The assessment of suicide risk in the general hospital

Availability, content and quality of local guidelines for the assessment of suicide attempters in university and general hospitals in the Netherlands

OBJECTIVE

This study was performed to investigate the availability, content and quality of local guidelines for the assessment of suicide attempters in the Netherlands.

METHOD

All university and general hospitals in the Netherlands were asked to provide their local guidelines. Published national guidelines and the Appraisal of Guidelines for Research and Education (AGREE) instrument were used to evaluate the content and quality of the local guidelines.

RESULTS

Eighty-eight hospitals (90.7%) responded; 34 (38.6%) reported that they used local guidelines. Twenty-seven guidelines were submitted for evaluation. Most of the guidelines were more than 5 years old and had not been updated recently. The contents of the guidelines differed. Criteria addressing patient safety, staff attitude toward patients, reassessment of nonalert patients, relevant stressors, involvement of significant others and aftercare were found in less than 50% of the guidelines. Although psychiatric consultation was incorporated in almost 80%, the psychiatrist's tasks were specified infrequently. The guidelines seldom required monitoring of staff compliance. Only in the AGREE domain "clarity and presentation" was the mean score above 60% of the maximum. According to the instructions for the AGREE instrument, 10 (37.0%) of the 27 guidelines were recommended (with provisos or alterations) and 1 was strongly recommended for use in practice.

CONCLUSIONS

In the Netherlands, a minority of hospitals reported use of local guidelines for the assessment of suicide attempters. When available, the guidelines were mostly not based on international standards, their contents varied greatly and their quality was unsatisfactory.

Adverse events during a placebo phase for inpatients with chronic schizophrenia

BACKGROUND

This report builds on a previous analysis examining the long-term effects of a placebo period on a group of inpatients with chronic schizophrenia. In the present analysis, outcome was evaluated through the use of the Psychiatric Adverse Events Rating Scale.

METHODS

This retrospective analysis examined adverse events for 55 patients with chronic schizophrenia who were placed in a double-blind placebo study on the inpatient units of the National Institute of Mental Health Neuropsychiatric Research Hospital. The number and severity of adverse events experienced by these patients during baseline, placebo, and discharge periods were analyzed.

RESULTS

The frequency and severity of adverse events for this group of patients were modest. Most patients did not experience a statistically significant increase in adverse events during their placebo phase; however, a subgroup of patients who were hospitalized for less than 2 months after antipsychotic medications were restored did experience a statistical elevation in adverse events, and that frequency remained statistically elevated at discharge.

CONCLUSIONS

The results confirm the findings from our previous analysis. Regardless of whether outcome is measured by a behavioral rating scale or by an adverse event scale, given a sufficiently lengthy recovery period, patients with chronic schizophrenia who go through a placebo phase return to baseline.

Constant observation practices in the general hospital setting: a national survey

The authors conducted a national survey of 355 general medical/surgical hospitals to assess constant observation (CO) practices. The authors assessed overall use, expense, staffing patterns, funding strategies, and cost-saving interventions. Virtually all responding hospitals (N = 102) reported using some form of CO. Several hospitals reported significant decreases in CO expenditures after the implementation of cost-saving interventions (the largest annual decrease reported was $340,000). Cost-saving interventions included utilizing consolidated bed spaces, relocating patients near nursing stations, placing at-risk patients in bed enclosure devices, and regularly assisting patients to the toilet. In addition, less costly personnel were hired, and volunteers and/or patient family members provided CO (or were required to assist with the cost of CO). Finally, hospital staff were educated about the costs and the appropriate use of CO. They were also taught to recognize and effectively treat delirium.

Suicide attempters in a psychiatric emergency room population

OBJECTIVE

The aim of this study was to describe the characteristics of psychiatric emergencies when the precipitating event for the emergency room visit was a suicide attempt, compared with other reasons for admission.

METHOD

For 1 year, all consultations (N = 1438) of a psychiatric emergency service were documented in a detailed questionnaire covering sociodemographic and diagnostic data as well as information about the consultation and the disposition decision. In 163 consultations, deliberate self-harm with possible fatal outcome was the precipitating event. In order to control for diagnosis, all emergency consultations with an adjustment disorder were analyzed in a second step (N = 366). In this subgroup, deliberate self-harm was the precipitating event in 78 cases.

RESULTS

Compared with the other emergencies, the suicide attempters were better integrated in the occupational as well as in private life. They were more often referred by others, and significant others such as relatives and friends were more frequently involved in the consultation. Nevertheless, the suicide attempters were significantly more often hospitalized. By and large, the same results were found when analyzing the consultations with adjustment disorders only. However, within a ligh-risk subgroup of suicide attempters, no differences with regard to disposition decision were found.

CONCLUSION

Clinicians should not automatically refer suicide attempters for inpatient treatment, particularly in low-risk patients and when the suicidal intent and the lethality of the suicidal act are not too threatening. Residents should be instructed more thoroughly in suicidology before being assigned to the emergency room.

Suicide: risk factors and therapeutic considerations in the emergency department

Emergency physicians often encounter covertly and overtly suicidal patients, and can thus play a key role in the prevention of suicide. The epidemiology and diverse presentations of suicidal behavior are reviewed. We then provide a detailed approach to the assessment of suicide risk, and criteria for safe discharge from the emergency department (ED). Finally, management considerations for the ED are discussed.

The use of constant observation in general hospitals

This study reports data describing a population of general hospital patients whose behavioral management required the use of constant observation (CO). In this retrospective chart review, the mean number of days of CO per patient was 3.8, with a median of 2.0 and a standard deviation of 14.8. The longest number of days of CO was twenty-four. The types of patients placed on CO included medically complicated suicide attempters, male trauma patients with personality disorder and substance abuse, elderly patients with delirium, patients in delirium tremens, and medical patients with concurrent severe psychiatric disorders. The majority of patients on CO had no psychiatric history. The clinical data presented provide a basis for policy development, as well as recommendations for financial and medicolegal management of this population.