ED Suicides: More Vigilance, Less Boarding

Screening, faster access to care needed.

January 2011

By Jennie Smith
Elsevier Global Medical News

More than a decade after issuing its first report on suicides in hospitals, the Joint Commission has followed up with a new one, reminding clinicians that suicides and suicide attempts can occur anywhere - not just in psychiatric units.

But emergency physicians say that suicides in nonpsychiatric units are part of a broader and more difficult problem to solve: a lack of appropriate care for psychiatric patients that forces other units - particularly emergency departments - to hold these patients in environments not designed for their safety.

Since 1995, the commission wrote, there have been 827 reports of patient suicides, 14% of which occurred in nonpsychiatric settings, more than half of these in emergency departments. The 827 cases represented only those voluntarily reported, the commission noted, and therefore is likely an undercount.

The suicides occurred in bathrooms, bedrooms, closets, showers, or just after patients left the hospital against medical advice. Patients hung, shot, lacerated, or asphyxiated themselves, jumped from high places, or ingested drugs. A number of suicides were carried out using materials immediately available in the hospital - bell cords, bandages, sheets, plastic bags, or elastic tubing.

Many patients who attempt suicide in hospitals are at unknown risk for suicide, and often lack a known psychiatric history, the commission noted, recommending in its report a number of measures that hospitals can take to become more vigilant about prevention. These measures include intensifying screening of new patients, having volunteer or family "sitters" assigned to at-risk patients, improving communication during handoffs, and empowering staff to take preemptive actions.

Dr. Sandra M. Schneider, attending physician at Strong Memorial Hospital in Rochester, N.Y., and current president of the American College of Emergency Physicians, said she welcomed the Joint Commission report as a "wake-up call" to provide more intensive screening to identify at-risk patients without psychiatric histories, including people who have had a recent stroke or heart attack and who can suddenly and temporarily be vulnerable to suicidal thoughts.

However, better screening can solve only part of the problem. "Many hospitals are boarding or holding psychiatric patients until a bed becomes available," said Dr. Schneider in an interview. "The bigger problem is access to timely care of these patients, and the ED is just not the best environment for them."

Dr. David J. Mendelson, an emergency physician and vice president of Medical Affairs for EmCare Inc. in Dallas, agreed. "I have nothing against the recommendations to better equip the doctors and staff to screen the patients," Dr. Mendelson said in an interview. "We do that anyway, though it's not formalized." Nonetheless, he said, the Joint Commission findings "do not address the core problem."

Dr. Mendelson was the lead author of a 2008 survey for the American College of Emergency Physicians on the problem of psychiatric boarding, a perennial issue in EDs.

Of the survey's 328 respondents - all ED physicians and most of them ED directors or department chairs - 79% said psychiatric patients were boarded in their EDs, with a third of the patients boarded for 6 hours or more; 62% said these patients received no psychiatric services while they were being boarded. Since 2008, Dr. Mendelson said, the problem seems to have only gotten worse, "probably because of the economy and because we're seeing fewer patients in EDs with any sort of insurance at all."

A new nationwide survey of 603 hospital ED administrators by the Schumacher Group found that 56% of EDs are often unable to transfer mental/behavioral patients to inpatient facilities in a timely manner, and 30% are sometimes unable to do so. Only 3% reported always being able to transfer mental/behavioral patients in a timely manner. Boarding times of 12 hours or less were reported by 29% of EDs, 30% said the longest they boarded these patients was 24 hours, 20% reported waits of as long as 2 days, 11% had boarded them for up to 5 days, and 10% had boarded mental/behavioral patients for more than a week.

"The mental health problem in America is being swept under the rug for hospital emergency departments to deal with," Dr. William Schumacher, CEO of the Schumacher Group, said in a statement.

Dr. Schneider said that the process of finding a bed for a psychiatric patient can take days, and that "even though we take great precautions, the emergency department does not have a protected environment for patients who might be interested in committing suicide." Once, she said, "we had a patient who tried to commit suicide by drinking the hand sanitizer. What are we supposed to do? Can we really get rid of the hand sanitizer?"

The American College of Emergency Physicians has published several policy papers in recent years addressing the issue of psychiatric patients presenting to emergency departments in lieu of a psychiatric care facility. Dr. Mendelson said that solving the suicide problem is partly a matter of resources, and that until these problems can be solved, "the fact that there are bad things happening" is not a surprise. "We need more money, especially more federal money, to deal with this," he said.

Dr. Schneider said that her hospital is fortunate to have a psychiatric department adjacent to its emergency department, social workers who screen every patient over age 70 - older male patients are at highest risk for suicide - and a psychiatric resident available much of the time. Most hospitals "would not have a psychiatrist or psychiatric nurse on duty and would not have immediate access to a psychiatric bed," she said. "But even we will hold these patients in the ED weekends or nights," she said.

Some of the ways Dr. Schneider and her team keep patients safe in the meantime, she said, involve "colored clothes and footies" that indicate to staff and guards an at-risk patient. Staff take evaluations from the friends of young patients who might not be candid about suicidal feelings. And any input from a paramedic with concerns about the state of a patient's home is taken seriously.

The important thing, she said, is that all members of the emergency department team are empowered to act. "In emergency medicine, we believe everyone on the team can push the button. Anyone can come to the physician or nurse and say, 'I'm worried about the patient in room 120.' This is a team sport."

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