Enhancing Mental Health Crisis Care Using Simulation Training Dr Mohan Bhat, Director of Medical Education, NELFT Dr Bini Thomas, Simulation Training Lead, NELFT Dr Lindsay Banham, Fellow in Medical Education, NELFT Helen Jameson, (Chief Financial Officer and Director of Corporate Programmes, UCL Partners)

What we’ll cover What is wrong with A&E’s Mental Health Crisis Care? What have NELFT and UCLPartners done to address the issues? A brief demonstration Feedback and work still to do Q&A

What is wrong with mental health crisis care? “Long waits” in inappropriate facilities “ Lack of knowledge and understanding ” “Judgmental staff” Very mixed experiences reported Only 40% hospitals have a psychiatric liaison department

What is wrong with A&E’s mental health crisis care?

Fewer than four in 10 respondents gave a positive response about their experience in A&E for any of these statements. Those coming into contact with specialist mental health services were only slightly more positive What is wrong with A&E’s mental health crisis care?

Stigma attached to those in crisis as inappropriate attention- seekers Only 40% hospitals have a liaison psychiatry service Acute clinicians can’t access ‘expert’ guidance during crisis and lack access to dedicated training A&E staff cope with high volumes of patients Patients in mental health crisis are perceived as complex, difficult, and time-consuming

Responding to the issues UCLPartners launched ‘Breaking Down the Barriers’ (early 2015) Aimed to work with multispecialty teams to improve mental and physical health One module focused on building mental health awareness and capability in doctors and nurses in emergency healthcare department Needs assessment: questionnaires, focus groups and structured interviews with clinicians to identify What are the specific training needs for clinicians? What training already exists? What already works? How should training be delivered to staff? NELFT joined UCLP’s expert reference group and designed/conducted pilot studies for BDTB

Training aims UCLP and NELFT aimed to lead the way in enhancing crisis care through simulation training Improving knowledge and confidence in dealing with mental health crises Improving inter-specialty and inter-professional working Improving attitudes to people with mental health problems More appropriate referrals Better experience for patient More opportunities for informal learning and teaching Increased professional respect More opportunity to compare and amend outdated attitudes Less avoidance of people in crisis Better experience for patient

Training to date 2 hours duration, during A&E protected teaching time Facilitated by liaison psychiatry consultants 1 role-play involving a trained actor; 2 case-based discussions Evaluation Before and after survey Clinician-rating/comment on: confidence and competence in mental health crisis scenarios relationship with other specialty attitude to patient University College London Hospital, July A&E nurses, 7 A&E doctors King George Hospital, June A&E doctors, 9 psychiatry doctors

A demonstration… In small groups, you have 5 minutes to discuss the scenario you have been given We will ask for feedback to the group and discuss both answers and process

Scenario 1 You are an A&E doctor and your next patient is a 16 year old girl called Alice. You can see from past A&E notes that she has presented to the department three times in the past month. This time she has told the triage nurse that she self-harmed after “an argument”. Alice has been brought in by her older brother, Sam, 21, who also lives at home and is Alice’s main carer as their mother has problems with substance misuse and is well known to the department. Alice and Sam both appear quiet and don’t give many details of the incident at home, but Alice is happy for you to check the multiple cuts on her arms she seems to have made using a razor blade. When her wounds are dressed, Alice asks to go home.

Scenario 1 a)What are your initial thoughts about what is going on for Alice? How can you best elicit the whole story? b)Who needs to be involved in Alice’s care and how can this be done in a way she finds acceptable?

Scenario 2 You are an A&E doctor and the next patient you are asked to see is 45 year old Mrs Mountfield. You can see from past A&E records, that she has a diagnosis of schizophrenia. She has not attended A&E for some time. You meet her and she presents as an oddly dressed woman with an eccentric manner. She makes little eye contact and seems to regard you and the nursing staff who have been taking her vital signs with some suspicion. She seems hesitant to answer your questions, but does give some information and seems willing to cooperate. When asked what the problem is, she tells you “my heart doesn’t quite feel like my own…it feels like someone else is controlling it”

Scenario 2 a)What are your initial thoughts about what is wrong with Mrs Mountfield and what are the first steps you might need to take? b)Why might you modify your communication style with Mrs Mountfield? How might you do this? How could you helpfully modify the environment in A&E?

Feedback

Has this training session impacted on the way you work with other professionals when helping people in mental health crisis? “more comfortable” “useful discussions” “good to see what the other parties do and what the common grade should be”

Feedback Has this training session impacted on the way you think about people in mental health crisis? “helps to take into account physical health problems in mental health patients “I have more empathy take into account their concerns” “I think I have a better perception”

Future Directions Incorporating service-users in training development/provision Extending training to more participants across North London Continue building links and capacity within local liaison departments Linking training sessions with patient safety outcome data Follow-up evaluation checking on impact of training on practice Extending multi-professional concept to other acute specialties Perinatal (midwives/obstetricians) Paediatrics (nurses/paediatricians)

Q&A