General Practitioners (GPs) are pivotal in the management of patients who self-harm. A recent review [1] suggested that one strategy that helps GPs manage these patients is efficiency of communication between secondary and primary care. Most patients who present to the Emergency Department (ED) with self-harm consult their GP soon afterwards [2, 3]. Many of these patients present with physical complaints, which may disguise an underlying risk of psychological problems [4]. At first point of contact after an episode of self-harm, the patient may be unknown to the GP. Prior knowledge of this history should assist in their assessment, yet less than half (41%) of GPs receive a discharge summary [5].
Clinical practice guidelines are systematically-developed statements that aim to assist physicians in supplying the appropriate health care for specific clinical circumstances [6]. Government guidelines in the UK provide recommendations for practice based on the best available evidence. One such guideline on the short-term management of self-harm patients in secondary care recommends that all patients presenting with self-harm should receive a psychosocial needs assessment including social, psychological and motivational factors, and mood and risk [7]. This information should be passed on to GP 'as soon as possible'. Mental capacity and evidence of mental illness should be communicated to GPs if patients leave before a specialist assessment. The guidelines endorse the Royal College of Psychiatrists' (RCP) recommendations [8] on the content of these communications. However, implementation of National Institute of Clinical Excellence (NICE) guidelines has been variable [9].
In light of developments in national policies and further research, the Royal College of Psychiatrists produced a revision of their earlier document [10] on a consensus of standards for assessment following self-harm. Several standard competencies (for non-specialist staff and specialist staff) were recommended [8]: psychosocial assessments should ideally be carried out by specialist staff; medical staff may undertake assessments if trained for the task; where a patient is not admitted or assessed by a specialist, ED staff should record information according to the recommended list below, which should be passed onto the GP; there should be a policy for referral to specialists for patients admitted to general medical wards; and information from assessments should be passed on to the GP (by fax) within 24 hrs and written communication within 3 working days. The recommended patient information to be obtained before discharge following self-harm included specific arrangements for any follow-up if not referred on for specialist opinion.
The aims of the present study were to assess the standard of documentation and communication after presentation to an ED in the northwest of England with self-harm of patients aged 16 years and over, based on national guidelines. Our objectives were to assess: the proportion of self-harm cases that were discharged from EDs that were notified to primary care services; the content and nature of communications from EDs to primary care services about such patients; the proportion of self-harm cases that were assessed by psychiatric services that were notified to primary care services; the content and nature of communications from psychiatric services to primary care services about such patients; and the timing of communication between EDs/psychiatric services to primary care services.
Definition of self-harm
Self-harm is defined as intentional self-poisoning or self-injury, irrespective of motivation [11]. Self-poisoning includes the intentional self-ingestion of more than the prescribed amount of any drug, whether or not there is evidence that the act was intended to result in death. This also includes poisoning with non-ingestible substances and gases, overdoses of 'recreational drugs' and severe alcohol intoxication where clinical staff considers such cases to be an act of intentional self-harm (rather than recreational binge drinking). Self-injury is defined as any injury that has been intentionally self-inflicted.
Service configuration
Service configuration at the study hospital included psychiatric nurse led ED liaison team (operating 7 days a week from 9 am to 10 pm). The on-call junior doctors in psychiatry are available 24 h a day. In addition the Self-Harm, Assessment, Follow-up and Engagement (SAFE) Team assess people who present with self-harm and live within the catchment area and are registered with a GP. GPs may receive correspondence based on ED records if patients have not been assessed by psychiatric services and are out of area. Within the ED, it is incumbent upon the doctor to make appropriate arrangements for follow-up.
