October 31, 2008 — After patients are seen in a hospital emergency department (ED) for intentional self-harm, such as a drug overdose or self-imposed cuts, they often fall through the cracks in the healthcare system, a new study suggests.
Information about a patient's visit to an ED for self-harm is frequently not passed on from providers of secondary care — psychiatrists, ED staff, or a self-harm liaison team — to the patient's primary-care provider, according to a study from Manchester, United Kingdom.
"Psychiatric services need to improve the rate of communication to the patient's general practitioner following psychosocial assessment, and ED staff must also have procedures in place to aid communication to primary-care providers," study author Elizabeth Murphy, from the Manchester Self-Harm Project at the University of Manchester, told Medscape Psychiatry.
Because primary-care providers play a vital role in following patients who have intentionally injured themselves, they need to be made aware of any such episodes as soon as possible, she said.
The study was published online October 23 in the Annals of General Psychiatry.
Self-Harm May Signal Suicide
Self-harm, defined as intentional self-poisoning or self-injury, is a major public-health problem, said Ms. Murphy.
Each year, at least 200,000 cases are seen in EDs in England, and the Manchester Self-Harm Project reports some of the highest rates in the country: 50 per 1000 population.
Although not all acts of self-harm are a suicide attempt, self-harm is a strong risk factor for suicide. An estimated 1 in 100 people die by suicide within a year of presenting to a hospital for self-harm, she added.
The National Institute for Clinical Excellence guidelines for self-harm for the National Health Service in England and Wales, which came into practice in 2004, recommends that all patients presenting with self-harm receive a psychosocial needs assessment, and that this information be transmitted to the patient's primary-care provider as soon as possible.
Although relaying information from secondary-care providers to primary-care providers is known to improve patient care, it is not known whether these national guidelines for follow-up after an episode of self-harm are being observed, say the researchers.
To assess whether communication from secondary-care providers to primary-care providers meets national guidelines for the short-term management of people who intentionally harm themselves, the investigators audited the medical records of 93 consecutive patients, aged 16 years and older, who presented to the ED at a single center after a self-harm episode over a 1-month period.
Communication Gap Identified
Information about the patient's self-harm episode was conveyed to 58 of 93 of the patients' primary-care providers (62%) — 26 cases by psychiatric staff only, 26 cases by the hospital's self-harm liaison team, 3 cases by ED staff only, and 3 cases by both ED staff and psychiatric staff.
The ED staff completed a psychosocial assessment for about half the patients seen for self-harm. However, of the 26% of patients who were not admitted or seen by a psychiatrist, this assessment was rarely forwarded to a primary-care provider.
Psychiatric staff assessed 60% of the patients, but only about half these assessments were forwarded to the patients' primary-care provider.
In 26 cases, mainly when patients were only seen in the ED and not admitted or evaluated by a psychiatrist, members of the hospital self-harm liaison service informed a patient's primary-care provider about the episode, using the information gleaned from ED records, but this information was not very detailed.
Information provided to primary-care providers from psychiatric assessment was the most detailed, and generally included psychiatric history and precipitating circumstances.
The information was passed on to the patient's primary-care provider within a day in 58% of cases, and within 3 days in 33% of cases.
The British government guidelines for communication from secondary care to primary care for the short-term management of self-harm patients are only partially being met, even in urban hospitals with a self-harm liaison service. Further study is needed to determine whether these findings apply to other populations, the group concludes.