How Veterans Health Administration Suicide Prevention Coordinators Assess Suicide Risk.

This cross-sectional study was designed to examine the suicide risk assessment practices of Suicide Prevention Coordinators (SPCs) within the Veterans Health Administration. Specifically, this study sought to (1) identify factors SPCs consider most important in assessing risk and patient priority; (2) measure the level of consistency and agreement between SPCs in assessing suicide risk and prioritizing cases; and (3) measure individual SPC consistency between cases. SPCs (n = 63) responded to online survey questions about imminent and prolonged risk for suicide in response to 30 fictional vignettes. Combinations of 12 acute and chronic suicide risk factors were systematically distributed throughout the 30 vignettes using the Fedorov () procedure. The SPCs were also asked to identify the level of priority for further assessment both disregarding and assuming current caseloads. Data were analysed using clinical judgement analysis. Suicidal plan, ß = 1.64; 95% CI (1.45, 1.82), and preparatory behaviour, ß = 1.40; 95% CI (1.23, 1.57), were considered the most important acute or imminent risk factors by the SPCs. There was less variability across clinicians in the assessment of risk when alcohol use (p = 0.02) and hopelessness (p = 0.03) were present. When considering acute or imminent risk factors, there was considerable variability between clinicians on a vignette-by-vignette basis, median SD = 0.86 (range = 0.47, 1.13), and within individual clinicians across vignettes, median R2 = 0.80 (0.49, 0.95). These findings provide insight into how this group of providers think about acute and chronic risk factors contributing to imminent suicide risk in Veterans. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Identifies factors that practitioners consider most important in suicide risk assessment Discusses how to distinguish between chronic and acute risk for suicide Identifies factors that lead to more consistent clinical judgments.

Clinically Inconsequential Alerts: The Characteristics of Opioid Drug Alerts and Their Utility in Preventing Adverse Drug Events in the Emergency Department.

STUDY OBJECTIVE: We examine the characteristics of clinical decision support alerts triggered when opioids are prescribed, including alert type, override rates, adverse drug events associated with opioids, and preventable adverse drug events. METHODS: This was a retrospective chart review study assessing adverse drug event occurrences for emergency department (ED) visits in a large urban academic medical center using a commercial electronic health record system with clinical decision support. Participants include those aged 18 to 89 years who arrived to the ED every fifth day between September 2012 and January 2013. The main outcome was characteristics of opioid drug alerts, including alert type, override rates, opioid-related adverse drug events, and adverse drug event preventability by clinical decision support. RESULTS: Opioid drug alerts were more likely to be overridden than nonopioid alerts (relative risk 1.35; 95% confidence interval [CI] 1.21 to 1.50). Opioid drug-allergy alerts were twice as likely to be overridden (relative risk 2.24; 95% CI 1.74 to 2.89). Opioid duplicate therapy alerts were 1.57 times as likely to be overridden (95% CI 1.30 to 1.89). Fourteen of 4,581 patients experienced an adverse drug event (0.31%; 95% CI 0.15% to 0.47%), and 8 were due to opioids (57.1%). None of the adverse drug events were preventable by clinical decision support. However, 46 alerts were accepted for 38 patients that averted a potential adverse drug event. Overall, 98.9% of opioid alerts did not result in an actual or averted adverse drug event, and 96.3% of opioid alerts were overridden. CONCLUSION: Overridden opioid alerts did not result in adverse drug events. Clinical decision support successfully prevented adverse drug events at the expense of generating a large volume of inconsequential alerts. To prevent 1 adverse drug event, providers dealt with more than 123 unnecessary alerts. It is essential to refine clinical decision support alerting systems to eliminate inconsequential alerts to prevent alert fatigue and maintain patient safety.

Perspectives on Tiered Older Driver Assessment in Primary Care Settings.

PURPOSE OF THE STUDY: Widespread screening of older drivers, with in-depth evaluation only of those who screen positive ("tiered assessment"), might efficiently balance driver safety and mobility. To inform program development, we sought to examine the perspectives of older drivers and clinicians on the concept of tiered assessment in primary care settings. DESIGN AND METHODS: Iterative focus groups and interviews with 33 community-dwelling current drivers aged ≥65 years and 8 primary care providers. We used inductive and deductive theme analysis to explore driver and clinician perspectives and to identify barriers and facilitators to establishing a tiered older driver assessment program in primary care settings. RESULTS: Four dominant themes emerged. Two themes addressed the overall concept: (a) support for the concept of tiered older driver assessment and (b) concerns about the consequences of older driver assessment and how these could affect program viability. Two themes addressed screening: (c) tension inherent in using a generalized approach to the highly individualized issue of driving and (d) logistical considerations for screening in primary care settings. IMPLICATIONS: Standardized older driver screening and referral might improve clinician-driver communication, but screening should occur in a context that includes personalized mobility counseling.

Driving Self-Restriction and Age: A Study of Emergency Department Patients.

BACKGROUND: Driving self-restriction is a well-documented among older drivers but might also occur among younger drivers. Little is known about the driving patterns of emergency department (ED) patients, who may be a high-risk population for motor vehicle crashes (MVCs). We sought to compare the driving patterns and MVCs of younger and older adult ED patients in order to inform development of injury prevention interventions in EDs. METHODS: We surveyed English-speaking younger adult (age 25-64) and older adult (age ≥65) ED patients, excluding non-drivers and those who were cognitively-impaired or too sick to participate. We compared drivers by age group and used logistic regression with adjustment for driving frequency to examine factors associated with driving self-restriction. RESULTS: Of those eligible, 82% (n=178) of younger adult and 91% (n=134) of older adult patients participated; approximately half were women. Similar proportions of younger and older adult patients reported driving everyday/almost everyday (80%) but also self-restricting driving in inclimate weather (48%), heavy traffic (27%), in unfamiliar places (21%), when travelling with passengers (1.6%) or when alone (1.3%). Fewer younger adult than older adult patients avoided driving at night (22% versus 49%) or on highways (6.7% versus 26%). In multivariable logistic regression, factors significantly associated self-imposed driving restriction in ≥1 driving situation were female gender (Odds Ratio [OR] 2.40; 95%CI 1.42-4.05) and ever feeling "confused, nervous or uncomfortable" while driving (OR 1.87; 95% CI 1.03-3.39). There was a non-significant trend for differences in proportions between younger adult (11%) and older adult (6.8%) drivers reporting ≥1 MVC as a driver in the past 12 months. CONCLUSIONS: Similar proportions of younger and older adult ED patients self-restrict driving, albeit in different situations, which has implications for behavioral interventions for injury prevention and for education of patients and medical providers.