Changing emergency department culture and processes

There is clearly an urgent need for systemic and cultural change in emergency departments if we are to meet the needs of people who present following self-harm. According to O'Keeffe and colleagues this may be fostered through approaches targeting practitioners, patients and carers. Strategies targeting practitioners might include training to address stigma (among emergency department staff but also more broadly across the community), improved supervision practices and strategies to reduce burden on individual staff members in the unfortunate (yet at times unavoidable) event that a patient subsequently dies by suicide. Strategies targeting vicarious trauma in emergency department practitioners also have the capacity to reduce burnout and improve well-being, and might include structured debriefing or reflective practice with peers. For patients, O'Keeffe and colleagues highlight the need for evidence-based interventions and discuss the potential utility of adapting the Attempted Suicide Short Intervention Program (ASSIP), an intervention designed to foster hope through building the therapeutic alliance,^{Reference Michel and Gysin-Maillart18} to the emergency department setting. Collaborative safety planning, in which practitioners work with patients to create a written, personalised plan outlining warning signs and coping strategies, has also shown promise in emergency departments.^{Reference Stanley, Brown, Brenner, Galfalvy, Currier and Knox19} More broadly (and in line with National Institute for Health and Care Excellence (NICE) guidelines and general good practice), applying the principles of compassionate care would also likely make a significant difference to the experiences of patients in the emergency department.^{Reference Cole-King, Green, Gask, Hines and Platt20} Beyond approaches targeting patients and practitioners, it is crucial that supports are provided to carers. These individuals are frequently neglected, yet they are often tasked with the responsibility of keeping the patient safe; this may be particularly important for carers of younger patients.^{Reference Byrne, Morgan, Fitzpatrick, Boylan, Crowley and Gahan21}

The physical environment of the emergency department is also often considered to be countertherapeutic to people presenting following self-harm or in a suicidal crisis;^{Reference Byrne, Bellairs-Walsh, Rice, Bendall, Lamblin and Boubis5} thus, there is scope to partner with patients and other stakeholders in order to improve some of the environmental characteristics of the emergency department (e.g. lighting), which in turn will likely lead to improved patient experiences.^{Reference Liddicoat22} More radically, dedicated psychiatric emergency services (PES) (in other words, stand-alone emergency departments specifically for psychiatric patients) may serve to remove some of the challenges associated with care provided in the emergency department.^{Reference Zeller23} PES units have been used with good effect in both the US and UK, and may also be worth pursuing elsewhere in the world. Finally, in addition to training for individual staff, strategies to improve adherence to best-practice guidelines in emergency departments should be adopted, including the active dissemination and promotion of guidelines by hospital leadership, developing protocols that clearly delineate roles and responsibilities, implementing decision support systems and ensuring that adequate time and resources are available to practitioners.^{Reference Fischer, Lange, Klose, Greiner and Kraemer24}

Access to services

Beyond emergency departments, there is a larger issue of service access. Indeed, it is acknowledged that there are risks associated with community-occurring self-harm (including risk of eventually presenting to the emergency department), yet there are barriers to accessing community-based mental health services. For example, long waiting lists, high levels of stigma and low visibility of available services often preclude people from accessing community-based support for self-harm in a timely manner. Aside from the need for extra funding for community-based services, a number of novel approaches have been developed to address this. For example some countries, including the UK, are developing alternatives to the emergency department; these are often referred to as ‘safe spaces’ and have a strong peer support component. Initial evaluations of these have shown that participants value the opportunity to develop supportive connections with peers and to discuss self-harm in an environment free of stigma.^{Reference Boyce, Munn-Giddings and Secker25} To date, however, limited evidence exists for their effectiveness. Another novel approach is the development of aftercare services. These are designed to deliver assertive follow-up care during the 3 months after presentation to the emergency department, with the aim of reducing suicide risk and increasing engagement with services. These are gaining traction in Australia, and early indications suggest that they are acceptable to patients and staff and that they appear to reduce rates of re-presentation to the emergency department.^{Reference Wright, Lee, Rylatt, Henderson, Cronje and Kehoe26} Robust evaluation is now required to assess their effectiveness, including their cost-effectiveness, and to ensure that they do not further fragment an already fragmented system of care. Of course, a patient's likelihood of engaging with aftercare services (or any other mental health service) is likely to be influenced by their experience in the emergency department, further emphasising the need to provide quality care at that first point of contact. Nonetheless, the broad implementation of new approaches such as safe spaces or aftercare services, combined with adequate funding for both primary and secondary healthcare services, would probably reduce pressure on emergency departments. This in turn would reduce the burden on practitioners and ultimately improve the experiences and treatment outcomes of patients.

Stigma

Finally, it is acknowledged that stigmatising attitudes towards self-harm are widely held, in both the healthcare system and beyond. At a broader population level, approaches addressing this stigma, such as media campaigns or psychoeducation programmes delivered in educational settings, are required. Reduced stigma at a population level will likely have flow-on effects, including increased compassion on the part of health practitioners and improved well-being for people who self-harm.