14 October 2005 - Melbourne

1. Extra Care Unit Program ReviewPresenter: Jenny Smith Hospital: St Vincent’s Health (Melbourne)Key contact person for this project: Anna Loveanna.love@svhm.org.au(03) 9288 4673 14 October 2005 - Melbourne

2. KEY PROBLEMS • Feedback from staff, patients, and Community Visitors, and Incident reports all indicated a level of dissatisfaction with the physical environment, and the quality of care that could be provided within existing resources. • The demand for ECU (HDU) beds outstripping the number of beds available, resulting in more then three patients being managed in ECU. For example when patients were admitted into ECU from the community or Emergency Department, before the patients already in ECU were reviewed. • On-call Registrar’s were reluctant to move possible high-risk patients onto the open ward after hours due to lack of a written plan being available from the treating doctor. • Patients in ECU were not reviewed early in the day; this in many cases led to frustration on the part of patients.

3. HOW WE DID IT • Project Started:ECU Advisory Committee was formed in October 2002 • Staffing: A senior nurse employed to coordinate the overall management of this process • Funding: One nursing staff salary plussignificant donations of materials and equipment • Duration:2002 -2004

4. INNOVATIONS IMPLEMENTED Physical Environment/Ambience • Extra Care Units - re-painted and floor coverings replaced where necessary. • All toilets and bathroom are now gender designated and can be locked by patients (reversible mechanism) • The garden outside the ground floor ECU - revamped with perfumed and flowering plants and a water feature added. • New vinyl foam lounge furniture and vinyl foam bed bases purchased. • Designated labelled lockers for patients’ belongings available. • Posters depicting scenic views on the walls • Kitchenettes installed in both units, these include a fridge, toaster, microwave oven, tea and coffee making facilities. • Blackboards installed in both courtyards for patient use. This has proved to be beneficial from a therapeutic viewpoint with patients using the blackboards to express themselves when they have been unable to communicate in any other way, e.g. use of drawing to express their delusional beliefs. Patients’ Rights & Responsibilities • brochure, outlining patients’ rights and responsibilities, was developed and printed and given to all patients in ECU. Safety • Development and introduction of a safety checklist • Replacement of hard plastic bedpans and urinals with Papier Maché items. • Introduction and adaptation of the heavy cotton gowns used in Seclusion. • Replacement of hard plastic water jugs and cups with paper items in Seclusion. • Introduction of safety syringes. • Introduction of red woollen seclusion blankets to replace cotton sheets and blankets. • Physical Observation kit was reviewed and replaced with more appropriate safe equipment.

5. INNOVATIONS IMPLEMENTED Activity Program • Whilst recognising the need for a low stimulus environment for patients needing psychiatric intensive care, feedback from both patients and staff had raised the issue of boredom. In an effort to address this issue a number of different groups and programs have been introduced to the Extra Care Units Medical review • form developed which was to be used for all reviews of patients in ECU or being ‘Specialled”. • policy that all patients in ECU must be reviewed in the mornings, so that the Admitting Doctor has a clear understanding regarding the number of patients in ECU when considering potential admissions Staffing • Training: Various training modules and in-service training sessions are available to staff • Orientation: All new staff to the SVMHS must attend an orientation session for the Extra Care Units before they can be rostered to work in the ECU. • Rostering: Staff are rostered to work in ECU for a full eight-hour shift, this has always been the practice, however staff are now allocated to work in ECU from the monthly roster. This practice informs staff a month in advance of when they will be working in ECU. • Staff roles: Clear roles and responsibilities have been developed to assist staff to ensure that a consistent approach is used when working with ECU patients.

6. OUTCOMES SO FAR Evaluation of activity program and effect on p.r.n. medication • Objective: To introduce a daily activity program with patients who require psychiatric intensive care in a locked environment: (HDU) that the activity program would reduce the level of disturbed behaviour as measured by the number of p.r.n., or ‘as required’ medications dispensed. • Method:A crossover between two units intervention study with a convenience sample.Baseline data of p.r.n. medication dispensed to patients was collected for a period of two weeks from both locked units prior to the introduction of the program. The program was conducted for a period of one month in alternate locked units. Both non-intervention and active program data was collected throughout the six months period of the study. • Results: Findings from the study demonstrated that an activity based nursing intervention was effective in reducing the number of p.r.n. medications dispensed in HDU compared with control conditions, the results were particularly significant on one unit. Figure 1 the mean number of p.r.n medications per day in the two wards under the same conditions

7. OUTCOMES SO FAR

8. OUTCOMES SO FAR • Improved consumer and staff satisfaction • Improved quality of care • Improved safety • 2 workshops for clinicians, to share our experience and learning during the review process. About 50 people from across Victoria attended these workshops • Silver Award Winner at 2005 Australian and New Zealand Mental Health Services Conference

9. LESSONS LEARNT • Need to consider model of care of entire inpatient service • Now expanded to include extensive day program on open ward a few months ago • This is one of several strategies addressing AWOL issues • Positive initial results from this in reducing AWOL and demand on ECU