By Stacey Kusterbeck
EDs continue to face a surge of patients who express suicidal ideation, and not all those patients are going to be admitted to an inpatient psychiatric facility. For all the suicidal patients who are discharged from the ED, there is the potential for legal exposure. The challenge for leaders is how to assess all these high-risk patients. “In the ED, everything has to be super-brief, because ED providers do not have a lot of time,” notes Gregory K. Brown, PhD, a research associate professor of clinical psychology in the department of psychiatry at the University of Pennsylvania.
In a randomized clinical trial conducted across eight EDs, Brown and colleagues analyzed a process improvement designed to reduce suicide-related behaviors.1 Researchers analyzed 2,761 ED encounters (25 patients per month at each ED who screened positive on a validated suicide risk tool from 2014 to 2018). Six months after discharge from the ED, nine patients had died by suicide and 538 recorded an acute healthcare visit related to suicide.
Investigators noted much less suicidal ideation after the EDs implemented changes in suicide prevention-related practices. This included personalized safety planning for those patients at risk for committing suicide who were discharged home.
Safety planning is a suicide prevention intervention that is designed to be administered in the ED or acute care setting. The process typically takes 30 to 45 minutes. “In the ED, they just don’t have that kind of time. In some large-volume EDs, they may have multiple suicidal patients waiting to be seen,” Brown reports.
Leaders can identify champions who are trained to conduct the intervention, such as social workers. Those designated individuals also can coordinate follow-up care for suicidal patients. “We try to do the intervention so it dovetails with the workflow in the ED,” Brown says. Some EDs conduct the narrative part of the intervention earlier in the visit, and the latter part when patients are closer to discharge.
Even with these approaches in place, the emergency setting still poses some unique challenges for suicide risk assessment. “If somebody comes in with a broken leg, you fix the leg. If somebody comes in with a suicide attempt, you can’t fix the attempt because it’s already happened. You can’t necessarily fix the ideation because it may be ongoing. So how do you fix something that’s down the lane, to prevent a future attempt?” Brown asks.
This is not necessarily seen as within the purview of the ED to address, since it is not something that can be resolved during the visit. “A lot of ED providers don’t feel well-trained to work with suicidal people. They would rather defer to a mental health professional to provide the intervention,” Brown adds.
Each department is unique regarding how staff manage suicidal patients, based on factors such as the level of consultation or psychiatric services that are available. “For EDs, the first thing is to be open to doing the intervention. The second thing is to be open to different ways of providing the intervention,” Brown offers.
Many individuals at risk for suicide are treated in EDs. “But their risk goes undetected. Moreover, even when detected, they often do not receive evidence-based care,” says Edwin D. Boudreaux, PhD, the study’s lead author and a professor in the departments of emergency medicine, psychiatry, and population and quantitative health sciences at the University of Massachusetts Chan Medical School. Some suicidal patients do not even undergo a mental health evaluation. “Most do not receive personalized safety planning, which is a best practice for suicide prevention,” Boudreaux says.
Brown, Boudreaux, and colleagues determined it was possible to alleviate post-visit suicidal behavior through improving both the detection of suicide risk and the delivery of evidence-based care. This should occur as part of routine care delivery across a range of geographically and demographically diverse EDs. The study team recognized system-based change would be challenging in emergency settings. “But the effort to deploy process improvements took even more time and effort than expected,” Boudreaux reports.
Thus, improvements in suicide-related outcomes were slow to develop. To succeed in this endeavor, EDs must plan carefully.
“EDs will need to build a multidisciplinary implementation team to review their current care delivery, build improved protocols, deploy those protocols, adjust them iteratively over time to work out the kinks, and install methods for sustaining the effort long-term,” Boudreaux advises.
Boudreaux says that with sufficient motivation, EDs can improve the quality of care provided to individuals at risk for committing suicide. “It is challenging, but it is feasible,” Boudreaux offers. “If done properly, it can result in a decrease in suicidal behavior post-visit.”
REFERENCE
1. Boudreaux ED, Larkin C, Vallejo Sefair A, et al. Effect of an emergency department process improvement package on suicide prevention: The ED-SAFE 2 cluster randomized clinical trial. JAMA Psychiatry 2023; May 17:e231304. doi: 10.1001/jamapsychiatry.2023.1304. [Online ahead of print].
EDs will need to build a multidisciplinary implementation team to review their current care delivery, build improved protocols, deploy those protocols, adjust them iteratively over time to work out the kinks, and install methods for sustaining the effort long-term.
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