As a leading cause of death in North America, suicide is an omnipresent clinical issue and the ED is the site of many encounters with suicidal patients. Those with suicidal attempts, thoughts, and intentions often present to the ED, but emergency physicians cannot predict with a high degree of sensitivity or specificity which patients will go on to die by suicide.
A prior suicide attempt is the strongest risk factor for suicide, and individuals with psychiatric illness are also much more likely to die by suicide. It is sometimes a formidable task to identify suicidal patients quickly and a much more difficult mandate to determine a course of treatment in the ED.
Managing Suicidal Patients in the Emergency Department
Betz ME, Boudreaux ED
Ann Emerg Med.
This article summarizes the best available evidence for managing suicidal patients in the ED, and includes practical recommendations where the evidence is incomplete or conflicting. Caring for ED patients with suicidal thoughts and behaviors is quite challenging, often because of time pressures, the wait for a psychiatric consultation or bed, and the inherent difficulty in predicting self-harm. These authors said not every ED patient with suicidal thoughts needs inpatient admission or even a mental health consultation.
Approximately eight percent of all adult ED patients, regardless of chief complaint, have had recent suicidal ideation, thoughts, or behavior. Unfortunately, many will not disclose them unless directly asked. The astute physician, however, can usually unravel suicidal thoughts during the initial ED evaluation.
Many emergency physicians are skeptical about the ability to prevent suicide, or they harbor biases against patients with mental illness. Overcoming these areas of discomfort is paramount. It is important to establish a sympathetic but direct approach that enhances communication and the quality of the ED assessment. Additional information from collateral sources is particularly important, including the police, the patient's family or friends, past medical records, and outpatient health care providers. The ED can contact available sources without the patient's consent to protect him or the public from an imminent or serious threat. Asking a patient about suicidal thoughts or plans does not encourage suicidal behavior, and it should be a part of the evaluation of a potentially suicidal patient.
Patients with suicidal thoughts or behavior should not be allowed to leave the ED until the evaluation is complete. They should also be protected from self-harm while in the ED, which usually includes placing them in a private room without access to an easy exit or dangerous objects, such as belts, shoelaces, and sharp instruments. Restraints are occasionally needed, but the EP should first try to calm an agitated patient with a collaborative and respectful conversation. Be sure to search for weapons in the initial evaluation and arrange for constant observation.
Physicians must also evaluate whether drugs, alcohol, or medical conditions may be affecting the patient's mental status. Mental health consultants often require laboratory testing, including toxicology screens, but routine diagnostic testing has never demonstrated a clinical benefit.
Risk assessment is an inexact and difficult science. Most suicidal patients require a formal mental health consultation, but some are low risk, such as those without a suicidal plan or intent, previous suicide attempt, history of significant mental illness or substance abuse, or agitation or irritability. The initial evaluation should include the questions in the table.
Drug testing is rarely valuable, but most clinicians order a blood alcohol level and urine drug screen. Patients who are under the influence of alcohol or drugs and express suicidal thoughts will often retract them when they are more sober. Acute and chronic alcohol use is a risk factor for suicide, and more than a third of completed suicides include alcohol use just before death.
Developing a contract for safety has been used in the past for patients who are discharged, but this has not been shown to prevent suicide and is no longer recommended. The rare suicidal patient who is discharged requires rapid outpatient follow-up, and that appointment should be made before he leaves the ED.
Numerous studies have shown an association between firearm access and completed suicides, so the discharge plan should determine if the patient has access to firearms. This access should be investigated and removed, not always an easy assignment. Guns have been shown to produce the highest fatality rate in potentially suicidal patients.
Comment: Identifying, evaluating, and managing patients with a psychiatric problem, including suicide risk, is a daunting task for any emergency physician. Suicidal patients are at risk for elopement from the ED, but the initial use of restraints is discouraged. Once placed in a room, the patient should be checked for weapons and drugs, and that room should be devoid of any potentially harmful devices, such as scalpels or needles, and not have a ready exit. Taking a patient's keys, putting him in a gown without his clothes nearby, and having someone stay in the room are common strategies. Patients often resist giving up their keys, wearing a gown, and staying in the room. I have had patients abscond from the ED in their underwear without shoes. I even had a patient climb into the ceiling to gain access to an exit and two patients who were allowed to go to the bathroom alone, then locked the door and attempted to harm themselves.
Extremely agitated, drunk, or violent patients may require medication, but the initial use of long-acting antipsychotic drugs is generally discouraged. IV lorazepam (2-4 mg) is probably the best initial treatment for agitated patients. Longer-acting drugs have been discouraged by psychiatrists because they make the patient unable to be evaluated by a consultant for a number of hours. It has recently become more common to use ketamine (1-2 mg/kg IV or 4-5 mg/kg IM) for the rapid and safe sedation of markedly agitated patients. Drugs used for treating acute psychosis, such as olanzapine or risperidone, may be required, but their long duration of action is problematic.
Physical restraints are occasionally required, but their widespread use is downplayed by most authors. EDs generally have strict guidelines on who can be restrained, and physicians must document their need and that the patient was repeatedly evaluated for their use. Restraints are often necessary to protect the hospital and patient.
The most problematic issue in evaluating a suicidal patient is the availability of a psychiatric specialist. Many hospitals simply do not have them. It is not uncommon for patients to wait for long periods to be seen, and they must be transferred in many cases. The rescue squad obviously should be told about the possibility of suicide when patients are transferred, and patients must be restrained or sedated during the transfer. Many suicidal patients, however, seek help from the ED for their life-ending thoughts or actions, and are quite cooperative and forthcoming. An individual who expresses suicidal ideation while under the influence of alcohol or drugs is particularly problematic because he often retracts his intent and is technically no longer suicidal once he is sober.
Hospitalization is a temporary fix, and admission has never been shown to prevent suicide. Often suicide is not preventable. Under ideal circumstances, patients with suicidal thoughts or actions should be evaluated by an emergency physician and a psychiatric consultant. This is not always the case, however, and occasionally it is not possible, and some patients can be discharged home with adequate safety measures. The emergency physician, however, should always err on the side of hospitalization or psychiatric consultation. I could not find any reports addressing a positive difference in final outcome for suicidal patients seen only in the ED by psychiatrists and then discharged. One study did confirm the effectiveness of a brief in-hospital educational intervention (three days) and follow-up contacts for up to 18 months after discharge that significantly reduced subsequent short-term repetition of suicide attempts. (Bull World Health Organ. 2008,86:703; https://bit.ly/2Of9k2F.) Another similar study, however, did not find a decrease in suicide at 18 months in another group undergoing in-hospital educational intervention. (Crisis. 2010;31:194.) In short, and seemingly counterintuitive, the value of a one-time psychiatric ED evaluation and the discharge of suicidal patients has never been proven to be better predictors of subsequent suicide than an emergency physician's evaluation.
Potentially suicidal patients who are discharged and then die by suicide are a medicolegal nightmare for emergency physicians who do not use psychiatric consultation. Of course, if a consultant sees the patient, the emergency physician should carefully document that the care and subsequent disposition of the patient were assumed by the consultant. Hopefully, this removes the EP from any relationship to subsequent events, which can often be disastrous. It is axiomatic that suicidal patients should never be allowed to sign out AMA, often a temptation for the frustrated ED staff.
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Dr. Robertsis a professor of emergency medicine and toxicology at the Drexel University College of Medicine in Philadelphia. Read the Procedural Pause, a blog by Dr. Roberts and his daughter, Martha Roberts, ACNP, PNP, athttp://bit.ly/EMN-ProceduralPause, and read his past columns athttp://bit.ly/EMN-InFocus.