Psychiatric Bulletin (2002) 26: 88-90. doi: 10.1192/pb.26.3.88
© 2002 The Royal College of Psychiatrists
Psychiatric Bulletin (2002) 26: 88-90
© 2002 The Royal College of Psychiatrists
An audit of risk assessment in an emergency setting
James Stone, Senior House Officer
Maudsley Hospital
George Szmukler
Maudsley Hospital, Denmark Hill, London SE5 8AZ
Correspondence: (tel: 020 7703 6333; e-mail:
g.szmukler{at}iop.kcl.ac.uk
)
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Abstract
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AIMS AND METHOD
Patient records from the emergency clinic at the Maudsley Hospital were
analysed from July 1999 to assess the standard of risk assessment for
self-harm and for harm to others routinely recorded by junior doctors. The
recorded risk factors for the consultation and the evidence that risk had been
considered were noted. An intervention that comprised two seminars and two
written reminders about the importance of risk assessment was made and the
analysis of records in the emergency clinic repeated for July 2000.
RESULTS
Risk factors were recorded more frequently for harm to self than for harm
to others. There was little recorded evidence that consideration had been
given to the overall risk of harm to self, and there was no evidence of this
for harm to others. Recording of risk did not change significantly between
1999 and 2000.
CLINICAL IMPLICATIONS
Assessment for risk of harm to others is not a part of the emergency
consultation that is emphasised by the majority of junior psychiatrists.
Changing practice will require a shift in the way that risk to others is
presented in psychiatric teaching.
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Introduction
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Risk assessment in psychiatry is a subject that has received much attention
in recent years, both in government policy and from the media. With the
increasing emphasis on the role of psychiatry in protecting public safety,
risk assessment and risk management have come to be seen as core skills in
mental health workers. The 1999 policy booklet from the Department of Health,
Modernising the Care Programme Approach, states that ‘risk
assessment and risk management is at the heart of effective mental health
practice and needs to be central to any training developed around the Care
Programme Approach’ (Department of
Health, 1999a: p. 22) and the National Service
Framework for Mental Health
(Department of Health
1999b) contains the expectation that local health and
social care communities ‘should focus on ensuring that staff are
competent to assess the risk of violence or self-harm, to manage individuals
who may become violent, and to know how to assess and manage risk and ensure
safety’ (p. 12, Executive Summary).
The emergency clinic at the Maudsley Hospital is a service that provides
emergency mental health care for the local catchment area. A central part of
its work is the assessment of patients for admission to hospital or for
community follow up and as such is ideal for an audit of risk assessment. The
emergency clinic accepts referrals from local general practitioners,
self-referrals and is also classified as a place of safety for the purpose of
Section 136 of the Mental Health Act 1983. It is staffed by one staff grade
psychiatrist, one junior doctor and three nurses from 9 a.m. to 5 p.m., and
between the hours of 5 p.m. and 9 a.m. by two nurses and one junior doctor
on-call.
This study aimed to assess the quality and type of risk assessment that was
recorded in the notes for patients who were seen out of hours by doctors
working in the emergency clinic and to evaluate the effect of a
multi-component intervention on this.
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Method
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Case notes from the emergency clinic were identified for all patients
attending in July 1999. The emergency clinic notes of the first 35 separate
new cases who were seen by doctors out of hours and who fulfilled our criteria
for needing a risk assessment (Table
1) were selected. The entries recorded by the doctors for the
initial assessment were analysed and the numbers of well-established risk
factors that were recorded (either as present or absent) in each entry noted.
It was noted whether an explicit statement about the level of risk was
recorded and also whether there was a statement reflecting an attempt to
balance factors increasing risk against those reducing it. Lastly, the
management plan for each patient was analysed: the communication between the
doctor and the patient's care provider and family was recorded as well as
whether or not admission was considered and if there was an emergency plan and
a plan explicitly to address the risk.
Intervention
The components of the intervention included two seminars on risk assessment
for the junior doctors covering the emergency clinic out of hours, one during
their induction and the other later in their training during an afternoon of
teaching that all junior doctors covering the emergency clinic were informed
about. At the same time the trust sent all staff, for consultation, guidelines
on risk assessment and management. Copies were placed in the emergency clinic
and all junior doctors in the trust were reminded, by e-mail and via the
internal mail, of the importance of risk assessment in the emergency clinic
and about the presence of the guidelines in the emergency clinic along with a
request for their comments. These components occurred between the months of
April and June 2000. The emergency clinic consultant was also available once a
week to discuss problems encountered by the on-call doctors.
Follow up
A further 35 sets of notes from July 2000 were obtained, using the same
selection criteria as for the previous year. The details of the risk
assessments and management in these were noted as for the previous set.
Data were analysed for significant change with the null hypothesis that
there was no increase in the number of risk assessments or risk factors
recorded in the notes for July 2000 compared to July 1999 using Fisher's exact
test.
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Results
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Thirty-nine sets of notes in 1999 and 37 sets in 2000 had to be analysed in
order to obtain 35 patients for each year that fulfilled the criteria for
warranting assessment. These 35 assessments were made by 18 different junior
doctors in 1999 and by 16 in 2000. For both sets of patients, all 35 who
fulfilled the criteria for a risk assessment required a risk assessment for
harm to self. In addition, 21 in 1999 and 27 in 2000 (Fisher's exact
test=0.06) also required a risk assessment for risk of harm to others
according to our criteria. The patient groups did not differ significantly in
their risk factors between 1999 and 2000
(Table 1). Of all the cases
that required a risk assessment, 54%, both in 1999 and in 2000, had been seen
previously in the trust.
Table 2 shows the risk
factors recorded in 1999 and 2000. The only statistically significant
difference between the risk assessments recorded in 1999 and in 2000 was the
evidence in the notes for weighing up the risk of self-harm that increased
from 14% in 1999 to 34% in the notes for weighing up the risk of self-harm
that increased from 14% in 1999 to 34% in 2000 (Fisher's exact test=0.034).
Comparable statements concerning risk of violence were practically
non-existent in both years.
Table 2 also shows the
recorded components of management plans. These did not differ significantly
between 1999 and 2000. While crisis plans were commonly formulated, specific
plans to manage risk were rare.
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Discussion
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This audit assessed only the documentation associated with risk assessment
and management. The clinical encounter in respect of risk may have been more
comprehensive and relevant information may have been communicated verbally
rather than in writing. We found that despite recent trends towards greater
emphasis on risk assessment in psychiatry and despite local specifically
targeted opportunities, the standard of documentation of risk of harm to
others remained unchanged between 1999 and 2000. It is possible that the
intervention was too weak, the numbers analysed were too small, or that there
were differences between the doctors in 1999 and 2000 that have not been
accounted for. The documentation of risk of suicide did improve significantly
between the 2 years however, suggesting that the intervention did have some
impact.
Unlike the assessment of the risk of self-harm, the assessment of the risk
of harm to others is a new task. Few psychiatrists have received any relevant
instruction while medical students. The standard textbooks of general
psychiatry usually fail to mention it. Risk assessment has not been regarded,
until very recently, as a standard psychiatric skill. We know that changing
the behaviour of clinicians is very difficult
(NHS Centre for Reviews and Dissemination,
1999). It is thus not surprising that there was little evidence of
change in our study. It is further confusing that it seems only in the UK is
risk assessment regarded as being ‘at the heart of effective mental
health practice’ (Department of
Health, 1999a: p. 22).
A number of senior house officers emphasised that in the context of working
with patients in a crisis, their first concern is the wellbeing of the
patient. This is what they as doctors have been trained to do. To think about
the risk to others does not seem to come naturally, especially when dealing
with a very ill patient. Some resistance to considering risk may also come
from the belief that doctors are there to treat patients, not to protect the
public. The poor predictive value of risk assessment may also be a factor.
What is the practical value of a risk assessment when individual risk factors
are common (as in an inner-city emergency clinic) yet serious incidents rare
(Szmukler, 2001)?
We believe there is a need for us to be clear about the value and
limitations of risk assessment. The assessment of the risk of violence to
others is inherently imprecise (as it is for the risk of suicide). Practice
aimed at avoiding later blame (managing the ‘risk to oneself’) is
not a good reason to advocate risk assessment. We suggest that the focus of
risk assessment should not be primarily to prevent violent acts, but to alert
the clinician that a particular patient may present a higher risk than others,
and that the consequences of an inadequate treatment plan could prove
damaging.
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References
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DEPARTMENT OF HEALTH (1999a)
Modernising the Care Programme Approach: A Policy
Booklet. London: Department of Health.
DEPARTMENT OF HEALTH (1999b)
National Service Framework for Mental Health. London:
HMSO.
NHS CENTRE FOR REVIEWS AND DISSEMINATION (1999)
Getting evidence into practice. Effective Health Care
Bulletin, 5(1),
1-16.
SZMUKLER, G. (2001) Violence risk prediction in
practice. British Journal of Psychiatry,
178, 84-85.[Free Full Text]
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Abstract
Introduction
