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Student Contribution  |   July 2009
Improving the Quality of Suicide Risk Assessments in the Psychiatric Emergency Setting: Physician Documentation of Process Indicators
Author Notes
  • From Touro University College of Osteopathic Medicine–California in Vallejo (Drs Mahal, Chee, Lee, and Nguyen) and from the University of California, Los Angeles Kern Medical Center Department of Psychiatry in Bakersfield (Dr Woo). Drs Mahal, Chee, Lee, and Nguyen were osteopathic medical students at the time this study was conducted. 
  • Address correspondence to Satinder K. Mahal, DO, 32909 Danville St, Union City, CA 94587-5504. E-mail: mahalsatinder@yahoo.com 
Article Information
Psychiatry
Student Contribution   |   July 2009
Improving the Quality of Suicide Risk Assessments in the Psychiatric Emergency Setting: Physician Documentation of Process Indicators
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 354-358. doi:10.7556/jaoa.2009.109.7.354
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 354-358. doi:10.7556/jaoa.2009.109.7.354
Abstract

Context: Suicide risk assessment in the emergency department is a challenging task for psychiatrists and is further complicated when patients are admitted involuntarily.

Objective: To evaluate the quality of suicide risk assessments in the psychiatric emergency setting by reviewing physician documentation of process indicators.

Methods: A retrospective review of medical records for patients who were admitted involuntarily to the Kern Medical Center Psychiatric Emergency Service in Bakersfield, Calif. All patients were deemed a “danger to self” as defined by California Law and were admitted for evaluation in June 2006. Medical records were reviewed for 19 process indicators, which were identified from risk factors and treatment guidelines described in the literature. Documentation that a process indicator was not met by a patient was included in the data. Patients were then separated into two study groups: those who were admitted to the inpatient psychiatric unit, and those who were released. Data were analyzed using t tests for continuous variables and χ2 tests for categorical variables.

Results: The medical records of 145 patients were reviewed. None of the suicide risk assessments documented all 19 process indicators. The three most commonly documented process indicators were access to firearms (75.9%), recent stressful life events (75.2%), and “contract for safety” (74.5%). According to medical records, patients admitted to the inpatient unit were more likely than patients released to home care to have been assessed for command auditory hallucinations (P=.02) or prior psychiatric diagnoses (P=.001). Discharged patients were more likely to have been assessed for a family history of suicide (P=.001) or symptoms of major depressive disorder (P=.02).

Conclusion: Many important risk factors for suicide were not documented in emergency department assessments, suggesting that overall quality of psychiatric risk assessments was not optimal. This lack of documentation has important implications from a treatment and medicolegal perspective.

Suicidal ideation and suicide attempts are common reasons for psychiatric emergency evaluation. In California, individuals may be brought involuntarily to a psychiatric emergency service (PES) for assessment if they meet certain criteria.1 Yet, as noted by Simon,2 psychiatrists cannot predict which patients will eventually commit suicide—they can only assess the risk for suicidal behavior. Despite efforts to establish effective suicide risk assessment guidelines,3-5 more than 32,000 people committed suicide in the United States in 2005.6 
While patient entry into a PES is an important step toward improved mental health, the quality of psychiatric consultations and the care of those who have attempted suicide differ substantially among treatment centers.7 However, studies7-9 have identified several factors associated with hospitalization versus discharge of suicidal patients presenting to a PES. These factors—or process indicators—highlight a general trend in determining patient hospitalization or discharge. 
Suominen and Lönnqvist7 examined the factors associated with the hospitalization of patients who attempted suicide. Determinants of hospitalization included a history of psychiatric treatment, severe mental illness, suicide attempted on a weekday, older age, and somatic illness. Goldberg et al8 demonstrated that present psychosis, past suicide attempts, and the presence of a suicide plan predicted hospitalization. In addition to these variables, Baca-García et al9 identified low psychosocial functioning, sustained suicidal ideation, increased lethality of suicide plan, and intention to commit suicide in a situation with little chance for discovery as causes for hospitalization. 
In 2003, the American Psychiatric Association published practice guidelines3 for the assessment and treatment of patients with suicidal behaviors. This tool emphasizes the importance of documenting suicide risk assessments to ensure that psychiatrists evaluate all aspects of patients' lives.3 Individual, clinical, and situational risk factors can play an important role in treatment decisions. Furthermore, thorough documentation of risk factors—as well as the lack of risk factors—helps provide a clear picture of patients' symptoms and the severity of those symptoms in a single “snapshot” of time, including the absence of risk factors when appropriate. 
Measuring adherence to suicide risk documentation by identifying process indicators would likely determine the quality of care for PES patients presenting with suicidal behaviors. Therefore, the present study aimed to evaluate the quality of suicide risk assessments in a psychiatric emergency setting as determined by physician documentation of process indicators. 
Methods
We conducted a retrospective review of electronic medical records for psychiatric patients who were admitted involuntarily to the psychiatric emergency service (PES) at Kern Medical Center in Bakersfield, Calif. Under California law,1 a person may be held involuntarily for 72 hours for psychiatric assessment if he or she is deemed a “danger to others, or to himself or herself, or gravely disabled.” Such individuals are identified by peace officers and others as designated by California law.1 
Patients were included in the study if they were admitted involuntarily to the PES in June 2006 and were determined to be a danger to self. To meet this classification, individuals must be an immediate threat to themselves, be suicidal, or be severely depressed. 
On admission to the PES, most patient evaluations were completed by first-, second-, and third-year general psychiatry residents under the supervision of an attending psychiatrist. Residents were from the University of California, Los Angeles Kern Medical Center Psychiatry Residency Program and were either on call or completing a 1-month rotation. During evaluations, physicians documented risk factors—or the lack thereof—in patients' medical records. After evaluation, patients were either admitted to the inpatient unit or discharged. 
For the present study, patients' medical records were pulled from an electronic database. Records were examined and relevant data were extracted using a structured medical record abstraction form that was developed for the present study. It comprised a list of 19 process indicators that were noted to be determinants of hospitalization or discharge in this patient population. These process indicators were identified from the American Psychiatric Association practice guideline3 as well as from published literature on suicide risk factors, as previously described.2,7-10 The form comprised 15 process indicators on suicidal risk factors, three on protective factors, and one on continuity of care (Figure). 
Figure.
Process indicators noted to be determinants of hospitalization or discharge of psychiatric patients as described in the American Psychiatric Asssociation's Practice Guidelines for the Treatment of Psychiatric Disorders3 as well as from published literature on suicidal risk factors.2,7-10 *Verbal agreement from the patient not to harm self. †Psychiatrist followed up with nursing staff or family members to ensure that patient medications were taken away or locked up.
Figure.
Process indicators noted to be determinants of hospitalization or discharge of psychiatric patients as described in the American Psychiatric Asssociation's Practice Guidelines for the Treatment of Psychiatric Disorders3 as well as from published literature on suicidal risk factors.2,7-10 *Verbal agreement from the patient not to harm self. †Psychiatrist followed up with nursing staff or family members to ensure that patient medications were taken away or locked up.
Three research assistants (S.K.M., J.C.Y.L., T.N.) were trained for the present study in collecting data from an electronic medical record database. Before extracting data for the present study and to assess interrater reliability, the three evaluators separately reviewed 25 records and reached 80% agreement on physicians' documentation of process indicators. Each medical record was then reviewed by a research assistant and benchmarked against the list of 19 process indicators. Because the absence of risk factors is also important in suicide risk assessment, if a medical recored indicated a patient did not have a process indicator (eg, “patient does not have access to a firearm”), it was still considered documentation and was included in the data. The research assistants also pulled the baseline characteristics and demographic data from patient records. 
The documentation of process indicators for patients admitted to the psychiatric inpatient unit and those not admitted were compared using t tests for continuous variables and χ2 tests for categorical variables. The Kern Medical Center institutional review board approved the study protocol. 
Results
In June 2006, 145 patients were admitted to the Kern Medical Center Psychiatric Emergency Service for involuntary psychiatric assessment under the category of danger to self. Seventy-six patients (52.4%) were men, 85 (58.6%) were never married, 75 (51.7%) were indigent, and 120 (82.8%) had not attempted overdose. Most subjects were white (95 [65.5%]) or non-white Hispanic (38 [26.2%]). Psychotic (38 [26.2%]), bipolar (32 [22.1%]), and depressive (30 [20.7%]) disorders were the most common existing diagnoses documented in patients' charts. The mean (SD) age was 36.5 (12.7) years. Table 1 further summarizes the demographic information of the patient sample. 
Table 1
Retrospective Review of Medical Records for Patients Admitted Involuntarily for Emergent Psychiatric Care: Characteristics of Patients (N=145)

Characteristic

No. (%)*
Sex
□ Men 76 (52.4)
□ Women69 (47.6)
Age, mean (SD) 36.5 (12.7)
Marital Status
□ Married 27 (18.6)
□ Never married85 (58.6)
□ Divorced 33 (22.8)
Race and/or Ethnicity
□ White 95 (65.5)
□ Hispanic38 (26.2)
□ African American 8 (5.5)
□ Asian3 (2.1)
□ Other 1 (0.7)
Mental Disorder Diagnosis
□ Psychotic 38 (26.2)
□ Bipolar32 (22.1)
□ Depressive 30 (20.7)
□ Substance abuse22 (15.2)
□ Adjustment 20 (13.8)
□ Other
3 (2.0)
 *Data are presented as No. (%) unless otherwise indicated.
Table 1
Retrospective Review of Medical Records for Patients Admitted Involuntarily for Emergent Psychiatric Care: Characteristics of Patients (N=145)

Characteristic

No. (%)*
Sex
□ Men 76 (52.4)
□ Women69 (47.6)
Age, mean (SD) 36.5 (12.7)
Marital Status
□ Married 27 (18.6)
□ Never married85 (58.6)
□ Divorced 33 (22.8)
Race and/or Ethnicity
□ White 95 (65.5)
□ Hispanic38 (26.2)
□ African American 8 (5.5)
□ Asian3 (2.1)
□ Other 1 (0.7)
Mental Disorder Diagnosis
□ Psychotic 38 (26.2)
□ Bipolar32 (22.1)
□ Depressive 30 (20.7)
□ Substance abuse22 (15.2)
□ Adjustment 20 (13.8)
□ Other
3 (2.0)
 *Data are presented as No. (%) unless otherwise indicated.
×
None of the suicide risk assessments documented all 19 process indicators. The three most commonly documented process indicators were access to firearms (110 [75.9%]), recent stressful life events (109 [75.2%]), and “contract for safety” (ie, verbal agreement not to harm self; 108 [74.5%]). Among the least common process indicators were new onset of a severe medical condition (5 [3.5%]), history of abuse (15 [10.3%]), command hallucinations to harm self (31 [21.4%]), current suicide plan (44 [30.3%]), and feelings of hopelessness (45 [31.0%]) (Table 2). 
Table 2
Retrospective Review of Medical Records for Patients Admitted Involuntarily for Emergent Psychiatric Care: Documentation of Process Indicators* (N=145)

Process Indicator

No. (%)
Suicide Risk Factors
□ Access to firearms 110 (75.9)
□ Recent stressful life events109 (75.2)
□ Suicidal ideation 99 (68.3)
□ Recent substance abuse or dependence95 (65.5)
□ Previous suicide attempts 94 (64.8)
□ Family history of suicidal behaviors94 (64.8)
□ Previous psychiatric diagnoses 90 (62.1)
□ Impulsivity or aggression85 (58.6)
□ Signs of major depressive disorder 78 (53.8)
□ Self-injurious behaviors71 (49.0)
□ Feelings of hopelessness 45 (31.0)
□ Current suicide plan44 (30.3)
□ Command hallucinations to harm self 31 (21.4)
□ History of verbal, physical, or sexual abuse15 (10.3)
□ New onset of severe medical condition 5 (3.5)
Protective Risk Factors
□ Contract for safety 108 (74.5)
□ Barriers to suicide or reasons for living99 (68.3)
□ Social support system 99 (68.3)
Continuity of Care
□ Follow-up removal of medications from patients who attempted overdose
6 (24)§
 *Medical records were reviewed for 19 process indicators that were identified from risk factors and treatment guidelines described in the literature. Assessments that stated a process indicator was not met by a patient were included in documentation data.
 Verbal agreement from patient not to harm self.
 Psychiatrist followed up with nursing staff or family members to ensure that patient medications were taken away or locked up.
 §Percentage is calculated based on the total number of patients whose medications were removed (n=25).
Table 2
Retrospective Review of Medical Records for Patients Admitted Involuntarily for Emergent Psychiatric Care: Documentation of Process Indicators* (N=145)

Process Indicator

No. (%)
Suicide Risk Factors
□ Access to firearms 110 (75.9)
□ Recent stressful life events109 (75.2)
□ Suicidal ideation 99 (68.3)
□ Recent substance abuse or dependence95 (65.5)
□ Previous suicide attempts 94 (64.8)
□ Family history of suicidal behaviors94 (64.8)
□ Previous psychiatric diagnoses 90 (62.1)
□ Impulsivity or aggression85 (58.6)
□ Signs of major depressive disorder 78 (53.8)
□ Self-injurious behaviors71 (49.0)
□ Feelings of hopelessness 45 (31.0)
□ Current suicide plan44 (30.3)
□ Command hallucinations to harm self 31 (21.4)
□ History of verbal, physical, or sexual abuse15 (10.3)
□ New onset of severe medical condition 5 (3.5)
Protective Risk Factors
□ Contract for safety 108 (74.5)
□ Barriers to suicide or reasons for living99 (68.3)
□ Social support system 99 (68.3)
Continuity of Care
□ Follow-up removal of medications from patients who attempted overdose
6 (24)§
 *Medical records were reviewed for 19 process indicators that were identified from risk factors and treatment guidelines described in the literature. Assessments that stated a process indicator was not met by a patient were included in documentation data.
 Verbal agreement from patient not to harm self.
 Psychiatrist followed up with nursing staff or family members to ensure that patient medications were taken away or locked up.
 §Percentage is calculated based on the total number of patients whose medications were removed (n=25).
×
We dichotomized patients based on admission status. A total of 64 patients (44.1%) were admitted for inpatient care and 81 (55.9%) were discharged. There were no statistically significant differences between the study groups in age (38.6 [13.6] years vs 34.8 [11.8] years, respectively [t143=1.81, P=.07]) or sex (χ21=1.04, P=.31). According to medical records, those admitted to the inpatient unit were significantly more likely to have been assessed for command hallucinations to harm self (χ21=5.63, P=.02) and previous psychiatric diagnoses (χ21=19.39, P=.001). For the discharged group, documented family history of suicidal behaviors (χ21=12.24, P=.001) and signs of major depressive disorder (χ21=5.40, P=.02) were more likely to have been assessed. 
Comment
We found that, of the 19 process indicators, three were documented in about 75% of assessments and nine were documented in more than 50% but less than 75% of patient assessments. These results demonstrate that many important suicide risk factors were not documented in emergency assessments. One explanation is that physicians are performing focused examinations and targeting complaint-specific symptoms. However, in this particular population—in which patients were held involuntarily for current or imminent suicidal behavior—current suicidal ideation, plan, history of attempts, and hopelessness were documented in less than 70% of all individuals. 
An adequate suicide assessment should “identify treatable and modifiable risk factors.”11 The indicators used in the present study have been found to help physicians identify patients who are at a higher risk for hospitalization. Moreover, all patients in the present study were deemed a danger to themselves and were therefore very ill. This quality is particularly important in evaluating patients who have been committed involuntarily because they have higher rates of suicide when compared to patients who voluntarily seek emergent psychiatric care.12 Therefore, physicians should use particular care when evaluating patients who meet these criteria. However, this suggestion poses a limitation of the present study in that a physician's approach to a voluntary patient may differ from that of an involuntary patient and is worthy of further research. 
In addition, patients admitted to the inpatient unit were significantly more likely to have been assessed for command auditory hallucinations or prior psychiatric diagnoses, which are considered Axis I diagnoses. Although the study protocol did not differentiate between whether documentation indicated the presence or absence of a risk factor, physicians are more likely to ask about command hallucinations if patients are responding to internal stimuli or admit to auditory hallucinations. In this situation, patients would probably have command hallucinations, which would therefore be documented. 
Command auditory hallucinations and prior psychiatric diagnoses correlate with an increased risk of suicide.13 In fact, 39% of individuals with command hallucinations for self-harm act on them, especially if the voice is identifiable.14 This statistic begs the question, do physicians tend to provide more thorough examination and document the presence of process indicators when their clinical judgment suggests a need to admit the patient? Conversely, are physicians thoroughly examining patients but not recording the absence of process indicators when they deem patients are safe to be discharged? 
These questions reflect a major limitation of the current study—the inability to distinguish between an adequate assessment with inadequate documentation of suicide risk vs an inadequate assessment with inadequate documentation. The differences between these two assessments have far-reaching implications should an adverse outcome occur or documents receive legal scrutiny. In court, the written medical record is used as evidence to demonstrate the depth of a suicide risk assessment by the physician. Clinical judgment alone does not constitute an adequate assessment. Thus, developing guidelines for suicide risk assessments from evidence-based studies is key.15 
Early training of residents in suicide assessment through lectures and posted guidelines may improve the quality of documentation.16,17 A 2008 study16 noted that participation in suicide risk assessment educational sessions improved documentation quality and self-rated scores of suicide risk assessment knowledge. Such an addition to the education of residents can also be a cost-effective means to providing care for this patient population.16 However, one study17 noted that initiation of a residency program resulted in changes in multiple areas of treatment, including overuse of resources (eg, intramuscular emergency medications, radiologic assessments). Thorough training of residents could potentially change the way the next generation of physicians approach suicide assessment and treatment by decreasing the overuse of medical resources. As suicide assessment is an inductive process in which clinical experience continues to play a vital role,6 close supervision from an experienced psychiatrist who provides feedback and reinforcement should be considered equally important in resident education. 
Another important limitation to the present study concerns the lack of outcomes available. We did not collect data to evaluate patient readmission rates after hospitalization or discharge or the prevalence of follow-up visits. Likewise, changes in overall functioning, symptoms, or other factors potentially affected by physician treatment decisions are unknown. Further research is warranted to determine if treatment decisions made after an inadequate suicide risk assessment led to adverse outcomes or whether improved suicide risk assessments lead to improvements in patient dispositions. 
Conclusion
Determining the causes of suicidal ideation continues to be an elusive concept in psychiatry. Gaining knowledge into the triggers of suicide, whether psychosocial or biological, has the potential to improve patient care. 
Overall, the documentation of process indicators in emergency suicide risk assessments was less than optimal. To further improve the healthcare of psychiatric patients, future studies should investigate physician thought processes during assessments, the levels of resident supervision and variations in documentation at psychiatric medical centers, and improvements in documentation and efficacy resulting from physician education programs. 
Cal Welfare and Institutions Code §5150.
Simon RI. Suicide risk assessment: what is the standard of care [editorial]? J Am Acad Psychiatry Law. 2002;30:340-344. Available at: http://www.jaapl.org/cgi/reprint/30/3/340. Accessed June 5, 2009.
Practice guideline for the assessment and treatment of patients with suicidal behaviors. In: Practice Guidelines for the Treatment of Psychiatric Disorders: Compendium 2004. 2nd ed. Arlington, Va: American Psychiatric Association; 2004.
Jacobs DG, ed. The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco, Calif: Josey-Bass; 1999.
Simon RI. Assessing and Managing Suicide Risk: Guidelines for Clinically Based Risk Management. Washington, DC: American Psychiatric Association; 2003.
Suicide: facts at a glance. Centers for Disease Control and Prevention Web site. August 2008. Available at: http://www.cdc.gov/ViolencePrevention/pdf/Suicide-DataSheet-a.pdf. Accessed June 16, 2009.
Suominen K, Lönnqvist J. Determinants of psychiatric hospitalization after attempted suicide. Gen Hosp Psychiatry. 2006;28:424-430.
Goldberg JF, Ernst CL, Bird S. Predicting hospitalization versus discharge of suicidal patients presenting to a psychiatric emergency service [brief report]. Psychiatr Serv. 2007;58:561-565. Available at: http://ps.psychiatryonline.org/cgi/content/full/58/4/561. Accessed June 5, 2009.
Baca-García E, Diaz-Sastre C, Resa EG, Blasco H, Conesa, DB, Saiz-Ruiz J, et al. Variables associated with hospitalization decisions by emergency psychiatrists after a patient's suicide attempt. Psychiatr Serv. 2004;55:792-797. Available at: http://ps.psychiatryonline.org/cgi/content/full/55/7/792. Accessed June 5, 2009.
Baraff LJ, Janowicz N, Asarnow JR. Survey of California emergency departments about practices for management of suicidal patients and resources available for their care. Ann Emerg Med. 2006;48:452-458.
Simon R, Shuman DW. The standard of care in suicide risk assessment: an elusive concept. CNS Spectr. 2006;11:442-445. Available at: http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=470. Accessed June 5, 2009.
Kallert TW, Glöckner M, Schützwohl M. Involuntary vs voluntary hospital admission. A systematic literature review on outcome diversity. Eur Arch Psychiatry Clin Neurosci. 2008;258:195-209.
Stern TA, Fricchione GL, Cassem NH, Jellinek MS, Rosenbaum JF, eds. Massachusetts General Hospital Handbook of General Hospital Psychiatry. 5th ed. Philadelphia, Pa: Mosby;2004 .
Junginger J. Command hallucinations and the prediction of dangerousness. Psychiatr Serv. 1995;46:911-914.
Simon RI. Suicide risk assessment: is clinical experience enough? J Am Acad Psychiatry Law. 2006;34:276-278.
McNiel DE, Fordwood SR, Weaver CM, Chamberlain JR, Hall SE, Binder RL. Effects of training on suicide risk assessment. Psychiatric Serv. 2008;59:1462-1465.
Woo BK, Ma AY. Psychiatric inpatient care at a county hospital before and after the inception of a university-affiliated psychiatry residency program. J Psychiatr Pract. 2007;13:343-348.
Figure.
Process indicators noted to be determinants of hospitalization or discharge of psychiatric patients as described in the American Psychiatric Asssociation's Practice Guidelines for the Treatment of Psychiatric Disorders3 as well as from published literature on suicidal risk factors.2,7-10 *Verbal agreement from the patient not to harm self. †Psychiatrist followed up with nursing staff or family members to ensure that patient medications were taken away or locked up.
Figure.
Process indicators noted to be determinants of hospitalization or discharge of psychiatric patients as described in the American Psychiatric Asssociation's Practice Guidelines for the Treatment of Psychiatric Disorders3 as well as from published literature on suicidal risk factors.2,7-10 *Verbal agreement from the patient not to harm self. †Psychiatrist followed up with nursing staff or family members to ensure that patient medications were taken away or locked up.
Table 1
Retrospective Review of Medical Records for Patients Admitted Involuntarily for Emergent Psychiatric Care: Characteristics of Patients (N=145)

Characteristic

No. (%)*
Sex
□ Men 76 (52.4)
□ Women69 (47.6)
Age, mean (SD) 36.5 (12.7)
Marital Status
□ Married 27 (18.6)
□ Never married85 (58.6)
□ Divorced 33 (22.8)
Race and/or Ethnicity
□ White 95 (65.5)
□ Hispanic38 (26.2)
□ African American 8 (5.5)
□ Asian3 (2.1)
□ Other 1 (0.7)
Mental Disorder Diagnosis
□ Psychotic 38 (26.2)
□ Bipolar32 (22.1)
□ Depressive 30 (20.7)
□ Substance abuse22 (15.2)
□ Adjustment 20 (13.8)
□ Other
3 (2.0)
 *Data are presented as No. (%) unless otherwise indicated.
Table 1
Retrospective Review of Medical Records for Patients Admitted Involuntarily for Emergent Psychiatric Care: Characteristics of Patients (N=145)

Characteristic

No. (%)*
Sex
□ Men 76 (52.4)
□ Women69 (47.6)
Age, mean (SD) 36.5 (12.7)
Marital Status
□ Married 27 (18.6)
□ Never married85 (58.6)
□ Divorced 33 (22.8)
Race and/or Ethnicity
□ White 95 (65.5)
□ Hispanic38 (26.2)
□ African American 8 (5.5)
□ Asian3 (2.1)
□ Other 1 (0.7)
Mental Disorder Diagnosis
□ Psychotic 38 (26.2)
□ Bipolar32 (22.1)
□ Depressive 30 (20.7)
□ Substance abuse22 (15.2)
□ Adjustment 20 (13.8)
□ Other
3 (2.0)
 *Data are presented as No. (%) unless otherwise indicated.
×
Table 2
Retrospective Review of Medical Records for Patients Admitted Involuntarily for Emergent Psychiatric Care: Documentation of Process Indicators* (N=145)

Process Indicator

No. (%)
Suicide Risk Factors
□ Access to firearms 110 (75.9)
□ Recent stressful life events109 (75.2)
□ Suicidal ideation 99 (68.3)
□ Recent substance abuse or dependence95 (65.5)
□ Previous suicide attempts 94 (64.8)
□ Family history of suicidal behaviors94 (64.8)
□ Previous psychiatric diagnoses 90 (62.1)
□ Impulsivity or aggression85 (58.6)
□ Signs of major depressive disorder 78 (53.8)
□ Self-injurious behaviors71 (49.0)
□ Feelings of hopelessness 45 (31.0)
□ Current suicide plan44 (30.3)
□ Command hallucinations to harm self 31 (21.4)
□ History of verbal, physical, or sexual abuse15 (10.3)
□ New onset of severe medical condition 5 (3.5)
Protective Risk Factors
□ Contract for safety 108 (74.5)
□ Barriers to suicide or reasons for living99 (68.3)
□ Social support system 99 (68.3)
Continuity of Care
□ Follow-up removal of medications from patients who attempted overdose
6 (24)§
 *Medical records were reviewed for 19 process indicators that were identified from risk factors and treatment guidelines described in the literature. Assessments that stated a process indicator was not met by a patient were included in documentation data.
 Verbal agreement from patient not to harm self.
 Psychiatrist followed up with nursing staff or family members to ensure that patient medications were taken away or locked up.
 §Percentage is calculated based on the total number of patients whose medications were removed (n=25).
Table 2
Retrospective Review of Medical Records for Patients Admitted Involuntarily for Emergent Psychiatric Care: Documentation of Process Indicators* (N=145)

Process Indicator

No. (%)
Suicide Risk Factors
□ Access to firearms 110 (75.9)
□ Recent stressful life events109 (75.2)
□ Suicidal ideation 99 (68.3)
□ Recent substance abuse or dependence95 (65.5)
□ Previous suicide attempts 94 (64.8)
□ Family history of suicidal behaviors94 (64.8)
□ Previous psychiatric diagnoses 90 (62.1)
□ Impulsivity or aggression85 (58.6)
□ Signs of major depressive disorder 78 (53.8)
□ Self-injurious behaviors71 (49.0)
□ Feelings of hopelessness 45 (31.0)
□ Current suicide plan44 (30.3)
□ Command hallucinations to harm self 31 (21.4)
□ History of verbal, physical, or sexual abuse15 (10.3)
□ New onset of severe medical condition 5 (3.5)
Protective Risk Factors
□ Contract for safety 108 (74.5)
□ Barriers to suicide or reasons for living99 (68.3)
□ Social support system 99 (68.3)
Continuity of Care
□ Follow-up removal of medications from patients who attempted overdose
6 (24)§
 *Medical records were reviewed for 19 process indicators that were identified from risk factors and treatment guidelines described in the literature. Assessments that stated a process indicator was not met by a patient were included in documentation data.
 Verbal agreement from patient not to harm self.
 Psychiatrist followed up with nursing staff or family members to ensure that patient medications were taken away or locked up.
 §Percentage is calculated based on the total number of patients whose medications were removed (n=25).
×