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. 2017 Jul 10;132(1 Suppl):88S–94S. doi: 10.1177/0033354917706933

Detecting Suicide-Related Emergency Department Visits Among Adults Using the District of Columbia Syndromic Surveillance System

S Janet Kuramoto-Crawford 1,2, Erica L Spies 3, John Davies-Cole 2,✉
Editors: Paula W Yoon, Amy I Ising, Julia E Gunn
PMCID: PMC5676504  PMID: 28692388

Abstract

Objectives:

Limited studies have examined the usefulness of syndromic surveillance to monitor emergency department (ED) visits involving suicidal ideation or attempt. The objectives of this study were to (1) examine whether syndromic surveillance of chief complaint data can detect suicide-related ED visits among adults and (2) assess the added value of using hospital ED data on discharge diagnoses to detect suicide-related visits.

Methods:

The study data came from the District of Columbia electronic syndromic surveillance system, which provides daily information on ED visits at 8 hospitals in Washington, DC. We detected suicide-related visits by searching for terms in the chief complaints and discharge diagnoses of 248 939 ED visits for which data were available for October 1, 2015, to September 30, 2016. We examined whether detection of suicide-related visits according to chief complaint data, discharge diagnosis data, or both varied by patient sex, age, or hospital.

Results:

The syndromic surveillance system detected 1540 suicide-related ED visits, 950 (62%) of which were detected through chief complaint data and 590 (38%) from discharge diagnosis data. The source of detection for suicide-related ED visits did not vary by patient sex or age. However, whether the suicide-related terms were mentioned in the chief complaint or discharge diagnosis differed across hospitals.

Conclusions:

ED syndromic surveillance systems based on chief complaint data alone would underestimate the number of suicide-related ED visits. Incorporating the discharge diagnosis into the case definition could help improve detection.

Keywords: suicide, syndromic surveillance, emergency department

Suicide is a critical public health problem in the United States, with 42 773 deaths attributable to suicide in 2014.1 In 2015, an estimated 9.8 million adults aged ≥18 reported having serious thoughts of suicide in the past year, and of the estimated 1.4 million who attempted suicide, approximately 60% received mental health services that year.2 The emergency department (ED) is a key setting to monitor and detect visits of patients presenting with risks for suicide.3 One study reported that approximately one-third of suicide decedents presented to an ED ≥1 time in the year before their death.4 Another study reported that approximately 10% of suicide decedents visited EDs ≤6 weeks before their death.5 Furthermore, a prospective study reported that about 1 in 4 adults who presented to the ED with suicidal ideation or a suicide attempt in the past week had subsequently attempted or died by suicide.6 Certain people exhibiting high-risk behaviors for suicide (eg, those who abuse drugs or have mental disorders) seek ED care, making EDs a critical source for identifying and preventing suicide and future suicide attempts.7

Understanding the magnitude of suicide, suicide attempt, and suicidal ideation is necessary to guide prevention and intervention efforts.8 Surveillance for self-inflicted injury, such as suicide attempt, in ED settings is possible through sources such as the National Electronic Injury Surveillance System and the National Hospital Ambulatory Medical Care Survey.9 However, national-level surveillance data lag in availability, which hinders the use of these data to guide prompt public health action locally. Furthermore, using national-level data to estimate the magnitude of ED visits involving suicidal ideation or suicide attempt (ie, suicide-related visits) for limited geographic regions can be challenging. To improve surveillance efforts for suicide, the Data and Surveillance Task Force within the National Action Alliance for Suicide Prevention recommended including items such as suicidal ideation and suicide attempt in surveillance systems that capture incidents in real time.9

Developed in early 2000 to enhance early detection of health consequences from bioterrorism attacks and to mobilize rapid response,10 the syndromic surveillance system might be useful for real-time surveillance of suicidal ideation and suicide attempt. A syndromic surveillance system was used to monitor suicide-related ED visits in an investigation of trends and risk factors for suicide among young people in Virginia in 201411 and during the 2008-2010 US economic recession.12 Such real-time surveillance is particularly useful locally to enable prompt public health action for areas in need10,13 and to evaluate and monitor prevention efforts. Near–real-time data can detect aberrant patterns in suicide-related ED visits to identify populations, hospitals, or geographic regions that require additional prevention efforts. Additionally, daily system monitoring can improve understanding of suicide attempt methods, lead to suicide means restriction, and guide local intervention efforts.

Multiple ED syndromic surveillance systems primarily rely on patient chief complaints to monitor and detect health events, because these systems provide the timeliest data to detect aberrant patterns.14,15 Chief complaints can be open-text fields or drop-down lists that document why patients presented to the medical system, often in the patients’ own words. One challenge in using chief complaint data is accurately identifying health events given the nonspecific nature of how patients present their problems, which might not translate into clinical terms.16,17 Several studies examined the use of discharge diagnosis data to improve detection of health events.15,16,18–20 These studies reported that agreement between discharge diagnosis and chief complaint can differ by the health events examined and that the use of a syndromic surveillance system might improve with the incorporation of data on discharge diagnosis.16,19,20 Whether chief complaint data alone can accurately detect suicide-related ED visits is unknown.

We evaluated the usefulness of ED syndromic surveillance to detect visits involving suicidal ideation or suicide attempt. Specifically, we examined the extent to which syndromic surveillance relying solely on chief complaint data detects suicide-related ED visits and assessed the added value of using information from discharge diagnoses to detect suicide-related ED visits.

Methods

The District of Columbia (DC) Department of Health in Washington, DC, uses the Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE),21 an electronic syndromic surveillance system used in multiple US jurisdictions to detect and monitor health problems of public health importance. Similar to other syndromic surveillance systems, DC ESSENCE focuses surveillance on physical syndromes (eg, influenza-like illness, respiratory illness, and gastrointestinal illness) encountered in DC acute care hospital EDs.14 The Johns Hopkins University Applied Physics Laboratory developed and maintains DC ESSENCE, which does not include hospitals operated by the US Department of Veterans Affairs. The Centers for Medicare & Medicaid Services’ electronic health record incentive program encourages DC hospitals to provide data on syndromic surveillance to the DC Department of Health. The International Society for Disease Surveillance and the Centers for Disease Control and Prevention recommend minimum data elements available for syndromic surveillance systems.22,23 Limited de-identified data (eg, chief complaint, discharge diagnosis, age, sex, and date and time of event from ED visits) are transmitted daily from each hospital’s electronic health record system to DC ESSENCE to monitor health-related events. Data elements submitted to DC ESSENCE differ by hospital. DC ESSENCE captures data on ED visits from 8 nonfederal acute care hospitals in DC (1 children’s hospital and 7 adult care hospitals).24 More than 500 000 visits (range, 35 000-88 000) were made to EDs at these 8 DC hospitals in 2015. These 8 hospitals also accounted for <9000 psychiatric admissions in 2015.24 For this study, we extracted 347 357 ED visits with chief complaint data for the period October 1, 2015, to September 30, 2016, for patients aged ≥18 from the 7 adult care hospitals. The ESSENCE system is described in detail elsewhere.21,25

We defined a suicide-related ED visit as any visit in which the patient presented with suicidal ideation or suicide attempt. We searched terms related to suicidal ideation or suicide attempt in the chief complaint field (collected as free text) and the discharge diagnosis field (collected as free text or codes from the International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]26 and International Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM]).27 The ICD-9-CM and ICD-10-CM codes used to identify suicide-related ED visits were based on the codes identified by experts at the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control28 and on nomenclature on suicide and related terms.29 We excluded self-injury without suicidal ideation, because nonsuicidal self-injury is epidemiologically and clinically distinct from suicide attempt and might have different implications for treatment and prevention.30

Six of 7 adult care hospitals also provided discharge diagnosis data for 248 939 (72%) ED visits with chief complaint data. The availability of discharge diagnosis data for the 6 hospitals ranged from 67% to 94%. We estimated percentages and conducted a Pearson χ2 test with SAS version 9.3.31 The Centers for Disease Control and Prevention determined this study to be exempt from institutional review board review.

Results

Of the 248 939 ED visits with chief complaint and discharge diagnosis data, 1540 (0.6%) suicide-related ED visits were identified with chief complaint only, discharge diagnosis only, or both. Most patients were male (n = 947, 61%) and aged 18-44 (n = 894, 58%). Of the 1540 visits, 566 (37%) mentioned suicide-related terms in the chief complaint but not in the discharge diagnosis; 384 (25%) mentioned suicide-related terms or discharge codes in both the chief complaint and discharge diagnosis; and 590 (38%) mentioned suicide-related terms or discharge codes in the discharge diagnosis but not in the chief complaint (Figure). Of the 98 418 ED visits without discharge diagnosis data, 745 had suicide-related terms in the chief complaint.

Figure.

Figure

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Number of suicide-related emergency department visits for adults aged ≥18 at 7 acute care adult hospitals, detected through chief complaint and discharge diagnosis data in syndromic surveillance, Washington, DC, 2015-2016. Data source: District of Columbia Electronic Surveillance System for the Early Notification of Community-Based Epidemics. Abbreviations: CC, chief complaint; DD, discharge diagnosis; ED, emergency department.

Among the 1540 visits, mention of suicide-related terms in the chief complaint only, discharge diagnosis only, or both varied by hospital location (P < .001) but not by patient sex (P = .79) or age (P = .19) (Table 1). For example, suicide-related terms were more likely to be mentioned in the discharge diagnosis than in the chief complaint for hospital F but were more likely to be mentioned in the chief complaint than in the discharge diagnosis for hospital E.

Table 1.

Characteristics of suicide-related emergency department visits (n = 1540), by whether visit was identified with chief complaint data, discharge diagnosis data, or both, Washington, DC, 2015-2016a

No. (%)a,b Suicide-Related Terms Mentioned, No. (%)a,b
Characteristic ED Visits With Chief Complaint and Discharge Diagnosis Data (n = 248 939) Suicide-Related ED Visits (n = 1 540) Chief Complaint Only (n = 566) Chief Complaint and Discharge Diagnosis (n = 384) Discharge Diagnosis Only (n = 590) P Valuec
Sexd .79
 Male 108 494 (44) 947 (61) 354 (37) 232 (24) 361 (38)
 Female 140 435 (56) 593 (39) 212 (36) 152 (26) 229 (39)
Age group, y .19
 18-44 131 063 (53) 894 (58) 343 (38) 228 (26) 323 (36)
 45-64 81 311 (33) 589 (38) 199 (34) 143 (24) 247 (42)
 ≥65 36 565 (15) 57 (4) 24 (42) 13 (23) 20 (35)
Hospital <.001
 A 21 183 (9) 141 (9) 40 (28) 58 (41) 43 (30)
 B 59 776 (24) 519 (34) 163 (31) 149 (29) 207 (40)
 C 43 337 (17) 263 (17) 130 (49) 80 (30) 53 (20)
 D 25 637 (10) 128 (8) 40 (31) 28 (22) 60 (47)
 E 47 778 (19) 304 (20) 184 (61) 46 (15) 74 (24)
 F 51 228 (21) 185 (12) 9 (5) 23 (12) 153 (83)
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Abbreviation: ED, emergency department.

aData source: District of Columbia Electronic Surveillance System for the Early Notification of Community-Based Epidemics.

bPercentages may not total to 100 because of rounding.

cBased on the Pearson χ2 test. P values significant at P < .05.

dOf the 248 939 ED visits from 6 acute care adult hospitals that reported discharge diagnoses and chief complaints among adults aged ≥18, 10 had a missing value for patient sex.

Among the 590 suicide-related ED visits detected by discharge diagnosis only, 367 (62%) chief complaints were related to mental health (eg, depression, anxiety, mental health, or psychiatric evaluation), and 156 (26%) were not related to mental health, alcohol or drugs, or other injury. However, 61 of these 156 visits (39%) mentioned pain (Table 2).

Table 2.

Types of chief complaints in suicide-related emergency department visits for adults aged ≥18, detected with discharge diagnosis data only (n = 590), 6 acute care adult hospitals, Washington, DC, 2015-2016a,b

Chief Complaint No. (%)
Mental health (including evaluation) 367 (62)
Alcohol or drugs 59 (10)
Other injury 13 (2)
None of the abovec 156 (26)
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aData source: District of Columbia Electronic Surveillance System for the Early Notification of Community-Based Epidemics.

bChief complaints could be counted in >1 category.

cOf the 156 chief complaints that were not mental health, alcohol or drugs, or other injury, 61 mentioned pain.

Discussion

Reliable detection of health events is critical for a syndromic surveillance system to monitor and detect public health problems and evaluate prevention programs. This study contributes to the limited literature on the use of ED syndromic surveillance to monitor suicide-related ED visits in near real time. Our findings indicated that the use of chief complaint data alone to identify suicide-related ED visits would underrepresent visits of patients with suicide risk, because discharge diagnosis data identified an additional 38% of suicide-related ED visits that were not captured with data on chief complaints alone. The suicide-related ED visits identified through chief complaint data alone, discharge diagnosis data alone, or both did not differ by patient age or sex but did differ by hospital.

Similar to studies of other health events, such as influenza,15 this study found that detection of suicide-related ED visits via the ED syndromic surveillance system can be improved by including discharge diagnosis data. Using additional electronic health record fields, such as triage notes (if available), to identify suicide-related ED visits could be beneficial. One study indicated that ED syndromic surveillance through automated coded classification based on triage notes can accurately capture mental health-related visits, when compared with clinician validations.32 However, multiple existing syndromic surveillance systems that rely on chief complaint data do not include automated categories to capture mental health-related events, including suicide-related visits.14,33 Using syndromic surveillance to examine behavioral health visits may have similar challenges as using administrative data, which vary in accuracy depending on the diagnosis of interest.34 Although use of E-codes for injury surveillance in EDs achieved high reliability,33 the impact of transitioning from ICD-9-CM to ICD-10-CM codes on injury surveillance warrants further investigation.

The percentage of suicide-related ED visits was comparable with national estimates found in a study that used National Hospital Ambulatory Medical Care Survey data.35 In our study, 1 in 4 suicide-related ED visits that were detected from discharge diagnosis alone had chief complaints that were not related to mental health or drugs. A previous study reported that approximately 25% of patients who disclosed suicidal ideation in a computer survey had suicidal ideation or other mental conditions noted in their ED medical charts, and the most frequently reported chief complaint was pain.36 Another study estimated that undisclosed suicidal ideation among patients who visited EDs for nonpsychiatric reasons might be 8% to 12%.37

Hospitals differed in whether suicide-related ED visits were identified through chief complaint data only, discharge diagnosis data only, or both. More consistent recording of suicide-related terms in discharge diagnoses and identifying suicide-related risks in EDs might increase the detection of suicide-related visits in the syndromic surveillance system. One multicenter study showed that suicide screening is not frequently used in the ED, even for patients who present with psychiatric complaints.38 Identifying and managing suicidal patients in EDs has been identified as a promising approach to suicide prevention39; goal 7 of the 2012 National Strategy for Suicide Prevention highlights training providers for suicide prevention.40 The Joint Commission published a sentinel alert to improve detection of suicide risk and the treatment process for suicidal patients in a health-care setting, including EDs.41 Additional tools to evaluate and triage for suicide risks in EDs are available,42,43 as is a proposed uniform definition for suicide-related risks for surveillance.29,44 One study reported the feasibility and effectiveness of using suicide screenings to improve detection and early intervention in EDs.45 These screenings could help identify suicide-related ED visits with chief complaint or discharge diagnosis data. By detecting suicide-related risks in both the chief complaint and the discharge diagnosis, patients could be connected to follow-up services to minimize suicide risk. Furthermore, examination of hospital procedures and electronic health record training might help ESSENCE users understand hospitals’ differences in mentions of suicide-related risks in chief complaints and discharge diagnoses.

Limitations

This study had several limitations. First, data on discharge diagnoses were missing from 1 hospital and were incomplete for other hospitals, which reduced the number of ED visits examined. Second, a suicide event might have been missed during the identification process because of versatility in free-text fields and lack of an automatic coding system to identify suicide-related visits, which could have affected the number of suicide-related visits detected with chief complaint or discharge diagnosis data. Third, possible suicide attempts without the corresponding ICD-9-CM or ICD-10-CM codes for suicidal ideation were not classified as suicide-related ED visits, because they could not be distinguished from nonsuicidal self-injuries. This could have resulted in underestimation of suicide-related visits based on the discharge diagnosis data. Fourth, our study might not be generalizable to all US hospitals, although data came from all non–Veterans Affairs adult acute care hospitals in DC with EDs. Last, data availability and quality varied by hospital, and information such as triage notes and treatment disposition was not available to further improve detection of suicide-related visits.

Conclusions

Syndromic surveillance in the ED can address the gap in suicide surveillance by offering near–real-time surveillance for disclosed suicidal ideation and suicide attempts, and supplementing chief complaint data with discharge diagnosis data could improve the detection of suicide-related ED visits. The structured query could be developed in the DC ESSENCE system by using both chief complaint and discharge diagnosis data to improve timely monitoring of suicide-related ED visits. Better detection of suicide-related risks through syndromic surveillance will improve the monitoring of suicide-related visits, the detection of aberrant patterns in suicide-related risks in near real time in EDs, and facilitation of prompt public health action.

Acknowledgments

We thank Danice K. Eaton, PhD, and Chad Heilig, PhD, from the Centers for Disease Control and Prevention; Keith Li, MPH, from the District of Columbia Department of Health; and the Johns Hopkins University Applied Physics Laboratory.

Authors’ Note: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the US Department of Health and Human Services.

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

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