The NICE CG16 self harm guide emphasises the need for comprehensive psychosocial assessment of all individuals presenting to general hospital services following self-harm. By using the clinical audit cycle we have been able to improve the quality of our psychosocial assessments and enhance practice by ensuring equity of service in a busy city psychiatric liaison service.
Aims and objectives
Our service developed a comprehensive psychosocial assessment based on NICE CG16 for use with all patients who present to the emergency department following an episode of self harm. The aims of the project were:#
- To further enhance the standard of our psychosocial assessment and ensure that service users are receiving the best possible care consistently and quality of assessment, regardless of the time of presentation to the emergency department following an episode of self harm.
- To ensure that standards of psychosocial assessment were consistent across staff groups.
- To facilitate this process by use of a full audit cycle.
Reasons for implementing your project
Before the project there was an obvious lack of consistency of quality of psychosocial assessment relating to the time of presentation to the emergency department. Out of hours trainee doctors were providing psychosocial assessments with little or no previous experience. A baseline audit in 2010 confirmed significant differences existed in the quality of the psychosocial assessment carried out by trainee doctors compared to Psychiatric Liaison Nurses. Also, assessments by some more experienced staff did not always include coverage of some key items.
Benefits identified were for patients, the Trust and the Emergency Department at the John Radcliffe:
- Potentially reducing the likelihood of further self harm and suicide
- Facilitating a better chance of eventual wellbeing for patients
- Instilling consistency and ensuring excellent care
- Enabling the Emergency Department to feel confident they were getting the same standard of response 24 hours a day
How did you implement the project
One of the problems that we faced with this project was the geographical location of the Psychiatric Liaison Service. The Psychiatric Liaison Service provides a service across 2 sites in Banbury and Oxford which are part of Oxford University Hospitals Trust. In terms of geographical location they are on sites that are 25 miles apart. Joint working and engagement across both Trusts and disciplines (medics and nurses) was essential.
An initial audit of the psychosocial assessment paperwork (from case notes) was undertaken and areas for improvement were identified. For example, history of abuse and child protection issues were not being routinely documented by trainee doctors and were on occasion being omitted by some well-established nursing staff. As a result of this, specific prompts were added to the psychosocial assessment paperwork. Training in the psychosocial assessment following self harm was provided for trainee doctors as part of their induction.
The costs incurred related to the number of hours in clinical staff time that it took to review the training, clinical time to re-design the psychosocial assessment paperwork and clinical time to undertake the audit. As part of the action plan it was agreed that a re-audit would take place within 18 months.
The overall quality of psychosocial assessments across the team were improved, not just those of the trainee doctors. The team started talking about the importance of asking delicate questions relating to abuse for example and the team linked more closely with the Trust child protection team. Our reflective dialogue was informed by the audit and in turn it informed and enhanced practice. The student nurses who have placements at the Barnes/EDPS benefit from observing and learning highly contemporary and skilled psychosocial assessments and as they move on and progress their career elsewhere they take this learning with them.
Progress was monitored through the audit cycle. An initial audit (n=61) was undertaken in 2010, a re-audit was undertaken in 2011 (n=20) and the 3rd cycle audit was undertaken in 2013 (n=29).
Key actions implemented and monitored following the 2011 audit:
- Training in self harm assessments to all new staff including doctors through induction
- Weekly supervision groups established
- Psychosocial assessment form revised
Assessment form was made available in hard copy in emergency room and also in shared team drive
Results from the 2013 audit demonstrate an overall improvement across all of the standards measured.
A particular area identified for improvement from previous audit results related to the documentation of information relating to the following:
- Recording of history of domestic abuse has increased over the 3 audit cycles from 8% in 2010 to 43% in 2011 and to 63% in 2013.
- Recording of issues relating to Child Protection issues has increased from 12% in 2010 to 33% in 2011 and 65% in 2013.
- Significant increase shown in the recording of psychological characteristics associated with self harm for example, the recording of the patient's view of the future/hopelessness has increased from 16% in 2010 to 61% in 2011 and 93% in 2013.
Results from the 2013 audit also demonstrate an improvement in the quality of psychosocial assessments undertaken by trainee doctors. Specific data analysis of the quality of psychosocial assessments undertaken by trainee doctors show improvements in the following key areas:
- The recording of any Child protection issues has increased from 0% in 2012 to 38% in 2013
- The recording of the history of abuse has increased from 41% in 2012 to 70% in 2013
- Recording of drug use has increased from 67% in 2012 to 100% in 2013.
Key learning points
As a result of the audit our service has very comprehensive psychosocial assessment documentation which reflects the standards in NICE CG16 and is easily transferrable to other organisations.
Other organisations addressing the issue of provision of effective psychosocial assessment for self harm patients should undertake a baseline audit to identify the main areas for improvement. They are encouraged to engage trainee doctors and other staff in the audit process by presenting the results in a sensitive way and offering solutions for improvement.
Involve your audit team as they were able to provide us with advice and support with the design of the clinical audit project. Always pilot your audit tool to test the reliability and validity of the data being collected.