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