Consultation-Liaison Psychiatry Services in Ireland: A National Cross-Sectional Study

Assessing the characteristics of suicidal ideation and self-harm in a national older adult population attending emergency departments across Ireland: cohort study protocol

INTRODUCTION

Older people (people aged 65 years and older) have high rates of death by suicide, and self-harm is a major risk factor for suicide. While rates of self-harm decrease with age, rates of suicide increase among this age group. The overall aim of this research project is to identify real-life evidence of the characteristics associated with older people who present with self-harm and suicidal ideation to emergency departments in Ireland. In examining the variables associated with self-harm, we may be better able to identify the characteristics of older adults who are at highest risk, including those presenting with high lethality attempts.

METHODS AND ANALYSIS

Our data are a cohort study of older people in Ireland involving two workstreams. The first will use a 5-year cohort of data from the National Clinical Programme for Self-Harm and Suicide-related Ideation (NCPSHI) which comprises over 70 000 presentations. The second workstream will use a 15-year cohort of electronic patient records from the Mater Misericordiae University Hospital (MMUH) comprising over 30 491 presentations (900 aged 65 years and older) to collect more detailed information on characteristics of older people presenting with self-harm and suicidal ideation.

ETHICS AND DISSEMINATION

This study has received full ethical approval. The Clinical Research Ethics Committee of the MMUH approved the MMUH workstream-Reference number: 1/378/2327 TMR. Ethical approval for the NCPSHI workstream has been granted by the University College Dublin's Office of Research Ethics.Our findings will be disseminated via peer-review publications and presentations to the scientific community, along with reports for clinicians and policymakers.

Factors affecting implementation of a National Clinical Programme for self-harm in hospital emergency departments: a qualitative study

BACKGROUND

A substantial number of people experiencing self-harm or suicidal ideation present to hospital emergency departments (EDs). In 2014, a National Clinical Programme was introduced in EDs in Ireland to standardise care provision. Internationally, there has been limited research on the factors affecting the implementation of care for people who present with mental health crises in EDs.

METHODS

This qualitative study examined factors influencing the implementation of the National Clinical Programme for Self-harm and Suicide-related Ideation in 15 hospitals in Ireland from early (2015-2017) through to later implementation (2019-2022). Semi-structured interviews were conducted with staff involved in programme delivery, with the topic guide and thematic analysis informed by the Consolidated Framework for Implementation Research.

RESULTS

A total of 30 participants completed interviews: nurse specialists (n=16), consultant psychiatrists (n=6), nursing managers (n=2), emergency medicine staff (n=2) and members of the national programme team (n=4). Enablers of implementation included the introduction of national, standardised guidance for EDs; implementation strategies led by the national programme team; and training and support for nurse specialists. The following inner-setting factors were perceived as barriers to implementation in some hospitals: limited access to a designated assessment room, delayed access to clinical input and poor collaboration with ED staff. Overall, these barriers dissipated over time, owing to implementation strategies at national and local levels. The varied availability of aftercare impacted providers' ability to deliver the programme and the adaptability of programme delivery had a mixed impact across hospitals.

CONCLUSIONS

The perceived value of the programme and national leadership helped to advance implementation. Strategies related to ongoing training and education, developing stakeholder interrelationships and evaluation and monitoring have helped address implementation barriers and promote continued sustainment of the programme. Continued efforts are needed to support nurse specialists delivering the programme and foster partnerships with community providers to improve the transition to aftercare.

Discharged from the emergency department following hospital-presented self-harm: referral patterns and risk of repeated self-harm

BACKGROUND

Presentation to the emergency department (ED) with self-harm provides an important opportunity for intervention.

AIMS

To investigate characteristics and self-harm repetition risk of those discharged from the ED without a referral for mental health-related aftercare.

METHOD

Data on consecutive self-harm presentations to EDs for the years 2013-2019 (n = 55,770) were obtained from the National Self-Harm Registry Ireland. Multilevel Poisson and Cox regression models were estimated.

RESULTS

Half of the self-harm presenters were discharged from the ED (49.8%) and almost half of them did not receive a mental health-related referral (46.8%). Receipt of a psychosocial assessment was associated with a 50% reduced risk of non-referral (IRR 0.54; 95% CI 0.51-0.57). Non-referral was also less likely for young people (< 18 years), presentations involving attempted hanging, persons with previous self-harm presentations, and in the latter half of the study period (2017-2019 vs. 2013-2016), but was more likely for those brought by ambulance, presenting outside 9 am-5 pm and admitted to an ED medical assessment unit. Of those not referred, 19.3% had a repeat presentation within 12 months, compared to 22.4% of those referred. No difference in repetition risk between these two groups was evident in adjusted analyses. Self-harm history had the strongest association with repetition, with highest risk among individuals with four or more previous presentations (HR 9.30, 95% CI 8.14-10.62).

CONCLUSIONS

The findings underline the importance of assessing all individuals who present with self-harm and highlight the need for comprehensively resourced 24hr services providing mental health care in the ED.

Determinants of workload-related clinician stress levels in general hospital consultation liaison psychiatry services during the COVID-19 pandemic in England and Ireland. Short report

OBJECTIVE

To explore workload-related stress levels experienced by consultation liaison psychiatry (CLP) staff in England and Ireland, and factors relevant to such a burden, during the COVID-19 pandemic.

METHODS

Data were obtained for England and Ireland from a European survey among CLP services in general hospitals spread via CLP networks (11th June - 3rd October 2021). The heads of respective CLP services in general hospitals responded on behalf of each service, on 100 CLP hospital staff in total.

DEPENDENT VARIABLE

workload-related stress levels in CLP services due to COVID-19 (0-10 point scale).

INDEPENDENT VARIABLES

hospital size, CLP service size, degree of hospital involvement in COVID-19-related care, and the number of support options available to hospital staff. Spearman's rho correlation analyses were performed.

RESULTS

There was a significant association between the hospital's involvement in COVID-19-related care and workload-related stress levels as reported by CLP staff: r(22) = 0.41, p = 0.045, R2 = 0.17. There were no significant associations between workload-related stress levels and other variables including staff support (p = 0.74).

CONCLUSION

Our findings suggest that perceived workload-related stress levels of CLP staff during the COVID-19 pandemic can be an indicator of COVID-19 involvement of the hospitals. Staff support seemed not to alleviate work stress in the context of the pandemic. Healthcare policies should improve working conditions for CLP hospital staff that play an essential role from a population health perspective. Rigorous measures may be needed to ensure mental healthcare provision remains tenable and sustainable in the long term.

Evaluation of a national clinical programme for the management of self-harm in hospital emergency departments: impact on patient outcomes and the provision of care

BACKGROUND

Emergency departments are important points of intervention, to reduce the risk of further self-harm and suicide. A national programme to standardise the management of people presenting to the emergency department with self-harm and suicidal ideation (NCPSHI) was introduced in Ireland in 2014. The aim of this study was to evaluate the impact of the NCPSHI on patient outcomes and provision of care.

METHODS

Data on self-harm presentations were obtained from the National Self-Harm Registry Ireland from 2012 to 2017. The impacts of the NCPSHI on study outcomes (3-month self-harm repetition, biopsychosocial assessment provision, admission, post-discharge referral, and self-discharge) were examined at an individual and aggregate (hospital) level, using a before and after study design and interrupted time series analyses, respectively. The 15 hospitals that implemented the programme by January 2015 (of a total of 24 between 2015 and 2017) were included in the analyses.

RESULTS

There were 31,970 self-harm presentations during the study period. In hospitals with no service for self-harm (n = 4), risk of patients not being assessed reduced from 31.8 to 24.7% following the introduction of the NCPSHI. Mental health referral in this hospital group increased from 42.2 to 59.0% and medical admission decreased from 27.5 to 24.3%. Signs of a reduction in self-harm repetition were observed for this hospital group, from 35.1 to 30.4% among individuals with a history of self-harm, but statistical evidence was weak. In hospitals with a pre-existing liaison psychiatry service (n = 7), risk of self-discharge was lower post-NCPSHI (17.8% vs. 14.8%). In hospitals with liaison nurse(s) pre-NCPSHI (n = 4), medical admission reduced (27.5% vs. 24.3%) and there was an increase in self-harm repetition (from 5.2 to 7.8%. for those without a self-harm history).

CONCLUSION

The NCPSHI was associated with improvements in the provision of care across hospital groups, particularly those with no prior service for self-harm, highlighting the need to consider pre-existing context in implementation planning. Our evaluation emphasises the need for proper resourcing to support the implementation of clinical guidelines on the provision of care for people presenting to hospital with self-harm.

Broadening the state of play - the second national survey of Consultation-Liaison Psychiatry services in New Zealand, 2021

OBJECTIVE

The original national survey of Consultation-Liaison Psychiatry (CLP) services in New Zealand (NZ) that was undertaken in 2018 (CLPSNZ-1) established a baseline but was limited in scope. The aim of the current study was to conduct a more in-depth national survey.

METHOD

A 44-question survey was emailed to clinicians at each of the 16 general hospitals in NZ with specialist adult CLP services in 2021.

RESULTS

Responses were obtained from all 16 CLP services. These services were found to be under-resourced (with mean total full-time equivalents of 0.26 psychiatrists and 1.10 clinicians per 100 inpatient beds, respectively), operate with highly variable service models (with major variations in operating hours and coverage of age groups, the Emergency Department and outpatients) and provide a predominantly consultation service.

CONCLUSION

While many of the findings from CLPSNZ-1 remain relevant, the current survey has extended our understanding of the circumstances, achievements and challenges of this psychiatric subspecialty in NZ.

Evaluation of consultation liaison psychiatry in Australian public hospitals (AU-CLS-1)

OBJECTIVE

This study aimed to determine whether consultation liaison psychiatric service (CLS) staffing within Australian public hospitals meet national and international minimum staffing standards.

METHOD

Semi structured interviews were conducted with CLS Directors across Australia from August to December 2021. Data were collected on demographics, staffing, funding, hospital size and admissions.

RESULTS

The majority of services did not meet minimum standards for CLS staffing. Non-medical staff outnumbered medical staff with increasing rurality. Psych-oncology CLS had the greatest resources, skill mix and service breadth.

CONCLUSION

Although CLS are heterogeneous, most services are inadequately resourced to provide baseline specialist mental health care in Australian hospitals. Establishing national minimum standards for CLS staffing will facilitate uniform service development and quality care provision.