Variations in the hospital management of self harm in adults in England: observational study
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《英国医生杂志》
1 Department of Social Medicine, University of Bristol, Bristol BS8 2PR, 2 Division of Primary Health Care, University of Bristol, Bristol BS6 6JL, 3 Centre for Suicide Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, 4 Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, Leeds LS2 9LT
Correspondence to: D Gunnell D.J.Gunnell@Bristol.ac.uk
Introduction
We selected a stratified random sample of 32 hospitals, four from each former health region (table and see bmj.com). At each hospital we interviewed two to five key emergency and psychiatric staff about hospital service structures and made arrangements with them to start audits of the processes of care. We assessed each hospital on 21 recommended self harm service standards (see table A on bmj.com).3 In 2001-2 each hospital did a prospective eight week audit of their management of self harm (see bmj.com). Trust staff used emergency department, medical, and mental health records if audit data were incomplete.
Variation in management of self harm patients across 32 English hospitals
A designated self harm or liaison service was available at 23 of the 32 hospitals. At 11 hospitals, more than half of the 21 recommended service structures were not in place (median score 12; range 7 to 20). The most commonly available aspects of service were guidelines for medical management (at 31 hospitals) and 24 hour access to specialist psychosocial assessments (at 30 hospitals) (see table A on bmj.com).
Guidelines for assessing the risk of suicide for use by staff in emergency departments were available at 17 hospitals. Only 14 hospitals had self harm service planning meetings with mental health services, emergency department, or medical staff. Routine contact with patients' general practitioners within 24 hours of discharge from emergency departments happened at only half of the hospitals. Service scale scores were weakly associated with hospital size (rank correlation 0.20, P = 0.28).
During the eight week audit, staff identified 4222 episodes of self harm. Hospitals varied widely in the proportion of attendances leading to a psychosocial assessment (median 55%; range 36% to 82%), hospital admission (42%; 22% to 83%), psychiatric admission (9.5%; 2.5% to 23.8%), and mental health follow up (51%; 35% to 82%). Using metaregression techniques, we found no significant difference in the proportion of assessments (55% v 58%; odds ratio 0.88; 95% confidence interval 0.56 to 1.38; P = 0.57), admissions (42% v 52%; 0.65; 0.37 to 1.13; P = 0.13), psychiatric admissions (10.5% v 11.4%; 0.89; 0.59 to 1.37; P = 0.61), or arrangements for follow up (53% v 56%; 0.91; 0.66 to 1.25, P = 0.54) between hospitals with and without a designated service. However, at hospitals with a designated service, assessments were considerably less likely to be undertaken by junior (training grade) psychiatrists alone (22% v 75%; 0.04; 0.01 to 0.14; P < 0.01).
Comment
Hawton K, Fagg J, Simkin S, Bale E, Bond A. Trends in deliberate self-harm in Oxford, 1985-1995: implications for clinical services and the prevention of suicide. Br J Psychiatry 1997;171: 556-60.
Department of Health. National suicide prevention strategy for England. London: DoH, 2002.
Royal College of Psychiatrists. The general hospital management of adult self-harm: a consensus statement on standards for service provision. London: RCoP, 1994.
Kapur N, House A, Creed F, Feldman E, Friedman T, Guthrie E. Management of deliberate self poisoning in adults in four teaching hospitals: descriptive study. BMJ 1998;316: 831-2.
Gunnell DJ, Brooks J, Peters TJ. Epidemiology and patterns of hospital use following parasuicide in the South West. J Epidemiol Comm Health 1996;50: 24-29.(Olive Bennewith, research)
Correspondence to: D Gunnell D.J.Gunnell@Bristol.ac.uk
Introduction
We selected a stratified random sample of 32 hospitals, four from each former health region (table and see bmj.com). At each hospital we interviewed two to five key emergency and psychiatric staff about hospital service structures and made arrangements with them to start audits of the processes of care. We assessed each hospital on 21 recommended self harm service standards (see table A on bmj.com).3 In 2001-2 each hospital did a prospective eight week audit of their management of self harm (see bmj.com). Trust staff used emergency department, medical, and mental health records if audit data were incomplete.
Variation in management of self harm patients across 32 English hospitals
A designated self harm or liaison service was available at 23 of the 32 hospitals. At 11 hospitals, more than half of the 21 recommended service structures were not in place (median score 12; range 7 to 20). The most commonly available aspects of service were guidelines for medical management (at 31 hospitals) and 24 hour access to specialist psychosocial assessments (at 30 hospitals) (see table A on bmj.com).
Guidelines for assessing the risk of suicide for use by staff in emergency departments were available at 17 hospitals. Only 14 hospitals had self harm service planning meetings with mental health services, emergency department, or medical staff. Routine contact with patients' general practitioners within 24 hours of discharge from emergency departments happened at only half of the hospitals. Service scale scores were weakly associated with hospital size (rank correlation 0.20, P = 0.28).
During the eight week audit, staff identified 4222 episodes of self harm. Hospitals varied widely in the proportion of attendances leading to a psychosocial assessment (median 55%; range 36% to 82%), hospital admission (42%; 22% to 83%), psychiatric admission (9.5%; 2.5% to 23.8%), and mental health follow up (51%; 35% to 82%). Using metaregression techniques, we found no significant difference in the proportion of assessments (55% v 58%; odds ratio 0.88; 95% confidence interval 0.56 to 1.38; P = 0.57), admissions (42% v 52%; 0.65; 0.37 to 1.13; P = 0.13), psychiatric admissions (10.5% v 11.4%; 0.89; 0.59 to 1.37; P = 0.61), or arrangements for follow up (53% v 56%; 0.91; 0.66 to 1.25, P = 0.54) between hospitals with and without a designated service. However, at hospitals with a designated service, assessments were considerably less likely to be undertaken by junior (training grade) psychiatrists alone (22% v 75%; 0.04; 0.01 to 0.14; P < 0.01).
Comment
Hawton K, Fagg J, Simkin S, Bale E, Bond A. Trends in deliberate self-harm in Oxford, 1985-1995: implications for clinical services and the prevention of suicide. Br J Psychiatry 1997;171: 556-60.
Department of Health. National suicide prevention strategy for England. London: DoH, 2002.
Royal College of Psychiatrists. The general hospital management of adult self-harm: a consensus statement on standards for service provision. London: RCoP, 1994.
Kapur N, House A, Creed F, Feldman E, Friedman T, Guthrie E. Management of deliberate self poisoning in adults in four teaching hospitals: descriptive study. BMJ 1998;316: 831-2.
Gunnell DJ, Brooks J, Peters TJ. Epidemiology and patterns of hospital use following parasuicide in the South West. J Epidemiol Comm Health 1996;50: 24-29.(Olive Bennewith, research)