Suicidal and self-harm presentations to Emergency Departments: The challenges of identification through diagnostic codes and presenting complaints

Near Real-Time Syndromic Surveillance of Emergency Department Triage Texts Using Natural Language Processing: Case Study in Febrile Convulsion Detection

BACKGROUND

Collecting information on adverse events following immunization from as many sources as possible is critical for promptly identifying potential safety concerns and taking appropriate actions. Febrile convulsions are recognized as an important potential reaction to vaccination in children aged <6 years.

OBJECTIVE

The primary aim of this study was to evaluate the performance of natural language processing techniques and machine learning (ML) models for the rapid detection of febrile convulsion presentations in emergency departments (EDs), especially with respect to the minimum training data requirements to obtain optimum model performance. In addition, we examined the deployment requirements for a ML model to perform real-time monitoring of ED triage notes.

METHODS

We developed a pattern matching approach as a baseline and evaluated ML models for the classification of febrile convulsions in ED triage notes to determine both their training requirements and their effectiveness in detecting febrile convulsions. We measured their performance during training and then compared the deployed models' result on new incoming ED data.

RESULTS

Although the best standard neural networks had acceptable performance and were low-resource models, transformer-based models outperformed them substantially, justifying their ongoing deployment.

CONCLUSIONS

Using natural language processing, particularly with the use of large language models, offers significant advantages in syndromic surveillance. Large language models make highly effective classifiers, and their text generation capacity can be used to enhance the quality and diversity of training data.

Accuracy of ICD-10 codes for suicidal ideation and action in pediatric emergency department encounters

Objectives

According to the ideation-to-action framework of suicidality, suicidal ideation and suicidal action arise via distinct trajectories. Studying suicidality under this framework requires accurate identification of both ideation and action. We sought to assess the accuracy of ICD-10 codes for suicidal ideation and action in emergency department (ED) encounters.

Methods

Accuracy of ICD-10 coding for suicidality was assessed through chart review of clinical notes for 205 ED encounters among patients 6-18 years old at a large academic pediatric hospital between June 1, 2016, and June 1, 2022. Physician notes were reviewed for documentation of past or present suicidal ideation, suicidal action, or both. The study cohort consisted of 103 randomly selected "cases," or encounters assigned at least one ICD-10 code for suicidality, and 102 propensity-matched "non-cases" lacking ICD-10 codes. Accuracy of ICD-10 codes was assessed using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Results

Against a gold standard chart review, the PPV for ICD-10 suicidality codes was 86.9%, and the NPV was 76.2%. Nearly half of encounters involving suicidality were not captured by ICD-10 coding (sensitivity=53.4%). Sensitivity was higher for ideation-present (82.4%) than for action-present (33.7%) or action-past (20.4%).

Conclusions

Many cases of suicidality may be missed by relying on only ICD-10 codes. Accuracy of ICD-10 codes is high for suicidal ideation but low for action. To scale the ideation-to-action model for use in large populations, better data sources are needed to identify cases of suicidal action.

Emergency Department Presentations for Injuries Following Agency-Notified Child Maltreatment: Results From the Childhood Adversity and Lifetime Morbidity (CALM) Study

Child maltreatment (CM) is associated with negative health outcomes in adulthood, including deliberate self-harm (DSH), suicidal behaviours, and victimisation. It is unknown if associations extend to emergency department (ED) presentations for non-DSH related injuries. Birth cohort study data was linked to administrative health data, including ED presentations for non DSH related injuries and agency-reported and substantiated notifications for CM. Adjusted analyses (n = 6087) showed that any type of agency-reported notification for CM was significantly associated with increased odds of ED presentation for injuries (aOR = 1.57; 95% CI 1.32-1.87). In moderation analyses, women yielded significantly higher odds of notified and substantiated physical abuse, substantiated emotional abuse, and being subject to more than one type of substantiated abuse than males. ED presentations for injuries could be a proxy for risky behaviours, disguised DSH/suicidal behaviours, or physical abuse. The consistent findings in women may point to victimisation via interpersonal violence.

"No Abnormality Detected": A Mixed-Methods Examination of Emergency Department Coding Practices for People in Suicidal Crisis

BACKGROUND

Accurate identification of suicidal crisis presentations to emergency departments (EDs) can lead to timely mental health support, improve patient experience, and support evaluations of suicide prevention initiatives. Poor coding practices within EDs are preventing appropriate patient care. Aims of the study are (1) examine the current suicide-related coding practices, (2) identify the factors that contribute to staff decision-making and patients receiving the incorrect code or no code.

METHOD

A mixed-methods study was conducted. Quantitative data were collated from six EDs across Merseyside and Cheshire, United Kingdom from 2019 to 2021. Attendances were analyzed if they had a presenting complaint, chief complaint, or primary diagnosis code related to suicidal crisis, suicidal ideation, self-harm or suicide attempt. Semi-structured interviews were conducted with staff holding various ED positions (n = 23).

RESULTS

A total of 15,411 suicidal crisis and self-harm presentations were analyzed. Of these, 21.8% were coded as 'depressive disorder' and 3.8% as 'anxiety disorder'. Absence of an appropriate suicidal crisis code resulted in staff coding presentations as 'no abnormality detected' (23.6%) or leaving the code blank (18.4%). The use of other physical injury codes such as 'wound forearm', 'head injury' were common. Qualitative analyses elucidated potential causes of inappropriate coding, such as resource constraints and problems with the recording process.

CONCLUSION

People attending EDs in suicidal crisis were not given a code that represented the chief presentation. Improved ED coding practices related to suicidal crisis could result in considerable benefits for patients and more effective targeting of resources and interventions.

Performance of International Classification of Disease-10 codes in detecting emergency department patients with opioid misuse

BACKGROUND AND AIMS

Accurate case discovery is critical for disease surveillance, resource allocation and research. International Classification of Disease (ICD) diagnosis codes are commonly used for this purpose. We aimed to determine the sensitivity, specificity and positive predictive value (PPV) of ICD-10 codes for opioid misuse case discovery in the emergency department (ED) setting.

DESIGN AND SETTING

Retrospective cohort study of ED encounters from January 2018 to December 2020 at an urban academic hospital in the United States. A sample of ED encounters enriched for opioid misuse was developed by oversampling ED encounters with positive urine opiate screens or pre-existing opioid-related diagnosis codes in addition to other opioid misuse risk factors.

CASES

A total of 1200 randomly selected encounters were annotated by research staff for the presence of opioid misuse within health record documentation using a 5-point scale for likelihood of opioid misuse and dichotomized into cohorts of opioid misuse and no opioid misuse.

MEASUREMENTS

Using manual annotation as ground truth, the sensitivity and specificity of ICD-10 codes entered during the encounter were determined with PPV adjusted for oversampled data. Metrics were also determined by disposition subgroup: discharged home or admitted.

FINDINGS

There were 541 encounters annotated as opioid misuse and 617 with no opioid misuse. The majority were males (54.4%), average age was 47 years and 68.5% were discharged directly from the ED. The sensitivity of ICD-10 codes was 0.56 (95% confidence interval [CI], 0.51-0.60), specificity 0.99 (95% CI, 0.97-0.99) and adjusted PPV 0.78 (95% CI, 0.65-0.92). The sensitivity was higher for patients discharged from the ED (0.65; 95% CI, 0.60-0.69) than those admitted (0.31; 95% CI, 0.24-0.39).

CONCLUSIONS

International Classification of Disease-10 codes appear to have low sensitivity but high specificity and positive predictive value in detecting opioid misuse among emergency department patients in the United States.

Emergency department presentations for deliberate self-harm and suicidal ideation in 25-39 years olds following agency-notified child maltreatment: results from the Childhood Adversity and Lifetime Morbidity (CALM) study

AIMS

To compare prospective reports of child maltreatment (CM) with emergency department (ED) presentations for deliberate self-harm (DSH) and suicidal ideation in individuals aged between 25 and 39 years old.

METHODS

Linked records between the Mater-University of Queensland Study of Pregnancy birth cohort and Queensland administrative health data were used, which included notifications to child protection agencies for CM. ED presentations for individuals aged between 25 and 39 years of age for suicidal ideation, suicidal behaviour or poisoning by paracetamol or psychotropic medications where the intention was unclear were examined using logistic regression analyses.

RESULTS

A total of 609 (10.1%) individuals were the subject of one or more CM notifications for neglect or physical, sexual or emotional abuse before the age of 15 years. Of these, 250 (4.1%) presented at least once to ED for DSH and/or suicidal ideation between 25 and 39 years of age. In adjusted analysis, any notification of CM was associated with significantly increased odds of presenting to ED for these reasons (aOR = 2.80; 95% CI = 2.04-3.84). In sensitivity analyses, any notification of CM increased the odds of the combined outcome of DSH and suicidal ideation by 275% (aOR = 2.75; 95% CI = 1.96-4.06) and increased the odds of DSH alone by 269% (aOR = 2.69; 95% CI = 1.65-4.41).

CONCLUSIONS

All CM types (including emotional abuse and neglect) were associated with ED presentations for DSH and suicidal ideation in individuals between 25 and 39 years of age. These findings have important implications for the prevention of DSH, suicidal ideation and other health outcomes. They also underscore the importance of trauma-informed care in ED for all individuals presenting with DSH and suicidal ideation.

The impact of COVID-19 on emergency department presentations for mental health disorders in Queensland, Australia: A time series analysis

BACKGROUND

The COVID-19 pandemic has been associated with detrimental effects on mental health and psychological well-being. Although multiple studies have shown decreases in mental health-related Emergency Department (ED) presentations early in the COVID-19 pandemic, the medium-term effects on mental health-related ED presentations have remained less clear. This study aimed to evaluate the effect of the pandemic on mental health ED presentations by comparing observed presentation numbers to predictions from pre-pandemic data.

METHODS

This retrospective cohort study tallied weekly ED presentations associated with mental health disorders from a state-wide minimum dataset. Three time periods were identified: Pre-Pandemic (January 1, 2018-March 8, 2020), Statewide Lockdown (March 9, 2020-June 28, 2020), and Restrictions Easing (June 29, 2020-June 27, 2021). Time series analysis was used to generate weekly presentation forecasts using pre-pandemic data. Observed presentation numbers were compared to these forecasts.

RESULTS

Weekly presentation numbers were lower than predicted in 11 out of 16 weeks in the Statewide Lockdown period and 52 out of 52 weeks in the Restrictions Easing period. The largest decrease was seen for anxiety disorders (Statewide Lockdown: 76.8% of forecast; Restrictions Easing: 36.4% of forecast), while an increase was seen in presentations for eating disorders (Statewide Lockdown: 139.5% of forecast; Restrictions Easing: 194.4% of forecast).

CONCLUSIONS

Overall weekly mental health-related presentations across Queensland public EDs were lower than expected for the first 16 months of the COVID-19 pandemic. These findings underline the limitations of emergency department provision of mental health care and the importance of alternate care modalities in the pandemic context.

Determining the Impact of Opioid Policy on Substance Use and Mental Health-Related Harms: Protocol for a Data Linkage Study

BACKGROUND

Increasing harms related to prescription opioids over the past decade have led to the introduction of a range of key national and state policy initiatives across Australia. These include introducing a mandatory real-time prescription drug-monitoring program in the state of Victoria from April 2020 and a series of changes to subsidies for opioids on the Pharmaceutical Benefit Scheme from June 2020. Together, these changes aim to influence opioid supply and reduce harms related to prescription opioids, yet few studies have specifically explored how these policies have influenced opioid prescribing and related harms in Australia.

OBJECTIVE

The aim of this study is to examine the impact of a range of opioid-related policies on hospital admissions and emergency department (ED) presentations in Victoria, Australia. In particular, the study aims to understand the effect of various opioid policies and opioid-prescribing changes on (1) the number and rates of ED presentations and hospital admissions attributed to substance use (ie, opioid and nonopioid related) or mental ill-health (eg, suicide, self-harm, anxiety, and depression), (2) the association between differing opioid dose trajectories and the likelihood of ED presentations and hospital admissions related to substance use and mental ill-health, and (3) whether changes in an individual's opioid prescribing change the risk related to ED presentations and hospital admissions related to substance use and mental ill-health.

METHODS

We will conduct a population-level linked data study. General practice health records obtained from the Population Level Analysis and Reporting platform are linked with person-level data from 3 large hospital networks in Victoria, Australia. Interrupted time series analysis will be used to examine the impact of opioid policies on a range of harms, including the rates of presentations related to substance use (opioid and nonopioid) and mental ill-health among the primary care cohort. Group-based trajectory modeling and a case-crossover design will be used to further explore the impact of changes in opioid dosage and other covariates on opioid and nonopioid poisonings and mental ill-health-related presentations at the patient level.

RESULTS

Given that this paper serves as a protocol, there are currently no results available. The deidentified primary health data were sourced from electronic medical records of approximately 4,717,000 patients from 542 consenting general practices over a 6-year period (2017-2022). The submission of results for publication is planned for early 2024.

CONCLUSIONS

This study will add to the limited evidence base to help understand the impact of opioid policies in Australia, including whether intended or unintended outcomes are occurring as a result.

TRIAL REGISTRATION

EU PAS Register EUPAS104005; https://www.encepp.eu/encepp/viewResource.htm?id=104006.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51825.

Secondary mental health service utilisation following emergency department contact for suicidal behaviour: A systematic review

OBJECTIVE

Engagement with secondary mental health services after an emergency department presentation with suicidal behaviours may be an important strategy for reducing the risk of repeat attempts. Our aim was to examine secondary mental health service contact following a presentation to emergency department with suicidal behaviours.

METHODS

A systematic review of papers published between 2000 and 2020 was undertaken. This identified 56 papers relating to 47 primary studies. Data were extracted and summarised separately by age group: (1) young people, (2) older adults and (3) adults and studies with participants of 'all ages'.

RESULTS

Studies in young people (n = 13) showed, on average, 44.8% were referred and 33.7% had contact with secondary mental health services within 4 weeks of emergency department discharge. In comparison, in adult/all ages studies (n = 34), on average, 27.1% were referred to and 26.2% had mental health service contact within 4 weeks. Only three studies presented data on contact with mental health services for older adults, and proportions ranged from 49.0% to 86.0%.

CONCLUSION

This review highlights poor utilisation of secondary mental health service following emergency department presentation for suicidal behaviours, and further research is needed to identify the reasons for this. Crucially, this information could assist in the allocation of resources to facilitate the timely implementation of suicide prevention services.

Surveillance of Hospital-Presenting Intentional Self-Harm in Western Sydney, Australia, During the Implementation of a New Self-Harm Reporting Field

Background: Hospital-presenting self-harm is a strong predictor of suicide and has substantial human and health service costs. Aims: We aimed to identify changes in case ascertainment after implementation of a new self-harm reporting field at a tertiary hospital in New South Wales, and to report event rates, demographic, and clinical characteristics. Method: Self-harm events presenting to the emergency department (October 2017 to August 2020) were identified using clinical documentation and a new reporting field. Changes in the frequency of self-harm in the period after implementation of the self-harm field were assessed through Poisson regression models. Results: A twofold increase in the frequency of self-harm was detected following the implementation of the new reporting field. The annual average age-standardized event rate of self-harm was 110.4 per 100,000 (120.8 per 100,000 for females; 100.1 per 100,000 for males). The highest rates by age and sex were for females aged 15-19 years (375 per 100,000) and males aged 20-24 years (175 per 100,000). Limitations: Self-harm identification relies on clinician coding practice, which is subject to variability and potential under-enumeration. Conclusion: These findings highlight the value of a self-harm reporting field in hospital record systems for accurate recording and long-term monitoring of self-harm event rates.

Suicide crises among women and mothers during and around the time of pregnancy: Prevalence and timing of initial contact with first responders and health services

OBJECTIVES

Suicide is a leading cause of maternal mortality. Suicidality during and around the time of pregnancy can have detrimental impacts on a child's development and outcomes. This paper examines prevalence, demographic characteristics, and timing of initial contact with first responders and health services for a cohort of women who experienced suicidality during and around the time of pregnancy.

METHODS

Findings are drawn from the Partners in Prevention (PiP) study, a population-wide linked data set of suicide-related attendances by police or paramedics in Queensland, Australia. A sub-cohort of women was identified, who were between 6 months preconception and 2 years postpartum at the time of a suicide-related contact with police or paramedics (PiP-Maternal). Findings are compared to other girls and women who had a suicide-related contact with police or paramedics (PiP-Female). Prevalence, demographic characteristics, timing of contact with first responders and health services, re-presentations, and mortality are reported.

RESULTS

The PiP-Maternal cohort comprised 3020 individuals and 3400 births. Women in the PiP-Maternal cohort were younger, more likely to be of Aboriginal and/or Torres Strait Islander descent and live outside of a major city than the PiP-Female cohort. There were high rates of out-of-hours calls to police and ambulance, and similar perceived seriousness of the call between women in the PiP-Maternal and PiP-Female cohorts. Women in the PiP-Maternal cohort were less likely to be admitted to an emergency department within 24 hours, even after matching on covariates. Prevalence of suicidality for women who were pregnant and up to 2 years postpartum was 1.32% (95% CI = [1.27, 1.37]).

CONCLUSION

Vulnerabilities and high rates of contact with police or paramedics, coupled with lower levels of follow-up, highlight the critical need to improve service responses for women with mental health needs during these phases of life.

The Use and Structure of Emergency Nurses' Triage Narrative Data: Scoping Review

BACKGROUND

Emergency departments use triage to ensure that patients with the highest level of acuity receive care quickly and safely. Triage is typically a nursing process that is documented as structured and unstructured (free text) data. Free-text triage narratives have been studied for specific conditions but never reviewed in a comprehensive manner.

OBJECTIVE

The objective of this paper was to identify and map the academic literature that examines triage narratives. The paper described the types of research conducted, identified gaps in the research, and determined where additional review may be warranted.

METHODS

We conducted a scoping review of unstructured triage narratives. We mapped the literature, described the use of triage narrative data, examined the information available on the form and structure of narratives, highlighted similarities among publications, and identified opportunities for future research.

RESULTS

We screened 18,074 studies published between 1990 and 2022 in CINAHL, MEDLINE, Embase, Cochrane, and ProQuest Central. We identified 0.53% (96/18,074) of studies that directly examined the use of triage nurses' narratives. More than 12 million visits were made to 2438 emergency departments included in the review. In total, 82% (79/96) of these studies were conducted in the United States (43/96, 45%), Australia (31/96, 32%), or Canada (5/96, 5%). Triage narratives were used for research and case identification, as input variables for predictive modeling, and for quality improvement. Overall, 31% (30/96) of the studies offered a description of the triage narrative, including a list of the keywords used (27/96, 28%) or more fulsome descriptions (such as word counts, character counts, abbreviation, etc; 7/96, 7%). We found limited use of reporting guidelines (8/96, 8%).

CONCLUSIONS

The breadth of the identified studies suggests that there is widespread routine collection and research use of triage narrative data. Despite the use of triage narratives as a source of data in studies, the narratives and nurses who generate them are poorly described in the literature, and data reporting is inconsistent. Additional research is needed to describe the structure of triage narratives, determine the best use of triage narratives, and improve the consistent use of triage-specific data reporting guidelines.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2021-055132.

Growth in emergency department self-harm or suicidal ideation presentations in young people: Comparing trends before and since the COVID-19 first wave in New South Wales, Australia

INTRODUCTION

Self-harm presentations in children and young people have increased internationally over the last decade. The COVID-19 pandemic has the potential to worsen these trends.

OBJECTIVE

To describe trends in emergency department self-harm or suicidal ideation presentations for children and young people in New South Wales before and since the COVID-19 pandemic.

METHODS

We studied presentations for self-harm or suicidal ideation by 10- to 24-year-olds to New South Wales emergency departments, using interrupted time series analysis to compare annualised growth before COVID (2015 to February 2020) and since COVID (March 2020 to June 2021). Subgroup analyses compared age group, gender, triage category, rurality and disadvantage. Time series decomposition via generalised additive models identified long-term, seasonal and short-term trends.

RESULTS

Self-harm or suicidal ideation presentations by young people in New South Wales increased by 8.4% per annum pre-COVID. Growth accelerated since COVID, to 19.2% per annum, primarily due to increased presentations by females aged 13-17 years (47.1% per annum since COVID, from 290 per 10,000 in 2019 to 466 per 10,000 in 2021). Presentations in males aged 10-24 years did not increase since COVID (105.4 per 10,000 in 2019, 109.8 per 10,000 in 2021) despite growing 9.9% per annum before COVID. Presentation rates accelerated significantly in socio-economically advantaged areas. Presentations in children and adolescents were strongly linked to school semesters.

CONCLUSION

Emergency department self-harm or suicidal ideation presentations by New South Wales young people grew steadily before COVID. Understanding the sustained increase remains a priority. Growth has increased since COVID particularly for adolescent females, but not among adolescent males. Surprisingly, the largest post-COVID increases in annual growth occurred in socio-economically advantaged and urban regions. The COVID-19 pandemic appears to have added new challenges, particularly in females in the developmentally critical early adolescent and teenage years.

Multi-site medical record review for validation of intentional self-harm coding in emergency departments

BACKGROUND

Codes in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), are used for injury surveillance, including surveillance of intentional self-harm, as they appear in administrative billing records. This study estimated the positive predictive value of ICD-10-CM codes for intentional self-harm in emergency department (ED) billing records for patients aged 10 years and older who did not die and were not admitted to an inpatient medical service.

METHODS

The study team in Maryland, Colorado, and Massachusetts selected all or a random sample of ED billing records with an ICD-10-CM code for intentional self-harm (specific codes that began with X71-X83, T36-T65, T71, T14.91). Positive predictive value (PPV) was determined by the number and percentage of records with a physician diagnosis of intentional self-harm, based on a retrospective review of the original medical record.

RESULTS

The estimated PPV for the codes' capture of intentional self-harm based on physician diagnosis in the original medical record was 89.8% (95% CI 85.0-93.4) for Maryland records, 91.9% (95% CI 87.7-95.0) for Colorado records, and 97.3% (95% CI 95.1-98.7) for Massachusetts records.

CONCLUSION

Given the high PPV of the codes, epidemiologists can use the codes for public health surveillance of intentional self-harm treated in the ED using ICD-10-CM coded administrative billing records. However, these codes and related variables in the billing database cannot definitively distinguish between suicidal and non-suicidal intentional self-harm.

Children and Young People Presenting in a Pediatric Emergency Department in North-West England in Suicidal Crisis: An Exploratory Case Series Study

Suicide is a leading cause of death among children and young people (CYP) worldwide, and rates have been increasing in recent years. However, while evidence exists regarding factors associated with suicide and self-harm, there is limited information publicly available on the CYP who present in suicidal crisis. This is a case series study of CYP (aged 8-16) experiencing suicidal crisis who presented in an Emergency Department at a pediatric hospital in North-West England between March 2019 and March 2021 (n = 240). Clinical records were extracted and audited to explore demographic data, methods of recording patient attendance, the clinical pathways available and the patterns of pathway usage, and differences in CYP presentations before and after the COVID-19 pandemic. Attendees were mostly White females, with a mean age of 13.5 years, and 24% had a diagnosed special educational need. "Social/social problems" was the most commonly used code for recording attendance (38%), and pathways varied depending on code used. A range of parental and familial factors were also identified. There were more CYP presenting with self-harm in addition to suicide ideation after the pandemic began (43 vs 27% pre-pandemic). This study provides the first clear insight into CYP who seek help at a North-West Emergency Department for suicidal crisis, and work is now needed to develop effective prevention strategies tailored toward the groups most at-risk.

Translating promise into practice: a review of machine learning in suicide research and prevention

In ever more pressured health-care systems, technological solutions offering scalability of care and better resource targeting are appealing. Research on machine learning as a technique for identifying individuals at risk of suicidal ideation, suicide attempts, and death has grown rapidly. This research often places great emphasis on the promise of machine learning for preventing suicide, but overlooks the practical, clinical implementation issues that might preclude delivering on such a promise. In this Review, we synthesise the broad empirical and review literature on electronic health record-based machine learning in suicide research, and focus on matters of crucial importance for implementation of machine learning in clinical practice. The challenge of preventing statistically rare outcomes is well known; progress requires tackling data quality, transparency, and ethical issues. In the future, machine learning models might be explored as methods to enable targeting of interventions to specific individuals depending upon their level of need-ie, for precision medicine. Primarily, however, the promise of machine learning for suicide prevention is limited by the scarcity of high-quality scalable interventions available to individuals identified by machine learning as being at risk of suicide.

Strategies to Care for Patients Being Treated in the Emergency Department After Self-harm: Perspectives of Frontline Staff

INTRODUCTION

Every year, approximately 500 000 patients in the United States present to emergency departments for treatment after an episode of self-harm. Evidence-based practices such as designing safer ED environments, safety planning, and discharge planning are effective for improving the care of these patients but are not always implemented with fidelity because of resource constraints. The aim of this study was to provide insight into how ED staff innovate processes of care and services by leveraging what is available on-site or in their communities.

METHODS

A total of 34 semi-structured qualitative phone interviews were conducted with 12 nursing directors, 11 medical directors, and 11 social workers from 17 emergency departments. Respondents comprised a purposive stratified sample recruited from a large national survey in the US. Interview transcripts were coded and analyzed using a directed content analysis approach to identify categories of strategies used by ED staff to care for patients being treated after self-harm.

RESULTS

Although respondents characterized the emergency department as an environment that was not well-suited to meet patient mental health needs, they nevertheless described 4 categories of strategies to improve the care of patients seen in the emergency department after an episode of self-harm. These included: adapting the ED environment, improving efficiencies to provide mental health care, supporting the staff who provide direct care for patients, and leveraging community resources to improve access to mental health resources postdischarge.

DISCUSSION

Despite significant challenges in meeting the mental health needs of patients treated in the emergency department after self-harm, the staff identified opportunities to provide mental health care and services within the emergency department and leverage community resources to support patients after discharge.

Implementing a systems approach to suicide prevention in a mental health service using the Zero Suicide Framework

OBJECTIVE

The Zero Suicide Framework, a systems approach to suicide prevention within a health service, is being implemented across a number of states in Australia, and internationally, although there is limited published evidence for its effectiveness. This paper aims to provide a description of the implementation process within a large health service in Australia and describes some of the outcomes to date and learnings from this process.

METHOD

Gold Coast Mental Health and Specialist Services has undertaken an implementation of the Zero Suicide Framework commencing in late 2015, aiming for high fidelity to the seven key elements. This paper describes the practical steps undertaken by the service, the new practices embedded, emphasis on supporting staff following the principles of restorative just culture and the development of an evaluation framework to support a continuous quality improvement approach.

RESULTS

Improvements have been demonstrated in terms of processes implementation, enhanced staff skills and confidence, positive cultural change and innovations in areas such as the use of machine learning for identification of suicide presentations. A change to 'business as usual' has benefited thousands of consumers since the implementation of a Suicide Prevention Pathway in late 2016 and achieved reductions in rates of repeated suicide attempts and deaths by suicide in Gold Coast Mental Health and Specialist Services consumers.

CONCLUSION

An all-of-service, systems approach to suicide prevention with a strong focus on cultural shifts and aspirational goals can be successfully implemented within a mental health service with only modest additional resources when supported by engaged leadership across the organisation. A continuous quality improvement approach is vital in the relentless pursuit of zero suicides in healthcare.

An emergency department medical record review for adolescent intentional self-harm injuries

BACKGROUND

Non-suicidal self-injury and suicide attempts are increasing problems among American adolescents. This study developed a definition for identifying intentional self-harm (ISH) injuries in emergency department (ED) records coded with International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. The definition is based on the injury-reporting framework proposed by the Centers for Disease Control and Prevention. The study sought to estimate the definition's positive predictive value (PPV), and the proportion of ISH injuries with intent to die (i.e., suicide attempt).

METHODS

The study definition, based on first-valid external cause-of-injury ICD-10-CM codes X71-X83, T14.91, T36-T65, or T71, captured 207 discharge records for initial encounters for ISH in one Kentucky ED. Medical records were reviewed to confirm provider-documented diagnosis for ISH, and identify intent to die or suicide ideation. The PPV of the study definition for capturing provider-documented ISH injuries was reported with its 95% confidence interval (95% CI).

RESULTS

The estimated PPV for the study definition to capture ISH injuries was 88.9%, 95% CI (83.8%, 92.8%). The estimated percentage of ISH with intent to die was 45.9, 95% CI (47.1, 61.0%). The ICD-10-CM code "suicide attempt" (T14.91) captured only 7 cases, but coding guidelines restrict assignment of this code to cases in which the mechanism of the suicide attempt is unknown.

CONCLUSIONS

The proposed case definition supported a robust PPV for ISH injuries. Our findings add to the evidence that the current ICD-10-CM coding system and coding guidelines do not allow identification of ISH with intent to die; modifications are needed to address this issue.

Development of a Self-Harm Monitoring System for Victoria

The prevention of suicide and suicide-related behaviour are key policy priorities in Australia and internationally. The World Health Organization has recommended that member states develop self-harm surveillance systems as part of their suicide prevention efforts. This is also a priority under Australia’s Fifth National Mental Health and Suicide Prevention Plan. The aim of this paper is to describe the development of a state-based self-harm monitoring system in Victoria, Australia. In this system, data on all self-harm presentations are collected from eight hospital emergency departments in Victoria. A natural language processing classifier that uses machine learning to identify episodes of self-harm is currently being developed. This uses the free-text triage case notes, together with certain structured data fields, contained within the metadata of the incoming records. Post-processing is undertaken to identify primary mechanism of injury, substances consumed (including alcohol, illicit drugs and pharmaceutical preparations) and presence of psychiatric disorders. This system will ultimately leverage routinely collected data in combination with advanced artificial intelligence methods to support robust community-wide monitoring of self-harm. Once fully operational, this system will provide accurate and timely information on all presentations to participating emergency departments for self-harm, thereby providing a useful indicator for Australia’s suicide prevention efforts.

Examining the Use of Police and Ambulance Data in Suicide Research

Background: Police and paramedics are often the first to respond to individuals in suicide crisis and have an important role to play in facilitating optimal care pathways. Yet, little evidence exists to inform these responses. Data linkage provides one approach to examining this knowledge gap. Aim: We identified studies that examined suicide behaviors and linked to police or ambulance data. Method: A systematic search of PubMed and Scopus was undertaken to identify data linkage studies that: (1) examined suicide behaviors, and (2) included police or ambulance data. Studies were reviewed to identify: aims; suicide behaviors examined; how these were measured; how the cohort was defined; topic area; and what datasets were linked. Results: Eight studies met the inclusion criteria. Six studies included police data, and two studies included ambulance data. No study included both. Two topic areas were identified: (1) suicide-related contact with police or ambulance services; and (2) associations between suicidal behaviors and violence, victimization, and criminality. Limitations: Limitations to the review include the potential to have missed studies that investigated or reported on suicidality under the guise of mental health problems; complexities and nuances arising from the role of police data in coronial investigations; and limitations in the number of databases searched. Conclusion: Police and ambulance data represent a currently underutilized source of valuable information relevant to suicide crises, and further research should aim to address this gap.

Suicidal Presentations to Emergency Departments in a Large Australian Public Health Service over 10 Years

This paper presents trends and characteristics for 32,094 suicidal presentations to two Emergency Departments (EDs) in a large health service in Australia across a 10-year period (2009–2018). Prevalence of annual suicidal presentations and for selected groups of consumers (by sex, age groups, and ethnicity) was determined from a machine learning diagnostic algorithm developed for this purpose and a Bayesian estimation approach. A linear increase in the number of suicidal presentations over 10 years was observed, which was 2.8-times higher than the increase noted in all ED presentations and 6.1-times higher than the increase in the population size. Females had higher presentation rates than males, particularly among younger age groups. The highest rates of presentations were by persons aged 15–24. Overseas-born persons had around half the rates of suicidal presentations than Australian-born persons, and Indigenous persons had 2.9-times higher rates than non-Indigenous persons. Of all presenters, 70.6% presented once, but 5.7% had five or more presentations. Seasonal distribution of presentations showed a peak at the end of spring and a decline in winter months. These findings can inform the allocation of health resources and guide the development of suicide prevention strategies for people presenting to hospitals in suicidal crisis.