Safeguarding vulnerable adults in the emergency department
Article Outline
Jack Troy1 has presented to the Emergency Department as a concerned neighbour has not seen him about for a few days. He has been brought to the ED by the ambulance crew although it took much persuasion by the crew to get him into the ambulance. On arrival he is undressed by the ED staff as his clothes are soiled with urine and faeces. His GCS
=15 and he wants to go home. On further examination he is found to have a Grade 4 pressure ulcer on his sacrum. The ambulance crew noted a number of empty bottles of vodka in the flat. He has also been recently visited by the District Nurse team.
Emergency nurses are in a key position to direct and respond to the abuse and neglect of vulnerable people. The abuse and neglect of vulnerable adults is a global issue and much is being done in the UK to protect this group of people. The original guidance for development and implementation of multi-agency policies to protect vulnerable adults appears as ‘No Secrets’ (Department of Health and Home Office, 2000). These guidelines are currently under review (Department of Health, 2008).
However, since the publication of ‘No Secrets’ a number of challenges have emerged. Subsequent inquires indicate that the development of policies and procedures has been uneven. Evidence from inquiries in the Cornwall Partnership NHS Trust (CSCI, 2006) and Sutton and Merton PCT (2007) and the report into the murder of Steven Hoskins (Cornwall Adult Protection Committee, 2007) demonstrated shortfalls in the operation of safeguarding policies and procedures.
The Steven Hoskins inquiry in particular noted missed protection opportunities within the ED in the events leading to Steven Hoskin’s eventual death. It also noted poor information sharing between agencies (including the ED, minor injury clinics, police and ambulance).
The assessment and stabilisation of the acutely unwell patient is always the priority for healthcare personnel in the Emergency Department. This, coupled with the need to admit or discharge 98% of patients within four hours, requires clinicians to have the appropriate knowledge and skills to address the four key elements to safeguard vulnerable adults during this time; Recognition; Safety; Evidence; Escalation.
One of the major skills acquired by all emergency clinicians is to triage patients quickly so that their need for treatment can be prioritised appropriately. Not infrequently, this initial assessment is undertaken by a member of the team who will not be managing or caring for the patient during the remaining time they spend in the department. This is the first challenge for the clinician. Initial contact with the patient and their relatives, carers or ambulance staff can often be the point at which information that raises concerns is first communicated:
The importance of an accurate handover from pre-hospital staff, which includes active listening skills on the part of the emergency clinician, can be the point at which concerns are first raised about a patient’s care. That said, it is not always appropriate to begin the somewhat lengthy process of establishing the events that led to the patient arriving in the ED but it is enough to recognise that more questions need to be explored during the patient’s time in the ED and beyond. If we return to Mr Troy1 we can all recognise the immediate problems; what we can not establish without further investigation is whether his case is a direct result of wilful neglect or abuse. This is where the skills and knowledge of risk factors relating to abuse and neglect are paramount. Shanley et al. (2008) do not explicitly state that staff put down common indicators of physical neglect or abuse e.g. poor hygiene, bruising, soiled clothing to the ‘inevitable’ consequences of health and wellbeing in later life but implicit ageism can result in poor decision-making. RECOGNITION is the first step in safeguarding the vulnerable adult.
From our experience the majority of emergency patients for whom an alert has been raised, have been admitted to hospital due to their need for more complex clinical care that can not be provided in the home or the community. Mr. Troy1 is an example of one such case. However, in conjunction with our risk management team and the development of both operational and strategic Safeguarding Committees there are regular opportunities to review all safeguarding alerts that have been raised and this feedback is used to inform practice and revise policy in terms of patient SAFETY. A very practical example is the cross-checking of patient demographics so that we are assured that those patients who are discharged back to their home or care facility do arrive safely at their point of destination.
On reflection, one of the greatest impacts in terms of facilitating the safeguarding process is preservation of EVIDENCE through accurate documentation of events. Our experience of emergency safeguarding alerts has influenced the type of documentation available as well as improving the documentation of key assessment findings. These range from photographing wounds and injuries to documenting events leading up to the ED attendance. Feedback to the staff in the ED has helped to reiterate the importance of documenting the presence or indeed absence of pressure ulcers when patients initially present to the ED. Equally, as is practiced in trauma assessment the need to document an incomplete full secondary survey due to the need to attend to life-threatening events is a lesson that could be adopted for medical presentations as well. It clarifies for all what still needs to be completed. Above all, raising an alert is just that, an opportunity to say that we need to gather more information and continue our assessment when appropriate.
In these situations, such as Mr. Troy’s1 case, the final step of the initial safeguarding process is to ESCALATE. Escalating the concern, may initially be to the Nurse in Charge of the department and the most senior clinician on shift. Local systems and policies may then dictate that another member of the hospital staff is contacted prior to raising the alert. At our hospital this escalation process is clearly outlined in our safeguarding policy however we continue to review this in light of case reviews and discussions with frontline staff. What we do know, however, is that any opportunity to limit the number of people emergency staff need to contact is critical. During the hours of 9–5 staff need only to contact the duty social worker for the hospital. This is regardless of the location of the alleged neglect or abuse. Hence, in Mr. Troy’s1 case a call to the social services department will then enable the clinical staff to continue giving the necessary care to the patient whilst the work of establishing the facts leading up to Mr. Troy’s attendance can be investigated by the social worker. However, for staff within the ED this almost invariably means maintaining a professional engagement with a vulnerable person’s care management beyond the department and on occasion after the patient’s death.
If we reflect on the case of Mr. Troy1 in conjunction with the 4 key elements discussed above we have to look at the systems and processes that sustain the ‘alert’ culture within our emergency care settings.
Part of this culture is to transform the perception that safeguarding adults is not just a social service led complaint system but an opportunity to embed safeguarding principals within emergency care.
References
- Commission for Social Care Inspection and Health Care Commission, 2006. Joint Investigation into the Provision of Services for People with Learning Disabilities at Cornwall Partnership NHS Trust.
- Cornwall Adult Protection Committee, 2007. The Murder of Steven Hoskins: A Serious Case Review.
- Department of Health and the Home Office, 2000. No Secrets: Guidance on Developing and Implementing Multi-agency Policies and Procedures to Protect Vulnerable Adults for Abuse.
- Department of Health, 2008. Safeguarding Adults: A Consultation on the Review of the ‘No Secrets’ Guidance.
- . Increasing the profile of the care of the older person in the ED: a contemporary nursing challenge. International Emergency Nursing. 2008;16:152–158
- 1 Jack Troy is a fictional account of some of the issues that have been reported in true cases.
PII: S1755-599X(09)00029-9
doi:10.1016/j.ienj.2009.04.002
© 2009 Published by Elsevier Inc.
