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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: Date of review 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. Location of master copy: Version number 1 Date fully ratified: Date of review 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: Version number 1 Date fully ratified: Date of review 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. Location of master copy: Version number 1 Date fully ratified: Date of review 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. Location of master copy: Version number 1 Date fully ratified: Date of review 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. Location of master copy: Version number 1 Date fully ratified: Date of review 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) Location of master copy: Version number 1 Date fully ratified: Date of review 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. Location of master copy: Version number 1 Date fully ratified: Date of review 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. Location of master copy: Version number 1 Date fully ratified: Date of review 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. Location of master copy: Version number 1 Date fully ratified: Date of review 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. Location of master copy: Version number 1 Date fully ratified: Date of review 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 Location of master copy: Version number 1 Date fully ratified: Date of review 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. Location of master copy: Version number 1 Date fully ratified: Date of review 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? ……………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………….. Location of master copy: Version number 1 Date fully ratified: Date of review 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? …………………………………………………………… Location of master copy: Version number 1 Date fully ratified: Date of review 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…………………………………………………………………………………………………………………………………….. Location of master copy: Version number 1 Date fully ratified: Date of review Page 18 of 18