Self-harm in A&E
In recent years A&E attendances for suicidal attempts have rocketed. It is now a daily occurrence to meet both children and adults in crisis needing our help. But are we prepared? Are we adequately trained? Are we ready to handle this new epidemic?
The Royal College of Emergency Medicine (RCEM) mandates that such training should be integrated into our induction. The importance of good training in managing mental presentations cannot be overstated. These cases are high risk. Death by suicide remains a significant and increasing problem facing young adults and teenagers both in the UK and across Europe. The ripples of suicide also travel far affecting large swathes of our communities.
Consider these cases to be important. Consider how (with trauma calls) we provide resource-intensive care for patients with comparable morbidity and mortality. Our mental health patients deserve nothing less than the same high-quality care provision. So what are our goals in A&E? In recognition of the need to raise standards, the RCEM outlines these goals as follows…
Self-harm must be risk assessed
Previous mental health issues must be recorded
A Mental State Examination (MSE) must be performed
A provisional diagnosis should be documented
Prompt referrals are essential
Within 1 hour the mental health team should review
Appropriate facilities to expedite the above should be available
Achieving all of the above in a timely fashion may feel impossible and the paperwork can feel overwhelming. Just take a breath, perhaps a sip of coffee, and remember what you’re trying to achieve. What follows is sampled from the “4 areas approach” to mental health assessment outlining what positive steps we can take in A&E (this is essential reading with more examples of what questions to ask). To this, I have added two additional steps. Firstly, physical needs must not be forgotten. Secondly, further stigmatisation of already vulnerable individuals must be avoided at all costs. If mental and physical health is to truly have equity in the NHS we must role model professional behaviour and call out discrimination in all its guises.
Area 1: Suicidal intent
It is very important to ask about thoughts of suicide. There is no evidence that doing so increases or encourages such thoughts provided you do so with sensitivity. Some departments use a pro forma. In all cases supplement with your own questions and without exception follow up with a mental health review. Examples of questions include…
What lead to the current crisis, suicide attempt or episode of self-harm?
What method was used?
What has been difficult in the last few days, weeks or months?
Area 2: Mental state
It is important not to miss problems with cognition. It is embarrassing to discover your patient is in fact acutely confused at the end of your assessment. If in doubt (for example) check orientation, basic recall and simple tasks. Missing psychosis is also easier than you might think. If the patient in front of you is hearing voices then the situation changes entirely. In both cases (confusion or psychosis) organic causes must be considered. The mental state exam and the mini mental state exam both have a role, certainly in adults and yes even in children. Use them if you suspect something is not quite right.
Further resources (adults)
Further resources (paediatric)
Area 3: Risk factors and Warning signs
Whilst gathering a brief history pay close attention for any of the following as they are considered particularly high risk…
Chronic illness
Chronic pain
Regret of survival
Well-formed plan
Websites promoting suicide
Hopelessness
Feeling a burden
Psychotic phenomena
Lack of social support
Relationship instability
Recently bereavement
Sense of ‘entrapment’
Repeated self-harm
Ligature use
Whilst age, sex, marital status, occupation and social class are additional relevant factors in an individual’s risk, it is important not to make assumptions (e.g. a recently separated middle-aged man is higher risk than a single woman). None the less, it is helpful to know that certain circumstances (e.g. recently leaving the armed forces, past domestic violence, access to lethal firearms) carry an unambiguous heightened risk.
Area 4: Protective factors and Suicidal mitigation
The glass isn’t always half empty. Enquiring about protective factors is equally important, not least to highlight potential positive strategies to self-care and recovery. Starting with attention to personal hygiene, diet, sleep and wellbeing, ending with limitation of alcohol, drugs and harmful behaviours.
Ask about which health professionals are already involved, (1) To get a sense of their current level of involvement in services, and (2) To know with whom to liaise or refer to.
Area 5: Physical health needs
Finally, it is worth remembering the associated physical health needs of those who self-harm. To overlook a “minor overdose” or neglect some “hidden cuts” is unforgivable. Be sure to prioritise the following at the start of your assessments, allowing subsequent mental health needs to be addressed concurrently.
In all cases…
ABCDE resuscitation as required.
Monitor physical observations, neurological signs at regular intervals.
Examination should be systematic and thorough.
Record a description of the patient in case they abscond.
Don’t fall foul of hidden tablets or blades etc.
Ensure a safety check has been performed.
In cases of overdose…
Follow TOXBASE advice.
Consideration of antidotes, and if ingestion within one hour or presentation, activated charcoal.
Consider baseline tests (e.g. blood glucose, ECG).
Blood tests ARE always appropriate, don’t trust the history.
Include; salicylate level, paracetamol level, U&Es, LFTs, Full blood count, International normalised ratio (INR). Consider a blood gas.
A urinary drug screen can be considered but has limited value.
In cases of physical injury…
Dress wounds, provide analgesia, treat injury, refer as appropriate.
Further resources
Hospital presentations: poisoning (e-module)
Area 6: Stop the stigma
Finally, in addition to such positive actions (i.e. fulfilling your professional duties), it is also vitally important that we lead by example in the battle to de-stigmatise mental health (a moral duty). Role modelling professional behaviour is essential to workplace culture. An awareness of the challenges that our patients face in our A&E is essential if we are to be truly sympathetic…
Critical comments – they raise barriers to recovery
Lack of privacy – confidentiality matters
Contradictions in advice – do it safely or don’t do it at all
Leaving out the family – when and where appropriate
Inappropriate physical spaces, long waiting times and longer referral periods
…to name but a few.
Remember…
Self-harm is the 2nd most common cause of death amongst young people. 1 in 4 children are affected at some point in their childhood, most commonly self-cutting. 1 in 10 self-harm on more than four occasions. Such early experiences have life-long consequences. Self-harm can manifest at any age in anyone. No one is immune.
Our actions are important.
Our actions can make a difference.
Our actions can save lives.
Careful risk assessment, meaningful psychosocial history-taking, compassionate care provision, effective referral and joined-up services from committed professionals who work together in the patient’s interest without stigma or judgement are the core ingredients to making an impact. Whilst overdue investment in mental health provision remains a political football, we owe it to our patients to be better informed, better trained and better prepared.
Recommended by the author…
Feeling on the edge – “Excellent leaflet for mental health patients in the waiting room”
Mental Health in Emergency Departments: a toolkit for improving care – “Practical toolkit for improving standards in your ED”
Characteristics of a First Suicide Attempt that Distinguish Between Adolescents Who Make Single Versus Multiple Attempts – “Excellent article highlighting the importance of initial assessment”
The Mental Health Act and how to put it into practice – “Up to date e-learning on the mental health act (not covered above)”
Managing self-harm in young people – “A comprehensive report by the Royal College of Psychiatrists on mental health”
Many thanks to Dr Sophie Moseley who helped co-author this blog post! Banner art by Ben the Illustrator.
