County Durham and Darlington Foundation Trust consists of 3 acute hospitals, it is estimated there are approximately 2,500 attendances at accident and emergency for self harm annually, care treatment and interventions following self harm is important as patients are statistically at higher risk of suicide (Hawton 2003). Service user's describe contact with services as often being difficult characterised by ignorance and negative attitudes and it is no longer acceptable for healthcare professionals to fail to address this experience of care by service users and their carers. With such statistics and issues the Mental Health Liaison Team from Tees, Esk & Wear Valleys NHS Trust in collaboration with the Acute hospital were awarded a place on a national quality improvement program with the aim of optimising and improving services for self harm and increasing compliance with NICE self harm guidelines.
Tees Esk and Wear valley NHS Trust
Guidance the shared learning relates to:
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?
The aims of the project were to: 1 Establish a collaborative gaining the support of key organisations including: the acute trust (Accident and Emergency), ambulance services and primary care. In addition to these core services, police, service user groups, service users, voluntary agencies were also key participants. This developed a strong partnership which worked across the boundaries and supported the development of interface agreements. 2 To develop a benchmarking tool based on the NICE self harm guidelines which could be re-audited to demonstrate improvement in services. (please see attached) 3 To benchmark current services by undertaking audits to measure current protocols between services especially mental health and the accident and emergency department. 4 To raise the standard of care and treatment for people who self harm, ensuring service user groups/service users and carers have a voice. 1 To develop a benchmarking tool using the NICE self harm guidance to include good practice points, that would benchmark current provision and be used annually to re-audit services and therefore demonstrate improvements and high quality delivery in the coming years, including conducting a case flow audit of people who attend University Hospital of North Durham with self harm, identifying deficits in the care pathway and highlighting areas for improvement. This would inform the design of a multi agency pathway which would include information from the Ambulance Trust and police when a person is taken to the acute trust who has self harmed. Undertake a survey of the service user experience and staff questionnaires to evaluate attitudes and opinions of staff and estimate training needs to deliver support and supervision for acute hospital staff especially the emergency department. 2 To improve and standardise information for service users relating to self harm and information service users receive when seen by the mental health Liaison team within the acute trust. 3 Develop innovative joint working with agencies from the voluntary sector.
The Mental Health Liaison Service represented in the collaborative are based within the local acute trust, they were responsible for developing and benchmarking the current service for people who self harm. The purpose of the document was to benchmark current care and practised against good practise standards and evidence based practice. It was designed with ease of reference on the traffic light performance monitoring system as a way of monitoring current provision and demonstrating improvement. The baseline audit against standards presented within this document was carried out in January 2006 at the beginning of the collaborative, and has been re-audited annually in 2007 and 2008 (please see supporting information). From the results of surveys the following actions were established and achieved: - A self harm leaflet was developed - aimed at standardising self harm information and including advice/ support for carers and helpful alternatives to self harm - A Mental Health Liaison service user leaflet was developed which included a copy of their care plan on discharge, details of further appointments, access to PALS (Patient Advice and Liaison Services) in both mental health and acute hospitals, how to make a complaint and emergency telephone nos. - A multi agency pathway was developed which was brief to be used in Accident and Emergency Departments and included information from police and ambulance staff. This included an agreed tool for risk assessment for future suicidal intent by non mental health professionals. - Self harm awareness in house training sessions; facilitated to acute hospital wards and departments by mental health Liaison staff. This occurs 4 times a year and is included in the acute trusts education and development portfolio. - Samaritans policy developed to provide telephone follow up by the Samaritans for someone following self harm. (Full policy available)
1 The NICE benchmarking tool measures 54 standards which have been monitored in 2006, 2007, 2008, 2009 (Pending).This has consistently demonstrated an improvement. The 2006 - 2007 audit demonstrated 10 categories where improvement was observed including treating people with respect, privacy and dignity, sharing the needs assessment via care plan and a choice of male/female worker. The 2007-2008 audit demonstrated 7 categories where improvements were observed, access to Dialectical Behaviour therapy, mental capacity assessments, follow up by MH team, providing written information, and education/ supervision for acute staff. 2 Self harm information leaflet - designed in collaboration with service users includes information for relatives/carers, emergency contact nos. This leaflet is available in the Acute Trust, GP surgeries, Police custody suites, mental health trust. 50% service users were given a leaflet in the acute trust, 60% received a care plan on leaving hospital, 75% service users were given information on emergency no?s and 100% given information on self help groups. 3 Self Harm awareness sessions - 60 + acute staff trained. The evaluations demonstrated that acute staff feel more supported, have developed an understanding of self harm behaviour and can identify risk factors related to future self harm/suicide. 4 Self Harm risk assessment tool was introduced to A&E Depts, enabling appropriate referral to mental health services. All patients who present with self harm will have a risk assessment completed. Service users have reported feeling positive about their care experience, and note an improvement in A&E staff attitudes. 33% A&E staff reported an improvement in the quality of risk assessment and felt people who self harm are treated as well as people with other illnesses. 5 Samaritans telephone follow up - agreed with local Samaritan groups to allow mental health team to refer a person with their consent for up to 3 telephone contacts
Monitored by 1 Quarterly collaborative meetings 2 Meetings with acute staff 3 Clinical Audit The following actions have been agreed and are ongoing. 1 Benchmarking of NICE self harm guidelines annually to monitor the progress and problem solve areas of difficulty 2 Self harm awareness sessions continue and have been extended to include mental health awareness and rolled out to all Acute Trust staff with 4 sessions delivered annually. 3 Discussion with Ambulance service re possible self harm awareness training for paramedics. 4 Agreement that the risk assessment tool used in Accident and Emergency Departments will be audited jointly between the mental health and acute trusts, with a benchmark of 85% completion agreed 5 Self harm leaflet now available on Durham Police Intranet site and Police Custody suites. 6 Emergency care practitioners introduced to assess in police custody suites receiving training to implement risk assessment for future suicidal intent. 7 Rolling out the Samaritans service user telephone follow up process to Accident & Emergency Departments, Local Crisis Resolution teams and Mental Health Liaison Teams within other local Mental Health Trusts. 8 Service user audit to continue annually to ensure their experience and views are key to informing future improvements across all sectors. Results have been shared at National Patient Safety conference in Nov 2008 and by recognition in an article in Emergency Nurse Nov 2008 published by RCP "Better Service Collaborative" and as category winner in the SHA Safer care awards.
The implementation of the NICE Self Harm Guidelines has brought together organisations with the aim of improving care for people who self harm. It is intended that County Durham will strive to improve this quality and this will be achieved through committed partnership working contributing to the ongoing and sustained improvement demonstrated in the NICE self harm benchmarking tool standards. - Implementation of these guidelines has major benefits for trusts e,g risk management and benefits for service users e.g increased and clarification of information which is standardised across County Durham leading to access the same high quality information from mental health liaison teams, police custody suites, A&E Depts and GP surgeries. - All partners involved experienced very positive outcomes and this has led to sustained improvement in collaborative working relationships across the organisations and agencies. In a drive for positive results there are also challenges and frustrations which can be learnt from. These were: - Difficulties in recruiting and maintaining service users we developed imaginative ways to ensure their views were considered. The service users views had a huge impact especially amongst our acute trust colleagues - Other blockages were capacity of the committed organisations. This required full dedication and commitment from the mental health and the acute trust leads. - Challenges encountered were when documents were developed e.g risk assessment tools, and the clinical pathway, members of the team encountered opposition when trying to implement change. This had to be worked through positively but was very frustrating for those involved. - Other frustrations were the length of time governance processes took within Trusts. E.g. for approval of information leaflets this included mental health and acute trust approval and PCT governance to agree the joint policies, pathways and leaflets which were developed.
Clinical Nurse lead
Tees Esk and Wear valley NHS Trust
Is the example industry-sponsored in any way?