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Introduction
The Health Service Executive (HSE) National Clinical Programme for the Assessment and Management of Self-Harm was first introduced to Irish emergency departments (EDs) in 2014 (HSE, 2016). This programme aims to ensure that those who present following self-harm to one of Irelands EDs which are open 24/7 will receive an expert, timely mental health assessment, with next of kin involvement and follow-up to next care. One key objective of the programme is to reduce the number of individuals who leave the ED without receiving a mental health assessment. The Model of Care (HSE, 2016) recommends that all EDs should have a suitable room for assessment of people with mental health problems. This recommendation is aligned with Irish and UK best practice (DoH Design Council, 2011, IAEM, 2007). This room should provide a calming atmosphere and be equipped for assessments of patients whose mental illness increases their risk of harm towards themselves or others (National Institute for Health and Care Excellence, 2005).
Standards suitable for this assessment room have been identified by the Psychiatric Liaison Accreditation Network (PLAN, 2017). The PLAN is a United Kingdom (UK) initiative of the Royal College of Psychiatrists’ Centre for Quality Improvement in partnership with the Royal College of Physicians, Royal College of Nursing, College of Emergency Medicine and the mental health charity Mind (PLAN, 2017). Patient and carer representatives are integral to the setting of quality standards and accreditation of services. These standards developed in the UK have been recommended for adoption in Irish EDs (McCraith Report, Reference McCraith2014; College of Psychiatrists of Ireland, 2018; National Clinical Programme Model of Care, 2016) The Emergency Medicine Programme has commented that Ireland has a stock of ED facilities which are, in the main, unfit for purpose (HSE, 2012).
There were 1.2 million attendances at Irish EDs in 2017 (HSE, 2017a). The provisional figures that have been reported but not yet published for ED attendances in 2018 (not including Injury Units) are 1,326,669 (EMP, 2019). It is unknown what percentage of these presentations relates to mental health problems. A systematic review and meta-analysis examining mental health attendances at EDs identified that between 4% and 5% of all ED presentations relate to mental health problems (Barratt et al. Reference Barratt, Rojas-Garcia, Clarke, Moore, Whittington, Stockhard, Thomas, Pilling and Riane2016). In 2017, the National Self-Harm Registry recorded 11,600 presentations to hospital due to self-harm nationally, involving 9,103 individuals (National Self-Harm Registry Ireland Report, National Suicide Research Foundation, 2017). It is estimated that self-harm accounted for approximately one-third of all mental health presentations to the ED (Barratt et al. Reference Barratt, Rojas-Garcia, Clarke, Moore, Whittington, Stockhard, Thomas, Pilling and Riane2016), and so the number of patients attending Irish EDs with mental health problems is estimated to lie between 35,000 and 50,000. These patients require facilities within the ED to ensure that they can have a safe and private mental health assessment.
A survey of psychiatric assessment rooms in the UK (Bolton et al. Reference Bolton, Palmer and Cawdron2016) found that only 23% of 60 EDs included in the survey met all the safety criteria and were judged to be sufficiently safe and private. In Ireland, a review of the implementation of the self-harm clinical programme in 2017 (HSE, 2017b) found only 12 (41%) of the 26 Adult EDs open 24/7 had rooms that substantially fulfilled all PLAN criteria. The HSE National Clinical Advisors and Group Leads for Acute Hospitals and Mental Health sent results of this review to the CEOs of each hospital group and requested they ensure rooms comply with PLAN criteria. The aim of this audit was to assess how many EDs complied with the PLAN criteria 1 year following those requests.
Methods
All Model 3 and Model 4 hospitals in Ireland were included. Model 3 hospitals include all hospitals that have 24-hour EDs, seven days a week, acute surgery, acute medicine and critical care, and Model 4 hospitals have these services plus specialist, supra regional care. A brief self-assessment audit tool (Appendix 1) was developed using the PLAN criteria (Table 1). This was sent to the Clinical Nurse Specialist who is employed by the mental health service to ensure the implementation of the clinical programme in the ED and to the Consultant Liaison Psychiatrist within the hospital. In seven services where the self-assessment tool showed substantial non-compliance with PLAN standards, the services were contacted by telephone for more detailed information.
Psychiatric Liaison Accreditation Network Criteria
Results
Results are available for 26 of the 26 Adult EDs in Ireland. Each service completed the audit on one assessment room, although two services reported having two identical assessment rooms. Table 2 outlines the number and percentage of EDs that are compliant with the PLAN standards. Rooms were rated as fully compliant when all the items from the PLAN standards were compliant. A rate of substantial compliance was given when the room was located within the ED, and there was compliance with four of the other six items. Twelve (46%) of the rooms are fully compliant with PLAN standards, with a further seven rooms substantially compliant – leaving 19 (72%) of rooms fully or substantially compliant. Of the seven rooms that are substantially compliant having ligature points and mobile furniture were the most common non-compliant items. Table 3 outlines the compliance with individual PLAN standards, and Table 4 outlines how many EDs undertook risk assessments of the ceiling and specific use of the room as a mental health assessment room. Table 5 shows the results for the seven rooms that are not compliant.
Compliance with Psychiatric Liaison Accreditation Network standards
Compliance with individual Psychiatric Liaison Accreditation Network Standards
Risk assessments of ceiling and use of the room
Characteristics of rooms that are non-compliant with Psychiatric Liaison Accreditation Network standards
Of the seven rooms that are not compliant – two are in Model 4 hospitals and four are in Model 3 hospitals. Three are in older hospitals where a purpose built room for mental health assessments has never been in place. All mental health assessments are carried out in a room that was originally a relative’s room. These are used also for relatives of very ill or deceased patients. In another two hospitals, a purpose built mental health assessment room was put in place some years ago. In both hospitals, in recent years, pressure on space within the ED has resulted in the rooms being used for medical emergencies. Gradually, more equipment, such as oxygen portals, drip stands, trolley and chairs, has been introduced to the room leaving the room unsafe and mostly unavailable for use. In both hospitals, mental health staff use the relatives’ room, which do not meet safety standards. Another room is located in a newly built ED, where, despite requests from the mental health staff, the designated room has doors that only open inwards, mobile furniture and a number of ligature points. The last of the seven rooms which is not compliant is located outside the ED, off a waiting room but away from ED staff.
Discussion
As far as we are aware, this is the first completed audit of standards of ED assessment rooms in Ireland. The response rate of 100% contrasts with a similar survey in the UK where responses were received from 60 (24%) of 245 EDs (Bolton et al. Reference Bolton, Palmer and Cawdron2016). The findings show Irish EDs have good facilities for mental health assessments with 96% of EDs have a room and 73% of these rooms are either fully compliant or substantially compliant with PLAN standards, being sufficiently safe and private. This is a marked improvement from 41% substantial compliance found in 2017.
In looking at the individual standards, most non-compliance was linked to furniture and ligature points. In the UK Confidential Inquiry into Suicide and Homicides (University of Manchester, 2018), reducing the number of ligature points within the inpatient mental health unit had been shown to reduce the number of inpatient deaths. A root cause analysis of suicides and suicide attempts within the ED in the Veterans Health Administration in the US found that 10% of all inpatient suicides occurred in the ED (Mills et al. Reference Mills, Watts, DeRossier, Tomolo and Baggian2012). Hanging, cutting and strangulation were the most common methods used. The most common anchor point for hanging was doors. They identified the most common root causes as being problems communicating risk and being short-staffed. They recommend regular reviews of mental health holding areas for suicidal hazards and development and implementation of specialised protocols for suicidal patients. In the UK, approximately three-quarters of patients who die by suicide on psychiatric wards do so by hanging/strangulation (Hunt et al. Reference Hunt, Shaw, Windfuhr, Appleby and Kapur2012). Increased awareness of the methods used by these patients may benefit prevention strategies in mental health services. Between 1999 and 2007, of the 448 suicides that occurred on psychiatric wards, 77% were by hanging. The number of hanging cases, however, has fallen by 74% since 1999. The most common ligature points and ligatures were doors, hooks/handles, windows and belts or sheets/towels, respectively. Use of shoelaces, doors and windows increased over time. These patient suicides had high rates of self-harm, alcohol/drug misuse and were more likely than other cases to have died early in admission and been formally detained for treatment. They recommend that despite the decrease in inpatient suicides by hanging, regular reviews of ward structures are needed, particularly as ligatures and ligature points change over time. Suicides occurring within the ED are extremely rare, and there are no available statistics in Ireland. Within the ED regular meetings with the ED management, acute hospital management and the mental health staff can ensure the risk of such ligature points is highlighted. It is not possible to have an ED free of ligature points, but the room used for mental health assessments can be ligature free. The Queensland guideline for managing ligature risk in public mental health (2012) is a comprehensive tool that can be used for regular risk assessment and management.
A little over half of the rooms (57%) were rated as having decoration that provides a sense of calmness. PLAN makes suggestions on using heavy but comfortable furniture and having soft colours and murals on the wall to support this sense of calmness.
Risk assessments of the room ceiling and of the use of the room have been completed in seven (30%) of services. Services used the PLAN standards to identify risks and then listed proposed changes. This risk assessment was sent to the local risk management forum. This risk assessment combined with the ligature risk assessment Queensland Guideline for Managing Ligature Risks in Public Mental Health (Queensland, 2012) has been used very effectively for this purpose.
The Clinical Lead for the HSE Clinical Programme for the Assessment and Management of Self-Harm has been in discussions with management teams within the hospitals in improving safety within rooms. A common difficulty encountered is the lack of space within the ED and the need to be flexible in using treatment spaces. Suggested solutions such as encasing medical gases behind a locked panel and only using portable medical equipment that can be removed from the room will assist with this (Huddy, Reference Huddy2016) It is noticeable that where services hold regular meetings between ED staff, acute hospital staff and mental health staff, improving the safety of the room has been a priority. There is a risk that improvements made could erode over time as competing priorities for the use of these rooms re-emerge. The authors have recommended that the Quality and Patient Safety division of the HSE prioritise repeat audits of these rooms thereby ensuring improvements will be maintained. The Mental Health Commission of Ireland and the College of Psychiatrists of Ireland are two bodies which inspect facilities where mental health services are delivered. Information obtained in this audit will be shared with both organisations.
Conclusion
Ensuring patients who presents to the ED with a mental health problem is safe and supported by staff who themselves are safe and supported is a central vision of the National Clinical Programme for the assessment and management of patients presenting to the ED following self-harm. Ensuring there is a safe and private room for assessments is one of many means to achieving this vision. The fact that 73% of EDs are either fully compliant or substantially compliant is encouraging. Anecdotal evidence shows that this is the result of work from liaison psychiatry services, the College of Psychiatrists of Ireland and the Irish Association of Emergency Medicine over the last 12 years. Improvements since 2017 have resulted from the clinical programme implementation. The aim of the clinical programme is to ensure that all services are fully compliant and so the office will be making the following recommendations:
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1. All services should complete a full ligature risk assessment and manage risks identified.
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2. Through the National Clinical Advisor and Group Leads for Acute Hospitals and Mental Health a further report on each hospital group will be sent to the respective CEOs.
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3. All mental health services will receive a copy of their individual report with recommendations.
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4. All services should introduce review of safety risks in ED department at quarterly mental health/ED staff/acute hospital meetings.
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5. Results of this audit will be sent to the Quality and Safety Division of the HSE, the Mental Health Commission, the College of Psychiatrists of Ireland, Office of Nursing & Midwifery Services Director, Irish Association of Emergency Medicine and the Emergency Medicine Programme clinical lead.
Acknowledgements
The authors acknowledge the work of the Clinical Nurse Specialists and the Consultant Psychiatrists who completed assessments of ED assessment rooms. The authors also acknowledge the advice on developing this audit from the Research and Audit group advising the National Clinical Programme.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflict of interest
Anne Jeffers has no conflicts of interest to disclose.
Rhona Jennings has no conflict of interest to report.
James O’Mahony has no conflict of interest to disclose.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008. As this is a clinical audit, ethical approval from a Research Ethics Committee was not sought. The audit was discussed and approved by the Research and Audit Group of the National Clinical Programme (NCP) for the Assessment and Management of Patients presenting to the ED following self-harm. All data are anonymised in the report.
Consent to publish
Staff who submitted data for this audit were informed the Audit would form part of published national reports.
Audit/Risk manager guidance
The Research and Audit Group of the NCP provided guidance in conducting the research.
Confidentiality and storage of data
Data are stored on HSE encrypted computers. Respondents were aware that data were collected in order to improve facilities and so it was shared with managers of the service. Information from the follow-up phone calls was reported in a confidential manner. The authors would have access to this information as part of their employment.
