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Did ICU in ICU?

The physical intervention lead from an Emergency Department got in touch with ourselves when they suddenly found themselves dealing with repeated accounts of injury, which arose from incidents involving a small number of patients in their Intensive Care Unit. These were patients who, as they emerged from sedation, exhibited behaviour that staff found to be really challenging and which was certainly of concern. Patient and staff injuries were considerably noteworthy – not that any injury shouldn’t be, lest we forget staff safety is paramount for patient safety;

“The legal right for staff to remain safe at work outweighs ethical considerations in the provision of treatment to patients.”

“It is unlawful for any NHS Trust to remove the legal right of staff to defend themselves.”

Dr Tony Bleetman

Emergency Departments are a consultant led 24 hour service with full resuscitation facilities and designated accommodation for the reception of accident and emergency patients. Emergency Departments often manage patients who may exhibit behaviours of concern. These are often associated with mental health problems, a learning disability, dementia, intoxication (alcohol/drugs) and autism.

It was acknowledged that these individuals who predominantly presented with head injuries, were young and many already had pre-existing diagnoses such as being on the autistic spectrum or identified as having ADHD. This could potentially indicate that staff may have already found certain behavioural traits, acts or omissions challenging even without the kind of trauma and distress that accompanies the ordeal of being seriously injured and waking up from sedation in a strange place. In a typical twist of fate, the incidents where the behaviour of a very small percentage of patients challenged staff, well they all seemed to be happening at exactly the same time adding further strain to the department.

In finding it difficult to manage this high risk patient group, staff found they were really struggling to manage aspects of behaviour which resulted in the patients trying to hurt themselves - through the pulling out of life preserving and safety critical devices, and hurting staff through uncoordinated lashing out. In many cases, staff claimed to be almost entirely sure that none of this was intentional and was more accountable to the fact that they were simply so confused by what was going on.

The lead estimated that around eighty percent of patients coming round from sedation could wake up with symptoms categorised as agitated or, suffering from so called ‘emergence delirium’. Patients are likely to be confused anyway due to anaesthetic agents, sedation or other medications they may have in their system. The use of certain recreational drugs and substances may also play a part in labelling patients as having “immunity” to certain routine drugs that may be prescribed as part of their pathway to recovery.

As part of the training needs analysis for this client, we looked at the system of physical skills and also asked the question of whether further medicating the patient was a safe option. Now this is where I was told, that it really isn’t as simple as just re-sedating patients. If a patient had a head injury, it's vital to assess their neurological function. If you keep sedating them, just to keep others safe? Well there’s a very high chance (amongst other risks) that you could delay their recovery process and even increase the risk of long term damage. One view I have heard is that certain types of sedation simply don’t act in the same way right across the board and some patients do appear to be ‘immune’ to sedation. In these cases, no matter how much was administered, it was having very little effect even where different combinations or “cocktails” of drugs were used. A safe way of trying to manage these patients needed to be sourced as aside from chemical restraint, physical restraint was failing or was being over-relied on. The amount of time an intervention lasts for should be just as important as the position the patient is held in when weighing up all variables and, considering how to evidence that the least intrusive and least restrictive option has been implemented. Also of concern when considering what is proportionate are dignity and how anxiety is managed, for all involved.

This problem isn’t one of magnitude or great scale, it’s not a daily or even weekly occurrence to put this in perspective, if you imagine 1000 – 1200 patients were in the ward annually we are talking about 4-6 patients who would fit this profile. A tiny amount of patients falling into this highly challenging category, where it may be necessary to keep them sedated for a longer period of time for their own recovery. The aim of looking at using Soft Restraints as a less intrusive option was to reduce the risks of repeated episodes of physical restraint - which in itself is exhausting, (if you’ve been part of a restraint team you will acknowledge how your body feels the next day) are likely to fail and, let's face it, are prolonged at best. As with any potential implementation or governance process, I always prefer to be part of the MDT and to perform a training needs analysis with the specialists from the workplace. The conclusion of this TNA would also help us to highlight what equipment or PPE may need to be sourced and implemented and, the correct policies and procedures that should be implemented (Section 6 requirements for ourselves and PUWER compliance for our clients).

The journey we all went on to justify their use involved far more staff members than were present at the initial chats and demonstrations, there ensued a strict governance process which included a really diverse multi disciplinary team. Participants included all the Clinical educators, the Matron, the lead consultant in ICU whose input was pivotal, Safeguarding, infection control, manual handling and of course the physical intervention lead. With the aim to try and find the best solution which would equally protect staff as it would the patients by ending these prolonged, highly intrusive and high risk restraint episodes. Now the whole team agreed that we simply didn’t like the term ”mechanical restraint” which was antiquated and conjured up images of archaic devices that should be confined to museums. The term 'Safe-Holding System' sat well with the group and looked 'right' on paper - may seem like a case of semantics or a euphemism but there's no point using a word every day that makes you wince. As we explored the various modules of the kit, how they could ease the stress by automating and mechanising the holding of limbs and above all make their processes safer- for all. It became apparent to many who were seemingly against the use of such devices initially, these were tools in the toolbox that exist somewhere between prolonged manual restraint and chemical restraint.

The physical intervention lead from the trust told me afterwards that after viewing some suggested devices from other providers, there was a certain level of mistrust associated with any items of mechanical restraint. She explained that it was refreshing to hear ion this occasion from the staff;

‘Wow this could be it, this could be what we need’
‘This could be a potential option for us to consider’

Every bedside a story

I remember being invited down to the hospital, making my way up the labyrinth of corridors to the ominous ICU ward. what opened up in front of me was an intimate and private story in each enclosed cubicle. A window into these poor people's worlds, a club we will all be in or be a part of at some point as clinical decisions and emotions stand shoulder to shoulder with compliance and compassion I guess. It was a real eye opener for me.

Delivering demonstrations in a side room with a bed that until a short while before was occupied, left me unnerved and wondering what twist of fate led each person to be incapacitated and cared for by the wonderful ICU staff I was in discussions with and, above all being scrutinised by. Working across various sectors and as I get older I am always learning from the specialists we visit, other trainers and the people who are on the frontline using our products. As my job is generally explaining general health and safety, use of force and legislation around equipment implementation - its a breeze and is really enjoyable. I get to spend my day like most specialist consultants, talking about the stuff I like to geek about and answering questions we've been asked before with a well rehearsed answer or joke. Sometimes people even laugh. Now despite this confidence I've built and the strict rules I apply to my every day to never make the cardinal mistake of getting into subjects outside my area of expertise? Well we can all suffer from imposter syndrome and sometimes wonder what our role is, how we got here and we almost want to double check our facts. Well let me tell you that I was very careful to read and reread the medical reviews around our products before delivering this briefing to the accolade of medical professionals I had captive for my demo! Nothing gets you on your game more than knowing a little bit about your audience's credentials - this is usually where I find that the medical term I've been spouting is actually pronounced completely differently than I read in the text book.

If you’re anything like me, with the news we have been facing recently, you’ve probably become a bit desensitised to hearing about intensive care units all the time. Hearing someone has been in and out of a unit, unless you visit, it just feels like time has passed and often you then see the person ‘well’ again. Oblivious As consultants we get to see on graphs, charts reports - paper or Datex details of the incidents, injuries and staff accounts of what happened. Even deaths and footage of deaths, an afternoon of Netflix documentaries and my wife and I are eating food as detectives compare bite marks in a corpse as we are just chomping away as if its completely normal which as I write this makes me wonder how that would be psychoanalysed. Actually being there however, is very different indeed. Actually putting yourself in the very clinical environment where nurses are thrown to the ground, patients slip in and put of consciousness, the palpable silence contrasted with the digital feedback of the technological equipment they so depend on (which I’m told is extremely expensive) and even smelling the sterility sparks nostalgia about my own personal experiences of ICU.

Thick tentacles constructed from wire and tubing sprawling out of lit up, noisy grey boxes, which seem to crawl up the bedframe and invade the bed space - a futuristic Japanese knotweed if you will. Ominous enough, is this assault on your senses and then I invite you to stand there and visualise what actually transpired from interpreting the well written staff accounts. Correlating these accounts where staff detail how during managing to maintain control of a patient, all of this vital lifesaving media, was literally dragged across a room as and pulled up from their root inside their host, well it makes me wince and I swear, could almost feel tubes pulling inside me and it made me flinch.

In one incident report, the Octopus like grey boxes zig-zagged across the room and spiralled down the ward after a crocodile rolling patient who was adamant they didn't want to be there. The tension of those wires, the internal damage done and the fear instilled in staff desperate to protect themselves and their patient I don't feel would have impacted e so much, had I not been shown the injuries and seen the setup first hand. As with all aspects of delivering training, the closer all involved can be to the realism, real life setting and privy to the background and details of each patient, and their particular circumstance makes scenarios actually worthwhile running.

Anybody can read an incident form and throw out “why didn’t they do this” or why wasn’t the patient safeguarded from harm – unless you see that space and see it from the point of view of those involved with managing the obstacles and pitfalls, then you should feel a wave of imposter syndrome.

Following the governance procedures we had a collaborative 31 page procedure for staff to follow which insisted on the Safe Holding System being risk assessed and prescribed by the consultant – there’s no way of getting round this. The last thing we want is people thinking that the use of the Safe Holding system is in some way an “easy option” or to quote the lead that it could be used 'willy nilly'. It was only ever of the understanding that based on the previous two years stats, the kit would only potentially be utilised to negate the aforementioned circumstances in five or maybe six cases annually.

In January this year the kit was used for the first time, following all the protocols and it was very much an example of the exact patient group this procedure was planned for. A young male who had a head injury and his parents warned that on waking, his behaviour could be potentially challenging anyway. Those of you who are familiar with the MHA 1983 will understand that where appropriate, not just the clinical team but family, carers and advocates would need to be in agreement about the parameters of the approach taken. Staff explained they were lining their ducks up in preparation to manage this young man's behaviour and an initial attempt was made to bring him round. In order to get some measurement to see how he would be and from this brief exposure, it was decided that the consultant would authorise the use of the Safe holding system. The patient was still sedated and this fits in with our ‘absolutes’ of making sure staff have control of the person before attempting to apply any aspects of the kit.

The patient was weaned off his sedation and was in aspects of the kit for 24 hours.

During this 24hr period the patient was calm, there were no injuries to staff members were hurt and the patient didn’t attempt to pull out any of his in dwelling devices, all safety critical and one of which was life preserving. Had he managed to do this, as he was when he was initially brought round he would have been seriously if not gravely injured.

Staff feedback

Previously it had been a battle between sedation, re-sedation, manual holds staff defending themselves and all the while trying to assess neurological function of someone in a critical state. The patient was hurting themselves and the staff were getting injured, in many respects by using that safe holding system on the patient has completely aided that persons recovery and in fact, it's safe to say its speeded up their recovery,.

The continual daily cycle for managing patients that fit into this high risk category had finally been broken. The fear, risk and tiresome cycle of;

Waking them up.

Restraining them.

Restraining them some more.

Patient goes back to sleep.

Wake them up again… ad nauseum.

Had been broken, staff feedback through leads, frontline staff and the clinicians, thankful we could help the members of staff on the ICU ward, and it being the first example of this nature I was involved with setting up, I wanted to share with you some comments from the team down at ICU:

‘It was amazing, his recovery was incredible he actually recovered, right around the 24 hour mark having already slackened the Cuffs and limb restraints reducing the level of tension.’

'I remember going down on the third day to see how the patient was getting on and as I entered the cubicle space a feeling of horror swept over me;

‘Where is he?’ I asked. ‘Where's the patient?’

‘He’s gone for a walk’ came the reply.

'To my amazement, the patient was in fact, walking around. I couldn’t believe it. Anyone in the identified group who would have qualified as the Safe Holding System being a viable alternative to prolonged manual holds or the use of chemical restraint, their recovery was usually 2-3 weeks. It's been a life saver.'

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