1. ED RE-PRESENTATIONS FOLLOWING INTENTIONAL SELF-HARM Silke Kuehl Dr 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  OverdoseBurn  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 1 st Presentati on 2 nd Presentati on Family/ Whānau/ friends 33 (45%)24 (32%) Health Worker 10 (14%)13 (18%) Police0 (0%)2 (3%) Unknown1 (1%) None documented 29 (40%)33 (46%)

19. 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.

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