Extended hours community mental health nursing service S. Putman
The Extended Hours Community Mental Health Nursing Service is an innovative service introduced within Milton Keynes following the success of an earlier project. The service operates every day and provides an on-call Community Mental Health Nurse (CMHN) who is available 1700-O IO0 h for people aged I7 years and over, in support of other health services. The function of the service is to offer: Immediate assessment/intervention to people presenting, with any mental health problem, to the out of hours GP service or the local Accident and Emergency department. CMHN support out of normal working hours to patients from the Community Mental Health Teams. Outreach to patients on leave from the wards. Professional support to consultant psychiatrists undertaking home assessments outside normal working hours. Better service to patients in Accident and Emergency by improved liaison between Accident and Emergency and the Mental Health Directorate.
RGN, RMN, Team Coordinatol; Campbell Centre, Hospttal Campus, StandIng Way Eaglestone, MIlton Keynes MK6 5NG, UK. Tel: +44(O) I908 243250; Fax +44(O) I908 23 I948 Manuscript I998
This is primarily a nurse-led initiative that has extended the scope of professional practice for all staff involved. The team comprises three G grade mental health nurses, one of whom is the team coordinator, a secretary and a team of ‘back up’ first level registered nurses who work on-call as and when needed.
Acndenr and EmergencyNmng ( 1998) 6. I92- I96 0 Harcourt Brace & Co. Ltd I998
Imagine that you are the nurse in charge of a busy Accident and Emergency (A & E) department one Saturday evening. The shift has started reasonably quietly with a steady stream of patients presenting with the usual bumps, cuts and non-serious broken bones. However, by 1900 h you are asked to deal with the results of a serious road traffic accident and the department is transformed into a hive of activity. In the midst of this a receptionist comes to speak to you and expresses concern about a man who is waiting to be seen. The gentleman presented earlier complaining of a painful toe; he was duly seen by the triage nurse who could find no obvious cause for his discomfort, however, he insisted on being examined by a doctor so was advised to wait. The man started muttering to himself and soon afterwards began speaking to others in the waiting area. After a while some of these people complained to the receptionist that he was being a nuisance. He initially complied with a request to sit down and be quiet but soon was up again pestering people. When the receptionist approached and again asked him to be quiet he told her that he was ‘only blessing everyone’, saying that he had special powers that he wanted to use to cure everyone in the waiting area to save the doctors and nurses time. Suddenly he became angry toward the receptionist and she had left to come and seek help ti-om you. The gentleman is seen by a doctor, who finds no sign of injury to the toe. The man is becoming increasingly agitated and bizarre in his behaviour and conversation, so, on behalf of the doctor, you contact the duty psychiatrist and request an urgent assessment. But you are told that the psychiatrist will not be available for at least an hour, possibly longer. Staff are concerned because other patients now need protecting from the man’s advances and his mood is volatile - being calm and reasonable one minute but angry and aggressive for no apparent reason the next. What would you do?
THE EXTENDED MENTAL HEALTH SERVICE
Fortunately for the A & E staff at Milton Keynes Hospital they have access to ‘on-call’ mental health nurses who will attend the department to assess patients presenting with
Milton Keynes Doctors On Call (MKDOC) is a semi-deputizing cooperative with 111 GP members covering 208 000 patients. The service operates a ‘call handling’ system for GP practices from 1800 h and becomes fully operational from 1900 h until 0800 h the following morning, dealing with all emergency calls to GP practices involved throughout this time. MKDOC is one of approximately 250 similar services throughout the UK (Featherstone 1998). GPs have formed the cooperative to provide an improved service for patients, decrease the number of times any one GP has to be on call overnight and reduce the number of home visits made. MKDOC have use of Primary Care Centre premises so the doctors have access to examination rooms and equipment; patients are asked to attend these premises whenever possible to be seen by a GP there. Three GPs are based here each evening, more at weekends and fewer after 2300 h. ig.
ny mental health problem. This innovative ervice was introduced in November 1997 folowing the success of an earlier project (started n 1994) known as the CPN/A & E Liaison iervice. The Extended Hours Mental Health \Tursing Service not only provides a prompt esponse to A & E but also serves the out of iours G P service, Milton Keynes Doctors On Zall (MKDOC) (Fig. l), and offers continued upport to known patients from the commucity mental health teams, outside of normal vorking hours. The Extended Hours Mental Health \Tursing Service operates every day of the year jetween 1700 and 0100 h, outside these times he A & E department reverts to the standard )rocedure of bleeping the duty psychiatrist vhen required and waiting for attendance (the ime 1700-0100 h was chosen at the outset of he original project as this was identified as the leak times for people to attend with mental wealth problems). The team consists of three G grade, first eve1 registered nurses and one part-time ecretary. One of the nurses is employed as he Team Coordinator and the other two as ‘ull time community mental health nurses CMHN) who work their 7.5 h shifts between he stated hours. These nurses are supported by t group of other registered nurses from within ,he mental health directorate who work as bank’ members of the team, providing addiional back up when permanent staff are absent br any reason. Two nurses are available every jay.
Administrative Organize and maintain an effective rota each month. Process pay claims at designated times. Collect statistical information about referrals and produce useful data in response to this. Recruitment and retention of staff. Organize and implement induction programmes for new team members. Appraise junior staff. Process completed assessment forms. Policy formulation and review.
l l l
Each person seen by the team has an assessment form completed. This is a three page (double-sided) document containing information about basic statistical data (age, gender, civil status, etc.), clinical risk assessment, details about the primary health care team, any other ‘contacts’ agencies and information about the mental health care team if the person is known to mental health services, locally or elsewhere. It is the Team Coordinator’s job to record this information for future reference, produce written reports when required and initiate any follow-up arrangements that may have been agreed during assessment. Copies of the form will be sent to any relevant others to ensure that all involved have access to the same information. This is done with the patient’s written consent, if consent is withheld then no information is passed on. Completed forms are collected each weekday morning.
The role of the Team Coordinator is vital to the uccess of the service. The job has two distinct rreas: administrative and clinical. These are described briefly:
Sound clinical knowledge is required both of mental health conditions and the Mental Health Act (1983). The Coordinator liaises with GPs about treatment plans and is often the main contact point for people wanting information about mental health problems and services. It is the Coordinator’s responsibility to inform all others involved with a patient who has been seen (often this is just
the GP but for others it will include a Social worker, Rehabilitation Officer, Counsellor or Substance Abuse Worker). There is a responsibility for providing teaching sessions (on mental health issues), primarily for A & E staff but also for others, as required. The Team Coordinator works as part of the on-call team when needed. Sound clinical knowledge is needed to undertake effective clinical supervision for team members.
The secretary also has an important role in the success of the service. She is onice-based and is available to take messages for staff, particularly important when community nurses wish to make a referral or pass on important information to the team. The secretary also deals with the administration associated with the service.
Within 10 min of receiving the call from A & E, in the scenario described above, one of the mental health nurses attended and was able to engage the gentleman in a meaningful conversation. Subsequently, the CMHN arranged for the man to be admitted to the mental health unit where he received treatment for a psychotic episode. Admission was agreed with the duty psychiatrist who attended A & E towards the end of the CMHN assessment. In the case described above, the CMHN was able to take control of the situation, perform a thorough assessment of the man’s mental state and make recommendations accordingly. This allowed A & E staff to return to other duties. The operational policy describes fully the criteria for referral from any of the areas covered by the service and these vary accordingly. People who are under the influence of alcohol or drugs and not thought likely to benefit from input at the time are not suitable. (This is because of the perceptual alteration associated with consumption of alcohol and many medications, particularly those taken illicitly, thereby making an accurate assessment of a person’s mental health state almost impossible until they are free from these effects). Another example of where this service is invaluable within an A & E department is in the case of those presenting with deliberate self harm, especially overdose. This group provides the largest section of referrals from Milton Keynes A & E (Table 1). Once the initial medical investigations/ treatment for the overdose have been completed
Mental Illness Overdose Self Harm Low Mood Total
3I 216 33 63
Alcohol related Section I36 Other Not Stated
30 8 173 I 555
the CMHN can attend and stay for as long as the patient needs them. These assessments are often lengthy, up to 2.5 h, or more on some occasions. A & E staff do not often have this time available to spend with one patient, however distraught they may be and however much the A & E nurse might like to stay and help. The pressure of other work prevents this. Often, too, the A & E nurses’ perceived inability to be able to deal with such a situation, fear of saying or doing the wrong thing, can also have an effect on their interaction with the patient (Baxter & Mowbray 1995). A & E staff have expressed concern that the patient may literally just walk out of the department if left or if they have to face a long wait for someone else to talk to, with no one doing anything positive to help. The CMHN has the skill and knowledge needed to make decisions based on their risk assessment. How serious was this as a suicide attempt for the patient? What are the risks in allowing the person to go home? Is it appropriate for this person to be referred for further psychiatric input or are there alternative sources of help/support available which might be more beneficial? Prompt and appropriate intervention at this time may save a life. The Health of the Nation document (1992) identified key areas to target with the aim of achieving significant improvements in the health of the people in the UK. One of the key areas for mental health practitioners was to reduce the overall suicide rate by 15% by the year 2000 (Department of Health 1992). Other studies showed that people who commit suicide had often previously attended A & E after an earlier ‘failed’ attempt (Hawton et al. 1994) so the establishment of the initial CPN/A & E Liaison Service attempted to focus on this and the Extended Hours Service continues. A separate local study is currently monitoring this. Once the patient has been declared medically fit the CMHN has authority to discharge the person from the A & E department, so they have to be sure that the decision they make is the correct one. This is an advantage to staff in A & E who know that the situation will be completed once accepted by the on-call CMHN. However, A & E staff are expected to share the care of the patient when it is appropriate (or necessary) to do so. The role of the CMHN on-call is to complement the A & E
nurses’ role and is not intended to replace it. General and mental health nurses work together to meet individual patient needs and the A & E department is an excellent area for this aspect of shared care to really work in giving a truly holistic approach for the patient’s benefit. Other less obvious benefits to A & E staff of this service include the option of the CMHN visiting known patients at home. This facilitates a more thorough assessment and may help to avoid a deterioration in the patient’s condition which could result in admission to the mental health unit later, via A & E. The fact that this service on‘ers support outside normal working hours has been welcomed by staff from the community mental health teams for the same reason. GPs at MKDOC have direct access to the CMHN and can arrange for assessments to take place at their premises, thereby avoiding the patient having to attend A & E (unless they require medical intervention for any other reason). However, this does not always happen and the management team are keeping this under review. In the report written at the end of the initial project, nurses &om A & E identified many learning opportunities gained from the CMHN with ‘lessons’ being learnt through conversation and also from observing the nurses at work (Baxter and Mowbray 1995). This continues with the work of the Extended Hours team. Sometimes the CMHN will have a personal professional knowledge about a patient who attends A & E. This can be invaluable when staff are dealing with clients who have a tendency to manipulate situations for personal gain. The liaison between the Extended Hours Service and other areas helps enormously in making sure that all staff are kept informed of relevant information, including details about care plans, so that all are working together and providing a consistent approach to the patient. This also applies to patients subject to conditions under Section 25 of the Mental Health (Patients in the Community) Act, (Department of Health 1995). Personal knowledge of patients can also be beneficial when dealing with those who find it very difficult to talk to ‘strangers’ about their problems. The CMHN may appear less threatening in this case and, therefore, easier to talk to as the patient already knows them and feels safe. Some A & E nurses in Milton Keynes have described feeling ‘uncomfortable’ when trying to talk to patients about certain mental health issues and have described the CMHN as having an almost visible aura of confidence when they enter the A & E department which is trans-
ferred to the patient, allowing the patient to achieve a rapport and have trust in the member of staff who is seen as an ‘expert’. Another benefit to emerge from the liaison aspect is that of improved communication between areas. The relationship between the A & E department and the Mental Health Directorate has significantly improved, to mutual benefit. New nurses to the mental health unit are invited to attend the A & E department and vice versa, at the very least this will be just a short visit but in some cases staff have negotiated to work a complete shift in the ‘other’ area to gain greater understanding of the work involved. Consequently, staff have come to know each other better and the relationship between the two clinical areas has improved. One sister from A & E is part of the management group overseeing the operation of the service and a senior staff nurse has taken on a specific liaison role between A & E and the mental health unit in-patient facilities as a result of the improved liaison between the two departments. Returning to the scenario: it’s now 2100 h and the first gentleman has been transferred to the mental health unit for admission. A young woman has been brought to the department. She has several lacerations on her forearms, some deep enough to require sutures. The woman is quiet and appears withdrawn, giving monosyllabic answers to questions from A & E staff who are concerned about her mental state. Again, the services of the CMHN are sought. Two hours later, the woman is stable enough to be discharged home with a friend. The CMHN has discovered that this woman had been sexually abused by her step father from the age of 6, she had left home at 16 and moved away to start a new life. Today she had been approached by a man at work which had brought memories flooding back to her; she had felt disgusted with herself and wanted to hurt herself and make herself unattractive to men so that she would not be hurt again. The physical pain caused by the cutting had helped (temporarily) to numb the emotional pain which these memories had evoked. This woman did not require admission to the mental health unit but would need further help and support to deal with her situation. The on-call CMHN was able to arrange for her to attend a specialist support group and give information about local counselling services which she had requested. The CMHN has access to many information leaflets/handouts which are used in conjunction with the nurse’s intervention. A selection of ‘Section papers’ are also kept in the department in case they are needed and also a folder of information about various mental
Total Abdominal Pain Chest Pain Mental Health
Discharge home Self discharge Other (includes admission to other hospitals, Police custody and return to prison) Total
100 4.00 3.70 2.43
22 759 910 842 555
394 27 40
health issues (including an easy to understand guide to the Mental Health Act, 1983) which the A & E nurses find useful. Once again the specialist skills and knowledge about local services of the CMHN were of benefit to the patient and A & E staff. If admission to the mental health unit is thought to be appropriate then the CMHN will contact the duty psychiatrist to discuss this with them. When the duty psychiatrist attends (and experience has shown that this is usually a prompt response) he/she will make use of the information already obtained by the CMHN and, therefore, avoid further delay for the patient. Throughout 1997 a total of 22 759 people presented to the Milton Keynes A & E department between 1700-0100 h and 555 of these were seen by the Extended Hours CMHN team (Table 2). Most of these people were well enough to be discharged home after intervention from the CMHN (Table 3). The service is still developing and is under constant review from representatives of all parties involved who meet regularly to reflect on its operation (MKDOC, A & E medical and nursing staff, Community Health Council, Social Services, Psychiatrists, users and voluntary groups involved with those who have mental health problems/concerns).
Admit. Mental Health Unit Admit. Care of the Elderly Admit. Milton Keynes General Hospital
within mental health nursing. Staff who work as part of the team are highly skilled individuals, capable of dealing effectively with a wide variety of situations and able to make the necessary arrangements for suitable follow-up. Sometimes, particularly within the A & E department, it can literally involve making lifesaving decisions, although they may not always appear to be so to staff working in the ‘resus’ room trying to save the life of a patient who has had a cardiac arrest. The effects on the life of the person concerned are not to be underestimated in either case.
R, Mowbray K 1995 Accident & Emergency psychiatric nurse liaison project. Milton Keynes Hospital,
UK of Health 1992 The Health of the Nation: for health in England. HMSO, London
Department of Health 1995 Mental Health Community) Act HMSO, London Featherstone M April 1998 Information from the service manager.
The Extended Hours CMHN Service in Milton Keynes is an exciting new development
a in the
Hawton K, Daniels R, James R 1994 General hospital services for attempted suicide patients in the Oxford region. Accident and Oxford, UK Milton Milton
1997 Population Census figures Hospital 1997 Attendance figures
for the A & E department
50 2 42