We will update the following guidelines on self-harm to merge the content into 1 guideline:
The purpose of this exceptional review was to consider the Healthcare Safety Investigation Branch (HSIB) recommendation for NICE to 'review and amend its guidance for the management of self-harm in the emergency department'.
No additional evidence published since the previous surveillance of NICE's guidelines on self-harm in September 2016 was considered by the exceptional review.
The HSIB report Investigation into the provision of mental health care to patients presenting at the emergency department (published in 2018) focused on the provision of care to patients who present at emergency departments (ED) with mental health problems; specifically, how psychological needs can be recognised and assessed alongside physical symptoms and how timely access to psychiatric liaison services can improve the management of care and patient safety.
The investigation found that lengthy and complicated guidelines about the diagnosis and management of numerous conditions created challenges for ED staff. In the area of self-harm, the investigation found there to be different guidance available from various national bodies; the report identified that guidance to emergency department staff for initial assessment 'lacked coherence and consistency', which contributed to variability in initial assessment of people who self-harm presenting to the ED. The report further noted that the traditional model of care was changing, with liaison mental health services demonstrating a positive influence on managing the care of patients in the ED. However, the provision of these services was reported to be variable with no consensus on commissioning models. Consequently, the report recommended that NICE should review and amend its guidance for the management of self-harm in the ED.
In the 2016 surveillance review, topic experts were asked whether new evidence would affect current recommendations in NICE guidelines CG16 and CG133. Generally, the topic experts thought that an update was not needed. However, the majority of topic experts felt that the current distinction between short and long-term management of self-harm is rather artificial and suggested considering combining NICE guidelines CG16 and CG133 when an update of the guidelines is decided. Topic experts indicated that there is overlap and ambiguity between the guidelines without a logical separation between short and long-term management of self-harm, and with ED attendance insufficiently covered.
NICE guideline CG16 covers ED attendance and cross refers to NICE guideline CG133 for longer term management. However, topic experts highlighted that NICE guideline CG133 does not address the issue of starting an intervention soon after ED attendance, which should be linked to that attendance. The scope of NICE guideline CG133 does not include specific recommendations for ED services, although the guideline is relevant to their work. There is therefore a gap in NICE guidance on the immediate follow up and transition from short to longer term care. This problem is also considered by experts to exist in the NICE Pathway on self-harm. The update and merger of NICE guidelines CG16 and CG133 will aim to address the transition between short and long-term care and review issues reported by the HSIB.
Experts also highlighted that:
There is a lack of clarity about which services should be involved in each part of the pathway. The responsibility between services is poorly set out. The guidelines could be restructured by linking the recommendations to the location of service delivery – ED, general hospital (liaison) services, secondary mental health, and primary care.
There is a need for fewer but clearer research recommendations, including health services research to cover assessment in ED and follow up care. In NICE guideline CG16, the research recommendations do not focus on the key question of managing new episodes of self-harm in ED and repeated self-harm in the absence of severe mental illness.
The combined intelligence from the HSIB investigation and previous topic expert feedback indicates a strong case for merging the 2 guidelines. This could potentially provide clearer guidance on the transition between short and long-term care, particularly ED attendance and immediate follow up. Further potential benefits are updating and rationalising the recommendations, resulting in a more concise guideline that reflects current practice. It should be noted that in the 2016 review of NICE guidelines CG16 and CG133, merging the guidelines was considered but no action was taken at the time because the guidelines were not proposed for update.
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