cylinder if the contents are at one quarter or less (in the red). Make sure there is a new

non re-breather oxygen mask available in the grab bag.o Document that oxygen therapy has been administered to patient stating litres per minute delivered.

For further information please refer to:The CNWL Medical Gases Policy and the CNWL Resuscitation Policy are available on Trustnet  (Staff based in Milton Keynes and Surrey please click here).

We are sending this out earlier than usual as we are getting our new IT on Monday 12 June.

Clinical message of the week – 12 June 2017

In a Medical Emergency remember to use DRSAB

Danger – think about your safetyResponse - ask ‘are you alright’ ‘open your eyes’ Shout - loudly for help, activate the alarm and call for the defibrillatorAirway - open airway head tilt/chin liftBreathing – check for 10 seconds then look, listen and feel for breaths

Call 9/999 or 2222 and state what and where the problem is If unconscious place in recovery position If not breathing deliver chest compressions at the rate of 100 – 120 per minute Check your Medical Emergency Procedure – it should be displayed on your ward or unit

For further information please refer to:Refer to the CPR policy available on Trustnet here. (Staff based in Milton Keynes and Surrey please use this link) or contact resus.CNWL@nhs.net

Clinical message of the week – 5 June 2017

Think SAFE when responding to a distressed patient!

Evidence: When people are distressed they may act in a way that is harmful to others. In 2016/2017 there were an astonishing 5,311 incidents of physical assaults and disruptive behaviours logged on Datix across CNWL.

Action:By sticking to the key de–escalation principles described below we can keep both ourselves and those we are working with SAFE.

De-escalation is a useful skill across all services and can be summarised in four easy points Stop and breathe Acknowledge the person and listen to their feelings Formulate a plan and work together Explore and focus on the person’s strengths

For further information please refer to: Please refer to Trustnet for Therapeutic Management of Violence and Aggression policy or click here . (Staff in Milton Keynes and Surrey

please use this link)

We add the clinical message of the week to Trustnet too so you can comment online here. (Staff in Milton Keynes and Surrey, please use this link)

Clinical message of the week – 30 May 2017

Helping smokers quit!

Evidence: Smoking is the leading cause of preventable death and disease in UK. Half of lifelong smokers will die prematurely, losing an average 10 years of life.

Helping smokers quit – Very Brief Advice (VBA), is a skilled ‘clinical conversation’ and not just a chat with a smoker.

Remember to Ask, Advise, Assist and Arrange help for people to stop smoking Ask – everybody their smoking status Advise – how important it is to stop Assist – by providing brief cessation advice Arrange – onward referral to local Stop Smoking Service (SSS)

If we provided this Very Brief Advice (VBA) the proportion of smokers would reduce by 2% each year.

For further information please refer to: Smoke free policy available on Trustnet. (Milton Keynes and Surrey staff should use this link) For staff interested in VBA training there are currently three short online modules on the National Centre for Smoking Cessation and

Training (NCSCT) website. (www.ncsct.co.uk). Such specialist modules are recommended for nurses who might be interested in offering more intense support.

 

We add the clinical message of the week to Trustnet too so you can comment online here. (Staff in Milton Keynes and Surrey, please use this link)

Clinical message of the week – 22 May 2017

Make sure all your patients ‘Drink and eat well’ Evidence: Malnutrition and dehydration remain major clinical and public health issues and are associated with increased rates of morbidity (admissions to A/E) and mortality. Timely and appropriate nutritional and hydration intervention improves clinical outcomes.

Please make sure that

Screening: Patients’ body mass index (BMI) is calculated at the first point of contact with services or at the point of admission and recorded in their notes. The Malnutrition Universal Screening Tool (MUST) is the accredited tool used to identify adults who are underweight and at risk of malnutrition.

Record fluid intake: Appropriate fluids are freely available to patients and recorded on care plans where indicated.

Nutritious food intake: Menus must clearly signpost patients to the healthier options available.

Protected meal times: The therapeutic role of food and the service of food is an important part of patients’ care.

Support: Some patients will require additional support to enable them to eat and drink as independently as possible patients should be assessed for the level of need and support required and it should be documented in care plans.

For further information please refer to: Nutrition and Hydration Policy available on Trustnet. (Milton Keynes and Surrey staff should use this link)

  

We add the clinical message of the week to Trustnet too so you can comment online here. (Staff in Milton Keynes and Surrey, please use this link)

Clinical message of the week – 15 May 2017 ‘Let’s get physical!’ This week highlights the poor physical health of many of our patients with serious mental illness; we can, and need, to change this. I would like consultants, team leaders and managers to print off the information below and use it throughout the week to raise awareness of the issue and the steps we can all take to get better physical health outcomes for these patients. Dr Con Kelly                         Andy MattinMedical Director                    Director of Nursing and Quality Evidence:

         Life expectancy of people with serious mental illness is reduced by up to 20 years because of poor physical healthcare         Internal audits and mortality reviews show that we are not managing their physical healthcare needs very well          Wide use of the Lester positive cardiometabolic health resource leads to better care and outcomes

 1.    Clinical staff in adult, older adult and learning disabilities services should assess and then treat or refer patients (as necessary)

for the following measures:          Blood pressure         BMI         Smoking Status         Blood Cholesterol         Blood Glucose and         Alcohol and          Substance misuse2.    Remember to document this on the electronic patient record either on SystemOne or JADE; staff using JADE must use the new

JADE Physical Health Assessment form (SHINE Physical Health Assessment). For further information please refer to:

        The Trust has Minimum Standards for Physical Health Monitoring in our Adult Mental Health Services. You can view these on Trustnet on the Physical Health page (staff in Milton Keynes or Surrey, please use this link)

        The Lester Cardiometabolic Resource (http://www.rcpsych.ac.uk/pdf/e-version%20NICE%20Endorsed%20Lester%20UK%20adaptation%20.pdf)

Clinical message of the week – 8 May 2017Message of the week is a new way of sharing learning across our organisation. These are clinically focused messages which will go out to all staff each Monday and spend two to three minutes on a key topic. The message should be discussed at your team meeting and at handover meetings every day throughout the week. Dr Con Kelly                         Andy MattinMedical Director                    Director of Nursing and Quality

In cardiac arrest situations delayed use of a defibrillator can lead to severe brain injury and death

Evidence: Learning from resuscitation reviews and a recent death in another London Trust where the coroner issued a verdict of neglect because staff didn’t use a defibrillator immediately and the patient suffered a brain injury and died.

Automated External Defibrillators (AED) - First priorityIf you discover a cardiac arrest - Call 9/999 or 2222 depending on where you are basedShout for help and Start chest compressions, then

Attach the defibrillator pads - The sooner the shock can be delivered the greater the chance of survival1. Open lid to switch on

2. Follow Instructions Given

3. Administer a safe shock if indicated to do so

4. Continue chest compressions,

5. Take out adult resuscitator and attach to oxygen and give two ventilations

6. Continue at a ratio of compressions to ventilations 30:2

For further information please refer to

CPR policy at: http://trustnet.cnwluk.local/Documents/Cardiopulmonary_Resuscitation_CPR_Policy.pdfOr contact Resus.CNWL@nhs.net