Data Collected about Intentional Self-poisoning in New Zealand Emergency Departments and the Implications of Data Limitations for Prevention Planning A Mixed Methods Study Eeva-Katri Kumpula A thesis submitted for the degree of Doctor of Philosophy at the University of Otago, Dunedin/Ōtepoti, New Zealand 2018 “Alle Dinge sind Gift, und nichts ist ohne Gift; allein die Dosis machts ein Ding kein Gift sei.” (”All things are poison, and nothing is without poison, the dosage alone makes it so a thing is not a poison.”) Paracelsus (Philippus Aureolus Theophrastus Bombastus von Bodenheim): “Die dritte Defension wegen des Schreibens der neuen Rezepte”, in Septem Defensiones, 1538. ii ABSTRACT Background Intentional self-poisoning (ISP; taking a purposeful overdose) results in significant morbidity and is a burden on population health. In order to reduce ISP by, for example, restricting inappropriate access to substances, information is required about which specific substances are commonly used. Aims I. What information about ISP can be obtained from Ministry of Health (MOH) datasets to plan poisoning prevention initiatives? What are the gaps in these data, and how could these be addressed? II. How do emergency medicine professionals identify poisonings and investigate intent behind them, and how does that information become national hospital presentation data? III. Which specific substances do people use in episodes of intentional self-poisoning, and where do they obtain these substances? Methods The MOH Mortality data and National Minimum Dataset (NMDS) public hospital presentation cases of intentional and undetermined intent self-poisoning were analysed to investigate demographic characteristics of people who present with ISP, and to investigate limitations of the current data. Poisonings of undetermined intent were included as they may be poorly identified cases of ISP. Specific poisoning data collected at one Emergency Department (ED; Wellington) were analysed to provide more information about specific substances used in ISP, and to investigate feasibility of clinicians recording these data. iii The process of identifying poisoning and intentionality in patients presenting to an ED, which is then recorded in NMDS data, was investigated through interviews with clinicians and clinical coders. Cross-sectional data were collected prospectively from three EDs. This included data on specific substances and sources to these substances. Results Females were at higher risk of hospital presentations for ISP, and males were at higher risk of death. Young people, Māori, New Zealand Europeans and people from deprived areas were most at risk. There are few details about specific substances in existing MOH data. The data recorded by clinicians in Wellington ED provided more detail about substances but coding was less systematic. A range of information along the care pathway is used to determine whether a poisoning has occurred and whether it is intentional. Intent can be complex to determine as it may change over time from the substance exposure to the time of treatment at the ED, particularly in cases of alcohol/recreational drug co-intoxication. We found that clinical coders do send data on specific substances to the MOH although these do not appear in the MOH datasets. The five most frequent substances used by people in the prospective study were paracetamol, ethanol, ibuprofen, quetiapine, and venlafaxine. Most people used their own prescription drugs. Conclusions Current national MOH datasets describing ISP are not detailed enough to identify specific substances of concern. The study shows that it is feasible to collect this data, but attention needs to be paid to standardisation. This data could inform measures to prevent ISP. iv ACKNOWLEDGEMENTS My sincerest thanks and immense gratitude go to: My primary supervisor, Professor Pauline Norris, from the School of Pharmacy, University of Otago, and co-supervisor, Dr Shyamala Nada-Raja, Senior Research Fellow, from the Department of Preventive and Social Medicine, University of Otago, for their guidance, advice, and patience during the three years of this PhD project. Further, for their faith and support during the two years of preparations before starting this PhD project, as well as co- authorship in the papers published as a result of this PhD project. The School of Pharmacy, University of Otago, for hosting me for the duration of my PhD studies, for the three-year PhD stipend and yearly consumables support, and a Dean’s Fund grant to cover data collection costs of the project; the Department of Preventive and Social Medicine, University of Otago, for financial support. Dr Bruce Lambie, MB ChB DipObst FACEM, Emergency Medicine Specialist, from the Dunedin Hospital ED, for his support of the studies, mentoring and invaluable clinician expert comments on results, and his unending patience with organising practical matters for the Studies 2 and 3, and for co-authorship. Dr Paul Quigley, MB ChB FACEM, Emergency Medicine Specialist, from the Wellington Regional Hospital ED, for his support of the studies, for his clinician expert comments on the findings, for being a mentor in all toxicology items and beyond, and for co-authorship. Dr Cecilia Smith-Hamel, MB ChB (Otago) FRANZCP, Chief of Psychiatry, Timaru Hospital, for her assistance in arranging locality authorisation for clinician interviews at Timaru ED, and for her invaluable clinician/practitioner/expert comments on results. Ruth Sharpe, Health Research South, for helpful practical advice on the procedures of obtaining locality authorisations in SDHB. Ruth truly helps researchers navigate the vast jungle of hospital administration! v Dr Caroline Collins, then ED Clinical Leader, Dunedin Hospital, for her support of Studies 2 and 3 being conducted in the ED. And for the kind help of Drs Lambie and Collins, in introducing me to staff and for allowing me to present Study 3 to staff at doctors’ handovers between shifts. Stephen Ryan, Registered Nurse, and Shona Willers, Nurse Educator, for facilitating data collection (Study 2, Study 3) at Dunedin ED, and for fruitful discussions about some of the limitations of the studies. Ms Lorraine Arnold, CATT nurse, and Dr Alexander Stewart, RMO, for being our on-site champions for data collection (Study 3) at Wellington ED and SSU. Christelle Vorster, PA for Wellington Regional Hospital ED, for invaluable facilitation of administrative tasks to get the studies going and running in Wellington. Sandra Allmark, Quality Systems Performance Analyst, and Peter Wash, Team Leader Reporting, from Wellington Regional Hospital/CCDHB, for extracting data for Study 1b and for invaluable explanations of the data collection practicalities and conventions. Dr Carissa Herbert, RMO, for facilitating the study at Southland ED; Dr Martin Watts, SMO, and Dr Chris Johnstone, ED Clinical Leader, for their support for Study 3. Rachel Mills, Charge Nurse Manager, for facilitating Study 2 at Timaru ED. Pat Bain and Darryn Grigsby from St John Ambulance Service, for facilitating Study 2. All staff at Dunedin, Invercargill, Timaru, and Wellington EDs, who kindly gave of their time for the clinician interviews (Study 2) and/or in data collection (Study 3). Southern, South Canterbury, and Capital & Coast District Health Boards for their support in allowing these studies to be conducted in their hospitals, and the Ministry of Health – Manatū Hauora for the data used in Study 1. Dr Adam Pomerleau, Director of the National Poisons Centre, Medical Toxicologist, for his invaluable comments and discussions on all things relating to toxicology during the last six months of this thesis work. vi Andrew Gray, Senior Research Fellow (Biostatistician), Department of Preventive and Social Medicine, for multiple discussions about statistical methods and how to best present results, in his weekly ‘drop-in’ statistical help desk sessions. Mark Brunton, Kaiwhakahaere Rakahau Māori – Research Manager Māori, Office of Māori Development, University of Otago, for helpful discussions about how to make study results available to those that could benefit from them. Dr Annette Beautrais, Suicide Prevention Coordinator for Canterbury and South Canterbury DHBs, researcher and long-time suicide prevention expert and advocate, for her invaluable comments and faith in me during the two-year preparation period prior to starting this PhD project, the initial introductions in CDHB and SCDHB, and the initial scoping of the PhD project. Professor Tim Stokes, Head of Department of General Practice and Rural Medicine, University of Otago, for stimulating discussions in the initial planning phase of the project. Dr Sue Nightingale, Chief of Psychiatry, Canterbury DHB, for her support and discussions in the initial planning phase of the project. Dr Shakila Rizwan, School of Pharmacy, University of Otago, for acting as my PhD Facilitator during these three years of study. Lea Doughty, PhD candidate and researcher, for patiently listening to interview recordings, trying to decipher the difficult bits, and for her immense help in proof-reading this thesis. My ‘office mates’ over the years - for the fruitful discussions as well as all the distractions. Kia kaha, kia māia! Staff at the School of Pharmacy, University of Otago for fruitful discussions, peer reviews for ethical approvals, all the invaluable help, and fun times over the three years of this PhD. I would especially like to thank Dr Alesha Smith for help with data enquiries, and Tim Campbell and Brian Young,