The Goalodicy Trap: Challenges of working with patients who have self-harmed within the limits of the 4hr target

Abstract

Objective: This paper considers the influence of the Emergency Department (ED) target wait time upon discharge outcomes for those who have self-harmed.
Background: EDs may already be invalidating environments for those who have self-harmed; negative attitudes from staff perpetuating feelings of dismissal and rejection. Pressures to discharge patients to achieve the four-hour target wait time may perpetuate this issue. This paper expands upon Harden’s application of destructive goal pursuit to the four-hour target, exploring how pressures to meet the four-hour target have the potential to distort clinical priorities and may result in adverse clinical outcomes.
Methods: Secondary data analysis was applied to the retrospective referral data of a Mental Health Liaison Team (MHLT). In total, 734 episodes of care were referred to the team from ED, where the primary presentation was recorded as self-harm.
Results: Over half of patients referred to the MHLT from ED having self-harmed were seen after already breaching the target and if seen after breaching the target, the potential for a more restrictive outcome reduced. Of those seen within four hours, the potential for a more restrictive treatment options are increased
Limitations: Lived experience was not considered due to the study design. Generalizability is reduced due to limited size and scope.
Conclusion: This paper challenges the concept of the target as being realistic and attainable for those who have self-harmed. Recommendations to improve the patient journey include mental health triage and treatment in clinical areas outside of the target.