Psychiatric Bulletin (2007) 31: 224-226. doi: 10.1192/pb.bp.105.007963
© 2007 The Royal College of Psychiatrists
Protocol for the assessment of self-harm in young people: initial audit and training implications
Sarah Huline-Dickens, Consultant in Child and Adolescent Psychiatry
Erme House, Mount Gould Hospital, Plymouth PL4 7QD, email:
sarah.huline-dickens{at}phnt.swest.nhs.uk
Tony Adiele, Specialist Registrar in Forensic Psychiatry
Edenfield Centre, Prestwich Hospital, Manchester M25 3BL
Declaration of interest
None.
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Abstract
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AIMS AND METHODS
This paper describes the development and initial audit of a protocol for
the assessment of young people up to the age of 18 years who presented to the
accident and emergency department (A&E) with self-harm. A key part of the
project was education and training.
RESULTS
Regular training of senior house officers (SHOs) in A&E may have
contributed to an increase in young people being admitted to a bed for proper
assessment (as per the protocol), but psychosocial assessments undertaken by
SHOs in A&E were still only partial, and there was no apparent use of the
mental state examination.
CLINICAL IMPLICATIONS
Child and adolescent mental health services have an important role to play
in liaising with local A&E departments in training of junior staff in
psychosocial assessment and the use of the mental state examination. This is
especially relevant in the light of the new training requirements of the
foundation years.
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Introduction
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Self-harm in young people is a significant public health problem and the
guidelines produced in 2004 (National
Institute for Clinical Excellence, 2004), in the same month that
this audit was planned, and therefore not taken into account in this work,
highlight the importance of psychosocial assessment, although nowhere has it
been specified who should be undertaking this.
In 2002, approximately 20 young people per month were presenting to the
accident and emergency (A&E) department of Derriford Hospital, Plymouth
with self-harm. Excluded from these figures are children under 5 years of age,
young people 18 years or older and those who had ingested alcohol
(approximately 5 young people per month), drugs and other substances by
accident.
Prior to 2002, a protocol for the assessment of self-harm in young people
had existed but was not easily available and had not been revised for some
time. It was unclear whether trainees knew of its existence. Staff in the
child and adolescent mental health service (CAMHS) would often hear
anecdotally about young people who were discharged from the A&E department
after taking significant overdoses. There were also frequent difficulties in
the A&E department over who was responsible for assessments.
An initial survey undertaken by a senior house officer (SHO) attached to
the CAMHS at the end of 2002 indicated that a third of young people presenting
with self-poisoning were admitted to the paediatric ward, while two-thirds
were discharged straight from the A&E department following psychosocial
assessments of varying quality. Two further surveys were undertaken during
this time, or started shortly afterwards, and concerned the nature of the
psychosocial assessments undertaken by paediatricians on the wards and what
happened to young people aged 16-18 years. It emerged that trainees in
paediatrics were undertaking good psychosocial assessments but confused the
mental state examination with the assessment of consciousness using the
Glasgow Coma Scale (Teasdale & Jennett,
1974). Moreover, paediatric trainees who had been trained outside
the UK had no experience of psychiatry as medical students. The proportion of
young people aged 16-18 years being admitted to a ward had increased slightly
from the previous survey (15 out of 30). A third of patients (10 out of 30) in
this age group are presenting at the weekend, when the duty rota for routine
assessment by CAMHS was not in operation.
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Development of the protocol
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A multidisciplinary, multi-agency group was therefore convened by S.H.-D.
comprising A&E consultants, the liaison health visitor (also a child
protection advisor), a social services team leader and a consultant in
paediatrics. The working party met on four occasions between July 2003 and
April 2004, during which time successive drafts of the protocol were amended
as consensus was reached.
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Features of the protocol
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The protocol incorporates national guidelines from the Royal College of
Psychiatrists (1998) and is
informed by guidelines from a number of other CAMHS (e.g. Chichester, Bath and
Swindon). It specifies what is required as part of the psychosocial
assessment, and teaching, audit and regular review are essential elements.
Important aspects of the protocol are:
- the recommendation that all young people up to 18 are admitted to a ward
and assessed the next working day by CAMHS, regardless of the type or quantity
of overdose taken
- the importance of the psychosocial assessment (as specified by the College
(Royal College of Psychiatrists,
1994) and highlighted by the National Institute for Clinical
Excellence (2004)
- a recommendation that suicide intent be estimated using the PATHOS scale
(Kingsbury, 1996), which is
simple to administer
- an outline of who to contact if there are child protection concerns
- a summary of legal matters pertaining to emergency treatment, such as
consent issues and use of the Mental Health Act 1983
- a system of triage undertaken by doctors in paediatrics and A&E at
weekends (Friday and Saturday) when young people are refusing to stay until
Monday. Thus, the young person, on the basis of the psychosocial assessment
and therefore risk, can be:
- discharged home (low risk)
- or discharged home with request to CAMHS for follow-up (low risk
but ongoing difficulties)
- or the SHO in psychiatry is called, who can then if necessary
liase with the consultant child psychiatrist on call (high risk).
Although the protocol deals mainly with young people presenting with
self-poisoning, suggestions are also made concerning the further management of
those young people presenting with alcohol intoxication and
self-mutilation.
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Teaching
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Teaching was provided to SHOs in A&E by S.H.-D. from April 2003 on a
6-monthly basis. This not only provided SHOs with a basic knowledge about the
CAMHS, but developed into a forum for disseminating the protocol and for
discussing the difficulties associated with the assessment of self-harm in
young people. Attitudes are notoriously negative towards individuals who
present with self-harm, especially if they are ‘repeaters’, or are
seen to be wasting doctors’ time, or if they don’t appear to be
overtly distressed. It was gratifying that SHOs could often see their
responses as unhelpful after a group discussion, and found it useful to
appreciate that young people presenting in crises can often improve over
time.
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Audit of the protocol
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Aims
The audit of the protocol in its final draft (March 2004) examined
adherence to the protocol by measuring the following four standards in the
A&E department:
- that all children under the age of 16 following an overdose should be
admitted to a paediatric bed
- that young people between the ages of 16 and 18 should be admitted to the
A&E observation ward overnight
- that a psychosocial history be undertaken (according to the guidance issued
by the Royal College of Psychiatrists in
1994) and also now part of the NICE guidelines
(National Institute for Clinical
Excellence, 2004). Areas to be covered are: level of
consciousness, triggers to the overdose, degree of intent, past psychiatric
history, drug and alcohol history and a mental state examination
- that there is a clear treatment plan in the notes.
Method and results
We inspected 20 consecutive casualty cards of young people presenting with
self-harm during the month of September 2004. Children under 5, young people
who were already 18, and those who had ingested alcohol, drugs and other
substances by accident were all excluded. All 20 assessments had been
undertaken by SHOs in A&E. For children under 16 years, 7 out of 10 (70%)
were admitted to a ward and 2 (20%) discharged home (in 1 the outcome was
unknown). For young people between 16 and 18 years, 6 out of 10 (60%) were
admitted and 3 (30%) discharged (again in 1 the outcome was unknown).
Doctors in the A&E department performed Glasgow Coma Scale assessments
in 19 (95%), asked about triggers to the overdose in 12 (60%), degree of
intent in 11 (55%), past psychiatric history in 17 (85%), and substance misuse
in 10 (50%). In only one instance was a mental state examination performed and
this was because that patient had also been seen by a psychiatric SHO on
request. A treatment plan was recorded for 11 young people (55%).
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Discussion
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Clearly, there are limitations to this work, the most obvious being that
the number of case notes examined was very small. Other criticisms apply to
the imperfect way the protocol was disseminated up to the time of the audit;
it had not been fully published in the A&E department handbook by then,
and it is also highly likely that not every SHO was able to attend the single
teaching session offered every 6 months owing to shift patterns of working.
These points must therefore be borne in mind when considering the results.
Nevertheless, in this snap-shot of practice in September 2004, results of this
exercise raise two main questions. Is the protocol being followed? The answer
is ‘to an extent’, if we can take figures for admission to a bed
as an indication. From the initial survey in 2002, approximately two-thirds of
young people were being discharged directly from the A&E department, and
now that proportion is 35%. Who should be undertaking the psychosocial
assessments? Although it had been agreed that as part of the protocol junior
doctors were to undertake these, and training was provided (notwithstanding
the limitations above), it was clear that although A&E doctors felt
comfortable with some aspects of the psychosocial assessment, such as the use
of the Glasgow Coma Scale, no mental state examinations were performed in this
small sample.
Much has been done since this audit was undertaken to improve practice
further. A front sheet has been designed for use in the A&E department,
which will outline the psychosocial assessment and include prompts for the
mental state examination, which, it is hoped, will enhance recording of
information and also prevent duplication of work. The protocol has also been
incorporated in the A&E department handbook. Plans also exist for it to be
made available on the Plymouth Hospitals NHS Trust’s intranet.
What are the possible reasons for the lack of mental state examinations in
this study? Perhaps it was assumed that these would be undertaken by another
assessor later (for example by CAMHS staff the next day), or perhaps a mental
state examination was not considered relevant to adolescents, or perhaps SHOs
feel unskilled in dealing with young people in complex psychosocial
situations. (We also recall the earlier point that doctors from overseas may
not have had any psychiatric training.) It has been suggested by some that
mental state examinations should only be undertaken by CAMHS staff who are
used to doing these routinely in young people. However, it is the
authors’ view that the mental state examination is an important
assessment tool and its use by doctors of any specialty should be encouraged.
Furthermore, performing a mental state assessment is now a core competency
that all graduating medical students and foundation trainees should be able to
do, as required by the General Medical Council and Postgraduate Medical
Education and Training Board (Foundation
Programme Committee, 2005).
Finally, since this audit was planned before the introduction of the NICE
guidelines (July 2004) and the curriculum for the foundation years
(implemented in August 2005), and also as further improvements to the
procedure have been made, it will need to be repeated with these in mind.
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Conclusions
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It is hoped that this project has provided useful training experiences in
audit activity for junior doctors attached to the CAMHS department. The
results of this small audit show that the protocol is largely being followed,
and as a result we hope that patient care is improving. This project has also
raised the interesting question of the use of the mental state examination by
non-psychiatric SHOs. Child and adolescent mental health services have an
important role to play in liaising with their A&E colleagues concerning
the group of vulnerable young people who self-harm. Teaching and training of
SHOs is an important aspect of this relationship.
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Acknowledgments
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We thank Drs Anthony Christopher, Maung Oakarr and Praha Savinduran for
collecting information; and members of the protocol working party, in
particular Iain Grant, Di Baumer and Robert Jones for their commitment to
developing the protocol between 2002 and 2004.
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References
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FOUNDATION PROGRAMME COMMITTEE OF THE ACADEMY OF MEDICAL ROYAL
COLLEGES (2005) Curriculum for the Foundation Years in
Postgraduate Education and Training.
http://www.mmc.nhs.uk/download_files/Curriculum-for-the-foundation-years-in-postgraduate-education-and-training.pdfKINGSBURY, S. (1996) PATHOS: a screening instrument
for adolescent overdose. Journal of Child Psychology and Psychiatry
and Allied Disciplines, 37, 609
-611.[CrossRef][Medline]
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2004)
Self-Harm: The Physical and Psychological Management and Secondary
Prevention of Self-Harm in Primary and Secondary Care.
NICE.
ROYAL COLLEGE OF PSYCHIATRISTS (1994) The
General Hospital Management of Adult Deliberate Self-Harm: A Consensus
Statement on Standards of Service Provision (Council Report
CR32). Royal College of Psychiatrists.
ROYAL COLLEGE OF PSYCHIATRISTS (1998)
Managing Deliberate Self-Harm in Young People (Council
Report CR64). Royal College of Psychiatrists.
TEASDALE, G. & JENNETT, B. (1974) Assessment of
coma and impaired consciousness. Lancet, ii, 81-83.
Top
Abstract
Introduction
