Abstract
Objectives
To provide estimates and predictors of screening for suicide in emergency departments (EDs).
Methods
Eight geographically diverse U.S. EDs each performed chart reviews of 100 randomly selected patients, ages 18 years or older, with visits in October 2009. Trained chart abstractors collected information on patient demographics, presentation, discharge diagnosis, suicide screening, and other mental health indicators. Univariate logistic regression was used to determine factors associated with suicide screening.
Results
The cohort of 800 patients had a median age of 41 years (interquartile range 27 to 53 years) with 57% female, 16% Hispanic, 58% white, 23% black or African American, and 10% other race. Suicide screenings were documented for 39 patients (4.9%; 95% confidence interval [CI] = 3.4% to 6.4%). Of those screened, 23 (2.9% of total sample; 95% CI = 1.7% to 4.0%) were positive for suicidal ideation or behavior. Approximately 90% of those screened had documented complaints of a psychiatric nature at triage. About one-third had either documentation of alcohol abuse (33%), or intentional illegal or prescription drug misuse (36%).
Conclusions
The presence of known psychiatric problems and substance use had the strongest associations with suicide screening; yet even patients presenting with these indicators were not screened for suicide. Understanding factors that currently influence suicide screening in the ED will guide the design and implementation of improved suicide screening protocols and related interventions.
INTRODUCTION
Emergency departments (EDs) are increasingly recognized as an important component of suicide prevention.1 Previous studies indicate that an average of 412,000 ED visits per year are related to intentional self-harm or suicide attempts.2 Although suicide is difficult to predict in the general population, ED patients presenting with suicide risk factors such as substance abuse or depression are a readily identifiable population at elevated risk for suicidal behavior.3 In addition, those who present to EDs for non-mental health reasons have higher proportions of occult or silent suicide ideation (3% to 11.6%).4 This has prompted The Joint Commission and other organizations to recommend adopting better suicide screening practices.5 However, little is known about current screening for adult suicide risk in ED clinical practice.
The goals of this investigation were to determine the frequency of suicide screening documentation, the proportion of patients with positive suicidal ideation or behavior, and predictors of suicide screening in a sample of EDs.
METHODS
Study Design
This was a retrospective, structured chart review of ED patients. Institutional review boards at all participating sites approved the study.
Study Setting and Population
We reviewed charts from patients presenting to eight participating sites involved in the Emergency Department Safety and Follow-up Evaluation (ED-SAFE) study, a suicide prevention study funded by the National Institutes of Health. Data were collected prior to study initiation.
Study Protocol
Each site reviewed 100 randomly selected charts from all patients, age 18 years or older, who visited the ED between October 1 and October 31, 2009. Chart type varied by site; half reported partial electronic and partial paper medical records, and the other half reported all electronic records. Each sites generated a list of patients seen at triage. Each visit was assigned a consecutive number and the list of numbers was sent to the project director at the coordinating center. The project director randomly selected 100 numbers from the list and sent back a file with the order in which charts should be reviewed. Chart abstractors attended a training presentation conducted by the study principal investigator (PI) and project director via telephone. Each site was provided with a PowerPoint presentation and a manual of procedures with step-by-step instructions. The first three charts reviewed were independently reviewed by the site PI or local research coordinator for accuracy. Inter-rater reliability (Kappa) was then calculated between the raters at each site. All chart review data were entered into a secure web-based data collection system (Research Electronic Data Capture (REDCap), Vanderbilt, TN).6
Outcome Measures
Sites completed a standardized abstraction form that included information such as patient demographics, ED presentation (e.g., complaint, triage code), documented mental health indicators, discharge diagnosis, presence of means to complete suicide, and receipt of referral resources or safety plan. A safety plan was defined as a written document provided to the patient that specifies steps that he or she should follow when feeling suicidal. All data were collected based on documentation made during the patient’s index ED visit only.
Charts were reviewed for documentation of whether the patient had any history, current or past, of suicidal ideation or attempted suicide. Documentation, either positive (yes) or negative (no), of suicide ideation or attempt constituted a suicide screening. Cases with no reference to suicidal ideation or behavior were considered a “no” for suicide screening.
Data Analysis
The primary analysis was a descriptive summary of suicide screening and other mental health indicators documented in the ED. All proportions are reported with 95% confidence intervals (95% CI). All analyses were conducted using STATA 11.0 (StataCorp, College Station, TX). We performed the univariate analyses using Fisher’s exact test.
RESULTS
The median age was 41 years (interquartile range 27 to 53 years), with 57% female, 58% white, and 52% non-Hispanic. Rates of suicide screening varied by site from 3% to 23% (average among eight sites: 13%). Most suicide screenings occurred during the weekdays and between 2:00 pm and 2:00 am. Screenings were typically documented by both the triage nurse and physician, or both the primary nurse and physician. For the major predictor variables in the current study, kappa values were >0.60, indicating a good level of agreement.
Only 39 patients were screened for suicide (4.9% of total sample; 95% CI = 3.4% to 6.4%). Of those screened, 23 (2.9% of total sample; 95% CI = 1.7% to 4.0%) were positive for suicidal ideation or behavior. Among patients screened for suicide, 90% reported a psychiatric problem (including depression) at triage, 59% had current or past suicidal ideation or behavior, and 21% reported self-harm behavior at triage. About one-third had either documentation of alcohol abuse (33%), or intentional illegal or prescription drug misuse (36%). Almost all of those screened for suicide (92%) had at least one characteristic that suggested elevated risk for suicide: being male, over 65 years, presenting with a psychiatric complaint, or a history of alcohol or drug use. Of those who screened positive for suicidal ideation or behavior, only 8% received a formal written safety plan, and only 36% received an evaluation from a mental health professional. Less than one-quarter (23%) were admitted to a medical ward for observation, and 5% were admitted to a psychiatric service (Table 1).
Table 1.
Characteristics of overall and screened for suicide emergency department visits at the 8 participating sites
| Variable | n | % | 95% CI | |
|---|---|---|---|---|
| Overall | 800 | |||
| Age, years | ||||
| 18–24 | 155 | 19.4 | 16.6 | 22.1 |
| 25–44 | 299 | 37.4 | 34.0 | 40.7 |
| 45–64 | 247 | 30.9 | 27.7 | 34.1 |
| 65–74 | 46 | 5.8 | 4.1 | 7.4 |
| ≥75 | 53 | 6.6 | 4.9 | 8.4 |
| Female sex | 459 | 57.4 | 53.9 | 60.8 |
| White race | 463 | 57.9 | 54.4 | 61.3 |
| Ethnicity | ||||
| Hispanic | 125 | 15.6 | 13.1 | 18.1 |
| non–Hispanic | 414 | 51.8 | 48.3 | 55.2 |
| Not documented | 261 | 32.6 | 29.4 | 35.9 |
| Suicide screening completed | ||||
| Yes | 39 | 4.9 | 3.4 | 6.4 |
| Age, years | ||||
| 18–24 | 5 | 12.8 | 1.8 | 23.8 |
| 25–44 | 22 | 56.4 | 40.1 | 72.7 |
| 45–64 | 10 | 25.6 | 11.3 | 40.0 |
| 65–74 | 1 | 2.6 | nc | nc |
| ≥75 | 1 | 2.6 | nc | nc |
| Female sex | 19 | 48.7 | 32.3 | 65.1 |
| White race | 10 | 69.2 | 54.1 | 84.4 |
| Ethnicity | ||||
| Hispanic | 3 | 7.7 | nc | nc |
| non–Hispanic | 20 | 51.3 | 34.9 | 67.7 |
| Not documented | 16 | 41.0 | 24.9 | 57.2 |
| Day of week screening completed | ||||
| Monday | 8 | 20.5 | 7.3 | 33.8 |
| Tuesday | 6 | 15.4 | 3.5 | 27.2 |
| Wednesday | 6 | 15.4 | 3.5 | 27.2 |
| Thursday | 6 | 15.4 | 3.5 | 27.2 |
| Friday | 6 | 15.4 | 3.5 | 27.2 |
| Saturday | 2 | 5.1 | nc | nc |
| Sunday | 5 | 12.8 | 1.8 | 23.8 |
| Time of day screening completed | ||||
| 8:00am - 2:00pm | 8 | 21.1 | 7.5 | 34.6 |
| 2:01pm - 8:00pm | 18 | 47.4 | 30.7 | 64.0 |
| 8:01pm - 2:00am | 11 | 28.9 | 13.8 | 44.1 |
| 2:01am - 7:59am | 1 | 2.6 | nc | nc |
| Aggregate location of screening documentation | ||||
| Triage nurse only | 0 | -- | -- | -- |
| Primary nurse only | 0 | -- | -- | -- |
| Physician only | 0 | -- | -- | -- |
| Mental health provider only | 0 | -- | -- | -- |
| Triage nurse and primary nurse | 1 | 2.6 | nc | nc |
| Triage nurse and physician | 10 | 25.6 | 11.3 | 40.0 |
| Triage nurse and MHP | 1 | 2.6 | nc | nc |
| Primary nurse and physician | 8 | 20.5 | 7.3 | 33.8 |
| Primary nurse and MHP | 0 | -- | -- | -- |
| Physician and MHP | 5 | 12.8 | 1.8 | 23.8 |
| > 2 documentation locations | 14 | 35.9 | 20.1 | 51.7 |
| Complaint at triage: psychiatric behavior (including depressed mood) | 35 | 89.7 | 79.8 | 99.7 |
| Complaint at triage: self-harm behavior | 8 | 20.5 | 7.3 | 33.8 |
| Current or past suicidal ideation or behavior | 23 | 59.0 | 42.8 | 75.1 |
| Non-suicidal self-injury ideation | 8 | 20.5 | 7.3 | 33.8 |
| Non-suicidal self-injury behavior | 6 | 15.4 | 3.5 | 27.2 |
| Thoughts of threat or harm toward other people | 1 | 2.6 | nc | nc |
| Alcohol abuse (current intoxication or evidence of any problem use) | 13 | 33.3 | 17.9 | 48.8 |
| Intentional illegal or prescription drug misuse | 14 | 35.9 | 20.1 | 51.7 |
| Safety plan created | 3 | 7.7 | nc | nc |
| Mental health evaluation performed | 14 | 35.9 | 20.1 | 51.7 |
| ED disposition | ||||
| Home | 16 | 41.0 | 24.9 | 57.2 |
| Admitted to medical ward/observation | 9 | 23.1 | 9.2 | 36.9 |
| Admitted to ICU | 1 | 2.6 | nc | nc |
| Admitted to psychiatric ward/facility | 2 | 5.1 | nc | nc |
| Admitted to substance abuse treatment facility | 3 | 7.7 | nc | nc |
| Transferred to other mental health evaluation facility | 3 | 7.7 | nc | nc |
| Left against medical advice | 0 | -- | -- | -- |
| Left without being seen | 0 | -- | -- | -- |
| Other (e.g., discharged to group home) | 4 | 10.3 | 0.3 | 20.2 |
| Not documented | 1 | 2.6 | nc | nc |
nc – not calculable due to sample size <4
ICU = intensive care unit; MHP = midlevel health care provider
Significant univariate predictors of suicide screening included psychiatric complaints or self harm; documentation of alcohol abuse, illegal, or prescription drug misuse (all P < 0.001); a history of ED visits in the previous six months (P = 0.002); as well as substance abuse (P = 0.005), and psychiatric inpatient hospitalizations (P < 0.001) in the previous six months (data not shown).
DISCUSSION
Although there are approximately 412,000 annual ED visits for suicide attempt and self-inflicted injury,2 ED staff do not routinely screen for suicidal ideation or behavior. We found that our rate for individuals who screened positive for suicidal ideation or behavior (2.9%) was similar to that of previous research on suicidal ideation in the general medical population (2.6%).7 In addition, our examination of medical records for adults presenting to the ED revealed that psychiatric/self harm complaints and substance use were strongly associated with suicide screening. However, many patients presenting with these indicators were not screened, suggesting that suicide screening is not universal or even indicated, but rather highly selective based on provider and service characteristics rather than patient characteristics. This may be because ED staff have not been properly trained to manage patients presenting with suicide related complaints.8
In addition, the number of mental health evaluations for patients presenting with psychiatric complaints was low. Even though the majority (90%) of those screened presented to the ED with psychiatric complaints including depressed mood, only 36% were evaluated by a mental health professional during their visit. Three of those who screened positive for suicidal ideation or behavior were provided with a formal safety plan, and three had documentation of receiving referral resources (e.g., hotline numbers). Similar to related research,9 our study shows that patient characteristics associated with a higher risk of suicide do not ensure a suicide screening.
Although the current study suggests that existing screening is not adequate, two current projects suggest progress toward empirically testing suicide screening and related intervention programs. The World Health Organization Suicide Trends in At-risk Territories (WHO/START) aims to better understand fatal and non-fatal suicide behavior in the Western Pacific by testing the effects of long-term contact for reducing suicidal behavior.10 In the United States, the ED-SAFE study is examining current ED screening practices, implementing universal screening to see if detection of suicide risk improves, and testing a telephone intervention post-discharge to reduce risk of future suicidal behavior.
LIMITATIONS
The limitations of this study are common to studies using a chart review design. The accuracy of the records may have been compromised by the author of the records, the interpretation of the reader, or any of the intervening steps. We tried to mitigate these limitations by designing a detailed protocol for data collection and analysis, implementing standardized abstractor training, and using REDCap for data capture. REDCap improves data quality by using required fields, branching logic, and validation loops.
Another possible limitation is the selection of risk factors for suicide. Although there are many risk factors, we selected a subset to focus our analysis. We directed our attention toward two main variables: psychiatric-related issues and substance use. Future studies should examine additional factors associated with suicide risk that we were unable to address, such as psychological or personality disorders.
CONCLUSIONS
In 2007, The Joint Commission adopted National Patient Safety Goal 15, which states that the organization providing treatment identify “safety risks inherent in its patient population.” Specifically, patients receiving treatment for emotional or behavioral disorders in inpatient, outpatient, and emergency settings should be assessed to determine if they are at risk for suicide.6 In 2010, The Joint Commission continued the call to action with an alert to increase vigilance for suicidal behavior. Our findings suggest that suicide screening for adults in the ED is far from universal, which is concerning as many individuals at risk for suicidal behavior seek treatment in the ED. Findings from the current study add additional emphasis to the need for improved suicide screening practices to ensure appropriate treatment for those at risk for suicide.
Acknowledgments
The authors would like to acknowledge the time and effort of the site principal investigators as well as the research coordinators and research assistants from the eight participating sites.*
Funding Sources/Disclosures: This project was supported by Award Number U01MH088278 from the National Institute of Mental Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health.
ED-SAFE Investigators
Marian E. Betz, MD, MPH, University of Colorado Hospital
Jeffrey M. Caterino, MD, The Ohio State University Medical Center
Talmage Holmes, PhD, MPH, University of Arkansas Medical Center
Maura Kennedy, MD, MPH, Beth Israel Deaconess Medical Center
Frank LoVecchio, DO, MPH, Maricopa Medical Center
Lisa A. Uebelacker, PhD, Memorial Hospital of Rhode Island
Wesley Zeger, DO, University of Nebraska Medical Center
Footnotes
Prior presentations: none
Conflict of interest: The authors have no conflicts of interest to report.
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