Developing an algorithmic mode of self harm management in enhanced medium secure services for womenDr. Chris Beeley chris.beeley@nottshc.nhs.uk

Co- author Dr. Jay Sarkar

Summary

• Aspects of self harm risk• Model description

– Types of self harm– Managing self harm

• Model fidelity on ward (and vice versa)

• Staff satisfaction and effectiveness

Context

• Medium secure women’s ward•High levels of self harm•Index offence typically arson/ harm to children or vulnerable adults•Disorders of attachment due to developmental trauma, abuse and neglect•Primary diagnosis of severe PD, co-morbid psychosis, substance abuse and PTSD

Self harm

• High levels of aggression to self and others

•In 18 month period 546 acts of self-harm and 536 acts of other-harm

•Severe self harm including:•Open wounds in subcutaneous tissue•Insertion of foreign objects into wounds•Ligation and suffocation•Poisoning and contamination of wounds

Aspects of risk

• Lethality is the probability that the patient’s act of self-harm is likely to end in death. It is also referred to as the ‘how quickly to death’ question.•Intentionality- intensity of the patient’s desire or wish to die.

•‘How likely to die’ question•Self reports can be unreliable and so inferred objectively from the nature and severity of self harm

•Inimicality- making the circumstances unfavourable or unduly complicated in order to avoid detection by others, and thus increase the likelihood of serious harm or death

•‘How to avoid detection’ question

Lethality

Lethality of the self-injury Types of self-injury (‘Act’)Traditional methods of suicide Hanging, strangulation, shooting, jumping

gas, drugs, pesticides), stabbing, electrocution, drowning from a high place, poisoning

Highly lethal Overdose, recreational drug-OD as self-harm, cutting, burning

Self-injury with tissue damage Self-biting, scratching, gouging, carving words of symbols on skin, sticking needles or pins into skin, interfering with wound healing

Less lethal Self-hitting, head-banging, fist against hard objects, pinching, pulling hair

Self-injury with no tissue damage Over-exercising, denying a necessity to hurt oneself, stopping medications, starving with intent to cause harm, tattoos, multiple body piercing

Non-lethal Deliberate recklessness with cars, drugs, trains, etc.

Inimicality

Inimicality of the self-injury

Monitoring

Three staff observing, two staff observing, line of sight observations, observations every 5/ 15 minutes

Level of observations

Graded access to objects based upon observation levels

Access to objects to self-harm with

Graded access to various parts of the ward, unit, hospital based upon observation and access to objects level

Access to spaces on/ off ward

Manage personnel deployed on high risk shifts (nights, weekends, bank shifts)

Access to certain staff profiles and shifts

Level 1 Level 2 Level 3 Level 4 Level 5 Cutting Superficial,

little blood loss

Subcutaneous, moderate blood loss

Puncture, stab wounds, deep wounds into muscle, deep biting, significant blood loss

Headbanging Gentle and brief

Gentle or brief Moderate Repetitive, forceful

Severe, intense, repetitive and staggering, altered consciousness

Self hitting Gentle, brief Firm brief Moderately hard causing tissue damage

Causes fracture Severe, intense, repetitive

Insertion/ stabbing

Causes tissue damage

Into old wounds

Into new wounds

Burning/ scalding

Scratching, rubbing

Clothes, carpet burns

Scalding Cigarette burn, embers

Ingestion Low lethality- convex, non-sharp, nontoxic

High lethality- any hooks, sharpness or toxicity

Ligation Low lethality- no fixed ligation point

High lethality- fixed ligation point

Suffocation Partial occlusion of airway

Full occlusion of airway

Level 1 Level 2 Level 3 Level 4 Level 5 Internal response

Staff HCSW under supervision

Senior staff on duty

Junior doctor/ PHC

Extra staff required to observe patient

Senior on-call nurse, consultant, manager

Blicks No On NICs judgement

Yes Yes Yes

PHC No On NICs judgement

Yes Post incident PHC management

Yes, also Toxbase

Level 1 Level 2 Level 3 Level 4 Level 5 Observation/ support

Observation From a distance

Level 1 Close obs, no formal physical obs

Vitals- pulse, BP

Mobility, gait, level of consciousness, coherent speech

Support Offer support- de-escalation

Dialogue, distraction and diversion

Intervention/ wound care

Intervention No hands on

Safely remove implements

Staff in close proximity

Immediately cut ligation

Wound care/ other medical intervention

Offer cleaning materials to patients (not steri-strips)

Wound cleaned and steri-strips applied by staff

Wash and remove objects if visible and/ or splint limb to prevent penetrating wounds

Tie ligatures and compress freely bleeding wounds

O2 cylinder available- cyanosis in fingertips only O2 cylinder used- cyanosis in face or lips

Introducing the model

• Manualised programme of self-harm training devised•Delivered over 3 days•Clinical vignettes and scenario planning•Policies and procedures updated•Particularly, senior clinical and managerial staff were to be involved

Method

•Iterative model testing and development•Model tested for fidelity to practice and vice versa

•Changes were made to the model following initial examination of the data

•External response removed•“Low risk” ligation added

•Testing particularly for:•Reducing level of intervention to lowest safe level•Clinical and resource implications

Response r=.79

1 2 3 4 5

12

34

5

Severity

Re

spo

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Observation/ support (inimicality) r=.75

1 2 3 4 5

12

34

5

Severity

Ob

serv

atio

n/ s

up

po

rt

Intervention/ wound care r=.69

1 2 3 4 5

12

34

5

Severity

Inte

rve

ntio

n/ w

ou

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re

Overall effectiveness

Week

Ave

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ek

0 50 100 150

0.0

0.5

1.0

1.5

2.0

2.5

Cutting• Assess

– Location and depth of wound– Risk to others– Blood loss

• Levels– Low

•Remove patient from area and encourage to stop•Help to dress and clean

– Medium•Intervene if no risk to staff•Medic/ PHC

– High•Intervene if safe (or if risk to patient outweighs risk to staff)•Blicks/ Medic/ PHC•A and E, 999 on medics’ judgement

Swallowing

• Assess– Physical obs, pain, breathing, vomiting

– Type of battery

• Levels– Low

•Observation only

– Medium•A and E (medics’ judgement)

– High•999

Ligature

• Assess– Consciousness, colour, respiratory

function/ damage, breathing, respiration, pulse

• Levels– Low

•Remove ligature and monitor– High

•Remove ligature•Summon medics•Consider use of oxygen/ 999

Headbanging

• Assess– Severity of banging and type of surface– Consciousness– Swelling/ bleeding– Physical obs, breathing, pulse, BP– Neuro obs

• Levels– Low

•Encourage to stop, obs

– Medium•Encourage to stop, increase obs

– High•Intervene where safe

Seclusion

• From interviews:– When secluded if there is blood loss or headbanging only verbal

intervention will be used- only where risk to patient outweighs risk to staff will they intervene

– In seclusion if there are sharp objects then important to assess as a weapon. Where serious weapons are involved seclusion will not be entered.

– Entering seclusion entered purely on basis of weighing risk to staff versus risk to patient

Enter seclusion where risk to patients clearly outweighs risk to staff, i.e. low risk to staff (unconsciousness, extreme

blood loss) or very high risk to patient (e.g. occluded airways)

General

• Outline – Patients feel unsafe when staff are unused to dealing with self

harm– When self harm is in seclusion need to ask who is most at risk,

staff or patient• Process developed

– Practice has “just developed”. Confidence has developed with practice

– The ward has become more comfortable with self harm over time• How

– Knowing the patient and risk factors is important– Blicks can be useful to summon other experienced staff– Environment makes it easier to manage risk– Response to self harm is fairly individualised according to care

plan

General

• Why– Works very well, and incidents of self harm

have reduced– Method is effective, especially considering

history of patients– Always going to be challenging with such

serious self harm– Nursing team are very aware of what to do.

Staff from other wards can find it hard

Developing an algorithmic mode of self harm management in enhanced medium secure services for womenDr. Chris Beeley chris.beeley@nottshc.nhs.uk

Co- author Dr. Jay Sarkar