Advice for healthcare professionals in any setting

Advice for healthcare professionals in any setting General principles Always treat people with care and respect Ensure privacy for service user Take full account of the likely distress associated with self-harm Offer the choice of male or female staff for assessment and treatment If it is not possible to give people their choice, explain why and write it in the notes Always ask the service user to explain why they have selfharmed in their own words Involve service user in clinical decision-making; provide information about treatment options Remember, when people self-harm often, the reason for each act may be different on each occasion; don t assume it s done for the same reasons Relatives, carers and friends Include family or friends if the service user wants their support during assessment and treatment Psychosocial assessment usually needs some time with service user alone Relatives/carers may need emotional support Self Harm: NICE guideline (January, 2004) Page 1 of 15

Consent Always assess mental capacity interview relatives/friends to help assessment Assume mental capacity unless evidence to the contrary Obtain fully informed consent before each treatment or procedure is started including taking to hospital If mentally incapable always act in the person s best interest even if against the person s wishes includes taking to hospital when person has refused Always attempt to gain consent for each and every new treatment. Remember, capacity changes over time. The mental health act can be used to treat the physical consequences of self-harm Specific issues regarding treatment and care When physical treatments are offered Ambulance staff and primary care practitioners involved in the treatment of self-harm should ensure that activated charcoal is always available for immediate use Always offer necessary physical treatments even if the person doesn t want psychosocial or psychiatric assessment Always use proper anaesthesia if treatment is painful Offer sedation if treatment may evoke distressing memories of previous sexual abuse, such as when repairing harm to the genital area Self Harm: NICE guideline (January, 2004) Page 2 of 15

Activated charcoal Primary care, ambulance and emergency department staff involved in the treatment of self-harm by poisoning should offer activated charcoal appropriately within 2 hours of ingestion Know how to administer it Know for which poisons activated charcoal should and should not be used Know the potential dangers and contraindications of giving activated charcoal Know that it s important to encourage and support service users when offering activated charcoal Self Harm: NICE guideline (January, 2004) Page 3 of 15

The management of self-harm in primary care Urgently establish physical risk and mental state in a respectful and understanding way Assess risk of further self-harm Especially consider depression, hopelessness and suicidal intent Inform other relevant staff and organisations of the outcome of this assessment Self-injury If in doubt about whether to refer Discuss with the emergency consultant Self-poisoning If there is significant risk to the service user refer to A&E urgently if can t get to A&E quickly (remote areas) Discuss with emergency consultant. Consider initiating treatment and collect samples as necessary (for self-poisoning) Tell the ambulance crew what treatment you have given Refer to A&E urgently unless you are sure this isn t necessary (always do so if you have given activated charcoal) Remember many people aren t sure what drugs they ve taken. Arrange for appropriate chaperone when service user going in ambulance to A & E if There is a risk of further self-harm Person is reluctant to attend Service user is very distressed Offer activated charcoal as early as possible If within two hours of ingestion, the service user is fully conscious, service user able to protect his or her own airway, substance ingested indicates use of activated charcoal Tell patient activated charcoal is unpleasant and encourage them whilst they are taking it Self Harm: NICE guideline (January, 2004) Page 4 of 15

When urgent referral to the emergency department is not necessary Does the person need urgent referral to secondary mental health services? Base decision on risk and needs assessment, including: Social and psychological aspects of episode of self-harm mental health and social needs hopelessness suicidal intent Send full details of assessments and treatment to the appropriate secondary mental health team as soon as possible Prescribing to service users at risk of selfpoisoning When prescribing drugs to: people who have previously self-poisoned people who are at risk of doing selfpoisoning people who live with someone at risk of selfpoisoning Always prescribe those drugs which are the least dangerous in overdose Prescribe fewer tablets at any one time Consider alternatives to co-proxamol Self Harm: NICE guideline (January, 2004) Page 5 of 15

The assessment and initial management of self- harm by ambulance personnel Urgently establish physical risk and mental state in respectful and understanding way Selfpoisoning Selfinjury Unless the service user s clinical condition requires urgent attention, record all relevant information at the scene: home environment, social/family support network and history leading to self-harm. Pass information to A&E staff on arrival If person is likely to refuse treatment assess mental capacity Obtain all substances and/or medications found at the scene. Give them to A&E staff on arrival If within two hours of ingestion, the service user is fully conscious, service user able to protect his or her own airway, substance ingested indicates use of activated charcoal Self-poisoning with opioids If unsure if pre-hospital treatment needed or ingestion of unusual substance provide information about the potential consequences of not receiving treatment Self Harm: NICE guideline (January, 2004) Page 6 of 15 continue to try to gain valid consent and follow guidance on consent Offer activated charcoal as early as possible Tell patient activated charcoal is unpleasant and encourage them whilst they are taking it Consider IV naloxone: Follow JRCALC guidelines Pay attention to the need for repeat doses Monitor vital signs frequently Consult TOXBASE If consent is withheld follow guidance on consent Take straight to A&E, even if they have responded well to initial treatment Consider service user s preference if more than one A & E nearby Ignore preferences if this increases risk If the service user does not require treatment at A&E consider taking the person to an alternative appropriate service. Must be agreed with alternative service and the service user

The treatment and management of self-harm in emergency departments Triage Take account of emotional distress as well as physical Remember, some people who self-harm may not show distress even when severe People waiting for physical treatments Don t delay psychosocial assessment until after medical treatment Provide verbal and written information about the care process Offer psychosocial assessment at triage to determine EXCEPT WHEN: Service user needs life-saving treatment Patient is unconscious Patient incapable of assessment (e.g. intoxicated) Must be in a language service user understands mental capacity willingness to remain for further psychosocial assessment distress levels presence of mental illness Provide a safe, supportive environment where people can wait Service user may need supervision to ensure safety People who wish to leave before assessment and/or treatment If person wants to leave before a psychosocial assessment If mental capacity diminished, and/or significant mental illness Assess for: mental capacity/ mental illness Record assessment in the notes refer for urgent mental health assessment prevent the person leaving Self Harm: NICE guideline (January, 2004) Page 7 of 15

Medical and surgical management of self-harm General treatment for ingestion Only offer gastrointestinal decontamination if person: presents early is fully conscious has a protected airway is at risk of significant harm from the ingested substance If consciousness is impaired, and patient cannot adequately protect their own airway, and there is considerable risk from the ingested substance Offer activated charcoal, unless contraindicated, as early as possible and within 2 hours after ingestion Consider giving activated charcoal via a nasogastric tube in conjunction with endotracheal intubation only Tell patient activated charcoal is unpleasant and encourage them whilst they are taking it Beware: increased risk of aspiration pneumonitis Don t offer multiple doses of activated charcoal, unless specifically recommended by TOXBASE or the NPIS Don t use emetics, including ipecac Don t use cathartics Don t use gastric lavage, except on the advice of NPIS or a poisons treatment centre Collecting samples and interpreting results Information and laboratory services available to clinicians treating selfpoisoning Collect samples Blood Ingested substances Other samples if NPIS require them Use TOXBASE as the primary source of information about the treatment of poisoning Contact the NPIS only after consulting TOXBASE Consult TOXBASE to select and interpret assays: If in doubt check with local laboratory Still in doubt consult with NPIS Except in the use of activated charcoal for self-poisoning In poisoning with unusual substance, pass data to NPIS Consult TOXBASE to interpret assay results: if in doubt check with local laboratory Still in doubt consult with NPIS Consult TOXBASE for the specific management and treatment of overdose with substances not covered in this guideline Self Harm: NICE guideline (January, 2004) Page 8 of 15

For all conscious patients with a history of paracetamol overdose, or suspected paracetamol overdose Paracetamol screening For patients with a presentation consistent with opioid poisoning Measure plasma paracetamol concentrations Management of paracetamol overdose Offer activated charcoal as indicated above Use TOXBASE to guide further management For unconscious patients with a history of collapse where drug overdose is a possible diagnosis Use IV N-acetylcysteine 1 (NAC) Except: in patients who report previous proper anaphylactic reactions following administration of NAC for people who abuse intravenous drugs where intravenous access may be difficult in people with needle phobia in these cases consult TOXBASE In cases of staggered ingestion of paracetamol Consult TOXBASE, then the NPIS If patient has anaphylactoid reaction to NAC Flumazenil in benzodiazepine overdose If benzodiazepine poisoning suspected and: Patient unconscious or marked impairment of consciousness and respiratory depression present Consider flumazenil to aid diagnosis Use small doses Resuscitation equipment must be available Check for other ingested substances If positive diagnosis, and improving consciousness clinical priority and respiration depressed, and concomitant tricyclic antidepressant poisoning excluded Then use flumazenil therapeutically use the minimum effective dose for only as long as is clinically necessary monitor and document known side effects, such as convulsions Self Harm: NICE guideline (January, 2004) Page 9 of 15

Treatment and management of poisoning with salicylates Use activated charcoal as above Use TOXBASE for further management Treatment of opioid overdose If opioid poisoning suspected, and Impaired consciousness and Respiratory depression Use naloxone for diagnosis and treatment Use minimum effective dose If patient dependent on opioids: give slowly and prepare for agitation if long-acting opioids (e.g. Methadone) present: consider IV Infusion Monitor vital signs and oxygen saturation until patient conscious and adequate breathing without further naloxone Giving advice to people who repeatedly self-poison Don t offer harm minimisation advice regarding selfpoisoning there are no safe limits. Consider discussing the risks of self-poisoning with service users (and carers, where appropriate) who are likely to use this method of self-harm again. Self Harm: NICE guideline (January, 2004) Page 10 of 15

General treatment for self injury Remember: Don t delay treatment because it is selfinflicted Take account of the distress involved in self-harm and in seeking treatment Explain the treatment options to the service user Discuss fully with the service user his or her treatment preferences Wound closure Always use anaesthesia if treatment may be painful For superficial uncomplicated injuries of 5cm or less in length offer tissue adhesive as the first-line treatment Offer skin closure strips if service user prefers this For superficial uncomplicated injuries of greater than 5cm, or deeper injuries of any length assess and explore the wound and follow good surgical practice Offering support and advice for people who selfinjure repeatedly Consider giving advice and instructions on Self-management of superficial injuries, including providing tissue adhesive. Harm minimisation issues and technique Appropriate alternative coping strategies Discuss with a mental health worker which service users should be offered this Voluntary organisations may have suitable materials Dealing with scar tissue Self Harm: NICE guideline (January, 2004) Page 11 of 15

Psychosocial Assessment Assessment of need (specialist mental health professionals) Assess needs and risks as part of the therapeutic process to understand and engage the service user Assessment of risk (specialist mental health professionals) Offer needs assessment to all people who self-harm. Consider integrating needs and risk assessment. Assess all people who selfharm for risk. Include: Include: Social, psychological and motivational factors specific to the act of self-harm current intent hopelessness mental health and social needs assessment Record assessment in notes Share written assessment with service user If disagreement consider service user recoding this in the notes Identification of the main clinical and demographic features known to be associated with risk of further self-harm and/or suicide Identification of the key psychological characteristics associated with risk: Depression Hopelessness continuing suicidal intent Record assessment in notes Only use a standardised riskassessment scale to aid identification of those at high risk of repetition of self-harm or suicide. Don t use standardised riskassessment scales to identify service users of supposedly low risk who are not then offered services Self Harm: NICE guideline (January, 2004) Page 12 of 15

Referral, Discharge and Admission following psychosocial assessment Explain to service user Write explanation in the notes Discuss: Treatment options Service users preference Provide relevant written information Decide options jointly with the Service User Base decisions about referral, discharge and admission on comprehensive assessment including needs and risks If: Very distressed Home considered unsafe Too difficult to undertake psychosocial assessment If not possible e.g. Reduced mental capacity Significant mental illness Consider admission overnight Re assess the following day Do not refer only on the basis that they have self-harmed Do not discharge without a follow up solely on the basis of low risk and no mental illness Consider offering an intensive therapeutic intervention combined with outreach to people who have selfharmed and are deemed to be at risk of repetition Intensive intervention should allow greater access to a therapist than good standard care, and outreach should include following up the service user when an appointment has been missed. The therapeutic intervention plus outreach should continue for at least 3 months Refer for further assessment and treatment according to underlying problems associated with self-harm Self Harm: NICE guideline (January, 2004) Page 13 of 15 Consider DBT for people with Borderline Personality Disorder However, don t ignore other psychological treatments for people with this diagnosis, which are outside the scope of this guideline

Triage, assessment and treatment should be undertaken by: paediatric nurses and doctors trained to work with children and young people who self-harm All children and young people should be admitted into a paediatric ward under the overall care of a paediatrician After admission, the paediatric team should obtain consent for mental health assessment from the child or young person s parent, guardian or other legally responsible adult Special issues for children and young people In A & E in a separate area for children and young people Alternative placements may be needed, depending on: Age Circumstances of the child and their family Time of presentation Child protection issues Physical and mental health of the child Preferences of the child or young person Undertake assessment addressing: Needs and risks for the child (similar to adults) The family The social situation of family and young person Child protection issues Assessors should be specifically trained and supervised to work with self-harm in this age group For young people who have self-harmed several times: If you are involved with children or young people in the emergency treatment of self-harm, you must understand how issues of capacity and consent apply to this group Special attention should be given to: Confidentiality, Consent (including Gillick Competence), Child protection issues, The use of the Mental Health Act and the Children Act During admission, the CAMHS team should: Provide consultation for: The young person Their family The paediatric team Before the child or young person goes home advise carers to remove all means of self-harm, including medication Self Harm: NICE guideline (January, 2004) Page 14 of 15 Social services Education staff Consider offering developmental group psychotherapy with other young people; this should include at least 6 sessions but can be extended by mutual agreement

Special issues for older people You must be experienced in assessing older adults who have self-harmed to undertake assessment of this age group. Follow the same principles as for the assessment of adults, but also include a full assessment with special attention to: the possible presence of depression cognitive impairment Be aware: physical ill health their social and home situation All acts of self-harm in people over the age of 65 years should be taken as evidence of suicidal intent until proven otherwise Always consider admission for: mental health assessment risk and needs assessment monitoring changes in mental state and levels of risk Self Harm: NICE guideline (January, 2004) Page 15 of 15