The finding:
A random sample of emergency department (ED) nursing directors was surveyed to ascertain whether their EDs provided best practices in suicide risk management for patients presenting after self-harm. Among 513 respondents, 73% reported assessing for suicidal ideation and past suicidal thoughts; 61% assessed for access to lethal means; 39% reported scheduled mental health appointments during business hours; and 30% completed safety planning for patients presenting after self-harm. The investigators then sought to identify differences between hospital characteristics and provision of emergency psychiatric services. Most hospital characteristics did not associate with service provision. However, EDs with contractual arrangements with outpatient providers were more likely to provide appointments. Also, screening was more common among EDs in areas with high suicide rates, and safety planning was more frequent among eds with more substantial psychiatric consultation resources.

Strength and weaknesses:
The authors achieved a very good response rate among a nationally representative sample of EDs. The descriptions of hospitals were obtained from a national hospital dataset. This methodology reduces the risk of response bias or inaccurate representation of included hospitals. Very little data were missing. However, information on service provision depended on a single respondent from each institution, and the survey instrument is not well-described or provided. Respondents are likely to overstate the provision of services, especially for elements such as screening and safety planning that are required or encouraged by regulatory bodies.

Relevance:
This study provides an important description of psychiatric emergency services in community and academic hospitals nationwide. Notwithstanding differences in the availability of mental health services across geographic regions and hospital systems, even basic mental health services that could be easily provided for patients after self-harm—such as safety planning and appointments to outpatient services—are not routinely provided. The ready availability of emergency care for persons with suicidal ideation or self-harm is not in doubt; whether that care is evidence-based and of high quality appears much less likely. Given the high-risk patients who present to EDs, C-L psychiatrists should be active partners in improving emergency care at their local institutions.

Type of study (EBM guide):
cross-sectional survey study