ED RE-PRESENTATIONS FOLLOWING INTENTIONAL SELF-HARM Silke Kuehl Dr Kathy Nelson

1. ED RE-PRESENTATIONS FOLLOWING INTENTIONAL SELF-HARMSilke KuehlDr Kathy Nelson

2. Overview Literature Aims & Objectives Methodology Findings Recommendations Conclusion

3. The Literature Statistics Risk factors The young, the old and men Views…ED staff, patients

4. Overcrowding

5. 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

6. 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

7. Intentional Self-harm Definition: • Attempted suicide • Suicidal ideation • Deliberate self-harm

8. Methodology • Descriptive research • Retrospective review • Data extraction tool • Variables: • Person • Presentation • Inclusion/exclusion Sent Ethics proposal

9. After Ethics • Retrieved data • Log book • Sample: • 48 people • 73 re-presentations • Analysis: SPSS

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

11. Coding • Patients are coded by their presenting complaint, irrespective of the intent • Identifying this population difficult • Previously identified 120 people presented 852 times

12. Type of ISH • Overdose Burn • Laceration Gassing • Attempted hanging • Ingestion/insertion foreign body • Head injury • Stabbing self • Traffic • Jumping from a height

13. Documentation/Assessment • Location of person often briefly described • Poor documentation of risk assessments • Inadequate triage assessment • Patient discharged without ED staff being aware

14. 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.

15. 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)

16. 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.

17. Physical/mental health • Ambulatory Care service – ‘quick’ • Nil checking of previous presentations • Nil highlighting on the IT system

18. Support people

19. Challenging Behaviours • Occurred in approximately 25% of presentations

20. 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%)

21. 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

22. Recommendations • Training and supervision • Psychiatric staff in ED • Cultural assessment/input

23. Number of presentations? – no idea… ED important for providing care Population is vulnerable, distressed and at high risk of suicide Conclusion