Annie Llewellyn Davies
Aneurin Bevan University Health Board
In the United Kingdom, deliberate self harm is one of the top five reasons for acute medical admissions.
Most patients with deliberate self harm have initial contact with hospital through the Emergency Department. Repetition of deliberate self harm is also common, ranging from 6% to 30% within 12 months, and 5% will go on to commit suicide. The mental health service, through the psychiatric liaison service, sees all patients with self poisoning for assessment and diagnosis and to determine discharge destination and follow-up, thus ensuring that service users are able to access the most appropriate care pathway.
This idea supports individuals through a non-pharmacological intervention. A postcard scheme has been co-produced with service users, and in addition to a credit card crisis card. The postcards will be forwarded every month for twelve months with an opportunity for service users to telephone at any time to stop receiving them if they are no longer required.
The work has been undertaken within the Emergency Department (ED) within the Aneurin Bevan University Health Board (ABUHB) in order to support the needs of mental health service users. Service user access into the department can be through multiple routes e.g. criminal justice system, GP and through a less structured approach - deliberate self harm/poisoning. In order to support service users and prevent multiple attendance a “Postcard Scheme” has been developed which aims to provide support and a regular point of contact for service users.
Recent figures from the Crisis Liaison Team (CLT) based in the Royal Gwent Hospital and Neville Hall Hospital have shown a marked increase in the number of people accessing the Emergency Departments with self harm, mental illness, suicidal ideation and substance abuse. For many of these patients this will be their first contact with mental Health services and although they may not need referral to secondary services there is undoubtedly a need for some level of support.
Research from Australia indicates that patients who access EDs with self harm felt that they were not being listened to and did not feel connected to services. The CLT felt strongly that this patient group needed further support with their difficulties and believed that utilising a “soft” and non-judgemental approach may encourage patients who utilise self harm to manage their internal distress to contact services prior to self harming.
The Crisis liaison team within the ED in the Royal Gwent Hospital undertook an analysis of those individuals who self harmed/poisoned within a 12 month period. Within that data a number of individuals reappeared several times. These individuals were those who were not known to mental health services, however did have a regular attendance within the ED due to self harm/poisoning. With the support of the ED team the Crisis Liaison service and ABCi researched the use of a postcard scheme to maintain contact with the service users who attended at ED. The postcard has been set up for service users who had self harmed and presented at the ED and the postcards are sent in the first, third, six and twelfth month after discharge and provide a consistent message of support.
Both clinicians and service users agreed that the service would not be useful for the following groups of people:
Individuals who have an addiction to either alcohol or drugs;
Individuals who are already known to Community Mental Health Teams, as a pathway back into secondary service is co-ordinated by the mental health liaison service; and/or
Individuals who have a diagnosed personality disorder and who are receiving care from secondary care services.
In addition in the first month, along with the postcard, a small credit card size information leaflet is sent which includes the number of crisis numbers and third sector organisations who are able to support in times of crisis. A telephone number is also provided on the postcards for the liaison service, which provides a 24 hour telephone answer machine line for enquiries and offers service users a point of contact.
Service users are able to opt out of the scheme at any time. In addition there is flexibility within the system to be able to continue the receipt of the postcards for longer than 12 months if required.
Goals and Targets
The impact of change is significant for this project to such an extent it will introduce a cultural change and positively challenge any preconceived ideas about mental health service users.
The measures are multi factorial;
Reduce the number of re-attendance for mental health service users who have self-harmed/ poisoned, attending at A&E;
Provide a more appropriate care pathway for service users’ Service user Feedback;
Staff satisfaction rate.
The project is still in its early stage, however the feedback from service users and professionals is extremely positive.
“It’s great that we have a safety net for this group of individuals, it’s a great idea.” ED Consultant
5% of those who have attended ED with self harm/poisoning have been picked up through the scheme thus far, and the impact for those service users has been no repeat admissions, no opt out from the postcard scheme, and positive feedback from the third sector, which has had a slight increase in referral for support with crisis.
The next 12-months will see an increase in those service users who use the service, and therefore the CLT is now in contact with the IT department to develop a text messaging service to send every service user a message following attendance at the Emergency department. The CLT will also offer this service to any service user referred into the team from any source, ie GP, police, ambulance service. Additionally the CLT, together with service users from HAFAL will develop a leaflet for all service users who have been assessed by the team.
This leaflet will advise where the service user can access support, whether it be from statutory services or third sector agencies, in hours or out of hours. It will also give service users appropriate electronic resources which can be accessed from home.
Plan stage: In order to determine what the postcard would look like and decide what words should be incorporated onto the postcard, the team leader met with service users and members of the third sector. The idea was very strongly supported. The design of the postcard and the wording on the postcard were co-produced during these sessions. Both service users and clinicians agreed that the postcard would have a non-clinical approach and would be offered as a tool of support.
Do stage: the literature was developed and shared with the third sector and service users. The design and the wording were shared with clinicians from both mental health and the ED. Outcome measures were determined:
● To reduce the number of repeat admissions for those who have self harmed to ED;
● To provide service users with alternative support options;
● To increase a positive service user approach to care, diverting individuals away from the ED as much as possible.
Study stage: In the first 3 months of the project there were no repeat admissions into ED for this service user group. No service users asked to be removed from the scheme
Act stage: the project continues and will be further monitored month upon month. Postcards continue to be sent out as previously described.
Initial data shows that of the 93 patients who were enlisted on the scheme over six months 6% re-attended the Emergency Department with self harm. This is a lower percentage than the national average. Therefore with the development of the texting system it has been decided that all service users seen by the CLT will be offered the opportunity to enlist in this scheme.
Part of Cohort Bevan Exemplar Projects 2015-16