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Involve mental health patients in preventing violence, say NICE proposals

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People with mental health problems should be involved in preventing violent behaviour and get a “debrief” after any incident that involved them being restrained or sedated, suggest proposals.

Proposed new quality standards for dealing with violent or aggressive behaviour also stress the need to monitor the health of patients during and after an incident where they are physically restrained or tranquilised to reduce the risk of serious harm.

“A calm, measured and reasonable approach has the potential to reduce violent or aggressive behaviour”

NICE document

The draft document, published by the National Institute for Health and Care Excellence, follows ongoing concern about the risks of injury, death and emotional trauma to mental health patients who undergo physical restraint.

From today, nurses and others are being consulted on the draft standards, which centre on five core statements and apply to hospital and community settings providing mental health, health and social care services, as well as care delivered at home.

“The five statements focus on caring for people if they had to be restrained to make sure they are handled safely and are helped to understand what went wrong,” said NICE.

Under the standards, people in contact with mental health services who have been violent or aggressive should be involved in identifying triggers and early warning signs to help prevent future incidents.

Patients with a history of violence or aggression should also help pinpoint de-escalation techniques that work for them and be consulted in advance about the use of restrictive interventions.

“A calm, measured and reasonable approach has the potential to reduce violent or aggressive behaviour at any point,” according to the NICE document.

“Identifying de-escalation techniques that have worked in the past, and finding out and recording the person’s preferences increases the likelihood that de-escalation will be effective,” it stated.

“Involving the person who had the intervention gives them the opportunity to discuss their experience”

NICE document

This could include people with a history of violence making a written “advance statement”, which is recorded in their care plan, about how they would prefer nurses and others to deal with repeat incidents, such as physically holding them or giving them an injection of medication.

The standards stress that restraint, tranquilisers and seclusion should only be used as a last resort, when other strategies have failed, and the person is at risk of hurting themself or others.

Anyone who is manually restrained or tranquilised must have their physical health monitored during and after “until there are no further concerns”.

“There is a risk of death from obstructing airways during manual restraint, but harm can also occur after the event,” noted the draft standards, which highlighted the fact existing health conditions may be exacerbated by being physically restrained.

Patients who are given “high-risk” rapid tranquilisation must have side effects, vital signs, hydration level and consciousness monitored, stated the draft standards.

Meanwhile, all patients who are restrained, sedated or placed in isolation, must have an “immediate debrief” to address the physical and emotional impact.

Such a debrief can help understand what led up to a violent incident and “what could have been done differently”, suggested the draft standards.

“Involving the person who had the intervention gives them the opportunity to discuss their experience and give their perspective of the event,” added the draft document.

The consultation runs until 20 February, with the final document expected to be published in June 2017.

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