ED RE-PRESENTATIONS FOLLOWING INTENTIONAL SELF-HARM

Silke Kuehl

Dr Kathy Nelson

Overview Literature Aims & Objectives Methodology Findings Recommendations Conclusion

The Literature Statistics

Risk factors

The young, the old and men

Views…ED staff, patients

Overcrowding

Help from IT expert

Approximately 45,000 ED presentations in 2006

• 1865 people – 1 x ISH • 120 people – 393 presentations• Nearly half 58 re-presented w/in

1/52

Aims & Objectives

Describe factors contributing to people re-presenting

Objectives: Describe demographic and clinical

features Describe and evaluate ED management Identify personal or system reasons

Intentional Self-harm

Definition:

Attempted suicide Suicidal ideation Deliberate self-

harm

Methodology Descriptive research Retrospective review Data extraction tool Variables:

Person Presentation

Inclusion/exclusion

Sent Ethics proposal

After Ethics

Retrieved data Log book Sample:

48 people 73 re-presentations

Analysis: SPSS

Findings

Coding Documentation/Assessments Cultural input Physical/mental health Support people Challenging behaviours Time to re-presentation

Coding

Patients are coded by their presenting complaint, irrespective of the intent

Identifying this population difficult

Previously identified 120 people presented 852 times

Type of ISH

Overdose Burn Laceration Gassing Attempted hanging Ingestion/insertion foreign body Head injury Stabbing self Traffic Jumping from a height

Documentation/Assessment

Location of person often briefly described

Poor documentation of risk assessments

Inadequate triage assessment Patient discharged without ED staff

being aware

Documentation/Assessment

Scenario: Person Y presented to ED with thoughts of killing his neighbour and suicidal thoughts. Y was assessed by the MH team and sent home. He arrived back in ED two days later. The triage nurse’s documentation is ‘Expected by CATT. Appears calm’ and allocated a code 4. CATT was delayed for three hours.

Cultural Input

Maori presented 23% of sample (approx 14.3 % in population)

Nil input of Maori services

Increased risk of suicide if not connected to culture (Coupe, 2002)

Physical/mental health

Scenario: Person X presents with a deep laceration to the hand. It requires plastic surgery. He states he works in a professional occupation and got his hand caught in a grinder by accident. Person X states that he has no past medical history. Previous admission notes showed that he had attended two days previously distressed and suicidal.

Physical/mental health

Ambulatory Care service – ‘quick’

Nil checking of previous presentations

Nil highlighting on the IT system

Support people1st Presentation

2nd Presentation

Family/Whānau/ friends

33 (45%) 24 (32%)

Health Worker

10 (14%) 13 (18%)

Police 0 (0%) 2 (3%)

Unknown 1 (1%) 1 (1%)

None documented

29 (40%) 33 (46%)

Challenging Behaviours

Occurred in approximately 25% of presentations

Scenario: Person N presents to ED with lacerations to her lower legs. While waiting in a cubicle, she tries to set light to herself. She requires restraint and two security staff to ensure her safety.

Time to re-presentation

55% of re-presentations happened within one day (expected by MH: 22%/29%)

Also… Decreased mental health services referral

(88%/74%) Decreased assessments by MH (66%/55%) Admission rates 40% higher on re-

presentation (23%/32%)

Limitations

Retrospective data relies on staff documenting the real event

Once-only patient group probably included people that presented multiple times

Unable to obtain documentation by MH services

Recommendations

Training and supervision

Psychiatric staff in ED

Cultural assessment/input

Conclusion Number of

presentations? – no idea…

ED important for providing care

Population is vulnerable, distressed and at high risk of suicide