Outpatient Mental Health Follow-up and Recurrent Self-harm and Suicide Among Patients Admitted to the ICU for Self-harm: A Population-based Cohort Study.

BACKGROUND: Patients surviving an ICU admission for deliberate self-harm are at high risk of recurrent self-harm or suicide after discharge. It is unknown whether mental health follow-up after discharge (with either a family physician or psychiatrist) reduces this risk. RESEARCH QUESTION: What is the association between mental health follow-up after discharge and recurrent self-harm among patients admitted to the ICU for intentional self-harm? STUDY DESIGN AND METHODS: Population-based cohort study of consecutive adults (≥ 18 years of age) from Ontario, Canada, who were admitted to ICU because of intentional self-harm between 2009 and 2017. We categorized patients according to follow-up, with 'early follow-up' indicating 1 to 21 days after discharge, 'late follow-up' indicating 22 to 60 days after discharge, and 'no follow-up' indicating no follow-up within 60 days of discharge. We conducted analyses using a cause-specific extended Cox regression model to account for varying time for mental health follow-up relative to the outcomes of interest. The primary outcome was recurrent ICU admission for self-harm within 1 year of discharge. RESULTS: We included 9,569 consecutive adults admitted to the ICU for deliberate self-harm. Compared with receiving no mental health follow-up, both early follow-up (hazard ratio [HR], 1.37; 95% CI, 1.07-1.75) and late follow-up (HR, 1.69; 95% CI, 1.22-2.35) were associated with increased risk in recurrent ICU admission for self-harm. As compared with no follow-up, neither early follow-up (HR, 1.10; 95% CI, 0.70-1.73) nor late follow-up (HR, 1.54; 95% CI, 0.84-2.83) were associated with increased risk of death by suicide. INTERPREATION: Among adults admitted to the ICU for deliberate self-harm, mental health follow-up after discharge was not associated with reduced risk of recurrent ICU admission for self-harm or death resulting from suicide, and patients seeking outpatient follow-up may be those at highest risk of these outcomes. Future research should focus on additional and novel methods of risk mitigation in this vulnerable population.

Suicide and self-harm in adult survivors of critical illness: population based cohort study.

OBJECTIVE: To analyse the association between survival from critical illness and suicide or self-harm after hospital discharge. DESIGN: Population based cohort study using linked and validated provincial databases. SETTING: Ontario, Canada between January 2009 and December 2017 (inclusive). PARTICIPANTS: Consecutive adult intensive care unit (ICU) survivors (≥18 years) were included. Linked administrative databases were used to compare ICU hospital survivors with hospital survivors who never required ICU admission (non-ICU hospital survivors). Patients were categorised based on their index hospital admission (ICU or non-ICU) during the study period. MAIN OUTCOME MEASURES: The primary outcome was the composite of death by suicide (as noted in provincial death records) and deliberate self-harm events after discharge. Each outcome was also assessed independently. Incidence of suicide was evaluated while accounting for competing risk of death from other causes. Analyses were conducted by using overlap propensity score weighted, cause specific Cox proportional hazard models. RESULTS: 423 060 consecutive ICU survivors (mean age 61.7 years, 39% women) were identified. During the study period, the crude incidence (per 100 000 person years) of suicide, self-harm, and the composite of suicide or self-harm among ICU survivors was 41.4, 327.9, and 361.0, respectively, compared with 16.8, 177.3, and 191.6 in non-ICU hospital survivors. Analysis using weighted models showed that ICU survivors (v non-ICU hospital survivors) had a higher risk of suicide (adjusted hazards ratio 1.22, 95% confidence interval 1.11 to 1.33) and self-harm (1.15, 1.12 to 1.19). Among ICU survivors, several factors were associated with suicide or self-harm: previous depression or anxiety (5.69, 5.38 to 6.02), previous post-traumatic stress disorder (1.87, 1.64 to 2.13), invasive mechanical ventilation (1.45, 1.38 to 1.54), and renal replacement therapy (1.35, 1.17 to 1.56). CONCLUSIONS: Survivors of critical illness have increased risk of suicide and self-harm, and these outcomes were associated with pre-existing psychiatric illness and receipt of invasive life support. Knowledge of these prognostic factors might allow for earlier intervention to potentially reduce this important public health problem.

Emergency physician risk assessment practices prior to prescribing opioids.

BACKGROUND: Safer opioid prescribing remains a crucial issue for emergency physicians. Policy statements and guidelines recommend deliberate risk assessment for likelihood of current or future opioid use disorder prior to prescribing opioids. However, the practice patterns of emergency physicians remain underreported. METHODS: We surveyed emergency physicians across Canada about their local opioid prescribing policies, their practice patterns of risk assessment prior to prescribing opioids, and which clinical risk factors they find most important. RESULTS: The response rate was 20.4% (n = 312/1532). 59.8% of respondents report usually or always assessing for risk. Physicians rely on gestalt (80.3%), targeted histories based on risk factors in the literature (55.6%) or their experience (57.6%), and reviewing medical (83.1%) and medication records (75.6%). Contacting primary prescribers is uncommon (16.3%). A minority routinely use opioid prescribing risk assessment tools (6.4%), have local opioid prescribing policies (27%), or make use of electronic medical record functions to assist risk stratifying (2.4%). CONCLUSION: Many Canadian emergency physicians make risk assessments based on gestalt rather than identifying literature-based risk factors. This conflicts with guidelines calling for routine comprehensive assessment. Further efforts should be directed towards education in optimizing risk assessment; and towards system-level initiatives such as clear local prescribing policies, electronic-systems functionality, and developing assessment tools for use in the ED.

RéSUMé: CONTEXTE: La prescription sûre d'opioïdes reste un enjeu essentiel pour les médecins d'urgence. Avant de prescrire des opioïdes, les énoncés de politique et les lignes directrices recommandent une évaluation des risques bien réfléchie pour la probabilité d'un abus d'opiacé actuel ou éventuel. Cependant, les modalités de pratique des médecins urgentistes font l'objet d'une documentation et d'une information insuffisante. MéTHODES: Nous avons mené une enquête auprès des médecins urgentistes partout au Canada au sujet de leurs politiques locales de prescription des opioïdes, de leurs modalités de pratique d'évaluation des risques avant de prescrire des opioïdes, et des facteurs de risque cliniques qu'ils jugent les plus importants. RéSULTATS: Le taux de réponse était de 20.4% (n = 312/1532). 59.8% des répondants déclarent évaluer habituellement ou toujours le risque. Les médecins dépendent du gestalt (80.3%), des antécédents ciblés basés sur des facteurs de risque de la littérature (55.6%) ou de leur expérience (57.6%) et d'une examination des dossiers médicaux (83.1%) et des dossiers pharmaceutiques (75.6%). Il est rare de contacter les principaux prescripteurs (16.3%). Une minorité utilise régulièrement des outils d'évaluation des risques liés à la prescription des opioïdes (6.4%), dispose de politiques locales de prescription d'opiacés (27%) ou utilise les fonctions de dossier médical électronique pour aider à la stratification des risques (2.4%). CONCLUSION: De nombreux médecins urgentistes canadiens évaluent les risques en se basant sur la gestalt plutôt que sur l'identification des facteurs de risque documentés. Cela est en contradiction avec les directives exigeant une évaluation complète de routine. Des efforts supplémentaires devraient être dirigés vers l'éducation pour optimiser l'évaluation des risques; et vers des initiatives au niveau du système telles que des politiques de prescription locales claires, la fonctionnalité des systèmes électroniques et l'élaboration d'outils d'évaluation à utiliser aux urgences.

Remifentanil for procedural sedation: a systematic review of the literature.

OBJECTIVE: We sought to determine the performance characteristics of remifentanil as an agent of procedural sedation and analgesia (PSA) for adult and paediatric patients undergoing procedures similar to those executed in the ED. METHODS: We systematically reviewed electronically published literature, grey literature, conference proceedings and trial registries from 1946 to 2015. Outcome measures included PSA effectiveness, recovery time, patient safety and resource management. We performed narrative summary analyses. Heterogeneity among selected studies precluded meta-analysis. RESULTS: We found 1525 citations, reviewed 34 full manuscripts (kappa=0.64) and included 10 studies (kappa=0.71). Seven were randomised controlled trials and three studies took place in the ED. Included procedures were lumbar puncture (80), cardioversion (66), orthopaedic manipulation (63), incision and drainage (15), thoracostomy (8) and nasal packing (2). There was extensive variation in remifentanil dosing (0.15- 1.5 µg/kg), administration protocols and use of additional PSA drugs. All studies noted superior or equivalent sedation effectiveness compared withcontrols. Several studies, including all those performed in the ED, noted faster procedure completion or patient recovery with remifentanil compared with control groups. The most commonly reported adverse event was respiratory depression, especially in paediatric patients. All studies were found to carry significant risk of bias. CONCLUSIONS: There is currently a lack of high-quality data on the use of remifentanil in the ED. Physicians should exert caution when using remifentanil in the absence of published standardised dosing protocols in light of frequently reported paediatric respiratory depression. However, PSA efficacy combined with faster recovery times merit ongoing investigations into its use.