Risk assessment of patients presenting with self-harm to Maidstone liaison psychiatry: a clinical audit

Adam Osman
Joel Lawson
Shandriya Rai
Laurence Potter

Introduction

This topic was chosen as self-harm is a very frequent presentation to the Maidstone liaison psychiatry team as well as to all liaison psychiatry team’s across the UK. In England, there is approximately over 200,000 presentations for self-harm to emergency departments’ annually [1]. Approximately 20% of people who self-harm will present again to the same hospital within a year [2]. For all age groups, annual prevalence of self-harm is 0.5%. Self-harm increases the probability that the person will eventually commit suicide by between 50-100 fold above the rest of the population in a 12 month period. Self-harm occurs in many different mental health conditions and is not specific to any one condition [3].

Risk assessment is a vital component of the specialty of psychiatry and guides us in formulation and management plans for our patients. The current working practice in our trust regarding risk assessing self-harm is based on collating information of the current risk event, current risk factors, protective factors and past risk events which then leads into a more detailed formulation and risk management plan.

NICE guidelines define a risk assessment as: “A risk assessment is a detailed clinical assessment that includes the evaluation of a wide range of biological, social and psychological factors that are relevant to the individual and, in the judgement of the healthcare professional conducting the assessment, relevant to future risks, including suicide and self-harm.”

Recommendations are set out in NICE guideline CG133: Self-harm in over 8s: long-term management”3.

In this audit, we intended to assess our current level of practice with regards to risk assessment of patients presenting to the Maidstone Liaison Psychiatry service and compare this to the NICE guideline CG133.

 

Audit Objectives

-To assess whether patients presenting with self-harm to Maidstone Liaison Psychiatry are being risk assessed in line with the current NICE guidelines.

-To generate recommendations on improving risk assessment where appropriate.

 

Method and Audit Standard

This audit included 20 patients referred to Maidstone Liaison Psychiatry clinically coded as self-harm presenting between 1st of August to 17th of August 2017.

Patient information was anonymised by completing coded data collection forms. Data collection involved reading through the patient’s Rio entry (Risk assessment form, Core assessment form and progress note), looking for each item on the NICE guidelines (Table 1). When an item was identified in the risk assessment, the corresponding box was ticked on the data collection form. See Appendix 1 for data collection form.

Table 1 lists the items recommended in NICE guideline CG133: Self-harm in over 8s: long-term management for inclusion in a psychiatric risk assessment. The standard to meet for inclusion of each item was 100%.

Table 1. Items included in NICE guideline CG133: Self-harm in over 8s: long-term management for inclusion in a psychiatric risk assessment.

No

Risk assessment criteria

 

Standard

Exception

1

Current method of self-harm

100%

None

2

Any past self-harm and method

100%

None

3

Frequency of past self-harm

100%

None

4

Current suicidal intent

100%

None

5

Past suicidal intent

100%

None

6

Depressive symptoms and their relationship to self-harm

100%

None

7

History of psychiatric illness and its relationship to self-harm

100%

None

8

Circumstances preceding self-harm (e.g. unpleasant affective states or emotions and changes in relationship)

100%

None

9

Risk factors to self-harm (e.g. social, personal, psychiatric, pharmacological,  motivational)

100%

None

10

Protective factors to self-harm

100%

None

11

Coping strategies to limit self-harm

100%

None

12

Supportive relationships

100%

None

13

Negative relationships (such as abusive or neglectful) that may lead to changes in the level of risk

100%

None

14

Immediate risks to self-harm

100%

None

15

Long term risks to self-harm

100%

None

16

Other risk-taking or destructive behaviours (e.g. exposure to unnecessary physical risks, drug misuse or drinking)

100%

None

17

Access to others’ medications

100%

None

Summary of Results

 Table 2. Numbers and percentage of criteria included in risk assessment

Risk assessment criterion

 

Result

 

Number

 

Percentage

Method of current  self-harm

20/20

100%

Circumstances preceding self-harm (e.g. unpleasant affective states or emotions and changes in relationships)

20/20

100%

Current suicidal intent

20/20

100%

Protective factors (e.g. social, personal, psychiatric, pharmacological,  motivational)

20/20

100%

Other risk-taking or destructive behaviours (e.g. exposure to unnecessary physical risks, drug misuse or drinking)

18/20

90%

Depressive symptoms and their relationship to self-harm

18/20

90%

Risk factors (e.g. social, personal, psychiatric, pharmacological,  motivational)

18/20

90%

History of psychiatric illness and its relationship to self-harm

16/20

80%

Method of past self-harm

16/20

80%

Supportive relationships

16/20

80%

Long term risks to self-harm

14/20

70%

Frequency of past self-harm

11/20

55%

Immediate risks to self-harm

9/20

45%

Negative relationships (such as abuse or neglect) that may lead to changes in the level of risk

8/20

40%

Past suicidal intent

5/20

25%

Coping strategies to limit self-harm

4/20

20%

Access to others’ medications

1 /20

5%

Green: 90-100% compliance

Amber: 50-89% compliance

Red:    0-49% compliance

 

Results

Following data collection, percentages were calculated for the inclusion of each item in the risk assessment of the 20 patients. Results showed:

  • 4 items were included in 100% of risk assessments (Method of current self-harm, Current suicidal intent, Circumstances preceding self-harm and Protective factors);
  • 3 items were included in 90% of assessments (Other risk-taking or destructive behaviours, Risk factors, and Depressive symptoms and their relationship to self-harm);
  • 5 items were included in between 50-89% of assessments (Method of past self-harm, Any psychiatric illness and its relationship to self-harm, and Supportive relationships);
  • 5 items were included in 5-49% of assessments (Immediate risks, Negative relationships that may lead to changes in the level of risk, Past suicidal intent, Coping strategies to limit self-harm, and Access to others’ medication).

 

Limitations

Data collection for this audit was limited by the information which was documented. It is likely that information was gathered in the history and not documented, especially if the answer was a negative. It may be a case that it is too time consuming for practitioners to document all negative answers. However this information would still have fed into the clinical decision that was made. For the purposes of data analysis we had to assume that if information was not documented that it was not included in the risk assessment. Similarly, helpful advice may still have been offered to the patient but not documented e.g. coping strategies for self-harm.

A further limitation is the small sample size and the short duration that data was collected over. Future audit could include a larger sample size collected over a number of months to increase the validity of the findings. Although the criteria were clearly set out by the guidelines, date collection involved a degree of interpretation due to the ambiguity of documentation.

 

Discussion

Although only 4 of the 17 items met the standard of 100%, 10 of 17 were above 80% inclusion. Certain items such as Protective factors are specifically asked for in the risk assessment form on Rio, and this reached 100% inclusion. This suggests it may be useful to include particular items on the Rio form to remind clinicians during interview. This particular item is necessary as part of the formulation. Supportive relationships may often be cited as a protective factor so may be documented frequently as Protective factors always asked. There appears to be a trend towards current risk factors being included more than historical ones. This would be expected as the current risk factors relate to the presenting self-harm.

Five of the 17 items were documented below 50% of the time.  Notably the immediate risk was recorded in 45% of assessments. The term is immediate risks is ambiguous and during data collection this was interpreted as an explicit and immediate wish to end life. However on reflection this is more likely to relate to current suicidal plans. This may have skewed the result for this criterion.

Negative relationships (such as abuse or neglect) that may lead to changes in the level of risk were documented in 40% of entries. This may have been low as practitioners only ask when this appears to be relevant to the history or if this is offered from the patient.

Past suicidal intent was documented in 25% of entries which may indicate that the focus on the encounter is on the current presentation. For recurrent attenders who were known to the practitioner, it may not have felt appropriate or helpful to explore past suicidal intent.

Coping strategies to limit self-harm was documented in 20% of entries. This low percentage is likely to indicate a lack of documenting in the notes. Support leaflets with information on coping strategies are frequently given to patients and this may be written on the care plan which is handed to patient and sent to GP, but not directly documented in the electronic notes on Rio.

Access to others’ medications was documented in 5% of entries. This again may not always feel relevant to the history e.g. if lives alone or if overdosed on own medication. However accessibility to prescription medication is an important aspect of assessing future risk.

The use of risk assessment tools is explicitly advised against in these guidelines. Decisions of risk rely upon the clinician’s experience and judgement of the clinical presentation. The list of items included in the NICE guidelines have been shown to give good predictive value on whether patients will repeat self-harm behaviours. As such this audit has assessed our practices with the aim of improving the inclusion of risk factors with our risk assessments.

 

Recommendations

Recommendation

Action required

Possible barriers to implementation

Responsible person

Timescale

NICE guidelines: Risk assessment criteria for self-harm

Improve practitioner awareness of risk assessment criteria through:

-Presentation of audit findings at Business meeting

-Posters in clinical office above workstations showing green, amber and red results.

-Email sent to all staff members giving summary of findings and areas to improve

Staff not attending business meeting due to rota.

Staff not reading emails or being aware of posters.

Service manager, consultant, team leader and clinical staff.

1 year

 

Appendix 1

Clinical audit of risk assessment in patients presenting with self harm to Maidstone Liaison Psychiatry – Data Collection form

Patient no: ________

Risk assessment item

Has this been included in assessment?

(If No, state the reason why if documented )

1

Method of current  self-harm

 

2

Method of past self-harm

 

3

Frequency of past self-harm

 

4

Current suicidal intent

 

5

Past suicidal intent

 

6

Depressive symptoms and their relationship to self-harm

 

7

Any psychiatric illness and its relationship to self-harm

 

8

Circumstances preceding self-harm (e.g. unpleasant affective states or emotions and changes in relationships)

 

9

Risk factors (e.g. social, personal, psychiatric, pharmacological,  motivational)

 

10

Protective factors (e.g. social, personal, psychiatric, pharmacological,  motivational)

 

11

Coping strategies to limit self-harm

 

12

Supportive relationships

 

13

Negative relationships (such as abuse or neglect) that may lead to changes in the level of risk

 

14

Immediate risks

 

15

Long term risks

 

16

Other risk-taking or destructive behaviours (e.g. exposure to unnecessary physical risks, drug misuse or drinking)

 

17

Access to others’ medications

 

 

References

1. Bergen H, Hawton K, Waters K, et al Epidemiology and trends in non-fatal self-harm in three centres in England: 2000–2007. Br J Psychiatry 2010;197:493–8.

2. Department of Health. Public Health Outcomes Framework: improving outcomes and supporting transparency. Part 2: summary technical specifications of public health indicators. 2014. http://www.gov.uk/government/collections/public-health-outcomes-framework#history (accessed 13th May 2019)

3. National Institute of Clinical Excellence. Self-harm in over 8s: long-term management Clinical guideline. 2011. nice.org.uk/guidance/cg133

 

About the authors

Adam Osman carried out this project whilst working as a foundation doctor in Liaison Psychiatry at Maidstone Hospital. He is currently working as a junior doctor in Maidstone A&E and plans to apply for Psychiatric training to start in 2021.

Shandriya Rai is a Psychiatric Core Trainee working in Kent and Medway NHS and Social Care Partnership Trust.

Joel Lawson is a Psychiatric Specialty Doctor working in Kent and Medway NHS and Social Care Partnership Trust.

Laurence Potter is a Liaison Consultant Psychiatrist working in Kent and Medway NHS and Social Care Partnership Trust.