Mind the Gap: A review of child & adolescent deliberate self-harm admissions to University

College London Hospital (UCLH)

Dr Golnar Aref-Adib, Esha Abrol, Arisa Harada, Dr Zaib Davids

Contents

• Background

• Aims

• Method

• Results

• Conclusions

• Recommendations

Self-harm and suicide in the UK

• 1 in 10 young people self-harm at some point

• 2nd most common cause of death in young people worldwide

• Hospital admissions = small proportion of those who self-harm

Common Assessment Framework (CAF)

“A framework to help practitioners working with

children, young people and families to assess children

and young people’s additional needs for earlier, and

more effective services, and develop a common

understanding of those needs and how to work

together to meet them.”

– Children’s Workforce Development Council

Common Assessment Framework (CAF)

Children with no identified

additional needs

Children with additional needs

Children with complex needs

Common Assessment Framework (CAF)

Social Service input

The use of the CAF in practice

• NICE recommendation:

�Professionals should consider using the CAF following

a presentation to Child and Adolescent Mental Health

Services (CAMHS)

�To help professionals, the family and the school to

support and protect the child

• UCLH recommends the use of an electronic

version (eCAF)

Contents

• Background

• Aims

• Method

• Results

• Conclusions

• Recommendations

Aims

• Determine current practice of eCAF reporting

• Develop a standardised tool to ensure the eCAF is

completed at each CAMHS presentation

Contents

• Background

• Aims

• Method

• Results

• Conclusions

• Recommendations

Methods

• Retrospective case note review

• Inclusion criteria:

�Self-harm CAMHS admissions to UCLH

− deliberate self-harm, suicidal ideation, suicidal attempt

�August 2012 to February 2013

• Data analysis

Methods

• Included:

Sex Length of admission

Age Previous contact with CAMHS services

Borough First admission or previously admitted

Ethnicity Nature of the presentation

Month of admission Nature of follow-up

Admission and discharge within or out of hours

Contents

• Background

• Aims

• Method

• Results

• Conclusions

• Recommendations

Results

• There were 40 admissions extracted from hospital

databases

• 29 admissions met our inclusion criteria

• 83% of admissions were female

• The average length of stay was 2 days

• 55% of patients were from Camden & Islington

• Ratio of patients known to CAMHS vs. not known was

approximately 1:1

• For the majority of patients (69%) this was their 1st

admission

Results – Age of admission

• Average age of admission was 15 years

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

1 to 5 years 6 to 10 years 11 to 15 years 16 to 18 years

Number of patients (%)

Age (years)

Results – Overall

Suicide attempt, 58.62%

DSH, 24.14%

Suicide ideation, 13.79%

Accidental overdose,

3.45%

Context of admission

eCAF completed,

62.07%

No eCAF completed,

20.69%

Previous eCAF only,

17.24%

eCAF forms

Results – Age: eCAF vs. Non-eCAF

11 to 15 years,

44.83%

16 to 18 years,

17.24%

eCAF completed

1 to 5 years, 3.45%

11 to 15 years,

17.24%

16 to 18 years,

17.24%

eCAF not completed

Results – Context of admission: eCAF vs. Non-eCAF

Suicide attempt, 27.59%

DSH, 24.14%

Suicide ideation, 10.34%

eCAF completed

Suicide attempt, 27.59%

Suicide ideation, 6.90%

Accidental overdose,

3.45%

eCAF not completed

Results – History of admissions? eCAF vs. Non-eCAF

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

eCAF completed eCAF not completed

First admission

History of admissions

Results – Ethnicity: eCAF vs. Non-eCAF

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

eCAF not completed

eCAF completed

Results – Follow up: eCAF vs. Non-eCAF

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

Follow upCAMHS

UCH

Follow upCAMHS

local

Dischargeto GP

In patientadmission

Unknown

eCAF completed

eCAF not completed

Results – Supplementary findings

• Gender: all male patients had an eCAF completed, whereas almost half (45.8%) of females did not

• Known to CAMHS: This did not affect whether they had an eCAFcompleted

• Residence of patient: Overseas patients (n = 2) did not have an eCAF completed

• Month of admission: Fewer were completed Sept– Nov (50% completed), most were completed Dec – Jan (66% completed)

• Out of hours admission / discharge: if both within working hours, there was a 50% chance of an eCAF being completed

• Duration of admission: Patients admitted for ≥4 days did not have eCAFs completed. 70% of those discharged on the same day had eCAFs completed.

Contents

• Background

• Aims

• Method

• Results

• Conclusions

• Recommendations

Conclusions

• eCAF forms are not being completed across all patient

groups

• They are significantly being missed in those from an ethnic

minority

• This may represent lack of clinician confidence across

varying cultural backgrounds

• A standardised tool with prompts for eCAF is being

developed to ensure that this vital referral is not

overlooked

Contents

• Background

• Aims

• Method

• Results

• Conclusions

• Recommendations

Recommendations

1. Leaflet distribution

2. Poster distribution

3. Departmental presentation at induction

4. Electronic pop-up on hospital systems

5. Electronic prompt on paediatric discharge summary

6. eCAF sticker for medical notes

7. Creation of an eModule on the use of eCAF

8. Re-audit

References

• http://www.rcpsych.ac.uk/expertadvice/problems/depression/self-harm.aspx

• Madge N, Hewitt A, Hawton K, de Wilde EJ, Corcoran P, Fekete S, van

Heeringen K, De Leo D, Ystgaard M. Deliberate self-harm within an

international community sample of young people: comparative findings from

the Child & Adolescent Self-harm in Europe (CASE) Study. Journal of Child

Psychology and Psychiatry 49:6 (2008), p 667-677.

• Hawton K, Saunders KEA, O’Connor RC. Self-harm and suicide in

adolescents. Lancet 379 (2012), p 2373-2382.

• guidance.nice.org.uk/cg133

THANK YOU!

• Dr Zaib Davids (Consultant Child & Adolescent Pychiatrist,

UCLH)

• Dr Golnar Aref-Adib (CT3 Psychiatrist)

• A&E Team UCLH