Quality Improvement Initiative in Mental Health Unit

Introduction

As a result of the changes that have occurred in the planning, provisioning and financing systems of health care in many countries over the past few years, quality care plans have become an essential tool for providing accessible, effective, equitable and adequate health services to the health needs of the population. The quality of care, as a regular instrument of work, is a relatively new topic in the field of health, and much more in the field of psychiatric and mental health care (American Psychiatric Association, 2018). The current work will analyze the use of PRN medications in patients to help with behavioral problems and if that does not work, then seclusion should be used to cut down on the use of restraints on patients for their safety.

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Use of Restraints On Patients

Physical restraint or mechanical restraint is a therapeutic measure used with some frequency for the management of agitated patients or in those patients who potentially pose a risk to the physical integrity of themselves or those around them. Several criteria were developed to legitimize the use of physical restraint including the warning that it should not be more violent or forced than the initial act of the disturbed person, and always in relation to the resistance offered by the patient (Currier & Allen, 2000). Fixations should also be withdrawn when a real threat of harm to the patient, the people around him, or property is no longer likely. In fact, as long as the containment of a person with serious disorders does not entail degrading or inhuman treatment, as established in the Universal Declaration of Human Rights (United Nations General Assembly), it is considered legitimate.

Restriction is the use of physical or mechanical procedures aimed at limiting the movements of part or the whole body of a patient, in order to control their physical activities and to protect them of the injuries that he could inflict on himself or others. This definition of restriction does not include those clamping procedures performed in a usual way in some diagnostic and/or therapeutic processes, such as the restraint of the body in surgical interventions or in some diagnostic methods, and the immobilization of the upper limb to facilitate access to a pathway (Donat, 2005). As its name suggests, this technique involves a physical restriction and a limitation of freedom of movement, which leads to the reflection on several issues: are the indications clear, is it used properly? are there alternatives? Is the protocol known by those who carry it out? Is it accepted by the professionals themselves, patients and relatives?

There are multiple physical restrictions performed incorrectly and many professionals, both nursing and auxiliary, are unaware of the indications and technique. All this ignorance sometimes causes that the treatment is badly indicated and badly carried out and that it becomes traumatic and potentially harmful both for the patient and for the professionals. In general terms, this type of procedure poses problems to all those affected directly or indirectly. The professional feel that she/he is restricting the freedom of the patient, the patient feels humiliated, and his/her relatives believe that he/she is receiving physical and psychological abuse (Hamers, Gulpers, & Strik, 2004). Since physical restraint or mechanical restraint is a technique that in itself limits certain rights and fundamental freedoms, it should always be used as a last resort, and only in patients who show signs of agitation, overt violent behavior or in those that show recognizable signs that violence is imminent and that the patient is certain that the patient is "about to explode", as long as other methods of containment have failed or it is certain that the application of such methods will be useless.

Physical restraint involves a lot of personnel. The minimum number of people needed to carry out a physical restraint are four people, although the optimum would be five: one to control each member and another to hold the head. The role of the fifth professional is extremely important since he/she will direct and coordinate the procedure, avoiding that other professionals have to divert their attention to the action of subjecting. In addition, maintain a constant communication with the patient, informing him/her of the events that are or will occur to provide maximum peace of mind. Generally, it will be the nurse, because of her proximity to the patient, who will value the need to contain the patient. If the need to perform the restraint is imperative, the nursing staff will indicate, perform and coordinate this restriction, immediately notifying the physician responsible for the patient (or the doctor on duty in his/her absence) to assess the patient and authorize or not the restriction.

The existence of complications dependent on the use of physical restraints is sufficiently documented, there are injuries caused directly by the restraint device, as well as indirect effects. These complications can be asphyxia, limb ischemia, neurological injuries (compression of the brachial plexus), bruises or lacerations. Among the adverse effects produced indirectly is the increase in pressure ulcers, increased cognitive deterioration, increased frequency of urinary and fecal incontinence, as well as an increase in mortality rates (Baker, Lovell, & Harris, 2007). Other complications can also be increased infections, as well as respiratory and cardiovascular complications, musculoskeletal disorders such as decreased muscle strength and increased joint stiffness, malnutrition, constipation, increased dependence for activities of daily living, and even increased psychomotor agitation. In addition, lesions may appear that are more specifically associated with a specific type of restriction, such as deaths from entrapment between the handrail and the mattress of the bed (Currier & Allen, 2000). Patients also end up feeling panic, fear, impotence, anger and frustration, and a feeling of injustice. Nurses may also feel emotionally uncomfortable with these measures, grief, fear and anguish, fear of abusing the rights of patients, making a restriction physical can be distressing and can cause anxiety to staff who perform it, the use of restraint can be cruel, bad and uncomfortable, and staff see the use of physical restraints as a need for which they have no alternative.

The Use of PRN Medications

PRN medications are the medications given as required by the patient. PRN stands for 'Pro re nata', that is a Latin word meaning 'as the thing is needed'. In some cases, psychiatric medications play the role than traditional methods. The psychiatric medication comes in seven categories, each to treat a separate mental disorder: antidepressants, stimulants, antipsychotics, mood stabilizers, depressants, anxiolytics, and psychedelics. Most of the psychiatric medications work on the imbalance of the brain, anti-depressant medication often hinders the breakdown of serotonin. Due to the medication, a person can quickly feel better (Baker, Lovell, & Harris, 2008). These medicines are not prescribed for daily intake, but for certain situations like pain. A nurse should check if last time the dose of this medicine had some side effects on the patient then the nurse could discuss it with the prescriber and withhold the medicine accordingly. Medicines given to the patient should not exceed the number of times they have to be administered (Baker, Lovell, & Harris, 2007). An excess number of doses can cause some or the other side effect, which is unwanted.

Taking pills is a lot easier and requires less energy than therapy. The medication can treat some symptoms that are very difficult to manage with any treatment and works well for depression. Taking PRN helps to balance neurochemistry and allows the mood centers in the brain to function optimally. Several studies have indicated that nurses resort to PRN as a first resort (Donat, 2005). Auditing the administration of PRN medication has been a significant contribution to the evaluation of the project and helped to engage night nursing staff in the process. Evidence presented suggests that a quiet room can help to reduce the amount of PRN medication administered, and as a result, improvements in patient safety have been identified by staff.

The Use of Seclusion In case PRN Medications Do Not Work

Seclusion is one of the oldest interventions that still persist in the treatment of people with mental illness. The responsibility to create and maintain a safe environment for patients and staff has traditionally belonged to psychiatric nurses especially in the emergency room and in hospitalization, situations in which it requires rapid action in order to predict and control potential violence (Donovan, Siegel, Zera, Plant, & Martin, 2003). Isolation has been used in an effort to achieve these objectives of nursing and is perceived by some of them as a therapeutic and effective strategy to control violent situations. The control offered by isolation allows staff to maintain high levels of effectiveness, by facilitating a conformist environment, reducing the anxiety produced by work in the psychiatric institution.

Isolation is considered preferable to medication and electroconvulsive therapy because it causes fewer side effects, despite the potential risk of misuse. The theoretical basis of its use in hospitalized psychiatric patients is based on the principles of containment, isolation and sensory reduction. The containment serves to limit the environment of the patient while the isolation aims to offer a parenthesis to the pain and the difficulty of the overloaded relationship of the patient (Donovan, Siegel, Zera, Plant, & Martin, 2003). On the other hand, it offers a calm and monotonous environment, reducing sensory activity that can be unbearable in patients who are vulnerable to perceptual distortions and who cannot build their own sensory-perceptual barriers (Donat, 2005). Isolation is very beneficial in terms of modifying undesirable behaviors and in order to regain emotional control of the patient. The use of isolation is an ethically sensitive issue because isolation is a form of restraint that has survived widespread release in psychiatric practice and, in this case, the isolated patient is doubly vulnerable because of his or her condition.

General Principles, Indications and Precautions for The Proper Use of Seclusion

Among the indications or reasons for initiating isolation is the prevention of harm to oneself or others as fundamental; There is also, although perhaps less important, the prevention of damage to property and strange or dissociated behaviors (Baker, Lovell, & Harris, 2007). Isolation carries a risk that must be taken into account, it should be used when, in the clinical judgment of the medical staff, less restrictive interventions have been inadequate or not appropriate. In special populations such as children, adolescents, the elderly and the disabled, special care must be taken and the clinical need for the use of isolation and restraint must be evaluated (Donat, 2005). Generally, isolation is a measure of last resort, used when other alternatives have failed. Isolation is an intervention that requires a medical indication. Once done, the doctor must examine and have an appropriate monitoring and care of the patient during the event; patients must be observed at frequent enough intervals to guarantee their safety and provide human care; and health personnel must be trained and demonstrate competence in the application of effective and safe techniques for the implementation of isolation. Those techniques, of course, must be approved by the medical staff.

At each isolation event, a meeting of...