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Quality assurance and parasuicides presenting to casualty departments

The data regarding missed appointments and early attendance underline the extent to which the experi enced clinician was able to respond flexibly to known patterns of behaviour, in a way that was impossible for colleagues unfamiliar with the patients. The great reduction in requests for an early appointment during Period Y suggests that patients may have been less prepared to approach the services when they knew that Dr C. A. B. was not available, although an early appointment might have circumvented a relapse. Service planners could therefore usefully take into account the beneficial effects of continuity of management when considering maintenance of patients in the community.

The data regarding missed appointments and early attendance underline the extent to which the experi enced clinician was able to respond flexibly to known patterns of behaviour, in a way that was impossible for colleagues unfamiliar with the patients. The great reduction in requests for an early appointment during Period Y suggests that patients may have been less prepared to approach the services when they knew that Dr C. A. B. was not available, although an early appointment might have circumvented a relapse.
Service planners could therefore usefully take into account the beneficial effects of continuity of management when considering maintenance of patients in the community.  In view of concern regarding rising youth suicide rates, suicide being a critical event in increasing emphasis on clinical accountability, I conducted a quality assurance exercise in relation to casualty department assessments of parasuicides. While much has been written in the area of suicide assessment and rating scales, I found nothing adequate for my purpose. Accordingly, I present a format for con ducting such an exercise with the aim of providing suggestions as to which clinical assessment items might usefully be emphasised in future clinical assess ments. It has been designed solely to guide this process with no attempts to estimate reliability or validity.

The setting
The working atmosphere of casualty departments may change by the minute, from tranquillity to chaos. At times there may be a queue of urgent cases necessitating brief assessment which may only be triage orientated. In addition, such patients may be unco-operative offering limited information. With out knowledge of the degree of environmental chaos and patient co-operation, it would be unwise to draw too many conclusions about adequacy of assess ments from examination of individual charts. How ever, it may be possible to compare the frequency of assessment of individual variables. For instance, if variables X and Y are equally important but variable X is assessed consistently more frequently than vari able Y it can be inferred that greater attention might be paid to variable Y.

Format
The aims are to evaluate the relative frequency of documentation of individual history items rele vant to the assessment and disposal of parasuicides; and to provide feedback for improvements in the assessment, and documentation of cases. A minimum of 20 cases (50 being ideal) should be randomly or consecutively selected for chart review by way of a register. The points to be considered are whether clinicians have considered and documented items with no attempts being made to determine the accuracy of those considerations. Repeating parasui cides are assessed once. Inspection should be per formed by two clinicians who should negotiate over discrepant interpretations of case-notes. Items on the assessment sheet (Appendix 1) should be rated for being recorded in a recognisable form or not recorded in a recognisable form.
For all items, the frequency distributions are then determined so that items can be compared with each other. While all items may be relevant, it is often not possible to state whether they were considered. For example, if there is a detailed family history sugges tive of good relationships, it might be unreasonable for the clinician to make further specific inquiry about sexual abuse. However, without specific docu mentation it would be incorrect to state that this item has been noted. Hence, for some items it would be unreasonable to expect them to be recorded all or even most of the time. For others, e.g. what tablets were taken, it would be reasonable to expect this to have been done 100% of the time. Readers are invited to determine their own ideas about the fre-Cantor quency with which items should be noted. To assist the reader in determining frequency levels for interitem comparison, description and discussion of the individual items follows. For reasons of brevity and the recognition of the experience of readers of this journal self-evident issues will not be discussed.
The items "Who was on admission" permits checking regard ing implementation of policies, i.e. the proportion of parasuicides that are psychiatrically assessed by psy chiatrists, registrars, social workers or not at all. "Length of history" provides a broad statement of quantity of information. If patients are interviewed more than once duplication may partly invalidate this item.

Description of parasuicides
These items describe the circumstances of the parasuicidal act for assessment of suicidal intent and an understanding of the motivation.   Items 5-8. Relate to preparations for suicide and precautions taken to avoid being rescued.
Item 9. "Intoxication" relates to disinhibition due to alcohol and drugs. Alcoholism is commonly associ ated with parasuicide (Hawton et al., 1989). It has been usually suggested that the life time risk of sui cide in alcoholics was between ll-15% (Miles, 1977). However, this has recently been challenged suggest ing a risk of 2.3^% (Murphy & Wetzel, 1990). Regardless of this alcoholics are at greater risk of further parasuicidal behaviour and have high rates of general health care utilisation.
Item 10. "Precipitant". The majority of parasuicides involve predisposing (vulnerability) and precipi tating (the insults bringing on the crisis) factors. PrÃ© cipitants may be missed by inexperienced clinicians yet are vital for understanding crises.

Background
Items 11-12. "Past psychiatric history" and "past parasuicide" provide information for prediction of future coping behaviours and assisting diagnoses. Items 14-15. "Drug and alcohol abuse" are common concomitants of parasuicide and are associated with a poorer prognosis.
Item 16. "Forensic" relates to past criminal and violent behaviour which may be associated with parasuicide and present difficulties to therapeutic relationships.

Family (of origin)
Item 17. Description of family members-a mini mum requirement would be the description of two parents and the presence or otherwise of siblings.
Item 18. "Atmosphere" relates to the colour of family relationships, e.g. violent, detached, overprotective, etc. Family violence and parental argu ments in particular are associated with suicidal behaviour in offspring (Pfeffer, 1989).

Item 19. "Supportive/unsupportive" relates to some
description of whether relatives provide reasonable support. This may not concur with item 18:e.g. "We seem to argue a lot but my parents really care". hem 20. "Child abuse", past child abuse has been found to be three times more common in 13-17 year old female parasuicides than other casualty depart ment attenders (Deykin et al, 1985). Parasuicidal acts provide an important opportunity for screening for abuse which may have contributed to the parasuicidal act. Similarly a pre-existing history of concerns regarding child abuse has been found in 29.8% of mothers attempting suicide (Hawton et al, 1985).

Future risk
Item 22. "Biological features" relates to physiologi cal features of affective disorder.
Item 23. "Psychotic symptoms". Clinicians may be so absorbed with crisis issues that they forget to ask regarding psychotic symptoms. The presence of these will often necessitate a substantially different management strategy, e.g. admission.
Items 25-26. "Ongoing ideation" and "ability to resist" are important both clinically and medicolegally. Statements by the patients that they feel they can contain their suicidal impulses may be reas suring and beneficial to the therapeutic alliance. Medico-legally informed consent requires patients to be informed and contribute their ideas on preferred management -even if the clinician decides to reject these ideas.
Item 27. Gun/availability of method. If a patient has considered his preferred means of suicide, e.g. gun or antidepressant tablets and has these available, the risk rises.

Collateral
Item 28. "Family". Collateral information from the family may diner from the patient's account altering the envisaged risks and/or shedding light on the underlying problems. The delivery of col lateral may provide observations relating to family atmosphere.
Item 29. "Other care giver". If a patient has had recent contact with clinicians regarding psychologi cal problems prior to a parasuicide, these clinicians should be invited to share their longitudinal obser vations at a time of a cross-sectional assessment.

Disposal
Item 30. "Follow-up arrangements" relate to who will assume responsibility for follow-up of the case.
Item 31. "Length of time until follow-up". Parasui cides occur during crises and as such require early follow-up. Recording how soon the patient is booked to be seen permits review of whether this is being practised.
Item 32. "General practitioner/other advised" re lates to advice regarding assessment and disposal being relayed to general practitioners and others, e.g. ongoing psychiatrists who assume responsibility for a high risk management task and may be at risk of providing drugs for further overdoses.

Conclusion
A format is presented for conducting a quality assur ance exercise relating to psychiatric assessment of parasuicides in casualty settings. Despite practical limitations imposed on historical data gathering, this exercise can provide guidance regarding areas worthy of upgrading clinical inquiry. Repeated over a period of years, it might promote the evolution of histories that reliably inquire regarding factors associated with lethality of intent, background issues including associated pathology, family problems and ongoing risk, providing a better basis for interventions.
= noted in recognisable form x = not recorded or recognisable Name: Who saw on admission: (medical only/psychiatric residents/psychiatric registrar/psychiatric resident and registrar/psychiatrist + others) Length of history (pages).