National Clinical Lead for the Assessment and Management of Patients presenting to the Emergency Department following Self-Harm.

Are we finally making progress with suicide and self-harm?

Professor Brendan Kelly’s editorial in IJPM June 2018 (Kelly, 2018) is a welcome historical account of the developments in suicide prevention in Ireland. He identifies the need for a coordinated, effective and compassionate approach to the problem of suicide.

Strategic developments in health care systems in Ireland are currently prioritised via the National Clinical Programmes structure. The first of the National Clinical Programmes in Mental Health to have been implemented is the National Clinical Programme (NCP) for the assessment and management of patients presenting to the emergency department (ED) following self-harm. This offers a coordinated, effective and compassionate approach to a priority group who have the highest risk of completed suicide – those who self-harm. The NCP specifically addresses the care and treatment required for people who present to the ED of acute hospitals following self-harm or with suicidal ideation. It aims to provide a standardised specialist response to all such patients and in so doing to reduce the number of people who leave the ED without receiving a biopsychosocial assessment, link people with appropriate next care, and involve families and supports as appropriate.

The NCP was developed by a national working group led by Dr Siobhan MacHale. The working group used an evidence base identified by Professor Eugene Cassidy and others (Cassidy et al. 2012) and developed a Model of Care, which has been approved jointly by the health service executive (HSE) and the College of Psychiatrists in Ireland (HSE, 2016). The Model of Care focuses on four main areas for improving practice which are outlined in Table 1.

Table 1 The main components of the National Clinical Programme (NCP) for the assessment and management of patients presenting to the emergency department (ED) following self-harm

Since 2015 additional funding has been provided to mental health services for 37 clinical nurse specialists (CNS) who are implementing the clinical programme. Each CNS works under the clinical supervision of a consultant psychiatrist. Detailed data has been collected for the clinical programme for 16 EDs in 2016 and 24 EDs in 2017. Plans are currently in train to appoint a CNS in each of the three Dublin Paediatric Emergency Departments and to further improve the response nationally to children who present following self-harm.

A detailed review of the operation of the NCP was conducted and published in October 2017 (HSE, 2017). This review describes the excellent compassionate service delivered by CNS and psychiatry Non-Consultant Hospital Doctors (NCHDs), with the support of consultant psychiatrists. The review identifies the need for one CNS per 200 per annum presentations of patients who have self-harmed. In all but the smaller EDS, this will permit full implementation of the NCP, with the CNS(s) providing clinical cover from 8 am to 8 pm, 7 days a week, and providing follow-up and bridging to next care for all patients, including those assessed out of hours by NCHDs. The NCP is being most successfully implemented in those services where the work is one component of a well integrated mental health service where there are close working relationships between the ED and all the mental health teams. These services have also developed effective community based services for crisis intervention and unscheduled care and the ED is only used for patients who, along with their mental health needs, have physical needs requiring intervention. In these services, unless there is a physical need, GPs and patients known to Community Mental Health Teams are directed to non-ED based crisis service. Services aim to deliver care through the most compassionate and patient-centred pathway.

In 2017, data was collected on 11,567 presentations to 24 EDs around the country, outlining the progress being made. In all, 93% of those presenting received a biopsychosocial assessment. In all, 81% of those assessed had next of kin involvement; in 88% of cases a letter was sent to the patients GP within 24 hours of their discharge. In all, 72% of those who were discharged were given an emergency care plan and 55% received a follow-up phone call within 24 hours of discharge.

In 2018 additional data will be collected on bridging to next care. 2018 will also see further training of CNS and training for psychiatry NCHDs and consultants. The full implementation of the NCP will be achieved when the work of the CNS and clinical lead is part of a well integrated mental health service.

The experience with the NCP to date has shown how it is an effective, coordinated and compassionate response to a group who are of high priority. The simple use of a suitable environment, specialist assessment, next of kin involvement and link to next appropriate care is a model that can be replicated for other priority groups.