Abstract
The authors report an ‘audit’ of healthcare professionals looking after patients who self-harm 1 and report lack of awareness and adherence to NICE guidelines and some negative attitudes from a minority of staff. That is not entirely surprising and probably mirrors attitudes across all areas of healthcare. In their survey the vast majority of staff had very positive, compassionate and supportive attitudes to such patients. This should be highlighted and applauded. The numbers in the ‘audit’ are relatively small particularly with regards to surgeons, so generalisations from the data should be interpreted with caution.
Timing of surgical intervention in burn patients depends on a number of factors that relate to the patient, co-morbidities, wound characteristics and healing potential. In major burns it is time critical; in smaller injuries it is not so critical. Care must be taken to assess and manage any co-morbidity to optimise patients for surgery and successful outcome. Mental health issues are no different in this respect to cardio-respiratory disease, diabetes, hypertension etc. Comprehensive assessment of these problems often leads to delays in surgical treatment. Patients with psychosocial issues leading to self-harm must be offered the same opportunity of assessment prior to surgical intervention as those with other co-morbidities.
The NICE guidelines are obviously excellent and give advice in general on best practice. They are not burn specific. They were published fourteen years ago in 2004 and although checked, they have not been revised. This may be a reason that many staff are unaware of them. They do state that patients should be offered the same care as other patients with injury but this should mean careful assessment of all co-morbidities including mental health ones. There is significant emphasis on risk assessment in the guidelines which has not really been explored or emphasised by the study either in terms of attitudes or its impact on treatment. The NICE guidelines are a little contradictory in themselves as they also state that treatment of small wounds can be modified from standard care to suit patient need.
The authors do not really distinguish the patient populations involved: for instance Isolated instances versus patients who repeatedly self-harm. The management of patients who repeatedly self-harm is most difficult and complex particularly in terms of risk assessment and reduction. I don’t think anyone knows the best way of managing such injuries to minimise risk of recurrence and the evidence for current best practice in burn patients is non-existent. Further research efforts should focus on this area. Amongst many question, it is clearly important to study the optimal timing of surgery in such patients and its associated risks.
I look forward to seeing a true audit of the author’s service management of such patients compared to the NICE guidelines published in a future edition of the journal.