An investigation of clinical decisionmaking: identifying important factors in treatment planning for suicidal patients in the emergency department

Abstract

Objective We sought to evaluate the influence of several well‐documented, readily available risk factors that may influence a psychiatric consultant's decision to admit an emergency department (ED) patient reporting suicidal ideation for psychiatric hospitalization. Methods We conducted a retrospective study of adult patients presenting to six affiliated EDs within Pennsylvania from January 2015 to June 2017. We identified 533 patients reporting current active suicidal ideation and receiving a complete psychiatric consultation. Socio‐demographic characteristics, psychiatric presentation and history, and disposition were collected. Decision tree analysis was conducted with disposition as the outcome. Results Four of 27 variables emerged as most influential to decisionmaking, including psychiatric consultant determination of current suicide risk, patient age, current depressive disorder diagnosis, and patient history of physical violence. Likelihood of admission versus discharge ranged from 97% to 58%, depending on the variables considered. Post hoc analysis indicated that current suicide plan, access to means, lack of social support, and suicide attempt history were significantly associated with psychiatric consultant determination of moderate‐to‐high suicide risk, with small‐to‐medium effect sizes emerging. Conclusions Only a handful of variables drive disposition decisions for ED patients reporting current active suicidal ideation, with both high and low fidelity decisions made. Patient suicide risk, determined by considering empirically supported risk factors for suicide attempt and death, contributes the greatest influence on a psychiatric consultant's decision to admit. In line with American College of Emergency Physicians (ACEP) recommendations, this study accentuates the importance of using clinical judgment and adjunct measures to determine patient disposition within this population.

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

“…Emergency departments (EDs) play a critical role in supporting, managing and treating suicidal crisis presentations, and thus represent a key opportunity for suicide prevention and intervention (Stapelberg et al., 2020). Individuals in suicidal crisis experience significant distress, often including thoughts of death, and the more pervasive the suicidal crisis the more likely the individual is to engage in self‐harm or attempt suicide (Knorr et al., 2020). It has been estimated that 9% of the world's population will experience suicidal thoughts at some point in their lives, 30% of whom will go on to make a suicide attempt (Al‐Azri, 2020).…”

“…In sum, the number of people presenting to EDs in suicidal crisis has significantly increased over the last decade (Stapelberg et al., 2020); thus, ED staff are often the first point of contact for people in suicidal crisis. Despite this, some ED staff receive minimal psychiatric training and few opportunities for further education on the treatment and management of people presenting in suicidal emergencies (Knorr et al., 2020; Zun, 2012). Despite the stressful and demanding nature of the ED for all staff, previous research primarily focuses on one staff group (e.g.…”