自殘病患需要更好的追蹤


  October 31, 2008 — 新研究認為,病患因為自殘如藥物過量或者故意劃傷而急診之後,他們常常在不全的健康照護系統中陷入風險。
  
  根據英國曼徹斯特的研究,病患因為自殘而急診的資訊,經常未能從二線照護者—精神科醫生、急診部門的員工或者自殘聯繫團隊(self-harm liaison team) —提供給病患的一線照護者。
  
  研究作者、曼徹斯特大學曼徹斯特自殘研究計畫的Elizabeth Murphy向Medscape Psychiatry表示,精神社會評估之後,需要提供精神科服務來改善病患與醫師之間的溝通,急診部門員工也必須加強和一線照護者之間的溝通。
  
  她表示,因為一線照護者扮演追蹤蓄意自殘病患的重要角色,須對任何可能跡象有所警覺。
  
  本研究線上發表於10月23日的Annals of General Psychiatry期刊。
  
  【自殘可能是自殺的徵兆】
  Murphy小姐表示,自殘定義是蓄意自我中毒或自我損傷,是一個重要的公共衛生議題。
  
  每年在英國急診案例中至少有200,000例自殘,曼徹斯特自殘研究計畫指出,這相當於每1,000人口中有50人的高比率。
  
  雖然並非所有的自殘都是為了自殺,但自殘是自殺的一個強烈風險因素;她指出,估計每100名因為自殘而就醫者中,有1人會在1年內自殺身亡。
  
  英國國家卓越臨床研究中心於2004年開始實施英格蘭和威爾斯地區有關自殘的國家健康服務規範,建議所有自殘病患接受精神社會需求評估,且應將此資訊盡可能提供給病患的一線照護者。
  
  研究者表示,雖然從二線照護提供者傳達相關資訊給一線照護提供者可以改善病患照護,但還不知道這些是否有遵守自殘發生後的國家追蹤規範。
  
  為了評估二線照護提供者和一線照護提供者之間的溝通是否符合國家規範的蓄意自殘病患短期處置,研究者檢視了93名年紀在16歲以上病患在自殘後1個月到某一醫學中心急診的病歷。
  
  【確認溝通代溝】
  有關病患的自殘資訊,在93名病患中,有58名被傳達給其一線照護提供者(62%) — 26 例由精神科員工、26例由醫院的自殘聯繫團隊、3例由急診員工、3例由急診員工和精神科員工。
  
  急診員工為約半數自殘病患完成精神社會評估,不過,26%未轉診給精神科醫師的病患中,很少要求一線照護提供者為病患進行此評估。
  
  精神科員工分析了60%的病患,但是只有半數的評估被傳達給病患的一線照護提供者。
  
  26個案例中,大部份病患只有於急診就醫,並未照會精神科醫師就診或評估,醫院的自殘聯繫團隊成員告訴病患的一線照護提供者有關自殘資訊,利用急診紀錄的資訊,但是這些資訊不夠詳細 。
  
  精神評估提供給一線照護提供者的資訊是最詳盡的,一般包括精神病史和造成壓力的情況。
  
  有58%的案例,在1天內將這些資訊提供給病患的一線照護提供者,33%的案例是在3天內。
  
  即使在有自殘聯繫團隊的都會區醫院,只有部份符合英國政府有關於蓄意自殘病患短期處置之二線照護提供者和一線照護提供者間溝通的國家規範。研究團隊結論表示,需要後續研究以確認這些發現是否運用到其他族群。
  
  本計畫由曼徹斯特心智健康與社會照護信託審計部門與曼徹斯特兒童大學醫院國家健康服務信託資助。作者宣稱沒有相關資金上的往來。

Self-Harm Patients Need Better Follow-up

By Marlene Busko
Medscape Medical News

October 31, 2008 — After patients are seen in a hospital emergency department for intentional self-harm, such as a drug overdose or self-imposed cuts, they often fall through the cracks in the healthcare system, a new study suggests.

Information about a patient's visit to an emergency department for self-harm is frequently not passed on from providers of secondary care — psychiatrists, emergency-department staff, or a self-harm liaison team — to the patient's primary-care provider, according to a study from Manchester, United Kingdom.

"Psychiatric services need to improve the rate of communication to the patient's general practitioner following psychosocial assessment, and emergency-department staff must also have procedures in place to aid communication to primary-care providers," study author Elizabeth Murphy, from the Manchester Self-Harm Project at the University of Manchester, told Medscape Psychiatry.

Because primary-care providers play a vital role in following patients who have intentionally injured themselves, they need to be made aware of any such episodes as soon as possible, she said.

The study was published online October 23 in the Annals of General Psychiatry.

Self-Harm May Signal Suicide

Self-harm, defined as intentional self-poisoning or self-injury, is a major public-health problem, said Ms. Murphy.

Each year, at least 200,000 cases are seen in emergency departments in England, and the Manchester Self-Harm Project reports some of the highest rates in the country: 50 per 1000 population.

Although not all acts of self-harm are a suicide attempt, self-harm is a strong risk factor for suicide. An estimated 1 in 100 people die by suicide within a year of presenting to a hospital for self-harm, she added.

The National Institute for Clinical Excellence guidelines for self-harm for the National Health Service in England and Wales, which came into practice in 2004, recommends that all patients presenting with self-harm receive a psychosocial needs assessment and that this information be transmitted to the patient's primary-care provider as soon as possible.

Although relaying information from secondary-care providers to primary-care providers is known to improve patient care, it is not known whether these national guidelines for follow-up after an episode of self-harm are being observed, say the researchers.

To assess whether communication from secondary-care providers to primary-care providers meets national guidelines for the short-term management of people who intentionally harm themselves, the investigators audited the medical records of 93 consecutive patients, aged 16 years and older, who presented to the emergency department at a single center after a self-harm episode over a 1-month period.

Communication Gap Identified

Information about the patient's self-harm episode was conveyed to 58 of 93 of the patients' primary-care providers (62%) — 26 cases by psychiatric staff only, 26 cases by the hospital's self-harm liaison team, 3 cases by emergency-department staff only, and 3 cases by both emergency-department staff and psychiatric staff.

The emergency-department staff completed a psychosocial assessment for about half the patients seen for self-harm. However, of the 26% of patients who were not admitted or seen by a psychiatrist, this assessment was rarely forwarded to a primary-care provider.

Psychiatric staff assessed 60% of the patients, but only about half these assessments were forwarded to the patients' primary-care provider.

In 26 cases, mainly when patients were only seen in the emergency department and not admitted or evaluated by a psychiatrist, members of the hospital self-harm liaison service informed a patient's primary-care provider about the episode, using the information gleaned from emergency department records, but this information was not very detailed.

Information provided to primary-care providers from psychiatric assessment was the most detailed and generally included psychiatric history and precipitating circumstances.

The information was passed on to the patient's primary-care provider within a day in 58% of cases and within 3 days in 33% of cases.

The British government guidelines for communication from secondary care to primary care for the short-term management of self-harm patients are only partially being met, even in urban hospitals with a self-harm liaison service. Further study is needed to determine whether these findings apply to other populations, the group concludes.

The project was funded by the audit departments of the Manchester Mental Health and Social Care Trust and the Central Manchester and Manchester Childrens’ University Hospitals National Health Service Trust. The authors have disclosed no relevant financial relationships.

Ann Gen Psychiatry. 2008;7:21.Abstract

    
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