Risk to staff in a crisis resolution team

Crisis resolution and home treatment (CRHT) teams are now well established. There is significant evidence that they reduce bed use, are cost-effective and patients prefer them to admission. ¹

A CRHT team is dependent on the expertise and imagination of its staff to help understand and resolve a crisis. However, the risk to staff of working intensively with people who would otherwise be in hospital is not well documented. The evaluations of CRHTs have not considered the staff or the impact of frequent visits from different staff on people at high risk of acting violently. ^1,2 Risk management is a continuous task in a CRHT team. There is some concern that risks to patients may increase with the introduction of a CRHT team, although this is far from established. ³

We conducted an anonymous survey of the Hammersmith and Fulham Crisis Resolution Team in London. We asked whether they had felt physically vulnerable during community visits and encouraged them to describe any relevant incidents. Respondents included doctors, nurses, occupational therapists, support workers and bank staff. Duration of work with the team ranged from a few weeks to over 6 years. All had at least two jobs in psychiatric services before joining the crisis team and most had several years of previous mental health experience, in CRHT teams and on wards.

More than half of the respondents (13 of 20) had felt physically vulnerable while on a home visit. Their experiences ranged from feeling concerned about personal safety when with patients who were aroused or were experiencing psychosis, to being chased out of an abode when violence was threatened. No one had been physically harmed. The remaining seven people had all worked with the team for less than a year. Everyone working in the team for longer than a year reported feeling physically vulnerable during at least one visit.

We found that exposure to risk from patients was ubiquitous among all established CRHT staff in our study. It is particularly important to document risk to staff to avoid minimisation. As health services reduce costs, crisis teams will be asked to increase the threshold and reduce the duration of in-patient care further. Crisis resolution home treatment teams receive several hundred referrals a year. The short response times, high expectations and anxiety of referrers, as well as pressure to act and prevent admission all potentially reduce thinking about risk.