Impact of Around-the-Clock Mental Health Staffing on Emergency Department Management of Patients Who Deliberately Self-Harm
Abstract
Objective:
Emergency departments (EDs) offer opportunities to deliver critical frontline suicide prevention services via assessment, safety planning, and linkages with community-based mental health care after discharge. Because mental health crises can occur at any time, this study sought to evaluate whether around-the-clock mental health staffing in the ED influences the likelihood of providing these evidence-based mental health services.
Methods:
ED nursing leadership from a national sample of 406 hospitals completed a survey on the ED management of patients who deliberately self-harm, including availability of mental health staff (psychiatrists, psychiatric nurses, psychologists, social workers, other mental health professionals). Analyses examined whether around-the-clock mental health staffing was associated with provision of key assessments, safety planning, and discharge practices, controlling for hospital characteristics.
Results:
There were no significant differences in the extent to which EDs with and without around-the-clock mental health staff routinely completed recommended assessment practices (71% and 70%, respectively). EDs with around-the-clock mental health staff were more likely than their counterparts to routinely provide two recommended safety planning practices (59% vs. 27%, p<0.001; adjusted odds ratio [AOR]=3.76) and were more likely to routinely schedule follow-up outpatient care (44% vs. 21%, p=0.002; AOR=3.26).
Conclusions:
Around-the-clock mental health coverage in the ED is associated with routine provision of key safety planning and discharge practices. EDs should have consistent access to staff either in person or remotely to facilitate the delivery of evidence-based mental health practices.
HIGHLIGHTS
•
A majority of emergency departments, with and without around-the-clock mental health care staff, reported routinely completing recommended assessment practices.
•
Emergency departments with around-the-clock mental health care coverage were significantly more likely than their counterparts to routinely provide several key safety planning practices and to schedule follow-up outpatient care for patients who deliberately self-harm.
•
Emergency departments should consider providing around-the-clock, evidence-based in-person or telehealth mental health care to address the needs of patients who present with deliberate self-harm.
In 2018, more than 48,000 Americans died by suicide (1). Because almost a quarter of adults who die by suicide have a deliberate self-harm (DSH) visit to an emergency department (ED) in the year preceding their suicide (2), EDs have the opportunity to deliver critical frontline suicide prevention services by helping to ensure short-term safety and by coordinating with outpatient mental health care. Best practices for ED management of patients who deliberately self-harm include three key components: assessment, safety planning, and linkages with outpatient care. These components can help detect subsequent risk of suicide (3), decrease the risk of repeat DSH (4), and provide access to mental health services during the high-risk periods after discharge and beyond (5). However, recent evidence suggests that these evidence-based practices are not routinely implemented in EDs (6, 7).
An analysis of Medicaid claims data found that fewer than half of discharged patients who deliberately self-harm received a mental health assessment in the ED, and almost half did not attend a follow-up outpatient mental health visit in the month following their ED discharge (6). A recent survey of ED leadership reported that only 15.3% of EDs routinely implement safety planning (7), which is a brief behavioral intervention that involves limiting access to lethal means, teaching coping skills, identifying a social and emergency network, and building motivation for continuing mental health treatment (4).
Previous research has found that, in general, ED patients are at risk for less efficient care during the evenings and on weekends. For example, medical patients admitted to the ED after standard hours or on weekends experience longer waits, longer hospital stays (8), delayed care, and greater risk of complications (9). A statewide survey found that during overnights and weekends, 43% of ED directors reported more problems, and 64.8% reported adverse clinical outcomes due to an absence of timely specialist coverage (10). Patients with psychiatric concerns, including DSH, who receive care during evenings or weekends may also be likely to experience psychiatric boarding in the ED (11), which puts them at risk for lower quality of care (12), missed medications, and adverse events (13). The goal of this study was to examine whether around-the-clock mental health staffing coverage in the ED is associated with the routine provision of evidence-based mental health care for patients who deliberately self-harm.
Methods
Study Design and Sample
National Medicaid claims data from the Centers for Medicare and Medicaid Services (14) were used to identify hospitals with five or more self-harm visits in 2012. Self-harm was defined as an act of nonfatal self-poisoning or self-injury with or without suicidal intent (ICD-9: E950–E959) (15). From the sampling frame, a nationally representative random sample of 665 hospitals was selected and sent surveys assessing the ED management of DSH between May 2017 and January 2018. Before we initiated recruitment, hospitals were called and operators or ED desk staff were asked for the name of the ED nursing director; in instances where this information was not provided, correspondence was addressed to “Current Nursing Director.” Nursing directors were selected to receive the surveys because, in addition to providing clinical care, they manage the nonmedical elements of patient visits and likely have knowledge of typical unit policies, practices, and staffing structure.
Survey recruitment included introductory phone calls, mailed and e-mailed copies of the survey, and follow-up calls and e-mails, yielding a 77% response rate (N=513). Hospitals with psychiatric EDs distinct from their medical EDs, which are typically staffed by mental health providers around the clock, were excluded from the study sample, yielding a final sample of 406 respondents. Although nursing leadership contributed to the majority (N=319, 78%) of completed surveys, not all surveys were completed by nursing directors. The breakdown of respondents was as follows: 61% (N=248) were ED nursing directors or managers; 19% (N=77) included more than one individual in the ED (e.g., nursing director and social worker; of these instances, a majority included nursing leadership); 8% (N=31) identified as “other,” such as registered nurses or behavioral health directors; 7% (N=29) were unknown (i.e., did not indicate their position); 3% (N=13) were social workers; and 2% (N=8) were medical directors. This research was approved by the institutional review board at the University of Pennsylvania.
Measures
Availability of mental health staff.
Respondents were asked, “During which times are the following personnel or their trainees available in person or remotely (telehealth) to evaluate the mental health of patients in your ED?” For this study, psychiatrist (adult or child), psychiatric nurse, psychologist, social worker, and other mental health professional were all considered mental health staff. Their availability was examined individually and then as a group. Responses included “during standard weekday hours,” “after standard weekday hours,” “on weekends,” and “none of these times.” Hospital EDs that had mental health staff available during standard weekday hours, after standard weekday hours, and on weekends were considered to have “mental health staff at all times.” The remaining combinations were considered to be “without mental health staff at all times.”
Assessment, safety planning, and discharge practices.
The survey included a series of questions focused on the EDs provision of patient assessment, safety planning, and discharge planning. The questions were based on components of the Safety Planning Intervention (SPI), a brief behavioral intervention consisting primarily of simple educational material that was designated as a best practice by the Suicide Prevention Resource Center and the American Foundation for Suicide Prevention (16–18). Respondents were asked how often patients who deliberately self-harm were assessed on current suicidal intent or plans, past suicidal thoughts or behaviors, and access to means (e.g., firearms or medications) needed to attempt suicide.
Next, safety planning practices were assessed with questions about how often, before discharge, patients are helped to recognize warning signs preceding a suicidal crisis, helped to learn strategies that take their mind off problems, helped to identify social activities that distract from their problems, helped to identify family members or friends whom they can ask for help, provided with a list of professionals or agencies that they can contact in a crisis, and helped to develop an individualized plan to make their home safer with regard to lethal methods.
Finally, to examine discharge practices, respondents were asked how often a follow-up outpatient appointment is scheduled before a patient who presented with deliberate self-harm is discharged from the ED. Response choices for all of the questions included “on a routine basis,” “usually but not routinely,” “sometimes,” or “never or rarely.” Practices were considered to be routine only if a respondent selected “on a routine basis”; these responses were compared with the remaining responses collectively considered to be “not routine.” In addition to the individual assessment and safety planning items, we also created two summary items to examine routine provision of all three assessment practices and all six safety planning practices.
Hospital characteristics.
The 2016 American Hospital Association annual survey was used to characterize the hospitals in our study (19). Specifically, we included patient volume as low (<23,000), medium (23,000–64,000), and high (>64,000) on the basis of estimated total annual hospital census; urbanicity (urban vs. rural); teaching status (teaching vs. nonteaching); and ownership (private not for profit, private for profit, and public/government). The geographic distribution of the responding hospitals was as follows: 39% (N=160) from the South, 39% (N=158) from the Midwest, 11% (N=46) from the Northeast, and 10% (N=42) from the West.
Data Analysis
We first described the proportion of EDs with any mental health staff and specific subspecialty mental health staff (e.g., psychiatric nurse, social worker) available at all times. Next, we examined whether hospitals that provide mental health staff coverage all the time differed from hospitals that did not on the basis of volume, urbanicity, teaching status, and ownership. Stratified rates of full-time staffing were calculated for these hospital characteristics. Adjusted odds ratios (AORs), controlling for all hospital characteristics, were calculated in a logistic regression model to assess the strength of association between the hospital characteristics and full-time staffing practices. Finally, we examined routine provision of each component of each assessment, safety planning, and discharge practice at EDs with and without mental health staff at all times by using chi-squares to compare the proportions. A series of adjusted logistic regression models were used to produce odds ratios to evaluate the strength of the associations between having mental health staff at all times and routine provision of each evidence-based practice, controlling for relevant hospital characteristics. All analyses included survey weights to account for nonresponse and a sampling design that selected hospitals proportionate to their volume of patients who self-harm. Statistical analyses were conducted using SAS, version 9.4.
Results
More than three-quarters of hospitals (N=329, 79%) reported having any type of mental health staff coverage (psychiatrist, psychiatric nurse, psychologist, social worker, or other mental health professional) all of the time (Table 1). In descending order of frequency, hospital EDs had the following mental health staff all of the time: other mental health professional (45%), social worker (43%), adult psychiatrist (27%), psychiatric nurse (24%), child psychiatrist (17%), and psychologist (10%).
| Specialist group | N | Weighted %b | 95% CI |
|---|---|---|---|
| Any mental health specialistc | 329 | 79.3 | 74.2–84.4 |
| Adult psychiatrist | 123 | 26.5 | 21.3–31.7 |
| Child psychiatrist | 71 | 16.7 | 12.3–21.1 |
| Psychiatric nurse | 127 | 23.9 | 19.0–28.8 |
| Psychologist | 46 | 10.2 | 6.6–13.7 |
| Social worker | 185 | 43.4 | 37.3–49.5 |
| Other mental health professional | 181 | 45.2 | 39.0–51.3 |
a
Availability “all of the time” includes standard weekday hours, after standard weekday hours, and weekend hours.
b
Analyses included survey weights to accommodate sampling design that selected hospitals proportionate to their volume of patients who self-harm.
c
Any mental health specialist includes psychiatrists, psychiatric nurses, psychologists, social workers, and other mental health professionals.
Table 2 illustrates relationships between mental health staffing coverage and hospital characteristics. Among hospitals with mental health staff all the time, more than half were medium-volume, urban, nonteaching, and private not-for-profit hospitals. Hospital EDs with and without mental health staff at all times did not significantly differ with respect to any of their background hospital characteristics.
| Weighted % of EDs with mental health staffing | Weighted % of EDs without mental health staffing | Rate of mental health staffing coverage all the time | ||||||
|---|---|---|---|---|---|---|---|---|
| Characteristic | coverage all the timea | coverage all the timea | p | % | 95% CI | AORb | 95% CI | p |
| Volume based on admissions per year (reference: low volume) | .57 | |||||||
| Low volume (<23,000) | 26.8 | 35.6 | 74.3 | 62.4–86.1 | ||||
| Medium volume (23,000–64,000) | 51.6 | 45.6 | 81.2 | 74.8–87.6 | 1.32 | .57–3.06 | .55 | |
| High volume (>64,000) | 21.6 | 18.8 | 81.4 | 71.8–91.0 | 1.18 | .41–3.36 | .95 | |
| Urbanicity (reference: urban) | .45 | |||||||
| Urban | 72.9 | 67.2 | 75.8 | 65.2–86.5 | ||||
| Rural | 27.1 | 32.8 | 80.5 | 74.7–86.2 | .97 | .43–2.16 | .94 | |
| Teaching status (reference: nonteaching) | .17 | |||||||
| Teaching hospital | 39.8 | 30.0 | 83.4 | 76.8–90.1 | 1.40 | .68–2.92 | .36 | |
| Nonteaching hospital | 60.2 | 69.9 | 76.6 | 69.4–83.7 | ||||
| Ownership (reference: private not for profit) | .81 | |||||||
| Private not for profit | 76.1 | 73.2 | 79.8 | 73.8–85.8 | ||||
| Private for profit | 14.7 | 14.6 | 79.2 | 66.7–91.8 | 1.01 | .42–2.46 | .82 | |
| Public/government | 9.2 | 12.2 | 74.2 | 58.1–90.3 | .82 | .32–2.16 | .69 | |
a
Analyses included survey weights to accommodate sampling design that selected hospitals proportionate to their volume of patients who self-harm.
b
Adjusted odds ratio (AOR) controls for all hospital characteristics.
As shown in Table 3, most EDs, both with and without mental health staff all the time, routinely completed all three assessment practices (71% and 70%, respectively). Controlling for relevant hospital characteristics, there were no statistically significant differences in the frequency of assessment practices between EDs with and without mental health staff all the time regarding current suicidal intent or plans (98% and 96%, respectively), past suicidal thoughts and behaviors (91% and 91%, respectively), and access to means needed to carry out the plan (77% and 74%, respectively).
| EDs with mental health staff all the time | EDs without mental health staff all the time | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Practice | Weighted %a | 95% CI | Weighted % | 95% CI | χ2 | dfb | p | AORc | 95% CI | p |
| Assessment practices | ||||||||||
| Routinely completed all assessment practices | 71.3 | 65.1–77.5 | 69.5 | 56.7–82.2 | .06 | 1, 405 | .03 | 2.57 | .87–7.62 | .09 |
| Routinely assessed current suicidal intent or plans | 98.4 | 97.1–99.7 | 96.2 | 89.0–100.0 | .33 | 1, 400 | .57 | 2.06 | .27–15.83 | .49 |
| Routinely assessed past suicidal thoughts and behaviors | 91.1 | 87.3–94.8 | 90.6 | 81.6–99.6 | .01 | 1, 397 | .92 | 1.05 | .32–3.45 | .93 |
| Routinely assessed access to means needed to attempt suicide | 76.8 | 70.8–82.7 | 73.7 | 61.2–86.3 | .18 | 1, 398 | .67 | 1.13 | .53–2.41 | .75 |
| Safety planning practices | ||||||||||
| Routinely helped patients complete all safety planning practices | 17.9 | 12.7–23.1 | 7.7 | .7–14.8 | 4.91 | 1, 405 | .03 | 2.57 | .87–7.62 | .09 |
| Routinely helped patients recognize warning signs preceding a suicidal crisis | 59.1 | 52.2–66.0 | 27.1 | 14.5–39.7 | 14.54 | 1, 376 | <.001 | 3.76 | 1.85–7.61 | <.001 |
| Routinely helped patients learn strategies that take their mind off problems | 29.7 | 23.0–36.3 | 11.0 | 2.7–19.3 | 10.01 | 1, 362 | .002 | 3.53 | 1.37–9.07 | .009 |
| Routinely helped patients identify social activities that distract from their problems | 29.2 | 22.7–35.8 | 15.1 | 4.8–25.3 | 4.89 | 1, 366 | .03 | 2.36 | .96–5.76 | .06 |
| Routinely helped patients identify family members or friends whom they can ask for help | 49.3 | 42.1–56.4 | 30.4 | 17.0–43.8 | 5.61 | 1, 373 | .02 | 2.23 | 1.10–4.53 | .03 |
| Routinely provided a list of professionals or agencies that patients can contact in a crisis | 82.9 | 77.6–88.1 | 65.0 | 51.3–78.6 | 5.34 | 1, 396 | .02 | 2.47 | 1.21–5.08 | .01 |
| Routinely helped patients develop an individualized plan to make their home safer by removing or restricting access to lethal methods | 38.2 | 31.1–45.4 | 20.2 | 8.8–31.6 | 6.36 | 1, 355 | .01 | 2.56 | 1.22–5.39 | .01 |
| Discharge practices | ||||||||||
| When patients who deliberately self-harm are discharged during standard weekday hours, a follow-up outpatient appointment is routinely scheduled before leaving the ED | 44.2 | 37.2–51.3 | 20.6 | 10.2–31.0 | 10.46 | 1, 375 | .001 | 3.26 | 1.55–6.88 | .002 |
a
Analyses included survey weights to accommodate sampling design that selected hospitals proportionate to their volume of patients who self-harm.
b
Numerator degree of freedom, denominator degree of freedom.
c
Adjusted odds ratio (AOR) controls for all hospital characteristics noted in Table 2.
In contrast, only 18% of EDs with mental health staff at all times and 8% of EDs without mental health staff at all times routinely completed all six recommended safety planning practices. After we controlled for relevant hospital characteristics, there were statistically significant differences between the groups on the following safety planning practices: recognizing warning signs preceding a suicidal crisis (59% of EDs with mental health staff at all times and 27% without; AOR=3.76, p<0.001); helping patients learn strategies that take their mind off problems (30% of EDs with mental health staff at all times and 11% without; AOR=3.53, p=0.009); helping patients identify family or friends whom they can ask for help (49% of EDs with mental health staff at all times and 30% without; AOR=2.23, p=0.030); providing a list or professionals or agencies that patients can contact in a crisis (83% of EDs with mental health staff at all times and 65% without; AOR=2.47, p=0.010); and helping patients develop an individualized plan to make their home safe, including addressing access to lethal means (38% of EDs with mental health staff at all times and 20% without; AOR=2.56, p=0.010). Finally, with regard to discharge planning, EDs with mental health staff at all times were significantly more likely than EDs without mental health staff at all times to routinely schedule follow-up outpatient appointments before patients leave the ED during standard weekday hours (44% of EDs with mental health staff at all times and 21% without; AOR=3.26, p=0.002).
Discussion
Hospital EDs with around-the-clock mental health staff were more likely than those without staff at all times to routinely implement evidence-based safety planning and discharge practices with patients who deliberately self-harm. Specifically, EDs with 24/7 mental health staff had 2–3 times the odds of EDs without mental health staff all the time to routinely engage in several recommended safety planning and discharge practices, including helping patients recognize warning signs and learn coping strategies as well as linking them with follow-up outpatient care. There were no significant differences between the two groups with respect to assessment practices.
Our findings on assessment practices, in conjunction with other research in this area, present a fairly optimistic picture that EDs routinely incorporate these evidence-based practices into clinical care. A recent statewide survey found that almost three-quarters of EDs had a written protocol for suicide risk assessment, although 53.2% did not include documentation of access to lethal means (20). Our study reported that more than 90% of all EDs (regardless of mental health staffing) routinely assessed current and past suicidal symptoms, and about three-quarters assessed access to lethal means. Thus, there may be specific areas within assessment that could benefit from additional clinical attention, such as educating clinicians about the importance of asking suicidal patients about lethal means (21) and giving them the tools to do so. For instance, the Suicide Prevention Resource Center’s free online course, CALM: Counseling on Access to Lethal Means (22), could improve routine adherence to this important aspect of assessment.
Our findings also confirm prior research suggesting that safety planning practices have not been regularly incorporated into the ED treatment of patients who deliberately self-harm (7). Some evidence-based safety planning interventions could be taught to non–mental health staff (e.g., staff nurses or aides) and implemented to address this deficit in EDs that do not have around-the-clock mental health staff coverage. For instance, the SPI (16) and ED-SAFE (Emergency Department Safety Assessment and Follow-Up Evaluation), another ED-initiated intervention that also includes telephone follow-up, have been reported to increase treatment engagement and reduce suicidal behavior (18, 23). Given that nurses without mental health training often feel ill equipped in psychiatric knowledge, assessment, and communication (24), training in SPI or ED-SAFE could help prepare ED staff to treat patients who deliberately self-harm.
Finally, there remains room for improvement in discharge practices. A comprehensive report by the American Association of Suicidology and the Suicide Prevention Resource Center on suicide attempts and deaths subsequent to discharge from EDs and inpatient psychiatric units stresses the importance of seamless, convenient, and coordinated services originating from the ED, including establishing standards for prompt outpatient care (3). Still, our study and others reveal that many patients who deliberately self-harm are discharged to the community without follow-up outpatient mental health care (6). The fact that EDs without around-the-clock mental health staffing had lower rates of referral to outpatient follow-up suggests that mental health staff may play an important role in linking patients who deliberately self-harm with postdischarge care. However, because hiring additional mental health staff may be cost prohibitive for many hospitals, EDs might consider staggering their mental health staffing coverage, perhaps by using other mental health professionals, peer supports, or telehealth to cover evening and weekend hours or by partnering with regional crisis services or local outpatient services to establish clear pathways for patients.
This study had some limitations. Although respondents were informed that all information would remain confidential and not identify them or their hospital, survey responses may have been subject to social desirability bias, and there were no objective measures available to validate responses. Additional bias may have resulted from nonresponse or incomplete responses at the survey or item level even though survey weights were used to help mitigate this issue. Because the study sample was based on EDs with five or more Medicaid-financed visits of patients who self-harm, the results may not be generalizable to hospitals that do not have a high volume of patients who deliberately self-harm or that do not accept Medicaid. Also, responses were predominantly from nursing leadership whose perspective may not reflect that of frontline nurses or other ED staff, including physicians and their trainees. In addition, it was not possible to determine whether reported services were provided directly by hospital employees, because they could have been delivered via telehealth or by an outside contractor. Furthermore, it was not possible to provide detailed information about the heterogenous group of “other mental health providers.” We also acknowledge that findings are based on perceptions (self-report) and are thus only a proxy for clinical practices rather than a true measure of outcomes. Finally, these self-report metrics may not fully measure the extent to which the services were actually provided or any variability by specific provider, level of education, or training of providers.
Conclusions
EDs remain poised as a critical partner in the care of patients who deliberately self-harm and in frontline suicide prevention efforts. Although it is encouraging that most EDs have mental health staff at all times and are engaging in recommended assessment practices with patients who deliberately self-harm, there is still room for improvement when it comes to safety planning and discharge practices. Given the unpredictable timing and nature of ED visits for DSH, it is important that EDs have staff available around the clock, either in person or remotely through the use of telehealth, to facilitate delivery of evidence-based mental health practices. Alternative solutions to hiring additional staff, such as staggered staffing or training non–mental health staff in basic evidence-based mental health practices, offer different approaches to balancing provision of optimal care with hospital staffing and financial constraints.
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Information & Authors
Information
Published In
History
Received: 28 October 2019
Revision received: 6 February 2020
Accepted: 19 March 2020
Published online: 22 May 2020
Published in print: September 01, 2020
Keywords
Authors
Competing Interests
Dr. Marcus reports receipt of consulting fees from Allergan, Alkermes, Johnson & Johnson, Sage, and Sunovion. The other authors report no financial relationships with commercial interests.
Funding Information
This research was supported by the National Institute of Mental Health grant 5R01-MH-107452 to Dr. Olfson and Dr. Marcus.
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