More than Suicide: Mortality after Emergency Psychiatric Care and Implications for Practice

Anticipating Patient Safety Events in Psychiatric Care

OBJECTIVES

Although suicide prevention often dominates patient safety efforts in psychiatry and behavioral health, patients who seek such services are also prone to other kinds of adverse events. The purpose of this study was to more fully characterize the types of safety events that occur in the context of psychiatric care.

METHODS

This was a retrospective study of safety events that had been reported to a hospital-based psychiatry department during a 4-year period. The authors reviewed each incident, developed new and more precise event categories, and assigned each report to a category. Events that could not be categorized were assigned to an "Other" category. The percentages of categorizable events between the new and old frameworks were compared.

RESULTS

A total of 366 reports were filed. In the updated framework, 324 events (89%) could be categorized compared to 225 (61%) in the original registry.

CONCLUSIONS

Understanding the kinds of safety events that clinicians are likely to encounter in the context of psychiatric care may help to expand patient safety efforts beyond suicide risk prevention.

A Mortality Surveillance Collaboration Between a Health System and Public Health Department

We describe a collaboration between a health system and public health department to create a mortality surveillance system. The collaboration enabled the health system to identify more than six times the number of deaths identified through local system medical records alone. This powerful epidemiological process, combining the nuanced data captured through clinical care in health systems with subsequent data on mortality, drives quality improvement, scientific research, and epidemiology that can be of particular benefit to underserved communities. (Am J Public Health. 2023;113(9):943-946. https://doi.org/10.2105/AJPH.2023.307335).

Use of an Agitation Measure to Screen for Suicide and Self-Harm Risk Among Emergency Department Patients

BACKGROUND

Suicidality alone is insensitive to suicide risk among emergency department (ED) patients.

OBJECTIVE

We describe the performance of adding an objective assessment of agitation to a suicide screening instrument for predicting suicide and self-harm after an ED encounter.

METHODS

We tested the performance of a novel screener combining the presence of suicidality or agitation for predicting suicide within 90 days or a repeat ED visit for self-harm within 30 days using retrospective data from all patients seen in an urban safety net ED over 27 months. Patients were assessed for suicidality using the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener and for agitation using either the Behavioral Activity Rating Scale or Richmond Agitation Sedation Scale. We hypothesized that a screener based on the presence of either suicidality or agitation would be more sensitive to suicide risk than the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener alone. The screener's performance is described, and multivariable regression evaluates the correlations between screening and outcomes.

RESULTS

The sample comprised 16,467 patients seen in the ED who had available suicide screening and agitation data. Thirteen patients (0.08%) died by suicide within 90 days after ED discharge. The sensitivity and specificity of the screener combining suicidality and agitation for predicting suicide was 0.69 (95% confidence interval, 0.44-0.94) and 0.74 (0.44-0.94), respectively. The sensitivity and specificity for agitation combined with positive suicide screening for self-harm within 30 days were 0.95 (0.89-1.00) and 0.73 (0.73-0.74). For both outcomes, augmenting the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener with a measure of agitation improved both sensitivity and overall performance compared to historical performance of the Columbia-Suicide Severity Rating Scale-Clinical Practice Screener alone.

CONCLUSIONS

Combining a brief objective measure of agitation with a common suicide screening instrument improved sensitivity and predictive performance for suicide and self-harm risk after ED discharge. These findings speak to the importance of assessing agitation not only for imminent safety risk during the patient encounter but also for reducing the likelihood of future adverse events. This work can improve the detection and management of suicide risk in emergency settings.