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Sister, Accident and Emergency/Crisis Response Triage Worker, Dorset County Hospital, Dorchester, Dorset DT1 2JY, email: leah.hughes{at}wdgh.nhs.uk
Consultant Psychiatrist and Clinical Director of Dorset Primary Care Trust, Dorset County Hospital, Dorchester
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Abstract |
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 Top Abstract IntroductionMethodResultsDiscussionReferences |
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RESULTS The service provided by the A&E department was sub-standard. Of particular concern was the lack of processes addressing risk assessment and safe discharge. A pro forma was designed with the aim of improving assessment of self-harm. A repeat audit 3 months after introduction of the pro forma showed an improvement in the recording of relevant information underpinning risk assessment.
CLINICAL IMPLICATIONS Procedures for those presenting to A&E departments with self-harm may not meet recommended guidelines. The use of a pro forma with staff training can improve risk assessment.
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Introduction |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Self-harm is an umbrella term for causing harm to oneself. Allen (1995) explores the difficulty with definition of this term, and describes a very wide range of methods that people use to hurt themselves, including scratching, cutting, stabbing, scalding, burning themselves or overdose of prescribed medication. The self-harm may or may not have suicidal intent.
Dealing with self-harm has been a national priority for some time (Department of Health, 1992, 2002). Those who harm themselves remain at a substantially increased level of completed suicide for some time after the episode of self-harm (Eastwick & Grant, 2004). Self-harm accounts for 150 000 attendances at general hospitals each year, and is one of the top five causes of acute medical admissions in the UK (Royal College of Psychiatrists, 2006; http://www.rcpsych.ac.uk/crtu/centreforqualityimprovement/self-harmproject.aspx).
The National Service Framework for Mental Health (Department of Health, 1999) emphasised the need for a specialist psychosocial assessment following self-harm. The Royal College of Psychiatrists' view (2004) is that this can be done by trained A&E personnel and doctors working in the A&E department, although this has been debated by other authors (Hughes & Owens, 1996; Cook, 1998).
The National Institute for Health and Clinical Excellence (2004) published guidelines on self-harm, which give recommendations to improve care for people who self-harm to all professionals involved in their care. Among other standards, this report gives service standards for A&E departments.
Simpson (2006) concludes that the NICE (2004) recommended that self-harm services needed to be reviewed as a matter or urgency, but Simpson considers that this is difficult to do inside an organisation where the term self-harm itself presents ambiguity; continuing that many of the recommendations made had to be differentiated between people that had presented with self-harm and those applicable to individuals that had attempted self-poisoning. Also difficulties arise where there exists prejudice from nurses towards people who self-harm. Owens (2006) also argues about the accuracy of psychosocial assessments and risk assessments in the A&E department and details the flaws in trying to meet the guidelines.
Lyons et al (2000) report that suicide risk assessment is an important part of the nurse's role and should be systematic. Some identified risk factors in suicide include being unmarried, being unemployed, living alone, poor physical health/chronic pain, previous self-harming behaviour, loss events (health, person, cherished idea, material possession), mental illness, substance use and suicidal behaviour in first-degree relatives (Cheng et al, 2000).
The problems in developing tools to support clinical decision-making after a person has self-harmed are the subject of a recent paper from the Manchester group (Cooper et al, 2006), and Lyons et al (2000) write that a one-off scoring system does not reflect the dynamic nature of suicidal behaviour.
Barr et al (2004) suggest that there is evidence that people presenting with self-harm are considerably likely to self-discharge or abscond. Pennycook et al (1992) report that 4% of all patients attending an A&E department self-discharged, with the most common medical diagnosis being self-poisoning.
This paper uses the results of a broad clinical audit to consider how well patients with self-harm presenting to the A&E department were managed. A pro forma to improve standards was designed and a repeat audit carried out to investigate the outcomes.
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Method |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Initial audit
There were 380 patients with self-harm that attended the A&E department
from May 2004 to November 2004. At random L.H. extracted the data from 103
A&E notes from this population. The audit examined patients' notes with a
clinical coding of ‘DSH’, ‘deliberate self-harm’,
‘overdose’, ‘self-poisoning’ and ‘accidental
overdose’, as well as ‘depressed’. Any notes with
‘accidental overdose’ were dismissed. The standards used were
derived from those in the NICE guidance (2004), and included the documentation
of capacity, willingness to stay for treatment, circumstances of self-harm,
mood, presence or absence of apparent mental disorder, and use of a formal
risk assessment (i.e. the use of a structured tool or the clear identification
of key risk factors).
As a result of this first audit, a pro forma was designed (see data supplement to online version of this paper) and included an adapted version of the Australian mental health triage process, as indicated in the NICE (2004) guidelines. There was broad local discussion to promote ownership of this new tool, with comments sought from A&E doctors and nurses and mental health services. The risk assessment process chosen for the pro forma was that used by the local intensive psychiatric care unit. Although there is no research evidence base for its use, this was felt to promote local consistency, and the process appears to have high face validity. A system was also developed whereby the pro forma was printed automatically with casualty notes that had an initial clinical coding of ‘overdose’, ‘deliberate self-harm’ or ‘self-poisoning’.
All staff working in the A&E department received a written training package, including a presentation on basic mental health assessment, psychiatric terminology and some information on capacity to consent, prior to the pro forma being introduced.
The pro forma was initially trialed over a 3-month period, then a repeat audit was carried out on 100 consecutive people attending with self-harm. The staff completing the pro forma did not know that an audit was being carried out.
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Results |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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Table 2 shows some of the parameters of care. Most patients were seen quickly (84% within 30 min). The most common initial disposal was assessment by psychiatric services (40%), with 21% being admitted to a medical or surgical ward. However, 16% were sent home without specialist assessment and 13% self-discharged before being assessed.
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Repeat audit
Table 3 gives results before
and after the introduction of the pro forma.
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Discussion |
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The pro forma that was subsequently designed allows A&E clinicians to make informed choices about appropriate treatment by helping them to discriminate between patients at higher and lower risks. Cooper et al (2006) have shown that a simple screening tool can work in an A&E department to highlight those patients at high risk and in need of a more specialist assessment by a trained mental health professional. They also report that the assessment is for short-term risk only.
The value of this new approach helped to challenge attitudes and cemented engagement. Nurses' attitudes can stand in the way of following the NICE guidelines (Simpson, 2006). McCann et al (2006) agree that A&E nurses frequently have negative attitudes and lack appropriate assessment and interpersonal skills to care for individuals who self-harm.
The results of the secondary audit suggest that the introduction of the self-harm pro forma improved the frequency of formal risk assessment and the documentation of important risk factors. It appears to be associated with a reduction in the frequency of patients discharging themselves before assessment and an increase in the number having specialist psychosocial assessment. Clinical implications are that the introduction of a relatively simple tool and consequent change in clinical process following work designed to improve local ownership can lead to an apparent improvement in clinical care for patients.
Limitations
Audit of this nature is subject to criticism. It is unclear whether the 103
patients seen before the introduction of the pro forma were representative of
the population attending the emergency department at that time, although it is
likely that this was the case. In addition, populations studied before and
after the introduction of the pro forma were not matched. However, the project
time frame was fairly tight at 6 months and staff turnover during that period
was minimal. One person completed data extraction using a consistent tool. It
is of course possible that the training and greater exposure of staff to
issues surrounding self-harm following the audit also improved practice on the
parameters assessed, however we would argue that this is still desirable.
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References |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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BARR, W., LEITNER, M. & THOMAS, J. (2004) Self-harm patients who take early discharge from the accident and emergency department: how do they differ from those who stay? Accident and Emergency Nursing, 12, 108 -113.[CrossRef][Medline]
CHENG, A. T. A., CHEN, T. H. H., CHEN, C., et al
(2000) Psychosocial and psychiatric risk factors for suicide:
case-control psychological autopsy study. British Journal of
Psychiatry, 177, 360
-365.
COOK, A. (1998) Assessing deliberate self harm, a team approach. Emergency Nurse, 6, 21-24.[Medline]
COOPER, J., KAPUR, N., DUNNING, J., et al (2006) A clinical tool for assessing risk after self-harm. Annals of Emergency Care, 48, 459 -466.
DEPARTMENT OF HEALTH (1992) The Health of the Nation. TSO (The Stationery Office).
DEPARTMENT OF HEALTH (1999) National Service Framework for Mental Health. Department of Health.
DEPARTMENT OF HEALTH (2002) National Suicide Prevention Strategy for England. Department of Health.
EASTWICK, Z. & GRANT, A. (2004) Emotional rescue: deliberate self-harmers and A&E departments. Mental Health Practice, 7, 12 -16.
HUGHES, T. & OWENS, D. (1996) Management of suicidal risk. British Journal of Hospital Medicine, 56, 151 -154.[Medline]
LYONS, C., PRICE, P., EMBLING, S., et al (2000) Suicide risk assessment: a review of procedures. Accident and Emergency Nursing, 8, 178-186.[CrossRef][Medline]
McCANN, T., CLARK, E., McCONNACHIE, S., et al (2006) Accident and emergency nurses' attitudes towards patients who self-harm. Accident and Emergency Nursing, 14, 4-10.[CrossRef][Medline]
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (2004) Self-Harm. The Short-term Physical Management and Secondary Prevention of Self-Harm in Primary and Secondary Care. NICE.
OWENS, D. (2006) Services for assessment and aftercare following self-harm. Psychiatry, 5, 271-274.[CrossRef]
PENNYCOOK, A., McNAUGHTON, G. & HOGG, F. (1992) Irregular discharge against medical advice from the accident and emergency department - a cause for concern. Archives of Emergency Medicine, 9, 230 -238.[Medline]
ROYAL COLLEGE OF PSYCHIATRISTS & BRITISH ASSOCIATION FOR ACCIDENT AND EMERGENCY MEDICINE (2004) Psychiatric Services to Accident and Emergency Departments (Council Report CR118). Royal College of Psychiatrists & British Association for Accident and Emergency Medicine.
SIMPSON, A. (2006) Can mainstream health services provide a meaningful care for people who self-harm? A critical reflection. Journal of Psychiatric and Mental Health Nursing, 13, 429 -436.[CrossRef][Medline]
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