Emergency Medicine Journal Club VignetteI
Mr. P., a 34-year old homeless male presents to your ED with suicidal ideations. He denies any prior suicide attempts or psychiatric diagnoses. Review of your hospital records reveals no prior ED evaluations or hospital admissions. He denies any other medical history. He drinks whiskey daily, but denies illicit substance abuse. Mr. P. has no local family and no primary care physician. His specific suicidal plan is to “jump in front of a car or jump off a bridge.” His physical exam is unremarkable except for an obviously depressed affect. He appears lucid with clear thought processes and no clinically obvious intoxication.
Judging his suicidal threat to be real, you request a psychiatric consultation. After an hour of evaluation time and a negative toxicology screen, your Psychiatrist deems Mr. P. low-risk and safe for outpatient evaluation. Uncomfortably, you discharge him wondering whether any EM-specific risk stratification tools exist for suicidal patients.
You feel fairly certain, based on the history provided by family, that the underlying cause of this patient’s cardiac arrest was an acute myocardial infarction. Despite the lack of ST-elevation the ECG, you wonder if the patient would benefit from early cardiac catheterization to assess for significant acute coronary artery occlusion. You head to the offices on the 8th floor, find a computer, and begin a search to see what the literature says…
Population: ED patients presenting with suicidal ideations
Intervention: Risk stratification with clinical decision rule
Comparison: Non-systematic (gestalt) risk stratification
Outcome: Suicide attempts, successful suicides, other violent behavior (self-harm or injuring others) post-ED evaluation (6-months).
Touring the ACEP bookstore online, you excitedly note a new textbook: Emergency Psychiatry by Randy Hillard and Brook Zitek (McGraw Hill 2004) which you purchase to help answer this PICO question. Unfortunately, “The Potentially Suicidal Patient” chapter covers only eight pages and does not mention a single CDR related to self-injury risk stratification. You next search the ACEP website for a clinical policy (none) and search fruitlessly for a website for The American Academy of Emergency Psychiatry referenced in Hillard’s textbook (never found). Frustrated and dejected, you turn to Rosen’s Emergency Medicine and quickly learn of Hockberger’s dated SAD PERSON scale which you pull. A Web of Science citation search for Hockberger’s article yields one useful review by Cochrane-Brink which also references the Beck Hopelessness Scale as “the best predictor of eventual suicide”. Coincidentally, while perusing the current issue of Annals of Emergency Medicine you note a brand new self-injury CDR. After discussing these findings with your Psychiatry colleagues, you decide little other literature exists to provide rapid, reliable ED decision making in the form of CDR’s.
All: Improving the Design of the Assessment of Emergency Department Patients at Risk for Self-Harm, Ann EM 2006; 48: 467-469. Don’t analyze this editorial, just read it to gain some important perspective!
1st Years: Clinical Rating Scales in Suicide Risk Assessment, Gen Hosp Psych 2000; 22: 445-451.
2nd Years: Relationship Between Hopelessness and Ultimate Suicide: A Replication with Psychiatric Outpatients. Am J Psychiatry 1990; 147: 190-195.
3rd Years: Assessment of Suicide Potential by Nonpsychiatrists Using the SAD PERSONS Score. J EM 1988; 6: 99-107.
4th Years: A Clinical Tool for Assessing Risk after Self-Harm. Ann EM 2006; 48: 459-466.
1st, 2nd, 3rd, & 4th use the Clinical Decision Rule Critical Review Form