Suicide Attempts and Completions in the ED in VA Hospitals
Suicide Attempts and Completions in the ED in VA Hospitals
Background This is the first study of suicide attempts and completions in the emergency department (ED) in a large national medical system.
Methods All root cause analysis (RCA) reports completed of suicides and suicide attempts that occurred in ED in the Veterans Health Administration between 1 December 1999 and 31 December 2009 were reviewed. The method, location, anchor point for hanging and implement for cutting as well as the root causes were categorised.
Results Ten per cent of all RCA reports of suicides and suicide attempts that occur within the hospital occur in the ED. Hanging, cutting and strangulation were the most common methods. The most common anchor point for hanging was doors, and the most common implement for cutting was a razor blade. In eight of the 10 cases of cutting, the implement was brought into the ED. The most common root causes were problems communicating risk and being short-staffed.
Conclusions Based on these results the following recommendations are made for helping to reduce suicide attempts in the ED: (1) use a systematic protocol and checklist to review mental health holding areas periodically in the ED for suicidal hazards; (2) develop and implement specialised protocols for suicidal patients that include continuous observation when possible; (3) conduct thorough contraband searches with suicidal patients; (4) designate specialised holding areas, when practically possible, for suicidal patients that are free of anchor points for hanging, sharps and medications, and medical equipment; and are isolated from exits to reduce the risk of elopement.
Suicide is the eleventh leading cause of death in the USA, resulting in the deaths of over 32 000 people each year. In 2003 the American Psychiatric Association reported that approximately 1500 suicides take place within hospital facilities in the USA each year, and one third of these take place while the patient is on 15-min checks. Dong et al found an inpatient suicide rate of 269 suicides per 100 000 psychiatric admissions in Hong Kong, while Shapiro and Waltzer reported rates of between five and 80 per 100000 psychiatric admissions in the USA. A Joint Commission on Hospital Accreditation review of inpatient suicides in the USA found that 75% involved hanging and another 20% resulted from patients jumping from a roof or window. Other studies of inpatient suicides include patients who committed suicide while on pass or eloping from the hospital so it is difficult to discern the specific environment in which patients committed suicide; however, all report hanging and jumping to be the most common methods. A recent study of inpatient suicides in Veterans Affairs (VA) hospitals also found that hanging was the most common method of inpatient suicide in VA hospitals (accounting for 43% of all inpatient suicides) and that doors and wardrobe cabinets accounted for 41% of the anchor points used when hanging was the method of self-harm.
Suicide is of particular concern within the Department of Veterans Affairs. Lambert and Fowler have noted an increased prevalence among veterans of the common risk factors for suicide including male gender, age over 65 years, poor physical health, mental illness, poor social support and firearm availability. Although it is difficult to count completed suicides accurately in the USA, and methodologies differ for estimating the suicide rate among veterans, Kaplan et al reported that veterans are twice as likely as non-veterans to take their own lives.
In 2005, in the USA 372722 people were treated in emergency departments (ED) for self-harm; however, there are few studies of suicides or suicide attempts that occur in ED. Mahal et al conducted a retrospective chart review of 145 patients involuntarily admitted as a 'danger to self'. The authors concluded that many important risk factors for suicide are not documented as part of the initial ED assessment; for example, current suicidal ideation, plan, history of attempts and hopelessness were documented in less than 70% of all cases. Buzan and Weisburg report that all states have statutes permitting detention by physicians of self-destructive patients and recommend one-on-one observation, removal of potentially lethal objects such as scissors, and prevention from jumping to death or hanging once a careful assessment has revealed suicidal intent. Finally, the joint commission recently reported that 8.02% of all inpatient suicides reported to the sentinel event database in the USA occur in the ED.
Whereas other studies have described the specific characteristics of patients who have committed suicide while in the hospital, or analysed environmental factors relevant to inpatient suicides or suicide attempts, this study describes suicide attempts in the ED and identifies environmental hazards associated with increased suicide risk in this setting. It is our perspective that studying specific types of adverse events can lead to systematic safety improvements in medicine.
Abstract and Introduction
Abstract
Background This is the first study of suicide attempts and completions in the emergency department (ED) in a large national medical system.
Methods All root cause analysis (RCA) reports completed of suicides and suicide attempts that occurred in ED in the Veterans Health Administration between 1 December 1999 and 31 December 2009 were reviewed. The method, location, anchor point for hanging and implement for cutting as well as the root causes were categorised.
Results Ten per cent of all RCA reports of suicides and suicide attempts that occur within the hospital occur in the ED. Hanging, cutting and strangulation were the most common methods. The most common anchor point for hanging was doors, and the most common implement for cutting was a razor blade. In eight of the 10 cases of cutting, the implement was brought into the ED. The most common root causes were problems communicating risk and being short-staffed.
Conclusions Based on these results the following recommendations are made for helping to reduce suicide attempts in the ED: (1) use a systematic protocol and checklist to review mental health holding areas periodically in the ED for suicidal hazards; (2) develop and implement specialised protocols for suicidal patients that include continuous observation when possible; (3) conduct thorough contraband searches with suicidal patients; (4) designate specialised holding areas, when practically possible, for suicidal patients that are free of anchor points for hanging, sharps and medications, and medical equipment; and are isolated from exits to reduce the risk of elopement.
Introduction
Suicide is the eleventh leading cause of death in the USA, resulting in the deaths of over 32 000 people each year. In 2003 the American Psychiatric Association reported that approximately 1500 suicides take place within hospital facilities in the USA each year, and one third of these take place while the patient is on 15-min checks. Dong et al found an inpatient suicide rate of 269 suicides per 100 000 psychiatric admissions in Hong Kong, while Shapiro and Waltzer reported rates of between five and 80 per 100000 psychiatric admissions in the USA. A Joint Commission on Hospital Accreditation review of inpatient suicides in the USA found that 75% involved hanging and another 20% resulted from patients jumping from a roof or window. Other studies of inpatient suicides include patients who committed suicide while on pass or eloping from the hospital so it is difficult to discern the specific environment in which patients committed suicide; however, all report hanging and jumping to be the most common methods. A recent study of inpatient suicides in Veterans Affairs (VA) hospitals also found that hanging was the most common method of inpatient suicide in VA hospitals (accounting for 43% of all inpatient suicides) and that doors and wardrobe cabinets accounted for 41% of the anchor points used when hanging was the method of self-harm.
Suicide is of particular concern within the Department of Veterans Affairs. Lambert and Fowler have noted an increased prevalence among veterans of the common risk factors for suicide including male gender, age over 65 years, poor physical health, mental illness, poor social support and firearm availability. Although it is difficult to count completed suicides accurately in the USA, and methodologies differ for estimating the suicide rate among veterans, Kaplan et al reported that veterans are twice as likely as non-veterans to take their own lives.
In 2005, in the USA 372722 people were treated in emergency departments (ED) for self-harm; however, there are few studies of suicides or suicide attempts that occur in ED. Mahal et al conducted a retrospective chart review of 145 patients involuntarily admitted as a 'danger to self'. The authors concluded that many important risk factors for suicide are not documented as part of the initial ED assessment; for example, current suicidal ideation, plan, history of attempts and hopelessness were documented in less than 70% of all cases. Buzan and Weisburg report that all states have statutes permitting detention by physicians of self-destructive patients and recommend one-on-one observation, removal of potentially lethal objects such as scissors, and prevention from jumping to death or hanging once a careful assessment has revealed suicidal intent. Finally, the joint commission recently reported that 8.02% of all inpatient suicides reported to the sentinel event database in the USA occur in the ED.
Whereas other studies have described the specific characteristics of patients who have committed suicide while in the hospital, or analysed environmental factors relevant to inpatient suicides or suicide attempts, this study describes suicide attempts in the ED and identifies environmental hazards associated with increased suicide risk in this setting. It is our perspective that studying specific types of adverse events can lead to systematic safety improvements in medicine.