Each year, an estimated 32,000 Americans commit suicide, about 1,500 of which occur within hospital facilities in the United States. About one-third of suicides occurring in hospitals take place even though patients are being checked on every 15 minutes. “The ED has the second highest number of reported completed suicides and attempts, trailing only inpatient psychiatric units,” says Peter D. Mills, PhD, MS. “Many important risk factors—including suicidal ideation or a history of suicide attempts—are not documented as part of initial ED assessments, yet more than 300,000 people are treated in EDs for self-harm each year. Understanding more about methods of suicides and attempts and the factors contributing to these events is an important initial step in eliminating these preventable adverse events.”
Characterizing Suicides in the ED
Previous studies have explored specific patient characteristics for those who have committed suicide while in the hospital, while others have looked at environmental factors relating to inpatient suicides and attempts. Few studies, however, describe suicide attempts in the ED and identify environmental hazards that increase suicide risk in this setting. In a 10-year study, Dr. Mills and colleagues conducted a retrospective review of all root-cause analysis reports of suicide attempts or completions in the VA healthcare system. Published in the May 2012 Emergency Medicine Journal, the study categorized the method of suicides as well as the root causes of suicides and attempts in the ED.
According to findings, about 10% of suicides and suicide attempts that occurred within the hospital happened in the ED. Hanging, cutting, and strangulation were the most common methods used for suicides and attempts (Figure 1). Doors were the most commonly used anchor points for hangings, while razor blades were the most common instruments used for cutting. Alarmingly, the implement used for cutting attempts was brought into the ED in eight of the 10 cases in the analysis.
“Problems with structural aspects of the ED can contribute to suicide attempts and completions,” says Dr. Mills. “It’s important to keep all rooms in mind—especially bathrooms—when considering how structural aspects play a role in suicides and attempts. When patients are a suicide risk, it’s important to hold them in rooms that have no unobserved interior doors, including locker or cabinet doors. The most effective way to reduce environmental hazards for hangings is to make efforts to eliminate anchor points. To reduce risks for cutting, ED personnel should consider conducting contraband searches with all potentially suicidal patients. Efforts are needed to ensure that holding rooms don’t have any sharp objects or potentially lethal equipment that can be accessed by patients.”
Root Cause of Suicides: Miscommunication
The most common root causes of suicides and attempts in the ED observed in the study were problems communicating risk and being short-staffed (Figure 2). “When critical information about level of suicide risk is lost, appropriate monitoring of patients and other safeguards may not be established during ED visits,” Dr. Mills says. “It’s easy in busy EDs to lose track of patients unless there are specific protocols to move suicidal individuals to secure holding areas that are free of anchor points for hanging, sharps, medications, and other risks. The key is to develop and implement specialized protocols for suicidal patients that include continuous observation whenever possible.”
Another strategy to reduce suicide attempts in EDs is to develop and use systematic protocols and checklists to periodically review mental health holding areas in these settings for suicidal hazards. The Mental Health Environment of Care Checklist (excel) is available here. In some cases, it may be feasible for EDs to designate specialized holding areas for suicidal patients that are both safe and removed from exits to reduce the risk of elopement.
Recent reports have shown that veterans are twice as likely as non-veterans to take their own lives. Although the study by Dr. Mills and colleagues only looked at events taking place in VA hospital EDs, he says that it is likely that lessons learned from their research can be applied to other ED systems. “Overcrowding and increasing demands on personnel are likely to continue in the ED setting,” says Dr. Mills. “As such, it’s important for EDs to be prepared for suicidal patients and make efforts to improve their approaches to reducing risk for suicide and suicide attempts.”
Readings & Resources (click to view)
Mills PD, Watts BV, DeRosier JM, et al. Suicide attempts and completions in the emergency department in Veterans Affairs hospitals. Emerg Med J. 2012;29:399-403.
Lambert MT, Fowler DR. Suicide risk factors among veterans: risk management in the changing culture of the Department of Veterans Affairs. J Ment Health Adm. 1997;24:350-358.
McCarthy JF, Valenstein M, Kim HM, et al. Suicide mortality among patients receiving care in the veterans health administration health system. Am J Epidemiol. 2009;169:1033-1038.
Mahal SK, Chee CB, Lee JC, et al. Improving the quality of suicide risk assessments in the psychiatric emergency setting: physician documentation of process indicators. J Am Osteopath Assoc. 2009;109:354-358.
Buzan RD, Weisberg MP. Suicide: risk factors and therapeutic considerations in the emergency department. J Emerg Med. 1992;10:335-343.
Mills PD, Watts BV, Miller S, et al. A checklist to identify inpatient suicide hazards in Veterans Affairs hospitals. Jt Comm J Qual Patient Saf. 2010;36:87-93.
Watts BV, Young-Xu Y, Mills PD, et al. An examination of the effectiveness of a mental health environment of care checklist in reducing suicide on inpatient mental health units. Arch Gen Psychiatry. 2012;69:588-592.