Discoveries, surprises and learnings from a research about people that presented to an emergency department with intentional self-harm and then re-presented within one week. Presentation by Silke Kuehl and Dr Kathy Nelson, New Zealand Guidelines Group at the 2009 SPINZ National Symposium: Culture and Suicide Prevention in Aotearoa: http://www.spinz.org.nz/page/108-events-archive+spinz-national-symposium-2009+symposium-coverage

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
 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
1st 2nd
Presentati Presentati
on on
Family/ 33 (45%) 24 (32%)
Whānau/
friends
Health 10 (14%) 13 (18%)
Worker
Police 0 (0%) 2 (3%)
Unknown 1 (1%) 1 (1%)
None 29 (40%) 33 (46%)
documented

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