Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, e109ee110
CORRESPONDENCE AND COMMUNICATION “Cuts are costly”: A review of deliberate self-harm admissions to a district general hospital plastic surgery department over a 12-month period Dear Sir, Deliberate self-harm is defined as an intentional injury to oneself, typically as an expression of a psychosomatic or psychiatric condition, however not necessarily associated with suicidal objective. The United Kingdom has one of the highest incidences of self-inflicted injuries in Europe; nationally between 1998 and 2005, these attributed to 77,854 attendances to hospital and 141,356 admissions.1 While self inflicted incised wounds were the commonest mode of presentation to our DGH, we noted differences in structural damage sustained by single attender patients compared to patients attending on multiple occasions. In this study we Table 1
compared the costs and injury patterns in single versus multiple attender patients. We generated a database of all patients seen with a selfharm injury by reviewing all emergency referrals to the Plastic Surgery Department from 1st January to 31st December 2012. Parameters examined included gender, requirement for admission, surgical intervention, length of inpatient stay and follow up. Patients who attended on numerous occasions with self inflicted injuries were defined as multiple attenders. We excluded management of these specific patients by other surgical and medical specialities. Information relating to each admission was obtained from medical notes review and costs were calculated from data obtained from the medical coding and finance department. Twenty-one patients were admitted under Plastic Surgery with a diagnosis of self-harm, accounting for a total of 42 episodes. Single attender patients accounted for a total of 14 episodes (males n Z 9, females n Z 5). Their treatment, follow-up and cost of stay is summarised in Table 1. Pre-disposing factors for self-harm included depression, alcohol and substance abuse. All patients presented with incised wounds. Twelve patients required a general anaesthetic exploration, ten of whom sustained structural injuries, two were managed with a local anaesthetic exploration with removal of a foreign body in one case and wound debridement and closure in the other. The average
Summary of single attender patients (male and female).
Length of stay (days)
GA/LA
Structures repaired
Clinic follow up
Total cost (£)
3 Daycase 1 Daycase 4 1 2 4 9 1 1 1 1 Daycase
GA GA GA GA GA GA GA GA GA GA GA LA LA GA
Flexor tendon þ Achilles Single flexor tendon All long flexors, ulnar nerve þ artery Flexor tendon and digital artery Single flexor þ ulnar nerve Soleus Removal foreign body Examination under anaesthetic MN, all long flexors Three flexor tendons Two flexor tendons EUA þ wound closure Pronator teres partial tear Flexor tendon þ cutaneous nerve
1 2 2 2 DNA 2 0 DNA DNA 2 2 0 DNA 2
6500 6200 4300 2200 2200 2000 2000 1900 1400 1300 1100 600 400 250
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.10.036
e110 Table 2 Admissions
Correspondence and communication Summary of multiple attender patients. Total length of inpatient stay (days)
3
3
6
2
4
11
2 3
3 1
7
1
3
4
GA/LA
Structures repaired
Clinic follow up
Total cost (£)
GAx2 LAx1 GAx4 LAx2 GAx4
Removal foreign body
2
8900
Removal foreign body
0
5600
Single extensor Wound closure Wound closure Removal foreign body
1
3700
1 0
3600 3000
Removal foreign body, wound closure
1
2200
Removal foreign body
1
1700
GAx2 GAx2 LAx1 GAx4 LAx3 GAx3
length of stay was 2 days (range 1e8 days). Patients were discharged to the care of the psychiatric team or home with community support, with outpatient hand rehabilitation. Seven patients attended on multiple occasions; all of whom were female and in-patient residents at a nearby psychiatric hospital. They accounted for a total of 28 episodes under Plastic Surgery over the 12-month period, which is summarized in Table 2. All of the patients in this group had a diagnosis of borderline/emotional unstable personality disorder; additional conditions included depression and anxiety. The vast majority of these episodes (n Z 27) involved either exploration of wounds and repair of skin lacerations or removal of foreign body. Procedures were performed in main theatre under general anaesthetic (21 episodes) or in the emergency department under local anaesthetic (7 episodes). Foreign bodies retrieved included broken CDs, biros, screws, hair grips, and paperclips. None of the patients in this group sustained significant structural injury, unlike the single attender group. The majority of these episodes were managed as day cases and the average length of stay per patient was 1 day. The cost of managing these patients was calculated from data provided by the coding and finance department. The total cost of single attender patients was £32,350, averaging £2300 per patient; while multiple attenders cost the Trust £28,700, with each patient costing £4100 on average. Our results demonstrate that both single and multiple attender self-harm patients cost substantial amounts of money to the NHS. Single attenders referred from the community, and particularly male patients tended to have more serious attempts at self-harm, with significant tendon and arterial injuries sustained yet conversely, all multiple attenders cost more on average (£4100 versus £2300) in the absence of significant structural injuries as a direct consequence of repeated admissions. The current management of surgical exploration and repair acts only as a temporary measure and does not address the actual cause of self-harm. Prevention of self inflicted injury in multiple attender patients was reported to be difficult by carers, in particular deterring access to objects with which to self-harm. Suggested methods to managing this includes multi-disciplinary management by collaboration with the psychiatric team,2 by options of leaving foreign bodies in situ1 and straightforward wound care rather than immediate general anaesthetic exploration.1,3 Early post
operative psychiatric follow-up to ascertain the precipitating factors for the episode of self-harm, improved supervision and supportive care, rewarding good behaviour and teaching coping mechanisms has been shown to be beneficial in preventing further injuries and thereby reducing number of admissions.4 Similarly, improving access to community care, support groups, alcohol rehabilitation, early recognition and referral to psychiatric services may help prevent self-harm in the single attender group. NICE guidelines have suggested carrying out an RCT examining 6 sessions of cognitive behavioural therapy following discharge post self-harm.5 We recommend further studies into promoting self-harm prevention through increased awareness of vulnerable patients and adherence to NICE guidelines in caring for them.
Conflict of interest/funding None.
References 1. Wraight WM, Belcher HJ, Critchley HD. Deliberate self-harm by insertion of foreign bodies into the forearm. J Plast Reconstr Aesthet Surg 2008;61(6):700e3. 2. Khundkar RMN, Estela C. Management of self-harm patients: a case for joint approach. J Plast Reconstr Aesthet Surg 2009; 62(12):e599e600. 3. Hold PM, Brackley P, Procter D, James MI. Self-harm, the psychiatric inpatient and the plastic surgeon. J Plast Reconstr Aesthet Surg 2010;63(1):e124e5. 4. Henderson A, Wijewardena A, Streimer J, Vandervord J. Selfinflicted burns: a case series. Burns 2013;39(2):335e40. 5. Self-harm. The National Institute for Clinical Excellence; 2004.
Fionnuala M. O’Leary Michelle C.I. Lo Frederik B. Schreuder Department of Plastic and Reconstructive Surgery, Lister Hospital, Coreys Mill Lane, Stevenage SG1 4AB, Herts, United Kingdom E-mail address: [email protected]
15 July 2013
CORRESPONDENCE AND COMMUNICATION “Cuts are costly”: A review of deliberate self-harm admissions to a district general hospital plastic surgery department over a 12-month period Dear Sir, Deliberate self-harm is defined as an intentional injury to oneself, typically as an expression of a psychosomatic or psychiatric condition, however not necessarily associated with suicidal objective. The United Kingdom has one of the highest incidences of self-inflicted injuries in Europe; nationally between 1998 and 2005, these attributed to 77,854 attendances to hospital and 141,356 admissions.1 While self inflicted incised wounds were the commonest mode of presentation to our DGH, we noted differences in structural damage sustained by single attender patients compared to patients attending on multiple occasions. In this study we Table 1
compared the costs and injury patterns in single versus multiple attender patients. We generated a database of all patients seen with a selfharm injury by reviewing all emergency referrals to the Plastic Surgery Department from 1st January to 31st December 2012. Parameters examined included gender, requirement for admission, surgical intervention, length of inpatient stay and follow up. Patients who attended on numerous occasions with self inflicted injuries were defined as multiple attenders. We excluded management of these specific patients by other surgical and medical specialities. Information relating to each admission was obtained from medical notes review and costs were calculated from data obtained from the medical coding and finance department. Twenty-one patients were admitted under Plastic Surgery with a diagnosis of self-harm, accounting for a total of 42 episodes. Single attender patients accounted for a total of 14 episodes (males n Z 9, females n Z 5). Their treatment, follow-up and cost of stay is summarised in Table 1. Pre-disposing factors for self-harm included depression, alcohol and substance abuse. All patients presented with incised wounds. Twelve patients required a general anaesthetic exploration, ten of whom sustained structural injuries, two were managed with a local anaesthetic exploration with removal of a foreign body in one case and wound debridement and closure in the other. The average
Summary of single attender patients (male and female).
Length of stay (days)
GA/LA
Structures repaired
Clinic follow up
Total cost (£)
3 Daycase 1 Daycase 4 1 2 4 9 1 1 1 1 Daycase
GA GA GA GA GA GA GA GA GA GA GA LA LA GA
Flexor tendon þ Achilles Single flexor tendon All long flexors, ulnar nerve þ artery Flexor tendon and digital artery Single flexor þ ulnar nerve Soleus Removal foreign body Examination under anaesthetic MN, all long flexors Three flexor tendons Two flexor tendons EUA þ wound closure Pronator teres partial tear Flexor tendon þ cutaneous nerve
1 2 2 2 DNA 2 0 DNA DNA 2 2 0 DNA 2
6500 6200 4300 2200 2200 2000 2000 1900 1400 1300 1100 600 400 250
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.10.036
e110 Table 2 Admissions
Correspondence and communication Summary of multiple attender patients. Total length of inpatient stay (days)
3
3
6
2
4
11
2 3
3 1
7
1
3
4
GA/LA
Structures repaired
Clinic follow up
Total cost (£)
GAx2 LAx1 GAx4 LAx2 GAx4
Removal foreign body
2
8900
Removal foreign body
0
5600
Single extensor Wound closure Wound closure Removal foreign body
1
3700
1 0
3600 3000
Removal foreign body, wound closure
1
2200
Removal foreign body
1
1700
GAx2 GAx2 LAx1 GAx4 LAx3 GAx3
length of stay was 2 days (range 1e8 days). Patients were discharged to the care of the psychiatric team or home with community support, with outpatient hand rehabilitation. Seven patients attended on multiple occasions; all of whom were female and in-patient residents at a nearby psychiatric hospital. They accounted for a total of 28 episodes under Plastic Surgery over the 12-month period, which is summarized in Table 2. All of the patients in this group had a diagnosis of borderline/emotional unstable personality disorder; additional conditions included depression and anxiety. The vast majority of these episodes (n Z 27) involved either exploration of wounds and repair of skin lacerations or removal of foreign body. Procedures were performed in main theatre under general anaesthetic (21 episodes) or in the emergency department under local anaesthetic (7 episodes). Foreign bodies retrieved included broken CDs, biros, screws, hair grips, and paperclips. None of the patients in this group sustained significant structural injury, unlike the single attender group. The majority of these episodes were managed as day cases and the average length of stay per patient was 1 day. The cost of managing these patients was calculated from data provided by the coding and finance department. The total cost of single attender patients was £32,350, averaging £2300 per patient; while multiple attenders cost the Trust £28,700, with each patient costing £4100 on average. Our results demonstrate that both single and multiple attender self-harm patients cost substantial amounts of money to the NHS. Single attenders referred from the community, and particularly male patients tended to have more serious attempts at self-harm, with significant tendon and arterial injuries sustained yet conversely, all multiple attenders cost more on average (£4100 versus £2300) in the absence of significant structural injuries as a direct consequence of repeated admissions. The current management of surgical exploration and repair acts only as a temporary measure and does not address the actual cause of self-harm. Prevention of self inflicted injury in multiple attender patients was reported to be difficult by carers, in particular deterring access to objects with which to self-harm. Suggested methods to managing this includes multi-disciplinary management by collaboration with the psychiatric team,2 by options of leaving foreign bodies in situ1 and straightforward wound care rather than immediate general anaesthetic exploration.1,3 Early post
operative psychiatric follow-up to ascertain the precipitating factors for the episode of self-harm, improved supervision and supportive care, rewarding good behaviour and teaching coping mechanisms has been shown to be beneficial in preventing further injuries and thereby reducing number of admissions.4 Similarly, improving access to community care, support groups, alcohol rehabilitation, early recognition and referral to psychiatric services may help prevent self-harm in the single attender group. NICE guidelines have suggested carrying out an RCT examining 6 sessions of cognitive behavioural therapy following discharge post self-harm.5 We recommend further studies into promoting self-harm prevention through increased awareness of vulnerable patients and adherence to NICE guidelines in caring for them.
Conflict of interest/funding None.
References 1. Wraight WM, Belcher HJ, Critchley HD. Deliberate self-harm by insertion of foreign bodies into the forearm. J Plast Reconstr Aesthet Surg 2008;61(6):700e3. 2. Khundkar RMN, Estela C. Management of self-harm patients: a case for joint approach. J Plast Reconstr Aesthet Surg 2009; 62(12):e599e600. 3. Hold PM, Brackley P, Procter D, James MI. Self-harm, the psychiatric inpatient and the plastic surgeon. J Plast Reconstr Aesthet Surg 2010;63(1):e124e5. 4. Henderson A, Wijewardena A, Streimer J, Vandervord J. Selfinflicted burns: a case series. Burns 2013;39(2):335e40. 5. Self-harm. The National Institute for Clinical Excellence; 2004.
Fionnuala M. O’Leary Michelle C.I. Lo Frederik B. Schreuder Department of Plastic and Reconstructive Surgery, Lister Hospital, Coreys Mill Lane, Stevenage SG1 4AB, Herts, United Kingdom E-mail address: [email protected]
15 July 2013
