Health Care Usage and Suicide Risk Screening within 1 Year of Suicide Death

Analysis of Hospitals Switching From a "Danger to Self" Question to Universal Columbia-Suicide Severity Rating Scale Screening: Impact on Screenings, Identification of Suicide Risk, and Documented Psychiatric Care

Objective

Sutter Health launched system-wide general population standardized suicide screening with the Columbia-Suicide Severity Rating Scale (C-SSRS) screen (triage) version in 23 hospitals in 2019, replacing a one-question "danger to self" (DTS) assessment. This study analyzed the impact of C-SSRS implementation on screening rates, positive screenings, and documented psychiatric care within 90 days for all patients and a subgroup diagnosed with Major Depressive Disorder (MDD).

Methods

Adults seen at hospitals in the pre-period (July 1, 2017-June 30, 2019) and post-period (July 1, 2019-December 31, 2020) were identified using electronic health records. Outcomes were compared using chi-square statistics and interrupted time series (ITS) models.

Results

Pre-period, 92.8% (740,984/798,653) of patients were screened by DTS versus 84.6% (504,015/595,915) by C-SSRS in the post-period. Positive screening rates were 1.5% pre-period and 2.2% post-period, and 9.2% pre-period versus 10.8% post-period for those with MDD. Among individuals with positive screenings, 64.0% (pre-period) had documented follow-up psychiatric care versus 52.5% post-period and 66.4% of those with moderate or high-risk. Among all patients seen there was an overall increase in documentation of psychiatric care within 90 days (0.87% pre- to 0.96% post-period). ITS models revealed a 9.6% decline in screening, 1.3% increase in positive screenings, and 12.9% decline in documented psychiatric care following C-SSRS implementation (all p < 0.01).

Conclusions

Following implementation, there was meaningful increase in suicide risk identification, and an increase in the proportion of patients with documented psychiatric care. Observed relative declines in screening warrant future research examining opportunities and barriers to general population C-SSRS use.

Survey of knowledge, self-efficacy, and attitudes toward suicide prevention among nursing staff

OBJECTIVE

This study aimed to explore the knowledge, self-efficacy, and attitudes toward suicide prevention among nurses with different demographic characteristics.

METHODS

A cross-sectional descriptive design was adopted, and the study was conducted between August and September 2020. The content of the questionnaire included basic demographics, knowledge, self-efficacy, and attitudes toward suicide prevention. Correlation analysis was performed to determine nurses' knowledge, self-efficacy, and attitudes toward suicide prevention.

RESULTS

The sample comprised 778 nursing staff from a medical center in southern Taiwan. The results showed that age, years of nursing experience, department type, education on suicide prevention, and care experience of nursing staff were associated with their knowledge, self-efficacy, and attitudes toward suicide prevention in general hospital patients. Younger and less experienced nurses demonstrated superior knowledge, self-efficacy, and attitudes toward suicide prevention. Nurses who received suicide-related education and training exhibited better self-efficacy and attitudes than those who did not. Nurses with care experience had better knowledge of suicide prevention than those without experience. Knowledge and self-efficacy in suicide prevention were both significantly and positively correlated with attitudes.

CONCLUSION

Younger, less experienced, psychiatric nurses demonstrated superior knowledge, self-efficacy, and attitudes toward suicide prevention. Therefore, education on suicide prevention should be strengthened for older, experienced, and non-psychiatric nurses.

Emergency Departments Treating Veterans for Suicide: Ensuring Quality Care for Veterans Outside of Department of Veterans Affairs Health Care Facilities

INTRODUCTION

Veterans die by suicide at higher rates than nonveterans. Given that the emergency department is often the first point of entry to healthcare following a suicide attempt, it would be beneficial for community providers to have knowledge of the characteristics, medical issues, and effective treatments most often associated with those having served in the military to ensure guideline concordant and quality suicide care. This study aimed to identify assessment and referral practices of emergency departments at rural community hospitals related to care for suicidal veterans and explore the feasibility and acceptability of identifying veterans in need of postdischarge aftercare.

METHODS

This qualitative exploratory study involved content analysis of semistructured interviews. Ten emergency clinicians from 5 rural Arkansas counties with high suicide rates were interviewed about their experiences working with suicidal patients within the emergency department and perceptions of assessment, management, and referral practices.

RESULTS

Although most of the emergency departments had a process for assessing for suicide risk, emergency clinicians did not always feel confident in their knowledge of assessing and caring for suicidal patients. Military history was not included in assessment, treatment, or aftercare planning, nor were brief interventions such as safety planning or lethal means safety education provided.

DISCUSSION

Best practices for suicide assessment and management of veterans exist; however, challenges specific to the emergency department regarding staff training and engaging the community to effectively link at-risk veterans to needed care hinder implementation. Veteran-inclusive assessment and intervention practices could enhance the quality of care provided in community emergency departments.

Feasibility of Peer-Delivered Suicide Safety Planning in the Emergency Department: Results From a Pilot Trial

OBJECTIVE

The emergency department (ED) is an important site for suicide prevention efforts, and safety planning has been identified as a best practice for suicide prevention among ED patients at increased suicide risk. However, few ED clinicians are prepared to assess suicide risk or guide patients in the creation of safety plans. This study was a pilot randomized controlled trial of the feasibility, acceptability, and preliminary effects of safety planning by individuals with lived experience of suicide attempt or of severe suicidal ideation but without medical training (i.e., peers) in the ED.

METHODS

Patients at risk for suicide in a general ED were randomly assigned to receive peer-delivered or mental health provider–delivered safety planning. Intervention feasibility measures included ED length of stay, safety plan completeness, and safety plan quality. Acceptability measures included patient satisfaction. Preliminary effects were assessed as number of ED returns within the 3 months after the ED visit.

RESULTS

Data from 31 participants were available for analysis. Compared with participants with provider-delivered safety planning, participants with peer-delivered safety planning had similar ED lengths of stay, higher safety plan completeness, and higher safety plan quality. Acceptability of the safety planning process was similar for the two groups. Compared with participants receiving provider-delivered safety planning, participants receiving peer-delivered planning had significantly fewer ED visits during the subsequent 3 months than during the 3 months preceding the ED visit.

CONCLUSIONS

Peer-delivered safety planning is feasible and acceptable and may result in fewer return ED visits. These findings provide preliminary support for peer-delivered safety planning in the ED.

Risk Assessment of Self-Injurious Behavior and Suicide Presentation in the Emergency Department: An Integrative Review

INTRODUCTION

Globally, there is a lack of clarity regarding the best practice to distinguish patients at the highest risk of suicide. This review explores the use of risk assessment tools in emergency departments to identify patients at high risk of repeat self-harm, suicide attempts, or death by suicide.

METHODS

The review question ("Does the use of risk assessment tools in emergency departments identify patients at high risk of repeat self-harm, suicide attempts, or death by suicide?") focused on exposure and outcome. Studies of any design were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used. Study characteristics and concepts were extracted, compared, and verified. An integrative approach was used for reporting through narrative synthesis.

RESULTS

Nine studies were identified for inclusion. Two risk assessment tools were found to have good predictive ability for suicide ideation and self-harm. Three had modest prediction of patient disposition, but in one study, the clinical impression of nurses had higher predictive ability. One tool showed modest predictive ability for patients requiring admission.

DISCUSSION

This review found no strong evidence to indicate that any particular risk tool has a superior predictive ability to identify repeat self-harm, suicide attempts, or death by suicide. Best practice lacks clarity to determine patients at highest risk of suicide, but the use of risk assessment tools has been recommended. Nevertheless, such tools should not be used in isolation from clinical judgment and experience to evaluate patients at risk. Education and training to augment risk assessment within the emergency department are recommended.

Improving Suicidal Ideation Screening and Suicide Prevention Strategies on Adult Nonbehavioral Health Units

BACKGROUND

Suicide is a risk in hospitalized patients within and outside of behavioral health units. Williams et al. (2018). Incidence and method of suicide in hospitals in the United States. Williams et al. (2018), suicides occur annually in hospitals, 14%-26% of occurrences outside of a behavioral health unit.

OBJECTIVES

The purpose of this project was to improve compliance with universal patient suicide ideation screening and targeted actions for patients screening positive admitted to nonbehavioral health units.

METHODS

Electronic medical record (EMR) changes to support screening and targeted patient safety measure documentation were implemented. Nursing education was provided to support these changes. Pre- and postassessments were used to measure knowledge gained from the education. A compliance report was generated from the EMR to measure compliance with universal screening and patient safety measures.

RESULTS

In a 4-month period, screening compliance improved by 20.6%, bedside safety companion use was 100%, suicide precautions, documentation 82.5%, and a behavioral health social work note documented 76% of the time.

CONCLUSIONS

Universal screening improvement is feasible and has the potential to improve patient safety. Implementation should be considered across health care organizations.

IMPLICATIONS FOR NURSING

Providing nursing education and easier EMR workflows for nursing documentation of suicide screening and prevention strategies improves patient safety.

Suicidal ideation in patients with coronary heart disease and hypertension: Baseline results from the DEPSCREEN-INFO clinical trial

BACKGROUND

A high proportion of cardiac patients suffers from depression, which is an antecedent for suicidal ideation. This study identifies clinical vulnerabilities for suicidal ideation in cardiac patients.

METHODS

The primary outcome of the study was severity of suicidal ideation as measured with the Patient Health Questionnaire (PHQ-9) item No. 9. Covariates were demographics, cardiac characteristics (i.e., Canadian Cardiovascular Society angina rating of chest pain and New York Heart Association rating of shortness of breath), depression (PHQ-8,i.e., PHQ-9 minus item No. 9), anxiety (Generalized Anxiety Disorder-7, GAD-7), somatic symptoms (PHQ-15), illness perception (Brief-Illness Perception Questionnaire), and health-related quality of life (EuroQol-5D, EQ 5D).

RESULTS

Data from 1,976 patients were analysed. At least 14% (95% CI [12%, 16%]) of patients indicated suicidal ideations within the last 2 weeks. Bivariate analyses yielded associations between suicidal ideation and higher levels of depression severity, anxiety severity, somatic symptom burden, chest pain, shortness of breath, negative illness perceptions, reduced health-related quality of life, and a higher probability of living alone (all p < 0.001). A multivariable ordinal regression revealed depression severity and anxiety severity to show the highest associations with suicidal ideation (OR_PHQ-8  = 1.22, p < 0.001; OR_GAD-7  = 1.09, p < 0.001). Having a defibrillator implant was associated with a lower probability of suicidal ideation (OR = 0.27, p = 0.017).

CONCLUSIONS

This study identified several clinical vulnerabilities of suicidal ideation. The results stress the importance of screening for suicidal ideation in clinical practice.

Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department

BACKGROUND

Suicide screening scales have been advocated for use in the ED setting. However, it is currently unknown whether patients classified as low-risk on these scales can be safely discharged from the emergency department. This study evaluated the utility of three commonly-used suicide screening tools in the emergency department to predict ED disposition, with special interest in discharge among low-risk patients.

METHODS

This prospective observational study enrolled a convenience sample of patients who answered "yes" to a triage suicidal ideation question in an urban academic emergency department. Patients were administered the weighted modified SADPERSONS Scale, Suicide Assessment Five-step Evaluation and Triage, and Columbia-Suicide Severity Rating Scale. Patients who subsequently received a psychiatric evaluation were included, and the utility of these screening tools to predict disposition was evaluated.

RESULTS

276 subjects completed all three suicide screening tools and were included in data analyses. Eighty-two patients (30%) were admitted or transferred. Three patients (1%) died by suicide within one year of enrollment; one was hospitalized at the end of his or her enrollment visit, dying by suicide seven months later and the other two were discharged, dying by suicide nine and ten months later, respectively. The screening tools exhibited modest negative predictive values (range: 0.66-0.73).

CONCLUSION

Three suicide screening tools displayed modest ability to predict the disposition of patients who presented to an emergency department with suicidal ideation. This study supports the current ACEP clinical policy on psychiatric patients which states that screening tools should not be used in isolation to guide disposition decisions of suicidal patients from the ED.