Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE)

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Emergency Department Safety Assessment and
Follow-up Evaluation (ED-SAFE)

• Phase 3 Intervention
• Site Training

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Outline of Presentation

• Overview
• New information for Phase 3
• Changes in REDCap databases
• Reminders

3
Outline of Presentation

• Overview
• New information for Phase 3
• Changes in REDCap databases
• Reminders

4
Overview

• In all phases
• Patient enrollment in ED
• 5 follow-up phone calls
• Similar to Phase 2, for Phase 3
• Staff KAP survey administered 3 months after the
  start of the phase
• Chart reviews of randomly selected patients
  performed after the phase is complete
• Expect that site enrollment goals will be met
  more quickly
• Fidelity interviews of 60 randomly selected ED
  patients with no documentation of SI/SA in past
  week
• First 2 weeks and last 2 weeks of the phase

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Site Enrollment Goal

• 60 subjects

30 subjects with suicidal ideation only in past
week
30 subjects with suicidal attempt in past week
60 / 26 weeks 2.3 / week
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In All Phases

• RAs will screen ED documentation (charts,
  electronic information systems) in real time to
  identify patients
• RAs will further screen anyone with evidence of
  any intentional self-harm ideation or behavior in
  the past week, including the current visit
• ? Reminder Administer eligibility screening
  questions even though questions about SI and SA
  have already been asked by clinical staff.
• This will involve asking the clinicians for
  permission to approach the patient

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In All Phases

• While clinical staffs cooperation is vital, we
  do not want to introduce treatment contamination
• Emphasize that we dont want clinical staff to do
  anything different than they ordinarily would
• The clinical staff should not be told to let the
  RAs know when a suicidal patient is present
  (i.e., referral)

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Outline of Presentation

• Phase overview
• New information for Phase 3
• Changes in REDCap databases
• Reminders

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New information for Phase 3

• Subject ID numbers start in the 300s
• (3-digit site sequential starting with 301)
• Example ?
• Subject ID for 3rd subject enrolled at site 600
  600303

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New for Phase 3 (contd)

• Use the Phase 3-specific consent form
• Collect data on incidental detections in
  screening log (see Changes in REDCap databases)

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New for Phase 3 (contd)

• The intervention for Phase 3 is called the Safety
  Assessment and Follow-up Telephone Intervention
  (SAFTI)
• Purpose to ensure that patients at-risk for
  suicide leave the care of the hospital with
  suicide prevention information
• Discharge nurse will ensure that patient receives
  safety plan and community resource sheet

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New for Phase 3 (contd)

• Subject Interview
• Same as Phases 1 and 2 Subjects enrolled will
  complete follow-up assessments at 6, 12, 24, 36,
  and 52-weeks following baseline enrollment
• New for Phase 3 Subjects will receive up to 7
  Advising Calls (previously labeled intervention
  counseling calls). In addition, if subject
  agrees, a significant other (chosen by the
  subject) also will receive up to 4 advising
  calls.

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New for Phase 3 (contd)

• Advising Calls
• Based on an integration of case-management,
  cognitive-behavioral and family/significant other
  interventions.
• To subject 1, 2, 4, 10, 22, 34, and 48 weeks
  following enrollment
• To significant other 3, 8, 20, and 32 weeks
  following enrollment

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New for Phase 3 (contd)

• Advising Calls to Subject
• Evaluate subjects current status (e.g., suicide
  risk)
• Review/evaluate safety plan
• Assess potential suicide risk factors
• Discuss potential solutions to identified
  issues/risk factors (problem solving)

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New for Phase 3 (contd)

• Advising Calls to Significant Other (SO)
• Review SOs concerns regarding subject
• Brief psychoeducation regarding suicide and risk
  factors
• Review of safety plan
• Discuss problem solving techniques for dealing
  with identified issues/risk factors

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New for Phase 3 (contd)

• Subject Interview
• Make sure to emphasize that it is up to 7
  advising calls this number is flexible
  depending on the needs/requests of the subject.
• Avoid focusing on the calls being a certain
  length (e.g., 15 minutes), simply emphasize that
  the advising calls will be brief and that the
  subject will have control over the call length.

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New for Phase 3 (contd)

• Subject Interview
• Subjects are NOT compensated for the advising
  calls
• Advising calls are NOT counseling
• Script for Phase 3 enrollment

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Outline of Presentation

• Overview
• New information for Phase 3
• Changes in REDCap databases
• Reminders

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REDCap Screening Logs

• No change in the way data are entered
• However, enter Phase 3 data into Phase 3-specific
  database
• New for Phase 3 Questions for identifying
  incidental detection cases. These cases are
  patients who present to the ED with
  non-psychiatric complaints, but screen positive
  for recent SI or SA on the Patient Safety
  Screener (PSS).

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REDCap Screening Logs

• New Question 1 Visit related to psychiatric
  complaint? (Yes/No)
• Yes Patient has documentation from ED visit
  that one of the reasons for visit was a
  psych-related issue (e.g., suicidal
  thoughts/behavior, depression, alcohol
  intoxication, substance withdrawal, accidental
  overdose)

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REDCap Screening Logs

• New Questions 2-4 (in yellow)

Any documented thoughts or behaviors related to
intentional self-harm, including suicidal and
non-suicidal, on patient chart?
Yes, past self-harm ideation/behavior only
(patient screened and endorsed self-harm
ideation/behavior in past, but not currently)
Yes, current self-harm (patient screened and
endorsed self-harm ideation/behavior currently)
Was this self-harm ideation/behavior documented
in the Patient Safety Screener?
No
Yes
Did the patient report attempting to kill
him/herself lt6 months before the current ED
visit? (Yes/No)
Did the patient report that over the past 2
weeks, he/she had thoughts of killing
him/herself? (Yes/No)
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REDCap Shift Summary

• No change to Shift Screening Summary Database
• Enter Phase 3 data into existing database

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Longitudinal Database

• No change to the Longitudinal Database
• Enter Phase 3 data into existing database

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Chart Review Database

• No change to chart review form/ functionality
• However, enter Phase 3 data into Phase 3-specific
  database
• No change in the way data are entered

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REDCap Fidelity Interview

• No change in Fidelity Interview database
• Enter Phase 3 data into existing database

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Outline of Presentation

• Overview
• New information for Phase 3
• Changes in REDCap databases
• Reminders

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Case Identification

• Do not use documentation of self-harm
  ideation/behavior from the patients medical
  history
• Only patients who endorse past/present self-harm
  ideation/behavior during the current visit should
  be approached (if all other eligibility criteria
  are met)

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Case Identification

• If chart or MD identifies transient exclusion
  criteria (e.g., intoxication) the patient should
  be pending or warm and approached later
• Pending patients should be resolved at the end
  of every shift
• Stable exclusion criteria
• Left ED before RA approach
• End of RA shift

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Eligibility

• Some may be eligible and interested, but the time
  may not be opportune (e.g., too distracted to
  participate during ED visit, busy with tests,
  being transferred to inpatient setting)
• May consent admitted or boarded patient within
  48 hours of ED discharge
• Warm transfer

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Screening Log

• Review all documentation available in the ED for
  the current ED visit
• At minimum, review the triage nursing notes (if
  patient presents with SI/SA/other self-harm
• Stop the review once you identify any self-harm
  and approach the patient
• When possible, review charts in order, but do not
  miss people with SI/SA
• If opportunity presents itself, enroll an
  attempter over an ideator

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Eligibility Considerations

• Ask to speak one-on-one with the patient if
  others are in the room
• Ask about self-harm and suicidal behavior even if
  the patient does not report self-harm or suicidal
  ideation

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Eligibility Screening

• Self-harm and suicidal behavior and ideation
• Thoughts of self-harm in past week
• Thoughts of ending life in past week
• Tried to hurt self in past week
• Tried to kill self in past week

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Wallet Card

• All patients approached regardless of whether
  or not they are enrolled receive a wallet card
  with a national hotline phone and safety plan
  tips

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Patient Resources

• Give all patients who decline to participate or
  meet exclusion criteria site-specific resources
  used by the ED for patients with psychiatric
  issues

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Baseline Assessment

• General Concepts
• If a patient refuses to answer a question, leave
  it blank in REDCap
• For questions that ask for exact numbers (e.g.,
  of suicide attempts) enter whole numbers. If a
  subject gives a range, take the average.

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Baseline Assessment (cont'd)

• May be completed after the subject leaves the ED
  if the subject
• already signed the written consent form
• is willing to finish the assessment in person or
  by phone within 48 hours

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Brochure

• All patients enrolled also receive a brochure
  that describes the study and expectations of
  participants.
• Enrolled subjects do NOT receive the list of
  patient resources.

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Chart Review

• In each phase, 2 groups have chart reviews
• Enrolled subjects (performed after index ED
  visit)
• Randomly selected ED patients from the period in
  which the site enrolled patients
• Note For TAU, the retro chart review served as
  2. For Phases 2 and 3, the chart review will be
  done after patient enrollment is complete.

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Chart Review (contd)

• Same form for all ED chart reviews
• Use any documentation that occurred while the
  patient was in the ED
• If a patient has both a current and past history
  of an item, document the most recent time period
  in which the indicator was present
• We will contact you at the end of Phase 3 to
  discuss random selection of charts

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REDCap Password Reset

• Need to reset your password if you havent logged
  into REDCap in the last 30 days
• Complete this form to reset your password
  https//arcsapps.umassmed.edu/redcap/surveys/?swE
  FY2U
• On form, enter Mardi Coleman as study
  coordinator

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Questions?

• REDCap inquiries Mardi Coleman
  (mardia.coleman_at_umassmed.edu)
• General ED-SAFE or AE inquiries Sarah Ting
  (sting_at_partners.org)

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