Impact of Emergency Department Safety Planning on 30-Day Mental Health Service Use.

OBJECTIVE: The aim of this study was to examine the association between emergency department (ED) safety planning and subsequent use of mental health care among individuals treated in the ED for suicidal behavior and to determine whether subsequent use differed by patients' receipt of recent mental health care. METHODS: Data from 130 hospitals, derived from a 2017-2018 national hospital survey, were paired with national health insurance data from 2,328 patients with suicidal behavior treated in the EDs of these hospitals. Rates of ED readmission, inpatient admission, and outpatient mental health follow-up care in the 30 days after discharge from the index ED visit were examined. RESULTS: During the 30 days after discharge from the index visit, readmissions to the ED (18% vs. 22%) and inpatient admissions (12% vs. 15%) for suicidal behavior or other mental health issues were significantly lower among patients treated in the EDs that routinely implemented safety planning, compared with those that did not, respectively. Among patients who had not received mental health care within 30 days before the index visit, those treated in an ED implementing routine safety planning were about half as likely (adjusted risk ratio=0.60) as those treated in an ED without such planning to have an ED readmission. CONCLUSIONS: Safety planning was associated with fewer subsequent ED and inpatient admissions among patients treated in the ED for suicidal behavior. The authors recommend that safety planning be universally implemented in EDs and included in routine outpatient care.

"Treat Them Like a Human Being They are Somebody's Somebody": Providers' Perspectives on Treating Patients in the Emergency Department After Self-Injurious Behavior.

To understand ED providers' perspective on how to best care for individuals who present to US emergency departments (EDs) following self-injurious behavior, purposive recruitment identified nursing directors, medical directors, and social workers (n = 34) for telephone interviews from 17 EDs. Responses and probes to "What is the single most important thing ED providers and staff can do for patients who present to the ED after self-harm?" were analyzed using directed content analysis approach. Qualitative analyses identified four themes: treat patients with respect and compassion; listen carefully and be willing to ask sensitive personal questions; provide appropriate care during mental health crises; connect patients with mental health care. Participants emphasized treating patients who present to the ED after self-injurious behavior with respect and empathy. Hospitals could incentivize provider mental health training, initiatives promoting patient-provider collaboration, and reimbursement strategies ensuring adequate staffing of providers with time to listen carefully.

Hospital and Community Correlates of Recommended Emergency Department Mental Health Care for Patients Presenting With Self-Harm.

OBJECTIVE: Emergency departments (EDs) are well positioned to deliver suicide prevention services. This study examined hospital and community correlates of recommended practices. METHODS: This study examined results from a national survey of ED nursing directors (N=513) focusing on hospital- and community-level variation in the routine provision of four recommended practices: suicide risk screening, access to means assessment, safety planning, and follow-up referrals. RESULTS: Few significant differences existed between hospitals that routinely provided these practices and hospitals that did not. Routine scheduling of follow-up appointments was associated with presence of formal contractual relationships with outpatient mental health facilities (p=0.005). Routine provision of safety planning was associated with higher levels of psychiatrist or psychologist staffing (p=0.032). CONCLUSIONS: There were few differences in the hospital and community characteristics between EDs that routinely provided recommended care and those that did not, suggesting few structural barriers to implementation of these recommended services for high-risk ED patients.

Treating Pediatric and Geriatric Patients at Risk of Suicide in General Emergency Departments: Perspectives From Emergency Department Clinical Leaders.

STUDY OBJECTIVE: We explored emergency department clinical leaders' views on providing emergency mental health services to pediatric and geriatric patients with suicidal ideation and suicide attempts. METHODS: We conducted semistructured interviews with a total of 34 nursing directors, medical directors, and behavioral health managers at 17 general hospital EDs across the United States, using purposive sampling to ensure variation among hospitals. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using Atlas.ti and a directed content analysis approach. RESULTS: Respondents from across a range of ED types expressed concerns regarding the capacity of their EDs to meet mental health needs of children and older adults. They experienced emotional distress over the increasing number of pediatric patients presenting to EDs with suicidal ideation/suicide attempt and described EDs as inappropriate environments for young patients with suicidal ideation/suicide attempt. Similarly, leaders expressed feeling ill-equipped to diagnose and treat geriatric patients with suicidal ideation/suicide attempt, who often had medical comorbidities that complicated treatment planning. Respondents noted that pediatric and geriatric patients frequently boarded in the ED. Some felt compelled to use creative solutions to provide safe spaces for pediatric and geriatric patients. Respondents voiced frustration over the lack of outpatient and inpatient mental health services for these patients. CONCLUSION: Clinical leaders in EDs across the nation expressed distress at feeling they were not adequately equipped to meet the needs of pediatric and geriatric patients with suicidal ideation/suicide attempt. Future innovations to provide ED care for children and older adults with suicidal ideation/suicide attempt might include training for ED teams, access to specialist mental health clinicians through telehealth, and adaptations of physical spaces.

Strategies to Care for Patients Being Treated in the Emergency Department After Self-harm: Perspectives of Frontline Staff.

INTRODUCTION: Every year, approximately 500 000 patients in the United States present to emergency departments for treatment after an episode of self-harm. Evidence-based practices such as designing safer ED environments, safety planning, and discharge planning are effective for improving the care of these patients but are not always implemented with fidelity because of resource constraints. The aim of this study was to provide insight into how ED staff innovate processes of care and services by leveraging what is available on-site or in their communities. METHODS: A total of 34 semi-structured qualitative phone interviews were conducted with 12 nursing directors, 11 medical directors, and 11 social workers from 17 emergency departments. Respondents comprised a purposive stratified sample recruited from a large national survey in the US. Interview transcripts were coded and analyzed using a directed content analysis approach to identify categories of strategies used by ED staff to care for patients being treated after self-harm. RESULTS: Although respondents characterized the emergency department as an environment that was not well-suited to meet patient mental health needs, they nevertheless described 4 categories of strategies to improve the care of patients seen in the emergency department after an episode of self-harm. These included: adapting the ED environment, improving efficiencies to provide mental health care, supporting the staff who provide direct care for patients, and leveraging community resources to improve access to mental health resources postdischarge. DISCUSSION: Despite significant challenges in meeting the mental health needs of patients treated in the emergency department after self-harm, the staff identified opportunities to provide mental health care and services within the emergency department and leverage community resources to support patients after discharge.

Defining Patient Safety Events in Inpatient Psychiatry.

OBJECTIVES: The past 20 years have seen the emergence of a national movement to improve hospital-based healthcare safety in the United States. However, much of the foundational work and subsequent research have neglected inpatient psychiatry. The aim of this article was to advance a comprehensive approach for conceptualizing patient safety in inpatient psychiatry as framed by an application of the Institute of Medicine patient safety framework. METHODS: This article develops a framework for characterizing patient safety in hospital-based mental health care. We discuss some of the conceptual and methodological issues related to defining what constitutes a patient safety event in inpatient psychiatry and then enumerate a comprehensive set of definitions of the types of safety events that occur in this setting. RESULTS: Patient safety events in inpatient psychiatry are broadly categorized as adverse events and medical errors. Adverse events are composed of adverse drug events and nondrug adverse events, including self-harm or injury to self, assault, sexual contact, patient falls, and other injuries. Medical errors include medication errors and nonmedication errors, such as elopement and contraband. We have developed clear definitions that would be appropriate for use in epidemiological studies of inpatient mental health treatment. CONCLUSIONS: Psychiatry has not been an integral part of the national safety movement. As a first step toward breaching this chasm, we have considered how psychiatric events fit into the safety framework adopted across much of medicine. Patient safety should become a key part of inpatient psychiatry's mission and pursued rigorously as the subject of research and intervention efforts.

The Relationship Between Evidence-Based Practices and Emergency Department Managers' Perceptions on Quality of Care for Self-Harm Patients.

OBJECTIVE: To understand the extent to which implementation of evidence-based practices affects emergency department (ED) nurse managers' perceptions of quality of care provided to deliberate self-harm patients. METHODS: ED nursing leadership from a nationally representative sample of 513 hospitals completed a survey on the ED management of deliberate self-harm patients, including the quality of care for deliberate self-harm patients on a 1 to 5 point Likert-type scale. Unadjusted and adjusted analyses, controlling for relevant hospital characteristics, examined associations between the provision of evidence-based practices and quality of care. RESULTS: The overall mean quality rating was 3.09. Adjusted quality ratings were higher for EDs that routinely engaged in discharge planning (ß = 0.488) and safety planning (ß = 0.736) processes. Ratings were also higher for hospitals with higher levels of mental health staff (ß = 0.368) and for teaching hospitals (ß = 0.319). CONCLUSION: Preliminary findings suggest a national institutional readiness for further implementation of evidence-based practices for deliberate self-harm patients.

If You Could Change 1 Thing to Improve the Quality of Emergency Care for Deliberate Self-harm Patients, What Would It Be? A National Survey of Nursing Leadership.

INTRODUCTION: Emergency departments increasingly treat patients for deliberate self-harm. This study sought to understand emergency department nursing leadership perspectives on how to improve the quality of emergency care for these patients. METHODS: ED nursing managers and directors from a national sample of 476 hospitals responded to an open-ended question asking for the 1 thing they would change to improve the quality of care for self-harm patients who present in their emergency departments. We identified and coded key themes for improving the emergency management of these patients, then examined the distribution of these themes and differences by hospital characteristics, including urbanicity, patient volume, and teaching status. RESULTS: Five themes regarding how to improve care for deliberate self-harm patients were identified: greater access to hospital mental health staff or treatment (26.4%); better access to community-based services and resources (26.4%); more inpatient psychiatric beds readily accessible (20.9%); separate safe spaces in the emergency department (18.6%); and dedicated staff coverage (7.8%). Endorsement of findings did not differ based on hospital characteristics. DISCUSSION: ED nursing leadership strongly endorsed the need for greater access to both hospital- and community-based mental health treatment resources for deliberate self-harm patients. Additional ED staff and training, along with greater continuity among systems of care in the community, would further improve the quality of emergency care for these patients. Broad policies that address the scarcity of mental health services should also be considered to provide comprehensive care for this high-risk patient population. KEY WORDS: Emergency department management of self-harm; Mental health care; Emergency nursing care.

How Well Do Incident Reporting Systems Work on Inpatient Psychiatric Units?

BACKGROUND: Adverse events and medical errors have been shown to be a persistent issue in health care. However, little research has been conducted regarding the efficacy of incident reporting systems, particularly within an inpatient psychiatry setting. METHODS: The medical records from a random sample of 40 psychiatric units within Veterans Health Administration (VHA) medical centers were screened and evaluated by physicians for 9 types of safety events. The abstracted safety events were then evaluated to assess if they were caused by an error and if they caused harm to the patient. These safety events were then matched to incidents that were reported to the VHA Adverse Event Reporting System (AERS), which includes all reported adverse events, close calls, and root cause analyses that occur within the VHA health system. RESULTS: Overall, 37.4% (95% confidence interval [CI] = 33.5%-41.5%) of safety events detected in the medical record were reported to the AERS. Among the patient safety events identified, the most commonly reported to the AERS were patient falls (52.3%), assaults (46.2%), and elopements (42.3%). Reporting rates increased when the patient safety event resulted in harm to the patient (48.2%; CI = 41.6%-55.0%). CONCLUSION: The majority of patient safety events that occur on VHA inpatient psychiatric units do not get reported to the VHA's Adverse Event Reporting System. These findings suggest that self-reporting is not a reliable method of tracking patient safety events. Future efforts should target the barriers to inpatient psychiatric reporting and develop mechanisms to overcome these barriers.

Family community integration and maternal mental health.

While the majority of women with mental health problems (MHPs) are mothers, little is known about the community integration (CI) of these women and their children. Given that poorer mental health status has been linked with lower CI, CI has become a long standing goal of mental health policy. Data from a national survey examined the association of maternal mental health status with the physical, social, and psychological integration of families. After adjusting for sociodemographics, mothers with MHPs reported similar physical integration but less social and psychological integration. Interventions focused on improving social networks, scarce resources, and neighborhood safety are needed for families impacted by maternal MHPs.

Toward understanding errors in inpatient psychiatry: a qualitative inquiry.

While prior research has identified the impact, nature, and causes of medical error in general medical settings, little is known about errors in inpatient psychiatry. Understanding the broad range of errors that occur in inpatient psychiatry is a critical step toward improving systems of care for a vulnerable patient population. An explorative qualitative analysis of key informant interviews identified a preliminary typology of errors and the contextual factors that precipitate them in inpatient psychiatry. The types of errors and their contextual factors fall broadly within the rubric of categories identified in medicine and surgery. However, many of the specific errors and contextual factors manifest themselves differently and are shaped by the uniqueness of the inpatient psychiatric setting and patient population. Interventions geared toward improving systems of care for psychiatric patients should draw on best practices for safety in medicine and surgery, but also be complemented with new strategies specifically tailored to the inpatient psychiatric setting.

Maternal mental health and pediatric health care use among a national sample of Medicaid- and SCHIP-insured children.

While the literature has shown that health care use is associated with mental health status, little is known about the relationship between a mother's mental health status and her children's health care use. This study examined the association of maternal mental health status and pediatric health care for their children in a nationally representative sample of 17,830 women parenting children ages 0-17 insured through Medicaid or a State Children's Health Insurance Program (SCHIP). Mothers with a mental health problem were significantly more likely to be poorer, single parents, with lower levels of education, fewer parenting supports, and greater difficulty coping with parenting than mothers without a mental health problem; however, they reported comparable receipt of pediatric health care for their children, indicating their resilience as caretakers. The findings also suggest that all Medicaid- or SCHIP-eligible families could benefit from targeted engagement strategies linking them with consistent and appropriate sources of pediatric health care.

Suicide in inpatient settings: are our hospitals safe enough?

The authors discuss the implications of findings regarding suicides in hospitals.