Elsevier

Annals of Emergency Medicine

Volume 48, Issue 4, October 2006, Pages 452-458.e2
Annals of Emergency Medicine

Injury prevention/original research
Survey of California Emergency Departments About Practices for Management of Suicidal Patients and Resources Available for Their Care

https://doi.org/10.1016/j.annemergmed.2006.06.026Get rights and content

Study objective

To determine the resources available and current practices for the treatment of patients with suicidal ideation or attempts in California emergency departments (EDs).

Methods

We conducted a mail and e-mail survey of the directors of all 346 EDs in the state of California. Data collected included identification of hospital and respondent, type of hospital, presence of separate psychiatric ED, total number of ED patients and number of ED patients with suicidal ideation or attempts who were treated per week, mental health personnel on call to evaluate suicidal patients, criteria for patient disposition, available disposition options, delays in patient care, changes desired in the ED treatment of suicidal patients, and adequacy of community resources for suicidal patients.

Results

Two hundred twenty-three of 346 (64.5%) ED directors responded to the survey. Overall, the mean estimate of the proportion of ED visits by suicidal patients was 1.7%. Though evaluation of patients with suicidal ideation by a mental health professional was the usual practice, 51 respondents (23%) reported that they occasionally send patients with suicidal ideation home without such an evaluation, and 8.5% reported this was done more than 10% of the time. No single type of mental health professional, including psychiatrist, social worker, county or private psychiatric evaluation team, psychiatric nurse, or psychologist, was available for evaluation of suicidal patients in more than 50% of respondent EDs. In the majority of EDs, psychiatric evaluations were performed by either mobile county or private psychiatric evaluation teams or social workers on call to the ED. Psychiatrists were reported to evaluate the majority of suicidal patients in only 10% of EDs. Only 27% of respondents had the ability to admit patients to a psychiatric service at their hospital. When patients needed to be transferred, the estimated mean wait for these transfers was 7 hours. Seventy-one percent of respondents reported needing improved access to mental health personnel for evaluation of suicidal patients; 61% reported needing improved access to mental health personnel for patient disposition.

Conclusion

In California EDs, there are limited mental health services for suicidal patients. Regional solutions to emergency and nonemergency mental health problems are needed, including improved access to mental health personnel for ED evaluation, disposition, and follow-up of suicidal patients and community mental health resources for patient referrals.

Introduction

In the United States, suicide is ranked as the 11th leading cause of death, the 4th leading cause of death in children, and the third leading cause of death for young people aged 15 to 24 years and accounts for more than 30,000 deaths annually.1, 2, 3, 4 Every day, nearly 1,500 Americans attempt to take their own lives.4 The majority of life-threatening and medically severe suicide attempts are treated in emergency departments (EDs). Patients who survive these attempts are at risk for repeated attempts with more lethal methods.5 During the last decade, hospital EDs have shouldered an increasing proportion of mental health care as state cutbacks and declining reimbursements have forced inpatient psychiatric units to close. The lack of adequate outpatient psychiatric services, especially for uninsured and underinsured patients, has rendered EDs one of the few remaining options for psychiatric patients. A study published in 2004 provided statistical evidence of this dynamic, showing that psychiatric-related ED visits, those reflecting any of 3 common psychiatric International Classification of Diseases, Ninth Revision codes for a suicide attempt, increased 15% nationwide, from 3.7 million in 1992 to 4.3 million in 2000, representing 5.4% of all ED visits.6 In a national survey of 340 emergency physicians conducted by the American College of Emergency Physicians (ACEP), 67% of respondents said mental health services had declined in their community during the previous year, and 60% reported increase pressure on the front line, particularly because psychiatric patients consume provider attention, increase patient boarding, and force ambulance diversions.7 Similarly, a recent analysis of 12 nationally representative communities, published by the Center for Studying Health System Change,8 cites psychiatric patient volumes as part of a “convergence … of pressures” currently taxing hospital EDs, restricting access to care, and increasing health care costs, which is especially pertinent because previous research has demonstrated that follow-up mental health treatment after a suicide attempt can reduce the rate of subsequent attempts.9, 10, 11 Moreover, a previous attempt is one of the biggest risk factors for suicide completion.10, 11, 12, 13, 14 Thus, it is important that EDs be equipped with adequate personnel to effectively evaluate and discharge suicidal patients and that adequate resources for follow-up exist in the community.

Between 1997 and 2001, there were an average of 412,000 annual ED visits for suicide attempts and self-inflicted injury,15 accounting for 1% of all ED visits.16 Consequently, emergency physicians and ED staff have the responsibility of treating the medical complications from suicide attempts, as well as assessing the risk of subsequent suicide in consultation with mental health professionals.12, 17 Approximately 70% of all nonfatal self-inflicted injuries treated in the ED are the result of a suicide attempt.15 The ED is often the first point of contact with medical and mental health care for these patients.12, 15 In a study by Gairin et al18 in 2003, 39% of suicide victims visited the ED at some point in the year preceding their deaths, with more than one third of these visits for nonfatal self-harm. The ED, therefore, represents an important part of access to mental health services and could play a crucial role in suicide prevention.10, 12, 19

For suicidal and self-harming patients, the ED serves as a link to mental health treatment and community resources for suicide prevention.20 Therefore, a better understanding of the needs of services available in EDs for suicidal patients is necessary to create effective suicide surveillance and prevention programs. The purpose of this research survey was to determine the resources available and current practices for the management of patients with suicidal ideation or attempts in EDs throughout California.

Section snippets

Study Design

We conducted a mail and e-mail survey of the medical or nursing directors of all EDs in the state of California from July 7 to December 6, 2004. ED medical directors were identified from a list of California EDs supplied by the California chapter of ACEP, which in most cases included the ED medical directors’ name and address and in some cases, their e-mail address. We used the listing of California EDs supplied by the California Office of Statewide Health Planning and Development to verify

Results

Two hundred twenty-three of 346 (64.5%) ED directors responded to the survey (205 medical directors, 17 nursing directors, and, in one case, a social worker [the hospital administrator forwarded the survey to the social worker, who responded]). There are 56 counties in California. All counties have at least 1 hospital with an ED. The number of EDs per county ranges from 1 in 13 rural California counties to 80 in Los Angeles County. There were no important differences in the survey response

Limitations

The survey response rate was 65%; however, there were no significant differences between the characteristics of respondents and nonrespondents. Therefore, we believe that this survey presents a relatively accurate picture of the ED medical directors’ views of the state of emergency care of suicidal patients in California EDs. Because this was a survey limited to California EDs, the results may be unique to California and not be generalizable to the rest of the United States. Another limitation

Discussion

We found that the majority of California ED medical directors stated they needed improved access to mental health professionals for both evaluation and disposition of suicidal patients. These findings underscore the need for greater community mental health resources, especially outpatient treatment facilities and mobile psychiatric evaluation teams. They also indicate a need for increasing the role of emergency physicians and staff in evaluating and treating a subset of these patients, although

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    Supervising editor: Debra E. Houry, MD, MPH

    Author contributions: LJB and NJ conceived and designed the survey and supervised data collection. JRA obtained research funding and contributed to the design of the study. LJB provided statistical oversight and analyzed the data. NJ and LJB drafted the article, and all authors contributed substantially to its revision. LJB takes responsibility for the paper as a whole.

    Funding and support: This publication was supported in part by grant No. R49/CCR921708 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of Centers for Disease Control and Prevention.

    Reprints not available from the authors.

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