Improving the Emergency Department Management of Deliberate Self-Harm

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 DESCRIPTION (provided by applicant): Preventing suicide is one of the great public health challenges facing the US health care system. People who seek emergency care in general hospitals for deliberate self-harm are at exceptionally high short-term risk of repeated self-harm and suicide. Yet only about one-half of these patients receive emergency mental health evaluations. Among self-harm patients who are discharged to the community, only one-half receive follow-up outpatient mental health care in the following month. The proposed study will inform efforts to address deficiencies in the emergency management of deliberate self-harm by testing whether access to each of the following five emergency services influences inpatient admission, timely outpatient mental health care, short- term risk of repeated self-harm and suicide: 1) suicide risk assessment and triage procedures, 2) routine use of safety plans, 3) an on-site discharge planner, 4) an on-site or on-call mental health specialist, and 5) availability o crisis mental health services. The specific aims of the study are 1) to identify patient, hospital and service environment characteristics that influence access to these five emergency mental health services; 2) to determine whether access to each of these emergency mental health services influences inpatient admission, increases the likelihood of timely outpatient mental health follow-up care and reduces the short-term risk of deliberate self-harm and suicide, and 3) to understand qualitatively how these emergency mental health services operate in community practice. We will address these aims by extracting a sample of over ten thousand privately and Medicaid insured deliberate self-harm patients from approximately 500 emergency departments. At each of the treating hospitals, we will survey emergency medical directors to determine the presence or absence of the five emergency department services. Additional information about the emergency departments will be available from the Statewide Emergency Department Databases, hospital information will be available from the American Hospital Association Annual Survey, and regional mental health service information will be available from the Substance Abuse and Mental Health Services Administration surveys. Repeated deliberate self-harm will be assessed with administrative claims records and suicide will be determined by matching individual patients to the National Death Index. We will then use this patient, emergency department, hospital, and service environment information in propensity score adjusted models of the effects of the key emergency services on inpatient admission, follow-up outpatient mental health care, early repeated deliberate self-harm, and suicide. These issues will be examined in greater detail through qualitative interviews with key front line staff at selected emergency departments to probe how these services operate and what impedes their implementation in community practice. This new information will guide improvements in the emergency management of deliberate self-harm.