Using the Delphi Method for Determining Key Performance Elements for Delivery of Optimal Suicide-Specific Interventions in Emergency Departments

Abstract

Objective

Evidence-based suicide prevention interventions directed to those seeking psychiatric crisis services for suicidality in the emergency department (ED) can reduce death by suicide and related suffering. Best practice guidelines for the care of suicidal patients in the ED exist but are not accompanied by fidelity tools for use in determining whether the interventions were applied, particularly when more than one intervention is delivered concurrently. We sought to develop a universal, treatment-agnostic Suicide Care Fidelity Checklist comprised of Key Performance Elements (KPE) across the recommended suicide-specific ED interventions.

Method

A comprehensive review of published care standards was first conducted to determine suicide-specific ED best practice treatment domains and KPEs. Subject matter experts (SMEs) were identified for each domain. Using the Delphi Consensus method, SMEs iteratively revised and refined the KPEs within their domain until achieving KPE item consensus.

Results

A total of three iterations was required to obtain consensus in five of six domains: comprehensive suicide assessment, lethal means counseling, suicide crisis planning, behavioral skills training, and psychoeducation about suicidality. Consensus was not fully attained for the domain involving engagement with people with lived experience.

Conclusions

We successfully identified six intervention domains and 74 KPEs across domains (60 deemed essential, and 14 deemed optional), with full consensus reached for 70 KPEs. While replication of the initial findings is required, the Suicide Care Fidelity Checklist can be used as a fidelity checklist to verify delivery of suicide-specific ED interventions.

HIGHLIGHTS

• Applied Delphi Consensus method with suicide-specific subject matter experts.

• Generated a treatment-agnostic, universal set of suicide prevention KPEs for EDs.

• Expert-derived KPEs help real-world settings to assess suicide care fidelity.

Keywords:

• Delphi method fidelity
• emergency department
• suicide

ACKNOWLEDGEMENTS

The sponsor had no role in review or approval of this manuscript. The authors wish to express their gratitude to Adam Haim, PhD, Chief, Treatment and Preventive Intervention Research Branch at the National Institute of Mental Health (NIMH) and Program Officer, for his continued guidance of our work, as well as Jane Pearson, PhD, Chair, Suicide Research Consortium at the National Institute of Mental Health, for her early encouragement to include people with lived experience in our research efforts. Her gentle “nudge” in this direction transformed our approach to our work, including this effort. We are indebted to the many suicide experts who participated as domain experts for this study. They include: Michael Anestis, Joan Asarnow, Amy Barnhorst, Marian Betz, Edwin Boudreaux, Amy Brausch, Craig Bryan, Kathrine Comtois, Shannon Frattaroli, Julie Goldstein Grumet, Kelly Green, Peter Gutierrez, Christa Labouliere, DeQuincy Lezine, Jocelyn Meza, Andrada Neacsiu, Nick Salsman, Dese’Rae Stage, Jessica Stohlmann-Rainey, Jeffrey Sung, Kelechi Ubozoh, Lauren Weinstock, and Lucas Zullo. Finally, we would like to thank Kelly Koerner, PhD, co-founder of Jaspr Health, for her thoughtful edits to this final manuscript.

DISCLOSURE STATEMENT

Linda Dimeff co-owns the Evidence-Based Practice Institute, Inc., a for-profit company and recipient of the NIMH grant award that funds this effort. She receives royalties for her books from Guilford Press. She is co-owner of Portland DBT Institute, Inc., a for-profit outpatient specialty clinic that provides training and consultation services. David Jobes is the treatment developer of CAMS and receives royalties for his books from American Psychological Association Press and Guilford Press. He is a founder and co-owner of CAMS-care, LLC, a for-profit training and consultation organization.

Additional information

Funding

This research was supported by the National Institutes of Health (NIH)/National Institute of Mental Health [R44MH108222].

Notes on contributors

Linda A. Dimeff

Linda A. Dimeff, PhD, Evidence Based Practice Institute, Inc., Seattle, WA, USA.

David A. Jobes

David A. Jobes, PhD, Tia Tyndal, BA, and Irene Zhang, MA, The Catholic University of America, Washington, DC, USA.

Tia Tyndal

David A. Jobes, PhD, Tia Tyndal, BA, and Irene Zhang, MA, The Catholic University of America, Washington, DC, USA.

Irene Zhang

David A. Jobes, PhD, Tia Tyndal, BA, and Irene Zhang, MA, The Catholic University of America, Washington, DC, USA.

Susan Stefan

Susan Stefan, JD, Rutland, Rutland, MA, USA.

Nadia Kako

Nadia Kako, BS, Hannah Lawrence, BA, and Maria Ilac, BS, Evidence Based Practice Institute, Inc., Seattle, WA, USA.

Hannah Lawrence

Nadia Kako, BS, Hannah Lawrence, BA, and Maria Ilac, BS, Evidence Based Practice Institute, Inc., Seattle, WA, USA.

Maria Ilac

Nadia Kako, BS, Hannah Lawrence, BA, and Maria Ilac, BS, Evidence Based Practice Institute, Inc., Seattle, WA, USA.