POLICY NUMBER: 007

BEDOC

BEDFORD ON CALL, ORTHOPAEDIC OUTPATIENT DEPARTMENT,

BEDFORDHOSPITAL NHS TRUST, KEMPSTON ROAD, BEDFORDMK42 9DJ

CHALLENGING PATIENT POLICY

Definition of challenging patients

  • Patients who call or present frequently with minor symptoms, particularly where there are underlying mental health problems. Typically the presented problem does not need to be dealt with in the out of hours period. Frequent out of hours callers tend to call more than 20 times in a one year period.
  • Patients with or without a history of substance misuse, who are requesting potentially addictive medication on more than one occasion, examples include tranquilisers (diazepam, temazepam, nitrazepam, chlordiazepoxide, lorazepam, zolpidem, zopiclone), and opiate analgesics (pethidine, morphine, diamorphine, buprenorphine, methadone, dihydrocodeine, etc.). Particular concern should be raised if the patient has presented before, if the patient has lost a prescription or has been unable to collect their regular supply of medication or run out of medication early for whatever reason.
  • Patients who call or attend when intoxicated or under the influence of drugs on any occasion.
  • Patients who are aggressive (verbally or physically) or who are abusive to staff on any occasion.
  • Patients in any of the above categories may give false names or pseudonyms, differing addresses, differing spelling of names, different telephone numbers. In these cases a new patient chart is generated and the special patient notes may not be visible.

Action by the executive team

  • Any member of staff can send the details of patients thought to fall within the definition of challenging patients to the Bedoc Chief Executive. The issue is to be discussed at the next Quality and Risk meeting, or Exec team meeting (which ever is sooner). If there is a more urgent need for action the Chief Executive must share the concern as soon as possible with both the Medical Director and Clinical Governance lead. The clinicians at the meeting (or outside the meeting if urgent action is needed) will discuss: whether the patient meets the criteria for a challenging patient; what the issues are; and advice on appropriate action, which should include:
  • Notification of both the registered GP and NHS Direct of the issues.
  • Dialogue with the patient’s GP to produce a specific patient action plan to cover the out of hours period.
  • Sharing of action plan with NHS Direct special patient notes co-ordinator.
  • Entering special patient notes to include the action plan and review date.
  • Report on special patient notes which expire will be discussed regularly by the Quality and Risk committee.
  • Patients who represent a significant risk of harm to staff should normally be under the PCT’s Safe Treatment Scheme. However, referral to this scheme is at the discretion of the patient’s GP. Good liaison and discussion with the registered GP is vital, and in many cases GPs may refer patients to this scheme is potential or actual harm has taken place in the out of hours period. In circumstances where the GP is happy to treat the patient, but the patient is felt to pose a risk to Bedoc staff out of hours, Bedoc may make an arrangement with the GP that only telephone advice will be given out of hours and that any direct patient contact will have to take place in A&E (in these circumstances ambulance crew and A&E must be informed of any referral in advance). The GP is responsible for agreeing and this arrangement with the patient and communicating with the patient about why this has happened. In these unusual circumstances the PCT Safe Treatment Scheme co-ordinator would be involved in the discussions.

Guidelines for clinicians

  • Any staff member can send the details of patients who cause concern to the Bedoc Chief Executive.
  • Always read special patient notes that apply to patients. These notes are there to help inform you and support you to provide better and more appropriate patient care. Try to follow action plans for patients.
  • When there are suspicious circumstances or incompatible or unusual histories of illness, all staff should be aware of potential false names or differing spellings/ addresses that would mean a special patient note is not seen. In these circumstances all staff should arrange to search the patient database (in Adastra version 2) for similar names or known aliases to find and read special patient notes that would otherwise have been missed.
  • Bedoc does not prescribe ANY controlled drugs to patients with addiction (e.g. diamorphine, morphine). Controlled drugs are only prescribed in the out of hours period in cases of terminal illness or severe pain in chronic illness (and in this case it would be unusual).
  • Sleeping tablets/ tranquilisers and non-controlled opiates should not be prescribed if there is a concern about addiction, or if there is a special patient note indicating not to prescribe. Patients who abuse these drugs will repeatedly attend if they find they can increase their supply this way. Many of these prescribed drugs are openly sold and traded for other drugs.
  • In certain circumstances (e.g. actual or impending withdrawal reaction from drugs or alcohol) it may be appropriate to prescribe very limited quantities of tranquilisers or non-controlled opiates. However, the supply should be limited to lasting only until the patient’s GP practice is open, and should only be prescribed if there is no potential risk of alcohol use with medication, or overdose. A supervising adult may be needed when prescribing a short home alcohol detoxification regime. If in any doubt it may be more appropriate to refer the patient for emergency psychiatric assessment.
  • Be wary of patients who ring requesting controlled drugs/ drugs of abuse. Look for warning signs:
  • Aggressive, demanding tone
  • A complicated or implausible story
  • Not interested in giving a history – more focussed on getting what they want
  • How to manage telephone calls for addictive drugs:
  • Remain assertive
  • Aim for a full and comprehensive telephone assessment of the clinical problem
  • DO NOT tolerate verbal abuse (See script for abusive calls)
  • Do not invite patients in to be seen if there is no clinical indication – it may be interpreted as a foot in the door to get drugs and potentially may cause an escalating problem
  • Be prepared to say NO on the phone.
  • Script for verbal telephone abuse:
  • If patient is verbally abusive on the phone, state clearly: “I’m sorry I cannot continue to talk to you and will not be able to help you if continue to be abusive”.
  • If the patient continues to be verbally abusive: “As you have continued to be abusive I’m sorry that I will now have to end the call”
  • Put the phone down.
  • Violence against NHS staff is rare.
  • Patients who are upset or under the influence of drugs or alcohol are more likely to become aggressive or violent.
  • Where possible try and prevent and predict potential problems:
  • On the telephone – verbal aggression, abuse, threats, demands. Try and contain and close call
  • Warnings from others – NHS Direct, A&E, receptionist, special patient notes
  • Care should be taken with any potentially aggressive, abuse or violent patient.
  • Look out for warning signs -
  • Patient becoming physically agitated, moving closer, staring or no eye contact, (non verbal clues)
  • Raised voices, demands, threats, verbal abuse
  • Protect yourself:
  • Move towards the door and exit
  • Press panic alarm (to be fitted in all consulting rooms)
  • Summon help from other staff (doctors, receptionist, drivers)
  • Receptionist can currently summon fast response from security with panic alarm
  • If your safety is absolutely compromised it may not be safe to see the patient yourself: you may need to arrange assessment in A&E where there are security guards and more staff (ALWAYS let A&E know if you do this), or with police attending first (if at home). If there is a lesser threat and you are in a position of needing to see the patient, consider calling hospital security to Bedoc, or using the driver as a chaparone at home. Do not aggravate a potentially difficult situation by becoming agitated or raising your voice. Stay calm, listen and understand the situation, be aware of dangers and consider your own safety (exits, hazard avoidance). All patients are entitled to care and treatment to meet their clinical needs. When a patient poses a risk to your health or safety, you should take all steps to minimize the risk, before providing treatment or making suitable alternative arrangements for treatment (GMC).
  • Support other staff:
  • If you recognise other clinical staff are at potential risk – take steps to protect them – invite them from the room, call emergency security response.
  • Don’t leave others vulnerable – if there is a potential problem consider dual consultation, consult with the door open, consider having hospital security on standby.
  • Patients on the safe treatment scheme should be referred directly to this service, and not be seen by Bedoc. The scheme provides full 24 hour cover, 7 days a week. NHS Direct will normally refer patient’s directly, but some may slip through. Patients on the safe treatment scheme are kept in folders both in the overnight doctors room, and in the Bedoc reception. These should be kept upto date with changes notified by the safe Treatment scheme co-ordinators.

Guidelines for reception staff

  • Notify clinicians if a patient with a special note entry attends, or a patient known to have a special note entry attends, but with different call details. Please help identify the previous special notes by doing a database search in Adastra version 2.
  • Be aware of safety issues when patients are aggressive, intoxicated or abusive. If necessary call immediately for help by pressing the panic button, or fast bleeping the security staff via switchboard. Stay calm, listen, speak clearly and softly. Sit well back from the desk and call for help from either doctor or driver, even if this means interrupting them.

DATE: MARCH 2008REVIEW DATE: MARCH 2010

BEDDOC: ‘PATIENT THAT CAUSES CONCERN’ NOTIFICATION

PATIENT NAME:ADDRESS:

DATE OF BIRTH:

REGISTERED GP:

DATE OF INCIDENT:TIME:

CONCERN RAISED BY:

DOCTOR(S) WHO HAD CONTACT WITH PATIENT ON THIS DATE:

DESCRIPTION OF CONCERN:

CLASSIFICATION OF CONCERN (CIRCLE ALL THAT APPLY):

FREQUENT ATTENDER

REQUEST FOR POTENTIALLY ADDICTIVE MEDICATION

CHALLENGING BEHAVIOUR/ AGGRESSION/ ABUSE

PATIENT INTOXICATED/ UNDER INFLUENCE OF DRUGS

FALSE NAMES/ PSEUDONYMS

OTHER (PLEASE DESCRIBE):

RETURN TO JAN CACCHIO, ROOM 8 BEEDEN HOUSE, BEDFORDHOSPITAL NHS TRUST, KEMPSTON ROAD, BEDFORD, MK42 9DJ.