1. Nadine Dougall School of Health & Social Care
Care pathways related to Scottish Ambulance Service contacts for people with psychiatric or self-harm emergencies
Study funded by the Chief Scientist Office of the Scottish Government
People categorised as having a psychiatric emergency or self-harm episode account for thousands of Scottish Ambulance Service (SAS) emergency calls every year. Most are conveyed to emergency departments (EDs). Anecdotally many are highly vulnerable, at increased risk of suicide and repeat ED attendance, but previously no data were available to support this supposition. Police Scotland see the same sorts of people, and therefore when I am describing this study, it will become obvious how powerful this study will be once we can also add in Police data. The aims of this study were to provide this epidemiological data, and to inform the development of alternative care pathways.
Nadine Dougall
School of Health & Social Care

2. Care pathways related to Scottish Ambulance Service contacts for people with psychiatric or self-harm emergencies
1. HTA rapid evidence synthesis- quality of services and outcomes for people who experience mental health crises are highly variable and compare poorly to those who receive a physical health emergency response.
Surprisingly little research has been carried out –15 studies.
The quality of the evidence was poor, and none were conducted in pre hospital environment.
2. Our own qualitative research suggested that professional find this very group challenging, and believe they are not getting the best service.
3. Yet, going to Research funders with an opening line that everyone knows this is a problem is not an effective method of gaining research funding to improve the outcomes for the patient population.

3. Unscheduled Care Data Mart Year 2011 & 2012
Scottish Ambulance Service
(SAS)
Emergency Dept
(A&E2)
Acute Hospital
(SMR01)
Psychiatric hospital
(SMR04)
1. Retrospective cohort study – SAS 2011
2. Data extracted from UCD – person level linked data
Scotland rich in patient data
Ambulance service has had electronic data for 10 years
UCD recent development that automatically links data from SAS, ED< Acute and MH

4. What are their outcomes?
Who are these people?
Describe the demographic characteristics from the first record for each person in 2011 (Index incident) .
What happens to them?
Summarise data by care pathways:
% calls attended but not transported;
% calls transported to ED but who self-discharge before being assessed;
% patients assessed in ED then discharged;
% patients admitted to ED then admitted to general hospital or transferred to a psychiatric facility.
What are their outcomes?
What is the % mortality
And repeat attendance over 12 months since index incident.

5. Who are these people? In the year 2011 there were:
9,014 psychiatric or self-harm calls.
6,802 people.
Male callers > female callers.
male (n= 4,708, 52.2%); female (n= 4306 ,48%)
Alcohol related calls = 1,816 (20.2%).
Drugs related calls = 94 (1.0%).
Most people (n=5,624, 83%) made one call, with the remaining (n=1178, n=17%) making two or more calls, including 21 people who made 9 or more calls.

7. What happens to them?

8. proportions of calls attended but not transported;
In the category of “Other’ there were >800 heterogeneous pathways
Stayed at home ‘see and treat’
What happens to people?
proportions of calls attended but not transported;
proportions of calls transported to ED but who self-discharge before being assessed;
patients assessed in ED then discharged;
patients admitted to ED then admitted to general hospital or transferred to a psychiatric facility.

9. Time in transit Median time from call to arrival at ED under an hour
- All calls median time 52 mins (IQR 42 to 68)
Median time from ED arrival to discharge/ transfer
- All calls median time 153 minutes (IQR 94 to 214)
Median days spent in hospital
- 1 day for acute hospital admission (IQR 0 to 1)
- 8 days for psychiatric hospital admission (IQR 3 to 23)
- 6 days for other pathways (IQR 2 to 23)
Regardless of pathway the call to ED arrival time was about the same
Slightly longer median time (just over 3 hours) if waiting a transfer to another ward than if being discharged
Police Scotland sit with similar people in ED for hours at a time, sometimes cuffed, most times in front of others – stigma is considerable for people with MH problems

10. What are their outcomes?

11. What were their outcomes? Mortality…
279 (4.1%) were dead within one year
Just over one third of these deaths were confirmed suicide (n=97; 35%).
‘accidents’ and ‘mental and behavioural disorders’ (n=64; 23%)
long term conditions with co-morbid psychological distress. (n=118; 42%)
240 people died >1 day and < 1 year of first SAS attendance
This data now relates to people (6802), not calls (9014).
4% of all people seen by ambulance service for psychiatric emergency in 2011 in Scotland died within the following year. About a 1/3 of these (97 people) documented as death by suicide on their death record.
Given that in Scotland less than 800 people die by suicide within 2011, this means that paramedics were in contact with about 13% of all people before they died by suicide in Scotland within the same time period…
ScotGov invested a lot of money in suicide prevention and so this seems an obvious point to intervene in future

12. What are their outcomes? Repeat calls…
3,564 people (52%) = one call.
3,238 people (48%) attended > 1 time
Making two mental health emergency calls within 12 months was relatively common (19%, n=1,294)
100 people (1.5%) were attended by the ambulance service more than 16 times
What are their outcomes? Repeat calls…
These are 6,802 people, not calls
There are a few super users of the service who are being attended to multiple times a year
What are their outcomes?
-Describe the cohort outcomes (mortality and repeat attendance) over 12 months since index incident.

13. Next steps
Ambulance service and emergency departments are currently missing opportunities to provide better care for this vulnerable population
Police Scotland data will provide a broader perspective of pressure on resources (PhD studentship in progress summarizing MH distress contacts on Vulnerable Persons Database)
This will enable evidence-informed opportunities for upstream interventions
This research has implications for all first responders, in particular with Police Scotland who are regularly in contact with people assessed as being vulnerable. Building on this work is a PhD project now assessing police contacts with vulnerable people who are categorised as having self-harmed or presented with mental health crises.

14. Next steps: the BIG picture
Blue lights data platform
Project team: S.McVie*, B.Matthews*, C.Dibben*, I,Heyman# & N.Dougall#
(*University of Edinburgh, #Edinburgh Napier University)
Consortia: Administrative Data Research Centre and Police Scotland, Scottish Ambulance Service, and Fire & Rescue Service in providing a national data solution
Brings societal perspective of pressure on resources
Will provide joined up thinking in approaches to people with available services
Can assess impact of tests of change in real time
Offers opportunities for saving resources for services

15. Contact: n.dougall@napier.ac.uk
Care pathways related to Scottish Ambulance Service contacts for people with psychiatric or self-harm emergencies
Edward Duncan1, Catherine Best1, Nadine Dougall2, Silje Skar1, David Fitzpatrick1,3, Josie Evans4, Alistair Corfield5, Cameron Stark6, Wojtek Wojcik7, Isabella Goldie8, Chris White8, Helen Snooks9, Margaret Maxwell1
1NMAHP Research Unit, University of Stirling, Stirling
2School of Health & Social Care, Edinburgh Napier University, Edinburgh
3Scottish Ambulance Service, Glasgow
4Faculty of Health Science and Sport, University of Stirling, Stirling
5Emergency Dept, Royal Alexandra Hospital, NHS Greater Glasgow & Clyde, Glasgow
6Dept of Public Health, NHS Highland, Inverness
7Dept of Psychological Medicine, Royal Infirmary, NHS Lothian, Edinburgh
8Mental Health Foundation, Glasgow
9Institute of Life Sciences, Swansea University, Swansea
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