In the first 12 months of being 24/7 the service saw a total of 3913 people. 2182 of the total referrals were from the ED, a proportionate increase of 57% compared to the previous year. Close working relationships between the teams within the ED and Liaison Psychiatry have no doubt improved the patient experience on attendance to the department. In order to improve the safety of people with a mental health presentation in the ED a risk triage tool and observation chart was co-produced by Liaison Psychiatry and the ED staff group – this is used to inform any presenting risk and a management plan whilst awaiting assessment by Liaison Psychiatry.
What We Did
In January 2016 the daytime Liaison Psychiatry Service, provided by Devon Partnership NHS Trust (DPT) in the Royal Devon & Exeter (RD&E) Hospital moved from a Core 15 service delivery model to a Core 24 service delivery.
Since the sign off of the Mental Health Crisis Care Concordat in 2014, local agencies in Eastern Devon have been working collaboratively to improve the key services provided to patients experiencing a mental health crisis. The Acute Care Pathway work led by DPT has focused on the four key areas identified by the Crisis Care Concordat, whilst also ensuring that mental health crisis care is integral to the wider urgent and emergency care work programme.
The Crisis Care Concordat outlines four key work programmes:
•Access to support before crisis point – making sure people with mental health problems can get help 24 hours a day and that when they ask for help, they are taken seriously.
•Urgent and emergency access to crisis care – making sure that a mental health crisis is treated with the same urgency as a physical health emergency.
•Quality of treatment and care when in crisis – making sure that people are treated with dignity and respect, in a therapeutic environment.
•Recovery and staying well – preventing future crises by making sure people are referred to appropriate services.
By providing a 24hr service delivery the Liaison Psychiatry team in the RD&E delivers all of the above within the general hospital, ensuring timely access to psychiatric assessment and review when required in crisis via the Emergency Department (ED) and the Acute Medical Unit (AMU), as well as preventing crisis by providing access to mental health support as required when in-patient on a general ward.
In the first 12 months of being 24/7 the service saw a total of 3913 people.
2182 of the total referrals were from the ED, a proportionate increase of 57% compared to the previous year.
Close working relationships between the teams within the ED and Liaison Psychiatry have no doubt improved the patient experience on attendance to the department – this is evident in recent feedback from a parent;
“My son visited A&E…. and I have to congratulate you on improving the service. The room we were in was more suitable and the Psychiatric team were friendly, responsive and gave signposting advice as necessary. I have filled in a questionnaire and sent it back saying I thought the service was excellent. I understand that in these times of underfunding the life in A&E is difficult and the changes you have made are of real value”.
In order to improve the safety of people with a mental health presentation in the ED a risk triage tool and observation chart was co-produced by Liaison Psychiatry and the ED staff group – this is used to inform any presenting risk and a management plan whilst awaiting assessment by Liaison Psychiatry.
We have also produced new ‘alert’ sheets which are sent out to GP and any other teams involved in someone’s care – this is a simple template which is sent out in the 24 hr period following assessment, informing of patient presentation and outcome and inviting professionals to make contact with the team prior to receiving our full report, which we aim to send out within 5 days of discharge. The alert ensures timely communication to all relevant people involved in someone’s care.
Collaborative and integrated working between the RDE and DPT has been essential to ensure the provision of 24/7 access to services for patients experiencing a mental health crisis. Supporting the provision of ‘CORE 24’ both the environment and training play an imperative role in the delivery of a 24/7 service. ED have transformed one of their ‘see and treat’ rooms into a welcoming, safe interview room, ensuring a more therapeutic as opposed to medical environment for interviews to occur in the department, thus improving patient safety and experience.
Patients who have attended the ED with combined psychiatric and medical needs, following self-harm for example, may require a short admission to the Acute Medical Unit (AMU). In these instances, the patient will need to be reviewed by Liaison Psychiatry on the AMU, where they have similarly provided a safe and therapeutic interview room for these reviews to occur
ED have also ensured the co-location of the Liaison Psychiatry team by providing a large office space within the department. This contributes not only to a more timely response to people accessing our service, but also to enhanced working relationships between the teams which has a subsequent positive impact on patient care.
Recent feedback from the ED management group has stated “The past 18 months has seen significant strides in both the development of Liaison Psychiatry in Exeter and their relationship with the ED team. The liaison staff are now perceived as an integral part of the ED team and feedback is that changes in the nature of the relationship have been well received and are mutually felt.”
The ED are also committed to releasing their staff to attend a weekly mental health teaching slot, which has now been in place for 18 months –we have delivered training via this slot to practitioners, ranging from healthcare assistants to consultants. As well as this they, alongside AMU, have put forward practitioners to lead in the role of ‘Mental Health Champions’ within their departments – committing to x5 study days over a year and promotion of mental health within the department. The development of Mental Health Champions has significantly improved knowledge in this area and ensures the dissemination of this knowledge amongst the clinical teams. The longer term aim of the ED is to produce a rota such that an ED mental health champion is present 24/7.
Shared governance – We have joint monthly clinical governance meetings where we share learning, incidents, best practice & service developments/innovation together. Psychiatry is also an agenda item on both the ED & AMU governance monthly meetings which is attended by the Liaison clinical team leader.
On a daily basis, the team leader attends the a.m. operational meeting in the general hospital, ensuring psychiatry is considered in line with all other directorates served.
Attendance at these meetings and ongoing teaching delivery ensures mental health parity with physical health and a reduction in stigma within the physical health environment. We are also engaged in a “Mental Health Summit” which is being led by the medical director of the RD&E – focussing on workstreams to improve the mental health and wellbeing of all patients and staff in the hospital and the community served.
The Liaison team also offer supervision to the clinicians at the RD&E – this can be planned debrief sessions or on a more informal adhoc basis. We are planning to set up a regular drop in supervision slot for anyone to attend to allow space to debrief / share concerns & positive experiences re caring for people with mental illness on general hospital wards.
We have an active Frequent Attenders forum, led by the ED team and Liaison Psychiatry, but attended by a range of other personnel including clinicians from specialities around the hospital, ambulance services, community teams, GP’s, drug and alcohol services, police – the aim being to address the needs of those attending the hospital frequently who may benefit from a more psychosocial approach as a way of maintaining health and wellbeing.
Service user involvement is routine and achieved by gaining their feedback on evaluation forms, which are distributed after assessment – this allows people the opportunity to describe their experience of the Liaison service as well as how the service could be improved or developed. This information is shared at our governance meetings and reviewed regularly.
Service users have been an active part of our recruitment process by sitting on our interview panels.
A service user also helped us with the renovation of our safe room in ED by giving her thoughts and opinions of what would feel safe for her.
We have also recently introduced a simple question sheet asking where people would prefer to attend as an alternative to an ED – the reason we are asking this is because we have been informed through various forums that people generally don’t want to attend an ED for psychiatric support. We are hoping this form will assist DPT in future planning of services.
We also offer carers the opportunity to feedback on our services via a carers questionnaire / evaluation sheet.
We have a clinician who leads on the promotion of “Together” within the team, a DPT initiative towards increased partnership working with people who use our services and their carers.
Our staff team have been integral to the development and sustainability of our 24/7 service. At no time has a shift been left uncovered or with a lone worker – the team are incredibly supportive and respectful of each other and have engaged in changing practices and ways of working in line with improved and extended service delivery. Staff engage in regular management supervision as well as reflective practice, both forums for encouraging feedback. The staff team are encouraged to invite speakers of interest to our internal weekly teaching sessions. Positive feedback has been received from staff in both the 2016 NHS staff survey (see below) and our recent accreditation review.
Looking Back/Challenges Overcome
One of our challenges was maintaining our team cohesiveness – we have overcome this by fortnightly Reflective Practice & Business Meetings, a communications board, weekly internal teaching sessions, a team newsletter & monthly Pay Day Fridays.
Another challenge has been delayed discharges from the department to psychiatric beds. On these occasions, patients have been given an exceptionally high standard of care from ED staff alongside Liaison Psychiatry staff who ensure hourly contact to allow monitoring and updates for the patient and their loved ones.
A number of new systems have been put in place to ensure safe and effective delivery of care and effective communication. This has included twice weekly board rounds, electronic handover sheets, an electronic whiteboard which is accessible for staff over both of the sites we are based in, a team newsletter, a communications board.
Staff retention is supported by:
• A rotation of staff to allow a 2 week break from acute frontline work to focus on our inpatient side of work within the general hospital,
• Reflective practice on a fortnightly basis,
• Weekly internal teaching sessions,
• Access to conferences and non-core training, ensuring professional and personal development,
• Regular managerial supervision – ensuring consistency in this.
• Monthly social get togethers “Pay Day Fridays” – these have been ongoing since January 2016.
Evaluation (Peer or Academic)
We have recently applied for accreditation with the Psychiatric Liaison Accreditation Network (PLAN). We have completed our self-review period, during which we received extremely positive feedback from patients, carers and colleagues within the Acute Trust. We are awaiting the final decision, but feedback from our peer review was also very positive.
We are self-evaluating on a regular basis via our data collection and learning from incidents / complaints and compliments.
Despite significant recruitment challenges, we worked hard to ensure the provision of a ‘CORE 24’ service by January 2016. This represented a pivotal change and the benefits are already evident. In the first 12 months of 24/7 service delivery 79% of patients attending the ED with mental health concerns were seen by the Psychiatric Liaison team within 1 hour of referral, which represents significant progress towards ensuring that patients presenting at the ED receive a timely and appropriate assessment. This is despite the increase in proportion of referrals over that period of a massive 57%.
Data collection has evidenced a reduction in our Acute medical unit (AMU) referral rate – suggesting that the proportion of our referrals coming from AMU reduced to 23.24% in 2016 compared to 28.86% in 2015 – evidencing that 24/7 cover has potentially reduced admission to the AMU from ED.
We are commissioned to respond to ED referrals within 1 hour and the rest of the hospital within 24 hours of referral. Our commissioned response time to the whole hospital was achieved overall in 86% of referrals in 2016, thus evidencing timely access to psychiatric assessment in the vast majority of cases referred.
Our admissions to psychiatric beds reduced from 8.93% in 2015 to 7.61% in 2016.
As a team we are all engaged in routine data collection to inform whether we are delivering a safe and effective service. The outcomes of this are fed back via our communications board and within governance/business meetings. We have been using the Clinical Global Impressions Scale for over 3 years – offering a readily understood, practical measurement tool that can easily be administered by a clinician in a busy clinical practice setting.
We regularly undertake audits within the team as well as Quality Improvement (QI) projects (a recent QI project has commenced looking at assisting in the reduction of use of IM medication on wards). We have also built and deliver a full days training programme titled “Rapid Tranquilisation – The Last resort” – both the QI project and the training delivery are on the back of an audit undertaken by the team regarding the use of IM medication and other rapid tranquilisation
2016 Devon Partnership Trust NHS Staff Survey
Our team response rate was higher than the Trust average response rate;
We scored significantly BETTER than average on 36 questions
We scored significantly WORSE than average on 0 questions
The scores were average on 52 questions
Over the 12 month period, our staff sickness rate evidenced significant reduction throughout the year.
January 2016 11.39% Dec 2016 1.78%
We have a number of visitors to the team and they are always welcomed. This includes practitioners from other teams, students of various disciplines. We are an active teaching team and have medical students and foundation doctors placed with us at all times throughout the year, as well as nursing and occupational therapy students.
We also welcome Liaison clinicians from around the country who are invited to come and see what our team are doing and how the transformation to a 24/7 service delivery has happened.
Our training delivery is a very effective way of sharing good practice – over the 12 month period we have trained over 500 staff from the RD&E in various mental health related topics. We at times go outside of our remit of the RD&E to deliver training – an example being we recently delivered x2 full days training to staff from the Walk In Centre and the Sexual Health Clinic based in Exeter. We have also presented at national conferences, most recently contributing to a “Hospital at Night” conference, highlighting the challenges and successes of a 24/7 Liaison Psychiatry service in the District General Hospital.
Over the last year we have committed to releasing individual staff to spend a week at a time shadowing our local Crisis Resolution and Home Treatment Teams and inviting the clinicians from those teams to spend time with us – this allows for sharing of good practice and relationship building between the 2 teams who often find themselves working mutually with patients. This has led to improved joint working and understanding of each others roles.
We also engage in regular meetings with the Police to ensure continued joined up working where indicated.
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Awards & Nominations
December 2016 – the Liaison Psychiatry team were joint winners of the “Integration” Category in Devon Partnership Trusts Celebrating Achievement Awards.
In the Autumn awards of 2016 we were part of a collective of DPT & RD&E staff that were chosen as winners of the “Extra Mile Team Award” in the RD&E’s Extraordinary People Awards, nominated by the Clinical Lead for the Acute Medical Unit.