Sarah A. Arias

Suicide Prevention in an Emergency Department Population: The ED-SAFE Study

Importance Suicide is a leading cause of deaths in the United States. Although the emergency department (ED) is an opportune setting for initiating suicide prevention efforts, ED-initiated suicide prevention interventions remain underdeveloped. Objective To determine whether an ED-initiated intervention reduces subsequent suicidal behavior. Design, Setting, and Participants This multicenter study of 8 EDs in the United States enrolled adults with a recent suicide attempt or ideation and was composed of 3 sequential phases: (1) a treatment as usual (TAU) phase from August 2010 to December 2011, (2) a universal screening (screening) phase from September 2011 to December 2012, and (3) a universal screening plus intervention (intervention) phase from July 2012 to November 2013. Interventions Screening consisted of universal suicide risk screening. The intervention phase consisted of universal screening plus an intervention, which included secondary suicide risk screening by the ED physician, discharge resources, and post-ED telephone calls focused on reducing suicide risk. Main Outcomes and Measures The primary outcome was suicide attempts (nonfatal and fatal) over the 52-week follow-up period. The proportion and total number of attempts were analyzed. Results A total of 1376 participants were recruited, including 769 females (55.9%) with a median (interquartile range) age of 37 (26-47) years. A total of 288 participants (20.9%) made at least 1 suicide attempt, and there were 548 total suicide attempts among participants. There were no significant differences in risk reduction between the TAU and screening phases (23% vs 22%, respectively). However, compared with the TAU phase, patients in the intervention phase showed a 5% absolute reduction in suicide attempt risk (23% vs 18%), with a relative risk reduction of 20%. Participants in the intervention phase had 30% fewer total suicide attempts than participants in the TAU phase. Negative binomial regression analysis indicated that the participants in the intervention phase had significantly fewer total suicide attempts than participants in the TAU phase (incidence rate ratio, 0.72; 95% CI, 0.52-1.00; P = .05) but no differences between the TAU and screening phases (incidence rate ratio, 1.00; 95% CI, 0.71-1.41; P = .99). Conclusions and Relevance Among at-risk patients in the ED, a combination of brief interventions administered both during and after the ED visit decreased post-ED suicidal behavior.

Improving Suicide Risk Screening and Detection in the Emergency Department

INTRODUCTION The Emergency Department Safety Assessment and Follow-up Evaluation Screening Outcome Evaluation examined whether universal suicide risk screening is feasible and effective at improving suicide risk detection in the emergency department (ED). METHODS A three-phase interrupted time series design was used: Treatment as Usual (Phase 1), Universal Screening (Phase 2), and Universal Screening + Intervention (Phase 3). Eight EDs from seven states participated from 2009 through 2014. Data collection spanned peak hours and 7 days of the week. Chart reviews established if screening for intentional self-harm ideation/behavior (screening) was documented in the medical record and whether the individual endorsed intentional self-harm ideation/behavior (detection). Patient interviews determined if the documented intentional self-harm was suicidal. In Phase 2, universal suicide risk screening was implemented during routine care. In Phase 3, improvements were made to increase screening rates and fidelity. Chi-square tests and generalized estimating equations were calculated. Data were analyzed in 2014. RESULTS Across the three phases (N=236,791 ED visit records), documented screenings rose from 26% (Phase 1) to 84% (Phase 3) (χ(2) [2, n=236,789]=71,000, p<0.001). Detection rose from 2.9% to 5.7% (χ(2) [2, n=236,789]=902, p<0.001). The majority of detected intentional self-harm was confirmed as recent suicidal ideation or behavior by patient interview. CONCLUSIONS Universal suicide risk screening in the ED was feasible and led to a nearly twofold increase in risk detection. If these findings remain true when scaled, the public health impact could be tremendous, because identification of risk is the first and necessary step for preventing suicide. TRIAL REGISTRATION Emergency Department Safety Assessmentand Follow-up Evaluation (ED-SAFE) ClinicalTrials.gov: (NCT01150994). https://clinicaltrials.gov/ct2/show/NCT01150994?term=ED-SAFE&rank=1.

Sepsis visits and antibiotic utilization in U.S. emergency departments

Objectives:To monitor the frequency of sepsis visits in U.S. emergency departments and assess the appropriateness of antibiotic utilization. Design:We analyzed data from the National Hospital Ambulatory Medical Care Survey, defining sepsis as an explicit diagnosis of sepsis via International Classification of Diseases, 9th Revision, Clinical Modification codes 038, 995.91, 995.92, or 785.52. We also monitored trends using cases inferred by infection plus organ dysfunction without explicit diagnosis of sepsis, which we refer to as implicit sepsis cases. We assess changes in visit frequency and ascertain emergency department antibiotic administration rates. Setting:Four-stage probability sample of visits to U.S. emergency departments, excluding Federal/military. Patients:Adult emergency department visits, United States, 1994–2009. Measurements and Main Results:Sepsis was diagnosed explicitly at 260,000 visits per year in U.S. emergency departments (95% CI, 251,000–270,000) or 1.23 visits per 1,000 U.S. population. The visit rate remained stable from 1994 to 2009 (p for trend 0.42). By contrast, the rate of visits with an implicit diagnosis of sepsis increased by 0.07 every 2 years (95% CI, 0.04–0.10; p for trend 0.002). Antibiotics were prescribed in the emergency department during 61% (95% CI, 57–65) of explicit sepsis visits. This increased from 52% in 1994–1997 to 69% in 2006–2009 (difference, 17%; 95% CI, 16.8–17.2). Of antibiotic regimens, 18% covered methicillin-resistant Staphylococcus aureus, 27% Pseudomonas, and 10% extended-spectrum beta-lactamase–producing bacteria, without evidence of targeting according to known risk factors. Of explicit sepsis cases, 31% were admitted to the ICU with 40% mortality (95% CI, 30–51). Overall hospital mortality was 17% (95% CI, 11–22). Conclusions:Explicitly diagnosed sepsis visits did not become more common during 1994–2009. Our data suggest that many emergency department patients with sepsis do not receive antibiotics until they arrive on the inpatient unit. When antibiotics are used among septic emergency department patients, drug-resistant bacteria are covered infrequently. These methods provide a simple approach to tracking the frequency with which sepsis is diagnosed among emergency department patients and to monitoring antibiotic therapy.

Change in Emergency Department Providers’ Beliefs and Practices After Use of New Protocols for Suicidal Patients

OBJECTIVE The study examined changes in self-reported attitudes and practices related to suicide risk assessment among providers at emergency departments (EDs) during a three-phase quasi-experimental trial involving implementation of ED protocols for suicidal patients. METHODS A total of 1,289 of 1,828 (71% response rate) eligible providers at eight EDs completed a voluntary, anonymous survey at baseline, after introduction of universal suicide screening, and after introduction of suicide prevention resources (nurses) and a secondary risk assessment tool (physicians). RESULTS Among participants, the median age was 40 years old, 64% were female, and there were no demographic differences across study phases; 68% were nurses, and 32% were attending physicians. Between phase 1 and phase 3, increasing proportions of nurses reported screening for suicide (36% and 95%, respectively, p<.001) and increasing proportions of physicians reported further assessment of suicide risk (63% and 80%, respectively, p<.01). Although increasing proportions of providers said universal screening would result in more psychiatric consultations, decreasing proportions said it would slow down clinical care. Increasing proportions of nurses reported often or almost always asking suicidal patients about firearm access (18%-69%, depending on the case), although these numbers remained low relative to ideal practice. Between 35% and 87% of physicians asked about firearms, depending on the case, and these percentages did not change significantly over the study phases. CONCLUSIONS These findings support the feasibility of implementing universal screening for suicide in EDs, assuming adequate resources, but providers should be educated to ask suicidal patients about firearm access.

Factors Associated With Suicide Outcomes 12 Months After Screening Positive for Suicide Risk in the Emergency Department

OBJECTIVE The main objective was to identify which patient characteristics have the strongest association with suicide outcomes in the 12 months after an index emergency department (ED) visit. METHODS Data were analyzed from the first two phases of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE). The ED-SAFE study, a quasi-experimental, interrupted time-series design, involved participation from eight general medical EDs across the United States. Participants included adults presenting to the ED with active suicidal ideation or an attempt in the past week. Data collection included baseline interview; six- and 12-month chart reviews; and six-, 12-, 24-, 36-, and 52-week telephone follow-up assessments. Regression analyses were conducted. RESULTS Among 874 participants, the median age was 37 years (interquartile range 27-47), with 56% of the sample being female (N=488), 74% white (N=649), and 13% Hispanic (N=113). At baseline, 577 (66%) participants had suicidal ideation only, whereas 297 (34%) had a suicide attempt in the past week. Data sufficient to determine outcomes were available for 782 (90%). In the 12 months after the index ED visit, 195 (25%) had documentation of at least one suicide attempt or suicide. High school education or less, an ED visit in the preceding six months, prior nonsuicidal self-injury, current alcohol misuse, and suicidal intent or plan were predictive of future suicidal behavior. CONCLUSIONS Continuing to build an understanding of the factors associated with future suicidal behaviors for this population will help guide design and implementation of improved suicide screening and interventions in the ED and better allocation of scarce resources.

Disparities in Treatment of Older Adults with Suicide Risk in the Emergency Department

We described characteristics and treatment received for older (≥60 years) vs younger (<60 years) adult emergency department (ED) patients with suicide risk.

Using structured telephone follow-up assessments to improve suicide-related adverse event detection.

Adverse event (AE) detection and reporting practices were compared during the first phase of the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE), a suicide intervention study. Data were collected using a combination of chart reviews and structured telephone follow-up assessments postenrollment. Beyond chart reviews, structured telephone follow-up assessments identified 45% of the total AEs in our study. Notably, detection of suicide attempts significantly varied by approach with 53 (18%) detected by chart review, 173 (59%) by structured telephone follow-up assessments, and 69 (23%) marked as duplicates. Findings provide support for utilizing multiple methods for more robust AE detection in suicide research.

Screening for Suicidal Thoughts and Behaviors in Older Adults in the Emergency Department

To estimate the prevalence of self‐harm, suicidal ideation (SI), and suicide attempts (SA) in older adults in the emergency department (ED), including differences according to age, sex, and race and ethnicity.

Frequency of lethal means assessment among emergency department patients with a positive suicide risk screen

Prior work from surveys and limited populations suggests many emergency department (ED) patients with suicide risk do not have documented lethal means assessments (e.g., being asked about home firearms). The specific objectives of this study were to, in an ED with universal screening for suicide risk: (1) estimate how often ED providers documented lethal means assessment for suicidal patients, and (2) compare patients with and without documented lethal means assessments. We reviewed 800 total charts from a random sample of adults in three a priori age groups (18-34 years; 35-59 years; ≥ 60 years) with a positive suicide risk screen from 8/2014 to 12/2015. Only 18% (n = 145) had documentation by ≥ 1 provider of assessment of lethal means access. Among these 145, only 8% (n = 11) had documentation that someone discussed an action plan to reduce access (most commonly changing home storage or moving objects out of the home). Among 545 suicidal patients discharged home from the ED, 85% had no documentation that any provider assessed access to lethal means. Our findings highlight an important area for improving care: routine, documented lethal means assessment and counseling for patients with suicide risk. There is an urgent need for further exploration of barriers and facilitators.

Implementation and use of a crisis hotline during the treatment as usual and universal screening phases of a suicide intervention study

BACKGROUND Although research suggests that crisis hotlines are an effective means of mitigating suicide risk, lack of empirical evidence may limit the use of this method as a research safety protocol. PURPOSE This study describes the use of a crisis hotline to provide clinical backup for research assessments. METHODS Data were analyzed from participants in the Emergency Department Safety and Follow-up Evaluation (ED-SAFE) study (n=874). Socio-demographics, call completion data, and data available on suicide attempts occurring in relation to the crisis counseling call were analyzed. Pearson chi-squared statistic for differences in proportions were conducted to compare characteristics of patients receiving versus not receiving crisis counseling. P<0.05 was considered statistically significant. RESULTS Overall, there were 163 counseling calls (6% of total assessment calls) from 135 (16%) of the enrolled subjects who were transferred to the crisis line because of suicide risk identified during the research assessment. For those transferred to the crisis line, the median age was 40 years (interquartile range 27-48) with 67% female, 80% white, and 11% Hispanic. CONCLUSIONS Increasing demand for suicide interventions in diverse healthcare settings warrants consideration of crisis hotlines as a safety protocol mechanism. Our findings provide background on how a crisis hotline was implemented as a safety measure, as well as the type of patients who may utilize this safety protocol.