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North Wales Section of Psychological Medicine, University of Wales Academic Unit, Technology Park, Wrexham, Wales LL13 7YP, e-mail: peter.lepping{at}new-tr.wales.nhs.uk
Arrowe Park Hospital, Wirral
Wrexham Maelor Hospital
North East Wales NHS Trust, Wrexham
None. Funding detailed in Acknowledgements.
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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To audit whether the introduction of a self-harm pathway and protocol increases the number of psychosocial assessments. All episodes of self-harm in a defined period during 2002 (n=335) and 2004 (n=390) were reviewed before and after the introduction of a self-harm pathway and protocol. Adherence to the protocol was also investigated.
RESULTS
After the introduction of the self-harm pathway and protocol, the proportion of psychosocial assessments requested had risen from 57% (2002) to 85% (2004). The proportion of psychosocial assessments completed had risen from 47% to 70%. Over the 2 years, the overall number of self-harm presentations was reduced by 27%.
CLINICAL IMPLICATIONS
The introduction of a self-harm pathway and protocol through a self-harm steering group is feasible, was well accepted and increased the number of psychosocial assessments after self-harm. It may also contribute to a reduction in the number of overall presentations with self-harm to the accident and emergency department.
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Introduction |
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The National Standard Framework for Mental Health Service (standard seven) states the aim of reducing suicide rates by 20% by the year 2010 (Department of Health, 1999). A functioning self-harm service planning group, and the provision of a psychosocial assessment after self-harm, are part of the recommended strategy to manage self-harm in the UK (Royal College of Psychiatrists, 1994, 2004; Lepping, 2004). The existing literature supports the idea that relatively minor service changes, especially checklists, can significantly improve delivery and the recorded standard of care (Dennis et al, 2001). Furthermore, it was recently shown that psychosocial assessment reduces the repetition rates of self-harm by up to 50% (Kapur et al, 2002) but the provision of psychosocial assessment in many hospitals remains poor (Kapur et al, 1998, 1999). These observations are supported by further studies showing those who leave the A&E department after self-harm without an assessment are at greater risk of repetition of self-harm (Hickey et al, 2001). It seems desirable, therefore, to ensure the optimal use of these assessments in A&E settings. To address this issue, we examined whether a self-harm pathway, developed by a local self-harm service planning group, could increase the number of psychosocial assessments.
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Method |
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Accident and emergency triage nurses initially assessed patients to ascertain their willingness to wait for psychosocial assessment. This first appraisal was followed by an extended risk assessment using questions designed to measure immediate risk and whether the patient was known to mental health services. It was agreed that an A&E doctor would complete a medical examination and be responsible for completing an immediate risk assessment. Following any necessary physical treatment, the liaison psychiatry team would perform a specialist psychosocial assessment. A discharge summary page would be completed by A&E or ward staff and faxed to the general practitioner (GP) and community mental health team where appropriate. The format for the pathway was similar to that of other pathways currently in use in the hospital and it was hoped this familiarity would further increase acceptance among staff.
Once the format for the pathway was agreed, consideration was given to potential problems, such as patients absconding or refusing assessment. In such cases telephone helpline numbers would be provided to the patient and the GP would be informed by faxing a copy of the pathway to the surgery. Consideration was also given to patients who required time to recover from overdose as well as any co-ingestants such as alcohol. It was agreed that patients who were not admitted to a medical or surgical ward would be allowed to recover in the observation ward adjoining the A&E department.
In order to promote and facilitate the use of the pathway, training needs were identified and a programme of training formulated. Accident and emergency doctors received training as part of their teaching programme and it was agreed this would continue with the liaison psychiatry team providing training. To raise awareness of the policy and pathway, all hospital staff were invited to a high profile launch day. The pathway was introduced in June 2003. Over a 3-month period from June to August 2004 we again examined all self-harm presentations to Arrowe Park Hospital using the same procedures as in 2002. Collected data included age, gender, day of admission, time of admission, type of self-harm, evidence of psychosocial assessments being requested, whether undertaken, and by whom, as well as the outcome of the assessments, including admission to other hospital units. We asked for a previous history of self-harm, whether patients were currently in receipt of mental health services and who provided follow-up. In 2002, data from all age-groups were recorded but data for those under 16 were later removed from the analysis. In 2004, only data from patients who were 16 years or older on the day of presentation were examined.
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Results |
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Reasons why psychosocial assessments were not requested included patients leaving the department before seeing a doctor, refusing an assessment, self-discharging, or not being medically fit. All these reasons were rare; only 17 patients in 2002 and 25 patients in 2004 left the department or self-discharged before being seen for a psychosocial assessment. Only eight patients in 2002 and nine patients in 2004 refused a psychosocial assessment; the vast majority were willing to stay for assessment. In 2 years, the overall number of self-harm presentations decreased from 355 to 261, with the months of June and July alone showing a reduction of 27% (Table 1). The reference group for 2002 excluded all episodes of pure alcohol or illegal drug self-harm.
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The proportion of assessments performed within 24 h rose sharply, and most patients were seen by a mental health liaison nurse or a psychiatric senior house officer in 2004 (92% v. 59% in 2002). In 2002, 23 patients left or discharged themselves before they were seen for a psychosocial assessment but after it had been requested. Only one refused assessment after agreeing to a request. In 2004, 35 left before the assessment was performed, 3 refused and 6 were not medically fit even 24 h after they first presented. The remaining patients had other explanations for non-attendance. In 2004, 77% of patients who presented were admitted. Psychiatric admissions were rare. In 2004, the proportion of patients with a history of self-harm had decreased by 10% (Table 1).
In December 2003, we audited how well our self-harm pathways were being followed. We applied very strict criteria for completion of forms and found that at triage 81% of all forms were fully completed with 6% mostly completed; 71% of all forms for psychosocial assessment were fully completed and 10% mostly completed (Table 2). This suggests that the pathway was very well accepted overall.
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Discussion |
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After the introduction of the pathway the number of people presenting to the A&E department with self-harm was considerably reduced (27%), coinciding with a 10% reduction of people presenting with a history of self-harm. This reduction cannot be explained by a national trend or by any other specific hospital intervention. It is unfortunate that this audit could not collect the necessary data that would show an association between reduced presentation with self-harm and the introduction of the pathway. More studies are needed to examine whether such a link exists.
Although we have robust data regarding the increase of psychosocial assessments there remain patients who do not receive such assessments despite local efforts. It is still unclear what intervention would most benefit this group. Furthermore, our data do not allow individuals to be followed up over 2 years and the overall reduction of self-harm presentations needs further research.
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Acknowledgments |
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References |
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