Detecting and responding to self-directed violence risk in an emergency department

Objectives

This study investigated how Emergency Department (ED) clinicians assess risk of self-directed violence by exploring clinician perceptions of the risk assessment process, the need for medical record documentation, and the impact of finite resources.

Methods

Focus groups were conducted with ED physicians at a large southwestern medical center, including three groups with medical ED attendings (N=10) and one with residents (N=6).  An interviewer trained in non-directive methods used an 8-question protocol to facilitate discussions of risk assessments.  Group discussions were recorded and transcribed.  Analysis included generation of themes, establishing inter-rater reliability, and coding passages using ATLAS.ti, with interpretation of results by the analytic team.

Results

Eight themes emerged from the focus groups:  provider resources, elements of patient assessment, general patient assessment, clinical management, suicide risk screen, provider apprehension about suicide risk, provider risk/benefit, and ED role and scope.  Altogether, 1,219 passages were coded.  Provider resources (33%) and elements of patient assessment (28%) were the most frequent themes, with all themes representing >9% of the total content.  Themes were further broken down into specific elements.

Discussion

Findings highlight complexities of risk assessment in an ED burdened by high demands on time, limited resources, clinicians’ personal concerns, and the consequences of accurately detecting and assessing suicidality.  Although possible solutions, such as increasing training or providing specialized support, appear obvious, the complex needs discussed here suggest that implementation of solutions requires accounting for the multiple competing demands on ED clinicians and the multifaceted nature of treatment in the ED.