Home > National clinical programme for the assessment and management of patients presenting to the emergency department following self-harm. Review of the operation of the programme.

National Clinical and Integrated Care Programmes. (2017) National clinical programme for the assessment and management of patients presenting to the emergency department following self-harm. Review of the operation of the programme. Dublin: Health Service Executive, Mental Health Division.

PDF (National Clinical Programme for Patients Presenting to the)

This report is for all who are responsible for delivering this Clinical Programme. It uses examples of good practice from services around the country to inform the further implementation. [Figures are given for presentations for overdose and alcohol at 16 emergency departments. Also place of referral (e.g. addiction services), p.19]

Executive summary:
• The National Clinical Programme (NCP) for the Assessment and Management of Patients presenting to the Emergency Department (ED) following self-harm was introduced to the first ED in 2014.
• The aim of the NCP is to ensure that all patients who present to the ED following self-harm or with suicidal ideation will receive a prompt biopsychosocial assessment, their next of kin will receive support and advice on suicide prevention, the patient will be linked with the next appropriate care, and both the patient and their general practitioner will receive a written plan of care.
• Funding for 35 clinical nurse specialists (CNSs) was made available and in 2015 the NCP was delivered in 16 services.
• Full data is available for 2016. In 2016 a further five services began implementing the NCP. In 2017, 24 of the 26 adult EDs in the country have a CNS delivering the NCP.
• This review uses the quantitative data submitted in 2016, along with detailed interviews completed on all sites between March and July 2017 by Dr Anne Jeffers, National Clinical Lead.
• A key performance indicator of the NCP is a reduction in the numbers leaving the ED before receiving a biopsychosocial assessment. This is achieved through improving the training of ED staff, improving the environment in which patients are assessed, and ensuring that patients with mental health needs are assessed in a timely manner.
• In 2016, out of 6,928 presentations of patients who had self-harmed or who were expressing suicidal ideation, 90% received a biopsychosocial assessment from an expert mental health professional.
• All CNSs have been offered training in raising awareness and skills for ED staff working with patients with mental healthcare needs. In three EDs, this training has been formally delivered. It is recommended that all CNSs be supported in delivering this training.
• Twelve of the 29 (26 Adult, 3 Paediatric) EDs in the country have a dedicated, suitable room for the assessment of patients with mental health needs. It is recommended that all EDs be provided with a suitable room.
• It is recommended that all patients receive parallel assessments, which has been shown to reduce waiting times to assessment
• In 2016, of 6,239 presentations where the patient received a biopsychosocial assessment, 32% were assessed by the CNS, 42% by the NCHD and 22% by a liaison nurse. The NCP recommends that all patients receive a biopsychosocial assessment from a CNS, a psychiatrist or a non-consultant hospital doctor (NCHD) in psychiatry.
• It is estimated that one CNS per 200 presentations per annum is needed to deliver the NCP. This would provide CNS cover from 8am-8pm, 7 days a week, and ensure that the CNS can follow up on patients assessed out of hours by the NCHD. It would also provide essential time for support and supervision of the CNS.
• The report highlights examples of excellent practices around the country; Good Practice Points are noted throughout the report. In implementing the report’s recommendations, services are encouraged to put these points into practice.
• Support and supervision are essential to ensure that staff remain healthy, and to prevent compassion fatigue and burnout.
• This review makes recommendations on the support, supervision and training of NCHDs, CNSs, liaison nurses and consultant psychiatrists.
• In each service, the NCP is delivered by the CNS and a clinical lead, who is a consultant psychiatrist. The success of this CP relies on true interdisciplinary working between the CNS and the clinical lead. The report makes recommendations to help ensure that the clinical leads are supported in their role.
• A total of 61% of presentations in 2016 included the patient’s next of kin in assessment and management. It is recommended that this number be increased to 100%.
• Each patient assessed is given an Emergency Care Plan. Examples of best practice are identified.
• Communication with the GP is paramount. In only 61% of presentations was a letter sent to the GP within 24 hours of discharge. It is recommended that the proportion be increased to 100% for those who have a GP.
• Each patient should receive a follow-up phone call within 24 hours of discharge from the ED. A phone call was received in only 47% of presentations. It is recommended that all patients, including those who present out of hours and are assessed by the NCHD, should receive a phone call from the CNS within 24 hours of discharge from the ED.
• Each patient should be linked to next care. Recommendations are made on how this can be achieved.
• In many services, it was clear that out-of-hours NCHDs were completing biopsychosocial assessments but did not fully comply with the NCP. Recommendations are made to ensure compliance. Extra training will be provided for NCHDs.
• A high number of patients without physical health needs have been presenting to the ED. They would be better assessed by a Community Mental Health Team (CMHT). Recommendations are made as to how the Executive Clinical Director
• (ECD) can work with CMHTs and the clinical lead so as to address this.
• Children are not included in the work of this NCP. There is good evidence that, in the three Dublin paediatric hospitals, the Paediatric Liaison Psychiatry team already provide most components of the NCP. Better liaison with the community is required, and this can be achieved by appointing CNSs with training in Child and Adolescent Psychiatry through the NCP. Improvements in providing a timely assessment are required countrywide.
• In 2018, Audit and Research networks will be developed. These will include CNSs and clinical leads who are delivering the NCP.

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