1. The Royal College of Emergency Medicine Mental Health in the ED Clinical Audit 2014-15 National findings The Royal College of Emergency Medicine Clinical Audits

2. Contents This shows how EDs are performing against the audit standards. For further information, please see the national report.

3. Audit objective Identify current performance in EDs against best practice clinical standards and display the results in order to facilitate quality improvement.

4. Standards StandardStandard type 1.Patients who have self-harmed should have a risk assessment in the ED Fundamental 2.Previous mental health issues should be documented in the patient’s clinical record Developmental 3.A Mental State Examination (MSE) should be recorded in the patient’s clinical record Developmental 4.The provisional diagnosis should be documented in the patient’s clinical record Developmental 5.Details of referral or follow-up arrangements should be documented in the patient’s clinical record Developmental 6.From the time of referral, a member of the mental health team will see the patient within 1 hour Developmental 7a. An appropriate facility is available for the assessment of mental health patients in the ED 7b. Assessment room meets all standards set by the Psychiatric Liaison Accreditation Network (PLAN) Fundamental Developmental

5. Executive summary This graph shows how EDs performed on all standards for this audit. ↑ Higher scores (e.g. 100%) indicate higher compliance with the standards and better performance.

6. National results Question RCEM Standard National Results (7913) Lower quartile Median Upper quartile Q4 STANDARD 1: Risk assessment taken and recorded in the patient’s clinical record 100%56%72%87% Q5 STANDARD 2: History of patient’s previous mental health issues taken and recorded 100%72%82%92% Q6 STANDARD 3: Mental state examination taken and recorded 100%14%30%58% Q7a Patient asked about their alcohol & illicit substance consumption within the last 24 hours 52%62%73% Q7b Patient assessed for their level of alcohol &/or illicit substance dependency 22%40%57% Q8 STANDARD 4: Provisional diagnosis documented100%52%74%90%

7. National results Question RCEM Standard National Results (7913) Lower quartile Median Upper quartile Q9 Patient assessed by a mental health practitioner (MHP) from organisation’s specified acute psychiatric service 58%70%86% STANDARD 6: Assessed by MHP within 1 hour100%0% 7% Where assessed by MHP Dedicated assessment room 0%4%46% Resus area 0% Majors area 0% 11% Minors area 0% Other 0%4%15% Q12 STANDARD 5: Details of any referral or follow-up arrangements documented 100%62%71%82% Q13 Liaison Psychiatry service available at organisation 100% Q14 STANDARD 7a: Dedicated assessment room for mental health patients 100% STANDARD 7b: Room meets all standards set out by the Psychiatric Liaison Accreditation Network 50% 100%

8. Case mix How do patients attending Emergency Departments compare nationally? This section helps you understand more about the case mix and demographics of the patients.

9. Date and time of arrival The natural distribution shows how the attendances would look if this event occurred equally throughout the week. These results indicate that nationally, mental health patients present at any time of day or night. The data clearly shows the need for 24/7, and in particular, full overnight mental health cover. Definitions: Normal hours: 09:00-17:00, Evening: 17:01-00:00, Night: 00:01-08:59, Weekend: Sat, Sun or bank holiday

10. Type of self harm It seems that recording the nature of self harm is not a problem, although it is quite possible that there is a confirmation bias as people may not document not presenting with self- harm.

11. Patient discharge location A high proportion of patients were admitted to an inpatient psychiatric facility (10% nationally). This underlines the high acuity of the mental health problems in the patient group seen in the Emergency Department. Of equal concern is the number of patients in whom there was no discharge data. It is recognised that there are a group of patients who may be ‘allowed’ to abscond, but only after having had a risk assessment.

12. Audit results How did EDs perform against the standards? This section helps you understand more about how EDs performed nationally.

13. Standard 1 - fundamental: Patients who have self- harmed should have a risk assessment in the ED. This is a fundamental standard because it was felt that a hospital would be on very difficult ground medico-legally if a patient came to harm and it could not be shown that a risk assessment had been performed. Risk assessment performed

14. Mental health history recorded Standard 2: Previous mental health issues should be documented in the patient’s clinical record. Previous mental health issues are a known ‘red flag’ for serious adverse outcomes. A history of previous mental health issues should form part of the risk assessment.

15. Mental state examination Standard 3: A Mental State Examination (MSE) should be recorded in the patient’s clinical record. A Mental State Examination in this context was defined as including, but not limited to: mental capacity level of distress/ hopelessness mental health problems willingness to stay for psychosocial assessment. A possible explanation for this low result might be that in an ED with a liaison psychiatry service, the ED staff do not attempt to document the MSE.

16. Provisional diagnosis recorded Standard 4 : The provisional diagnosis should be documented in the patient’s clinical record. Provisional diagnosis seems to be inadequately recorded in the notes. This could be due to dual diagnosis of physical and mental health.

17. Patient assessed by mental health practitioner Standard 6: From the time of referral, a member of the mental health team will see the patient within 1 hour. There is a clear lack of performance anywhere near the standard – the national median was 0%. The possible causes and actions to consider are discussed in the analysis section below.

18. Referral or follow-up arrangements documented Standard 5: Details of any referral or follow-up arrangements should be documented in the patient’s clinical record. Although there was quite a large degree of variation, it is possible that most patients did have a follow up plan.

19. Dedicated mental health assessment room Standard 7a - fundamental: An appropriate facility is available for the assessment of mental health patients in the ED. An average of 77% EDs nationally met this this standard. However, it is encouraging these hospitals have implemented a dedicated facility that maintains dignity.

20. National recommendations 1.Evaluate feasibility of ‘one hour response’ by a member of the mental health team 2.Re-audit to include phone triage, to understand its role in models of service provision.

21. Site-level recommendations 1.Develop proforma for mental health assessment to help clinical staff structure and document assessments, and record times (examples in RCEM Mental Health Toolkit). 2.Review PLAN recommendations regarding assessment room features and layout. Consult with estates regarding work to be done to meet the minimum standards.

22. Site-level recommendations 3. If no liaison psychiatry service, consider whether this should be provided or alternatives. 4. Review timeliness of service provided with evidence from this audit. Does this match experience on the shop floor? 5. Undertake rapid cycle quality improvement if ED performance on any standard is below the expected level.

23. Next steps Read the full report Action planning Rapid cycle quality improvement Contact other EDs for tips & solutions