Factors Influencing Emergency Department Staff Decision-Making for People Attending in Suicidal Crisis: A Systematic Review

Figures & data

TABLE 1. Inclusion and exclusion criteria.

Inclusion criteria Population(s) and condition of interest	Population(s): ED doctors, triage nurses, mental health nurses, psychiatrists/psychiatry residents, medical record coders, ED managers. Condition of interest: suicidal ideation, self-harm, suicide attempt.
Intervention(s)/Exposure	People who have attended an ED for suicidal behavior and/or thoughts.
Comparators	None.
Outcome	Factors influencing ED staff decision-making on patient clinical pathways. Outcomes included: admission to hospital, self-discharge, referral to psychiatric inpatient unit.
Setting	Accident and emergency departments.
Study designs	Qualitative, mixed methods, randomized controlled trial, non-randomized quantitative studies.
Exclusion criteria	Non-English language studies where translation could not be obtained. Studies only reporting on mental health, with no mention of suicide. Studies outside of the ED, e.g., psychiatric emergency units, GP setting. Studies examining patient decision-making. Exclude: protocols, chapters, case studies.

FIGURE 1. PRISMA flow diagram indicating the steps taken to retrieve relevant articles for systematic review.

TABLE 2. Studies included in this review.

Author(s)	Study design	Participants	Setting	Relevant findings
Arensman et al. (2018).	Cross-sectional	101,904 Presentations, involving 63,457 self-harm attendances (2004–2012).	Ireland.	Male gender, older age, method of self-harm, time of attendance and residence of patient were identified as influencing care. Lethal methods of self-harm associated with psychiatric admission.
Baca-García et al. (2004).	Cross-sectional	Staff: on-call psychiatry residents. 509 Patients following a suicide attempt (1996–1998).	Madrid, Spain.	Patient factors (intent, lethality, previous psychiatric hospitalization and suicide attempt in past year) increased odds of hospitalization.
Betz et al. (2013)	Questionnaire	631 ED staff. 48% were nurses and half were attending (22%) or resident (30%) physicians.	Eight EDs, USA.	Confidence among clinicians was higher for suicidal ideation screening (81–90%) than creating safety plans (23–40%). Screening for suicidal ideation associated with confidence, feeling that suicidal patient care was a top ED priority and 5+ postgraduate years of experience.
Drew et al. (2006).	Cross-sectional	Hospital A: medical record coders. Hospital B and C: psychiatric residents. 163 Presentations with suicidal ideation (n = 110) or behavior (n = 53) over 1-month period.	Three EDs, Northeast Ohio, USA.	Regardless of a patient’s level of suicidality, decision-making was cautious. Most patients admitted to psychiatric inpatient units (34.4%) or transferred to another facility (36.8%). Of the 19% discharged home, 6% referred to mental health services or addiction treatment programmes.
Egan et al. (2012)	Questionnaire	125 Medical staff (28 doctors and 97 nurses).	Five EDs, Ireland.	Staff knowledge and confidence in managing self-harm influenced decision-making. The majority of staff felt ‘somewhat confident’ in responding to self-harm (74%). 63.2% reported a ‘somewhat negative’ attitude toward self-harming patients.
Faris et al. (2019).	Retrospective case review.	195 Patients requiring psychiatric consultation (July–December 2016)	Beirut, Lebanon.	Hospital admission was associated with being female (OR = 3.042), family history of psychiatric disease (OR = 2.040) and suicidal ideation (OR = 12.949). Living alone, age and employment status were not associated with hospitalization.
Griffin et al. (2020).	Cross-sectional	14,555 Self-harm presentations (January 2017–December 2018).	ED, Ireland.	Patient factors were primarily associated with: Self-discharge: male, younger age, alcohol involvement. Medical admission: older age, drug overdose as sole method, ambulance presentations. Psychiatric admission: male, lethal methods and older age. Variation in psychiatric admissions and psychosocial assessments was due to hospital factors (availability of psychiatric inpatient facilities and mental health staff).
Hepp et al. (2004).	Cross-sectional	Staff: psychiatric residents. 324 Presentations following a suicide attempt (1996–1998).	Zurich, Switzerland	Older patients more likely to be hospitalized. Outpatient treatment was received more by women. Lethal methods, history of psychiatric inpatient treatment, and psychotic disorders were associated with inpatient treatment. Outpatient treatment was linked to adjustment and neurotic disorders.
Jimenez-Trevino et al. (2015).	Cross-sectional	2,281 Suicidal presentations.	Three EDs. Madrid, Oviedo and Santa Cruz de Tenerife, Spain.	Intent was the most important factor impacting hospitalization. Older age, living alone, self-harm method, history of suicidal behaviors, and psychiatric diagnosis of schizophrenia, mood, or personality disorder were independently associated with being admitted.
Kroll et al. (2018).	Questionnaire	40 Adults requiring inpatient psychiatric care due to suicide risk.	USA.	25% Of the patients could have been discharged had social support become available. Clinical severity was the only driver to admission decision.
McCann et al. (2007).	Questionnaire	43 ED Nurses.	Australia.	Most nurses had no educational preparation or training to support self-harm. Over 20% had either no practice guidelines for self-harm or they did not know of their existence. One-third of those who were aware of their existence had not read them. Overall, nurses had sympathetic attitudes toward self-harm and did not discriminate in their triage or care decisions.
Phillips et al. (2015).	Cross-sectional questionnaire	211 Mental health nurses.	Australia.	High level of variation in outcomes; despite agreement about the intent of self-harm. Agreement was often reached regarding intent, but not for imminent risk. Little agreement about whether to admit a patient with self-harm to hospital or treat in the community.
Polling et al. (2019).	Cross-sectional	20,750 Self-harm attendances (2009–2016).	Four EDs, Southeast London, UK.	Admissions varied substantially between hospitals; one hospital was two and a half times more likely to admit than another. This was not altered by patient demographics, deprivation or self-harm method.
Pope et al. (2017).	Semi-structured interviews	11 ED doctors, 3 ED nurses, 3 managers and 4 inpatient doctors.	Three EDs, London, UK.	Service availability, outpatient alternatives, staffing, busyness, time of day and the 4-hour waiting time target influenced decision to admit rather than discharge. ED culture (staff attitudes, motivation and relationships) had a strong influence (negatively or positively) on the decision to admit patients.
Schmutte et al. (2019a).	Retrospective cohort analysis.	16,495 Adults ≥65 years deliberate self-harm attendances.	USA.	Hospitalization associated with recent depression and psychiatric inpatient care. People of African American ethnicity less likely to be hospitalized. 56.4% Of community discharges received an ED medical disorder diagnosis and 39.0% received 30-day follow-up outpatient mental health care.
Schmutte et al. (2019b).	Retrospective cohort analysis.	50,472 Suicidal ideation or self-harm presentations in 2015.	USA.	Self-harm with suicidal ideation attendances were most likely to result in hospitalization (94.7%), compared to ideation (84.0%) or self-harm alone (73.1%). Hospital admission associated with current diagnosis of depression, bipolar, anxiety or personality disorder and severity of current medical comorbidity.
Schmutte et al. (2020).	Retrospective cohort analysis.	52,383 Suicide-related Medicare claims for adults ≥65 years (2015).	USA.	Suicide attempt and ideation presentations were less likely to be discharged to the community than self-harm. These encounters were more likely to be diagnosed with a mental disorder in the ED and were also more likely to receive follow-up mental health care compared self-harm presentations.

Arensman, E., Griffin, E., Daly, C., Corcoran, P., Cassidy, E., & Perry, I. J. (2018). Recommended next care following hospital-treated self-harm: Patterns and trends over time. PLOS one, 13(3), e0193587.

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Baca-García, E., Diaz-Sastre, C., Resa, E. G., Blasco, H., Conesa, D. B., Saiz-Ruiz, J., & De Leon, J. (2004). Variables associated with hospitalization decisions by emergency psychiatrists after a patient’s suicide attempt. Psychiatric services, 55(7), 792–797.

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Betz, M. E., Sullivan, A. F., Manton, A. P., Espinola, J. A., Miller, I., Camargo, C. A., … Jr, ED-SAFE Investigators. (2013). Knowledge, attitudes, and practices of emergency department providers in the care of suicidal patients. Depression and Anxiety, 30(10), 1005–1012.

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Drew, B. L., Jones, S. L., Meldon, S. W., & Varley, J. D. (2006). Emergency department visits for suicidality in three hospitals. Archives of Psychiatric Nursing, 20(3), 117–125. doi:10.1016/j.apnu.2005.11.001

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Egan, R., Sarma, K. M., & O'Neill, M. (2012). Factors influencing perceived effectiveness in dealing with self-harming patients in a sample of emergency department staff. The journal of Emergency Medicine, 43(6), 1084–1090.

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Faris, N., Baroud, E., Al Hariri, M., Bachir, R., El-Khoury, J., & Batley, N. J. (2019). Characteristics and dispositional determinants of psychiatric emergencies in a University Hospital in Beirut. Asian journal of Psychiatry, 42, 42–47.

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Griffin, E., Gunnell, D., & Corcoran, P. (2020). Factors explaining variation in recommended care pathways following hospital-presenting self-harm: A multilevel national registry study. BJPsych open, 6(6), 1–8.

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Hepp, U., Moergeli, H., Trier, S. N., Milos, G., & Schnyder, U. (2004). Attempted suicide: Factors leading to hospitalization. The Canadian Journal of Psychiatry, 49(11), 736–742.

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Jimenez-Trevino, L., Saiz, P. A., Corcoran, P., Burón, P., García-Portilla, M. P., Chinea, E. R., … Bobes, J. (2015). Factors associated with hospitalization after suicide spectrum behaviors: Results from a multicenter study in Spain. Archives of Suicide Research, 19(1), 17–34.

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Kroll, D. S., Karno, J., Mullen, B., Shah, S. B., Pallin, D. J., & Gitlin, D. F. (2018). Clinical severity alone does not determine disposition decisions for patients in the emergency department with suicide risk. Psychosomatics, 59(4), 388–393.

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McCann, T. V., Clark, E., McConnachie, S., & Harvey, I. (2007). Deliberate self‐harm: Emergency department nurses’ attitudes, triage and care intentions. Journal of Clinical Nursing, 16(9), 1704–1711. doi:10.1111/j.1365-2702.2006.01555.x

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Phillips, G., Gerdtz, M. F., Elsom, S. J., Weiland, T. J., & Castle, D. (2015). Mental health nurses’ dispositional decision‐making for people presenting to the emergency department with deliberate self‐harm: An exploratory study. Perspectives in Psychiatric Care, 51(2), 148–153.

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Polling, C., Bakolis, I., Hotopf, M., & Hatch, S. L. (2019). Differences in hospital admissions practices following self-harm and their influence on population-level comparisons of self-harm rates in South London: An observational study. BMJ open, 9(10), e032906.

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Pope, I., Burn, H., Ismail, S. A., Harris, T., & McCoy, D. (2017). A qualitative study exploring the factors influencing admission to hospital from the emergency department. BMJ open, 7(8), e011543. doi:10.1136/bmjopen-2016-011543

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Schmutte, T., Olfson, M., Xie, M., & Marcus, S. C. (2019a). Deliberate self‐harm in older adults: A national analysis of US emergency department visits and follow‐up care. International journal of Geriatric Psychiatry, 34(7), 1058–1069.

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Schmutte, T., Olfson, M., Xie, M., & Marcus, S. C. (2019b). National study of emergency department disposition for high suicide risk geriatric patients. General hospital Psychiatry, 58, 67–70.

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