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Acute Adult Mental Health joint approach to emergency assessments

Lorraine Robertson
Clinical Nurse Manager
Submitted Date: 16/02/2012
Review Date: 17/08/2012
An innovated development to provide emergency assessments to those presenting with mental health challenges.
Local Area
Forth Valley
Care Setting
All types of care
Care Group
All Care Groups
Evidence Base for Practice
There is broad agreement in the literature, best practice statements and in National Guidance that a multi-disciplinary approach to care and treatment is beneficial. This is mirrored in the literature relating to Mental Health Assessment where a joint approach is posited as being most effective/beneficial. This project has allowed NHS Forth Valley to deliver acute Mental Health assessments, undertaken by clinicians from both a medical and nursing background.

The evidence base is drawn from a wide range of literature relating to assessment. Staff who undertake the training in Mental Health assessment are exposed to this literature and analyse its application to practice. In a broader, national sense the recommendations (as detailed above) from Rights, Relationships and Recovery and Delivering for Mental Health have driven the development of this protocol and will continue to influence its development. The review of this protocol is undertaken with review of current/emerging research, best practice statements and National Guidance.
Quality assurance/impact of practice
The practice is evolving. A protocol and evaluation form has been introduced to support practice. Prior to implementation the protocol was approved by the appropriate care groups and clinical governance structures in NHS Forth Valley. An evaluation form is completed after each assessment. Qualitative data was obtained from junior doctors on their experience of joint assessments.
Practice Summary
The project involved the development of a protocol to guide the process of emergency assessments. Emergency assessments are classed as assessments which are undertaken on the day of referral, with patients who are referred by the acute hospital, A&E, GP or other community resources. These assessments may take place at any time of the day, 365 days of the year. A rota for joint assessments is drawn up monthly, identifying a member of the inpatient nursing team on each nursing duty to be responsible for joint assessments. The designated Nurse participates in joint assessments, either leading the assessment or supplementing the skills of the junior doctor in assessing risk, formulating a clinical impression/working diagnosis, developing a management plan which may include follow-up from secondary or third sector services, inpatient care or Intensive Home Treatment. The assessing Nurse also has a sound knowledge of local resources through experiential learning and frequent exposure to the external agencies and resources accessed by Mental Health patients.
Practice Detail
The introduction of Mental Health Liaison Services and Intensive Home Treatment Teams (IHTT) resulted in many Mental Health assessments being completed by band 7 Nursing staff. In NHS Forth Valley neither the liaison or IHTT services operate twenty four hours per day. Junior doctors carry out Mental Health assessments when neither team is available. Evidence indicated admission rates were higher when a junior doctor completed the assessment alone. Mental Health Nurses working in the acute admission wards were passive participants in the assessment process. A team of Senior Mental Health Nurses developed in partnership with the University of Stirling a Mental Health assessment, double weighted, degree module. All Nurses working in Acute Mental Health services in NHS Forth Valley are encouraged to complete the course. On completion of the course, which involves clinical skills assessment, submission of a portfolio of evidence and academic examination, Mental Health Nurses working in the inpatient wards are placed on a rota and carry out assessments with the junior doctor becoming active participants in the assessment process.

The aim of this project was to use a joint approach to assessment, drawing on the skills of doctors, Nurses and allied health professionals. It also involved the development of a rota system to identify ward based Nurses to take responsibility for participating in joint assessments on a shift-by-shift basis. Key goals were:
•Evaluate the joint approach to assessment.
•Gain intelligence to inform improvements in the process and to highlight periods of peak activity.
•Provide clinical supervision for the nursing staff involved in the joint assessment process on both a group and an individual basis.
•Enhance the patient experience for patients referred out of hours by giving an appointment time to attend the unit, which avoids waiting for long periods during episodes of distress.
•Allow staff to meet patients on arrival, introd
As the majority of referrals are received from A&E which has implications on response times due to the 4 hour Waiting Time Target. There are particular challenges when multiple referrals are made at the same time, or within a short period of time. In August there was a significant peak in the number of referrals from A&E. The timing of assessments has implications on the availability of nurses to attend assessments particularly around change of shift for nursing staff between 20.00 and 23.00. However, duty rotas should where possible allow for extra staff during those peak times.

There are times when there is an unavailability of staff trained through the Mental Health Assessment course on the rota this is due to the limited amount of staff who have completed the education on duty but also the time that ward staff were being asked to participate within assessment. It is recommended that the service continues to offer and encourage continual participation within Mental Health Assessment course for staff working within the acute mental Health services.

Evaluation of this service did demonstrate a significant amount of patients who were assessed were discharged with no ongoing or additional psychiatric care. Most of those were patients who were referred by junior staff in A&E which may highlight a training issue for A&E staff. Recommendation would be education for A&E staff in the presentation of psychiatric patients or those who present with self harm and other resources available to this client group.
Additional Comments
Junior doctors participated within semi-structured interviews. Outcomes of which illustrated the following:

All of the doctors commented positively on the experience nurse assessors bring to the assessment process.
“The nurses always have a lot of experience and therefore can impart there own knowledge.”

Similarly there was broad agreement amongst those interviewed that assessing alone was more difficult.
“...especially at night when you feel alone and there is no senior staff to help with the decision making.”

Eight of the nine doctors commented on the availability of nurses to undertake assessments.
“Accessibility was very variable and I appreciate that the nurses are really busy and can’t really come away from the wards.”

Recommendations were made following an evaluation of practice and may assist any other services who wish to develop similar services.

Examination of when referrals are received, appointment time given and when assessment commenced, and if any delays were encountered and why.
Patient’s satisfaction with the appointment system.
Data should be obtained on why patients are seen in A&E when A&E is not the referral source.
Data is required on which service nurses attend from (Adult or Old Age Mental Health).
Data should be provided on who leads the assessment, shared decision making and communication of the assessment.
Data should be obtained on why an emergency assessment was requested by junior doctors in A&E not solely on the reason for referral.

Semi-Structured interviews should be undertaken to obtain qualitative data from junior doctor and nursing staff.
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