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Developing an algorithmic mode of self harm management in enhanced medium secure services for women Dr. Chris Beeley

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Presentation on theme: "Developing an algorithmic mode of self harm management in enhanced medium secure services for women Dr. Chris Beeley"— Presentation transcript:

1 Developing an algorithmic mode of self harm management in enhanced medium secure services for women Dr. Chris Beeley chris.beeley@nottshc.nhs.ukchris.beeley@nottshc.nhs.uk Co- author Dr. Jay Sarkar

2 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

3 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

4 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

5 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

6 Lethality Lethality of the self-injuryTypes of self-injury (‘Act’) Traditional methods of suicideHanging, strangulation, shooting, jumping gas, drugs, pesticides), stabbing, electrocution, drowning from a high place, poisoning Highly lethalOverdose, recreational drug-OD as self- harm, cutting, burning Self-injury with tissue damageSelf-biting, scratching, gouging, carving words of symbols on skin, sticking needles or pins into skin, interfering with wound healing Less lethalSelf-hitting, head-banging, fist against hard objects, pinching, pulling hair Self-injury with no tissue damageOver-exercising, denying a necessity to hurt oneself, stopping medications, starving with intent to cause harm, tattoos, multiple body piercing Non-lethalDeliberate recklessness with cars, drugs, trains, etc.

7 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

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10 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

11 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

12 Response r=.79

13 Observation/ support (inimicality) r=.75

14 Intervention/ wound care r=.69

15 Overall effectiveness

16 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

17 Swallowing Assess –Physical obs, pain, breathing, vomiting –Type of battery Levels –Low Observation only –Medium A and E (medics’ judgement) –High 999

18 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

19 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

20 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)

21 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

22 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

23 Developing an algorithmic mode of self harm management in enhanced medium secure services for women Dr. Chris Beeley chris.beeley@nottshc.nhs.ukchris.beeley@nottshc.nhs.uk Co- author Dr. Jay Sarkar


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