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. Author manuscript; available in PMC: 2021 Jul 1.
Published in final edited form as: Arch Suicide Res. 2019 Jul 18;24(3):342–354. doi: 10.1080/13811118.2019.1635932

Usual care for Emergency Department patients who present with suicide risk: A survey of hospital procedures in Washington state

Eric Zhou 1, Christopher R DeCou 2, Jennifer Stuber 3, Ali Rowhani-Rahbar 4, Kosuke Kume 5, Frederick P Rivara 6
PMCID: PMC6980417  NIHMSID: NIHMS1534358  PMID: 31248352

Abstract

Hospital Emergency Departments (EDs) are important settings for the implementation of effective suicide-specific care. Usual care for suicidal patients who present to EDs remains under-studied. This study surveyed EDs in Washington State to assess the adoption of written procedures for recommended standards of care for treating suicidality. Most (N=79, 84.9%) of the 93 EDs in Washington State participated. Most (n=58, 73.4%) hospitals had a written protocol for suicide risk assessment, but half (n=42, 53.2%) did not include documentation of access to lethal means. There was evidence of an association between patient volume and the adoption of suicide-specific protocols and procedures. Our findings suggest the need to enhance the adoption and implementation of recommended standard care in this setting.

Keywords: Suicide, Emergency Department, Means Safety, Usual Care, Treatment protocols

Suicide is the tenth leading cause of death in the United States and is the second leading cause of death among people aged 15–34 (Centers for Disease Control and Prevention [CDC], 2019). More than 47,000 suicides occurred in the U.S. in 2017 (CDC, 2019), and the rate of suicide has increased in nearly every state from 1999–2016 (CDC, 2018). The 2017 suicide rate in Washington State of 16.86 per 100,000, which increased by 20% from 1999–2017, surpasses the national rate of 14.00 per 100,000 (CDC, 2019; Bree Collaborative, 2018). Of the 1,297 suicides which occurred in Washington in 2017, 49% involved firearms, and 75% of firearm deaths in Washington State were suicides (CDC, 2019).

Emergency departments (ED) play an important role in screening, assessing, and managing suicide attempts and ensuring continuous follow-up care via outpatient mental health treatment. In many cases, EDs are the only facilities that initially evaluate patients with suicide ideation or suicide attempt (Larkin & Beautrais, 2010; Stanley et al., 2018). In a study of Nationwide Emergency Department Sample (NEDS) data, the annual incidence of ED visits for self-directed violence ranged from 163.1 to 173.8 per 100,000 between 2006 and 2013 (Canner, Giuliano, Selvarajah, Hammond, & Schneider, 2018). The majority (71.4%) of suicide-related presentations to the ED involved “non-violent” (e.g., overdose; p. 98) mechanisms, and more than one quarter (28.6%) involved “violent” (p. 98) mechanisms (e.g., cutting, hanging, firearms; Canner et al., 2018). Given the role of dangerous objects or circumstances in cases of attempted suicide or acute suicidal thoughts and plans that present for ED care, EDs represent an important point of entrée for implementing brief interventions including safety planning and means-safety to reduce future risk of death by suicide. Previous studies have found that nearly one-third of suicide decedents who sought mental health care in the year prior to suicide did so at an ED (Schaffer et al., 2016), which suggests that enhancing patient access to timely and effective suicide-specific care in the ED may yield significant public health benefits.

To decrease the rate of suicides, national and federal groups such as the National Action Alliance for Suicide Prevention and the Joint Commission have recommended that health facilities such as EDs have a written protocol for the care of patients at risk of suicide (The Joint Commission, 2016; National Action Alliance for Suicide Prevention [NAASP], 2018). Recently published standards of care for ED management of suicide risk emphasize the need for standard operating procedures that promote: (1) identification of suicidality and stratification of suicide risk, (2) determination of need for inpatient admission or outpatient care with support, (3) detailed and collaborative safety planning prior to discharge, (4) Means Safety assessment and interventions, and (5) Caring Contacts (NAASP, 2018). These strategies have demonstrated effectiveness in a large multi-site study of ED-based suicide prevention strategies (i.e., ED-SAFE; Miller et al., 2017), with 28% lower incidence of suicide attempts. Lethal means counseling in particular is an important part of reducing risk of death by suicide, in that it offers patients, providers, and families a tangible approach to reducing future risk (Hogan & Grumet, 2016). Many studies across diverse contexts have demonstrated that reducing the availability of lethal means directly corresponds with reductions in death by suicide and does not lead to means substitution or similar unintended consequences (Barber & Miller, 2014). Previous studies have found that physician assessment and counseling interventions to promote safe storage of lethal means (e.g., firearms, sharp objects, pills) are perceived by patients and providers to be acceptable and appropriate in the ED setting (Betz, Azrael, Barber, & Miller, 2016). Further, a large cohort study of suicidal veterans presenting for ED care found that safety planning and follow-up contact by telephone reduced the odds of subsequent suicidal behavior, and also increased the likelihood of patients attending outpatient mental health appointments relative to usual care (Stanley et al., 2018). The evidence in support of Caring Contacts is more mixed, with several studies reporting null findings (Milner, Carter, Pirkis, Robinson, & Spittal, 2015), though a recent meta-analysis found Caring Contacts to be effective for preventing re-attempts within 6 months among ED patients (Inagaki, Kawashima, & Yamada, 2019). Furthermore, Caring Contacts remains one of the few interventions to have demonstrated a significant effect with regard to reducing the risk of death by suicide (Motto, 1976; Motto & Bostrom, 2001). These suicide-specific interventions are based on the assumption that brief interventions can be effective for suicidal patients in ED and other crisis intervention settings, and that such interventions are particularly important to implement given the modest number of patients that attend outpatient follow-up care as recommended after a suicidal crisis (Stanley & Brown, 2012).

In a recent nationwide survey of randomly selected ED nursing directors, Bridge and colleagues (2019) found that most hospitals routinely assessed suicidal intent and plans for suicidal patients, though relatively fewer routinely assessed access to lethal means. This survey also found that less than half of hospital EDs routinely completed many of the key components of safety planning (Bridge, Olfson, Caterino, Cullen, & Diana, 2019). However, there are few studies documenting the extent to which EDs adopt and adhere to written protocols to promote effective implementation of means safety counseling and brief interventions as part of usual care for suicidal patients. This is important to assess, as previous research has found that EDs with written protocols report higher rates of means safety implementation (Betz et al., 2013). Similarly, it is unknown as to what extent other elements of recommended standard care for suicidality are routinely included within written hospital procedures for ED operations.

To address this gap in the literature, the present study undertook a survey of all hospital EDs in Washington State, to assess the extent to which hospital EDs had adopted policies consistent with the recommended standards of care for patients with suicide risk, including means safety assessment and intervention, and the extent to which this was accomplished via written policies and procedures.

Methods

The study population was all 93 acute care EDs in Washington state. The list of EDs was obtained from the Washington Chapter of the American College of Emergency Physicians.

To obtain details of ED suicide treatment protocols, a survey was created in Research Electronic Data Capture (REDCap). The survey assessed hospital characteristics (e.g., number of ED beds, annual ED volume), hospital staffing (e.g., number of ED attending physicians), and the adoption of written protocols for routine care of patients identified at risk of suicide. Elements of standard care for suicide risk that were assessed included: risk assessment/stratification, use of restraints, lethal means assessment/counseling, and implementation of brief suicide-specific interventions. The full survey is shown in Appendix A. After pilot testing, the survey was initially sent by the WA ACEP to each ED’s physician director in the WA ACEP email listserv. For non-respondents, each ED was contacted via telephone, and the ED nurse manager or director was asked to complete the survey on the phone or electronically in REDCap. Because the survey did not ask for personal information from respondents, and only assessed the characteristics of particular EDs, it was not considered human subjects research, and thus was not subject to IRB review.

Individual hospital data were obtained from the 2016 Washington Department of Health (DOH) Year End Hospital Report (Washington State Department of Health [WSDOH], 2016), the most recent year available. The report included data on annual hospital admissions, patient days, total beds, and psychiatric bed availability. We determined whether an ED was in a rural hospital based on its designation as a Critical Access Hospital (CAH; i.e., small hospitals with 25 or fewer beds operating in a rural area) by the Washington State DOH (WSDOH, n.d.). Psychiatric bed availability was determined from the 2016 Washington DOH Year End Hospital Report (WSDOH, 2016)

Analysis

The survey results were compiled and exported into Microsoft Excel. Survey responses were used to characterize quantitatively the proportion of EDs which had a written protocol to assess suicide risk and the proportion of EDs which asked about lethal means accessibility. The number of ED protocols which asked about access to specific types of lethal means (i.e., firearms, medications), as well as efforts made to remove those lethal means, was also determined. Descriptive statistics were also calculated for other suicide-specific procedures and interventions that were assessed.

Contingency tables were generated to determine the association between various characteristics of the ED (annual ED volume, CAH status, psychiatric bed availability) and elements of the hospital’s suicide protocol. Annual ED volume was divided into quartiles. Associations were tested using a chi-square test of independence, and alpha was set at 0.05 for all analyses.

Results

Seventy-nine (84.9%) of the EDs in Washington State contributed survey responses for this study, including 27 (69.2%) of the 39 designated Critical Access Hospitals (i.e. rural hospitals with fewer than 25 beds) in Washington State. Responding hospitals had annual ED patient volumes that ranged from 455 to 96,000, and number of ED beds that ranged from 3 to 79. Descriptive statistics for ED characteristics, including staffing for psychiatric patients, are reported in Table 1. Nearly one-fourth (n=19) of hospitals reported having a separate area of the ED for patients with psychiatric presentations and estimated that annual patient volumes for designated psychiatric ED facilities that ranged from 12 to 8,000 patients. Approximately one-third (n=7) of EDs with a separate area for psychiatric patients indicated staffing by a psychiatrist or psychologist. Only two of the EDs without a separate psychiatric area of the ED reported staffing by a psychiatrist, and none indicated staffing by a psychologist.

Table 1.

Hospital and Emergency Department Characteristics

Hospital/ED Characteristics Rural Hospitals (n=27) Non-Rural Hospitals (n=52) All Hospitals (N=79)
Annual ED Patient Volume Median (IQR) 5,000(3,600–12,000) 42,500(25,250–57,500) 25,000(8,200–50,000)
Number of ED Beds Median(IQR) 7.00(5.00–9.00) 24.50(18.00–37.75) 18.00(8.00–31.00)
Separate Psychiatric ED area n(%) 2(7.4) 17(32.7) 19(24.1)
Number of Psychiatric ED Beds Median(IQR) 1.00(1.00–1.00) 5.00(2.00–6.50) 4.00(2.00–6.00)a
Annual Psychiatric ED Volume Median(IQR 12.00(12.00–12.00) 1,750(1,300–3,525) 1,500(1,000–3,500)b
Staffing in Separate area of ED for Psychiatric Patients n(%):b
Psychiatrist 0(0) 5(29.4) 5(26.3)
Social Worker 0(0) 15(88.2) 15(78.9)
Mental Health Practitioner 1(50.0) 9(52.9) 10(52.6)
Psychologist 0(0) 2(11.8) 2(10.5)
Other 1(50.0) 8(47.1) 9(47.4)
“Who sees potential psychiatric patients?” if no separate area of ED n(%):c
ED Physician 23(88.5) 35(100.0) 58(96.7)
Psychiatrist 0(0) 2(5.7) 2(3.3)
Social Worker 4(15.4) 25(71.4) 29(48.3)
Mental Health Practitioner 17(65.4) 23(65.7) 40(66.7)
Psycho1ogist 0(0) 0(0) 0(0)
Other 5(19.2) 2(5.7) 7(11.7)
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ED = Emergency Department

a

, n=19, due to missing and “unknown” values reported by respondents.

b

, n=11, due to missing and “unknown” values reported by respondents.

c

, respondents were able to select more than one category, and thus proportions may add up to more than 100%

Twenty-one (26.6%) of the EDs surveyed had no written suicide protocol of any kind, and the majority of EDs (n=42, 53.2%) did not have a written protocol that included assessment of access to lethal means. Two-thirds (n=53, 67.1%) of EDs had a standardized form used to assess suicidality, though relatively few of these included routine assessments of access to firearms (n = 26, 32.9%) and/or stockpiles of pills (n = 17, 21.5%). Approximately one-quarter (n = 21, 26.6%) of EDs described routine documentation of efforts to remove lethal means.

In regard to ED-based brief suicide-specific interventions, most EDs reported routine implementation of detailed safety-planning (n = 64, 81%) and referral to outpatient mental health follow-up (n = 70, 88.6%), and nearly two-thirds of EDs routinely provided patients with contact information for the Suicide Crisis Lifeline (n = 52, 65.8%). In contrast, only five EDs (6.3%) reported adoption of Caring Contacts to prevent suicide.

The study also examined the association between suicide-specific assessment and brief interventions, and annual ED volume, rurality, and psychiatric bed availability. The proportion of EDs reporting suicide-specific procedures, stratified by annual ED patient volume, is reported in Table 2. Hospitals with higher ED patient volume tended to report greater proportions of suicide-specific procedures relative to EDs with lower annual patient volumes. There were few statistically significant differences among EDs in this small sample with regard to brief suicide-specific interventions (see Table 2). However, EDs with higher patient volumes reported a significantly higher proportion of providing Crisis Lifeline information to patients when compared to EDs with lower patient volumes (see Table 1). There were no significant differences between rural and non-rural hospitals with regard to the proportions of EDs that reported different suicide-specific assessment, documentation, or intervention procedures, as is reported in Table 3. Similarly, there were no significant differences between hospitals with and without inpatient psychiatry beds, as is demonstrated in Table 3.

Table 2.

Association between annual patient volume quarti1es, ED characteristics, and suicide-specific procedures

annual Patient Volume
Assessment & Intervention Procedures, n(%) Q1 Q2 Q3 Q4 χ2(3)a
Assessment & Documentation:
All Suicidal Patients Placed in Restraints 1(5.3) 0(0) 1(5.0) 0(0) 2.11
Written Protocol for Suicide Risk Assessment 10(52.6) 15(78.9) 15(75.0) 18(85.7) 6.16
Estab1ished form for Assessment of Suicidality 10(52.6) 14(73.7) 12(60.0) 17(81.0) 4.46
Assessment of Reasons for living/Dying 5(26.3) 6(31.6) 4(20.0) 13(61.9) 9.33*
Stratification of patient risk of death 6(31.6) 8(42.1) 7(35.0) 17(81.0) 12.81**
Assessment of suicidal intent 7(36.8) 9(47.4) 7(35.0) 16(76.2) 8.92*
Assessment of access to lethal Means 6(31.6) 9(47.4) 7(35.0) 15(71.4) 8.00*
Assessment of access to Guns 3(15.8) 5(26.3) 7(35.0) 11(52.4) 6.54
Assessment of access to Stockpile of Medication 3(15.8) 3(15.8) 5(25.0) 6(28.6) 1.50
Assessment of efforts to remove lethal means 3(15.8) 4(21.1) 5(25.0) 9(42.9) 4.31
Brief Suicide-Specific Interventions:
Detai1ed Safety Plan 13(68.4) 15(78.9) 18(90.0) 18(85.7) 3.36
Referral to Outpatient Mental Health Fo11ow-up 17(89.5) 18(94.7) 17(85.0) 18(85.7) 1.15
Caring Contacts 1(5.3) 0(0) 2(10.0) 2(9.5) 2.14
Crisis 1ife1ine Information 12(63.2) 8(42.1) 13(65.0) 19(90.5) 10.49*
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Note.

a

, Pearson’s chi-squared test. N=79.

*

, p<.05.

**

, p<.01.

annual Patient Volume, Quartile 1 (Q1) = 455–8,199; Quarti1e 2 (Q2) = 8,200–24,999; Quarti1e 3 (Q3) = 25,000–49,999; Quarti1e 4 (Q4) = 50,000–96,000.

Table 3.

Differences in written protocols by presence-absence of in-hospital inpatient psychiatry, and rurality

Inpatient Psychiatry Rural-Non-Rural location
Assessment & Intervention Procedures, n(%) In Hospital (n=21) Not In Hospital (n=58) pa Rural (n=27) Non-Rural (n=52) pa
Assessment & Documentation:
All Suicidal Patients Placed in Restraints 2(9.5) 0(0) .068 0(0) 2(3.8) .544
Written Protocol for Suicide Risk Assessment 17(81.0) 41(70.7) .565 18(66.7) 40(76.9) .422
Estab1ished form for Assessment of Suicida1ity 13(61.9) 40(69.0) .595 18(66.7) 35(67.3) 1.00
Assessment of Reasons for living/Dying 8(38.1) 20(34.5) .795 7(25.9) 21(40.4) .226
Stratification of patient risk of death 10(47.6) 28(48.3) 1.00 11(40.7) 27(51.9) .477
Assessment of suicidal intent 8(38.1) 31(53.4) .310 13(48.1) 26(50.0) 1.00
Assessment of access to lethal Means 11(52.4) 26(44.8) .615 12(44.4) 25(48.1) .815
Assessment of access to Guns 9(42.9) 17(29.3) .287 6(22.2) 20(38.5) .207
Assessment of access to Stockpile of Medication 5(23.8) 12(20.7) .764 4(14.8) 13(25.0) .392
Assessment of efforts to remove lethal means 7(33.3) 14(24.1) .406 5(18.5) 16(30.8) .292
Brief Suicide-Specific Interventions:
Detailed Safety Plan 17(81.0) 47(81.0) 1.00 19(70.4) 45(86.5) .129
Referral to Outpatient Mental Health Fo11ow-up 18(85.7) 52(89.7) .693 24(88.9) 46(88.5) 1.00
Caring Contacts 1(4.8) 4(6.9) 1.00 1(3.7) 4(7.7) .656
Crisis lifeline Information 16(76.2) 36(62.1) .292 16(59.3) 36(69.2) .455
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a

, Fisher’s exact test.

Discussion

These results showed that of the EDs which responded to the survey, most did possess a written suicide protocol of some sort, and a majority had an established form for suicide risk assessment and stratification. Furthermore, most EDs did report having suicide-specific interventions including safety planning, referral to outpatient mental health follow up, and crisis lifeline information, despite the relatively limited adoption of procedures that included Caring Contacts. However, less than half of the EDs in Washington State who responded to this survey reported written policies that include regular assessment of access to lethal means, and relatively few reported written policies that required staff to document efforts to work collaboratively with trusted allies of the patient to remove and/or restrict access to lethal means.

These findings highlight several areas for enhancing the repertoire of suicide-specific care available to patients during routine ED care in Washington State. First, the non-trivial proportion of EDs that reported no written protocol suggests the need for developing and promoting evidence-based protocols that are acceptable, appropriate, and feasible for EDs that currently lack such policies. This may be particularly important for EDs with lower annual patient volumes, as these settings may experience lower rates of exposure to suicidal patients, and thus may have more limited routine experience and knowledge with regard to effective suicide care. Established written policies may be helpful in overcoming this circumstance and may occasion timely access to suicide-specific care across the diverse socio-demographic and geographic areas of Washington State that were included in this survey.

In addition, our findings support the need for increased dissemination and implementation of means safety interventions in Washington State EDs, including policies that support formal assessment and documentation of efforts to remove or limit access to lethal means among patients who are discharging to home. Previous findings support the appropriateness and acceptability of addressing this issue directly with patients (Betz et al., 2013; 2016), and recent ED-based interventions that included a means safety component have demonstrated strong evidence of the feasibility of these interventions in applied ED settings (Stanley et al., 2018; Miller et al., 2017). Resolving suicidality definitively often requires psychotherapeutic intervention spanning at least several weeks and is thwarted by suicide attempts that occur prior to the initiation of outpatient care. Because means safety is a brief and timely strategy for insulating patients from dangerous objects, places, and circumstances prior to discharge, it can function as a critical link to outpatient care when enacted prior to discharge from the ED. As a component of a detailed safety plan, or as a standalone intervention, means safety typically consists of: (1) Assessment of suicidal plans; (2) Assessment of means availability in the home; (3) Identification and recruitment of trusted others (e.g., friends, family) to remove means; (4) Direct communication between providers and trusted others to ensure removal and/or restriction of lethal means; (5) Provision of locking and/or storage devices, if available (e.g., Counseling on Access to Lethal Means [CALM]; Suicide Prevention Resource Center, 2018). In this way, increasing the adoption and implementation of means safety across Washington hospitals can buttress comprehensive efforts to prevent death by suicide across systems of care. However, adoption of written policies and procedures for these evidence-based interventions is likely not sufficient to ensure effective implementation, including sustained quality and fidelity of suicide-specific interventions over time. Previous work has indicated the necessity of incorporating quality improvement and quality assurance mechanisms to promote the fidelity of interventions over time, above and beyond discrete efforts to adopt written policies (Green, Kearns, Rosen, Keane, & Marx, 2018; Gamarra, Luciano, Gradus, & Wiltsey-Stirman, 2015).

Limitations

Our findings are limited by the self-report and retrospective nature of the survey methods employed. It may be that many of the suicide-specific interventions assessed are implemented more widely than our survey suggested based on the training and experience of staff in the absence of a formal written procedure. Alternatively, it is possible that hospital policies that were reported in this study reflect aspirational efforts by agencies that have limited ecological significance for patient care outcomes above and beyond specific charting and workflow requirements set forth in written protocols. In particular, our findings demonstrate inconsistencies in hospitals that reported implementation of safety planning, yet did not report enactment of some of the active ingredients of safety planning (e.g., means safety, crisis line contact information), as defined within manualized approaches (e.g., Stanley, Brown, & Brenner, 2018). This reflects both a limitation of our survey design, which did not operationalize one particular form of safety planning, as well as a broader challenge to the effective implementation of robust approaches to safety planning that includes means safety and distribution of contact information for the lifeline. It is also possible that our study underestimated hospitals’ implementation of procedures for some suicidal patients but not others, since our survey items only assessed universally-implemented procedures.

Further, our findings may not be generalizable to EDs that chose not to respond to this survey, or to hospitals outside of Washington State. Notably, the number of community hospital in Washington is near the median (53rd Percentile) for number of hospitals per State in the United States and District of Columbia (American Hospital Association, 2019). This study also demonstrated levels of staffing by mental health practitioners in EDs that was comparable to a recent National survey that was similar in scope to our State level investigation (Bridge et al., 2019). Therefore, despite potential limits to the generalizability of our findings, it is reasonable to assert some degree of relevance to the practice of suicide prevention in EDs outside of Washington State.

Conclusion

Taken together, our findings support the need for wider adoption and implementation of suicide-specific procedures among hospital EDs in Washington State, particularly hospitals with lower annual patient volumes. In addition to the policies assessed in this study, future research is needed to assess the actual behavior of ED providers via audit, chart review, and simulated patient methodologies. Suicidal patients represent a growing proportion of ED presentations, and it is essential that EDs adopt and implement evidence-based standards of care to ensure optimal treatment and referral for this at-risk patient population prior to discharge.

Acknowledgments

The preparation of this article was supported in part by the National Institute of Child Health and Development of the National Institutes of Health (T32HD057822). The authors have no conflicts of interest to declare.

Appendix A

Survey Instrument

  1. Name of Hospital:

  2. Number of Emergency Department Beds:

  3. Annual ED Volume:

  4. Number of ED Attending Physicians:

  5. Type of ED Physician Practice:
    1. ED Physicians work for hospital
    2. ED Physicians work for a practice group contracted with hospital
    3. ED Physicians are part of an academic department
    4. Other, please specify: ____________
  6. Is there a separate part of the ED in which potential psychiatric patients are assessed? (yes/no)
    1. If yes, For this separate area, what is the number of beds?
      1. Annual volume in separate area:
      2. Staffing in separate area (check all that apply):
        1. Psychiatrists
        2. Social Worker
        3. Mental Health Professional
        4. Psychologist
        5. Other, please specify: ____________
      1. Patients presenting for which problems are seen in the separate psych part of the ED? (check all that apply)
        1. Suicide Ideation
        2. Suicide Attempt
        3. Psychosis
        4. Depression
        5. Anxiety
        6. Substance Abuse
        7. Other, please specify: ____________
  7. If no for Question 5, who sees potential psychiatric patients? (check all that apply):
    1. Emergency medicine physician
    2. Psychiatrists
    3. Social worker
    4. Mental health professional
    5. Psychologist
    6. Other, please specify: ____________

  8. Are patients who disclose suicidal thoughts and/or intent automatically placed in restraints upon presentation to the ED, pending completion of a formal safety evaluation? (yes/no)

  9. Is there a written protocol for assessment of risk of suicide? (yes/no)

  10. Is there a form (paper or electronic) that is used in the assessment of risk of suicide? (yes/no)

  11. If yes, does it ask patient’s reason for living and reasons for dying? (yes/no)

  12. Does it ask the assessed strength of the patient’s risk to die? (yes/no)

  13. Does it ask the assessed strength of expressed intent to commit suicide? (yes/no)

  14. Does it ask whether patient has access to lethal means? (yes/no)
    1. If yes on access to lethal means, does it specifically ask about access to guns? (yes/no)
    2. If yes on access to lethal means, does it ask if there is a stockpile of pills? (yes/no)
    3. If yes on access to lethal means, does it ask if efforts have been made to remove those lethal means? (yes/no)
  15. Are any of the following brief interventions to prevent suicide universally implemented for patients who screen positive for recent suicidal thoughts or behavior? (check all that apply):
    1. Completion of a detailed safety plan
    2. Referral for outpatient mental health follow-up
    3. Caring contacts
    4. Crisis lifeline contact information (e.g., wallet card or refrigerator magnet)
  16. If you checked Caring Contacts, how are they delivered?
    1. Caring letters or postcards
    2. Caring text messages
    3. Caring emails
    4. Other, please specify:____________

  17. Do you have any question, comments, and/or concerns that you would like to share with the research team?

Contributor Information

Eric Zhou, Harborview Injury Prevention & Research Center, Amherst College.

Christopher R. DeCou, Harborview Injury Prevention & Research Center, University of Washington School of Medicine

Jennifer Stuber, Forefront Suicide Prevention, University of Washington School of Social Work

Ali Rowhani-Rahbar, Harborview Injury Prevention & Research Center, University of Washington School of Public Health

Kosuke Kume, Harborview Injury Prevention & Research Center, University of Washington.

Frederick P. Rivara, Harborview Injury Prevention & Research Center, University of Washington School of Medicine and School of Public Health

References

  1. Barber CW, & Miller MJ (2014). Reducing a suicidal person’s access to lethal means of suicide: a research agenda. American Journal of Preventative Medicine, 47(3), S264–72. doi: 10.1016/j.amepre.2014.05.028 [DOI] [PubMed] [Google Scholar]
  2. Betz ME, Azrael D, Barber C, & Miller M (2016). Public Opinion Regarding Whether Speaking With Patients About Firearms Is Appropriate: Results of a National Survey. Annals of Internal Medicine, 165, 543–550. doi: 10.7326/M16-0739 [DOI] [PubMed] [Google Scholar]
  3. Betz ME, Miller M, Barber C, et al. (2013). Lethal means restriction for suicide prevention: beliefs and behaviors of emergency department providers. Depression and Anxiety, 30(10), 1013–20. doi: 10.1002/da.22075 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Canner JK, Giuliano K, Selvarajah S, Hammond ER, & Schneider EB (2018). Emergency Department visits for attempted suicide and self-harm in the USA: 2006–2013. Epidemiology and Psychiatric Sciences, 27, 94–102. doi: 10.1017/S2045796016000871 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2005). Web-based Injury Statistics Query and Reporting System (WISQARS) [online software]. Accessed on 2019 Jan 29. Available from URL: www.cdc.gov/injury/wisqars [Google Scholar]
  6. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2018). Suicide rising across the US: More than a mental health concern. Vital Signs. Available from URL: https://www.cdc.gov/vitalsigns/pdf/vs-0618-suicide-H.pdf [Google Scholar]
  7. Dr. Robert Bree Collaborative. (2018). Suicide care report and recommendations. Available from URL: http://www.breecollaborative.org/wp-content/uploads/Recommendations-Suicide-Care-Draft-2018.pdf
  8. Gamarra JM, Luciano MT, Gradus JL, & Wiltsey-Stirman S (2015). Assessing Variability and Implementation Fidelity of Suicide Prevention Safety Planning in a Regional VA Healthcare System. Crisis, 36, 433–439. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Green JD, Kearns JC, Rosen RC, Keane TM, & Marx BP (2018). Evaluating the Effectiveness of Safety Plans for Military Veterans: Do Safety Plans Tailored to Veteran Characteristics Decrease Suicide Risk? Behavior Therapy, 49(6), 931–938. [DOI] [PubMed] [Google Scholar]
  10. Hogan MF, & Grumet JG (2016). Suicide prevention: An emerging priority for healthcare. Health Affairs, 35(6),1084–1090. [DOI] [PubMed] [Google Scholar]
  11. Inagaki M, Kawashima Y, Yonemoto N, & Yamada M (2019). Active contact and follow-up interventions to prevent repeat suicide attempts during high-risk periods among patients admitted to emergency departments for suicidal behavior: a systematic review and meta-analysis BMC Psychiatry, 19(44). [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Larkin GL, Beautrais AL (2010). Emergency Departments are underutilized sites for suicide prevention. Crisis, 31(1), 1–6. doi: 10.1027/0227-5910/a000001 [DOI] [PubMed] [Google Scholar]
  13. Miller IW, Camargo CA, Arias SA, et al. (2017). Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. JAMA Psychiatry, 74(6), 563–570. doi: 10.1001/jamapsychiatry.2017.0678 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Milner AJ, Carter G, Pirkis J, Robinson J, Spittal MJ (2015). Letters, green cards, telephone calls and postcards: systematic and meta-analytic review of brief contact interventions for reducing self-harm, suicide attempts and suicide. British Journal of Psychiatry, 206(3), 184–90. [DOI] [PubMed] [Google Scholar]
  15. Motto JA, (1976). Suicide Prevention for High- Risk Persons Who Refuse Treatment. Suicide and Life-Threatening Behavior, 6(4), 223–230. [PubMed] [Google Scholar]
  16. Motto JA, & Bostrom AG (2001). A randomized controlled trial of postcrisis suicide prevention. Psychiatric Services, 52(6), 828–833. [DOI] [PubMed] [Google Scholar]
  17. National Action Alliance for Suicide Prevention: Transforming Health Systems Initiative Work Group. (2018). Recommended standard care for people with suicide risk: Making health care suicide safe. Washington, DC: Education Development Center, Inc. [Google Scholar]
  18. Schaffer A, Sinyor M, Kurdyak P, et al. (2016). Population- based analysis of health care contacts among suicide decedents: identifying opportunities for more targeted suicide prevention strategies. World Psychiatry, 15(2), 135–145. doi: 10.1002/wps.20321. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Stanley B, & Brown GK (2012). Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice, 19, 256–264. [Google Scholar]
  20. Stanley B, Brown GK, Brenner LA, et al. (2018). Comparison of the Safety Planning Intervention with follow-up vs usual care of suicidal patients treated in the Emergency Department. JAMA Psychiatry, 75(9), 894–900. doi: 10.1001/jamapsychiatry.2018.1776 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Suicide Prevention Resource Center. (2018). Counseling on Access to Lethal Means. Waltham, Massachusetts: Education Development Center. [Google Scholar]
  22. The Joint Commission. (2016). Sentinel Event Alert 56: Detecting and treating suicide ideation in all settings. Available from URL: www.jointcommission.org/sea_issue_56/ [PubMed]
  23. Washington State Department of Health. (2016). Year End Reports: 2016 Reports by Hospital [online]. Available from URL: www.doh.wa.gov/DataandStatisticalReports/HealthcareinWashington/HospitalandPatientData/HospitalFinancialData/YearEndReports/2016HospitalYearEndReports
  24. Washington State Department of Health. (n.d.). Rural Health: Designated Critical Access Hospitals [online]. Available from URL: www.doh.wa.gov/ForPublicHealthandHealthcareProviders/RuralHealth/HealthcareFacilityResources/CriticalAccessHospitals/DesignatedCriticalAccessHospitals [Google Scholar]

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