Improve coding practices for patients in suicidal crisis

"No Abnormality Detected": A Mixed-Methods Examination of Emergency Department Coding Practices for People in Suicidal Crisis

BACKGROUND

Accurate identification of suicidal crisis presentations to emergency departments (EDs) can lead to timely mental health support, improve patient experience, and support evaluations of suicide prevention initiatives. Poor coding practices within EDs are preventing appropriate patient care. Aims of the study are (1) examine the current suicide-related coding practices, (2) identify the factors that contribute to staff decision-making and patients receiving the incorrect code or no code.

METHOD

A mixed-methods study was conducted. Quantitative data were collated from six EDs across Merseyside and Cheshire, United Kingdom from 2019 to 2021. Attendances were analyzed if they had a presenting complaint, chief complaint, or primary diagnosis code related to suicidal crisis, suicidal ideation, self-harm or suicide attempt. Semi-structured interviews were conducted with staff holding various ED positions (n = 23).

RESULTS

A total of 15,411 suicidal crisis and self-harm presentations were analyzed. Of these, 21.8% were coded as 'depressive disorder' and 3.8% as 'anxiety disorder'. Absence of an appropriate suicidal crisis code resulted in staff coding presentations as 'no abnormality detected' (23.6%) or leaving the code blank (18.4%). The use of other physical injury codes such as 'wound forearm', 'head injury' were common. Qualitative analyses elucidated potential causes of inappropriate coding, such as resource constraints and problems with the recording process.

CONCLUSION

People attending EDs in suicidal crisis were not given a code that represented the chief presentation. Improved ED coding practices related to suicidal crisis could result in considerable benefits for patients and more effective targeting of resources and interventions.

Factors Influencing Emergency Department Staff Decision-Making for People Attending in Suicidal Crisis: A Systematic Review

BACKGROUND

Emergency department (ED) staff are often the first point of contact for individuals in suicidal crisis. Despite this, there is no published research systematically examining the factors influencing decision-making for this patient group.

METHODS

MedLine, CINAHL, PsycINFO, Web of Science and Cochrane Library databases were searched for three key concepts: (1) suicide, (2) accident and emergency department and (3) decision-making. Three reviewers screened titles, abstracts and full papers independently against the eligibility criteria. Data synthesis was achieved by extracting and analyzing study characteristics and findings. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of included studies.

RESULTS

Seventeen studies met the eligibility criteria and were included in this systematic review. Studies were published from 2004 to 2020 and were of good methodological quality. A number of patient (method of self-harm, age, gender), contextual (availability of services and staff) and staff-related factors (attitudes, training, knowledge) were reported to influence decision-making for patients in suicidal crisis presenting to EDs.

CONCLUSION

Decision-making in the ED is complex and is influenced by patient, contextual and staff-related factors. These decisions can have an impact on the future care and clinical pathways of patients in suicidal crisis. Additional training is needed for ED staff specifically related to suicide prevention.

Staff perspectives of emergency department pathways for people attending in suicidal crisis: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: Emergency departments (ED) are key settings to support and manage suicidal crisis; thus, ED staff are often the first point of contact for people in suicidal crisis. Despite this, some ED staff receive little training and/or education on how to best support such patients.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Previous research focuses on one staffing role (e.g. triage nurses) whereas this paper includes staff working across the ED pathway. Administrative staff have often been excluded from research, despite representing a key part of the clinical pathway and being a person's initial contact with the ED. Overall findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. Staff also perceive there to be a negative ED culture, which often leads to poor attitudes towards suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention. Findings build upon previous research to highlight key challenges different staff face along the clinical pathway and the implications this can have on a patient's journey and follow-up care provided. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Findings are of particular importance and relevance to ED managers, and more broadly NHS England. Negative ED culture, poor staff attitudes and confidence can have a detrimental impact on both staff health and wellbeing, as well as a patient's journey throughout the ED, resulting in repeat presentations and absconding as appropriate support is not received. Policymakers need to consider staff burnout and lack of resources in mental health care strategies, and training programmes should be developed to improve culture and confidence among ED staff and managers to improve care for people attending EDs in suicidal crisis.

ABSTRACT

INTRODUCTION: Emergency departments (EDs) are often the first point of contact for people in suicidal crisis. Yet, previous work has tended to focus on only one type of staffing role, failing to account for different staff perspectives along the clinical pathway.

AIMS

To explore and synthesise the perspectives of ED administrative (i.e. receptionists), medical (triage nurses) and mental health staff (liaison psychiatrists) working with people presenting in suicidal crisis.

METHOD

Qualitative study guided by thematic analysis of semi-structured interviews with 23 ED staff across six EDs in Cheshire and Merseyside, England.

RESULTS

Findings demonstrate that staff experience a lack of confidence, training and burnout due to regularly supporting people in suicidal crisis. The main challenges reported are an increase in working pressures, unavailability of resources and staff retention.

DISCUSSION

Staff felt unequipped to deal with suicide-related presentations. Organisational support is perceived to be lacking, with increased staffing pressures and poor service availability. This lack of support was linked to job dissatisfaction.

IMPLICATIONS FOR PRACTICE

Findings are of particular relevance to individual EDs and NHS England. Addressing the challenges staff are reporting can have positive implications for staff wellbeing, as well as a patient's experience and journey throughout the ED.

Children and Young People Presenting in a Pediatric Emergency Department in North-West England in Suicidal Crisis: An Exploratory Case Series Study

Suicide is a leading cause of death among children and young people (CYP) worldwide, and rates have been increasing in recent years. However, while evidence exists regarding factors associated with suicide and self-harm, there is limited information publicly available on the CYP who present in suicidal crisis. This is a case series study of CYP (aged 8-16) experiencing suicidal crisis who presented in an Emergency Department at a pediatric hospital in North-West England between March 2019 and March 2021 (n = 240). Clinical records were extracted and audited to explore demographic data, methods of recording patient attendance, the clinical pathways available and the patterns of pathway usage, and differences in CYP presentations before and after the COVID-19 pandemic. Attendees were mostly White females, with a mean age of 13.5 years, and 24% had a diagnosed special educational need. "Social/social problems" was the most commonly used code for recording attendance (38%), and pathways varied depending on code used. A range of parental and familial factors were also identified. There were more CYP presenting with self-harm in addition to suicide ideation after the pandemic began (43 vs 27% pre-pandemic). This study provides the first clear insight into CYP who seek help at a North-West Emergency Department for suicidal crisis, and work is now needed to develop effective prevention strategies tailored toward the groups most at-risk.