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.

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.

OBJECTIVES: The objective was to describe self-harm assessment practices in U.S. emergency departments (EDs) and to identify predictors of being assessed. METHODS: This was a prospective observational cohort study of adults presenting to eight U.S. EDs. A convenience sample of adults presenting to the EDs during covered research shifts was entered into a study log. Self-harm assessment was defined as ED documentation of suicide attempt; suicidal ideation; or nonsuicidal self-injury thoughts, behaviors, or both. Institution characteristics were compared relative to percentage assessed. To identify predictive patient characteristics, multivariable generalized linear models were created controlling for weekend presentation, time of presentation, age, sex, and race and ethnicity. RESULTS: Among 94,354 charts, self-harm assessment ranged from 3.5% to 31%, except for one outlying site at 95%. Overall, 26% were assessed (11% excluding the outlying site). Current self-harm was present in 2.7% of charts. Sites with specific self-harm assessment policies had higher assessment rates. In the complete model, adjusted risk ratios (aRR) for assessment included age >/= 65 years (0.56, 95% confidence interval [CI] = 0.35 to 0.92) and male sex (1.17, 95% CI = 1.10 to 1.26). There was an interaction between these variables in the smaller model (excluding outlying site), with males < 65 years of age being more likely to be assessed (aRR = 1.14, 95% CI = 1.02 to 1.37). CONCLUSIONS: Emergency department assessment of self-harm was highly variable among institutions. Presence of specific assessment policies was associated with higher assessment rates. Assessment varied based upon patient characteristics. The identification of self-harm in 2.7% of ED patients indicates that a substantial proportion of current risk of self-harm may go unidentified, particularly in certain patient groups.

BACKGROUND: We sought to examine the knowledge, attitudes, and practices of emergency department (ED) providers concerning suicidal patient care and to identify characteristics associated with screening for suicidal ideation (SI). METHODS: Six hundred thirty-one providers at eight EDs completed a voluntary, anonymous survey (79% response rate). RESULTS: The median participant age was 35 (interquartile range: 30-44) years and 57% of the participants were females. Half (48%) were nurses and half were attending (22%) or resident (30%) physicians. More expressed confidence in SI screening skills (81-91%) than in skills to assess risk severity (64-70%), counsel patients (46-56%), or create safety plans (23-40%), with some differences between providers. Few thought mental health provider staffing was almost always sufficient (6-20%) or that suicidal patient treatment was almost always a top ED priority (15-21%). More nurses (37%, 95% confidence interval [CI] 31-42%) than physicians (7%, 95% CI 4-10%) reported screening most or all patients for SI; this difference persisted after multivariable adjustment. In multivariable analysis, other factors associated with screening most or all patients for SI were self-confidence in skills, (odds ratio [OR] 1.60, 95% CI 1.17-2.18), feeling that suicidal patient care was a top ED priority (OR 1.73, 95% CI 1.11-2.69) and 5+ postgraduate years of clinical experience (OR 2.06, 95% CI 1.03-4.13). CONCLUSIONS: ED providers reported confidence in suicide screening skills but gaps in further assessment, counseling, or referral skills. Efforts to promote better identification of suicidal patients should be accompanied by a commensurate effort to improve risk assessment and management skills, along with improved access to mental health specialists.

Objectives: The objective was to provide estimates and predictors of screening for suicide in emergency departments (EDs). Methods: Eight geographically diverse U.S. EDs each performed chart reviews of 100 randomly selected patients, ages 18 years or older, with visits in October 2009. Trained chart abstractors collected information on patient demographics, presentation, discharge diagnosis, suicide screening, and other mental health indicators. Univariate logistic regression was used to determine factors associated with suicide screening. Results: The cohort of 800 patients had a median age of 41 years (interquartile range = 27 to 53 years) with 57% female, 16% Hispanic, 58% white, 23% black or African American, and 10% other race. Suicide screenings were documented for 39 patients (4.9%; 95% confidence interval [CI] = 3.4% to 6.4%). Of those screened, 23 (2.9% of total sample; 95% CI = 1.7% to 4.0%) were positive for suicidal ideation or behavior. Approximately 90% of those screened had documented complaints of a psychiatric nature at triage. About one-third had either documentation of alcohol abuse (33%) or intentional illegal or prescription drug misuse (36%). Conclusions: The presence of known psychiatric problems and substance use had the strongest associations with suicide screening, yet even patients presenting with these indicators were not screened for suicide. Understanding factors that currently influence suicide screening in the ED will guide the design and implementation of improved suicide screening protocols and related interventions. ACADEMIC EMERGENCY MEDICINE 2012; 1-5 (c) 2012 by the Society for Academic Emergency Medicine.