Factors associated with the non-assessment of self-harm patients attending an Accident and Emergency Department: Results of a national study

doi:10.1016/j.jad.2005.08.011

Journal of Affective Disorders

Volume 89, Issues 1–3, December 2005, Pages 91-97

https://doi.org/10.1016/j.jad.2005.08.011 Get rights and content

Abstract

Background

Psychosocial assessment of self-harm patients by mental health service staff is an important aspect of their care. Nevertheless, in England around half of those attending a general hospital following a self-harm episode do not receive such an assessment. We have investigated the reasons for this and the characteristics of patients associated with self-discharge or planned discharge without a psychosocial assessment.

Method

8-week audits of self-harm attendances were carried out in 32 Accident and Emergency Departments in England. Where a specialist psychosocial assessment by mental health services was not carried out, information on the reason for this was requested. Due to incomplete data 10 of the 32 hospitals were excluded from analysis.

Results

There were 2780 self-harm attendances at the 22 hospitals. Psychosocial assessments were carried out on 59% of episodes. Among those not assessed, 57% discharged themselves and the remainder were discharged by hospital staff. In multivariable models, being male, taking illegal drugs/alcohol, attendance out of office hours and not being admitted to a hospital bed were associated with an increased risk of self-discharge. Younger subjects were more likely to self-discharge, but this association was explained by age-related admission patterns. Young age (< 45 years), no previous self-harm and not being admitted were associated with an increased likelihood of discharge by hospital staff without a psychosocial assessment. The apparent increased risk of discharge without an assessment for those who self-lacerated was attenuated after allowing for their lower admissions rates.

Limitations

Missing data from 10 hospitals led to their exclusion from analysis. Only the primary reason for discharge was reported on the audit forms.

Conclusions

Those at elevated risk of suicide – older patients and those with a history of self-harm – were the least likely to be discharged by hospital staff without a psychosocial assessment. However, males (at increased risk of suicide compared with females), those who had taken illegal drugs or/and alcohol and those attending ‘out of hours’ were more likely to self-discharge. Services need to be modified and evaluated, based on further information about why such individuals are not currently engaging in services.

Introduction

In England and Wales about 140,000 people present to hospital each year following self-harm (Hawton et al., 1997). It is recognised that the psychosocial assessment of these patients is an important aspect of their management and may influence the likelihood of repeat episodes (National Institute for Clinical Excellence, 2004, Royal College of Psychiatrists, 1994, Kapur et al., 1998, Kapur et al., 2002). In a previous paper (Bennewith et al., 2004), we reported that a psychosocial assessment was carried out in just over half of Accident and Emergency self-harm attendances in a representative sample of hospitals in England. There was also wide variation between hospitals in the proportion of patients assessed, with between a third and four-fifths of self-harm episodes resulting in an assessment at different sites (Bennewith et al., 2004). We found that patients attending Accident and Emergency Departments between 9 am and 5 pm. Monday to Friday were more likely to receive an assessment than those attending at other times, and that those who had self-lacerated were least likely to be assessed (Gunnell et al., 2004). In order to inform the development of services to optimise assessment levels, here we report the reasons given by health service staff for psychosocial assessment not being carried out, and the characteristics of patients associated with self-discharge or planned discharge without a psychosocial assessment.

Section snippets

Method

Data were collected on all self-harm attendances at 32 hospitals in England over an 8-week period between September 2001 and September 2002. The aim of the selection process, the detailed methodology of which is described in a previous paper (Bennewith et al., 2004), was to ensure that the hospitals studied were a nationally representative sample of all hospitals in England providing an Accident and Emergency service. Data on all episodes of self-harm presenting to the hospitals over the 8-week

Primary reason for non-assessment

There were 2780 self-harm attendances over the study period at the 22 Accident and Emergency Departments, 54.5% by females. Information on self-harm method was recorded for 2776 (99.9%) episodes. Of these, in most cases (80.6%, 2237/2776) the patient had taken an overdose, 11.6% (322/2776) had self-lacerated, 4.2% (118/2776) had both self-lacerated and overdosed and 3.6% (99/2776) had used other methods (e.g. self-poisoning with non-medicinal products, attempted hanging, jumping). Just under

Discussion

This is the first nationally representative study of the management of self-harm patients attending hospital Accident and Emergency departments in England and the first study in which information has been collected on the reasons why psychosocial assessments were not carried out by mental health staff. For data protection reasons, data were collected on episodes and not individuals. We were, therefore, not able to adjust for the effect of patterns of care and responses to services for those who

Acknowledgements

We would like to thank Dr. Navneet Kapur for his advice on the setting up and running of the audits and Dr. Andrew Newton, Dr. Jeremy Hyde and Mr. Anthony Harrison for their assistance in the piloting of the audit form. Emily Bennewith assisted with audit data entry.

We are grateful to the hospital and mental health services staff at the participating hospitals for their assistance in the running of the audits.

This research was funded by a project grant from South West NHS R&D. The authors have

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Cited by (68)

Characteristics of self-harm presentations to the emergency department of the Royal Melbourne Hospital, 2012–2019: Data from the Self-Harm Monitoring System for Victoria
2023, Australasian Emergency Care
Rates of self-harm and suicide are increasing world-wide, particularly in young females. Emergency departments (EDs) are a common first point-of-contact for young people who self-harm. We examined age- and sex-related differences in: (1) rates of self-harm over an eight-year period; (2) changes in demographic, presentation, and treatment characteristics over this period, and; (3) rates of, and time to, self-harm re-presentation.
This was a retrospective observational study of all self-harm presentations in persons aged nine years and older to the Royal Melbourne Hospital ED over an eight-year period, 1 January 2012–31 December 2019. The Royal Melbourne Hospital is one of the largest and busiest public EDs in Melbourne, Australia and serves a primary catchment area of approximately 1.5 million people.
There were 551,692 presentations to the Royal Melbourne Hospital ED over this period (57.6 % by females). Of these, 7736 (1.4 %) were self-harm related. These self-harm presentations involved 5428 individuals (54.8 % female), giving an overall repetition event-rate of 11.2 %. Self-harm related presentations increased by 5 % per year (Incidence Rate Ratio [IRR 1.05, 95 % CI 1.02–1.08); a 44 % increase over the eight-year period (IRR 1.44, 95 % CI 1.15–1.80). This increase was more pronounced for young people aged< 25 years. The most common method was self-poisoning, primarily by anxiolytics or analgesics. The proportion of presentations involving self-poisoning alone declined modestly over time, whilst the proportion involving self-injury alone increased. For just over half of all presentations the person was seen by ED mental health staff. The median time to first re-presentation was 4.5 months (Inter-Quartile Range [IQR] 0.7–13.2 months).
Rates of hospital presenting self-harm may be increasing, particularly amongst young people, whilst most self-harm presentations occurred outside office hours; so appropriate ED staffing, training and clinical care models are needed. Around half of those with a repeat episode of self-harm repeated within three months of their index (i.e., first recorded) presentation. Efforts to establish appropriate aftercare services, including alternatives to ED services with service availability 24 h a day 7 days a week, aimed at reducing repetition rates, should be prioritised.
Rupture of the abdominal aorta artery due to self-inflicted injuries in a young man
2022, International Journal of Surgery Case Reports
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Suicide prevention strategies in many countries are based on lowering the risk of suicide among those who have a history of self-harm [8]. Intentional drug overdose is the most common method of self-harm among patients who arrive at hospitals and is the most likely to be referred for a psychological assessment [9]. Evidence shows that infrequent, high-lethality methods of self-injury, such as hanging, are associated with a greater risk of suicide [10,11].
Intentional drug poisoning is the most common method of suicide in the population. Self-inflicted injuries are usually limited to parts of the body that are easily accessible with one's hand, such as the neck, thorax, or upper extremities. Penetrating aortic trauma has a high mortality rate, and open surgery is frequently required.
We report a 19-year-old man who stabbed himself in the anterior abdomen with a kitchen knife after ingesting numerous benzodiazepine tablets, resulting in a rupture of intra-abdominal viscera, including the abdominal aorta artery.
Aortic penetrating injuries have a high mortality rate. The retroperitoneal position of the abdominal aorta and the minor size of the rupture were associated with the formation of very large clots, which were essential in controlling bleeding and hemodynamic abnormalities.
In any patient with drug poisoning following committing suicide, in case of acute abdominal symptoms and hemodynamic disturbance, after controlling the level of consciousness, respiratory, and hemodynamic correction of the patient, immediate consultation with the surgical service should be considered.
Self-harm and the COVID-19 pandemic: A study of factors contributing to self-harm during lockdown restrictions
2021, Journal of Psychiatric Research
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A further limitation is the fact that the patients included in the study were, of necessity, only those who received a psychosocial assessment. While the rates of assessment are very high in both centres compared with those found nationally (Cooper et al., 2013), it is recognised that patients who do not receive an assessment may differ from those who do with regard to gender, method of self-harm and other characteristics such as alcohol use (Hickey et al., 2001; Bennewith et al., 2005; Kapur et al., 2008), which could also apply to whether the pandemic influenced their self-harm. However, we did not find any difference in the methods of self-harm used by the assessed patients with and without COVID-19 factors influencing their self-harm.
The COVID-19 pandemic and resulting public health measures may have major impacts on mental health, including on self-harm. We have investigated what factors related to the pandemic influenced hospital presentations following self-harm during lockdown in England.
Mental health clinicians assessing individuals aged 18 years and over presenting to hospitals in Oxford and Derby following self-harm during the period March 23rd to May 17, 2020 recorded whether the self-harm was related to the impact of COVID-19 and, if so, what specific factors were relevant. These factors were organized into a classification scheme. Information was also collected on patients’ demographic characteristics, method of self-harm and suicide intent.
Of 228 patients assessed, in 46.9% (N = 107) COVID-19 and lockdown restrictions were identified as influencing self-harm. This applied more to females than males (53.5%, N = 68/127 v 38.6%, N = 39/101, χ² = 5.03, p = 0.025), but there were no differences in age, methods of self-harm or suicide intent between the two groups. The most frequent COVID-related factors were mental health issues, including new and worsening disorders, and cessation or reduction of services (including absence of face-to-face support), isolation and loneliness, reduced contact with key individuals, disruption to normal routine, and entrapment. Multiple, often inter-connected COVID-related factors were identified in many patients.
COVID-related factors were identified as influences in nearly half of individuals presenting to hospitals following self-harm in the period following introduction of lockdown restrictions. Females were particularly affected. The fact that mental health problems, including issues with delivery of care, predominated has implications for organisation of services during such periods. The contribution of isolation, loneliness and sense of entrapment highlight the need for relatives, friends and neighbours to be encouraged to reach out to others, especially those living alone. The classification of COVID-related factors can be used as an aide-memoire for clinicians.
ED recommendations for suicide prevention in adults: The ICAR<sup>2</sup>E mnemonic and a systematic review of the literature
2020, American Journal of Emergency Medicine
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While there is no hard and fast rule that can reliably predict which patients will go on to die by suicide in the immediate future, there is nonetheless a large body of evidence that informs suicide risk assessment [29,30,33,34,39,43,47,51,52,54-56]. Unfortunately, available evidence from Class III studies by Bennewith et al. [30] and Carroll et al. [36] indicate that not all patients with suspicion of suicide risk receive a full risk assessment in the ED, despite the fact that patients who present to an ED with SI are likely to attempt suicide in the future, especially during the several days to weeks following discharge from the ED [29]. Although the relative weights of each are uncertain, the determination of risk factors and protective factors (Table 1) is the traditional method of assessing suicidal risk [72].
Caring for suicidal patients can be challenging, especially in emergency departments without easy access to mental health specialists. The American College of Emergency Physicians and the American Foundation for Suicide Prevention appointed a working group to create an easy-to-use suicide prevention tool for ED providers.
The writing group created an easy-to-use mnemonic for the care of adult patients as a way of organizing sequential steps, accompanied by a systematic review of available ED-based suicide prevention literature. The systematic review was performed both to ensure that all relevant evidence was taken into account as well as to evaluate the strength of evidence for each recommendation. Levels of evidence were assigned utilizing the ACEP level of evidence classification.
The writing group created the mnemonic ICAR²E, which stands for Identify suicide risk; Communicate; Assess for life threats and ensure safety; Risk assessment (of suicide); Reduce the risk (of suicide); and Extend care beyond the ED. 31 articles were identified in the search, and were included in the systematic review.
The ICAR²E mnemonic may be a feasible way for practicing ED clinicians to provide evidence-based care to suicidal patients. However, further research is needed.
Patterns of self-harm methods over time and the association with methods used at repeat episodes of non-fatal self-harm and suicide: A systematic review
2019, Journal of Affective Disorders
The risk of self-harm repetition and suicide may be influenced by self-harm method choice. However, there are mixed findings regarding whether there is a discernible pattern in self-harm methods over successive episodes of non-fatal self-harm, and if so, how these may be associated with self-harm repetition and/or suicide.
A systematic review of five electronic databases was undertaken until 31 May 2018 to identify cohort studies on patterns of self-harm methods and their association with methods used either at repeat self-harm episodes and/or suicide.
15 studies were included reporting data on of 127,371 participants. Over an average follow-up period of 2.8 years, one-third (33.3%) switched methods between episodes of self-harm, most commonly from self-injury to self-poisoning. For suicide, almost one-half (42.1%) switched methods over an average follow-up period of 11.2 years.
Studies were characterised by a moderate study quality. Studies tended to group all methods into self-injury and/or self-poisoning with little consideration as to the diverse range of self-harm methods included within these broad categories and the likely differences in potential lethality between these methods. Few investigated the role of alcohol and/or drug dependence and mental illness on self-harm method choice.
Given the frequency of method switching observed, and the lack of discernible patterns over time, all patients should be routinely assessed for risk and needs irrespective of the method used at the index episode of non-fatal self-harm.
Combination of self-harm methods and fatal and non-fatal repetition: A cohort study
2017, Journal of Affective Disorders
Citation Excerpt :
It is, however, a consistent observation that, compared with those who have attended hospital because of self-poisoning, people who attend due to self-injury are much less likely to receive adequate psychosocial assessment and ensuing aftercare. One reason for this state of affairs is almost certainly the widespread but erroneous belief that self-injury is not a suicide risk (Grandclerc et al., 2016) – self-injury is, in fact, associated with higher rates of subsequent non-fatal and fatal repetition of self-harm (Bennewith et al., 2005; Cooper et al., 2005; Lilley et al., 2008; Bergen et al., 2012a; Hawton et al., 2012; Carroll et al., 2014). Here we have investigated two fairly common categories of self-harm method that go beyond the simple self-poisoning/self-injury dichotomy: combined self-poisoning and self-injury (usually self-cutting) on the same occasion, and acts that represent rapid repetition of non-fatal self-harm following a recent episode.
Assessment and aftercare for people who self-harm needs to be related to an understanding of risks of adverse outcomes. We aimed to determine whether self-harm by a combination of methods and its early repetition are associated with adverse outcomes – especially non-fatal repetition and suicide.
10,829 consecutive general hospital attendances due to self-harm in one large English city were monitored, through scrutiny of Emergency Department attendances, over three years and followed up to determine the incidence of non-fatal repetition. Subsequent deaths, by any cause and by suicide, were determined from national statistical records.
6155 patients accounted for the 10,829 episodes: 72% by self-poisoning, 21% self-injury, and 746 episodes (7%) due to a combination of methods. After a combined-methods index episode, non-fatal repetition (P=0.001) and suicide (P=0.002) occurred sooner and more frequently than it did among those who had self-poisoned. Further hospital attendance due to self-harm within a month was associated with a 3.7-fold (95% CI 2.1–6.4) risk of subsequent suicide.
The data exclude self-harm episodes that do not result in a hospital attendance. Index episodes in the study are not generally life-time first episodes so follow-up data are based on an arbitrary start-point. Both of these limitations are common to all studies of this kind.
At psychosocial assessment and the making of aftercare arrangements, combined methods of self-harm or another recent episode should be considered ‘red-flag’ indicators for attention to care.

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Research reportFactors associated with the non-assessment of self-harm patients attending an Accident and Emergency Department: Results of a national study

Abstract

Background

Method

Results

Limitations

Conclusions

Introduction

Section snippets

Method

Primary reason for non-assessment

Discussion

Acknowledgements

J. Psychosom. Res.

Variations in the hospital management of self-harm in adults: an observational study

Br. Med. J.

Attendance at the Accident and Emergency Department in the year before suicide: retrospective study

Br. J. Psychiatry

The epidemiology and management of self-harm amongst adults in England

J. Public Health

Trends in deliberate self-harm in Oxford, 1985–1995. Implications for clinical services and the prevention of suicide

Br. J. Psychiatry

Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital

Br. J. Psychiatry

Self-injury attendances in the Accident and Emergency Department

Br. J. Psychiatry

Research report
Factors associated with the non-assessment of self-harm patients attending an Accident and Emergency Department: Results of a national study