Protocol for the acute management of young people presenting with Deliberate Self Harm and acute mental health problems Outlining acute liaison between Surrey CAMHS and St Peter s Hospital NHS Foundation trust Introduction Suicide is the fourth commonest causes of death for young people and yet is highly preventable. By conducting careful risk assessment and care planning, we can make a difference to the young people presenting to services. As outlined in NICE guidance, a joined up approach is needed in which presentations are taken seriously, stigma is avoided and follow up is carefully planned. Principles Below is a list of principles intended to guide the protocol and relationships:- 1) CAMHS has the responsibility for overseeing assessment and intervention processes through Consultant Child Psychiatrists. 2) Medical responsibility for patients rests with the hospital regardless of mental health condition. 3) The hospital has the responsibility for contributing to the assessment of young people. This includes gathering information when in A&E, and likewise on the ward. When on the ward contributing to coordination and liaison is also needed. 4) Assessment arrangements take place as per the current protocol for in-hours assessments. 5) The hospital, CAMHS and Adult Mental Health services all have responsibility to work together to provide out of hours services. 6) Following an initial assessment, consultant child psychiatry input will be available as appropriate on a second on call basis. 7) A young person presenting following self harm should have a risk assessment and a clear plan for their safety involving other adults, before leaving. 8) Hospital admission should be minimised in terms of length of stay. This is dependent on timely, but proper assessment. 1
9) There should be compliance with the NICE guidelines regarding self-harm, and this emphasises the need to treat patients with dignity and respect. 10) The safety and experience of other patients on the ward should be taken into consideration when considering admitting a patient. 11) When a young person has been disruptive and a mental health problem is suspected, the hospital will collaborate with CAMHS in negotiating the next steps, including consideration of risk versus benefits. 12) Interventions should be designed to promote management of mental health problems in the community, where safe and possible to do so. DEFINITIONS Self Harm Self-harm includes behaviours, which have the intention of harming the individual, such as overdose of medication, cutting, jumping and shooting. Self-harm may be an indicator of a range of serious problems that include mental illness, dysfunctional family relationships, substance abuse, developmental disorders, bullying and other forms of physical and sexual abuse. Factors, which are most likely to be associated with completed suicide, include male gender, older age, high suicidal intent, past suicide attempt, substance misuse, psychosis, depression, hopelessness and having an unclear reason for the act of DSH. Alcohol & Substance Abuse Alcohol or substance abuse for recreational use when this leads to intoxication is NOT regarded as self-harm. Young people may present to the A & E Department in an intoxicated state but only a minority will have the same significance as self-harm. Factors that may increase concern include frequent presentation, drinking or taking substances when alone or with the intention to self-harm or commit suicide. These young people may be referred for assessment or admission. If the concerns are ONLY regarding Substance or Alcohol Misuse, an assessment can be requested from Catch-22., Tania Gauci, who works for Catch- 22, covers all the general hospitals in Surrey for young people under the age of 21 who have used drugs and/or alcohol and have been brought to A&E. Her role is specifically A&E liaison. Referrals to her can be made using the attached form (Appendix 4), or by ringing 01372 832 905. 2
PRACTICE POINTS Consent and confidentiality The Children Act makes it clear that Children & Teenagers up to the age of 18 years old can refuse to submit to assessments if they are of an age and understanding to do so. If this occurs, consent (for young people up to 16 years old) can be obtained from a parent with parental responsibility. Such a person therefore needs to be approached. In very rare circumstances even this may be thought to be clinically inappropriate. If a young person aged between 16 to 18 years old refuses to consent to assessment or treatment, their capacity should be assessed and discussed with the consultant paediatrician and/or child and adolescent psychiatrist (Mental Capacity Act 2005). Giving information, clarification of concerns, persuasion and encouragement should be tried to overcome an impasse. If unsuccessful, the reasons for the refusal and response of the young person and the adult must be recorded If a young person is a danger to themselves, the doctor has a duty of care to protect them. Confidentiality is not absolute, and it may be necessary to contact parents/carers or others against the wishes of the young person (as spelt out in the Privacy Act 1993 and Health Information Privacy Code 1994) in order to ensure their safety. If there is evidence of mental illness e.g. depression or psychosis the young person who has already been admitted to the ward, can be detained under SECTION 5 ii of the Mental Health Act. 1983 (in practice this rarely needs to be done, as parental authority for under 16 year olds is usually sufficient). (N.B. Section 5 ii cannot be used in A&E) Admission is the usual course of action The Royal College of Psychiatrists guidelines Managing Deliberate Self Harm in Young people state that admission is usually desirable, regardless of the toxicological state of the young person. The purpose of the admission is to ensure that adequate physical and psychological assessments can occur and care can be planned and any intervention initiated. The clinical purpose of this is that assessments need to be undertaken in a calm and considered manner, when children and carers are not overly tired or disorientated, with the opportunity to contact other agencies. The latter helps both with the completion of a thorough assessment and also assists with the formulation of a good quality discharge and care plan NICE guidance says that under 16s should be admitted following self harm. Admission is usually advisable for 16 18 year olds as well, particularly if safety is in any doubt. 3
Age of young person and sources of information Risk assessments should not be based on information from the young person alone. Information and input should always be drawn from several sources including the young person, their parents or guardians, and reports from other individuals close to the young person The above points are particularly critical with young people under 16 years, where clinicians may be acting in loco parentis in the absence of their parents/guardians. Self-harm among children under 15 is less common but should be treated very seriously. The younger the child, the greater the likelihood that child protection matters are at play. Hence, the child s immediate environment should be checked for safety (e.g. what is happening at home? at school?) and they should be referred to appropriate services (this may include Child, Youth and Family Services). Bear in mind child protection issues. Children who are in abusive situations may show their distress by self-harming. Self cutting without suicidal intent Self cutting is quite common amongst young people, but is not necessarily an act of attempted suicide. Typically it is an attempt to manage distress, which does not need to involve admission to hospital Most acts of self cutting do not present to hospital and are instead managed at home or primary care. Initial risk assessment should evaluate whether suicidal intent existed as part of the presenting self harm. If it was, then the suicide protocol should be followed. If not, disposal directly from A&E can be considered. If in doubt, follow the self harm protocol. Other mental health presentations Sometimes young people present to hospital with concerning symptoms that may indicate a mental health problem but without Deliberate Self Harm or thoughts of Deliberate Self Harm such as low mood, significant anxiety. These could be considered non acute liaison cases. In these situations, written referral to the appropriate CAMHS team may be necessary. A discussion with the duty worker in the CAMHS team (during hours) will help to clarify the degree of urgency of the referral. CAMHS has the capacity to see children urgently but only if there are clear risk-related reasons to do so. Possible Psychosis If an acute psychosis is suspected, the same processes should be followed as for self harm. The exceptions are that suicidal intent is not so important as a decision point, and secondly consultation from the consultant child psychiatrist should be considered earlier. Behavioural disturbance This can be difficult to manage in A&E or on the ward. A joint approach is usually needed. As outlined in the principles above, behavioural disturbance 4
does need to be taken in to consideration when making decisions about care and treatment for a young person. If a young person needs to be admitted to the ward and there are concerns about behavioural difficulties which cannot be managed with regular nursing input, then additional RMN nursing cover may need to be considered Ongoing safety concerns after mental health assessment and medically fit On occasions, after a mental health assessment discharge from the hospital is not considered safe, despite the young person being medically fit. Psychiatric admission should be considered, but this may not be appropriate or desirable. In these circumstances, it may be really valuable for a young person to stay in the hospital. However this must be time limited to a maximum of 72 hours from the time that the person is declared medically fit Additional RMN nursing may be considered necessary The CAMHS consultant or nominated representative is obliged to undertake a daily round. Safeguarding or social care related issues Where there are concerns about safeguarding issues these should be directed to children s services. Sometimes there is a complex interplay between social care and mental health issues. A single agency assessment may not manage risk effectively in these circumstances, so joint assessment is often required. This can be a slower process. In addition, because of children s services assessment time frames being prolonged, this can lead to further delays. Geographical variations Surrey and Borders partnership Trust provides for young people registered with a Surrey GP. Acute CAMHS liaison functions are primarily incident based the young person is seen for assessment according to the location of presentation rather than the location of origin. There are however some exceptions to this as below: - Hampshire and Berkshire GP registered young people who present to Frimley Park Hospital are seen for acute assessment. Follow up input where needed is provided by the relevant county service Sussex GP registered young people are seen by Horsham CAMHS (Office Hours tel 01403223200) at East Surrey hospital. Out of hours contact CAMHS consultant for Crawley on 01444441881 St Peter s hospital covers a large catchment area. In order to help manage service capacity and to promote continuity of follow up, those 5
originating from the Ashford and West Elmbridge area, are seen by the Ashford CAMHS team, and those originating from the St Peter s area are seen by St Peter s CAMHS 6
APPENDIX 1 RESPONSIBILITIES OF PROFESSIONALS INVOLVED WITH ASSESSING SELF-HARM IN YOUNG PEOPLE The Role of the A& E Medical team 1. To take lead medical responsibility 2. To complete a physical assessment and immediate treatment. 3. To conduct an initial risk assessment which should include information about reason for self-harm, previous history of self-harm, a description of mood and degree of suicidal intent 4. To ensure that every young person is either admitted or leaves the department following a Risk assessment 5. To consult with CAMHS colleagues as necessary The Role of the Paediatric team on call 1. To take lead medical responsibility 2. To treat the physical effects if the self-harm episode 3. To clarify the history of the self-harm episode 4. To declare patient medically fit and complete discharge paperwork at an appropriate time 5. To decide appropriateness of admission to paediatric ward for 16 to 18 year olds The Role of the CAMHS duty worker/weekend assessment service/junior psychiatry doctor on-call/home treatment team 1. To carry out a Risk assessment, make a preliminary assessment of the young person s overall mental health and development, his/her psychosocial situation and the ability of the adults responsible for them to ensure their safety 2. To identify any Child Protection issues 3. To take account of the opinions of medical and nursing staff 4. To develop a management plan, either in the A&E department or on the ward 5. To consult with the Consultant Child & Adolescent Psychiatrist, The Role of Consultant Child & Adolescent Psychiatrist 1. To consult to the assessing CAMHS duty worker/weekend assessment service/ duty adult psychiatry junior doctor and the medical / nursing teams as required. 7
2. To provide a psychiatric assessment as required and provide medical advice to hospital staff. 3. To refer to an in-patient unit for children & adolescents where this is indicated 4. To oversee mental health input and management of patients remaining on the ward / unit beyond the time when the young person is physically fit for discharge to share medical responsibility with hospital consultants The Role of nursing staff 1. To liaise with hospital staff and if required, to liaise with CAMHS and young person's family about assessment arrangements 2. Advise hospital medical staff on the appropriate levels of observation needed if admitted to the ward 3. To create a safe environment through actions including, removing sharp or hazardous object, nursing on the main ward, establishing clear ground rules for behaviour, and a clear explanation of the plans 4. Provide support to young person as appropriate and pass on information including relationships with visitors, to the CAMHS worker 8
APPENDIX 2 A GUIDE TO SELF-HARM ASSESSMENT Assessment in an emergency setting must answer the following questions: Was this a suicide attempt? If so, how serious was it? How safe are they now? Do they have a psychiatric illness? Do they have a substance abuse problem? Are there other risks the young person is exposed to (such as physical/sexual abuse)? Was This A Suicide Attempt? The intent needs to be inquired for specifically, e.g. What did you think would happen when you took the pills? or if the answer is unclear: Did you mean to die? Many teenagers take small overdoses in an attempt to escape a difficult situation but don t mean to kill themselves. Others harm themselves (e.g. by cutting) as a distraction from distressing emotions. Obviously, those who intended to die must be taken more seriously, but all self-harm must be considered dangerous behaviour. Self-harm is a communication. (Usually about the situation that the young person is in). How Serious Was It? Health professionals often assume that the seriousness of an overdose is directly related to the number and type of tablets taken i.e. the medical seriousness. You have to be pretty determined to take more than 10 tablets. However, this is only one factor to be considered. In addition, the following need to be asked about: Circumstances of The Self-Harm Was discovery inevitable or unlikely? (e.g. waiting until everyone was out versus taking an overdose in another room, while the family is home). Was this spontaneous or pre-planned? Was a note left? Was the person intoxicated, therefore less in control of their behaviour? Method Used Most teenagers will have taken overdoses or cut themselves superficially. Anything more serious than this, e.g. guns, hanging, jumping, carbon monoxide, is very serious, and probably related to a higher incidence of psychiatric disorder (e.g. schizophrenia, depressive illness) or later completed suicide. How Safe Are They Now? 9
This includes the answers to questions 1 and 2 but also their attitude to survival i.e. if they are disappointed that they are not dead, they must be considered a suicide risk. This can be asked directly, e.g. How do you feel about still being alive? In practice most will say that they felt upset at the time of the attempt but are glad they are still alive. In fact, embarrassment is quite common in teenagers. Equally important are the available social supports. Is there someone family, friend, who will be around to support the teenager or are they on their own? (Often found in disrupted families). Abuse issues should also be considered by asking the young person about bullying, physical assaults and sexual abuse. Do They Have A Psychiatric Illness? Depressive Illness (most common) Symptoms include: Low mood all the time for at least 2 weeks, not improved by anything much. Poor sleep (or excessive sleep sometimes) Poor appetite and/or weight loss Poor concentration Poor energy Hopelessness about the future Suicidal Depressive illness is rare in childhood, but the incidence increases dramatically at puberty. Schizophrenia (less common, but occasionally seen) Suicide attempts in young people with schizophrenia may be unusual in the method used or emotional response afterwards. The main symptoms of schizophrenia are hallucinations (usually auditory), delusions, and decline in general function. Young people often have a florid presentation with highly disturbed behaviour including agitation and extremely bizarre ideas (sometimes bodily symptoms which may bring them to medical services). Screening questions for schizophrenia include: Do you ever hear sounds/people talking when there is no one there? Has anything strange or unusual been happening to you? Is there any problem with your thinking? If the young person is very disturbed family/carer will probably give a clearer history of unusual behaviour. Do They Have A Substance Abuse Problem? High proportions of young people who self-harm also have substance abuse problems and may be intoxicated at the time of the attempt. This can complicate 10
assessment, especially if they are still under the influence of a substance when they present at A&E. Serious substance abuse is also a risk factor for completed suicide so needs to be identified. Ask usual questions about types/amounts/frequency of substance use. To Summarise In the psychiatric assessment of self-harm, those at greater risk of subsequent suicide include: Current Mental State Current disordered mental state Continued wish to die The Suicide Attempt: Intention to die Medically serious attempt Violent attempt (i.e. other than overdose or superficial cutting)) Planning an attempt so that it was likely to succeed Leaving a note History: Older males Little social support Young people with issues around sexual identity Psychiatric illness, especially depressive disorder or psychosis Substance abuse Prior suicide attempts 11
Appendix 3 - Suicide intent scale and Sad persons scale Suicide intent Scale Aspect of intent Description Score Patient score 1 Isolation Someone present Someone nearby / in contact No-one nearby 0 1 2 2 Timing Timed so that intervention is: Probable Not likely Highly Unlikely 3 Precaution against discovery / intervention 4 Action to get rid of help during the act 5 Final acts before attempt 6 Degree of pre planning None Passive precaution Active precaution Told potential helper of attempt Contacted potential helper but did not inform of attempt Made no contact with potential helper None Made some arrangements or thought about them Definite acts e.g. made a will No preparation Minimal / moderate planning Extensive preparation 7 Suicide note None Written but destroyed or thought about Note present Total score Level of intent and future risk; 0-2 low risk, 3 5 moderate risk, 6 or more high risk SAD PERSONS Score Detail Description Score Patient score S Sex Male 1 A Age 16 or above 1 D Depression Symptoms of depression such as: - disturbance of 2 concentration, sleep or appetite; social withdrawal P Previous DSH / Previous DSH (attempted self killing) Previous 1 Psych history inpatient, / out patient psychiatric care E Excessive Recent, frequent alcohol / drug use or history of 1 addiction R Rational Has no rational or reasonable cause for attempt 2 (e.g. bereavement, financial worries) S Status Relationship break up or significant life event 1 O Organised Well planned or life threatening attempt 2 N No support No good social or family support 1 S Stated intent Stated future intent of DSH 1 Total score Level of intent and future risk; 0-2 low risk, 3 6 moderate risk, 7 or more high risk N.B. These are adjuncts to clinical judgement. If in doubt liaise with the relevant team and seek advice 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 12
Tool to Identify the Drug / Alcohol Needs of Young People Aged 21 and Under o PART 1: HOW TO USE THIS TOOL Not all young people who use drugs, alcohol or solvents will require interventions from substance misus services. On many occasions low level drug/alcohol use can be addressed by non specialist services particularly in instances where there is already an open and trusting relationship developed between th worker and the young person. In these instances information, guidance and further support from well traine staff can help young people to make healthier choices. However there will be situations where youn people s drug/alcohol use is of concern and where a referral to a specialist service is required. This tool gives some useful questions to ask about drug/alcohol use to elicit the relevant information as we as a scoring format to organise this information to identify how to respond. PART 2: USEFUL QUESTIONS Drug/alcohol use can be a sensitive subject for young people to talk about with professionals. Where possible it may be important to establish a level of trust before the subject can be broached. The following questions may be helpful when talking about drugs/alcohol and identifying concerns: o Has anyone ever talked to you about drugs/alcohol? o Did you understand what they told you? o Have you ever used drugs/alcohol? If so what? How often? o Is there anything else you would like to know? o Do you have any concerns for yourself, friends or family? o PART 3: IDENTIFYING DRUG/ALCOHOL RELATED NEEDS This section provides a format for organising information about young people s drug/alcohol use and the scoring system will help to identify concerns. This section should be completed and sent with the referral form (see over) if the young person is referred to a substance misuse services. Frequency of substance use Injecting 1 Occasional drug/alcohol use (fortnightly / Monthly) 0 Not injecting 2 Regular drug/alcohol use (weekly use) 5 Currently Injecting 3 Daily drug/alcohol use OR heavy bingeing Drugs used- If the drug is unidentifiable contact a substance misuse service for advice. PLEASE TICK THE RIGHT BOX 1 Cannabis / Ecstasy / Amphetamine / LSD / GHB / Alcohol / Ketamine 4 Heroin / Methadone or other opiates / Crack Cocaine / Cocaine powder / solvents (Glue/Gas /aerosol) OR a combination of any of the above drugs (including alcohol) Intoxication PLEASE TICK THE RIGHT BOX 1 Loss of consciousness, memory loss, aggression, or hospitalisation associated with substance use Circumstances the following are likely to contribute to the young person s substance misuse increasing 1 Not attending school 1 Mental health problems 1 History of trauma, bereavement or loss 1 Involved in criminal activity 1 Homelessness / unstable accommodation 1 Pregnant 1 Difficult relationship with parents and/or an experience of living in care 1 Partner / close friends / family members who use drugs/alcohol 13
o PART 4: ADDING UP THE SCORE Score 2-4 Score 5 + Provide the young person with information and advice about their drug/alcohol use. Ensure they are involved in positive activities and monitor the situation. o Provide the young person with information and advice about their drug/alcohol use. Ensure they are involved in positive activities and monitor the situation. You may want to seek advice from substance misuse services about how to support the young person and whether a referral is needed. Referrals should b made using the referral form on the back page or if a CAF has been completed through the Common Assessment Framework (CAF) Form. All referrals should be made with the consent of the young person. For information and/or referral please contact Catch 22, 24/7 Service on 01372 832 905 The Referral Form Young person s details Name Address Postcode Contact number Mobile Number Date of Male Birth Female Risk Issues Please outline any risk issues presented by the young person or family. YES NO UNKNOWN Family details If under 16 and where possible Name of parent Address: (If different from young person s) Contact number: Are the parents / person with parental responsibility aware of the referral? YES / NO Has the YP consented to the referral? YES / NO Please describe the relationship the young person has with their parents and / or people they live with. Reason for referral Young Person s expectations Health issues Please summarise any physical / mental health problems including any prescribed medication. Young person s circumstances Please summarise any information that may impact on how/where the young person accesses services. This 14
includes housing, family situation (family substance use), history of violence. Referrer details Name Team Agency Contact Number Date Completed Other key professionals Name Agency Contact Number Aware of referral YES / NO YES / NO YES / NO How to refer Service provided Referral route Catch22 Tel: 01372 832 905 In Fax 01372 363 675 Any young person with a substance misuse related need. Surrey Email: 247@catch-22.org.uk SMS Don t Forget to include a completed Section 3: Identifying Drug/Alcohol Related Needs (see previous page) with this referral. 15
Day time CAMHS team by hospital Phone numbers and useful contacts In hours Hospital Frimley park Link CAMHS consultant Dr Andrew Hill-Smith Royal Surrey County hospital Link CAMHS consultant Dr Ramya Mohan St Peter's hospital Link CAMHS consultant Dr Ui Peng Khoo Epsom General Hospital Link CAMHS consultant Dr Shereen Haffejee East Surrey county hospital Link CAMHS consultant Dr Mona Botros Day time contact number for assessments Tel:01483 782900 Fax: 01483 782914 Tel:01483 783330 Fax: 01483 783332 Tel: 01932 722561 Fax: 01932 722563 Tel:01372 204120 Fax: 01372 204125 Tel: 01737 277701 Fax: 01737 277705 EIIP team: Central 01252 350387 East 01372 206262 HOPE team East 01372 203404 West 01483 517190 Catch 22.Service 01372 832 905 or www.catch-22.org.uk/services/detail/247-surrey 16
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Phone numbers and useful contacts Out of Hours Weekend assessment team access via Emergency Duty Team (EDT) Emergency Duty team - 01483 517 898 SABP switchboard - 03005555222 Home Treatment teams Home Treatment Team Mid Surrey Tel. 01372 206313 Fax. 01372 206301 Home Treatment Team North West Surrey Home Treatment team Surrey Heath and NE Hants Tel: 01932 722458 Tel: 01276 605511 Fax: 01276 605556 Home Treatment Team South West Tel: 01932 722458 Fax: 01932 723943 Home Treatment Team East Tel: 01737 281057 Fax: 01737 281055 Hampshire CAMHS out of hours Manager Tel. 0844 6641074 On call consultant (phone only) Tel: 0844 5852208 18