Clinical pathways for suicidality in emergency settings: a public health priorityKay Wilhelm A B D , Viola Korczak B , Tad Tietze A B and Prasuna Reddy B C
A School of Psychiatry, Faculty of Medicine, University of New South Wales, Randwick, NSW 2031, Australia.
C School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia. Email: firstname.lastname@example.org
D Corresponding author. Email email@example.com
Australian Health Review - https://doi.org/10.1071/AH16008
Submitted: 1 February 2016 Accepted: 1 May 2016 Published online: 23 June 2016
Rates of self-harm in Australia are increasing and constitute a concerning public health issue. Although there are standard treatment pathways for physical complaints, such as headache, abdominal pain and chest pain, in Emergency Medicine, there is no national pathway for self-harm or other psychiatric conditions that present to the emergency department. Herein we outline the difference between clinical practice guidelines and clinical pathways, discuss pathways we have identified on self-harm in Australia and overseas and discuss their applicability to the Australian context and the next steps forward in addressing this public health issue.
Additional keyword: emergency department.
Suicidality, clinical practice guidelines and clinical pathways
Although suicide is a comparatively rare event, suicidality (self-harm behaviours and suicidal ideation) is relatively common in the community and an important part of the work of emergency departments (EDs) and acute mental health services.
Over their lifetimes, 2.1 million Australians aged 16–85 years experience serious thoughts about taking their own life; over 600 000 make a suicide plan and over 500 000 attempt suicide.1 Hospitalisation rates for intentional self-harm have increased in Australia to 27 112 presentations in 2011–12 and suicide is the commonest cause of death in Australians aged 18-44 years.2
Although most people presenting with suicidality are acutely emotionally distressed, depressed and/or in crisis, they are a very heterogeneous group. This is evidenced by the wide variety of risk factors identified for suicidality, including anxiety and depressive disorders, substance abuse,3,4 history of sexual abuse,5 body image or weight control issues,6,7 psychiatric problems or social isolation,7,8 and poor family communication or family breakdown.3,9 This diversity creates challenges in providing appropriate clinical management and has led experts to highlight the need to understand the patient’s predicament10 rather than focusing on psychiatric diagnosis in assessment and management.
There are local and UK clinical practice guidelines (CPGs) available for self-harm.11,12 CPGs are defined as ‘systematically developed statements that assist clinicians and patients in making decisions about appropriate treatment for specific conditions’.12 They should provide current evidence-based recommendations that set clinical standards and assist patients to make informed decisions.12 The National Institute for Heath and Care Excellence (NICE) guidelines12,13 have been particularly influential in this regard. CPGs are usually thick documents with recommendations intended as general guidance, but their usefulness is limited by factors such as whether they are easily accessible and translatable into local contexts, lack of research evidence on effectiveness and low-quality implementation methodology.12
The term ‘clinical practice guideline’ is often used interchangeably with ‘clinical pathway’, despite their differences. Although CPGs are predicated on high-level principles requiring translation into local clinical use, clinical pathways ‘integrate medical treatment protocols, nursing care plans and activities of allied healthcare professionals into a single care plan, which clearly defines the expected progress and outcomes of a patient through the hospital system’.14 The term ‘clinical pathway’ has been in the literature since the 1980s.15,16
Where CPGs are broader in scope, more detailed and seek to include all patient population groups, effective clinical pathways should capture 60–80% of the target population because they are designed for ‘usual’ patients.14 Pathways are focused on the clinical side, or ‘coalface’, of medicine and the best ones are driven by practicing clinicians.14 The advantages of clinical pathways include reduced delays, lower length of stay and less variation in treatment.14,17,18
What clinical pathways are available?
We reviewed the literature to identify clinical pathways for self-harm and to determine what they covered, as well as their potential for use in an Australian context. Kinsman et al.15 had undertaken a systematic literature review and we used their criteria (noted in Table 1) to assess the seven pathways we identified. Of the seven pathways we identified (Table 1), six included a flow diagram to facilitate interpretation and expedite use, something that increases the usefulness of the pathways for busy clinicians.
Most of the pathways19–23 were developed and implemented within the UK for young people in local health areas as a response to the NICE guidelines.12,13 The single Australian pathway18 was more broadly based and the only one evaluated empirically. The nurse-led pathway is for all attenders and aims to expedite the course of suicidal people through ED24. Locally in New South Wales (NSW), Project Air is intended only for people with personality disorders,25 and the Green Card Clinic at St Vincent’s Hospital26 provides pathways for suicidal people that go beyond the ED and could dovetail with ED-focused pathways. Between them, these pathways provide elements to inform models for clinical pathways that local services could develop across all age bands.
We note the finding that people presenting with suicidality often have poor lifestyle habits and increased future morbidity not only from suicide and accidents, but also from many common medical conditions.27,28 This, coupled with the increasing number of suicidality presentations in a heterogeneous group of patients and the need to encourage community-based approaches for follow-up instead of using the ED for repeat crisis presentations, highlights the importance of implementing clinical pathways for local settings as important issues in health service and public health domains.
Where to next?
There are several steps in developing a clinical pathway for suicidality: (1) moving the conversation from ‘what is a clinical pathway?’ to ‘why is a pathway needed for suicidality’?; (2) bringing together relevant stakeholder groups at a local health service or district level; (3) appraising available models and the relevant CPGs; and (4) evaluating the implementation of candidate pathways for outcomes such as the number of people for whom it is relevant, the effect at different time points and decreases in the number of repeat presentations to the ED and attempted suicide rates.
There are well-established pathways used in EDs in NSW for physical health problems such as chest pain, headache, abdominal pain and head injury. There is a recently revised state-wide reference guide for psychiatric presentations,29 alongside a new policy statement on care of people who may be suicidal.30 However, both deal with these issues in a very general way. The nearest either gets to a pathway is a rudimentary flowchart in the former, the ‘Framework for Suicide Risk Assessment and Management for NSW Health Staff’, itself republished from a 2004 guideline for managing suicidality in EDs.31 Addressing the discrepancy between how physical and mental health presentations (including suicidality) are approached is a good starting point. The updated Australian CPG11 will be available in late 2016 and provide added opportunity for this to happen. We also recommend extending suicidality pathways beyond the confines of the ED to anticipate longer-term solutions for people presenting in crisis and to decrease the reliance on the ED for those with repeated suicidality and crisis presentations. We propose that treating suicidality as a public health issue will promote appropriate prevention and management strategies inside and outside hospital and clinical settings.32
Professor Greg Carter, Professor Michael Dudley and Associate Professor Peter McGeorge provided helpful comments and advice on the current pathways and guidelines locally.
References Australian Government Department of Health. Mental health of Australians 2: suicidality. 2009. Available at: http://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-m-mhaust2-toc~mental-pubs-m-mhaust2-hig~mental-pubs-m-mhaust2-hig-sui [verified 17 December 2015].
 Australian Bureau of Statistics. Causes of death, 2014. 2016. Available at: http://www.abs.gov.au/ausstats/abs@.nsf/Previousproducts/78FC28EE32C91EC3CA257B2E000D75C3?opendocument [verified 16 May 2016].
 Anderson M. Waiting for harm: deliberate self-harm and suicide in young people: a review of the literature. J Psychiatr Ment Health Nurs 1999; 6 91–100.
| Waiting for harm: deliberate self-harm and suicide in young people: a review of the literature.CrossRef | 1:STN:280:DyaK1MzosVGgsw%3D%3D&md5=1fff965283e9cc9a17b25a5043e6305eCAS | 10455619PubMed |
 Fortune SA, Hawton K. Suicide and deliberate self-harm in children and adolescents. Paediatr Child Health 2007; 17 443–7.
| Suicide and deliberate self-harm in children and adolescents.CrossRef |
 Tsai MH, Chen YH, Chen CD, Hsiao CY, Chien CH. Deliberate self-harm by Taiwanese adolescents. Acta Paediatr 2011; 100 e223–6.
| Deliberate self-harm by Taiwanese adolescents.CrossRef | 21575057PubMed |
 Wan YH, Hu CL, Hao JH, Sun Y, Tao FB. Deliberate self-harm behaviors in Chinese adolescents and young adults. Eur Child Adolesc Psychiatry 2011; 20 517–25.
| Deliberate self-harm behaviors in Chinese adolescents and young adults.CrossRef | 21866416PubMed |
 Mahadevan S, Hawton K, Casey D. Deliberate self-harm in Oxford University students, 1993–2005: a descriptive and case-control study. Soc Psychiatry Psychiatr Epidemiol 2010; 45 211–9.
| Deliberate self-harm in Oxford University students, 1993–2005: a descriptive and case-control study.CrossRef | 19396386PubMed |
 Haw C, Hawton K. Life problems and deliberate self-harm: associations with gender, age, suicidal intent and psychiatric and personality disorder. J Affect Disord 2008; 109 139–48.
| Life problems and deliberate self-harm: associations with gender, age, suicidal intent and psychiatric and personality disorder.CrossRef | 18221789PubMed |
 Hawton K. Deliberate self-harm. Medicine 2004; 32 38–42.
| Deliberate self-harm.CrossRef |
 Ryan CJ, Large M, Gribble R, Macfarlane M, Ilchef R, Tietze T. Assessing and managing suicidal patients in the emergency department. Australas Psychiatry 2015; 23 513–16.
| Assessing and managing suicidal patients in the emergency department.CrossRef | 26224697PubMed |
 Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Deliberate Self-harm Australian and New Zealand clinical practice guidelines for the management of adult deliberate self-harm. Aust N Z J Psychiatry 2004; 38 868–84.
| Australian and New Zealand clinical practice guidelines for the management of adult deliberate self-harm.CrossRef | 15555020PubMed |
 National Collaborating Centre for Mental Health. Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. National Clinical Practice Guideline Number 16. London: Gaskell & British Psychological Society; 2004.
 National Institute for Heath and Care Excellence (NICE). Self-harm: the NICE guideline on longer term management. Guideline Number 133. London: NICE; 2012.
 Cheah TS. Clinical pathways: the new paradigm in healthcare? Med J Malaya 1998; 53 87–96.
| 1:STN:280:DC%2BD3cvjtVGqsQ%3D%3D&md5=cee665d5fb62a83201248f85646087c1CAS | 10968144PubMed |
 Kinsman L, Rotter T, James E, Snow P, Willis J. What is a clinical pathway? Development of a definition to inform the debate. BMC Med 2010; 8 31
| What is a clinical pathway? Development of a definition to inform the debate.CrossRef | 20507550PubMed |
 Rotter T, Kinsman L, James E, Machotta A, Willis J, Snow P, Kugler J. The effects of clinical pathways on professional practice, patient outcomes, length of stay, and hospital costs: Cochrane systematic review and meta-analysis. Eval Health Prof 2012; 35 3–27.
| The effects of clinical pathways on professional practice, patient outcomes, length of stay, and hospital costs: Cochrane systematic review and meta-analysis.CrossRef | 21613244PubMed |
 Coffey RJ, Richards JS, Remmert CS, LeRoy SS, Schoville RR, Baldwin PJ. An introduction to critical paths. Qual Manag Health Care 2005; 14 46–55.
| An introduction to critical paths.CrossRef | 15739581PubMed |
 Whyte IM, Dawson AH, Buckley NA, Carter GL, Levey CM. Health care. A model for the management of self-poisoning. Med J Aust 1997; 167 142–6.
| 1:STN:280:DyaK2svhsVGktA%3D%3D&md5=0f38fd46cd45fb0a21af38c03d9aea24CAS | 9269269PubMed |
 Children’s Trust Partnership Hertfordshire. Self-harm and suicidal behaviour: a guide for staff working with children and young people in Hertfordshire. 2010. Available at: http://www.thegrid.org.uk/leadership/programmes/conferences/documents_safeguarding/selfharm_suicide_guidance.pdf, page 11 [verified 17 May 2016].
 Derby City Council. Multi-agency self-harm protocol. 2010. Available at: http://www.derby.gov.uk/media/derbycitycouncil/contentassets/documents/safeguardingchildreninformation/SelfHarmBooklet.pdf, page 12 [verified 16 May 2016].
 Lancashire NHS Trust. Lancashire Care self-harm pathway. 2009. Available at: https://www.lancashirecare.nhs.uk/media/Clinical%20Care%20Pathways/Self%20Harm%20Pathway%20Full.pdf [verified 16 May 2016].
 Shropshire Safeguarding Children Board. Suicide prevention: care pathway for children and young people in Shropshire, page 21. 2013. Available at: https://shropshire.gov.uk/committee-services/documents/s1822/Appendix%20C%20V18%2004.03.14%20Self%20Harm%20Policy%20and%20Guidelines.pdf [verified 16 December 2015].
 Kripalani M, Nag S, Nag S, Gash A. Integrated care pathway for self-harm: our way forward. Emerg Med J 2010; 27 544–6.
| Integrated care pathway for self-harm: our way forward.CrossRef | 20584956PubMed |
 Steel M. A nurse-led pathway to treat self-harm injuries. Nurs Times 2015; 111 17–20.
| 26427255PubMed |
 Greyner B. An integrated step-down model of care: the Project Air strategy for personality disorders. Acparian 2015; 9 8–13.
 Wilhelm K, Finch A, Kotze B, Arnold K, McDonald G, Sternhell P, Hudson B. The Green Card Clinic: overview of a brief patient-centred intervention following deliberate self-harm. Australas Psychiatry 2007; 15 35–41.
| The Green Card Clinic: overview of a brief patient-centred intervention following deliberate self-harm.CrossRef | 17464632PubMed |
 Wilhelm K, Handley T, Reddy P. Exploring the validity of the Fantastic Lifestyle Checklist in an inner city population of people presenting with suicidal behaviours. Aust N Z J Psychiatry 2016; 50 128–34.
| Exploring the validity of the Fantastic Lifestyle Checklist in an inner city population of people presenting with suicidal behaviours.CrossRef | 26681263PubMed |
 Hawton K, Harriss L, Zahl D. Deaths from all causes in a long-term follow-up study of 11,583 deliberate self-harm patients. Psychol Med 2006; 36 397–405.
| Deaths from all causes in a long-term follow-up study of 11,583 deliberate self-harm patients.CrossRef | 1:STN:280:DC%2BD28%2FovVeitw%3D%3D&md5=a073b6ca60eec3ee2463a9db65396174CAS | 16403244PubMed |
 Mental Health and Drug and Alcohol Office. Mental health for Emergency Departments: a reference guide. Sydney: NSW Department of Health; 2009.
 NSW Health. Suicide risk assessment and management: Emergency Department. Sydney: NSW Health; 2004.
 Centre For Mental Health Policy. Guidelines for the management of patients with possible suicidal behaviour for NSW Health staff and staff in private hospital facilities. NSW Department of Health Circular 98/31. Sydney: Ministry of Health; 2016.
 Martin G, Swannell SV, Hazell PL, Harrison JE, Taylor AW. Self-injury in Australia: a community survey. Med J Aust 2010; 193 506–10.
| 21034383PubMed |