Frequently Asked Questions
Assured is an NIHR-funded research programme in over 10 hospitals across the UK led by Professor Rose McCabe from City, University of London. ASSURED aims to improve patients’ experience and reduce repeat attendance for self-harm in the Emergency Department over 18 months. We are conducting a randomised controlled trial will compare usual practice with the Assured intervention. Practitioners will be randomly allocated to deliver treatment as usual or the Assured approach.
The Assured intervention consists of:
- 4 follow-up contacts over eight weeks
- 3 letters over 9 months.
(further detail in ‘What will it involve’ section at bottom of page)
Potential benefits to you individually and as a team
What are the benefits of using the Assured approach for you?
You may find conducting follow up sessions enjoyable using the Assured approach and get clinical satisfaction from it. We hope you will be able to use new skills that will be helpful without being a stretch from what you are already doing.
What are the benefits of patient follow-up appointments for you?
Follow-up appointments can offer you something more predictable and a different aspect to your work. It can potentially help with burnout by
- enabling you to do therapeutic work with people using your new skills
- giving you more clinical autonomy
- the opportunity to work with your patients by offering them something that you wouldn’t normally be able to. This can be helpful if they are on a waiting list for services or if they don’t need an admission or referral but could still benefit from some intervention.
Will the Assured approach reduce reattendance for self-harm?
We are doing the trial for a definitive answer to this question. However, preliminary evidence is promising. Two established follow-up clinics found:
- 73% of people seen in a follow-up clinic at the Royal London did not attend in the subsequent 6-month period (Royal London Hospital)
- All individuals who attend follow-up clinic in another UK hospital showed a reduction in the number of presentations to the emergency department following self-harm in the six months following the intervention, compared to the six months before the intervention. They reduced their attendances from 3.5 attendances in the 6 months before to 0.75 in the 6 months after the follow-up clinic (Brand, 2015)
How does the Assured study fit with usual care?
Will the patient’s involvement in the study affect access to/ use of services?
Think of the intervention as “running alongside other service input”. An entry on electronic patient records (RiO, SystemOne, etc.) with the statement:
XX is participating in a study called Assured, which is in addition to NOT instead of usual care. Each brief follow-up contact with ED liaison staff will be conducted alongside current or future care for the patient. Participation in this study should not affect the patient‘s usual care including referrals or access to services.
Every follow-up contact will be documented on electronic patient records with the heading:
ASSURED RESEARCH STUDY FOLLOW-UP CONTACT. Participation should not affect access to current or future care.
Researchers will also send a letter to the GP informing them about the person’s participation in the research study which should not affect access or support from services.
If services are offering intensive support and don’t allow any other psychological input, e.g. DBT, it would be assessed on a case-by-case basis whether or not the follow-ups should go ahead.
What happens if the person is in crisis during the follow-up session?
Usual procedure should be followed depending on the severity of the crisis, e.g. Crisis Team, Crisis Café, ED, care-coordinator. This should not exclude the patient from continuing follow-up sessions with the original practitioner. The case will be discussed with your clinical team and research team.
What if the person re-presents to the ED?
Usual procedures should be followed, the person would be assessed by the practitioner on duty.
Patients will receive a psychosocial assessment as per NICE guidelines.
Shift patterns/ Time constraints & Protected Time
It will be difficult to stick to the follow-up time points with changing shift patterns. Do we have to conduct the follow-up appointments exactly within 1, 2, 4, 8 weeks after the patient has consented to participate?
There is some flexibility in the timings of the follow-up appointments. It is good to have an idea of your shifts for the 1-week follow-up. The patient should be informed of any changes to appointments. Practitioners should book patients in to see them at a mutually convenient time.
Researchers at each site will provide administrative support to arrange and remind the patient of follow-up appointments.
Will we have protected time for the follow-up sessions?
Yes, your trust will receive ‘Excess Treatment Costs’ to cover extra time spent delivering the intervention. Some trusts find the best way to do this is a follow-up/callback clinic so that practitioners are not on duty in the ED for the duration of the clinic. Half a working day should cover four follow-up slots and ‘Excess Treatment Costs’ could be used to arrange for bank staff cover in order to allow time for study practitioners to conduct the follow up sessions. It may be useful to combine the clinic with a paperwork/admin day for the practitioner.
There is also the option to use ‘Excess Treatment Costs’ to be paid as overtime for trial practitioners where this is suitable.
What if the person misses a session (DNA)?
Contact the person to rearrange the session. If you are unable to rearrange the session, the missed session will count towards the three appointments and will not be replaced.
Is this intervention only for low-risk patients/ first-time presenters?
No. Any individual meeting the inclusion criteria presenting to the ED is eligible. Risk level is not an exclusion criterion.
We are interested to see how and whether the intervention would work for different presentations (people who self-harm and attend ED regularly, people who present for the first time).
What if the patient requires admission?
Short admission: If the patient is admitted for short-term crisis admission, the person will can be contacted after they are discharged for their follow-up sessions.
Long-term admission: Wherever possible, the patient should still be offered the follow ups although this may not be possible, in which case the patient would need to be withdrawn from the intervention. This will be assessed on a case-by-case basis.
Experience from previous pilot study: Practitioners from the previous pilot study have carried out the intervention with patients who were admitted for short-term crisis admission. The follow-up sessions continued after the patient was discharged from crisis admission.
What counts as ‘intensive psychological input’?
If a person is receiving intensive psychological input it would be assessed on a case-by-case basis whether or not it is appropriate for the follow-ups to go ahead. We define ‘intensive’ as: at least one-hour individual sessions with a psychologist/ therapist/ counsellor per week. However, if patients are on a waiting list, they are eligible.
What if the patient requires input from drug/alcohol services?
Input from drug and alcohol services is NOT an exclusion criterion. Patients should still be included and followed-up. If patients don’t have capacity to provide informed consent (e.g. intoxicated), they are not eligible to participate at that time.