Manuals+

RCEM Mental Health (Self-Harm) National Quality Improvement Programme

Information Pack 2022 - 2024

Published: October 2023

Quick Guide to Running an Awesome QIP

Introduction

Patients presenting to the ED with mental health needs make up around 5% of total attendances. They may have both physical and mental health needs to be met concurrently and some present with high risks of further self-harm and suicide.

In 2018, the Healthcare Safety Investigation Branch (HSIB) published a report on the provision of mental health care to patients presenting at the Emergency Department. A recommendation for RCEM was to improve and standardise the initial assessment of patients. This QIP is part of the ongoing response to this recommendation.

In 2022, RCEM published a revised toolkit for Mental Health in Emergency Departments, which includes clinical standards for the care of mental health patients in the ED. The standards were developed by consensus and based on guidance published by NICE and the Royal College of Psychiatrists.

This QIP will track the current performance in EDs against clinical standards in individual departments and nationally on a real-time basis over a 2-year period. The aim is for departments to be able to identify where standards are not being reached so they can do improvement work and monitor real-time change.

As well as the three standards above for individual patient care, there are organisational standards for each department to consider and an emphasis on working with mental health professionals to provide joint care and parallel assessment where possible. Departments may also use this 2-year QIP period as an opportunity to consider other ways of improving care of patients with mental health problems. This could be by collecting and responding to patient feedback, initiatives to reduce stigma, improving the ED environment, or reviewing the care of patients who are agitated or aggressive.

Quality Improvement Information

The purpose of this QIP is to continually quality assure and improve your service whereby the patient benefits as an outcome of the programme. The RCEM system allows your team to record details of QIPs and see on your dashboard how each initiative affects your data on key outcome and process measures.

We encourage you to use this feature in your department. If you are new to QIPs, we recommend you follow the Plan Do Study Act (PDSA) methodology. The Institute for Healthcare Improvement (IHI) provides a useful worksheet which will help you to think about the changes you want to make and how to implement them.

Further information on ED quality improvement can be found on the RCEM website.

Objectives for all RCEM QIPs

To identify current ED performance against clinical standards and previous performance

How RCEM supports you: Expert teams of clinicians and QIP specialists have reviewed current national standards and evidence to set the top priority standards for this national QIP. RCEM have built a bespoke platform to collect and analyse performance data against the standards for each ED.

Show EDs their performance in comparison with other participating departments both nationally and in their respective country in order to stimulate quality improvement.

To empower and encourage EDs to run quality improvement (QI) initiatives based on the data collected, and track the impact of the QI initiative on their weekly performance data

How RCEM supports you: The RCEM platform includes a dashboard with graphs showing your ED's performance as soon as data are entered to benchmark against yourself. The dashboard graphs are SPC charts (where applicable) with built-in automatic trend recognition, so you are able to easily spot statistically significant patterns in your data. The portal has built-in tools to support local QI initiatives, such as an online PDSA template.

Once you have completed a PDSA template with your team, this is overlaid onto your dashboard charts so you can easily see the impact of your PDSA.

RCEM have also published a QI guide to introducing a range of excellent QI methodologies to enhance QI knowledge and skills.

Standards

Organisational Standards

StandardGradeReference
1. Each department should have a named Mental Health Lead.FRecommendations | Self-harm: assessment, management and preventing recurrence | Guidance | NICE
2. A policy in place for assessing and observing patients should be in place for those considered to be high or medium risk of self-harm, suicide, or leaving before assessment and treatment are complete.FRecommendations | Self-harm: assessment, management and preventing recurrence | Guidance | NICE
3. EDs should have a policy which clearly states when patients can or cannot be searched. This should be compliant with relevant legislation. Searches which are for the clinical safety of the patient should be conducted by clinical staff rather than security guards.DMental Health Toolkit – RCEM 2022
4. ED and mental health teams should have joint pathways which promote parallel assessment of patients with both physical and mental health needs. NICE guidance states that psychosocial assessment should not be delayed until after medical treatment is completed.FSide by side Consensus statement - 2020
Recommendations | Self-harm: assessment, management and preventing recurrence | Guidance | NICE
5. Is there an appropriate area in ED available where patients with mental health problem could be observed? (i.e., A designated quieter/safer area than a regular cubicle)AQuality statement 5: Safe physical environments| Quality standards | NICE
6. Departments should follow their trust's policy for restrictive intervention and should follow guidance for Rapid Tranquilisation (NICE or their own guideline).FRestrictive interventions for managing violence and aggression in adults NICE Pathways
7. EDs should have a policy for patients under the relevant policing and mental health legislation - including section 297 (Scotland), section 130 (Northern Ireland) or section 136 (England and Wales) to ensure safety, dignity, and timely management.FMental Health Toolkit – RCEM 2022
8. An appropriate room should be available for the assessment and assistance of people with mental health needs within the ED. These should meet the standards of the Psychiatric Liaison Accreditation Network (PLAN).FPsychiatric Liaison Accreditation Network (PLAN) Quality Standards for Liaison Psychiatry Services – RCPSYCH 2020
9. An appropriate programme should be in place to train ED nurses, health care assistants, and doctors in mental health and mental capacity issues.FMental Health Toolkit – RCEM 2022

Clinical Standards

StandardGradeReference
1. Patients should have mental health triage by ED nurses/clinician on arrival to briefly gauge their risk of self-harm and/or leaving the department before assessment or treatment is complete.FMental Health Toolkit – RCEM 2022
Recommendations | Self-harm: assessment, management and preventing recurrence | Guidance | NICE
Quality statement 2: Initial assessments| Quality standards | NICE
2. Patients at medium or high risk of further self-harm or of leaving before assessment and treatment are complete should be observed closely during the period that they are considered to be high-risk/medium-risk. There should be documented evidence of either continuous observation (1:1) or intermittent checks, interactions and care delivery (recommended every 15 – 30 minutes)FMental Health Toolkit – RCEM 2022
Recommendations | Self-harm: assessment, management and preventing recurrence | Guidance | NICE
Quality statement 4: Monitoring | Self harm | Quality standards | NICE
3. When an ED clinician reviews a patient presenting with self-harm, they should record a brief risk assessment of suicide and further self- harm.FMental Health Toolkit – RCEM 2022

Grading Explained

F - Fundamental
This is the top priority for your ED to get right. It needs to be met by all those who work and serve in the healthcare system. Behaviour at all levels of service provision need to be in accordance with at least these fundamental standards. No provider should offer a service that does not comply with these fundamental standards, in relation to which there should be zero tolerance of breaches.
D - Developmental
This is the second priority for your ED. It is a requirement over and above the fundamental standard.
A - Aspirational
This is the third priority for your ED and is about setting longer term goals.

Equality Statement

The College is committed to assessing health inequalities relating to patient ethnicity and gender to support departments to provide high quality and equitable care to all.

We will be collecting ethnicity and gender data, monitoring them for systemic inequalities and reporting at the national level.

Our last attempt demonstrated difficulties collecting comprehensive ethnicity data with many reported as 'not specified' – We are exploring the cause of this to improve future data sets to increase the accuracy of ongoing analysis of such data.

Measures

Process Measures

Process measures include capturing the times of the key moments in the patient's journey and overall quality of care delivered in the ED.

Mental health triage of patients presenting with self-harm takes time. This will include some time to gain a rapport, asking about risks of further self-harm, or wanting to leave, considering safeguarding and mental capacity issues.

See Mental Health (MH) toolkit for examples of MH triage and documentation of observations.

From the 2018 QIP feedback, it was apparent that getting this done ≤ 15 minutes was a challenge. For this reason, a decision was made to record mental health triage done ≤15 minutes and ≤ 30 minutes. Time to mental health triage refers to the start of the mental health triage process.

Outcome Measures

Outcome measures are difficult to measure in this cohort. EDs can determine their own outcome measures based on local need for improvement. Some examples are: reduction in incidents, reduction in length of stay of non-admitted patients, reduction in patients absconding.

Methodology

Forming your QIP team

RCEM recommends forming a multidisciplinary QI team; to include consultants, trainees, advanced care practitioners (ACPs), specialty and associate specialist (SAS) doctors, nursing, and patient representatives and others to suit your local set up.

Data entry portal

You can find the link to log into the data entry site at www.rcem.ac.uk/audits (registered users only).

Inclusion criteria

Patients must meet the following criteria for inclusion:

Exclusion criteria

Do not include:

Sample size

Please collect a minimum of 5 randomised cases per week that meet the eligibility criteria.

Data entry frequency

Recommended: To maximise the benefit of the run charts and features, RCEM recommends entering a minimum of 5 cases each week. This will allow you to see your ED's performance on key measures changing week by week. PDSA cycles should be regularly conducted to assess the impact of changes on the week-to-week performance.

Alternative: If your ED will find weekly data entry too difficult to manage, you may enter data fortnightly instead. The system will ask you for each patient's arrival date and automatically split your data into weekly arrivals, so you can get the benefit of seeing weekly variation if you spread the cases across the fortnightly. If you decide to enter data fortnightly, we recommend that you enter at least 10 cases fortnightly (5 cases from week 1 and 5 from week 2). You can then consider fortnightly cycles of PDSA with specific interventions and evaluate their impact by reviewing the trend over that time period.

Data Collection Period

Data should be collected on patients between 4 Oct 2022 – 3 Oct 2024

Specific QIP Year reporting period:

Please note that these dates are different to the usual dates for RCEM QIPs to allow for staff adjustments to new departments during the August changeover period and to relieve pressures on services that have undergone reconfigurations as a result of the Covid-19 pandemic.

The programme length has been increased to allow time to understand your local service offering and establish areas of need. These can then be targeted with PDSA interventions and change monitored over enough time to embed real change. Nationally, we are aiming to improve sharing of best practice to facilitate idea development.

Data Submission Period

Data can be submitted online between 4 Oct 2022 – 3 Oct 2024.

Data submission period per QIP year:

Each year's patient data must be entered within the same year's submission period. For example, all patient data collected in Year 1's collection period must be submitted in the Year 1's submission period to be valid.

Any patient data submitted outside the submission period for its collection year will be invalidated and the patient data may not contribute towards reporting.

It is recommended to enter data as close to the date of patient attendance as possible, and to review progress regularly. This will help your QI team spot the impact of intervention more promptly for refinement or disposal depending on the changes observed.

Data to be Collected

Organisational data

(please complete this section three times per ED - at the start of the QIP; One year after the start of the QIP; at the end of the QIP)

QQuestionOptions
Q1Does the ED have a named mental health lead?
  • Yes
  • No
Q2Is there a policy in place for assessing and observing patients at medium/high risk of self-harm, suicide or leaving before assessment and treatment are complete?
  • Yes
  • No
Q3Is there a policy in place which clearly states when patients can or cannot be searched?
  • Yes
  • No
Q4Is there an appropriate room available for assessment and assistance of patients with mental health needs?
  • Yes
  • No
Q5Is there an appropriate area in ED available where patients with mental health problem could be observed?
  • Yes
  • No
Q6Does the ED have a policy of parallel assessment of physical and mental health needs where possible?
  • Yes
  • No
Q7Is there a Policy in place for restrictive intervention including rapid tranquilisation?
  • Yes
  • No
Q8Does the ED have a policy for patients under the relevant policing and mental health legislation? Including section 297 (Scotland), section 130 (Northern Ireland) or section 136 (England and Wales) to ensure safety, dignity, and timely management.
  • Yes
  • No
Q9Is there an appropriate programme in place to train ED nurses, health care assistants, and doctors in mental health and mental capacity issues?
  • Yes
  • No

Clinical data – Attendance, Referral and Review

QFieldFormat/Options
Q1.1Reference(do not use patient identifiable data e.g. NHS or hospital number.)
Q1.2Date and time of arrival
  • dd/mm/yyyy
  • HH:MM
Q1.3Date and time of mental health triage
  • dd/mm/yyyy
  • HH:MM
  • patient did not undergo mental health triage
Q1.4Ethnic categorySee Appendix 1 for ECDS category details
Q1.4.1GenderSee Appendix 1 for ECDS category details
Q1.5Date and time of ED clinician review:
  • dd/mm/yyyy
  • HH:MM
  • Not recorded
  • Not seen by ED clinician, referral direct to adult psychiatric liaison services
  • Did not wait (Will lead to Q2.4, Q2.8)
Q1.6Date and time of first referral to Adult Psychiatric liaison services (or equivalent).
  • dd/mm/yyyy
  • HH:MM
  • Not recorded
Q1.6.1Who made this referral?
  • Triage nurse
  • ED clinician
  • Other clinician
  • Not recorded
Q1.7Date and time of Adult Psychiatric liaison services review of patient in ED:
  • dd/mm/yyyy
  • HH:MM
  • Not recorded
  • Not applicable – Patient admitted before review by Adult Psychiatric Liaison to medical ward or shifted off site for mental health assessment following ED management / acceptable safe discharge plan by ED
  • Did not wait/Self-discharged (will lead to Q2.4, Q2.8)
Q1.8Date and time of leaving ED (Discharged after ED and Adult Psychiatric liaison team review / admitted to ED SSU or ward / Transferred off site for mental health assessment):
  • dd/mm/yyyy
  • HH:MM
  • Unknown (Patient did not wait & time entered not accurate)

Clinical data - Assessment and Observation

QQuestionOptions
Q2.1What was the patient risk level documented at triage, of further self-harm or leaving ED before further assessment and treatment.
  • Low-risk
  • Medium-risk
  • High-risk
  • Not documented/recorded
Q2.1.1Is there evidence of appropriate observation, interactions or care of the patient (for example continuous (1:1) or every 15 - 30 mins) during the period that they are considered to be high-risk/medium-risk?
  • Yes - Good documented evidence of continuous or intermittent observation, interaction or care of the patient
  • Partially met – Some evidence of continuous or intermittent observation, interaction or care of the patient
  • No evidence – No recorded evidence of observation, interaction or care of the patient
Q2.1.1.1Who were the observations carried out by? (This Qn appears only if answered Yes/Partially met for Q2.1.1)[select all that apply]
  • Nurse
  • Health Care Assistant
  • Mental Health Nurse
  • Doctor
  • Others (Free text)
  • Not recorded
Q2.2Was the following information documented by the ED clinician: For Q2.4 (A – D): Locally agreed form could be used as part of risk assessment by the ED clinician NB- Q2.4 refers to Clinical Standard 3 – if all 4 below questions (Q2.4 A, Q2.4 B, Q2.4 C, Q2.4 D) answered Yes – Standard 3 met
Q2.2 (A)Type of self-harm
  • Yes
  • No
Q2.2 (B)Reason / Trigger for self-harm
  • Yes
  • No
Q2.2 (C)Future suicidal thoughts and plans
  • Yes
  • No
Q2.2 (D)Has an adequate past psychiatric and social history been taken (e.g. home circumstance, employment, Safe-guarding concerns, drug and alcohol issues)
  • Yes (Met) - adequately explored
  • Partially explored
  • No/minimal – Poorly explored/not explored
Q2.3Has an adequate physical health assessment, relevant investigation and treatment been carried out by the ED clinician appropriate to patient presentation (Management of Self-harm or Self-poisoning)
  • Yes - Adequate assessment
  • No - Inadequate assessment
Q2.4Was a Capacity assessment documented if patient did not wait / self-discharged
  • Yes
  • No
Q2.5Is there documentation that safe-guarding concerns were considered?
  • Yes
  • No
Q2.5.1IF 2.5 = Yes: Was there documentation that safe-guarding concerns were actioned appropriately? (e.g., no action required / appropriate referral made to social services)
  • Yes
  • No
2.6Is there documentation that drug and alcohol concerns were considered?
  • Yes
  • No
Q2.6.1IF 2.6 = Yes: Was there documentation that drug and alcohol concerns addressed appropriately? (e.g., no action required / Information given or referral made)
  • Yes
  • No
Q 2.7If not seen by Adult Psychiatry liaison and discharged by ED: Was an acceptable safe discharge plan documented?
  • Yes
  • No
Q 2.8If patient left prior to ED Clinician review or Adult Psychiatric liaison services review, was this acted upon?
  • Yes – appropriate measures taken
  • No
  • Not documented
Q2.9Is there evidence of compassionate and practical care within the notes, e.g. Food and drink offered, patient's own medication given, pain relief offered, information given to the patient, discussions with the patient documented
  • Yes – Good evidence
  • Partial evidence
  • No/minimal evidence

Parallel Assessment by Adult Psychiatric Liaison Services and ED Team

Timing of mental health assistance should be based on the needs of both the patient and referrers. A patient should be referred to mental health services as soon as they are fit for interview, rather than waiting for medical treatment to be complete. Even prior to interview, liaison psychiatry staff can give advice based on past records, take collateral history from family or carers, support patients, advise clinical teams and plan appropriate timing for psychiatry interview. If a person is agitated, distressed or aggressive then timely assistance from mental health professionals may alleviate distress, prevent escalation, and improve both safety and patient experience [7].

Parallel Assessment

QQuestionOptions
Q3.1Would the patient have been able to have their mental health and physical health needs addressed in parallel? i.e., They were fit for interview by Adult Psychiatric liaison services
  • Yes
  • No
Q3.2If 'Yes' to Q3.1 (this Qn appears as drop box only if yes to Q3.1) did a parallel assessment take place?
  • Yes
  • No
  • Other reason (free text) e.g., Parallel assessment not offered in our service, Patient assessed in a different location

Notes
This section is provided for local use, e.g. to record information that might help during your PDSA cycles. No patient identifiable data should be entered. It will not be analysed by RCEM.

Data Sources

ED patient records including nursing notes (paper, electronic or both).

Flow of data searches to identify QIP cases. For information about using the Emergency Care Data Set (ECDS) or your ED's electronic patient record to identify relevant cases, and to extract data from your system, please see Appendix 1.

Using the codes list in Appendix 1, first identify all patients attending your ED between the relevant dates, then by age at time of attendance, then through the other relevant criteria.

If your ED is reliably using the Emergency Care Data Set (ECDS), then your IT department or information team should be able to a) pull off a list of eligible cases for you, and b) extract some or all of the data you need to enter. Please see Appendices 1 and 2 for the list of codes they will need to identify eligible cases or extract the data.

Contact Us

If you have a clinical or methodology question regarding this QIP, you can email our QIP Clinical Team directly at the below email address. Your question will be sent directly to the relevant team, automatically sharing on your name and contact email for reply.

ad641f8d.rcem.ac.uk@uk.teams.ms

If you would prefer to send your question anonymously, you can send it to our general QIP email address below. Our team will then pass your question onto the relevant team and email you back from our general account.

RCEMqip@rcem.ac.uk.

References

  1. Overview | Self-harm: assessment, management and preventing recurrence | Guidance | NICE
  2. Mental Health Toolkit – RCEM 2022
  3. The Patient who absconds - RCEM 2020
  4. Side by side Consensus statement - 2020
  5. Update information | Self-harm | Quality standards | NICE
  6. CQC Guidance: Assessment of mental health services in Acute Trusts (2020)

Appendix 1: ECDS Codes to Support Case Identification

The codes below can be used to help initially identify potential cases. This is not an exhaustive list; other search terms can be used but all potential patients should then be reviewed to check they meet the definitions & selection criteria before inclusion in the QIP.

The ECDS codes below relate to CDS V6-2-2 Type 011 - Emergency Care Data Set (ECDS) Enhanced Technical Output Specification v3.0.

QIP questionECDS data item nameECDS national codeNational code definition
Date and time of arrival or triage whichever is earlierEMERGENCY CARE ARRIVAL DATE
EMERGENCY CARE ARRIVAL TIME		an10 CCYY-MM-DD
an8 HH:MM:SS		Date
Time
Ethnic groupETHNIC CATEGORYA
B
C
D
E
F
G
H
J
K
L
M
N
P
R
S
Z
99		White British
White Irish
Any other White background
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
Indian
Pakistani
Bangladeshi
Any other Asian background
Caribbean
African
Any other Black background
Chinese
Any other ethnic group
Not stated e.g. unwilling to state
Not known e.g. unconscious
GenderPERSON STATED GENDER CODE1
2
9
X		Male
Female
Indeterminate (unable to be classified as either male or female)
Not Known (PERSON STATED GENDER CODE not recorded)

Appendix 2: Analysis Plan (Clinical Data)

This section explains how the RCEM team will analyse and display your data. You may wish to conduct analysis locally. ‘Analysis sample' shows which records will be included or excluded. 'Analysis plan (Dashboard Charts)' defines how the RCEM team will present the data graphically, and which records will meet or fail the standards.

Relevant questionsAnalysis plan (conditions for the standard to be met)
Q1 Time to mental health triageAnalysis Q1.3 – 1.2
Q2 % Of Patients who had a mental health triageAnalysis: numerator: proportion of patients that had mental health triage (date and time entered), where the denominator is all cases submitted.
Q3 Time to ED clinician review after triageAnalysis Q1.5 – 1.3
Q4 Time to Adult Pschiatric Liaison Service patient review in the ED following referralAnalysis Q1.7 – 1.6
Q5 Total time spent in ED before either discharged / admitted / transferred off site for a Mental health assessmentAnalysis Q1.8 – 1.2
Q6 Parallel assessmentAnalysis Q3.2 (Yes/No)
Q7 Evidence of compassionate and practical careAnalysis Q2.9 (Yes/Partial evidence/No or Minimal evidence)
Q8 Adequate physical health assessment, relevant investigation and treatment been carried out by the ED clinician appropriate to patient presentationAnalysis Q2.3 (Yes/No)
Q9 Safe-guarding concerns addressedAnalysis Q2.5.1 (Yes/No)
Q10 Drug and alcohol concerns addressedAnalysis Q2.6.1 (Yes/No)
Q11 If not seen by Adult Psychiatry liaison and discharged by ED: Was this documented and an acceptable safe discharge plan madeAnalysis Q2.7 (Yes/No)
Q12 If patient left prior to ED Clinician review or Adult Psychiatric liaison services review, was this followed up?Analysis Q2.8 (Yes – appropriate measures taken/No/Not documented)
Q13 Person carrying out observations for patients at medium or high risk of further self-harm or leaving before assessment or treatment completionAnalysis Q2.1.1.1 (Nurse / HCA / MH Nurse / Doctor /Others (Free text)/not recorded)

Clinical Standards – Analysis plan (Dashboard Charts)

StandardRelevant questionsAnalysis sampleAnalysis plan – Conditions for the standard to be metData Validation
1Q1.2
Q1.3 NOT
patient did
not undergo
mental health
triage		Q1.3Title: Proportion of patients who had a complete mental health triage with risk assessment by ED nurses/clinician ≤ 15 minutes and ≤ 30 minutes of arrival -
Analysis:
1. Q1.3-1.2 ≤ 15 mins – Yes
2. Q1.3-1.2 ≤ 30 mins – Yes
3. Q2.1 – Low-risk, Medium-risk or High-risk
Met: Q1.3 – 1.2 ≤ 15 mins AND Q2.1 = Low-risk OR Medium-risk OR High-risk (for ≤15 mins)
Data also captured for Q1.3 – 1.2 ≤ 30 mins AND Q2.1 = Low-risk OR Medium-risk OR High-risk (for ≤30 mins)
2Q2.1
Q2.1.1		Q2.1 =
Mediumrisk/High-risk		Title: Proportion of medium or high-risk patients who had an appropriate level of observation
Analysis:
Met:
Q2.1.1 = Yes
• Good documented evidence of continuous or intermittent observation, interaction or care of the patient
Not met:
Q2.1.1 = No
• Some evidence of continuous or intermittent observation, interaction or care of the patient
• No evidence of observation, interaction or care of the patient
3Q1.5
Q2.2 (A-D)		Q1.5 IS NOT 'Did not wait'
OR
'Not seen by
ED clinician,
referral direct
to adult
psychiatric
liaison
services'		Title: Proportion of patients who had a brief risk assessment of suicide and further self- harm.
Analysis:
• Met Q2.2 (A-D) = Yes to 4 out of 4
• Partially met Q2.2 (A-D) = Yes to 3 out of 4
• Not met Q2.2 (A-D) = Yes to ≤ 2 out of 4
Models: 2022 National Quality Improvement Programme, 2022, National Quality Improvement Programme, Quality Improvement Programme, Improvement Programme

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