Suicide Prevention Intervention in the Emergency Department

Lack of Mental Treatment and Support
Introduction and Overview
Emergency departments (EDs) can play a major role in reducing the risk and occurrence of suicide, self-harm and harm caused to others by taking steps to create a safety plan for the patient (Stanley et al., 2018). However, many EDs do very little to actually assist patients in this regard. My own experience at Legacy Treatment Center, where I interned, allowed me to see as much. Legacy is in Lee County’s Screening Center for Mental Health Crisis and is located inside Main St Hospital, and patients from all over the county are processed through the Emergency Room. At Legacy, patients will be screened using the Columbia Assessment to see whether they are currently suicidal, homicidal or a danger to others. However, these patients are not offered counseling services. Instead, they are referred or voluntarily or involuntarily committed. The lack of any other treatment is a problem because as Olfson, Marcus and Bridge (2013) point out, “each year in the United States, roughly two-thirds of a million patients present to emergency departments for the treatment of deliberate self-harm” (p. 1442). These patients are, moreover, at an elevated and very high risk of suicide (Cooper et al., 2005). Yet at Legacy and many other EDs, there is no follow up, and some clients return once a week and still need to be evaluated. By not providing them with treatment other than resources for them to access on their own, it leaves a huge gap in mental health services for the community. Clients are brought to the hospital via the police, ambulance, referred from the school district, nursing homes or come as walk-ins. The ER becomes a revolving door and clients are treated for chief complaints and not for the underlining problem. The issue is relevant to social work because there is a need to address the underlying concerns of this population so that the revolving door situation can be overcome and the individuals can improve their lives.
Background/History
The issue of individuals not receiving proper care at the ER has emerged as a concern for social work in recent years; however, the issue was present as far back as the 1970s when Groner (1978) published his study and provided description of an existing program for others to understand. However, in more recent years there has been more emphasis on the need for a solution-based intervention to be used in EDs instead of simply passing these patients along without treating them (Kondrat & Teater, 2012). The target population for this intervention is thus the ER population presenting with issues of self-harm or suicide or who may present as a threat to others. Past initiatives have focused on providing assessments like the Columbia Assessment but more needs to done in terms of follow-up (Stanley et al., 2018). In terms of multicultural practice issues, social workers always need to possess cultural competence when dealing with individuals because no two people are going to be the same, and everyone has a unique background, set of experiences, beliefs and culture that should be understood before attempting to treat the person. Leininger’s transcultural model of care can be used for this purpose. The current major social and professional concern is, however, that these patients are not getting the help they need.
Individuals of this population, who come to the ER and are assessed to be at risk for self-harm, should receive extra care and special treatment because of the fact that they are at higher risk for suicide than other patients. Such a risk reduction response would not be a response to to any existing regulation but rather to the lack of proper interventions in place. This is a social work safety issue that the research has exposed for this particular population. If Legacy does not address the risk by developing and implementing a strategy, it will be failing in its mission and not upholding its vision for itself and its patients.
One example of how pervasive this problem is can be seen in the fact that, currently, only approximately half of all the patients who are on Medicaid receive a mental health diagnosis before being discharged when reporting to the emergency room for self-harm (Olfson et al., 2013). This statistic essentially puts half of all health care facilities in a risky situation with regard to failing to help this population. If health care facilities and social workers are not providing these patients with the mental health assistance they require, they will be failing in their aim to provide quality care to every patient who presents to them.
Theory
The theory that best explains the issue is that provided by Burnette, Ramchand and Ayer (2015) who state that people on the front lines of health and human services can be seen as gatekeepers who can prevent suicide, self-harm or harm to others by having knowledge of the mental health issue, understanding that this conduct is preventable, being mindful of the stigma that goes around, and having he self-efficacy to intervene. The problem that care providers and social workers see is that there is not enough training in place and no tool for treatment this mental health issue in the ER. This theory influences my thinking about how to intervene to alleviate the problem in the sense that those in the ER need more training about the issue, more knowledge that suicide can be prevented, and a better tool for intervening.
Literature Review
Contributing scholars on this area tend to be operating in health care relating fields but Groner (1978) set the stage for showing the need for a proper assessment. At this point, however, researchers are looking at what more can be done than a simple assessment like what is currently used in most ERs. The lack of assessment tools is not a problem as there are numerous tools available for physicians and social workers to assess patients and predict the likelihood of future suicidal behavior. There is the Columbia Suicide Severity Rating Scale (C-SSRS), the Patient Safety Plan Template, and the Safety Plan Treatment Manual to Reduce Suicide Risk. The overall aim that researchers say should be sought is to improve access to mental health assessments that provide help for these patients in the emergency department (Olfson et al., 2013). Three strategies for improving that access are:
1. training emergency department staff to provide mental health evaluations and give acute management of patients at risk for self-harm (Appleby et al., 2000)
2. providing access for these patients to mental health specialists (Callaghan, Eales, Coates & Bowers, 2003)
3. integrating the services of mental health professionals into the emergency department (Browne et al., 2011).
Each of these strategies is viable, as Olfson et al. (2013) point out. Training emergency department staff to provide mental health assessments and give acute care for self-harm is not beyond the capacity and ability of emergency department staff to handle. Tools to assist in that process have already been developed, as stated above. Likewise, as Callaghan et al. (2003) point out, offering a liaison service to mental health specialists would also be feasible and well within the mandate of emergency room staff to provide. Or there is the option of simply integrating mental health services into the emergency department’s own services, though the practicality of this step would hinge upon budgetary issues and constraints (Browne et al., 2011).
The empirical literature describes the problem, issue and social work intervention by backing up the intervention that will be discussed. With roughly 660,000 people presenting to ERs in the US for self harm each year, there is a major need for an intervention beyond the Columbia Assessment (Olfson et al., 2013). Because only half of those receive an appropriate diagnosis before they leave, the problem is one that needs attention now (Olfson et al., 2013). Additionally, 80% of persons who commit suicide presented themselves to the emergency room for self-harm issues at some point in the year prior to their suicide (Chaterjee, 2018). This indicates an intervention is desperately needed now.
Interventions
Past initiatives have focused mainly on giving an assessment like the Columbia Assessment, which is what is done at the Legacy clinic. However, more needs to be done for these patients than that: they need to be supported as they sign up for counseling and get involved in therapy. Leaving them to themselves only makes it all the more likely that they will commit suicide, harm themselves or harm someone else in the future.
As Stanley et al. (2018) point out, emergency department staff can be trained to provide a quick suicide prevention intervention to patients presenting to the emergency room for suicide-related issues. Doing so can both reduce the risk of suicide and improve the quality of care that these patients receive in the emergency department (Stanley et al., 2018). Training can be provided to staff on how to conduct a suicide prevention intervention for patients presenting to the ED for self-harm concerns. The intervention that the hospital staff should provide is the Safety Planning Intervention, which Stanley et al., (2018) tested and found to be significantly helpful in reducing the risk of suicide and enhancing the quality of care provided these patients. Once trained in how to provide the Safety Planning Intervention, staff should implement it for every patient who presents in the ED for suicide-related problems.
Legacy should implement this simple strategy for assisting patients who present to the emergency room for self-harm related issues. The staff can be trained to provide the patient with the Safety Planning Intervention, the purpose of which is to help patients “who are experiencing suicidal ideation with a specific set of concrete strategies to use in order to decrease the risk of suicidal behavior” (Safety Planning Intervention, 2019). Stanley et al. developed the intervention and tested it on 1,200 patients at five different VA hospitals across the U.S. (Stanley et al., 2018). One of the strengths of the Intervention is its brevity: it does not require a great deal of time to conduct and the patient senses the helpfulness of it immediately.
The strategy of using the Safety Planning Intervention can be implemented easily in approximately 30 minutes. It is a collaborative exercise between the patient and the care provider. The first step is to work with the patient to identify the warning signs that a suicidal crisis is about to strike. The second step is to work with the patient to identify the patient’s own coping strategies. The third step is to contact others to assist in distracting from the suicidal thoughts. The fourth step is contact the support network (family or friends) who can help to bring the crisis to a resolution. The fifth step is contact mental health services. The final step is to remove or reduce the means available for accomplishing suicide. This is the essence of the Safety Planning Intervention (Stanley et al., 2018). With a little basic training, every care provider in the ED could provide this intervention. The intervention can be paired with follow-up phone contact post-discharge within 72 hours of discharge. During the phone contact, the care provider encourages the patient to make an appointment with a long-term mental health services provider. Phone contact continues until the patient has been for two appointments with a mental health services provider such as a therapist or counselor. At the point, the intervention is concluded (Stanley et al., 2018).
Policy
The policies that are important to understand in relationship to the issue are those regarding the principles of 1) respect for persons, 2) beneficence, and 3) justice as described in the Belmont Report (1979). The principle of respect for persons focuses on the autonomy of the individual. People are to be treated with courtesy and respect. They are not to be used in experiments like lab rats or deceived into participating in an experiment for which they did not give their informed consent. The crucial tenet of this principle of beneficence is to “do no harm.” So long as the care provider or social worker avails himself of this important tenet, the intervention will be conducted appropriately. The principle of justice refers to the need of the care provider or social worker to make certain that processes are conducted fairly and without bias, and that no one patient receives more benefit than another. No one should be taken advantage of or exploited; processes should be carefully thought out so that they can be rationally justified.
The Belmont Report was used to influence the way people go about researching in the field of health and social or psychological sciences; however, it applies equally well to the issue of social work intervention and the creation of new programs. There should be no bias in terms of program implementations. There should be instead respect shown for all persons so that no patient receives an intervention he does not consent to; there should be a policy principle of doing no harm to anyone employed throughout; and there should be justice and fairness shown to all involved.
In social work services, it is important for justice especially to be shown because people who are afflicted with mental health issues often are afraid of being diagnosed because of the stigma that goes along with carrying a mental health label. There are taboos and stigmas attached to schizophrenia, for instance, and some people act as though schizophrenia were contagious or that it is something that means a person can no longer have a normal life, when just the opposite is true. Individuals with schizophrenia can absolutely go on to have normal, healthy, fully-functioning lives so long as they take the appropriate steps to confront their illness and address it.
These are the types of issues that have to be addressed at the policy level of social work intervention. The fact that there currently are no existing policies involving treatment or follow-up support interventions of the nature recommended by Stanley et al. (2018) shows that more work needs to be done on the policy front. As Jackson (2019) points out, “it is imperative for social workers to move out of their comfort zones and ask the hard questions: First, ‘Have you been thinking about suicide?’ And, if the answer is affirmative, ‘Have you developed a plan for how to end your life?’ And finally, ‘Do you have access to lethal means?” (p. 8). Joe and Niedermeier (2008) likewise point out that “suicide is a serious health problem that is in need of evidence-based treatments and preventative interventions” (p. 528). If ERs do not address this issue by more thoroughly developing an appropriate policy for intervention that respects the person, focuses on beneficence, and promotes justice, the problem is only going to worsen.
As Stanley et al. (2018) have shown, their intervention does help to reduce the risk of suicide for patients who present to ERs with mental health issues. Their intervention should thus become a staple of ER policy and intervention. Training can be conducted in a simple manner, according to the developers of the intervention. The training steps are:
1. reading the safety plan manual by Stanley et al. (2018),
2. reviewing the brief instructions and the safety planning form;
3. attending a training in which the intervention, its rationale and evidence base are described; and
4. conducting role-plays to practice implementing the intervention (Safety Planning Intervention, 2019).
The resources needed for this training are the safety plan manual, which can be obtained from http://www.suicidesafetyplan.com/Training.html. A training room and practice intervention session will be required in which trainees get to role play implementing and receiving the intervention. This is a form of simulation that gives the care providers extra assistance in learning how to conduct the intervention. The trainer, presumably the head nurse or instructor nurse at the ED, or social work leader, will require the rationale and evidence base provided by Stanley et al. (2018) to assist with the instruction phase of the training.
To measure the effectiveness of this policy, a statistical percentage of patient-suicide rate should be obtained similar to what Stanley et al. (2018) did for their longitudinal study when they tested their intervention on 1200 patients over the course of several years following the intervention to see what the success rate was based upon the decrease in suicide rates per patients who received the intervention. Data would be analyzed by conducting a simple percentage analysis and comparing it to the baseline and trend line that existed prior to the intervention.
Conclusions
The risk of suicide for patients presenting at the ED is one that has received attention recently by researchers, particularly Stanley et al. (2018). Patients who visit the ED but fail to receive the care they require should not be discounted by the hospital but rather should be considered as they are an example of the type of population most vulnerable to death and therefore most in need of assistance. If the statistics indicate that there is a national problem in the area, then it is more than apparent that it is a risk that needs to be addressed. Part of quality care is preventive medicine and the intervention proposed by Stanley et al. (2018) is an excellent example of preventive care that a risk manager should be able to identify and recommend as a suitable intervention. Too many patients who present with mental health problems are not receiving the type of intervention and quality care they require—not there or anywhere nationally. Thus, in order to help reduce the risk of suicide for these patients, an intervention is needed that will be preventive in nature and facilitative in practice. An appropriate intervention to use with respect to this issue would be the Safety Planning Intervention developed and tested by Stanley et al. (2018).
References
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Belmont Report. (1979). Ethical Principles and Guidelines for the Protection of Human
Subjects of Research The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. Department of Health, Education, and Welfare. Retrieved from https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html
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