Emergency Department Safety Assessment and Follow-up

Evaluation (ED-SAFE)

Phase 3: Intervention

Site Training

Outline of Presentation

• Overview

• New information for Phase 3

• Changes in REDCap databases

• Reminders

Outline of Presentation

• Overview

• New information for Phase 3

• Changes in REDCap databases

• Reminders

Slide 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

Slide 5

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

Slide 6

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

Slide 7

In All Phases…

While clinical staff’s cooperation is vital, we do not want to introduce treatment contamination

–Emphasize that we don’t 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)

Outline of Presentation

• Phase overview

• New information for Phase 3

• Changes in REDCap databases

• Reminders

Slide 9

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

Slide 10

New for Phase 3 (cont’d)

• Use the Phase 3-specific consent form

• Collect data on “incidental detections” in screening log (see Changes in REDCap databases)

Slide 11

New for Phase 3 (cont’d)

• 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

Slide 12

New for Phase 3 (cont’d)

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.

Slide 13

New for Phase 3 (cont’d)

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

Slide 14

New for Phase 3 (cont’d)

Advising Calls to Subject

– Evaluate subject’s 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)

Slide 15

New for Phase 3 (cont’d)

Advising Calls to Significant Other (SO)

– Review SO’s 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

Slide 16

New for Phase 3 (cont’d)

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.

Slide 17

New for Phase 3 (cont’d)

Subject Interview

– Subjects are NOT compensated for the advising calls

– Advising calls are NOT counseling

• Script for Phase 3 enrollment

Outline of Presentation

• Overview

• New information for Phase 3

• Changes in REDCap databases

• Reminders

Slide 19

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).

Slide 20

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)

Slide 21

REDCap Screening LogsNew Questions #2-4 (in yellow):

Any documented thoughts or behaviors related to intentional self-harm, including suicidal and non-

suicidal, on patient chart?

Yes, current self-harm (patient screened and endorsed self-harm

ideation/behavior currently)

Yes, past self-harm ideation/behavior only (patient screened and endorsed self-harm

ideation/behavior in past, but not currently)

Was this self-harm ideation/behavior documented in the Patient Safety Screener?

No

Yes

Did the patient report that over the past 2 weeks, he/she had thoughts of killing

him/herself? (Yes/No)

Did the patient report attempting to kill him/herself <6 months before the current

ED visit? (Yes/No)

Slide 22

REDCap Shift Summary

• No change to Shift Screening Summary Database

• Enter Phase 3 data into existing database

Slide 23

Longitudinal Database

• No change to the Longitudinal Database

• Enter Phase 3 data into existing database

Slide 24

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

Slide 25

REDCap Fidelity Interview

• No change in Fidelity Interview database

• Enter Phase 3 data into existing database

Outline of Presentation

• Overview

• New information for Phase 3

• Changes in REDCap databases

• Reminders

Slide 27

Case Identification

• Do not use documentation of self-harm ideation/behavior from the patient’s 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)

Slide 28

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

Slide 29

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

Slide 30

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

Slide 31

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

Slide 32

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

Slide 33

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

Slide 34

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

Slide 35

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.

Slide 36

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

Slide 37

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.

Slide 38

Chart Review

In each phase, 2 groups have chart reviews:

1. Enrolled subjects (performed after index ED visit)

2. 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.

Slide 39

Chart Review (cont’d)

• 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

Slide 40

REDCap Password Reset

• Need to reset your password if you haven’t logged into REDCap in the last 30 days

• Complete this form to reset your password https://arcsapps.umassmed.edu/redcap/surveys/?s=wEFY2U

• On form, enter “Mardi Coleman” as study coordinator

Slide 41

Questions?

• REDCap inquiries: Mardi Coleman (mardia.coleman@umassmed.edu)

• General ED-SAFE or AE inquiries: Sarah Ting (sting@partners.org)