Emergency psychiatric assessments: implications for senior house officer training

AIMS AND METHOD

In order to examine the opportunities for senior house officers(SHOs) to undertake emergency psychiatric assessments we conducteda retrospective cohort study of such assessments in a districtgeneral hospital.

RESULTS

Senior house officers conducted few assessments for self-harmcompared with psychiatric liaison nurses (P<0.001), andwere involved in only 40% of emergency referrals where psychiatricopinion was requested. Senior house officers continue to undertakemore assessments out of hours than any other group (P<0.01).

CLINICAL IMPLICATIONS

Although the introduction of psychiatric liaison nurses hasimproved capacity and reduced waiting times for emergency assessment,the opportunity for SHOs to undertake emergency assessmentshas been reduced, particularly with regard to assessment ofsuicidal risk following self-harm. These results suggest theneed for better monitoring of SHO experience, particularly inthe light of service developments that have an impact on psychiatrictraining.

Introduction

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Introduction

The Royal College of Psychiatrists (2003) has developed a detailed syllabus for the theoretical and clinical training of seniorhouse officers (SHOs) in psychiatry. This document specifiesthat trainees must be exposed to the full range of psychiatricpresentations in order for them to gain experience in assessment,clinical decision-making and risk management.

Junior doctors in the UK have experienced reductions in hoursspent on call with the introduction of the European WorkingTime Directive (2004; details available at http://www.dh.gov.uk/PolicyAndGuidance/HumanResourcesAndTraining/WorkingDifferently/EuropeanWorkingTimeDirective/fs/en). This has led to a reduction in exposure to emergency psychiatricassessments. Additional factors, such as increasing clinicalworkload, pressure on mental health services to reduce waitingtimes, and pressure on National Health Service (NHS) truststo free beds by discharging patients more quickly, have ledto an increase in the number of psychiatric nursing staff deployedto undertake liaison assessments in the UK. These staff providea valuable service by increasing capacity for urgent assessment,decreasing the time between request and assessment, and facilitatingthe medical discharge of patients who require a psychiatricopinion. Studies suggest that there is no significant differencein outcome when nurses and junior doctors undertake psychiatricliaison assessments, although the methodology of some of these studies has been questioned (Griffin & Bisson, 2003; Lepping, 2003;Weston, 2003; Whyte & Blewitt, 2003).

One concern is that the combined effect of a reduction in junior doctors’ hours and the introduction of nurse liaisonassessment services might reduce trainee psychiatrists’experience of performing self-harm assessments. This paperreports the second part of a retrospective study of emergencypsychiatric assessments over a 2-month period.

Method

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Method

The case records were examined of all patients aged 16–65years referred from the community (general practitioner (GP),community mental health teams, police) and other hospital services(e.g. accident and emergency, other medical and surgical services)for psychiatric assessment at Wrexham Maelor Hospital (NorthEast Wales NHS Trust, catchment 280 000) over a 2-month period(December 2002 to January 2003). The following information was recorded: demographic details of patient; date, time and sourceof referral; date and time of assessment; healthcare professional(consultant, specialist registrar, SHO, liaison or duty psychiatricnurse, approved social worker) undertaking the assessment;and primary diagnosis recorded (ICD–10 criteria; World Health Organization, 1992).

Statistical analyses of data by unpaired t-test, analysis of variance, and ${chi}$ ² tests were undertaken to compare frequencyof assessment for each disorder, with a particular focus onthe healthcare professional undertaking the assessments. Dataare presented as means (±s.d.) unless otherwise stated.

Results

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Results

During the sampling period, 144 assessments were undertaken(mean age of patient=34.8 years, s.d.=11.1, n=70 male). Mostassessments (75%) were undertaken in normal working hours andmainly involved assessing patients admitted to medical wardsfollowing self-harm (58%, Table 1). Significantly more out-of-hoursreferrals came from the accident and emergency department andGPs than any other sources ( ${chi}$ ²=59.7, n=144, d.f.=5, P<0.001).Table 2 shows that, although not mutually exclusive in thatmore than one professional could carry out an assessment, themajority were carried out by liaison nurses (101 assessments)and SHOs (58 assessments). Consultant psychiatrists carried out only 7 assessments, an approved social worker carried outonly 1 assessment and a duty nurse undertook 27 assessments (Table 2). Thus, a liaison nurse was present in 70% of assessments.Almost all of these were undertaken during normal working hours(99%). Conversely, SHOs were involved in only 40% of assessments,and most of these (59%) occurred out of hours.

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Table 1. Source of psychiatric referral and timing of the 144 assessments

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Table 2. The assessor and the timing of the 144 emergency assessments

Table 3 shows the primary diagnosis recorded for each assessmentgrouped according to ICD–10 criteria and the healthcareprofessional in the assessment. Note that the assessments carriedout were not exclusive to each healthcare professional. In somecases, two or more professionals were involved in the assessment. Therefore the sum of assessments across all the healthcareprofessionals may exceed 144. Few assessments were classifiedas behavioural disorders with physiological symptoms, mentalretardation, non-psychiatric or organic disorders. These datahave been grouped to form the category ‘Other’in Table 3. The most common reason for requesting psychiatricopinion was self-harm by poisoning (35%), followed by affectivedisorder (19%). Emergency assessment of psychotic illnesses(e.g. schizophrenia) accounted for only 4% of assessments. Assessmentof self-harm was undertaken most often by liaison nurses (98%of all assessments involved a liaison nurse); SHOs were involvedin only 18% of all self-poisoning assessments. Most referralsof affective disorder were from GPs; SHOs saw the majorityof these patients (78%).

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Table 3. Primary diagnosis and healthcare professional involved in assessments

Discussion

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Discussion

During the 2-month study period, resident SHO cover was providedby a1 in 8 on-call rota (24 h), whereas two liaison nursesworked normal hours only, i.e. Monday to Friday, 9 a.m.–5p.m. Each SHO saw an average of seven emergency referrals duringthe 2-month period, less than one per on-call session. Theaverage number of psychiatric assessments undertaken by the liaison nurse team was 50.5 in the same period. Hence, theexposure of nurses and SHOs to emergency assessments was verydifferent, with significant implications for the opportunityfor trainee psychiatrists to gain relevant experience. Traineesspend most of their on-call periods managing routine requestsfrom wards regarding in-patients and ‘clerking’planned admissions. They also gain experience in assessmentof patients in planned out-patient clinic settings. These areall valuable skills to acquire, but they do not confer experiencein assessment and management of acute psychiatric emergencies.Furthermore, significant differences exist with respect tothe nature of psychiatric problems presenting to each group.For example, the majority of self-harm assessments are notbeing undertaken by SHOs; in the study period, only 6 self-harmassessments were undertaken (15 including self-poisoning),approximating to 1 per SHO per 2 months, or an annual rateof 6 assessments per year. This is clearly insufficient to gain adequate experience and training in assessing and managingself-harm as recommended by the guidelines for training providedby the Royal College of Psychiatrists (2003) and the NationalInstitute for Clinical Excellence (2004). These are difficult skills to master (Hassan et al, 1999; Bennewith et al, 2002)and represent an important competency for all psychiatrists.

Overall, the results indicate that although the creation ofpsychiatric nurse liaison posts can benefit service delivery,it can also lead to a serious reduction in core clinical experiencefor psychiatric SHOs. It is important that training implicationsof service developments are considered, in this case to allowpsychiatric trainees to gain adequate training in all areasof emergency psychiatry. This could be ensured by includingperiods of attachment for SHOs to self-harm liaison teams.We recommend that Royal College of Psychiatrists’ approvalof training schemes requires that trainees are adequately exposedto emergency psychiatry, in particular the assessment and managementof self-harm. One method that could assist in the monitoringof such experience is for psychiatric trainees to maintain logbooks of emergency assessments and for these to be regularly reviewedby supervisors and clinical tutors.

A possible limitation of the study is that the 2-month samplingperiod includes Christmas and New Year, with associated emotionaldisturbance possibly escalating demand for emergency psychiatricassessments. For example, if more people were presenting tothe service with self-harm at Christmas, this might have animpact on the use of liaison services, in particular the activitiesof liaison nurses. Further examination of patterns of clinical demand and the role of different health professionals in emergencypsychiatric assessments across different settings is required.

The impact of service organisation on training extends to othermedical disciplines as well. For example, the European WorkingTime Directive has similarly restricted the emergency experienceof surgical trainees, raising concerns about the adequacy oftraining to equip new consultants with requisite skills formanaging acute presentation (Morris-Stiff et al, 2004). Theimpact of nurse practitioners on medical practice has beena long-standing issue (Dowling et al, 1995). With a drive tofocus the work of doctors on clinical tasks that require medicalinput only, is there a cost of losing general competency? Implicationsfor postgraduate clinical training of SHOs in various disciplinesthus need to be carefully considered in the light of employmentlaw as well as current and planned service developments.

Acknowledgments

We thank staff of the Mental Health Directorate, North EastWales NHS Trust for assistance with record retrieval.

References

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