Optimising Decision-Making in Child and Adolescent Mental Health Crisis Calls: A Quality Improvement Initiative for Clinicians
T. Mehdi, E. Perrin, A. Caston, A. DaudIntroduction
England’s National Health Service (NHS) Long Term Plan (2019) mandated 24/7, open-access mental health crisis care via NHS 111, with COVID-19 accelerating delivery; by August 2024, NHS 111 provided nationwide, round-the-clock access linking children and young people (CYP) to local crisis teams. Berkshire Healthcare NHS Foundation Trust (BHFT) established a 24-hour Child and Adolescent Mental Health (CAMH) Services crisis line; however, clinicians receiving unplanned calls lacked a structured approach to call management, and internal reviews suggested that around 50% of decisions were inappropriate, highlighting the need for improvement.
Objectives
This Quality Improvement (QI) project aimed to embed a standardised, evidence-informed process for decision-making during and after child and adolescent mental health crisis calls. It sought to provide clinicians with a structured information-gathering framework that preserves therapeutic engagement, strengthen confidence and consistency when agreeing next steps and safety/support plans with young people and families and optimise team resources. The primary aim was to increase the proportion of appropriate decisions to at least 80%.
Methods
We used a QI approach with Plan–Do–Study–Act (PDSA) cycles in the Berkshire Healthcare NHS Foundation Trust CAMH crisis service. Two panels of 3–4 crisis clinicians, each moderated by a senior specialist, reviewed notes from 22 consecutive crisis calls over two months; 50% of call outcomes were judged inappropriate. Root cause analysis identified insufficient information gathering and the absence of a clear call structure as the predominant contributors. Achievable countermeasures were co-designed and implemented, which included the development of a crisis call triage guide; followed by a repeat review of 22 crisis calls over a subsequent two-month period to assess impact.
Results
After implementation, 21/22 crisis-call outcomes (95%) were rated appropriate, up from 50% at baseline. Clinicians reported the guide was universally helpful, increased confidence, clarified outcome pathways, and enabled timely escalation to senior clinicians when uncertain. Decision-making shifted from risk-centric assessments to a formulation- and needs-led approach.