The Emergency Department: Challenges and Opportunities for Suicide Prevention.
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ABSTRACT:
SUBMITTER: Asarnow JR
PROVIDER: S-EPMC6768433 | biostudies-literature | 2017 Oct
REPOSITORIES: biostudies-literature
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The Emergency Department: Challenges and Opportunities for Suicide Prevention.
Asarnow Joan Rosenbaum JR Babeva Kalina K Horstmann Elizabeth E
Child and adolescent psychiatric clinics of North America 20171001 4
Emergency departments (EDs) can offer life-saving suicide prevention care. This article focuses on the ED and emergency services as service delivery sites for suicide prevention. Characteristics of EDs, models of emergency care, ED screening and brief intervention models, and practice guidelines and parameters are reviewed. A care process model for youths at risk for suicide and self-harm is presented, with guidance for clinicians based on the scientific evidence. Strengthening emergency infrast ...[more]
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Project description:ImportanceSuicide 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.ObjectiveTo determine whether an ED-initiated intervention reduces subsequent suicidal behavior.Design, setting, and participantsThis 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.InterventionsScreening 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 measuresThe primary outcome was suicide attempts (nonfatal and fatal) over the 52-week follow-up period. The proportion and total number of attempts were analyzed.ResultsA 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 relevanceAmong at-risk patients in the ED, a combination of brief interventions administered both during and after the ED visit decreased post-ED suicidal behavior.
| S-EPMC5539839 | biostudies-literature
Project description:BackgroundInterprofessional education opportunities are commonly university-based and require further development during clinical practice. Many clinical contexts offer the potential for meaningful learning of both collaborative and discipline-specific practice. The emergency department (ED) demands efficient teamwork, so presents a logical location for interprofessional learning.MethodsAn interprofessional clinical placement program was implemented with the aim to enhance students' capacity and self-efficacy for collaborative practice. Fifty-five medical and nursing students participated as interdisciplinary pairs in a two-week clinical placement in the ED. Students' perceptions of the learning environment were measured pre- and post-placement with the Self-efficacy for Interprofessional Experiential Learning Scale and the Interprofessional Clinical Placement Learning Inventory was completed post-placement. Non-parametric tests were used to establish change differences.ResultsThe Placement Learning Inventory revealed positive outcomes; the majority (16/19) agreed/agreed strongly that the placement provided sufficient learning opportunities, was interesting, and made them feel as if they belonged and most (14/19) reported they achieved the discipline specific learning objectives set by the university. Self-efficacy improved significantly (p = 0.017), showing promise for future use of the placement model Challenges were identified in the organisation and supervision of students. In the absence of additional dedicated student supervision, this model of interprofessional student pairs in the ED was challenging.ConclusionsInterprofessional clinical placements in ED are an effective clinical learning approach for final year undergraduate medicine and nursing students. Recommendations for improvements for students' clinical supervision are proposed for the placement model.
| S-EPMC9764718 | biostudies-literature
Project description:We sought to examine the beliefs and behaviors of emergency department (ED) providers related to preventing suicide by reducing suicidal patients' access to lethal methods (means restriction) and identify characteristics associated with asking patients about firearm access.Physicians and nurses at eight EDs completed a confidential, voluntary survey.The response rate was 79% (n = 631); 57% of respondents were females and 49% were nurses. Less than half believed, "most" or "all" suicides are preventable. More nurses (67%) than physicians (44%) thought "most" or "all" firearm suicide decedents would have died by another method had a firearm been unavailable (P < .001). The proportion of providers who reported they "almost always" ask suicidal patients about firearm access varied across five patient scenarios: suicidal with firearm suicide plan (64%), suicidal with no suicide plan (22%), suicidal with nonfirearm plan (21%), suicidal in past month but not today (16%), and overdosed but no longer suicidal (9%). In multivariable logistic regression, physicians were more likely than nurses to "almost always" or "often" ask about a firearm across all five scenarios, as were older providers and those who believed their own provider type was responsible for assessing firearm access.Many ED providers are skeptical about the preventability of suicide and the effectiveness of means restriction, and most do not assess suicidal patients' firearm access except when a patient has a firearm suicide plan. These findings suggest the need for targeted staff education concerning means restriction for suicide prevention.
| S-EPMC4347862 | biostudies-literature
Project description:BackgroundSuicide is a leading cause of death among adolescents in North America. Youth who present to the Emergency Department (ED) with acute suicidality are at increased risk for eventual death by suicide, thereby presenting an opportunity for secondary prevention of suicide. The current study evaluates the effectiveness of a standardized individual and family-based suicidal behaviour risk reduction intervention targeting adolescents at high-risk for suicide.MethodsA randomized controlled trial (RCT) will be conducted to evaluate the effectiveness of a manualized youth- and family- based suicide prevention strategy (SPS) as compared with case navigation (NAV) among adolescents aged 12 to 18 years of age who present to the ED with acute suicidal ideation (SI) or suicide risk behaviours (SRB). We will recruit 128 participants and compare psychiatric symptoms including SI/SRB, family communication, and functional impairment at baseline and follow-ups (post-intervention [6 weeks], 24 weeks). The primary outcome is change in suicidal ideation measured with the Suicide Ideation Questionnaire- Junior. SRBs are measured with the Suicide Behaviour Questionnaire. Secondary outcomes are change in depressive and anxious symptoms measured with semi-structured psychiatric interview and Screen for Child Anxiety Related Disorders; acute mental health crises measured by urgent medical (including ED) visits; family communication measured with Conflict Behaviour Questionnaire, functional impairment measured by Columbia Impairment Scale; cost effectiveness, and fidelity of implementation measured by audio recording and fidelity checklist.DiscussionResults of this study will inform a larger multi-centre RCT that will include both community and academic hospitals in urban and rural settings. Study results will be shared at international psychiatry and emergency medicine meetings, in local rounds, and via publication in academic journals and clinician-oriented newsletters. If effective, the intervention may provide a brief, scalable, and transportable treatment program that may be implemented in a variety of settings, including those in which access to children's mental health care services is challenging.Trial registrationClinicalTrials.gov: NCT03488602, retrospectively registered April 4, 2018.
| S-EPMC6961291 | biostudies-literature
Project description:OBJECTIVE::We estimate associations between emergency department (ED) diagnoses and suicide among youth to guide ED care. METHOD::This ED-based case-control study used data from the Office of the Chief Coroner and all EDs in Ontario, Canada. Cases ( n = 697 males and n = 327 females) were aged 10 to 25 years who died by suicide in Ontario between April 2003 and March 2014, with an ED contact in the year before their death. Same-aged ED-based controls were selected during this time frame. Crude and adjusted odds ratios (aORs) and 95% confidence intervals were calculated. RESULTS::Among youth diagnosed with a mental health problem at their most recent ED contact (41.9% cases, 5% controls), suicide was elevated among nonfatal self-inflicted: 'other' injuries, including hanging, strangulation, and suffocation in both sexes (aORs > 14); cut/pierce injuries in males (aOR > 5); poisonings in both sexes (aORs > 2.2); and mood and psychotic disorders in males (aORs > 1.7). Among those remaining, 'undetermined' injuries and poisonings in both sexes (aORs > 5), 'unintentional' poisonings in males (aOR = 2.1), and assault in both sexes (aORs > 1.8) were significant. At least half of cases had ED contact within 106 days. CONCLUSIONS::The results highlight the need for timely identification and treatment of mental health problems. Among those with an identified mental health problem, important targets for suicide prevention efforts are youth with self-harm and males with mood and psychotic disorders. Among others, youth with unintentional poisonings, undetermined events, and assaults should raise concern.
| S-EPMC6405805 | biostudies-other
Project description:Importance:Emergency departments (EDs) have the potential to play a pivotal role in suicide risk detection and prevention, yet little is known about the profile of risk of suicide after ED visits in the United States. Objectives:To examine 1-year incidence of suicide and other mortality among ED patients who presented with nonfatal deliberate self-harm, suicidal ideation, or any other chief concern, and to examine sociodemographic and clinical factors associated with suicide mortality risk. Design, Setting, and Participants:This retrospective cohort study included statewide, all-payer, longitudinally linked ED patient records and mortality data from all California residents who presented to a California-licensed ED at least 1 time from January 1, 2009, to December 31, 2011, with deliberate self-harm, suicidal ideation but not self-harm, or neither (a 5% random sample). Age-, sex-, and race/ethnicity-adjusted standardized mortality ratios (SMRs) for suicide and other manners or causes of death were determined for each patient group using statewide mortality data. Data were analyzed from January 10 to July 18, 2019. Main Outcomes and Measures:Suicide and other manners or causes of death were ascertained using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Suicide rate and all mortality rates were measured per 100?000 person-years. Results:Among 648?646 individuals (mean [SD] age, 43.8 [20.6] years; 350?687 [54.1%] women) who visited an ED in California from 2009 to 2011, the rates of suicide deaths per 100?000 person-years in the year after index ED presentation were 693.4 deaths among 83?507 individuals presenting with deliberate self-harm (SMR, 56.8; 95% CI, 52.1-61.4), 384.5 deaths among 67?379 individuals presenting with suicidal ideation but not self-harm (SMR, 31.4; 95% CI, 27.5-35.2), and 23.4 deaths among 497?760 reference patients (SMR, 1.9; 95% CI, 1.6-2.3). Compared with the demographically matched general population, the rates of nonsuicide external-cause mortality were also increased among patients with self-harm (SMR, 14.2; 95% CI, 12.9-15.5), patients with suicidal ideation (SMR, 11.8; 95% CI, 10.6-13.0), and reference patients (SMR, 2.2; 95% CI, 2.0-2.3). In all 3 groups, the rates of suicide mortality per 100?000 person-years were higher among men (deliberate self-harm: 1011.1 deaths; suicidal ideation: 539.8 deaths; reference: 36.6 deaths), people 65 years or older (deliberate self-harm: 1919.5 deaths; suicidal ideation: 691.2 deaths; reference: 28.6 deaths), and non-Hispanic white patients (deliberate self-harm: 914.1 deaths; suicidal ideation: 511.6 deaths; reference: 33.8 deaths) than among their respective referent groups. Other sociodemographic factors and clinical diagnoses were associated with striking differences in suicide rates, but these patterns were heterogeneous across patient groups. Conclusions and Relevance:These findings suggest that ED patients with deliberate self-harm or suicidal ideation are associated with substantially increased risk of suicide and other mortality during the year after ED presentation. The process of planning for ED discharge may present opportunities to help ensure safe transitions to continuing outpatient mental health care and to consider broader risk for unintentional injury and other causes of premature mortality.
| S-EPMC6991205 | biostudies-literature
Project description:IntroductionThe 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).MethodsA 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.ResultsAcross 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.ConclusionsUniversal 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 registrationEmergency Department Safety Assessmentand Follow-up Evaluation (ED-SAFE) ClinicalTrials.gov: (NCT01150994). https://clinicaltrials.gov/ct2/show/NCT01150994?term=ED-SAFE&rank=1.
| S-EPMC4801719 | biostudies-literature
Project description:Prevention of diabetes poses significant challenges; especially when applied as public health intervention. While several trials, most importantly Diabetes Prevention Program, show that intensive lifestyle modification leading to weight loss is the most important intervention, many individuals and some populations may show resistance to these interventions. Roadblocks to lifestyle intervention alone or in combination include: age, some ethnic groups (e.g., south Asians), genetic make-up, and some characteristics of body phenotype. Recent data show that non-alcoholic fatty liver disease along with insulin resistance may constitute 'metabolically unhealthy phenotype'. These subgroups would need more intensive interventions to convert prediabetes to normal glucose regulation. Whether 'fatty pancreas' and sarcopenia, latter more often seen in Asian Indians and with advancing age, are other phenotypes requiring intensive and different interventions (e.g., more resistance exercise in latter) remains to be researched. Further, variations in dietary quality (Mediterranean diet enriched with extra virgin olive oil, high-protein diets) without changing much of calories, provide attractive options for intervention. Many of such innovations require more research. Translation of lessons from diabetes prevention studies to general population is daunting but possible. However, such community-based interventions need substantial human and material resources, which pose hurdles in underserved populations and developing countries. In such situations, low-cost modalities, for example, use of trained community educators and digital and social media, constitute attractive approaches.
| S-EPMC6125020 | biostudies-literature
Project description:BackgroundAccording to the Centers for Disease Control and Prevention, suicidality and suicidal behavior among youth continues to increase significantly each year. Many of those who die by suicide interact with health services in the year before death. This systematic review sought to identify and describe empirically tested screening tools for suicidality in youth presenting to Emergency Departments (ED).Objective(1) To identify and compare existing tools used to screen for suicidality in children and adolescents who present to the ED and (2) to ascertain the prevalence of suicidality in pediatric populations found with these tools.MethodsWe searched Ovid Medline, CINAHL, Scopus, and Cochrane databases for primary research studies that identified and evaluated screening tools for suicide risk in pediatric ED patients. A total of 7,597 publications published before August 25, 2021 met search criteria and were screened by two independent reviewers based on our inclusion and exclusion criteria, with any conflicts resolved via consensus meetings or an independent reviewer. A total of 110 papers were selected for full text review, of which 67 were excluded upon further inspection. Covidence was used to extract and synthesize results.Results43 articles were eligible for inclusion. Most studies (n = 33) took place in general pediatric EDs; the quality was generally high. Patients ranged from 4-24 years old, with most screening tested in patients 12 years and older. The most researched tools were the Ask-Suicide Screening Questions (ASQ) (n = 15), Columbia-Suicide Severity Rating Scale (C-SSRS) (n = 12), Suicidal Ideation Questionnaire (SIQ) (n = 11), and the Risk of Suicide Questionnaire (RSQ) (n = 7). Where screening was applied to all patients, about one-fifth of pediatric ED patients screened positive; where suicide screening was applied to psychiatric patients only, over half screened positive. Positive screens were more likely to be female and older than negative screens and they were more likely to be assessed and admitted.ConclusionSeveral validated screening tools exist for the purpose of screening pediatric populations in EDs for suicidality. Such tools may help to support early detection and appropriate intervention for youth at risk of suicide.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=276328, identifier: 276328.
| S-EPMC9314735 | biostudies-literature
Project description:Controversy surrounds the linkage of prevention counseling with emergency department (ED)-based HIV testing. Further, the effectiveness and feasibility of prevention counseling in the ED setting is unknown. We investigate these issues by conducting a preliminarily exploration of several related aspects of our ED's HIV prevention counseling and testing program.Our urban, academic ED provides formal client-centered prevention counseling in conjunction with HIV testing. Five descriptive, exploratory observations were conducted, involving surveys and analysis of electronic medical records and programmatic data focused on (1) patient perception and feasibility of prevention counseling in the ED, (2) patient perceptions of the need to link prevention counseling with testing, and (3) potential effectiveness of providing prevention counseling in conjunction with ED-based HIV testing.Of 110 ED patients surveyed after prevention counseling and testing, 98% believed privacy was adequate, and 97% reported that their questions were answered. Patients stated that counseling would lead to improved health (80%), behavioral changes (72%), follow-up testing (77%), and discussion with partners (74%). However, 89% would accept testing without counseling, 32% were willing to seek counseling elsewhere, and 26% preferred not to receive the counseling. Correct responses to a 16-question knowledge quiz increased by 1.6 after counseling (95% confidence interval 1.3 to 12.0). The program completed counseling for 97% of patients tested; however, 6% of patients had difficulty recalling the encounter and 13% denied received testing. Among patients undergoing repeated testing, there was no consistent change in self-reported risk behaviors.Participants in the ED prevention counseling and testing program considered counseling acceptable and useful, though not required. Given adequate resources, prevention counseling can be provided in the ED, but it is unlikely that all patients benefit.
| S-EPMC3690122 | biostudies-literature