Evidence review for admission to hospital
Evidence review H
NICE Guideline, No. 225
Admission to hospital
Review question
What are the benefits and harms associated with admission to acute general hospital for people who have self-harmed but no longer require physical care?
Introduction
All children and young people who have self-harmed are admitted to hospital overnight and assessed fully the following day in current practice. However, concerns have arisen regarding this blanket admission for children and young people, with specific attention paid to whether admission causes distress and conflicts with therapeutic risk-taking strategies. The aim of this review is to evaluate the benefits and harms of admission to hospital for people who have self-harmed but no longer require physical care.
Summary of the protocol
See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol (PICO table).
For further details see the review protocol in appendix A.
Methods and process
A modified version of the GRADE approach to rate the certainty of evidence in systematic reviews was used as part of a pilot project undertaken by NICE. Instead of using predefined clinical decision/ minimal important difference (MID) thresholds to assess imprecision in GRADE tables, imprecision was assessed qualitatively during committee discussions. Other than this modification, GRADE was used to assess the quality of evidence for the selected outcomes and this evidence review developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document (supplementary document 1).
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
Effectiveness evidence
Included studies
One randomised controlled trial (RCT) was included for this review (Waterhouse 1990). This study was conducted in England and compared admission to hospital with discharge home in patients who presented to the emergency department with self-harm and were assessed as having no immediate medical or psychiatric treatment need.
The included study is summarised in Table 2.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
Studies not included in this review are listed, and reasons for their exclusion are provided, in appendix J.
Summary of included studies
A summary of the study that was included in this review is presented in Table 2.
Table 2
Summary of included studies.
See the full evidence tables in appendix D.
Summary of the evidence
Only 1 study was included (Waterhouse 1990), reporting only the outcome of self-harm (self-poisoning) repetition and found no significant difference in this outcome between the admission and discharge groups either at 1 week or at 16 weeks (moderate quality).
See appendix F for full GRADE tables.
Economic evidence
Included studies
A single economic search was undertaken for all topics included in the scope of this guideline but no economic studies were identified which were applicable to this review question. See the literature search strategy in appendix B and economic study selection flow chart in appendix G.
Excluded studies
Economic studies not included in the guideline economic literature review are listed, and reasons for their exclusion are provided in appendix J.
Economic model
No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.
Evidence statements
Economic
No economic studies were identified which were applicable to this review question.
The committee's discussion and interpretation of the evidence
The outcomes that matter most
Self-harm repetition, suicide and service user satisfaction were prioritised as critical outcomes by the committee. Self-harm repetition and suicide were prioritised as critical outcomes because they are direct measures of any differential effectiveness associated with the interventions and captures both of fatal and non-fatal self-harm. Service user satisfaction was chosen as a critical outcome due to the importance of delivering services which are centred around the patients’ experiences and because patient satisfaction is likely to influence whether the patient engages with the intervention.
The committee agreed that family/carer satisfaction, receipt of biopsychosocial assessment, time to receipt of biopsychosocial assessment and perceived stigma/discrimination were important outcomes. Family/carer satisfaction was selected as an important outcome because self-harm often does not just affect the patient, but also their families and carers. Family members and carers are also often involved in the management of people who self-harm. It is therefore important to determine the impact of admission or discharge from the family’s or carers’ perspectives. Receipt of biopsychosocial assessment and time to receipt of biopsychosocial assessment were selected as important outcomes to determine if the decision to admit to hospital or discharge home after presentation at the emergency department affected whether patients were more likely to receive this assessment, and the timeliness of receiving this assessment, respectively. Perceived stigma/ discrimination were considered important outcomes due to the psychological impact this can have on patients who may already be suffering with their mental health.
The quality of the evidence
The quality of the evidence was assessed with GRADE and was rated as moderate. The evidence was downgraded due to risk of bias as per Cochrane RoB 2.0 (uncertainty about the randomisation process).
No evidence was identified for the following outcomes: service user satisfaction; suicide; family/ carer satisfaction; receipt of biopsychosocial assessment; time to receipt of biopsychosocial assessment; perceived stigma/ discrimination.
Imprecision and clinical importance of effects
The committee agreed that the evidence presented did not allow them to make strong recommendations on the overall benefit or potential harm of admission to hospital for people who have self-harmed but no longer require physical care. Overall there was only 1 study on which to base recommendations which found no significant difference in repeat self-harm between the admission and discharge groups, and the committee agreed that there was serious imprecision for the evidence regarding this outcome.
Given the lack of useful evidence, the committee discussed whether a research recommendation should be made. The committee agreed that new evidence regarding the effectiveness of admission to hospital for people who have self-harmed would likely have an effect on whether admission would be recommended after an episode of self-harm. In particular, the committee agreed that different populations, such as adults and children, might have different reactions to being admitted to hospital and the committee agreed it was important to know whether these populations should have specific recommendations made for them. As a result, the committee prioritised this area for research.
Benefits and harms
Because of the lack of any evidence for children, the committee discussed current practice and agreed based on their knowledge and experience that it was no longer appropriate to admit all children and young people to hospital. The committee agreed based on their experience that the potential benefit of providing a safe setting after an episode of self-harm was outweighed by the potential risk that admission could cause significant distress to some people who had self-harmed, including children and young people. The committee also agreed there was a risk that blanket admission could conflict with a therapeutic risk-taking strategy if one was in place, particularly if the strategy involved discharge home with the understanding that doing so would support their personal resilience and growth. They discussed the risks and benefits of admission and agreed based on their expertise that safeguarding concerns and the risk of being discharged to an unsafe or potentially harmful environment should be considered when assessing whether to admit the person to hospital, including when admission was required to facilitate safeguarding planning or where there were concerns about the person’s safety due to distress or intoxication. The committee agreed this applied to children and young people as well as adults. They also agreed that admission to hospital could be considered when it facilitated a psychosocial assessment. An adequate psychosocial assessment may be completed for some individuals including children and young people who have self-harmed at presentation without the need for a full multi-disciplinary assessment and admission to hospital. However, the committee agreed that admission may be necessary if the relevant multidisciplinary agencies required to provide an adequate psychosocial assessment are not available out of hours.
Admission for individuals who have self-harmed should be to the most appropriate location to ensure optimal continuous assessment and care, which may include admission to a general hospital ward. The committee discussed the risk of 16/ 17 year-olds being admitted to adult wards inappropriately and agreed based on their expertise that when admitting young people of this age group to hospital, they should be admitted to wards where the needs of children could be met, primarily paediatric wards, teenage and young adult units, or a child or adolescent psychiatric inpatient unit where necessary.
The committee agreed based on their knowledge and experience that physical and mental health care should always be delivered concurrently as much as possible in order to prevent a delay in treatment and ensure the patient’s mental or physical needs are not prioritised at the expense of the other. The committee also agreed that treatment for physical injuries should never be used as a reason to delay or deny a psychosocial assessment, as this would be considered malpractice, potentially resulting in heightened distress or neglect of the person’s other healthcare needs.
The committee discussed current practice regarding what happens when a person self-harms while in hospital, and agreed that full investigations should continue to be recommended when an incident occurs, in order to consistently improve services and ensure further incidents are prevented. The committee also discussed the Patient Safety Incident Response Framework and agreed that local areas should be aware of the framework where it is being implemented, in order to facilitate its rollout.
The committee considered the fact that the majority of presentations for self-harm at the emergency department are out-of-hours and agreed that choosing not to admit someone carried a risk that the person who had self-harmed could be discharged without receipt of an adequate psychosocial assessment or a plan for further management. The committee agreed that this could lead to the person not receiving adequate follow-up or treatment as necessary, potentially leading to repeat self-harm or suicide, and reducing the likelihood that the person will engage with healthcare services in the future. The committee therefore agreed based on their knowledge and experience that people who had self-harmed should only be discharged once they had received an adequate psychosocial assessment and had a plan for further management drawn up. The committee agreed that any plans should be communicated to the primary care team to facilitate aftercare and ensure the appropriate staff can continue to provide the appropriate care and support. They also agreed that discharge planning meetings also enable the person to receive ongoing care after discharge, lowering the risk of hopelessness and repeat self-harm, and improving engagement with services post-discharge.
There is still a lack of research in this area not only for children and adolescents but across all age groups. Clinical practice appears to vary considerably. Working age adults who self-harm are not routinely admitted and it is unlikely to be feasible to do so in the current service context. However given the ongoing uncertainty about whether to admit children, young people and older adults the committee made a research recommendation.
Cost effectiveness and resource use
The committee noted that no relevant published economic evaluations had been identified and no additional economic analysis had been undertaken in this area. They highlighted the considerable variation across the NHS in general hospital services. Therefore, they originally suggested this topic as a high priority for bespoke economic modelling. However, as identified clinical evidence was inadequate to support the development of a bespoke economic model, this topic was no further considered an economic priority.
The committee noted that discharging people who have self-harmed to other care settings is likely to incur lower costs compared with admitting them to general hospitals, either after a psychosocial assessment or not. However, they agreed that in some cases admitting people to a general hospital can be helpful in giving the person time to recover. The committee expressed the opinion that the recommendations they made may reduce variation in practice and reduce the potential for distress because of any unnecessary admissions. The committee expressed the view that recommendations could increase the number of beds available in hospitals and reduce overall costs related to overnight admissions to hospital for people who have self-harmed.
Recommendations supported by this evidence review
This evidence review supports recommendations 1.9.1–1.9.6 and the research recommendation 3 on routine admission compared to automatic admission effective for young people or older adults who have self-harmed.
References – included studies
Waterhouse 1990
Waterhouse, J., Platt, S., General hospital admission in the management of parasuicide. A randomised controlled trial, British Journal of Psychiatry, 156, 236–242, 1990 [PubMed: 2180527]
Effectiveness
Economic
No studies were identified that met the inclusion criteria.
Appendices
Appendix A. Review protocols
Appendix B. Literature search strategies
Appendix C. Clinical evidence study selection
Appendix D. Evidence tables
Appendix E. Forest plots
Forest plots for review question: What are the benefits and harms associated with admission to acute general hospital for people who have self-harmed but no longer require physical care?
No meta-analysis was conducted for this review question and so there are no forest plots.
Appendix F. Modified GRADE tables
Appendix G. Economic evidence study selection
Appendix H. Economic evidence tables
Economic evidence tables for review question: What are the benefits and harms associated with admission to acute general hospital for people who have self-harmed but no longer require physical care?
No evidence was identified which was applicable to this review question.
Appendix I. Economic model
Economic model for review question: What are the benefits and harms associated with admission to acute general hospital for people who have self-harmed but no longer require physical care?
No economic analysis was conducted for this review question.
Appendix J. Excluded studies
Excluded studies for review question: What are the benefits and harms associated with admission to acute general hospital for people who have self-harmed but no longer require physical care?
Excluded effectiveness studies
Table 6
Excluded studies and reasons for their exclusion.
Excluded economic studies
Table 7
Excluded studies from the guideline economic review.
Final version
Evidence review underpinning recommendations 1.9.1 to 1.9.6 and research recommendation 3 in the NICE guideline
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.