dhulwa mental health unit (dmhu) - clinical risk ...€¦ · web view2.2.2 the...

CHHS16/220

Canberra Hospital and Health ServicesClinical Procedure Dhulwa Mental Health Unit (DMHU): Clinical Riske Assessment and Management – Violence and AggressionContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Introduction............................................................................................................2

Section 2 – Clinical Risk Assessment.........................................................................................2

2.1 Recovery and Positive Risk Taking...................................................................................3

2.2 Clinical Risk Assessment Tools........................................................................................4

2.2.1 Dynamic Appraisal of Situational Aggression: Inpatient Version (DASA-IV).............4

2.2.2 The Historical-Clinical-Risk Management-20 (HCR-20 V3)..........................................4

2.2.3 Anamnestic assessment...........................................................................................5

Section 3 – When to conduct a clinical risk assessment............................................................6

Section 4 – Documentation of the TPRIM.................................................................................7

Implementation........................................................................................................................ 7

Related Policies, Procedures, Guidelines and Legislation.........................................................8

References................................................................................................................................ 9

Search Terms............................................................................................................................ 9

Attachments............................................................................................................................10

Attachment 1 – Sample DASA-IV.........................................................................................11

Attachment 2 – Sample Treatment and Management Plan - TPRIM...................................12

Doc Number Version Issued Review Date Area Responsible PageCHHS16/220 1 21/11/2016 01/11/2018 MHJHADS - JHS 1 of 15

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

CHHS16/220

Purpose

The purpose of this procedure is to provide clinical staff with information regarding processes for the assessment and management of the risk of violence and aggression in consumers at Dhulwa Mental Health Unit (DMHU).

This procedure is underpinned by the Clinical Risk Assessment and Management (CRAM) A Practical Manual for Mental Health Clinicians placeholder accessible from the ACT Health Policy Register.

Back to Table of Contents

Scope

This document applies to all clinical staff working within DMHU.


Section 1 – Introduction

In a secure mental health setting there are many risks that can be identified, mitigated and managed with comprehensive clinical risk assessment and management procedures. The risks include self-harm, suicide, victimisation, reputation, non-adherence to treatment and violence and aggression. This procedure considers only the issues of risk of violence and aggression. All other risks applicable to consumers must be considered by the Multidisciplinary Team (MDT) as part of a comprehensive clinical assessment.

All DMHU clinical staff must be formally trained in Clinical Risk Assessment and Management (CRAM). This training is informed by the CRAM: A Practical Manual for Mental Health Clinicians placeholder accessible from the Policy Register.

All consumers that are admitted to DMHU must be comprehensively assessed for risks at the times as set out in this procedure and at any other times where it is clinically, operationally or legally appropriate to do so. All risk assessments must be documented in the consumer’s clinical record.


Section 2 – Clinical Risk Assessment

Risk assessment is a continuous process which forms an integral part of clinical care and risk management at Dhulwa Mental Health Unit (DMHU). It is a task that is completed on an ongoing basis and not at a single point in time. A structured approach to risk assessment improves the reliability of decisions regarding risk management based on those risk assessments. The risk assessment is used to determine factors that may indicate risk level



CHHS16/220

and assist with the development of the realistic risk management plan that can be implemented.

Principles of risk management in DMHU are as follows: Risk is dynamic and continually changes. Clinical Risk assessment and management is a continual process. A risk assessment is never complete without a risk management plan that has been

documented, communicated to the clinical team and implemented. Risk cannot be eliminated and therefore, any identified risks are managed using the risk

management plan. Risk assessment and management begins with the identification of risk factors, for the

consumer and using assessment tools that are reliable and evidence based. No single risk factor predicts the outcome. Identification of risk factors allows clinicians to develop and implement a plan to manage

those risk factors. Risk factors may be unrelated to mental illness symptoms. However, a consumer’s

mental illness symptoms, when present, may significantly alter risk and provide opportunities to provide treatment to modify risk.

Dynamic factors external to the consumer should also be reviewed such as unit dynamics, staff factors, as well as the presence of protective factors.

2.1 Recovery and Positive Risk TakingRisk assessment should maximise the involvement of consumers and carers, nominated persons, emphasising strengths, protective factors, positive risk-taking and recovery. A recovery oriented mental health service should balance, and support, opportunities for positive risk taking whilst considering duty of care and risk of harm to self and others. In other words, decisions are made with the aim of improving the consumer’s quality of life and the recovery journey. However, DMHU clinical staff must remain aware of the safety needs of the consumer, their carer, family and friends, and the public.

As part of the CRAM process, positive risk taking: is part of a carefully constructed plan that is developed through a collaborative approach

and documenting the agreed plans accordingly. involves making decisions based on knowledge of research evidence, knowledge of the

consumer’s own experiences, clinical risk assessment and clinical judgment. involves using available resources and support to achieve the desired outcomes, and to

minimise the potential harmful outcomes. includes decisions that carry some risks. This should be explicit in the decision making

process and will involve working with the consumer and /or their carer/nominated person and documenting the agreed plans accordingly

2.2 Clinical Risk Assessment ToolsThere are a number of approaches to risk assessment and in DMHU the Dynamic Appraisal of Situational Aggression: Inpatient Version (DASA-IV), HCR-20 (Historical, Clinical, Risk 20 item checklist) and Anamnestic Assessment will be used as tools to assess for risk of violence. The assessments using these tools will assist in the completion of the Clinical Risk Doc Number Version Issued Review Date Area Responsible PageCHHS16/220 1 21/11/2016 01/11/2018 MHJHADS - JHS 3 of 15


CHHS16/220

Assessment and Management Plan in the TPRIM format (Treatment, Placement, Restrictions, Implementation and Monitoring). The forms will be available on the Clinical Forms Register or a file note will be used on the clinical record for the Anamnestic Assessment.

For further information on these risk assessment tools, please refer to the CRAM: A Practical Manual for Mental Health Clinicians accessible through a placeholder on the Policy Register.

2.2.1 Dynamic Appraisal of Situational Aggression: Inpatient Version (DASA-IV)The DASA-IV is a seven item risk assessment tool to assist identifying consumers at risk of aggression within the next 24 hours. The seven items are as follows: Irritability Impulsivity Unwillingness to follow instructions Sensitive to perceived provocation Easily angered when requests are denied Negative attitudes Verbal threats

The DASA-IV must be completed by a clinician who has been trained in the use of the tool and who is familiar with the current presentation of the consumer being assessed.

Refer to Attachment 1 for a sample DASA-IV Form.

2.2.2 The Historical-Clinical-Risk Management-20 (HCR-20 V3)

The HCR-20 V3 is a 20-item checklist that is used to identify further violent behaviour. The HCR-20 assesses both static and dynamic risk factors associated with an increased risk of violent recidivism. It asks assessors to utilise a range clinical information sources to determine the presence of past, recent, or potential future problems with identified risk factors which may be a feature of their history, clinical presentation, or context/situation.

The ten Historical (past) items are as follows: 1. Violence2. Other antisocial behaviour3. Relationships4. Employment5. Substance use6. Major Mental Disorder 7. Personality Disorder8. Traumatic Experiences9. Violent Attitudes10. Treatment or Supervision Response

The five Clinical (present) variables are as follows:1. Insight2. Violent Ideation or Intent3. Symptoms of Major Mental DisorderDoc Number Version Issued Review Date Area Responsible PageCHHS16/220 1 21/11/2016 01/11/2018 MHJHADS - JHS 4 of 15


CHHS16/220

4. Instability5. Treatment or Supervision Response

The five Risk (future context) variables are as follows:1. Professional Services and Plans2. Living Situation3. Personal Support4. Treatment or Supervision Response5. Stress or Coping

The HCR-20 V3 must only be completed by a clinician who has been trained in the use of the HCR-20 V3 tool or under the supervision of a clinician who has been trained in its use.

A decision will be made by the MDT about the use of additional assessments based on individual clinical need. The use of the HCR-20 V3 may be complemented by the use of other relevant assessments including the SAPROF (Structured Assessment of Protective Factors for violence risk) and PCL-R (Psychopathy Checklist - Revised). In addition, specialist assessments of personality, sexual offending risk, stalking risk, or arson risk may be utilised. A decision will be made by the MDT about the use of additional assessments based on individual clinical need.

Alert: In the case of young persons (a person aged between 12 and 18), the SAVRY (Structured Assessment of Violence Risk in Youth) will be used as an alternative to the HCR-20 V3 unless clinically indicated otherwise.

The SAPROF, PCL-R and the SAVRY will be available in the clinical record and must only be completed by a clinician trained in the use of the tool or under supervision of a clinician who has been trained in its use.

2.2.3 Anamnestic assessment

An Anamnestic assessment involves a detailed review of previous incidents of violence and aims to identify common factors and patterns. The analysis will assist in ensuring the risk management plan for each consumer addresses the consumer’s individual needs and vulnerabilities. The assessment should be completed on the most recent and/or serious episodes of aggression.

The Anamnestic assessment will utilise the 5 W’s format by reviewing the Who, What, Where, When and Why across the incidents: When the episode occurred Where it occurred Who the victim(s) were (role, age, sex, and relationship) What behaviour they engaged in and what the consequences were Why they engaged in the behaviour



CHHS16/220

A 5W’s report should also be completed after each incidence of violence as a file note in the clinical record with 5Ws at the beginning of the file title. This information could also be included in the Riskman Clinical Incident report form.


Section 3 – When to conduct a clinical risk assessment

A comprehensive risk assessment must be conducted at the following times: Admission – on admission to DMHU each consumer must have a documented interim

risk assessment (completed on the DMHU Admission Assessment form and TPRIM. Both forms are available on the Clinical Forms Register.o DASA-IV must be completed daily by a clinician who has been trained in the use of

the tool and who is familiar with the current presentation of the consumer being assessed.

o The HCR-20 V3 will generally be done within six to eight weeks of admission and reviewed at the time of the three-monthly Individual Case Review (Refer to the DMHU Referral, Admission and Transfer of Care Procedure).

Review – at each MDT Ward Round the consumers TPRIM must be reviewed and updated. The HCR-20 V3, SAPROF and TPRIM will be reviewed and updated at each Individual Case Review meeting, held every 3 months, with full risk HCR-20 V3 and SAPROF risk assessments formally conducted every 6 months. All risk assessment tools and documents can be reviewed at any time if clinically indicated.

Leave – if a multidisciplinary team is considering an application for community leave then a risk assessment must be completed and the TPRIM must be updated identifying how the plan (incorporating the management of identified risk factors) can be safely implemented and included as part of the leave application.

Reports – prior to the preparation of reports for the ACT Civil and Administrative Tribunal (ACAT) or other body, a risk assessment must be completed and the TPRIM updated.

Discharge Planning or Transfer of Care – when recommending the discharge or transfer of care of a consumer to another setting, a risk assessment must be completed and the TPRIM updated identifying how the Treatment & Management Plan (incorporating the management of identified risk factors) can be safely implemented in the proposed environment.

In addition, a risk assessment must be completed if there is a significant change in the consumer’s clinical status or risk factors, or in the event of a serious incident of violence or other harmful behaviour. An Anamnestic assessment is to be conducted after an incident.


Section 4 – Documentation of the TPRIM

To document the CRAM for a consumer, the TPRIM must be completed in the clinical record. The TPRIM is the tool used to document the management plan, once a clinician has



CHHS16/220

completed the clinical risk assessment and formulation. The document is also used for regular monitoring and review of the consumer’s progress with the management plan.

The process for developing a plan is documented in detail in the CRAM: A Practical Manual for Mental Health Clinicians placeholder accessible from the Policy Register. Below is an overview of what is required in each section of the document and a sample TPRIM is located in Attachment 2.

Treatment – the biological, psychological and social treatment interventions to address historical but predominantly dynamic risk factors and strengths.

Placement – determining where the location of treatment and decision making in regards to ensuring the least restrictive alternative is used and balancing this with enabling safe delivery of care to the consumer.

Restrictions – referring to the constraints and coercive mechanisms that might be required to keep the person safe and reduce opportunity to harm others. Restrictions can be:o environmental (external to the person and manipulated by others),o personal (internal and relies on the person’s motivation to adhere), oro legal (legislation or orders).

Implementation – identifying who is responsible for implementing the plan. Monitoring – determining what needs to be monitored, by whom and when. Review – identify when and who will review the TPRIM.

Refer to Attachment 2 for a sample Treatment and Management Form.


Implementation

The contents of this procedure will be communicated through the following means to DMHU staff: Education Orientation documentation and sessions Leadership and governance expectations regarding adherence to policy, procedure and

legislation. This will be monitored with Performance Management plans. Structured Case review and MDT Ward Rounds that reflect the procedure


Related Policies, Procedures, Guidelines and Legislation

Policies ACT Health Work Health and Safety Policy ACT Health Work Health and Safety Management System ACT Health Incident Management Policy ACT Health Consumer and Carer Participation Policy



CHHS16/220

ACT Health Waste Management Policy ACT Health Electrical Safety Policy ACT Health When Death Occurs Policy CHHS Medications Handling Policy

Procedures ACT Health Incident Management Procedure ACT Health Significant Incident Procedure ACT Health When Death Occurs Procedure CHHS Clinical Handover Procedure CHHS Healthcare Associated Infections Procedure CHHS Mobile Electrical Equipment including Clinical Equipment MHJHADS Director on Call Roles and Responsibilities Procedure MHJHADS Unauthorised Leave of Admitted People from MHJHADS Inpatient Units MHJHADS Clinical Handover Procedure MHJHADS Significant Incidents Reporting Procedure MHJHADS Assessment and Intervention for People Vulnerable to Suicide Procedure MHJHADS Confidentiality, Privacy and Access to MHJHADS Clinical Records MHJHADS Daily Clinical Meetings in Community Mental Health Settings Procedure MHJHADS Clinical Management for Mental Health Services Procedure DMHU Search Procedure DMHU Referral, Admission and Transfer of Care Procedure

Guidelines Placeholder - Clinical Risk Assessment and Management: A Practical Manual for Mental

Health Clinicians

Frameworks DMHU Security Procedural Framework



CHHS16/220

Standards Australian Charter of Healthcare Rights National Standards for Mental Health Services 2010 National Safety and Quality Health Service Standards 2012

Legislation Mental Health Act 2015 Mental Health (Secure Facilities) Act 2016 Children and Young People Act 2008 Public Advocate Act 2005 Human Rights Act 2004 Carers Recognition Act 2010 Health Records (Privacy & Access) Act 1997 Guardianship and Management of Property Act 1991 Crimes Act 1900 Privacy Act 1988 Discrimination Act 1991 Work Health and Safety Act 2011 Corrections Management Act 2007 Official Visitor Act 2012


References

1. Allnutt, S., O’Driscoll, C., Ogloff, J.R.P., Daffern, M. & Adams, J (2010) Clinical Risk Assessment and Management: A Practical Manual for Mental Health Clinicians. Sydney, NSW; Justice Health

2. Dept of Health, National Risk Management Program (2007) Best Practice in Managing Risk. London, United Kingdom: National Risk Management Programme

3. National Mental Health Strategy (2013) A national framework for recovery-oriented mental health services: Guide for practitioners and providers. Canberra, ACT: Commonwealth of Australia

4. NHS (2014) Clinical Guidelines for the Assessment and Management of Clinical Risk, South Essex Partnership University NHS Foundation Trust

5. NSW Govt (2011) Clinical Risk Assessment and Management – The Forensic Hospital Policy. Sydney, NSW: Justice Health


Search Terms

Clinical Risk Assessment, Violence, Aggression, DMHU, Dhulwa, TPRIM, Risk Assessment Tools, DASA, HCR20, CRAM, Anamnestic




CHHS16/220

Attachments

Attachment 1 – Sample DASA-IVAttachment 2 – Sample Treatment and Management Plan - TPRIM

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair



CHHS16/220

Attachment 1 – Sample DASA-IV



CHHS16/220

Attachment 2 – Sample Treatment and Management Plan - TPRIM

XXXXXXXXX 20/05/23MANAGEMENT PLAN

RISKS Physical Aggression – towards peers, nursing staff and serious episode of aggression towards medical teamEARLY WARNING SIGNS Increasing irritability and expressed anger Increasing persecutory and bizarre ideas (particularly of a sexual and violent nature) Increasing thought disorder Increasing use of neologisms Worsening sleep pattern Increasing preoccupation with his perceived needs not being met (issue regarding PRN medication has

been ceased by stopping this as a treatment option) Speaking in a louder volume and speech more pressured, particularly on the telephone with his father Engaging staff and fellow patients in a fixed stare Non-compliance with overall management plan Increased concerns regarding financial issues Perceived challenge to ward status Denial of access to a tangible object that he perceives he should have access to – particularly medical

review e.g. dentist Repeatedly seeking staff attention at the nursing staff station (lessened by increased staff presence in the

area) Medical problemsTRIGGERSExternal Factors Lack of contact with family Contact with father when financial or other triggers are discussed, leading to reciprocated increased

agitation Mental Health Review Tribunal review Significant losses & external psychosocial stressorsWard Factors Actual provocation by fellow patients New admissions to the unit – this is less of a trigger recently Fellow patients not reacting to initial verbal hostility and intimidation by xxxx or responding in a

provocative manner – less evident over last 6 months Loss of informal supports when patients progress on from ward Upcoming ACAT Distress over movement of other patient’s discharge pathwaysStaff Factors Inconsistency in tolerating patient X’s levels of aggressive behaviour Inconsistency in management plan Inconsistency in addressing Patient X’s early warning signsPROTECTIVE FACTORS

TREATMENTPharmacological / Biological Regular Medication as charted PRN Medication as per chart and as clinically indicatedPsycho-social Reflective interventions & positive feedback throughout the day Continue to provide Patient X with CONSISTENCY in his daily plan, routine & medication management



CHHS16/220

Staff to contacting XXX (father) regularly to keep him informed & keep communication lines open, also contact XXX mother, Ms xxxx.

Increased attendance in therapeutic programs as per timetable Continue to implement early distraction techniques & diversional activities (such as going for walks /

watching television) when observed to be displaying any EWS. Continue to liaise with psychology re: ongoing interventions- on hold until early 2014GroupsCompletedCurrently attending Computer group Gardening groupReferred Addressing Substance Use, Module 1PLACEMENT Bronte, 17 bedded side - Room 23 Ongoing discussion with regard to medium secure placement. To be referred to Complex Needs Committee re future placement. Has voiced willingness

to go to Orange.RESTRICTIONS Scale C2 General observations. Phone calls limited-SEE SPECIFIC MANAGEMENTIMPLEMENTATION Care Coordinator to ensure management plan implemented reviewed weekly by MDT. Care Co-ordinator: xxxxx Associate Care Co-ordinator: xxxxxMONITORING Review extent of clinical staff being incorporated into his delusions Weekly ECG: on Tuesdays Clozapine protocol Date of last ECHO: 06th February 2013 Date of last dental appointment: 1.3.13 – treatment in progress Document MSE and level of arousal post attendance at Computer group on Tuesdays. Cardiology appointment – continue 6-12 monthly review. On-going Hep C monitoring Monitor his willingness to engage in mediation with co-pt xxxx. Monitor for potential bullying of co-patients when they are on the phone – when he wants to get

on the phone he will demand they get off immediately. Attended dentist: 13/01/2014RESTRICTIONS Scale C2 General observations. Phone calls limited-SEE SPECIFIC MANAGEMENTIMPLEMENTATION Care Coordinator to ensure management plan implemented reviewed weekly by MDT. Care Co-ordinator: xxxxx



CHHS16/220

Associate Care Co-ordinator: xxxxxMONITORING Review extent of clinical staff being incorporated into his delusions Weekly ECG: on Tuesdays Clozapine protocol Date of last ECHO: 06th February 2013 Date of last dental appointment: 1.3.13 – treatment in progress Document MSE and level of arousal post attendance at Computer group on Tuesdays. Cardiology appointment – continue 6-12 monthly review. On-going Hep C monitoring Monitor his willingness to engage in mediation with co-pt xxxx. Monitor for potential bullying of co-patients when they are on the phone – when he

wants to get on the phone he will demand they get off immediately. Attended dentist: 13/01/2014SPECIFIC MANAGEMENTTelephone Calls xxxx numbers to remain deactivated at all times other than those indicated below. If xxxx becomes abusive, hostile or threatening → phone call to be terminated.Phone calls to father: xxxxxx Maximum of two phone calls to father each day, one in the morning and one in the

afternoon/evening. Times to be negotiated between xxxx and his nurse and documented in file. If xxxx is unavailable without previously notifying staff then xxxx is not to repeatedly call. Staff

should call Bill so they can reassure Luke re his father.Phone calls to mother xxxx has been asked to call his mother less frequently e.g. 1930 hours If xxxx continually calls his mother MDT to implement set plan similar to abovePhone calls to others No phone calls to the bank Phone calls to xxxxx, Solicitor, once a week Tenille to speak with xxxxxx (friend) about concerns he has expressed about xxxx calling him too

frequently.Visits from father: xxxx xxxx has been informed he is to call the ward upon his arrival (to reduce the chance of security

error such as not calling the ward) Staff are to be at the front gate 10/60 prior to xxxx visit time to ensure a timely visit xxxx permitted to call xxxx post visit to ensure his safety xxxx has been informed to notify the ward if he is running late & staff are to notify Luke so he is

aware If staff go to the front gate 10/60 prior to the visit time & xxxx is not there OR he is late & has not

contacted the ward - please contact allocated nurse or care coordinator so she can speak directly with xxxx about this issue

xxxx nurse for the day to inform xxxx of such an instance with reassurance and reality orientation at the forefront.

After Visits This can be a difficult time for xxxx, even for several days. Requests for PRN need to be

explored with LukeManaging Aggressive/Threatening Behaviour



CHHS16/220

One nurse to be communicating with xxxx. Provide him with options and a rationale for same, i.e. time out in bedspace, PRN medications-to help ensure the safety of self and others. Validate concerns but firm limits and redirection re: appropriate behaviours.

Next ACAT meeting date: 24/04/2014

Next Individual Case Review date: 8/04/2014

Primary nurse has discussed plan with xxxxx.Signed: _______________________



dhulwa mental health unit (dmhu) - clinical risk ...€¦ · web view2.2.2 the...

Documents