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The State Hospital
Physical Health Interventions in
High Secure Care
Frances Waddell (Lead Dietitian)
Karen Burnett (Learning/Development)
AIMS & OBJECTIVES
Aim:
The aim of this workshop is to gain an understanding of
the Physical Health challenges in delivering physical
health interventions within a High Security Hospital.
Objectives:
To describe the facilities & health related services
available within the setting.
To describe some of the strategies to support physical
health and the challenges in implementation.
The State Hospital
The State Hospital
INTRODUCTION
The State Hospital
ABOUT US
It is part of the NHS in
Scotland and provides care
for patients from Scotland
and Northern Ireland.
The State Hospital
ABOUT US
As a Special Health Board is accountable to
Scottish Ministers through the Scottish
Government.
There are 140 high-secure beds for male
patients requiring maximum secure care: 12
specifically for patients with a learning disability.
The State Hospital
ABOUT PATIENTS
All patients are male, with an average age of 42.
75.5% of the patients are restricted and the most
common primary diagnosis is schizophrenia.
The current average length of stay is 6.8 years, with
individual lengths of stay ranging from two months to over
30 years.
The State Hospital
ADMISSIONS / DISCHARGES
During 2015/16 there were 36 patient admissions
and 39 patient discharges.
Patient Discharges (39)
3
11
25
Courts
Prisons
Other NHS Hospitals
Patient Admissions (36)
13
9
13
1
Courts
Prisons
Other NHS Hospitals
Community
The State Hospital
642 staff worked at The State
Hospital (31 March 2016)
ABOUT STAFF
The State Hospital
OLD TO NEW!!
In 2008 the
State Hospital
signed the
contract to
begin the
transformation
The State Hospital
In 2011 the
new State
Hospital was
complete!
The State Hospital
PATIENT ACTIVITY
There are seven purpose built
patient activity centres within the
Skye Centre:
Atrium (i.e. social club / hobbies)
Craft & Design
Patient Learning
Primary Care (i.e. Health Centre)
Sports & Fitness
Woodcraft
Gardens & Pet Therapy
The State HospitalThe State Hospital
HEALTH CENTRE
The Health Centre aims
to meet and support
most primary healthcare
requirements of patients.
The State Hospital
HEALTH CENTRE
• Admission Bloods
• ECG
• Optician
• Dentist
• Podiatrist
Blood Borne Virus Assessment by APIC
The State Hospital
SPORTS & FITNESS
Offer many varied
sports and activities
throughout the day,
and at weekends.
The State Hospital
PHYSICAL ASSESSMENT
PROCESS
Patient Admission Pathway Variance
Analysis Tool
What is it?
The State Hospital
NURSING INTERVENTIONS
Day of admission• Complete particulars of admission and pass to Health
Records
• Complete Observation Level plan in PMVA section of RiO
• Complete Blood Borne Virus risk assessment on RiO
• Physical examination completed on RiO and forwarded to Health Centre (including neurological examination & general medical history completed)
• Initial admission risk assessment tool completed on RiO(as per PMVA Policy)
• Carer/relative successfully contacted
PHYSICAL HEALTH V MENTAL
HEALTH!
• Priority?
• Obesity levels are rising
• Co-morbidities
• In Scotland Food, Fluid and Nutritional
Care standards 2003/updated 2014
• National Catering and Nutritional
Specification 2010.
The State Hospital
STATISTICS
• Over 85% patients are overweight or
obese
– Increasing trajectory since records started
in 2003
• Over 40% have Metabolic syndrome
– Higher rates in those on Clozapine
• Over 17% have diabetes (mainly type 2)
– Majority developed following admission to
HSC
The State Hospital
HEALTH CARE
• Focus on health promotion - education
– Weight management
• Dietetics focus predominately on co-
morbidities of overweight and obesity
• Gastrointestinal difficulties
• Some therapeutic need around liver
conditions, renal impairments, cancer,
neurological illnesses
The State Hospital
The State Hospital
NUTRITIONAL SCREENING
TOOL
Why must we Nutritionally Screen Patients?
• National Standards (QIS (Scotland) 2003)
• Recommended as good practice (BAPEN 2003)
• To be able to manage their nutritional care appropriately
• To manage any risks associated with their nutritional care
• To provide optimum nutritional care to support their recovery.
NUTRITIONAL SCREENING
• Agreed screening to occur by day 7
(vs. national recommendation of 24hrs).
• Local validated tool used to reflect
mental health needs.
• Nutritional care plan developed by day
14.
– Focus to develop these into Nutrition and
health care plans.
The State Hospital
NUTRITIONAL SCREENING TOOL
(TSH)
• Developed in-house
• Validated
• External medium secure hospital input
• Based on MUST (BAPEN’s national
NST)
• Identifies risk factors relevant to Mental
Health
The State Hospital
The State Hospital
SECTION 2
The State Hospital
SECTION 3
The State Hospital
SECTION 4SECTION 4 - Nutritional Assessment Comments/
Details
1. Has the patient been prescribed an antipsychotic,
antidepressant or mood stabiliser?
YES = 1
NO = 0
UNKNOWN =0
1. Does the patient have any ongoing physical. (therapeutic
reason for a special diet or require assistance Examples are
allergies, diabetes, constipation, high cholesterol, ethnic or
religious needs physical or learning disability)?
YES = 1
NO = 0
UNKNOWN =0
1. Is the patient currently experiencing any physical short-term
acute illness, disease or treatment which may limit their ability
to meet their current nutritional requirements? (examples are
vomiting and diarrhoea, flu, infection, chemotherapy)
YES = 1
NO = 0
UNKNOWN =0
1. Does the patient have difficulty chewing, swallowing, or
digesting food? (If swallowing difficulties reported, refer
directly to Speech and Language Therapist)
YES = 1
NO = 0
UNKNOWN =0
1. Does a global assessment of the patient suggest inappropriate
nourishment? (loose/tight fitting clothes, fragile skin, poor
wound healing, apathy, wasted muscles, poor appetite, altered
taste sensation, altered/heavy smoking habits).
YES = 1
NO = 0
UNKNOWN =0
1. Does the patient indicate a disordered eating pattern (e.g.
binging, restricting food) or pre-empt thoughts for food, and/or
refuse 2 or more meals a day?
YES = 1
NO = 0
UNKNOWN =0
SECTION 4 score (maximum score 6) = _ _ _
The State Hospital
SECTION 5
INTERVENTIONS
• Dietetics
– 1:1
– Small group interventions
– LCD/Orlistat
• Groups
– ‘Slim and trim’ – weight watchers style group
– Healthy Living Group (HLG) – Psychological,
Dietetics and sports/activity staff
– Healthy Eating Group (HEG) – OT led
The State Hospital
WEIGHT MANAGEMENT
PATHWAY
The State Hospital
SUPPORTING HEALTHY
CHOICES
• Prevention
– Patient & carers information packs on
nutrition
– Earlier opportunities for physical activity
– Healthy lifestyle (nutritional care) plan
• Including assessment of intake/expenditure
The State Hospital
SUPPORTING HEALTHY
CHOICES
Reduction– Weight management groups on all hubs
– Implementation of healthy retail standard
guidelines (SGF)
– Cessation of external food purchases
– Individualised shopping plans/wide options
– Visitors guidance to bring food items based on
healthy lifestyle plans only
– Exercise equipment on wards/outside gyms
– Calorific notification on the menus
The State Hospital
The State Hospital
DAY 14
• BEST-Index Assessment Completed on
RiO(+ Care Plan updated)
• PECC Nursing Assessment Completed
on RiO(+ Care Plan updated)
• Complete LUNSERs/GASS and pass
to Health Records(if approp, e.g. if on
anti-psychotic medication)
• Nutritional Care Plan completed
The State Hospital
BY DAY 42
• Admission fitness assessment
completed
• Dietetic report completed on RiO and
MDT informed Dietician discusses
content of report with patient prior to
Admission Case Review and log
conversation in RiO Progress Notes
The State Hospital
THE STATE HOSPITAL LDP
2013-2016 TARGET
• National Target of 30mins
x 5 days per week
• The State Hospital target of
30mins x3 days per week
The State Hospital
ADMISSION PHYSICAL ACTIVITY
PATHWAY
Initial Sports & Fitness assessments completed: -
PARQ, Fitness assessment, Motivation & goals assessment
Hub fitness room induction completed
Drop-ins to Sports & Fitness
Skye Centre induction completed
Referred to Sports & Fitness and allocated sessions
Sports & Fitness induction completed
PHYSICAL ACTIVITY
3 main opportunities
• On ward
– pacing, patio area, games
• On hub
– interactive games, pool, hub gym, pacing
• Activity Centres –
– Sports centre with gym, weights, gardens, pet
& animal assisted therapy
Definition of physical activity
The State Hospital
The State Hospital
CHALLENGES
• Motivation – Patients
• Competing with other disciplines &
activities e.g. Psychological therapies,
OT sessions, shop
• Resources
The State Hospital
THE WAY FORWARD
• Ensuring / reinforcing Physical Health is everyone's responsibility
• Physical Activity Leaflet
• Collaborative working
• Trainee health psychologist
• Health Improvement Model – Health Champions!
YOUR THOUGHTS!
What are your thoughts on our LDP target
30mins 3 x/week v National
recommendations 30mins 5x/week
– Are you meeting the targets?
What strategies have you implemented in
relation to any issues faced by us?
The State Hospital
The State Hospital
WHAT DO YOU DO?
