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Academic Unit of Psychiatry and Behavioural Sciences, 15 Hyde Terrace, Leeds LS2 9LT
Abstract
Self-harm is a major risk factor for suicide (Gunnell & Frankel, 1994) with around a quarter of suicides preceded by non-fatal self-harm in the previous year (Owens & House, 1994). Strategies for suicide prevention should include accurate monitoring of health service contacts due to self-harm. Unfortunately, the published literature points to few practical steps for ensuring this accuracy. We offer an account of running a database, to assist others who might be setting out on this monitoring process.
Planning the data collection
Leeds is an industrial and commercial city of about 750 000 people in the north of England, served by two large teaching hospitals. In recent studies of the epidemiology of self-harm (Horrocks et al, 2002, 2003), we aimed to record details of all those who attended hospital because of non-fatal self-harm over an 18-month period, regardless of the stage at which they left the hospital.
Deciding on the point of case ascertainment
In the published epidemiology of hospital contact after self-harm, cases
have been ascertained in a variety of settings: specialist mental health
services; general hospital wards; accident and emergency attendances; or
combinations of these (Evans et
al, 1996). To determine the number of people attending
hospital because of self-harm in Leeds, we chose accident and emergency as our
point of ascertainment for two reasons. First, it has been established that
most people who present to health services after self-harm either attend
accident and emergency as their first point of contact or they are referred
there (Crawford & Wessely,
1998). Second, the evidence is clear that a high proportion of
those attending accident and emergency are discharged home directly, often
without any specialist mental health service contact
(Owens, 1990;
Kapur et al 1998).
We defined attendance at accident and emergency as an occasion when the person had stayed long enough for their details to be recorded by a clerk and for a record card to be produced.
Defining self-harm
An attendance because of self-harm was one in which the patient reported
harm of any sort as being self-inflicted, or in which a clinician deemed the
harm to be self-inflicted. The definition applied easily to many cases of
self-poisoning by ingestion and by inhalation of carbon monoxide, and to
self-injuries such as lacerations, multiple injuries from jumping,
strangulation, asphyxiation and gunshots. More difficult were
‘rescues’ from an attempt - people about to jump off a bridge or
retrieved from the middle of a busy road; we decided to classify these few
attendances as self-harm even though no physical harm had occurred. We
excluded people who attended accident and emergency simply because they
reported feeling suicidal. We included cases where people had punched walls or
deliberately put their hand through glass; these cases were recorded as
‘probable’ self-harm so that we could include or exclude them in
analyses. We included harm arising from recreational use of drugs only where
it was clear that the person had intentionally taken an excess to cause
harm.
Identifying episodes of self-harm
Clerical staff in the accident and emergency reception area record
patients’ reasons for attending and basic personal information -
obtained from each patient, or from accompanying friends or relatives or
ambulance crew. We received a printed list of relevant attendances regularly
from each accident and emergency department. The two local accident and
emergency departments used different computer systems and have different
methods of coding attending at, and discharge from, accident and emergency.
The codes that comprised our regular reports therefore differed at each site
and were approximately as follows: Hospital 1 - all reasons for attending
coded as ‘deliberate self-harm’ or ‘psychiatric’ or
‘did not wait for examinations’; or diagnosis coded as
‘poisoning/overdose’; or method of departure coded as ‘left
before treatment’. Hospital 2 - all reasons for attending coded as
‘deliberate self-harm’ or ‘psychiatric’; or booking-in
code of ‘deliberate self-harm’ or ‘overdose/poisoning’
or ‘mental illness’ or ‘behaving strangely’ or
‘appears drunk’.
Therefore at Hospital 1, we only used codes applied at entry to the accident and emergency department, whereas at Hospital 2 we used codes at entry and exit from the department. We collected these reports twice weekly at each hospital for all people aged 12 years or over, and we used them to locate each clinical case record in the accident and emergency department in order to ascertain whether the attendance was for self-harm.
Identifying individuals who attend more than once
To make the distinction between episodes and separate people, we completed
two research data sheets for every attendance. On the first sheet we recorded
patient identity information and two study numbers; one for the episode of
self-harm and the other to identify the individual person. As we added new
episodes to the database, each was checked against existing names. Using this
method we were able, from the point of first entry of data, to keep
patients’ names away from all demographic and clinical data about
episodes - stored separately in a password-protected document. We routinely
used a laptop computer for collection of data so that we could allocate
identity numbers, check accurately for previous attendances of self-harm and
anonymise data at the site and point of collection. At the end of the 18-month
study period, we again checked all names and dates of birth to ensure that
each person had only one unique identity number and that all episode identity
numbers were different so that no episode was entered twice.
Additional methods for identifying episodes of self-harm
The above method does not identify all self-harm attendances because of
inconsistent coding of episodes or diagnoses and delay in entering information
on the accident and emergency computer systems. We therefore used a number of
additional methods to identify retrospectively these ‘missed’
attendances.
First, we printed a monthly report and thereby identified attendances that did not appear on the twice weekly reports. Second, we examined at each hospital the mental health service’s records of referral from accident and emergency or in-patient wards. Telephoned referrals were recorded in a single ledger, which the researcher cross-checked once a month, returning to accident and emergency to locate the clinical record when an additional case was found. This ascertainment of otherwise missing cases was impeded in two ways: inconsistent recording of out-of-hours referrals by the mental health services; and our access only to referrals to the service for working-age adults but not those for older adults or children.
Clinical records were often missing from accident and emergency: we created a separate database for them and the researcher re-checked for missing records once a week. At the end of the study period, we carried out a laborious final check of subsequent attendances, in the hope of finding the record in question, stored alongside the person’s later records.
What happened in practice
Definition of self-harm
The researcher could not always easily determine whether an attendance was
due to self-harm. There was particular difficulty when notes were incomplete
and when recreational drugs had been taken in large amounts. On these
occasions, the researcher had to use judgement based on the amount of drugs
taken, the context of the overdose and any existing study data about that
person’s history of self-harm.
Identifying episodes of self-harm
We identified 5066 episodes of self-harm at the two accident and emergency
departments in 18 months, undertaken by 3239 people
(Horrocks et al,
2002). With an episode-to-people ratio of 1.6, identification of
reattendance is a major task, impeded by factors such as: errors in the
recording of names, addresses and dates of birth; people sharing the same
name; names changed after marriage; and the occasional use of pseudonyms. The
researchers had to develop methodical procedures for decision making. Where
there was persisting doubt about attributing new episodes to an existing
person, two of the research team made a joint decision.
Many episodes in the final list were derived not from the accident and emergency printed lists but from the additional steps outlined above. For example, at one of our hospitals 120 out of 2644 (4.5%) attendances were identified using the post-dated monthly reports, and 532 out of 2644 (20%) attendances were identified from the ledger that recorded psychiatric referrals. For a further 71 episodes (spread across the two hospitals) identified through the psychiatry ledger, we could find no corresponding record on the accident and emergency computer system for that person and date, even after trying alternative spellings and wider searches of names and dates. Some might have arisen from direct transfer of psychiatric in-patients to medical wards, but most were probably a consequence of inaccuracy in the giving or recording of biographical information.
In the end, we could not locate 440 accident and emergency case records. One hundred and twenty-eight of these were likely to have been episodes of self-harm because they were recorded as such in the psychiatric ledger, but they could not be included because we could not find demographic and clinical information. An unknown proportion of the other missing records were also likely to have represented episodes of self-harm.
Resources
We had one full-time research assistant and one part-time clerical
assistant; this was barely adequate for the task. We believe that two
full-time data collectors would be preferable for a database of this size - to
allow for analysis of data. The provision of a comprehensive protocol,
together with training at the start of the study and good supervision, should
be adequate preparation for research staff not experienced in this area of
work.
Concluding remarks
Most of the difficulties we encountered were not related directly to self-harm but were consequences of the administrative systems of large hospitals, where the volume and speed of information collection leads to inaccuracy. Our experience points to the need to incorporate cross-checking procedures. Finally, we have set out a checklist of points for consideration when establishing a clinical database of self-harm attendances to hospital (Box 1).
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References
CRAWFORD, M. & WESSELY, S. (1998) The changing epidemiology of deliberate self harm - implications for service provision. Health Trends, 30, 66 -68.
EVANS, J., JOHNSON, C., STANTON, R. et al
(1996) How to establish case registers: 2. Non-fatal deliberate
self-harm. Psychiatric Bulletin,
20, 403
-405.
GUNNELL, D. & FRANKEL, S. (1994) Prevention of
suicide: aspirations and evidence. BMJ,
308, 1227
-1233.
HORROCKS, J., HOUSE, A. & OWENS, D. (2002) Attendances in the Accident and Emergency Department Following Self-Harm: a Descriptive Study. Leeds: University of Leeds.
HORROCKS, J., PRICE, S., HOUSE, A., et al
(2003) Self-injury attendances in the accident and emergency
department: a clinical database study.British Journal of
Psychiatry, 183, 34
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KAPUR, N., HOUSE, A., CREED, F., et al (1998)
Management of deliberate self poisoning in adults in four teaching hospitals.
BMJ, 316, 831
-832.
OWENS, D. (1990) Self-harm patients not admitted to hospital. (1990) Journal of the Royal College of Physicians of London, 24, 281 -283.
OWENS, D., HOUSE, A. (1994) General hospital services for deliberate self-harm: haphazard clinical provision, little research, no central strategy. Journal of the Royal College of Physicians of London, 28, 370 -371.[Medline]
This article has been cited by other articles:
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  M. Olfson, M. J. Gameroff, S. C. Marcus, T. Greenberg, and D. Shaffer Emergency Treatment of Young People Following Deliberate Self-harm Arch Gen Psychiatry, October 1, 2005; 62(10): 1122 - 1128. [Abstract] [Full Text] [PDF]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| British Journal of Psychiatry | Advances in Psychiatric Treatment | All RCPsych Journals |
