Abstract
This study provides estimates of how frequently evidence-based management practices are used by emergency departments when treating patients presenting for self-harm.
Approximately 500 000 patients in the United States present to emergency departments (EDs) annually after deliberate self-harm1 and are at high short-term risk for repeat self-harm2 and suicide.3 Improving their emergency care is a key focus of national strategies to reduce the suicide rate,4 yet little is known about ED management of deliberate self-harm. We provide the first national estimates, to our knowledge, of how frequently evidence-based management practices are used by EDs when treating patients who present for self-harm.
Methods
Between May 2017 and January 2018, we mailed a survey about ED management of self-harm to a random sample of 665 ED nursing directors at hospitals that were selected from 2228 hospitals with 5 or more self-harm visits in the prior year identified within national Medicaid claims data. Respondents received $100, and the response rate was 77.1% (n = 513). Using a 4-point Likert-type scale, the survey assessed the availability of key mental health services that were provided to ED patients after an episode of deliberate self-harm, which refers to nonfatal self-poisoning or self-injury with or without suicidal intent.3 Responses were dichotomized as: “on a routine basis” or “not on a routine basis” (never or rarely, sometimes, or usually but not routine). Emergency departments were characterized according to their patient volume, teaching status, location, and staffing. Emergency departments with high mental health staffing were defined by having continuous availability of a mental health specialist or by having continuous availability of a social worker with mental health specialist at least part time. The University of Pennsylvania institutional review board approved the study. A waiver of written consent for the survey was provided given the study presented no more than minimal risk of harm to participants.
Means and frequencies were tabulated overall and stratified by hospital characteristics. t Tests and χ2 tests were performed (P < .05, 2-tailed) using survey weights to accommodate the sampling design that selected hospitals with probability proportional to their volume of patients presenting with self-harm and to produce estimates of the 2228 hospitals (weighted N). To control for multiple comparisons, we used false discovery rate correction.5
Results
Most EDs sampled were urban (1669 [75.4%]), nonteaching hospitals (1276 [57.6%]) and had high mental health staffing (1299 [58.3%]). Overall, EDs routinely provided a mean (SE) of 5.44 (0.14) of 10 specified self-harm management practices. Emergency departments most commonly assessed patients who present with self-harm for current suicidal intent/plans (2156 [97.6%]), past suicidal thoughts/behaviors (1989 [90.6%]), and access to lethal means (1708 [77.7%]) (Figure). Provision of individual safety planning elements ranged from 24.8% (n = 492) to 79.2% (n = 1710), with 2 of 6 elements being routinely provided more than 50% of the time: lists of professionals or agencies to contact in a crisis (1710 [79.2%]) and helping patients to recognize warning signs of suicide (1075 [52.2%]). Only 15.3% (n = 342) routinely provided all recommended safety planning elements. There were no significant differences in emergency self-harm management practices by urban/rural status, mental health staff availability, or hospital volume. However, EDs associated with teaching hospitals were significantly more likely than EDs affiliated with nonteaching hospitals to provide professional contact lists (791 [86.5%] vs 909 [73.7%]; P = .004) (Table).
Figure. Frequency of Emergency Department (ED) Provision of Evidence-Based Management Practices When Treating Patients Who Present for Self-harma.
aAssess refers to ED management practices where patients who present with self-harm are evaluated for current and past suicidal thoughts and behaviors, and access to lethal means. Act refers to ED management practices where providers help or engage patients who present with self-harm in the delivery of suicide risk reduction services.
Table. Emergency Department (ED) Management of Self-harm Survey Responsesa.
| Self-harm Management Practices | No. (%) | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| High Mental Health Staffing (n = 1299) | Low Mental Health Staffing (n = 929) | P Value | High Volume (n = 559)b | Medium Volume (n = 1088)b | Low Volume (n = 581)b | P Value | Rural (n = 546) | Urban (n = 1669) | P Value | Teaching (n = 939) | Nonteaching (n = 1276) | P Value | |
| When patients who present with self-harm are discharged during standard weekly hours, how often is a follow-up outpatient appointment scheduled before they leave the ED? | 541 (44.0) | 327 (37.9) | .31 | 233 (45.0) | 383 (37.4) | 252 (45.9) | .37 | 238 (43.7) | 624 (40.6) | .65 | 364 (41.4) | 498 (41.4) | .99 |
| For ED patients who present with self-harm, how often does a staff member assess: | |||||||||||||
| Current suicidal intent or plans? | 1258 (97.6) | 898 (97.6) | >.99 | 542 (98.0) | 1059 (98.1) | 555 (96.4) | .84 | 512 (96.3) | 1630 (98.0) | .57 | 910 (98.1) | 1233 (97.2) | .55 |
| Past suicidal thoughts and behaviors? | 1157 (89.9) | 832 (91.6) | .63 | 470 (85.6) | 971 (90.7) | 548 (95.2) | .14 | 471 (88.9) | 1505 (91.1) | .63 | 844 (91.2) | 1131 (90.1) | .73 |
| Access to means (eg, firearms or medications) needed to carry out the plan? | 1012 (78.8) | 696 (76.1) | .59 | 460 (84.2) | 844 (78.3) | 404 (70.2) | .15 | 408 (76.7) | 1286 (77.8) | .87 | 746 (80.8) | 948 (75.1) | .24 |
| Safety Planning Elements | |||||||||||||
| Before they are discharged from the ED, how often are patients who present with self-harm: | |||||||||||||
| Helped to recognize warning signs (situations, moods, or behaviors) that immediately precede a suicidal crisis for them? | 699 (57.1) | 375 (45.0) | .05 | 304 (60.2) | 521 (50.5) | 250 (47.8) | .23 | 250 (50.5) | 819 (52.7) | .76 | 498 (56.5) | 571 (48.9) | .19 |
| Helped to learn strategies, such as relaxation techniques or physical activities, that they can do by themselves to take their minds off problems? | 324 (27.3) | 168 (21.0) | .23 | 119 (23.6) | 280 (28.6) | 92 (18.5) | .28 | 145 (30.5) | 347 (23.1) | .25 | 219 (26.2) | 273 (24.0) | .66 |
| Helped to identify social activities, such as spending time with family or friends, that provide distraction from their problems? | 331 (27.6) | 187 (23.0) | .39 | 123 (24.1) | 298 (30.1) | 97 (19.0) | .22 | 146 (29.9) | 373 (24.6) | .41 | 244 (28.9) | 275 (23.6) | .30 |
| Helped to identify family members or friends whom they can ask for help? | 578 (47.4) | 366 (44.8) | .67 | 249 (47.1) | 492 (48.8) | 203 (40.6) | .58 | 235 (48.9) | 708 (45.7) | .66 | 432 (49.5) | 510 (44.2) | .36 |
| Provided a list of professionals or agencies that they can contact in a crisis? | 1073 (84.0) | 637 (72.3) | .02 | 471 (85.4) | 831 (78.7) | 409 (74.1) | .19 | 398 (76.4) | 1302 (80.0) | .55 | 791 (86.5) | 909 (73.7) | .004c |
| Helped to develop an individualized plan to make their home safer by removing or restricting access to lethal methods, such as firearms or medications? | 440 (37.7) | 232 (30.2) | .20 | 207 (41.4) | 338 (35.4) | 127 (26.4) | .17 | 173 (38.3) | 499 (33.8) | .53 | 328 (39.9) | 344 (31.1) | .13 |
| Provide all safety planning elements | 222 (17.1) | 120 (13.0) | .31 | 90 (16.1) | 193 (17.7) | 59 (10.2) | .26 | 99 (18.1) | 244 (14.6) | .48 | 172 (18.3) | 171 (13.4) | .22 |
| Summary of ED self-harm management practices | |||||||||||||
| Total score, mean (SE)d | 5.71 (0.16) | 5.08 (0.24) | .03 | 5.69 (0.21) | 5.53 (0.20) | 5.06 (0.30) | .23 | 5.45 (0.34) | 5.45 (0.15) | .99 | 5.73 (0.18) | 5.25 (0.20) | .08 |
Responses rated “on a routine basis” stratified by hospital characteristics.
Determined by the weighted survey responses for yearly ED volume. Low was up to the 25th percentile (22 000 visits), medium was the 25th to 75th percentiles (23 000 to 64 000), and high was anything above the 75th percentile.
Values are statistically significant differences at P < .05, applying a false discovery rate (25%) correction.
Possible range of scores, 0 to 10, indicating provision of no emergency self-harm management element to provision of all 10 elements.
Discussion
Most EDs in the United States routinely assess patients who present with deliberate self-harm for suicidal thoughts/behaviors and access to lethal means, but relatively few routinely act to provide basic aspects of safety planning, such as creating individualized plans to restrict access to lethal means, helping patients to use internal coping strategies, or accessing available social supports/activities. Emerging research indicates that safety planning in combination with structured telephone follow-up can significantly reduce suicidal behaviors after ED discharge compared with usual care.6 Because provision of these services in our study was largely independent of ED characteristics, there are widespread opportunities for improvement.
Study limitations include use of self-report rather than an audit, the possibility that our ED sample may not generalize to all US EDs, and an inability to know whether social workers have mental health specialty training or which professionals provide the services. The study also was not designed to assess the effect of severity of the self-harm incident or recognition of a mental disorder in the ED on self-harm management practices. Future research should evaluate whether specific aspects of emergency management of deliberate self-harm lower the risk of repeat self-harm and suicide.
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