Risk assessment of patients presenting with self-harm to Maidstone liaison psychiatry: a clinical re-audit-2nd cycle.

Adam Osman
Joel Lawson
Shandriya Rai
Laurence Potter

Audit Objectives

-To re-audit whether patients presenting with self-harm to Maidstone Liaison Psychiatry are being risk assessed in line with the current NICE guidelines following interventions generated by the first cycle of audit.

Interventions from 1st cycle

The interventions were as follows:

-1st cycle results discussed at team business meeting to raise awareness and highlight areas for improvement.

– Email sent out to raise awareness and highlight areas for improvement for all members of the team and to inform those who couldn’t attend business meeting.

– Posters put up in clinical office highlighting green, amber and red areas.

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 31st of August 2018.

The same method and resources were used as in the first audit cycle.

Summary of Results

Table 1. Numbers and percentage of criteria included in risk assessment

Risk assessment criterion

Result

 

Result of previous audit

Trend

Number

Percentage

RAG rating

   

Current method of self-harm

20

100%

 

Green

100%

 

Method of past self-harm

 

20

100%

Green

80%

Current suicidal intent

20

100%

Green

100%

History of psychiatric illness and its relationship to self-harm

20

100%

Green

80%

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

20

100%

Green

90%

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

20

100%

Green

100%

Immediate risks to self-harm

20

100%

Green

45%

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

19

95%

Green

100%

Long term risks to self-harm

19

95%

Green

70%

Frequency of past self-harm

18

90%

Green

55%

Depressive symptoms and their relationship to self-harm

18

90%

Green

90%

Supportive relationships

16

80%

Amber

80%

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

16

80%

Amber

90%

Past suicidal intent

15

75%

Amber

25%

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

12

60%

Amber

40%

Coping strategies to limit self-harm

7

35%

Red

20%

Access to others’ medication

2

10%

Red

5%

 

Results

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

-There were improvements in recording in 11 areas.

-There was no change in 5 areas.

-There was worsening of scores in 2 areas.

Discussion

The second cycle results show a significant overall improvement in risk assessment documentation for self-harm. This is likely to be secondary to the interventions which increased awareness, cementing current good practice and highlighting areas for improvement. The posters served as reminders above work stations when documenting assessments.

As well as being a genuine improvement in history taking, these results may also reflect an improvement in documentation. It is possible that some areas were already being explored in clinical interview but were not being recorded in documentation.

The two areas that remained in the ‘red’ area were ‘coping strategies to limit self-harm’ and ‘access to others’ medication’. We note that on the electronic record there is no specific area to document these two factors and this may explain the poor recording. Furthermore many patients live alone and therefore ‘access to others medication’ may not be a logical question to ask. Practices could be improved by including these items specifically in the 3 tiered risk assessment form in the electronic record.

Overall it is difficult to interpret whether the significant improvement in results is secondary to the intervention improving interview technique, documentation or both. To explore this further would require data collection at the time of interview in addition to reviewing documentation. This would be an interesting area for further audit. In order to improve some of the ‘red’ categories it may require a more intensive intervention and education process for all clinical staff.

The main goal of risk assessment in self-harm is to safeguard patients and ensure the best and most appropriate level of care is offered to treat mental illness if present. By improving adherence to the NICE self-harm guidelines, as was the goal of this audit, it would aim to improve patient risk assessment and therefore optimise the care plan. In conjunction the risk assessment and care plan would aim to prevent escalation of self-harm, reduce harm arising from self-harm and reduce or stop self-harm. It could also identify other risk-related behaviours amenable to intervention.

Detailed risk assessment explores specific factors that are associated with increased risk to be identified and addressed. These factors include the psychological, pharmacological, social and relational. This would help to reduce the risk of repetition of self-harm and risk of suicide. Detailed risk assessment allows a thorough crisis plan to be created, focusing on self-management strategies and how to access services during a crisis when these measures fail. In summary, achieving optimal risk assessment in line with the NICE guidelines improves care plans, with the aim to improve quality of life and reduce the burden of mental illness and its associated risks.

 

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.