Adam Thornton, works as a Psychiatry Liaison Nurse in the A&E department at Homerton University Hospital. The Psychiatric Liaison Team is available 24 hours a day all year round. They undertake mental health assessments for people who present in the A&E department with mental health issues, dementia/delirium or substance misuse problems. They also support inpatients at Homerton University Hospital who have mental health issues in addition to the physical health issues which they are in hospital for.
... My day begins at 06.00 switching off my alarm as quickly as possible before it wakes anyone else. The snooze button is out of the question if I want to avoid starting my day with a telling off!
As a nurse I’m used to an early start so I spring out of bed pretty easily. This is the only time I can enjoy a quiet house so I take my time waking up and getting ready. By 07.00 I’m heading out of the door, hopefully into dry weather for the 15km cycle ride into work. I try to use my car as infrequently as I can. Riding to work, I feel physically and mentally fresh and ready to get on with whatever the day will turn up.
There’s usually an air of anticipation before shift: What happened during the night? Are there patients waiting to be seen? Who will come in during the day? Will it be busy or quiet? Who will we be working with? These are all questions that go through my mind.
Start of Shift
At 08.00, we take a handover from the night shift. Night shifts can be the busiest and most challenging times. If there are no patients waiting, there might be a chance to read and respond to emails, follow up referrals and other admin type jobs. However if anyone is waiting to be seen in A&E, we could be straight into an assessment or completing any tasks which the night shift have been unable to.
At 09.00 the whole team meets for our daily planning meeting. This is our opportunity to discuss all the patients and allocate any jobs for the day.
We have a one hour target to respond to patients in A&E and we aim to have fully assessed them and discharged them within a four hour breach period. As people are aware from media reports, there is a huge national demand on A&E departments to meet this breach time. It can often be a bit of juggling act when several patients are in the department at once.
At around 10:30 each day there is a ‘breach’ meeting to discuss with the A&E consultant any of our patients who have be in the department longer than four hours. It can feel a bit like being called to the head teacher’s office to explain ourselves sometimes. However it’s really more of a chance to understand better the way the department is operating than a telling off!
By this time, it’s likely we’ve had at least one patient present to A&E. We frequently see people who feel suicidal or may have attempted taking their own life or self-harmed. We see people relapsing psychotic illnesses, depression and anxiety or maybe people presenting to mental health services for the very first time which can be quite sensitive. As there is no entrance requirement for A&E and people’s perceptions of what constitutes a mental health emergency or crisis can vary, we can end up seeing people with all sorts of problems.
Since qualifying as an RMN I’ve worked across a range of different services including psychiatric inpatient wards and community teams. I started working in this team in Spring this year so I’m the newest addition to the team. I was attracted to this job for various reasons. I enjoy the challenge and stimulus of working under pressure and am able to remain calm in quickly changing circumstances so am well suited to the A&E aspect of the role. I also find the management of mental health problems alongside physical health problems within an acute hospital particularly within the older population fascinating - with an infinitely broad scope for learning. I’ve previously worked in two other neighbouring mental health trusts and can honestly say my only regret about coming to ELFT is that I didn’t do it years ago! I have really enjoyed working here so far, am part of a really good team and feel like a valued member of staff.
Trying to Understand the Full Picture
Ward patients are admitted with physical health problems initially but it may become apparent that they have mental health problems too. They may be previously known or under the care of a community mental health team before being admitted. We also support patients transferred from the psychiatric wards who have become physically unwell. There are usually a high proportion of older adults in the wards so we have two consultants one for older adults and one for working age adults. Meanwhile in A&E there could be a range of different situations to deal with. Part of the role of a liaison nurse is liaising with other services and hospitals. Residents of Hackney can present in A&E departments in other parts of London or the country. Or we may be seeking background information about a current patient in A&E.
We don’t have a designated lunch time so most of us will take the opportunity to get something to eat whenever it presents. Generally I try to get at least 20 minutes away from the desk even if it means just taking a walk round the block.
By the afternoon, A&E generally begins to get busy. Patients can come in at any time specifically to see us or might be brought in by the ambulance service for various other reasons, and have a mental health disorder too.
Careful Assessment and Decision-making
During the assessment, we will need to find out about the presenting complaints including the person’s mental state and any symptoms of mental illness. We are interested in knowing the duration of these issues, onset, triggers, precipitating factors and impact they’re having.
Assessing risk is another big feature and co-producing safe follow up plans with the patient is a priority. For example, ensuring that someone experiencing suicidal ideation (thinking about killing themselves) is discharged to a safe environment where they are adequately and safely supported with measures in place if their situation deteriorates.
The assessment carries with it huge responsibility as decisions made and care planned could have vast influence over the outcome for the patient.
We have a range of resources available to utilise for follow up. This could range from formal admission under the mental health act at one end of the scale to signposting individuals to other sources of support that can help them. We can refer individuals to the Home Treatment team if we think they need a high level of support but are safe to be supported at home.
One of the things which appeals to me about working in Hackney is the range of community services available. We are also increasingly reliant on third sector services and often encourage people to seek out help from as wide a range of sources as possible.
At 17.00, our medical team finish for the day and the duty senior doctor will take over until 21.00. This is often our busiest period and there is always pressure to finish off the day’s work before we leave and to try and let the night staff arrive to an empty waiting room.
At 20.00 the night staff arrive. It is unlikely they will see any patients in the wards but there is usually a constant stream of patients presenting to A&E throughout the night. We also cover the 24hr crisis line during the night, offering telephone support for people in crisis at home.
My working day finishes with the ride home, which is usually a bit of a race to relieve my wife from the kids for an hour or two before bed, so she can get to the pool for a swim. By the time I’m back, the cycle through the evening traffic has flushed away any thoughts or reflections on the day. I try to get a good hour or two to focus on my 3 and 7 year old children. This usually involves a finishing off some homework, reading some stories or maybe a dvd. By the time all that is out of the way, I’m basically finished for the day myself and turn in as soon as the kids are asleep, despite plans to sit up sipping wine and watching fascinating stuff on Netflix.
Maybe I’ll get to do that on a day off one day.