PROTOCOL FOR LOCATING A CAMHS TIER 4 BED AT CRISIS PRESENTATION Title: Protocol for locating a CAMHS Tier 4 Bed at crisis presentation Reference Number: Version No: V1 Issue Date: December 2017 Review Date: December 2018 Purpose and Background Scope (i.e. organisational responsibility) Vital functions affected by this procedure: The following protocol has been adopted from the Central Manchester University Hospitals NHS Foundation Trust Guidelines on Locating a CAMHS Tier 4 Bed at Crisis Presentation 20/12/17 and Cheshire And Wirral Partnership guidelines This protocol applies to East Cheshire NHS Trust staff, in particular Paediatric and Emergency Department teams. Monitoring Compliance Requirement to be monitored. Process to be used for monitoring e.g. audit Responsible individual/ committee for carrying out monitoring Frequency of monitoring Responsible individual/ committee for reviewing the results Responsible individual/ committee for developing action plan N/A N/A N/A N/A N/A N/A N/A Escalations (if you require any further clarification regarding this procedure please contact): Joanne Shippey Matron for Paediatrics Responsible individual / committee for monitoring action plan Consultation: Approval: Committees / Group Joanne Shippey - Clinical Manager / Matron Children s Services Liz Owen - Urgent Care Matron Anne Marriott - Associate Director for Acute and Integrated Community Care Kath Senior Director of Nursing Performance and Quality Date December 2017 December 2017 Acute and Paediatric SQS meeting January 2018
OPERATING PROCEDURE IN HOURS PROCESS TRUST STAFF All children and young people who present with mental health issues should have a documented environmental and self-harm risk assessment completed and the associated remedial action required to maintain as safe as an environment as possible. Patients may be cared for in Accident and Emergency Department or on the Paediatric Ward. Referral for mental health assessment via the CAMHS team must take place at the earliest opportunity to allow prompt assessment of the child/ young person s mental health. Once the initial mental health assessment has taken place, if it is deemed that further tier 4 assessment and possible inpatient admission is needed, this should be organised by the mental health team. The process to obtain tier 4 assessment and inpatient beds can be lengthy and children may wait inappropriately in Accident and Emergency or on the acute paediatric ward. There is, therefore a need to ensure that, where possible, treatment (e.g. psychotropic medication) commences whilst they are waiting and that regular reviews include the assessment of the continued necessity of admission or whether, or not, other appropriate alternatives can be sourced. The on-call paediatrician should take advice from the on call CAMHS consultant for the appropriate treatment of the child/young person. When patients have to wait on a Paediatric Ward until a mental health bed is available, it is part of the CAMHS assessment/risk management plan to advise on the need for additional staffing (and whether or not this needs to be a qualitied mental health nurse). Some trust s may decide on additional staffing to support observation and risk management. Following assessment, advice will be given if it is deemed appropriate for the trust to make necessary arrangements for agency staff to be arranged. Funding for these additional staff has to be paid for by the respective trust as NHS England will only pay for the care once the young person is in a tier 4 bed and approval for this should be given by the site manager. RESPONSIBILITIES OF MENTAL HEALTH SERVICE It is important that, if the mental health service duty practitioner determines that further tier 4 assessment and potential admission to a CAMHS in-patient bed is necessary, then arrangements must be made for a Consultant Psychiatrist (or delegated ST4 as minimum) to review the patient. This input or review can be done by face to face assessment or via consultation with the accessing clinician. If it is agreed that an inpatient mental health bed is required, then an NHS bed should be sought by completion of a referral form and phone call to ascertain availability and acceptance of referral, along with response time. Units require the completion of a referral form (to be faxed) and this is essential. NHS England CAMHS T4 (1) Referral for As If all local CAMHS NHS Beds are full then an option of an Independent Sector bed (private bed) maybe required Commissioners (NHS England) would need to be alerted and they will confirm NHS bed availability and advise on course of action necessary. Protocol for Tier 4 Referral Page 2 02/03/2018
All NHS CAMHS beds are now nationally commissioned by NHS England, so there is no requirement for staff to inform local or NHS England Commissioners for admission to an NHS bed. If there is no NHS bed available in the local units, NHS England should be contacted (to help the search wider and/or authorise funding for private provision and/or advice in general when accessing 24 hour mental health support). Contact no. for NHS England are: Claire Cunningham Case Manager, Cheshire Warrington and Wirral Area Team. 07747007501 or Email: claire.cunningham6@nhs.net Or Tahmaiza Yaqub- Secure and Specialised Case Manager, Cheshire, Warrington & Wirral Area Team 07900715425 or Email: tahmaiza.yaqub@nhs.net Or Main Office 0113 825 2809/0113 824 7515/0113 825 2752 Private Hospitals (NHS England Commissioner s approval must be sought before contacting): Cheadle Royal Hospital 0800 188 4770/ 0845 277 4679 Alpha (need to be under a Section of MHA) 0161 762 7250 The process can be lengthy and children may wait inappropriately in Accident and Emergency or on acute wards. We therefore need to ensure that, where possible, Whilst waiting for this bed the CAMHS assessment/risk management plan should advise on:- - Whether any further measures can be put in place to keep the child/young person safe - The need for additional staffing (and whether or not this needs to be a qualified mental health nurse). - Appropriate management strategy for the child s behaviour - Contact details of CAMHS staff available to support if behaviour/situation escalates - Whether treatment (e.g. psychotropic medication) should be commenced whilst they are waiting and that the reviews include the assessment of the continued necessity of admission or whether, or not, other appropriate alternatives can be sourced. Appendices 1 and 2 depicts this process in a flow chart in and out of hours OUT OF HOURS PROCESS TRUST STAFF All children and young people who present with mental health issues should have a documented environmental and self-harm risk assessment completed and the associated remedial action required to maintain as safe as an environment as possible. Patients may be cared for in Accident and Emergency Department or on the Paediatric Ward. Referral for mental health assessment via the CAMHS team must take place at the earliest opportunity to allow prompt assessment of the child/ young person s mental health but this is only available during hours. If immediate advice/assessment of the child/young person behaviour/mental health crisis is required on call CAMHS team can be contacted via MDGH switch. Protocol for Tier 4 Referral Page 3 02/03/2018
RESPONSIBILITIES OF MENTAL HEALTH Following referral from the trust in line with usual processes, mental health staff will need to ring the units direct to ascertain availability and whether the tier 4 staff will undertake face to face assessment or accept direct admission. Out of Hours or if NHS England are inaccessible/not responding then the Consultant can communicate direct with the private sector provider to ascertain if there are any beds and facilitate an emergency admission informing NHS England by email and phone call the following day of the need to take such a pathway. Assessment Under the Mental Health Act If it is assessed that a formal detention of the young person is required then the attendance of an Approved Mental Health Practitioner is required. Trust staff should liaise with CAMHS and Social care to ensure the appropriate personal attend. The CAMHS team will need to remain involved in the case and ensure that the necessary 2 Consultant Assessment Opinions are co-ordinated (Section 12 Approved Status) and that an in-patient bed has been secured. Protocol for Emergency Admission of Children under 14 Core Principles The decision to admit a child under 14 years old to a psychiatric ward is a major one. Apart from the stigma for the child and their family, separation from family, disruption of school and social life and potentially being placed far away from home are all major considerations especially pertinent for younger children. All steps must have been taken to ensure a child could have been managed in their own locality before the decision to admit is made. The decision to admit a child under 14 years to a CAMHS bed is a multiagency, multi-disciplinary decision, should involve senior clinicians and should usually be undertaken in a planned way. It is for this reason that most of the units in the UK that support children s beds do not take emergency (direct from A&E admissions). Some have the resource and infra-structure to assess and admit from a paediatric ward on the same day. The highly unusual decision to admit a child direct from A&E or the community in an emergency (immediate and unplanned) way must always be made with due regard for ensuring all other options have been explored by all professionals and not seen as a substitute for alternative and potentially more appropriate means of home based crisis management. Tier 3 CAMHS/ On call CAMHS psychiatrist to complete the NHS England forms 1 and 2 and make contact with the local unit Dewi Jones Unit (Liverpool) 0151 928 3888 Dewi Jones unit will triage the referral and assess suitability for admission and bed availability. See Appendix 3 Protocol for Tier 4 Referral Page 4 02/03/2018
APPENDIX 1 Referral Pathway For Under 13 Referrals See Appendix 4. Referral from CWP/Merseyside Triage referral information regarding the appropriateness for assessment. Initial triage will aim to occur within 2 hours. Referral considerations may include Signposting to specialist services close Consultation, continued Tier 3 CAMHS support close Appropriate for planned assessment - AOT to arrange assessment in collaboration with referrer. Joint assessment is preferred Appropriate for urgent assessment respond within 48 hours ensuring current place of safety Emergency referrals to be assessed or triaged within 12 hours Request for bed under the Mental Health Act Document referral on Care Notes Referral Pathway between 9am and 9pm Telephone call to AOT team secretary as first point of contact Telephone call will be passed to the AOT as AOT staff will gate keep referrals establish the locality of the referral establish assessment capacity email the NHS England Form 1 to referrer for the referral form to be fully completed. Referral from England outside of North West Ensure local Tier 4 CAMHS assessment is completed, faxed and reviewed using NHS England Form 1 for appropriateness to admit. No young person to be admitted without confirmation from their local commissioner. Bed enquiry Coral Ward Nurse-in-Charge to take referral information Referrer details Young person s name, DOB, NHS Number, Address GP details Clinical presentation Email information to AOT secretary/team using the generic email address TIER4CAMHSAOT@cwp.n hs.uk Inform enquirer if beds are available or not. Document an entry on Carenotes. Inform referrer of the need for a NHS England Form 1 to be completed prior to bed being agreed. Referral from North West Referral to come directly from local Tier 4 CAMHS. Inform referrer if no available beds. Ensure local Tier 4 CAMHS assessment is completed. Request for bed under MHA Remain in Tier 3 CAMHS and close Admission offered Admit if clinically appropriate or request further information to enable admission Suggest referral to Specialist Service and Close Protocol for Tier 4 Referral Page 5 02/03/2018
APPENDIX 2 - Out of Hours Referral Pathway Bed enquiry Coral Ward (Ancora House) Nurse-in-Charge to take referral information Referrer details Young person s name, DOB, NHS Number, Address GP details Clinical presentation Email information to AOT secretary/team using the generic email address TIER4CAMHSAOT@cwp.nhs.uk Inform enquirer if beds are available or not. Document an entry on Carenotes. Inform referrer of the need for a NHS England Form 1 to be completed prior to bed being agreed. Referral Out of Hours 9pm-9am Telephone call to Coral Ward (Ancora House 0300 303 3179 )as first point of contact Establish if 1 st line Mental Health Assessment has been completed by Crisis Team Psychiatric Liaison CAMHS SPR/Consulta nt On-call If the young person Is under 16 and self-harmed provide advice on the selfharm pathway/protocol of admission to paediatric ward overnight/weekend for local Tier 3 CAMHS assessment at next available opportunity. If there are difficulties with this or the young person is being detained No Nurse-in-Charge to request that this is completed. Yes Nurse-in-charge to email the NHS England Form 1 to referrer for completion. The completed form can be returned by email or fax for Nurse-in-Charge to clinically review. If over 16 or young person is unmanageable on paediatric ward or acutely unwell/detained under the mental health act Nurse-in-Charge to triage referral re suitability for admission Protocol for Tier 4 Referral Page 6 02/03/2018
APPENDIX 3 Under 13 Referrals 24hrs For Urgent Referrals Within 48hrs during the working week. For Planned Referrals Within 2 weeks If admission is indicated admission date to be agreed. If admission is not indicated advice to be given to referrer. If no beds available locally NHSe to support sourcing a bed. Case closed. Protocol for Tier 4 Referral Page 7 02/03/2018
Patient Referral for Access Assessment Part A: ALL FIELDS TO BE COMPLETED BY CAMHS T3 CLINCIAN or ADULT CRISIS TEAM Personal Details Referral Type (please circle relevant type) Rationale for referral: (i.e. why now? What has changed?) Emergency Response in 12 hrs; assessment in 24 hrs Urgent Review and response within 48 hrs Routine Review and respond within 1 week; assessment within 4 weeks The existing clinical team will retain responsibility for patient care until an admission into CAMHS T4 takes place. Is there any restriction on sharing information? If so please give details: 1. Personal Details Full name: Address: Telephone No: Special consideration for communications: Previous surnames: NHS No: Gender Religion: Ethnicity: First language: CCG: GP name and address: Parent or guardian name: Address: Does the person above have Yes No parental responsibility? Name of person with parental responsibility: Contact telephone number: 2. Legal Status at time of Referral Is the Child: tick as appropriate Yes No Currently detained under the Mental Health Act? If yes, what section: Under Section 136 Living with parent/carer with parental responsibility Voluntarily accommodated by the Local Authority (s20) Subject to Care Order (s 31) If s20 or s31, are they placed in: tick as appropriate Foster Care Residential Care With Parents 1
Patient 2. Legal Status at time of Referral Is the Child: tick as appropriate Yes No Is the child subject of: Child in need plan Child Protection Plan Child in Care (LAC) Plan Any other legal status (Children Act; Criminal Justice)? 3. Consent Has CAMHS T3 Team received consent from the young person, their parent(s)/carer to be assessed by the Access Assessor? Consent Received By: (Print name) Date: Signature: Time: Is the young person willing to share/receive any relevant information with other professionals/agencies, such as school/social Services? Date: Time: If the child is under 16 year of age has the parent/carer consented to transfer of referral information to CAMHS or other partnership agency if assessed as more appropriate for their needs? If the young person is over 16 years of age, have they consented to transfer of referral information to CAMHS or other partnership agency if assessed as more appropriate for their needs? Yes No 4. CAMHS Tier 3 Assessment Date of Clinical Assessment: Name and job title of Referrer: Name of consultant endorsing referral: Referring Team and NHS Trust: Signature of Referrer: Time of Assessment: Contact Tel No: 5. Reason for Referral for Access Assessment Detail the rationale of why an inpatient admission is necessary and care and treatment cannot be effectively delivered in the community. If there is clinical documentation that includes all of the following information please attach, if not please complete sections below. 2
Patient 6. Presenting Problem/ Mental State Examination Current presentation: include: Duration, frequency and severity of triggers, Maintaining factors, Coping mechanisms, Current resources Date of latest MSE: Appearance and behaviour: Undertaken by: Speech: (rate; intonation; volume; pitch; use of language; disorders of speech) Mood and affect: (subjective and objective) Thought processes and content: (Formal thought disorder; delusions; preoccupations; obsessions; self-image) Perceptions: (hallucinations; derealisation/dissociation) Cognitions: (Orientation to time; place; person; age; attention; concentration) Insight: (Understanding of difficulties and motivation to change) Most Recent outcome measurements HoNOSCA CGAS SDQ Other History of presenting problem: Precipitating factors, Previous life events/trauma, History of mental health difficulties, What has been tried; what has worked/not worked 3
Patient 5. Reason for Referral for Access Assessment Aims of Admission (from the referrer): Aims of Admission (from young person) Aims of Admission (from parent/carer) 7. Risk Factors Date of recent risk assessment: Completed by: Details of recent risk assessment: (attach a copy if available) To self: Yes No Please note details below: To others: Yes No Please note details below: Self-neglect: Yes No Please note details below: Exploitation: Yes No Please note details below: Forensic History: Yes No (If ticked, please complete section 13 Part Two) Important additional Information: Drug/ Alcohol use: Yes No Please note details below: Physical Health e.g. Diabetes/ Allergies: Yes No Please note details below: Other: 4
Patient 8. Developmental History Is there a diagnosis available: (e.g. ASD or other disorder) If so, what: Yes / No Difficulties during pregnancy/birth: Key development milestones: 9. Education Current School: Previous School: Preferred Contact Person: Current School Year: Academic performance: Learning difficulties: Is there a statement of educational need? Any other agencies involved? If so, who: 10. Hobbies/Skills/Strengths 11. Family Situation Composition of household and significant adults: Family history of mental health difficulties, Physical illness: 5
Patient 11. Family Situation Current/historical bullying: History of domestic violence: Siblings DoB: School: Carer & Address: GP: 12. Safeguarding If under 16 years, is the young person sexually active? Yes No Likely to be pregnant? Yes No If yes, EDD: Midwife: Consultant: Hospital details: 13. Previous Psychiatric History Previous psychiatric history (including admissions): Details of Care Coordinator: Interventions tried so far: Input from other Health Professionals or agencies: 14. Forensic History Forensic history: Involvement with Youth Offending Team Criminal charges: 6
Patient 14. Forensic History Court orders: Court dates: 15. Drugs/Alcohol / Smoking Drugs: Past and current use (include amount; frequency; motivation to use/change; effects) Alcohol: Past and current use (include amount; frequency; motivation to use/change; effects) Smoking: Past and current use (include amount; frequency; motivation to use/change; effects) 16. Signatures Full Name (printed): Signature: Date: Email: Tel: 7
Patient IMPORTANT CONTACTS SHEET PLEASE LIST ANY CONTACTS THAT YOU FEEL SHOULD BE KEPT INFORMED OF THIS YOUNG PERSON S CASE AND INVITED TO MEETINGS SUCH AS CPAs. Primary community contact or care coordinator Nearest relative (under the MHA) if different from next of kin Psychologist Family Therapy Social work contact Community psychiatrist Dietician Other 8