Abstract
Prior work from surveys and limited populations suggests many emergency department (ED) patients with suicide risk do not have documented lethal means assessments (e.g., being asked about home firearms). The specific objectives of this study were to, in an ED with universal screening for suicide risk: (1) estimate how often ED providers documented lethal means assessment for suicidal patients, and (2) compare patients with and without documented lethal means assessments. We reviewed 800 total charts from a random sample of adults in three a priori age groups (18–34 years; 35–59 years; ≥60 years) with a positive suicide risk screen from 8/2014 to 12/2015. Only 18% (n=145) had documentation by ≥1 provider of assessment of lethal means access. Among these 145, only 8% (n=11) had documentation that someone discussed an action plan to reduce access (most commonly changing home storage or moving objects out of the home). Among 545 suicidal patients discharged home from the ED, 85% had no documentation that any provider assessed access to lethal means. Our findings highlight an important area for improving care: routine, documented lethal means assessment and counseling for patients with suicide risk. There is an urgent need for further exploration of barriers and facilitators.
Keywords: suicide, firearms, mental health evaluation, safety planning, emergency department
1. Introduction
In 2015, suicide was the 10th leading cause of death in the United States (NCHS, 2016), and emergency departments (EDs) remain a pivotal site where many patients with suicide risk are evaluated. Nearly 650,000 ED visits annually relate directly to suicidal behavior,(Ting et al., 2012; Larkin et al., 2008), and 6–10% of all adult ED patients, including those with a non-psychiatric reason for their visit, have current or recent SI.(Claassen and Larkin, 2005; Ilgen et al., 2009; Boudreaux et al., 2015). These figures have led to calls for EDs to implement universal screening for suicide risk (Joint Commission, 2016).
Lethal means counseling – counseling patients with suicide risk about how to reduce their access to firearms and other lethal means of suicide – is an evidence-based suicide prevention approach (Mann and Michel, 2016) and recommended practice for EDs (Capoccia and Labre, 2015). Unfortunately, in a prior study involving ED provider self-reports, we found that lethal means assessment was not routine; less than 50% of providers ‘almost always’ or ‘often’ ask about suicidal patients’ access to firearms, even though more than half thought that this assessment is important (Betz et al., 2013). When we compared ED providers self-report to their documentation in the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) trial (Miller et al., 2017), we confirmed that documentation of assessment was not common, occurring in only 50% of the 1,358 patients with suicidal ideation (SI) or suicide attempts (SA) (Betz et al., 2016b).
The patients in that chart review, however, were enrolled in a clinical trial and the results might not be highly generalizable. In the present study, we sought to examine documentation of lethal means access among patients identified with suicide risk as part of a universal screening protocol. We hypothesized that the rates of documented lethal means assessment might be lower than in the cohort of clinical trial patients (many of whom had presented with suicide-related complaints). The specific objectives of this study were: (1) to estimate how often ED providers documented lethal means assessment for suicidal ED patients, and (2) to compare the characteristics of patients with and without documented lethal means assessment. A better understanding of clinical practices in routine care could enhance efforts related to healthcare provider training and ED protocols for lethal means counseling, toward the ultimate goal of reducing suicide deaths (Surgeon General, 2012).
2. Methods
2.1. Study design & setting
This was a chart review study of patient visits at an urban, tertiary-care ED that was a site for the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study (Boudreaux et al., 2013; Miller et al., 2017). ED-SAFE was a quasi-experimental, eight-center study that implemented universal screening for suicide risk among ED patients, and had three phases: Treatment as Usual (Phase 1), Universal Screening (Phase 2), and Universal Screening + Intervention (Phase 3). The intervention included nurse-delivered Safety Planning, a secondary assessment tool for physicians, and post-discharge telephonic counseling (Miller et al., 2017); of note, no specific instruction was given concerning lethal means assessment or documentation. This retrospective chart review included only patients seen after the start of ED-SAFE Phase 3 so as to include the most recent data available without mixing data from two phases; reviewed visits occurred between 8/2014 through 12/2015.
Eligible patient visits included those with a positive “Patient Safety Screener,” a series of screening questions asked by the primary nurse and documented in the ED’s electronic medical record (Epic). A positive screen was defined as endorsing SI in the past two weeks, reporting a SA within the last six months, or both. We identified potentially eligible charts through an Epic report of all visits with positive screens; from these, we drew a random sample for full review among three age groups (18–34 years, n=300; 35–59 years, n=300; and ≥60 years, n=200). These age groups were chosen a priori because of an interest in examining age-related differences in care, as described in more detail elsewhere (Arias et al., 2017).
For each chart, trained abstractors reviewed the entire ED medical record and entered data into a secure online REDCap database (Research Electronic Data Capture, Vanderbilt, TN) hosted by the Colorado Clinical & Translational Sciences Institute (Harris et al., 2009). To test inter-rater reliability, the abstractors and site investigator separately reviewed a 10% subset of charts, with kappa values >0.74 for the major predictor variables (including lethal means assessment documentation), indicating a good level of rater agreement.
2.2. Measures
The abstraction form included patient demographics, medical and social history, and ED visit characteristics (including chief complaint, disposition, and formal mental health details), as well as medical encounters in previous 6 months and documentation of SI/SA screening on those visits. Lethal means variables were whether the “presence of means to complete suicide” was assessed (yes; no/not documented), and if so, which means (firearms; toxic medications; knives/sharp objects; hanging supplies; other; ≥1 allowed). Abstractors additionally recorded whether a provider documented discussion of “a means action plan with the patient (yes; no; not documented/not done), and, if yes, what the plan was (change object storage at home; move objects out of home, other). The primary outcome was documentation of assessment of lethal means access during the visit.
2.3. Data analysis
We used descriptive analyses to compare lethal means assessment among patients with SI/SA based on patient and ED visit characteristics, with chi-square tests for statistical significance. We then conducted unadjusted logistic regression analyses and reported odds ratios (ORs) with 95% confidence intervals (CIs). For the multivariable logistic regression model, we included demographic characteristics (age, sex, race) and all other variables with bivariate p-values <0.10 in the overall model to predict documentation of lethal means assessment. We sequentially and manually included and excluded multivariable model variables by assessing individual variables’ significance, impact on other variables, and global goodness-of-fit. For the final model, we considered P<0.05 statistically significant. We decided a priori to include age in the model because our sample was abstracted in age groups. All analyses were conducted using STATA 14.2 (StataCorp, College Station, TX).
3. Results
Among 800 patients with positive screens during an ED visit whose charts were reviewed, approximately half were women or Non-Hispanic whites (Table 1). The vast majority (93%) had English listed as a primary language. Roughly one-quarter of patients arrivals were on weekends, and 12% of arrival times were on the night shift (11pm to 7am). Two-thirds of this positive screen patient population presented with a chief complaint involving a psychiatric issue, with one-third presenting with self-harm ideation or behavior. The majority (82%) had documentation of SI within the past week, while fewer (22%) were in the ED for a suicide attempt. Low proportions had documentation of homicidal ideation (7%) or domestic violence (4%); 19% had documentation of being intoxicated with alcohol in the ED; and 37% had a urine test positive for alcohol or drugs (Table 1). During their ED visit, 62% of these 800 patients with identified suicide risk saw a mental health consultant. Ultimately, 68% were discharged home from the ED, while 17% were admitted or transferred to a psychiatric ward (Table 1).
Table 1.
Characteristics of Patients (n=800)
| n | % | |
|---|---|---|
| Demographics | ||
| Age Group | ||
| 18–34 | 300 | 38 |
| 35–59 | 300 | 38 |
| 60+ | 200 | 25 |
| Female | 410 | 51 |
| Race/ethnicity | ||
| Non-Hispanic White | 474 | 59 |
| Non-Hispanic Black | 162 | 20 |
| Hispanic | 131 | 16 |
| Other | 33 | 4 |
| Primary language is English | 741 | 93 |
| ED visit characteristics | ||
| Day of week | ||
| Weekday (M–F) | 596 | 75 |
| Weekend (Sa–Su) | 204 | 26 |
| Time of day | ||
| 7:00am–2:59pm | 321 | 40 |
| 3:00pm–10:59pm | 382 | 48 |
| 11:00pm–6:59am | 97 | 12 |
| Chief complaint involved psychiatric behavior | 527 | 66 |
| Chief complaint involved self-harm behavior | 265 | 33 |
| ED disposition | ||
| Discharged home | 545 | 68 |
| Admitted to medical ward/observation/intensive care unit | 38 | 5 |
| Admitted/transferred to psychiatric ward/facility | 132 | 17 |
| Admitted/transferred to substance abuse treatment facility | 27 | 3 |
| Other (including AMA, LBVC, not documented) | 53 | 7 |
| ED total length of stay | ||
| ≤5 hours| | 333 | 42 |
| >5 hours – 10 hours | 148 | 19 |
| >10 hours | 319 | 40 |
| Seen by ED mental health consultant | 495 | 62 |
| Healthcare Utilization | ||
| Number of ED visits in the previous 6 months | ||
| None | 357 | 45 |
| 1–5 | 354 | 44 |
| >6 | 89 | 11 |
| Number of substance abuse visits in the previous 6 months | ||
| None | 790 | 99 |
| 1–5 | 10 | 1 |
| >6 | 0 | 0 |
| Number of psychiatric visits in the previous 6 months | ||
| None | 791 | 99 |
| 1–5 | 8 | 1 |
| >6 | 1 | 0 |
| Substance use | ||
| Tobacco use (current) | 403 | 50 |
| Alcohol abuse (current abuse or intoxication) | 276 | 35 |
| Intentional illegal or prescription drug use (current) | 284 | 36 |
| Alcohol intoxication during ED visit | 149 | 19 |
| Positive urine drug/alcohol test1 | 295 | 37 |
| Suicide- or violence-related (in past week) | ||
| Suicidal ideation | 658 | 82 |
| Current suicide attempt | 173 | 22 |
| Thoughts or threats of harm toward other people | 55 | 7 |
| Any interpersonal violence | 46 | 6 |
| Domestic violence | 33 | 4 |
| Depressed mood | 657 | 82 |
| Any Documentation of lethal means assessment | 145 | 18 |
| If yes, what means (1+ allowed) | ||
| Firearms | 86 | 59 |
| Toxic medications | 37 | 26 |
| Knives/sharp objects | 37 | 26 |
| Hanging supplies | 9 | 6 |
| Other | 17 | 12 |
| Not documented | 1 | 1 |
| If yes, did provider discuss a means action plan with the patient? | ||
| Yes | 11 | 8 |
| No | 127 | 88 |
| Not documented/not done | 7 | 5 |
| If yes, what was the action plan? | ||
| Change storage at home | 3 | 27 |
| Move object(s) out of home | 3 | 27 |
| Other | 5 | 45 |
| Not documented/done | 0 | 0 |
Urine drugs of abuse screen tests for (substance (cut-off value): amphetamines/methamphetamines (1000ng/mL); barbiturates (200 ng/mL); benzodiazepines (200 ng/mL); cannabinoids, THC (50 ng/mL); cocaine (300 ng/mL); opiates (300 ng/mL); ethanol (10 mg/dL); and phencyclidine, PCP (25 ng/mL).
Overall, only 18% (n=145) of these positive screen patients had documentation by at least one provider of assessment to access to lethal means (Table 1). Among these 145 patients, the most common means documented was firearms, followed by toxic substances (Figure 1). Among those with documented lethal means assessment, only 8% (n=11) had documentation that someone discussed an action plan to reduce access. Among these 11 patients, the most common plans were changing home storage (n=3) or moving object(s) out of the home (n=3). Among the 546 patients with a positive suicide screen who were discharged home, the majority (n=464, 85%) had no documentation that any provide assessed access to lethal means.
Figure 1. Type of means assessed (among patients with documented means assessment; n=145).
More than one response allowed. Other incldued: death by police; jumping in front of traffic or off of bridge; crashing car; and non-specific “weapon”
Patients with documented assessment of lethal means access were more likely to: be aged 18–59 or male; have a chief complaint involving self-harm or other psychiatric behavior; express current depression, SI or thoughts of harm towards others; or be involved in domestic or other interpersonal violence (Table 2). In addition, they were more likely to be intoxicated with alcohol or having a positive urine toxicology test, to see a mental health consultant, and to be admitted to the hospital (rather than discharged home).
Table 2.
Characteristics of Patients by Documented Assessment of Lethal Means Access (n=800)
| Lethal means assessment (n=145) | No lethal means assessment (n=655) | Odds Ratio | 95% CI | P | ||||
|---|---|---|---|---|---|---|---|---|
|
|
||||||||
| n | % | n | % | |||||
| Demographics | ||||||||
| Age Group | ||||||||
| 18–34 | 63 | 43 | 237 | 36 | (Ref) | -- | -- | |
| 35–59 | 68 | 47 | 232 | 35 | 1.10 | 0.75 | 1.62 | 0.621 |
| 60+ | 14 | 10 | 186 | 28 | 0.28 | 0.15 | 0.52 | <.001 |
| Female | 61 | 42 | 349 | 53 | 0.64 | 0.44 | 0.92 | 0.01 |
| Race/ethnicity | ||||||||
| Non-Hispanic White | 86 | 59 | 388 | 59 | (Ref) | -- | -- | |
| Non-Hispanic Black | 25 | 17 | 137 | 21 | 0.82 | 0.51 | 1.34 | 0.433 |
| Hispanic | 28 | 19 | 103 | 16 | 1.23 | 0.76 | 1.98 | 0.403 |
| Other | 6 | 4 | 27 | 4 | 1.00 | 0.40 | 2.50 | 0.996 |
| Primary language is English | 135 | 93 | 606 | 93 | 0.95 | 0.81 | 1.11 | 0.46 |
| ED visit characteristics | ||||||||
| Day of week | 113 | 78 | 483 | 74 | (Ref) | -- | -- | 0.290 |
| Weekday (M–F) | 32 | 22 | 172 | 26 | 0.80 | 0.52 | 1.22 | |
| Weekend (Sa–Su) | ||||||||
| Time of day | 57 | 39 | 264 | 40 | (Ref) | -- | -- | 0.300 |
| 7:00am–2:59pm | 64 | 44 | 318 | 49 | 1.15 | 0.88 | 1.51 | |
| 3:00pm–10:59pm | 24 | 17 | 73 | 11 | 1.15 | 0.88 | 1.51 | |
| Chief complaint involved psychiatric behavior | 135 | 93 | 392 | 60 | 9.00 | 5.00 | 17.00 | <.001 |
| Chief complaint involved self-harm behavior | 66 | 46 | 199 | 30 | 1.93 | 1.34 | 2.78 | <.001 |
| ED disposition | ||||||||
| Discharged home | 82 | 57 | 463 | 71 | (Ref) | -- | -- | |
| Admitted to medical ward/observation/intensive care unit | 4 | 3 | 34 | 5 | 0.66 | 0.23 | 1.92 | 0.450 |
| Admitted/transferred to psychiatric ward/facility | 48 | 33 | 84 | 13 | 3.23 | 2.11 | 4.94 | <.001 |
| Admitted/transferred to substance abuse treatment facility | 6 | 4 | 21 | 3 | 1.61 | 0.63 | 4.12 | 0.317 |
| Other (including AMA, LBVC, not documented) | 5 | 3 | 53 | 8 | 0.53 | 0.21 | 1.37 | 0.192 |
| ED total length of stay | ||||||||
| ≤5 hours | 35 | 24 | 298 | 45 | (Ref) | -- | -- | <.001 |
| >5 hours | 110 | 76 | 357 | 55 | 2.62 | 1.74 | 3.95 | |
| Seen by ED mental health consultant | 132 | 91 | 363 | 55 | 1.22 | 1.05 | 1.43 | 0.01 |
| Healthcare Utilization | ||||||||
| ED visits in previous 6 months | ||||||||
| None | 71 | 49 | 286 | 44 | (Ref) | -- | -- | 0.308 |
| ≥1 | 74 | 51 | 369 | 56 | 0.87 | 0.66 | 1.14 | |
| Substance abuse visits in previous 6 months | ||||||||
| None | 141 | 97 | 649 | 99 | (Ref) | -- | -- | 0.001 |
| ≥1 | 4 | 3 | 6 | 1 | 3.07 | 0.86 | 11.02 | 0.100 |
| Psychiatric visits in previous 6 months | ||||||||
| None | 139 | 96 | 652 | 99 | (Ref) | -- | -- | 0.001 |
| ≥1 | 6 | 4 | 3 | 0.5 | 9.38 | 2.32 | 37.97 | |
| Substance use | ||||||||
| Tobacco use (current) | 80 | 55 | 323 | 49 | 1.27 | 0.88 | 1.82 | 0.20 |
| Alcohol abuse (current abuse or intoxication) | 49 | 34 | 227 | 35 | 0.96 | 0.66 | 1.41 | 0.843 |
| Intentional illegal or prescription drug use (current) | 57 | 39 | 227 | 35 | 1.22 | 0.84 | 1.77 | 0.290 |
| Alcohol intoxication during ED visit | 39 | 27 | 110 | 17 | 0.85 | 0.81 | 0.90 | <.001 |
| Positive urine drug/alcohol test1 | 80 | 55 | 215 | 33 | 0.82 | 0.77 | 0.87 | <.001 |
| Suicide- or violence-related (in past week) | ||||||||
| Current suicidal ideation | 139 | 96 | 519 | 79 | 6.07 | 2.62 | 14.04 | <.001 |
| Current suicide attempt | 41 | 28 | 132 | 20 | 1.56 | 1.04 | 2.35 | 0.032 |
| Current homicidal ideation | 17 | 12 | 38 | 6 | 2.16 | 1.18 | 3.94 | 0.012 |
| Any interpersonal violence | 9 | 6 | 37 | 6 | 0.42 | 0.18 | 0.99 | 0.04 |
| Domestic violence | 5 | 3 | 28 | 4 | 0.80 | 0.30 | 2.11 | 0.64 |
| Depressed mood | 131 | 90 | 526 | 80 | 2.30 | 1.28 | 4.11 | 0.002 |
Urine drugs of abuse screen tests for (substance (cut-off value): amphetamines/methamphetamines (1000ng/mL); barbiturates (200 ng/mL); benzodiazepines (200 ng/mL); cannabinoids, THC (50 ng/mL); cocaine (300 ng/mL); opiates (300 ng/mL); ethanol (10 mg/dL); and phencyclidine, PCP (25 ng/mL).
After adjustment through multivariable logistic regression, the only variables that remained significantly associated with having documented lethal means assessment were: age 18–34 years (Odds ratio [OR] 3.26, 95%CI 1.70–6.25) or age 35–59 years (OR 3.86, 95%CI 2.01–7.14), each compared to age ≥60 years; chief complaint involving psychiatric behavior (OR 4.91; 95%CI 2.35–10.26); psychiatric admission/transfer (versus discharge; OR 2.01; 95%CI 1.23–3.28); ≥1 ED visit for substance use or a psychiatric issue in previous 6 months (OR 7.96, 95%CI 2.05–30.90), and current SI (OR 3.61; 1.42–9.19; Table 3).
Table 3.
Final multivariable model of factors associated with documented lethal means assessment (n=800)
| Adjusted Odds Ratio1 for having documented lethal means assessment | 95% CI | P | ||
|---|---|---|---|---|
| Age Group | ||||
| 18–34 | 3.26 | 1.70 | 6.25 | <.001 |
| 35–59 | 3.86 | 2.01 | 7.41 | <.001 |
| 60+ | 1.0 (Ref) | -- | -- | -- |
| Female | 0.76 | 0.51 | 1.15 | 0.19 |
| Chief complaint involved psychiatric behavior | 4.91 | 2.35 | 10.26 | <.001 |
| Chief complaint involved self-harm behavior | 0.82 | 0.53 | 1.27 | 0.36 |
| ED disposition | ||||
| Discharged home | 1.0 (Ref) | -- | -- | -- |
| Admitted to medical ward/observation/intensive care unit | 1.18 | 0.36 | 3.83 | 0.79 |
| Admitted/transferred to psychiatric ward/facility | 2.01 | 1.23 | 3.28 | <.01 |
| Admitted/transferred to substance abuse treatment facility | 1.21 | 0.43 | 3.42 | 0.72 |
| Other (including AMA, LBVC) | 0.55 | 0.20 | 1.54 | 0.26 |
| ED total length of stay >5 hours | 1.10 | 0.66 | 1.83 | 0.71 |
| Seen by ED mental health consultant | 1.07 | 0.84 | 1.36 | 0.60 |
| ≥1 ED visit for substance use or psychiatric issue in previous 6 months | 7.96 | 2.05 | 30.90 | 0.003 |
| Alcohol intoxication or positive urine drug/alcohol test2 | 1.40 | 0.91 | 2.15 | 0.13 |
| Current suicidal ideation | 3.61 | 1.42 | 9.19 | <.01 |
| Current suicide attempt | 0.85 | 0.53 | 1.36 | 0.51 |
| Thoughts or threats of harm toward other people | 0.92 | 0.47 | 1.78 | 0.80 |
| Any interpersonal violence | 0.73 | 0.32 | 1.68 | 0.46 |
| Depressed mood | 1.55 | 0.79 | 3.06 | 0.21 |
Bold denotes statistically significant result (P<0.05).
Adjusted for all other variables shown. Goodness of Fit: Hosmer-Lemeshow Chi Square=6.13; p=0.63.
Urine drugs of abuse screen tests for (substance (cut-off value): amphetamines/methamphetamines (1000ng/mL); barbiturates (200 ng/mL); benzodiazepines (200 ng/mL); cannabinoids, THC (50 ng/mL); cocaine (300 ng/mL); opiates (300 ng/mL); ethanol (10 mg/dL); and phencyclidine, PCP (25 ng/mL).
4. Discussion
In this large, retrospective study of ED patients with positive screens for suicide risk, only 18% had documentation that any ED provider had spoken with them about their access to firearms or other lethal means of suicide. Although we recognize that counseling may occur without documentation, our findings still suggest a dramatic discrepancy from ideal care, where lethal means counseling – along with documentation – is a part of ED care for all patients with suicide risk (Capoccia and Labre, 2015). It is also much lower than estimates from a survey of ED nurse managers in eight states in the mountain west; among the 190 facilities responding, 80% said their discharge counseling includes addressing firearm access at home, although we did not review charts at those sites to corroborate the nurses’ estimate (Runyan et al. under review). Our study’s estimate is also lower than estimates from our prior chart review of patients enrolled in the ED-SAFE cohort, where 50% of patients had documentation about lethal means conversations (Betz et al., 2016b). We used similar abstraction methods and definitions for the current and ED-SAFE study, so we suspect the difference is real, most likely arising from differences in the two patient populations. Patients in the current study were identified as having suicide risk through universal screening, so many were likely at lower acute risk of suicide compared to those who came to the ED for suicidal thoughts or behaviors. Indeed, most (68%) were discharged home from the ED, while only 25% of participants in the ED-SAFE cohort were discharged (Betz et al., 2016b). Unfortunately, it is the patients discharged home who would benefit most from lethal means safety counseling, which in adolescent ED populations has been associated with subsequent storage behavior changes to reduce home access to firearms or other lethal means (Roszko et al., 2016). Therefore it is concerning that the large volume of patients discharged home did not receive safety counseling, even if they probably were at lower acute suicide risk than those admitted.
The association between low rates of admission and of lethal means assessment may also reflect provider usage of information about access to firearms and other lethal means. Specifically, providers use such information in their overall risk assessment, with access to means (especially when accompanied by a plan) supporting the case for hospitalization. In the current study, as in our past work (Betz, et al., 2016b), those who were admitted were more likely than those discharged to have documentation about lethal means access. Providers may be less aware about the importance of lethal means safety counseling prior to discharge, or they may feel uncomfortable or unsure about how to deliver such counseling (Roszko et al., 2016; Betz et al., 2013; Barber and Miller, 2014). An online training course for lethal means counseling exists but has not yet been widely disseminated (CALM); other guides are also available (AGO/MMS, 2017), but there more work is needed in the area of provider training.
In the US, suicide rates are highest in middle-aged and older men, in part because they are more likely to use firearms (CDC, 2017), which are the most lethal means of suicide. While lethal means assessment and counseling is important in all age groups, it is concerning that we found documented lethal means assessment to be less common in older rather than younger men, even after adjustment for discharge versus admission. This represents another important area for study and action, including development of appropriate ED provider training and protocols around suicide risk in various demographic groups. In related work, we have found other age-related disparities in suicide screening and care of ED patients with suicide risk (Arias et al. 2017; Betz et al., 2016a), suggesting that deficiencies in diagnosis and treatment of suicidal older adults previously observed in outpatient settings may persist in acute care settings.
One positive finding from our study was that, when they were assessed, the most common form of lethal means documented was firearms. Firearms accounted for 61% of all suicide deaths in the United States in 2015 (CDC, 2017), largely because of their high lethality and the often short deliberation time before an attempt (Barber and Miller, 2014). Healthcare provider counseling about firearm access—with a focus on how to reduce that access during periods of crisis or elevated suicide risk—is supported by multiple medical, public health, and legal organizations (Weinberger et al., 2015; AMA, 2017). As of June 2017, healthcare provider questioning or counseling about firearm access was legal in all states (Parmet et al., 2017), and a campaign urges physicians to commit to asking patients about firearms when there are risk factors for suicide or other forms of violence (Wintemute, 2017). Many questions remain about the best messages and messengers for lethal means safety (Parmet et al., 2017), including whether counseling without documentation (or direct questioning) is an appropriate strategy to use with patients who are concerned about medical record documentation of firearm storage (Knoepke et al., 2017). Other questions include how best to increase options for out-of-home firearm storage (such as at gun shops or ranges) and how state background check laws might affect storage options (McCourt et al., 2017). Research and partnerships with firearm owners – including organizations, retailers, instructors, and individuals – offer opportunities to clarify messages, address liability concerns, and enhance suicide prevention efforts from the local to national level (Wolk et al., 2017; Knoepke et al., 2017; Runyan et al., 2017; Barber et al., 2016; Simonetti et al., 2017).
Strengths of the present study include a large sample and reliable chart reviews. Nonetheless, some limitations to consider include that this retrospective study relied on medical record documentation, which may under-represent lethal means assessment or counseling (as providers may discuss many things that they do not record in the chart). There is no standardized place in this hospital’s chart for documentation of lethal means assessment or counseling; such standardized templates might be useful to prompt providers to both discuss lethal means and document these conversations. The study took place at a single tertiary care, academic hospital in a mountain west state with a high prevalence of firearms and high suicide rate, so results may not generalize to other settings. In addition, this ED’s participation in the ED-SAFE studies may have made providers more knowledgeable about suicide prevention, although the ED-SAFE study itself did not include lethal means training.
Despite these limitations, our study offers important findings as the first objective review of documented lethal means assessment among suicidal patients at a hospital with universal screening for suicide risk. The overall rate of documentation – only 18% – further heightens concerns about how infrequently lethal means counseling may be occurring for suicidal ED patients. Age-based differences in assessment support the need for further examination of care of older adults with suicide risk, as this population has particularly high suicide rates (and their deaths often involve firearms). Further work clarifying the most effective training for providers and most effective messaging for patients (Ranney et al., 2017; Barber and Miller, 2014; Parmet et al., 2017) will be critical to reduce the toll of suicide in the United States.
Highlights.
Guidelines recommend asking suicidal patients about access to lethal means
Only 18% of suicidal ED patients had chart documentation of such questioning
Firearms were the most commonly documented form of lethal means addressed
Lethal means documentation was more common in suicidal patients <60 years
Suicidal ideation and psychiatric chief complaint or admission predicted recording
Acknowledgments
Funding: This work was supported by the National Institutes of Health [grant numbers R03MH107551, K23AG043123, UL1 RR025780] and by the Paul Beeson Career Development Award Program (The John A. Hartford Foundation; and The Atlantic Philanthropies).
Footnotes
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