“Severe pain can trigger suicide in hospital ERs” the headline reads. If they’re still calling it an “ER” you already know they’re clueless.
The article at the National Library of Medicine cites a new “Sentinel Event Alert” from the Joint Commission (.pdf download) urging emergency departments to be on the lookout for patients who may commit suicide in the Emergency Department.
Since 1995, there have been 827 reports of patient suicides in the United States. Of those, about 14% are in non-behavioral health units, making a total of about 116 non-psychiatric inpatient suicides in 15 years. That’s about 8 inpatient suicides per year out of 198 million inpatient days per year (644 inpatient days per 1000 population in US x 307 million US population) for a total chance of an inpatient committing suicide on any given day of … 1 in 24.75 million. Now I admit that the numbers may be off by one in a couple million or so because reporting suicides is voluntary for hospitals, so not all suicides get reported.
The Joint Commission also breaks down the number of suicides reported in the emergency department since 2005 — 8% of 827 reports or about 66 patients. In 15 years in all the emergency department in the country, 66 people killed themselves. That adds up to about 4 patients per year. Let’s round up to 5 patients per year who kill themselves in emergency departments. During that same time period, the number of emergency department visits per year averaged 100 million. Latest statistics show that we’re up to about 117 million emergency department patient visits per year. So the number of suicides committed per patient visit in the emergency department is about … 1 in 25 million – give or take a few million.
Now the Joint Commission’s “Sentinel Event Alert” wants hospitals to take a bunch of additional affirmative steps to make sure that even less than 1 in 25 million patients commits suicide.
Hospital staff is more likely to buy a winning lottery ticket than they are to find an inpatient who will commit suicide on any given day. Yet not only are hospital staff required to keep a close look-out for suicidal patients, but they and/or the hospitals will be held responsible for a “never event” if an inpatient actually does commit suicide.
You want an example of how people expect medicine in the United States to be “perfect”? Here it is.
I’m sure that all of the JCAHO minions are furiously typing out a counterargument that “WhiteCoat is a cold heartless person. He doesn’t care about trying to save people who might commit suicide.” Yeah, well cool your keyboards. Maybe we can ask a patient if they’re depressed or suicidal. Give them a number to follow up with a counselor. I might agree to that.
But JCAHO and our government have a page and a half long list of “recommendations” that medical providers are supposed to follow in order to prevent suicide – include “doing suicide screenings in the ER, screening all patients for depression when they’re admitted to a hospital, checking anyone deemed to be at risk for items they could use to harm themselves, and encouraging staff to call a mental health professional to evaluate patients believed to be at risk.” I uploaded the alert to EP Monthly’s site here in case JCAHO decides to take it down or the link goes dead.
Let’s say that we implement all of JCAHO’s recommendations – just in the emergency department. Not only do we need to perform all the screening, we also need to DOCUMENT that we perform all the screening because when the clipboard brigade comes knocking for an audit, you better be able to prove that you actually did the screening that they “recommend.” Conservatively, let’s say that such screening and documentation takes 10 minutes. Multiply that by 117 million patient visits. If every emergency department in the country implements JCAHO’s recommendations, emergency department staff will spend an extra 2o million hours each year looking for a needle that is in a haystack the size of Texas (which just happens to have a population of 25 million).
Those screening and documentation procedures add up to 20 million hours less patient care. That’s 20 million hours that won’t be available to treat patients waiting in the waiting rooms. Twenty million less hours to dispense medications, discharge patients, and monitor critically ill patients. More than 100 million extra pieces of paper to document adherence. And those numbers don’t even count all the extra time spent doing additional screening and documentation when the patient make it to the medical floors.
What’s the cost to the system? If we assume that emergency department nurses make $35/hour, those 20 million hours add up to $700 million per year … to screen for a problem that occurs 5 times per year. Then add in the cost of the paper and of all the supervisors who then have to go through the charts to make sure that the documentation is present (and properly completed) and the time cost throughout the country easily surpasses $1 billion. Well, if only half the hospitals in the US implement the recommendations, the cost is only a measly $500 million.
These safety recommendations were created by the government’s Patient Safety Advisory Group, a group that was chaired by an astronaut named James Bagian and co-chaired by a pharmacist named Michael Cohen. Now you have another example of what happens when non-clinicians create policy for those of us in clinical practice.
But at least patients are safer …. right?