Factors explaining variation in recommended care pathways following hospital-presenting self-harm: a multilevel national registry study

Abstract

Background: People who present to hospital following self-harm are at high risk of suicide. Despite this, there are considerable variations in the management of this group across hospitals and the factors influencing such variations are not well understood.

Aims: The aim of this study was to identify the specific hospital and individual factors associated with care pathways following hospital-presenting self-harm.

Method: Data on presentations to hospitals by those aged 18 years and over were obtained from the National Self-Harm Registry Ireland for 2017 and 2018. Factors associated with four common outcomes following self-harm (self-discharge, medical and psychiatric admission and psychosocial assessment before discharge) were examined using multilevel Poisson regression models.

Results: Care pathways following self-harm varied across hospitals and were influenced by both hospital and individual factors. Individual factors were primarily associated with self-discharge (including male gender, younger age and alcohol involvement), medical admission (older age, drug overdose as a sole method and ambulance presentations) and psychiatric admission (male gender, methods associated with greater lethality and older age). The hospital admission rate for self-harm was the only factor associated with all outcomes examined. The availability of psychiatric in-patient facilities and specialist mental health staff contributed to variation in psychiatric admissions and psychosocial assessments prior to discharge. Hospital factors explained the majority of observed variation in the provision of psychosocial assessments.

Conclusions: Characteristics of the presenting hospital and hospital admission rates influence the recommended care pathways following self-harm. Provision of onsite mental health facilities and specialist mental health staff has a strong impact on psychiatric care of these patients.

Keywords: Self-harm; emergency psychiatry; emergency services; hospital services; outpatient treatment.

Fig. 1

Care pathways following hospital-presenting self-harm ¹It may not always be recorded if a patient was admitted to an offsite psychiatric facility. In addition those which were transferred to another hospital for psychiatric admission are not included here, so this figure is likely to be an underestimate.

Fig. 2

Funnel plots demonstrating the variation by hospital in the proportion of presentations resulting in (a) self-discharge, (b) medical admission, (c) psychiatric admission or (d) psychosocial assessment prior to discharge.