Download CAMHS guideline for emergency department CAMHS self-harm

Emergency Department Children & Young Person’s Mental Health guideline for self-harm
Paediatric Services Clinical Guideline
DOCUMENT TITLE
EMERGENCY DEPARTMENT CHILDREN &
YOUNG PERSON’S MENTAL HEALTH
GUIDELINE FOR SELF-HARM
DOCUMENT VERSION
1
SUPPORTING
REFERENCES
TARGET AUDIENCE
SEE PAGE 13
DISTRIBUTION
Trust Intranet
AUTHOR(S)
DR VICTORIA FOX (PAEDIATRIC EMERGENCY MEDICINE
CONSULTANT)
WRITTEN IN CONJUNCTION WITH:
DR JONATHAN GARSIDE (CLINICAL DIRECTOR PAEDIATRICS)
DR MINI PILLAY (CLINICAL DIRECTOR CAMHS)
ANGELA SALMONS (PAEDIATRIC SISTER)
GILL HARRIES (GENERAL MANAGER, CHILDRENS
DIRECTORATE)
RICHARD SHAW (CAMHS PORTFOLIO LEAD – LAC)
JANET YOUD (NURSE CONSULTANT)
RATIFIED BY
PAEDIATRIC FORUM
DATE ACCEPTED
SEPTEMBER 2015
AUTHORISED BY
1. Emergency Dept.
2. Families and Specialist Services
Directorate
SEPTEMBER 2018
NEXT REVIEW DATE
Location of master copy:
Version number 1
Date fully ratified:
Date of review
Emergency Department Children & Young Person’s Mental Health guideline for self-harm
Page 1 of 18
Contents
Contents ........................................................................................................................ 2
Introduction .................................................................................................................... 3
Self-harm flowchart ........................................................................................................ 5
DNA Policy………………………………………………………………………………………. 8
References .................................................................................................................... 13
List of interested groups ................................................................................................. 13
Equality Impact Assessment .......................................................................................... 13
Document checklist ........................................................................................................ 14
Appendices .................................................................................................................... 15
Location of master copy:
Version number 1
Date fully ratified:
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Emergency Department Children & Young Person’s Mental Health guideline for self-harm
Page 2 of 18
Emergency Department Children & Young Person’s Mental Health guideline for self-harm
Introduction
The following guideline has been devised to be used in the Emergency Departments
at Calderdale & Huddersfield for the assessment of all patients under 16 years of
age who are presenting with self-harm or thoughts of self-harm. The Mental State
Assessment Form (Appendix A) is for the assessment of the mental wellbeing of a
child/young person and should be commenced at triage by the assessment nurse
and follow the patient through their treatment journey. If the patient requires medical
or surgical intervention then the assessment form may be used by other agencies
i.e. paediatric inpatient team to assess the patient’s mental state when medically fit
to be assessed by the CAMHs team.
For patients who require a period of observation / treatment or a cooling off period
then the CAMHs referral should be made the next working day at the earliest
convenience, ideally before 10am.
All patients should have the Mental Health Assessment (MHA) form completed by
the referring clinician prior to communication with the CAMHs team.
The role of the Triage Nurse
On assessment at triage the following 4 questions should be asked:
1. Is the patient currently feeling like harming themselves?
2. Is the patient currently feeling like they could do harm to others?
3. Is the patient currently in possession of any medications/alcohol or weapons
to self-harm with?
4. Is the patient willing to stay?
If the answer to questions 3 is yes then security should be informed if weapons are
being carried.
If the patient is unwilling to stay but has a guardian with them then they can wait in
the waiting room. If alone they should be placed in the next available cubicle.
A full set of observations including a BM should be recorded at triage if any of the
following apply:
 Self-harmed with medication regardless of the quantity involved
 Is under the influence of alcohol or consumed alcohol recently
 Is under the influence or has consumed recreational drugs recently
 Has attempted a serious form of self-harm e.g. attempted hanging/jumping
from a height/jumping from a moving vehicle.
 If the patient has significant self-harm wounds with likely structural damage.
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Page 3 of 18
Emergency Department Children & Young Person’s Mental Health guideline for self-harm
Ideally the individual should be placed in the next available cubicle with a guardian to
be seen by the Emergency Department (ED) doctor. At times of high intensity work
load this may not be possible, in such circumstances the individual should be asked
to wait in the main waiting room with an appropriate guardian and should be visible
at all times. Should the individual become distressed by this situation it is important
to reassess the availability of a suitable cubicle within the central ED. Remember
individuals may not outwardly display distress (1). Patients, who will need a higher
degree of visibility and supervision will include those who are overtly distressed, look
vulnerable, have learning difficulties or you consider being a high risk of absconding.
Once triage has been completed all individuals should be assessed by an ED doctor
and the following flow diagram followed. It is not appropriate to refer directly to the
CAMHs team until a suitable assessment of mental state has been performed using
the ED MHA form even if the individual is medically fit for referral.
Location of master copy:
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Page 4 of 18
Individuals who are actively suicidal but have NOT self-harmed
These patients will fall into two categories:
1) Those who are not under the influence of alcohol/drugs and are medically fit
for assessment
2) Those who will require a period of sobriety/observation until medically fit for
assessment.
Patients in category one will require a mental state assessment (see Appendix A) by
the ED doctor before referral to the CAMHs team. The MHA form has been devised
to obtain important information regarding the mental wellbeing of the individual and
their support network to enable the CAMHs team to make a decision on prioritising
workload based on the information relayed by the ED doctor after this assessment.
It is important to obtain all of this information to the best of your ability before
contacting the CAMHs team to make the referral. Once completed the referral can
be made regardless of time of day. A cooling off period is NOT required if the
individual has only thoughts of self-harm and is sober/ not under the influence of
drugs.
Patients who are under the influence of alcohol and/or recreational drugs cannot be
assessed until sober and GCS 15/15. These cases aged should be admitted to the
Paediatric Ward (ward 3 at CRH). Once sober the MHS form should be commenced
on the appropriate ward and completed in full before referring to the CAMHs team.
These referrals should be made at the earliest convenience the next working day
ideally before 10am.
Individuals who have already self-harmed
Patients may fall into one of three categories:
1) Self-harm requiring further treatment or observation on the Paediatric ward
2) Self-Harm with a delayed presentation or minor wounds not requiring further
treatment.
3) Those who have attempted to self-harm by a dangerous mechanism e.g.
attempted hanging etc. and/or are overtly distressed.
Patients in category one will include:
 Patients with a medical overdose* requiring treatment
 Patients with a medical overdose requiring a period of observation
 Patients with an overdose or self-harm injury that may not require treatment
but the individual is under the influence of alcohol and/or recreational drugs
 The patient has a single large or multiple wounds requiring additional
treatment.
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Page 6 of 18

The patient attempted to self-harm with a considered violent mechanism e.g.
attempted hanging/ jumping form a moving vehicle/ jumping from a window or
height. Patients in this last category are the exception to a cooling off
period and may require an urgent CAMHs assessment due to the nature
of the attempt. In such cases contact the CAMHs team immediately for
advice.
*Medical overdose = ingestion of prescribed or over the counter medications.
If a patient requires immediate surgical intervention for a wound then referral to the
appropriate speciality should be completed. However assessment of the patient’s
mental state must be discussed with the accepting speciality and any concerns
relayed and documented. In such cases it may be the exception to get a mental
health assessment prior to transfer, if the speciality so requests. However treatment
should not be delayed for such an assessment if a transfer is time critical and
life/limb threatening.
Patients in category one under 16 years of age should be admitted under the care of
the paediatric inpatient team on Ward 3 at CRH or the appropriate ward for the
speciality accepting responsibility for the patients care e.g. plastics/ENT etc. Once
all treatment has stopped and the patient is medically fit the MHA form should be
completed by the appropriate admitting speciality before referring to the CAMHs
team on the next working day prior to 10am.
Treatment of poisons –
 If you are unsure of the treatment plan for a specific overdose then consult
with TOXBASE or contact the NPIS for additional information.
 For the treatment specifically of Paracetamol overdose see the RCEM
Paracetamol guidelines(2)
Treatment of wounds –
 In the treatment and management of superficial uncomplicated wounds of 5
cm or less length, the use of tissue adhesive should be offered as first line
treatment. Skin closure strips (Steristrips) may be offered if the patient
expresses a preference. (1)
Patients in category two include:
 Those with a delayed presentation of overdose not requiring any medical
treatment or observation.
 Patients who present with minor small abrasions/cuts not requiring any further
treatment.
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Page 7 of 18
In such cases the MHA form should be completed by the ED doctor responsible for
the patient prior to discussion with the CAMHs team. There are no definitions of a
“cooling period” and this will need to be assessed on an individual basis. This will
depend on the patient’s appeared mental state, support network and previous
attendances. Hence it is crucial that all information should be gathered before
discussing with CAMHs. Individuals who are acutely distressed or have presented
immediately after self-harming may require a period of “cooling off” in order to
remove them from the environment causing the distress. This should be discussed
with the CAMHs duty team. If such a period is required then patients aged less than
16 years of age should be admitted under the paediatric team on Ward 3 at CRH. In
such cases once discussed with CAMHs the ED doctor can refer the patient directly
to the Paediatric inpatient team. Formal referral to CAMHs will need to be made the
following morning before 10am.
It should be noted that the time of day should not impact on the decision making
process. If there is a significant delay in presentation (e.g. overnight) but the patient
self presents out of hours the on call CAMHs clinician should still be contacted for
advice.
Patients in category three:
These patients are deemed high risk due to the nature of their attempt or their level
of distress. High risk methods include:
 Attempted hanging
 Attempting to jump from a significant height
 Attempting to jump from a moving vehicle
 Attempted stabbing
 Thorough thought process behind the attempt with suicidal note and planning.
This category also includes those who are obviously very distressed whilst in the
department.
These patients should be referred to the CAMHs duty team after completing the
MHA form in the ED. Due to the seriousness of the attempt immediate assessment
in the ED may be required prior to admission so the level of risk and extent of
observation required can be assessed. Obviously all life or limb threatening injuries
should be dealt with first but this should be followed by a mental health assessment
as soon as possible.
Mental Health Assessment (MHA) Form
The MHA form has been devised to make a brief assessment of the patient’s current
mental state, previous problems, support network and triggering factors for selfharm. Completion of the form will enable CAMHs to make a judgement on prioritising
cases and workload. It should be completed prior to any referral to CAMHs in cases
of potential or actual self-harm.
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Page 8 of 18
It has been divided into categories:
 Circumstances – why did the individual want to self-harm, and are there any
triggering factors?
 Intention – what did the individual think or hope would happen?
 Planning – the method chosen and the degree of thought in the planning
process
 Current feelings – Is the individual regretful or still actively suicidal?
 Past Medical History relevant to the current presentation e.g. history of an
eating disorder, ADHS, Drug or Alcohol abuse
 Agencies previously or currently involved including the patients social worker
if relevant
 Social support at home/college/school
The final section focuses on the appearance of the individual and requires brief
notes only.
It is important at the end of the assessment to ask the adult responsible for the child
if they are happy they can keep the child/young person safe at home from self- harm
in the immediate period.
The time of the referral to the CAMHs team should be documented and the outcome
of each case once assessed.
Individuals who leave prior to assessment or refuse admission
If an individual decides to leave prior to a psychosocial assessment it is important to
document the patient’s mental capacity. Each individual case should be assessed on
the level of risk the individual presents with. If the patient appeared distressed, used
a violent mechanism of attempt, still requires on going treatment or observation or
has a poor support network then every effort should be made to return the patient to
the department. In such cases it will be necessary to inform the Police immediately.
If there are safeguarding concerns it is also necessary to inform the patient’s social
worker or the duty team if out of hours. If you have concerns discuss with the
CAMHs duty team.
There may be occasions when an individual is well known to the CAMHs team and
follow up may be possible the next day. If you are unsure then discuss with the
CAMHs duty team.
In cases when admission is required but the individual refuses, capacity must be
assessed by an appropriate clinician and the findings clearly documented. Cases
should be discussed with CAMHs once permission has been sought from the
individual. Detail should also be passed to the patients GP to enable rapid follow
up.(1)
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Page 9 of 18
In cases where mental capacity is felt to be diminished and/or the patient has a
significant mental illness and urgent mental health assessment will be required, the
patient may have to be prevented from leaving the department. See Restraint
details below.
The decision to discharge a patient without follow up following an act of self-harm
should not be assessed solely upon the presence of low risk repetition of self-harm
and the absence of a mental illness. The reasoning behind such a decision should
be clearly documented after a mental health assessment has been made. (1) No one
should be discharged without being offered a psychosocial assessment.
Restraint
Restraint should only be used as a last resort to prevent an individual from harming
themselves or others. Where ever possible seek the consent of the guardian. Any
restraint should be documented in the patient record.
Restraint of children within health care settings may be required to prevent
significant and greater harm to the child themselves, practitioners or others. For
example in situations where the use of de-escalation techniques have been
unsuccessful for children/young people under the influence of drugs or alcohol and
who are violent and aggressive. If 'restraint' is required the degree of force should be
confined to that necessary to hold the child or young person whilst minimising injury
to all involved. (RCN 3)
The welfare of the child is paramount in all cases and senior advice should be
sought. Further advice can be sought from the Safeguarding team and Trust legal
advisor.
Sedation
On rare occasions a child or young person may be so distressed as to require
pharmacological intervention in the form of sedative drugs. This should be as a last
resort when all other measures have failed and with the consent of the patient’s
guardian to act in their best interest. Senior advice should be sought before
prescribing sedative drugs and advice sought from the CAMHs Consultant via
switchboard (ask for the 2nd or 3rd on call for CAMHs).
If sedative drugs are prescribed and administered the patient must be observed and
monitored under close supervision. The administration should be conducted in line
with the Trust’s Medicine Policy and Consent Policy.
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Page 10 of 18
Capacity & Consent
The General Medical Council describes the capacity to consent as:
“the understanding of the nature, purpose and possible consequences of
investigations or treatments you propose, as well as the consequences of not having
treatment. Only if they are able to understand, retain, use and weigh this information,
and communicate their decision to others can they consent to that investigation or
treatment(4)”.
When assessing a young person’s capacity to consent a young person aged over 16
years of age can be presumed to have capacity. Those aged under 16 may still have
capacity to consent depending upon their maturity and level of understanding of the
situation.
If a child or young person is deemed to lack capacity of consent then it is appropriate
to seek consent from the parent/guardian. If consent from a guardian cannot be
obtained, responsibility for consent rests with the treating clinician. If this is the case
the person giving treatment must record their decision and rationale for this in the
patient record.
See GMC guidance(4) and local policy on the intranet under the Safeguarding
Symbol.
After a CAMHs Assessment
Time of assessment - Patients who present with thoughts of self-harm should first
be assessed in the ED by a doctor completing the MHA Form. Following completion
of the form the CAMHs team should be contacted to perform an assessment of the
individual in the ED regardless of the time of day. An immediate assessment by
CAMHs may also be required if the individual is very distressed, attempted a violent
form of self-harm or requires transfer to another hospital without life or limb
threatening injuries. All other assessments can take place the next working day. It is
never acceptable for an assessment to take place over the telephone.
Admissions - If an admission is then required for ongoing mental health
assessment it is the responsibility of the CAMHs assessor to liaise with the
Paediatric Registrar/Consultant on duty to arrange the admission to Ward 3. It is not
the role of the ED staff to arrange the admission.
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Page 11 of 18
If a patient aged under 16 requires a cooling off period after an attempt of self-harm
then admission should be arranged directly between the ED and Paediatric Middle
Grade doctors after consulting with the CAMHs team. The MHA form should be
commenced but cannot be completed until the cooling off period (usually overnight)
has been observed. At this point refer to the CAMHs team before 10am the next day.
If there are prolonged delays in seeking a psychiatric bed suitable for the patient’s
age the CAMHs escalation policy must be followed. (See appendix) A Datix entry
must be completed if the patient is awaiting a Tier 4 bed.
Place of assessment - During Monday to Friday 9-5pm it is not appropriate for
CAMHs to send a child/young person to the ED for assessment unless an act of selfharm has occurred. Should a patient be assessed by CAMHs in the ED and require
follow up the next day for further assessment it is not appropriate to perform such an
assessment in the ED. A designated place for assessment should be arranged
between CAMHs and the patient prior to discharge form the ED.
Presentation of patient known to CAMHs - If a child or young person has attended
the ED for another reason but is known to CAMHs it is not acceptable to make a
referral to the duty CAMHs team out of hours. This can wait until the next working
day to inform them of the attendance after seeking the patient’s permission and only
if relevant.
Re-attenders - There occasions when individuals are well known to the CAMHs
team and may have a care plan in place. In such circumstances it may not be
necessary for the individual to have an immediate assessment. Patients with a care
plan will have an alert on EDIS indicating this and the care plan can be found in the
ED reception.
Post assessment- Once an assessment has been made in the ED by the CAMHs
team the management plan must be relayed to the Nurse in charge and documented
on EDIS prior to discharge of the patient.
Disagreement of a treatment plan – On rare occasions there may be disagreement
regarding the treatment plan of a patient. For example ED staff being asked to
discharge a patient over the telephone for follow up the following day. The
completion of the MHA form should provide the CAMHs team with a better mental
state picture for basing a decision on. However if ED staff are unhappy to discharge
a patient who they regard as high risk it should be escalated to the Consultants on
call for both specialities to have a discussion and formulate a plan.
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Page 12 of 18
Safeguarding
It is important in self-harm cases to also assess the safeguarding concerns both of
the patient and other children who might be at home with a potentially distressed
individual. All safeguarding policies should be adhered to throughout the assessment
and appropriate documentation completed whilst the patient is in the ED.
If a patient or family has a Social Worker or if the patient is highlighted on the EDIS
system with a Child Protection Plan or a Looked after Child, the duty social team
should be informed of the patient’s attendance as soon as possible. All contacts with
the social team should be recorded on EDIS along with the outcomes of such
discussions.
See Safeguarding Team Intranet pages for further advice.
References
1)
Self-Harm. The short –term physical and psychological management and secondary
prevention of self-harm in primary and secondary care. Guideline 16, July 2004
https://www.nice.org.uk/guidance/cg16
2)
Royal College of Emergency Medicine. Paracetamol poisoning proforma to guide the
management of all oral ingesions in patients aged > 1 month and < 16 years of age.
http://www.rcem.ac.uk/ShopFloor/Clinical%20Guidelines/College%20Guidelines/Paracetamol%20Overdose
3)
Royal College of Nursing. Let’s talk about restraint. March 2008.
https://www.rcn.org.uk/__data/assets/pdf_file/0007/157723/003208.pdf
4)
General Medical Council. Consent: Patients and Doctors making decisions together.
June 2008.
http://www.gmcuk.org/guidance/ethical_guidance/consent_guidance_accessing_capacity.asp
Please also see the Trust guidance on Capacity and Consent
http://nww.cht.nhs.uk/divisions/trust-wide-information/safeguarding-index/
List of interested groups
Group name
Paediatric Forum
Information
only
Yes
Requires
Sign-off
Date signed
off
Equality Impact Assessment
See Trust guideline on intranet.
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Page 13 of 18
Document checklist (please note that this will be used for monitoring purposes and will be
completed following completion of all stages of the above)
Yes No
N/A
Comments
Version number (footer)

Date fully ratified (footer)

Date for review (footer)

Author (individual or team)

List of interested groups completed

(including ratification dates)
Page numbered

Consistent font style – Trust format

Referenced to national guidance/

expert opinion
Strength of evidence stated

Equality impact assessed

Arrangements for training detailed

List of changes and dates changed

Monitoring/audit process

Process for review of monitoring/
audit results
Process for monitoring of resulting
action plans
Guideline available on Trust
intranet



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Page 14 of 18
PAEDIATRIC MENTAL HEALTH ASSESSMENT FORM
PATIENTS PRESENTING WITH SELF HARM OR THOUGHTS OF SELF HARM
For triage nurse to complete page one only
Ask patient if:
a) They are currently feeling suicidal or like harming themselves?
Yes
No
b) They are currently feeling that they wish to harm others?
Yes
No
Yes
No
Yes
No
c) They are carrying any weapons, implements, alcohol or
medications on their person.
d) Are you willing to stay?
If yes to questions (a) and/or (b) place in the next conveniently available cubicle with
carer/parent/guardian. (NB if obviously distressed/vulnerable consider immediate placement
into cubicle.)
If yes to question (c) ask for the tablets/alcohol to be surrendered. If potential of any weapons
or threatening others call security immediately.
Complete and document on EDIS:


If patient has consumed alcohol/illicit drugs/medications or proprietary drugs
And/ or self- harmed with a significant mechanism e.g. attempted hanging, multiple
wounds or large wound
Complete a full set of observations if patient has self- harmed or under the influence of drugs or alcohol
at the time of presentation. These should be recorded on EDIS and include:
PR/RR/O2sats/BP/BM/GCS and temperature.


Document a brief description of the person in triage note
Ensure NOK and accompanying adult has been recorded.
Place the patient in the appropriate area for a doctor to complete the rest of the MHA form.
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Page 15 of 18
To be completed by the ED doctor or Paediatric doctor when patient is medically fit for CAMHs
review. Please complete to the best of your ability before contacting the CAMHs team.

Have any prescriptive/proprietary drugs been taken?
Time taken:…………………………………..

Treatment received (if any):…………………………………….
Has any alcohol been consumed?
Time taken:…………………………………
Amount consumed:…………………………………………………
Circumstances

Did something happen to make you feel like self- harming/ or actually self- harm?
....…………………………………………………………………………………………………………………………………………………

Is someone bullying/harassing/making threats or abusing you in any way?
……………………………………………………………………………………………………………………………………………….......
Intention

What did you think would happen by harming yourself?
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
Planning

How long have you felt like this? ……………………………………………………………………………………..

Have you self- harmed before?
Yes
No

Did you make a plan?
Yes
No

Did you inform anyone of your plan?
Yes
No

If yes to above what was the plan/who was informed?
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………..
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Page 16 of 18
Current Feelings

Do you regret self-harming?
Yes
No

Do you feel you would try again?
Yes
No
Past History
Agencies Involved

Eating Disorder
Camhs

ADHD
School

Substance abuse
Police

Alcohol abuse
Alcohol/Drug

Anxiety
Social services

Depression
Name of social worker if has one
Other: …………………………………………..........
………………………………………………………………
………………………………………………………………
………………………………………………………………
Social History

Who is at home with you?
Safeguarding
Is this a LAC?
Yes
No
……………………………………………...............
Name of Current Carer………………………..
…………………………………………………………..
……………………………………………………………..

Is this child on a
School/College attended
…………………………………………………………….
Yes
Protection plan?
……………………………………………………………
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Page 17 of 18
No
Examination

Appearance
Appropriate
Inappropriate

Behaviour
Appropriate
Inappropriate

Speech
Appropriate
Inappropriate

Thoughts
Appropriate
Inappropriate

Mood
Low
Normal
High
If inappropriate recorded above explain why…………………………………………………………………………..
…………………………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………
Safety Question – To the parent/guardian/carer
If you were to take your child home now would you
feel you would be able to keep them safe from
YES
NO
self harm?
PLEASE NOW REFER TO CAMHS WHO CAN BE CONTACTED VIA SWITCHBOARD. USE THE
INFORMATION GATHERED ABOVE TO RELAY THE MENTAL STATE EXAMINATION TO THE CAMHS
PRACTITONER.
TIME REFERRED………....................
TIME SEEN……………………………….
OUTCOME……………………………………………………………………………………………………………………………………..
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