An examination of the accident and emergency management of deliberate self harm.

Abstract

Objective-To examine the adequacy of assessment and management ofdeliberate self harm (DSH) undertaken by accident and emergency (A&E) medical staff. Methods-The records for attendances to the Leicester Royal Infirmary A&E department with a diagnosis of "self inflicted" injury for the 12 month period April 1994 to March 1995 were scrutinised. If the episode was identified as DSH, then assessment and management were examined, using an instrument based on the Royal College of Psychiatrists' standards of service for the general hospital management of adult DSH. Results-There were 934 episodes of DSH involving 854 patients. The mean age was 32 (SD 14.2), with an even sex distribution. Overdose was by far the most common method of DSH (91.5%). Information concerning suicide intent was documented in 70% of cases, and psychiatric history in 67%. Less information was recorded for medical history (50%), mental state (51%), recent stress (55%), or previous DSH (47%), and only 23% had an assessment of risk of further DSH. Very little was recorded concerning alcohol or substance misuse. In 291 cases (31%), the patient was discharged directly home by A&E medical staff, and 50 of these were referred for psychiatric outpatient follow up; 210 (23%) were referred for specialist assessment in the department and 423 (45.5%) were admitted to medical/surgical wards. The frequency with which information was recorded varied significantly between outcome groups. At night A&E staff were far more likely to discharge a patient home themselves than refer for specialist assessment (P << 0.001). Conclusions-With over half the sample not admitted, the responsibility for the initial risk assessment lies with A&E medical staff. The study reveals a need for improved planning and delivery of services. The A&E department of the Leicester Royal Infirmary has a catchment area of 0.9 million persons, and a multidisciplinary specialist service for the assessment of those presenting with DSH. This service, comprising of psychiatric nurse specialists and a social worker, is however restricted to weekdays between the hours of 9 am and 5 pm, and is dependent on A&E or ward staff to perform the initial screen and instigate referral.Our principal objective was to examine the adequacy of the management of DSH in the A&E department by comparing with an "ideal" standard.4 In addition to examining the management of 934 consecutive attenders to the Leicester Royal Infirmary with a diagnosis of DSH, we also surveyed A&E staff concerning their knowledge, confidence, attitudes, and postgraduate training in the psychosocial assessment of this behaviour. MethodsAll attendances at the Leicester Royal Infirmary A&E department with a discharge diagnosis of "self inflicted injury" for the 12 month period April 1994 to March 1995 were retrospectively identified from the PAS (patient activity analysis) system. The year chosen for the project spanned three rotations of junior medical staff. A&E records were located for 1592 of 1702 episodes of "self inflicted injury...

Assessment and management of self‐harm in older adults attending accident and emergency: a comparative cross‐sectional study

“…Our finding that older patients were significantly more likely to be admitted to a general hospital ward concurs with that from the city of Leicester (Dennis et al, 1997). Published research shows that there is also great variation around the UK in the arrangements for specialist psychosocial assessment after self-harm.…”

Utilization of the emergency department after self‐inflicted injury

“…30 With respect to treatment options for these patients, many possible options (e.g., medications, therapy and counseling, and addiction treatment) are available to emergency physicians; however, limited evidence exists to direct the clinician. Systematic reviews have shown that antidepressants have little effect on reducing the rate of suicidal behavior among those with previous selfinjuries.…”

Deliberate self-poisoning in an Irish county hospital

“…Deliberate selfharm is now a major health issue throughout Europe, particularly the UK, 23 Following a decline in rates during the late 1970s and early 1980s, the Oxford study noted rates rising again in the late 19805.24 From 1985 to 1996, there was a 5% increase per annum in the number of overdoses in the UK, mostly among young males," correlating with an increase in completed suicide 2 " 9 especially amongst young men. 8 " 6 When suicide is attempted 90% choose overdose, 25 typically with more than one drug. Alcohol and alcoholism play a role in attempted suicide ' 29 parasuicide repetition3° and completed suicide."…”