Shared learning database

Sheffield Teaching Hospital, Sheffield Care Trust, Sheffield Ambulance Service
Published date:
December 2006

Establishing a collaborative approach to implementing NICE's guidance for the psychological management of self-harm in primary and secondary care.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The publication of the guideline provided an opportunity to establish a collaborative approach. A joint team was formed from the Sheffield Teaching Hospitals (STH) Accident & Emergency (A&E) staff, Sheffield Care Trust's (SCT) liasion service and South Yorkshire Ambulance Service NHS Trust. Sheffield Care Trust is the major provider of mental health services in Sheffield. Both teams included service users, voluntary sector and members of clinical effectiveness and audit staff from SCT and STH. The aim was to ensure cross organisational implementation of this guideline, improve relationships and improve the service. The main objectives were to: 1. Establish a joint approach to implementation of the guideline. 2. Audit findings at baseline and compare with NICE criteria and change strategy. 3. Combine with national Royal College of Psychiatrists (RCP) project on self harm and establish peer-to-peer contact with another local A&E department.

Reasons for implementing your project

Acute Trust A&E departments are frequently the first, and often repeat, starting points for clients who have self harmed. We needed to establish a baseline audit of what happened to clients who attended STH A&E department following an episode of self harm. This was done from the perspective of STH, the Ambulance Service and SCT. The work was needed because historically, cross organisational management of this client group frequently involved long waits in A&E, clients who refuse to travel with the ambulance and clients admitted to assessment units or wards in an acute trust environment which may not be wholly suitable. All Accident & Emergency (A&E) cards were manually examined for a 1 month period for evidence of self harm (A&E nurse, A&E audit staff) and outcome. 172 were identified as self harm. Patient details were cross referenced with SCT & Ambulance databases. We also visited and established a collaboration with a further A&E department who, with STH, had taken part in a separate but closely related project on self harm conducted by the RCP. The admission cards contained details which enabled audit against the standards in the NICE guidelines. This and information collated from the Ambulance Service provided the main dataset.

How did you implement the project

Initial Audit (n = 172 cases): 1. 16 years to 50 years form predominant presenting group who self harm. 2. There was a 25% reduction in suicidal intent after arrival in A&E (compared to time-of-act). 3. Alcohol is frequently involved, although as an "enabler". 4. 30% had adequate triage at assessment (area for improvement). 5. 65% had previous self harm adequately documented (area for improvement). 6. Use of illicit drugs recorded in only 36% of cases (area for improvement). 7. Ambulance staff attended 118 calls involving self harm over 1 month period, yet only 45% travelled to A&E. 8. A large proportion (33%) were not known previously (unmet need). 9. There are still pockets of negative views towards this client group from staff.

Key findings

This audit was only possible because of close and productive collaboration with other organisations. The group was allowed access to A&E and A&E notes and worked together with A&E staff. As a result of this work, STH agreed and funded a secondment from A&E for a senior member of nursing staff to join the SCT liasion service. The idea is to implement training for acute A&E staff at a later stage to better enable them to deal with this client group and mental health clients in general. In addition, the input provided by the liasion service (Monday to Friday working hours) to relieve pressure on crisis teams and improved A&E waiting times for self harm clients who wait to be seen by mental health staff. This project will be written up for publication in relevant journals although this work is ongoing.

Key learning points

1. Good relationships and working arrangements - Other local trusts welcome collaborative work and it gets the attention of trust boards and others. This gave a better chance of providing evidence for resource provision to improve working arrangements. 2. For guidelines that are clearly cross organisational, involving local partners and the voluntary sector is important - so ask. Even if they are unable to collaborate at this time it is good groundwork. 3. Get issues of confidentiality, information sharing, etc, out of the way first using official channels (usually Caldicott Guardian in each organisation). Failure to do this can result in significant problems down the line. 4. Involve service users and disseminate results adequately with an action plan (we used a local conference on suicide to present this work).

Contact details

S Batson, S Cross, J Thompson & *B Hockley
Projects Manager
Sheffield Teaching Hospital, Sheffield Care Trust, Sheffield Ambulance Service

Secondary care
Is the example industry-sponsored in any way?