PS ED toolkit 8-2012 v1 Layout 1/media/Confederation/Files/public...2 Preventing suicide: A toolkit...

Preventing suicideA toolkit for emergencydepartments

Overview and instructions 2

The standards 4

Standard 1 Consent and capacity 4

Standard 2 Intervention and care 6

Standard 3 Suicide prevention 8

Standard 4 Family or carer contact 11

Standard 5 Appropriate medication 12

Standard 6 Follow-up care 13

Standard 7 Post-incident review 14

Standard 8 Training of staff 15

Contents

Preventing suicide: A toolkit for emergency departments2

Overview

Emergency departments are busy places. They are high-risk environments for patients with mentalhealth problems. Attendance for self-harm is often a precursor for attempts at suicide. Emergencystaff can identify people at risk. This unique toolkit, based on NICE quality standards, equipsemergency department staff with the right skills, processes and procedures to identify andappropriately care for vulnerable people. It includes prompts for safety checks and monitoringperformance. It gives guidance on approaches to risk management policies and multi-disciplinarysupport for suicide prevention strategies.

Instructions

This section gives details of how to use the toolkit, including an explanation of the assessment tools andthe use of case note review, and an example completed audit form and checklist. The eight standardsare then set out. All the documents are available to download from www.nhsconfed.org/mhn

The standardsThe eight standards are organised to look at the process of admission through to discharge.Accompanying these standards are detailed audit procedures which will help you measure yourcurrent practice and identify areas for improvement. It is necessary to read through each of thestandards prior to commencing the general audit tool, in order to provide you with a more detailedcontext for each standard criteria.

Assessment – the general audit toolThe general audit tool provides an annual method of tracking and measuring the level of careprovided to patients at risk of suicide or self-harm. It provides a comprehensive view of the level ofadherence to the suicide prevention standards contained in the updated toolkit, and combines areview of trust policy, environmental and patient risk assessments, and the review of a small sampleof patient records. It is recommended that the general audit tool is used on an annual basis. The general audit tool contains:

• a performance summary and performance dashboard that are automatically generated aftercompleting responses to each of the questions

• audit questions relevant to each of the eight standards

• an action plan that lists all actions that have not reached 100 per cent compliance in the sample of patient case notes reviewed.

It is recommended that the general audit tool is undertaken on an annual basis. It is alsorecommended that organisations print the performance summary worksheet to provide both front-line staff and the board with regular feedback on the level of care. However, if your trust has a well functioning method of updating both front-line staff and the board on such matters, there is no need to adopt a new practice.

Preventing suicide: A toolkit for emergency departments 3

Example of a completed performance dashboard

Bar Chart Key:Standard 1 - Consent and capacityStandard 2 - Intervention and careStandard 3 - Suicide preventionStandard 4 - Family or carer contactStandard 5 - Appropriate medicationStandard 6 - Follow-up careStandard 7 - Post incident reviewStandard 8 - Training of staff

Example of a completed performance summary


Standard 1 Consent and capacity

Standard 2 Intervention and care

Standard 3 Suicide prevention

Standard 4 Family or carer contact

Standard 5 Appropriate medication

Standard 6 Follow-up care

Standard 7 Post-incident review

Standard 8 Training of staff

The standards

Standard 1 Consent and capacity

Issues of consent,capacity and mental ill health in theassessment andtreatment of people who self-harm should be understood andaddressed by allhealthcare professionals.

1.1 Is there an up-to-date policy/guidance which encompassesconsent to treatment issues and the Mental Capacity Act?

1.2 Does relevant policy/guidance include that all treatmentsshould be explained to the patient unless being delivered in an emergency?

1.3 Is there a policy in place detailing what staff should do if apatient who lacks capacity or who has not had a capacityassessment completed, leaves the ward before treatment canbe given?

1.4 Do clinicians know how to access an emergency assessmentunder the Mental Health Act where required?

1.5 Is there an up-to-date policy detailing Gillick competencefollowing admission of a child or young person who has self-harmed and the need for the admitting team to obtainparental (or other legally responsible adult) consent for themental health assessment of the child or young person?

Criteria Audit procedure


1.6 Is there evidence that capacity was assessed?

1.7 If the patient was deemed not to have capacity to consent to treatment did consultation take place with the lastingpower of attorney or court appointed deputy, as appropriate?

1.8 If the patient was deemed not to have capacity to consent to treatment were the reasons for this recorded in the clinical record?

1.9 Is it recorded that actions taken were in the patient's bestinterests?

1.10 If care was being delivered to a child or young person, is thereevidence that all treatments have been explained to thepatient if Gillick competent, or the consenting adult?



Standard 2 Intervention and care

Specific personal,cultural, religious orother factors that need to be considered whenexamining or treating the individual areascertained and informthe care given.

2.1 Is there a policy/guidance in place detailing how staff shouldaccess face-to-face and telephone interpreters?

2.2 Is it detailed within policy/guidance that the relatives of thepatient should not be used as interpreters except in the case of medical emergency?

2.3 Is written information about treatments available inlanguages other than English?

2.4 Is information about treatments available for people withsight, learning or language difficulties?

2.5 Is there a policy/guidance detailing procedures regardinggender specific care and chaperoning, as appropriate?

2.6 Does the policy/guidance dictate that patients are offered achoice of assessment and treatment from male and femalestaff, as appropriate?

2.7 Is the preferred language of the patient recorded in the notes?

2.8 Are there examples of specific personal, cultural, religious orother factors being assessed?

2.9 If it is not possible to offer a choice of male or female staff forassessment and treatment, is there evidence that the reasonsfor this have been explained to the patient?

2.10 Are there examples that patients' needs regarding genderspecific care has been assessed, documented and met inclinical records?


People who have self-harmed will betreated with the samecare, respect and privacyas any patient.Healthcare professionalstake full account of thelikely distress associatedwith self-harm.

2.11 Are there methods of collecting data regarding patientexperience in place?

2.12 Are there examples of how patient experience information hasbeen used to inform clinical development within service?

2.13 Is this monitored within trust clinical governance processes?

2.14 Is there evidence of complaints received by patients whoreceived treatment for self-harm?

2.15 Is there evidence of what action was taken in response tothose complaints?


Provision will be made to ensure that care given to children andyoung people who haveself-harmed is tailored to the specific needs ofthese client groups.

2.16 Is there a protocol stating that appropriately trained children'sdoctors or nurses are available at all times to triage, assess andtreat children and young people who have self-harmed?

2.17 Is there evidence that paediatric inpatient facilities and childand adolescent psychiatric inpatient unit beds are available forchildren and young people who need admission?

2.18 Is written information about treatment available for childrenand young people that is child friendly and easily understood?

2.19 Is there evidence of parental consent in clinical records ofchildren and young people?


Provision will be made toensure that care givenolder persons who haveself-harmed is tailored tothe specific needs of theseclient groups.

2.20 Is there evidence that appropriately trained older person'sdoctors or nurses are available at all times to triage, assess andtreat older people who have self-harmed?

2.21 Is there a protocol stating that all acts of self-harm in peopleolder than 65 should be regarded as evidence of suicidalintent until proven otherwise?

2.22 Is there evidence of psychiatric liaison services based withinan acute general care establishment for team integration andcross-boundary working?

2.23 Is there evidence of health care professionals with mentalhealth qualification working within the EmergencyDepartment (ED) team?


Standard 3 Suicide prevention

All people who have self-harmed will beoffered a preliminarypsychosocial assessmentat triage or at the initialassessment in primarycare following an act ofself-harm.

3.1 Is there a validated assessment/prioritisation scale used atthe point of triage that assists staff to make the decision aboutthe clinical urgency of the situation and whether specialistpsychosocial assessment is required?

3.2 Is there evidence that the use of the triageassessment/prioritisation tool is audited on a regular basis bylocal examination of clinical records?

3.3 Is there evidence that this process is monitored within thetrust clinical governance processes?


Where specialistpsychosocial assessmentis required, this will beoffered without delay.

3.4 Is there a policy/guidance detailing how staff should accessspecialist psychosocial assessment for people who have self-harmed and require psychosocial assessment during triage?

3.5 Does the policy detail standards that first line attendance ofmental health teams for urban areas is 30 minutes and forrural areas is 90 minutes?

3.6 Is there evidence that the response times are audited on aregular basis by the local examination of clinical records?

3.7 Are there examples of how practice has been improved inresponse to audit outcomes?

3.8 Is the audit process monitored within trust clinical governanceprocesses?

Professionals who arelikely to assess children,young people and olderadults over the age of 65have the ability to accessadvice from a seniorspecialist.

3.9 Is there a process in place for staff to access specialistprofessionals for advice when assessing children, young adultsand older adults over the age of 65, who have self-harmed?

3.10 Is there evidence that this information has been disseminatedto staff and is monitored?

3.11 Is there a separate, child friendly, appropriately staffed andfurnished area for the triage, assessment and treatment ofchildren and young people?


A copy of the initial, andwhere completed,psychosocial assessmentand treatment outcomeswill be forwarded to thepatients GP and anyknown, involvedprofessionals within 24 hours.

3.12 Is there a formal process to ensure that assessments areforwarded to patients' GPs and any known, involvedprofessional within a specified time period?

3.13 Is there a process in place for informing the patient's GP aboutincidents of self-harm even where the patient has not agreedto participate in any treatment or initial assessment?

3.14 Is there evidence that patients were informed of whom copiesof their assessments have been forwarded to?


If a person who has self-harmed has to waitfor treatment, he or sheshould be offered anenvironment that is safe,supportive and minimisesany distress.

3.15 Is there a separate waiting room for those that have self-harmed away from the general waiting area?

3.16 Does the risk assessment document who should use this room?

3.17 Is there a confidential room for the assessment of patientswho have self-harmed?

3.18 Have ligature points and potential opportunities to harm inthe room been assessed and are the findings of thisassessment available to staff?

3.19 Does the risk assessment detail how patients will besupervised?

3.20 Does the risk assessment detail how patients will be updatedon waiting times and progress?

3.21 Is there an annual environmental risk assessment thatincludes ligature assessment within the ED and surroundingareas to which patients have easy access?

3.22 Is there evidence that the most recent risk assessment wascarried out in the last 12 months?

3.23 Are there examples of where the environment has beenmodified as a result of the environmental risk assessment?

3.24 Is there evidence that the environmental risk assessmentprocess is monitored within the trust clinical practicegovernance processes?


Specialist psychosocialassessment will becompleted for those whohave been assessed toneed it during initialassessment.

3.25 Is there a process in place to ensure ED staff have access toprofessionals who are trained to carry out specialist mentalhealth needs and risk assessments at all times?

3.26 Are risk assessments present in clinical records?

3.27 Are risk assessments completed in full?

3.28 Is there documentation that a copy of the assessmentinformation has been passed to the patient's GP?

3.29 Is there documentation that a copy of the assessmentinformation has been passed to any relevant mental healthservices?

3.30 Is there evidence that patients have been involved in theformulation of the assessment, treatment and aftercare plan?

3.31 Is the assessment of needs clearly recorded in the patientrecord?

3.32 Is the assessment of current and future risk recorded in thepatient record?

3.33 Is the treatment and/or referral plan clearly recorded in thepatient record?

3.34 Is the aftercare plan clearly recorded in the patient record?


Provision will be made toensure that care givenolder persons who haveself-harmed is tailored tothe specific needs of theseclient groups.

3.35 Is there evidence that consideration was given to refer olderadults who have self-harmed for a specialist old age psychiatryassessment and mental health risk and needs assessment?

3.36 Is there evidence that consideration was given to monitoringchanges in mental state and levels of risk for older adults whohave self-harmed?


Standard 4 Family or carer contact

Healthcare professionalswill provide emotionalsupport, help andinformation aboutsources of help ifnecessary to anyrelatives/friends/carerspresent.

4.1 Is information on crisis and advice organisations, socialservices departments, independent advocacy services,patient/carer's support groups etc available, as appropriate?

4.2 Is there a process in place for provision of support tocarers/relatives, as appropriate?

4.3 Is there evidence in clinical records that support andinformation has been given to family/carers?

4.4 Is there a policy/guidance to obtain consent from the patientto involve family/carers in gathering information/contributingto assessment of a patient who has self-harmed, asappropriate?

4.5 Have staff been trained in how to engage with families/carersof patients who have self-harmed?



Standard 5 Appropriate medication

Adequate anaesthesiaand/or analgesia shouldbe offered to people whohave self-injuredthroughout the process ofsuturing or other painfultreatments.

5.1 Is there evidence that auditing of appropriate medication ismonitored within trust clinical governance processes?

5.2 Is there evidence that any instances of adequateanaesthesia/analgesia not being given are subject toappropriate management action?


Staff will have access toadvice and informationat all times.

5.3 Is there a policy to ensure that TOXBASE and National PoisonsInformation Service (NPIS) is available to all clinical staff at all times?

5.4 Is there evidence that a risk assessment of medications hasbeen carried out, for instance minimum dispensing?


Standard 6 Follow-up care

Temporary admission oralternative support willbe available to peoplewho have self-harmedwho remain at risk aftertreatment.

6.1 Is there a policy/guidance in place to ensure that overnightadmission or home treatment from Crisis Intervention Teamsis available to people who:• are very distressed?• have not been fully assessed due to alcohol and or drug

intoxication?• are returning to a potentially harmful or unsafe environment?


People who repeatedlyself-harm should beoffered advice on therisks of self-harm andadvice on minimisation,self management andcoping strategies.

6.2 Is there a clinical protocol detailing what advice to give topeople who self-harm?

6.3 Does this information include: • details for when harm minimisation advice is and is not

appropriate (for example, for those who harm themselves by self-poisoning)?

• details of advice for those who self-poison?• details of who should deliver advice to those who self-poison?• instructions on how to advise those who inflict superficial

injuries regarding wound care, how to obtain appropriate sterile dressings and equipment and how to deal with scar tissue?

• alternative coping strategies?

The psychosocialassessment of needs andrisk will inform decisionsrelated to aftercare andor discharge.

6.4 Is there evidence that the patient has been given informationabout what to do in the event of a psychiatric emergency?

6.5 Is the rationale for the treatment plan included in clinical notes?

6.6 Is the rationale for the referral plan included in clinical notes?

6.7 If relevant, is the rationale for decision to discharge withoutfollow up care included in the clinical notes?


Standard 7 Post-incident review

Services should haveaccess to a dedicatedself-harm servicesplanning group whichincludes Accident andEmergency departmentstaff, generalpractitioners, ambulancestaff and mental healthservices.

7.1 Is information available about how to complain and askquestions if a patient in unhappy with their treatment?

7.2 In the terms of reference for Post Incident Review Groups isthere evidence of:• multidisciplinary working• details for cross-organisational audit• incorporation of patient views and action taken in response

to satisfaction survey data• examination of performance data, incidents and complaints

and action taken in response to this• plans for, and records of cross organisational training• practice and service development activity• the development and implementation of joint protocols• mechanisms for providing formal feedback and information

to trust boards and commissioners

7.3 Is there a policy to ensure that family/carers are included inpost incident reviews?


All incidents of seriousself-harm or suicide in the community areinvestigated under therelevant primary careorganisation and whereapplicable, mental healthservices’ serious incidentprocedure.

7.4 Does the serious incident policy include:• involvement of parents/carers in the investigation process?• support for parents/carers in the investigation process?• psychological support mechanisms for staff?• process for learning and disseminating lessons?• process for governance and reporting to trust board and

commissioners?

The psychological effectsexperienced by staffshould be a component ofall major incident plans.

7.5 Is there evidence that staff support was addressed?


Standard 8 Training of staff

Staff who have contactwith people who self-harm are providedwith regular training.

8.1 What proportion of relevant clinical staff have receivedtraining to equip them to understand and care for people whohave self-harmed in the last three years?

8.2 Is there a policy regarding the provision of clinical supervisionto staff who care for those who self-harm?

8.3 What proportion of currently employed clinical staff havereceived clinical supervision in the last month?

8.4 What proportion of relevant non-clinical staff have receivedtraining to equip them to understand and assist people whohave self-harmed?

8.5 What proportion of clinical staff have received training abouttaking physical and psychological factors into account whenmaking decisions about priority for treatment?

8.6 What proportion of staff who have emergency contact withchildren and young people who have self-harmed havereceived additional specialist training regarding this in thepast three years?

8.7 What proportion of staff who have emergency contact witholder people who have self-harmed have received additionalspecialist training regarding this in the past three years?


Clinical staff who havecontact with people whoself-harm are providedwith appropriate trainingto equip them tounderstand and care for people who have self-harmed.

8.8 Does the training course for clinical staff cover:• patient involvement?• the problems faced by people who self-harm when they have

contact with services?• an exploration of some of the meanings of and motives for

self-harm?• capacity and consent in relation to self-harm?• preliminary psychosocial and risk assessment of people who

self-harm?• early management, including the use of activated charcoal?• the impact of cultural issues on self-harm?• carers' issues?• the content of the NICE guideline?• specific issues relating to the safeguarding, care and

assessment of asylum seekers, children, young adults and older persons over the age of 65?


Non-clinical staff whocome into contact withpeople who self-harm(including receptionists,domestic staff, securitystaff etc) should beprovided with basictraining to equip them to understand and assist people who haveself-harmed.

8.9 Does the training course for non-clinical staff cover:• basic awareness of mental health issues? • the problems faced by people who self-harm when they

have contact with services? • an exploration of some of the meanings of and motives for

self-harm? • risk awareness? • safety issues relating to the care environment in relation

to those who have self-harmed and are at risk of further self-harm?


Clinical staff who havecontact with children and young people whoself-harm are providedwith specific training toequip them to understandand care for people whohave self-harmed.

8.10 Does the training course include:• the concept of Gillick competence?• Child protection and safe guarding issues?• recognition of abuse?• confidentiality issues relating to children and young people?• the use of the Mental Health Act in young people?• The Children's Act?• assessing risk in young people?• work specifically with children and young people, and their

families, after self-harm?

Clinical staff who havecontact with older peoplewho self-harm areprovided with specifictraining to equip them to understand and care for people who have self-harmed.

8.11 Does the training course include:• the potential presence of depression in older people?• cognitive impairment?• physical ill health?• social situation?• family/social support?• accommodation (including type, tenure and suitability)?• local provisions available in the community to support

independent living?

© National Patient Safety Agency andMental Health Network 2012.

You may copy or distribute this work, butyou must give the author credit, you maynot use it for commercial purposes, andyou may not alter, transform or buildupon this work.

The NHS ConfederationFloor 4, 50 Broadway, London SW1H 0DBwww.nhsconfed.org/mhn

Registered Charity no: 1090329

National Patient Safety Agency4–8 Maple StreetLondonW1T 5HDwww.npsa.nhs.uk

INF29101

PS ED toolkit 8-2012 v1 Layout 1/media/Confederation/Files/public...2 Preventing suicide: A toolkit...

Documents

Transcript of PS ED toolkit 8-2012 v1 Layout 1/media/Confederation/Files/public...2 Preventing suicide: A toolkit...