ABSTRACT
Background: The COVID 19 pandemic and the murder of George Floyd have prompted healthcare organizations to reexamine racial inequities in their care, challenging us to produce lasting, fundamental change. Mental health disorders, both diagnosed and undiagnosed, have increased in volume and developed new challenges for acute care practitioners during the pandemic. Additionally previous research has suggested that there are intrinsic and extrinsic biases that affect how care is delivered to patients presenting with mental health crises. Method(s): Through nominal group technique, we identified topics for equitable-care-oriented QI in the emergency department (ED) of our Level-1 Trauma center. Initial review of triage, left-without-being-seen, and fast-track data did not demonstrate significant racial disparities in standard benchmarks. We therefore focused on behavioral codes and restraint use. We prospectively collected data on all behavioral codes over a 3-month period, including demographics, visit characteristics, and certain aspects of restraint use including type of restraint, length of restraints, medication use, and reinitiation of restraints. In addition to tracking these metrics, employee perceptions of the psychiatric mental health emergencies were polled and evaluated. Result(s): Our QI process identified varying levels of disparities in care. Over the study period, white, non-white, and black patients comprised 50.5%, 49.5%, and 28.7% of the ED patient population, respectively, and 50%, 50%, and 44% of the patients who were subject to behavioral codes. Of those patients who had behavioral codes called, restraints were used for 64.8% of white patients, 64.3% of non-white patients, and 67.2% of black patients. Of those arriving by ambulance or police, 20% arrived with pre-hospital restraints or handcuffs, and of those, 90.9% were placed in restraints on arrival to the ED. Of those patients who had restraints placed, 4-points were used for 34.1%, 26.1%, and 25.5% of white, non-white, and black patients, respectively, and the restraint chair was used for 30.7%, 38,6%, and 41.8% of those same groups. Medications were given to 80.7%, 88.7%, and 91.4% of white, non-white, and black patients who were placed in restraints, respectively, and to 77.4%, 80.6%, and 83.3% of those same groups of patients who were not placed in restraints. None of the differences were statistically significant. Of those patients who had restraints placed and then discontinued, 13% were re-restrained at some other point during their visit. Among other responses, nearly half of all ED employees thought that patients should ideally not be restrained during behavioral codes and that, if necessary, the restraint chair provides a better experience than 4-point restraints. Conclusion(s): Continuous QI around a variety of measures can identify disparities and targets for sustained anti-racist improvements in emergency department care. This study will guide further intervention and education around inequities in care in our department and has prompted further consideration of, when restraints are deemed necessary, preferentially using less invasive measures like the restraint chair over 4-point restraints. Although decision-making around chemical and physical restraints for mental health emergencies is complex and difficult to study, EDs should carefully examine their use through continuous QI in order to optimize patient-centered outcomes.
ABSTRACT
In 2020, suicide was the 12th leading cause of death for all ages in the United States, changing from the 10th leading cause in 2019 due to the emergence of COVID-19 deaths and increases in deaths from chronic liver disease and cirrhosis (1). As the second leading cause of death in people aged 10-34 and the fifth leading cause in people aged 35-54, suicide is a major contributor to premature mortality (1). Suicide rates increased from 2000 to 2018 (2-5), but recent data have shown declines between 2018 and 2020 (6,7). This report presents final suicide rates from 2000 through 2020, in total and by sex, age group, and means of suicide, using mortality data from the National Vital Statistics System (NVSS). This report updates a provisional 2020 report and a previous report with final data through 2019 (6,7).
ABSTRACT
This study described the epidemiology of suicide from 2018 to 2019. From 2018 to 2019, the suicide rate declined significantly among all persons, with decreases among males and females. Among American Indian/Alaskan Native individuals, the rate was highest in 2019. In 2019, the suicide rate among persons aged 85 years was highest among males, at 16.3 per 100,000. It was also highest among persons aged 55-64 years. The rate among females was highest among those aged 45-54 years. The suicide rate in 2019 was lowest in central metropolitan areas, with a rate of 11.9 per 100,000 residents. It increased as the urbanisation level declined. The rate remained stable in nonmetropolitan areas. In 2019, the majority of suicides were caused by firearms, with a suicide rate of 6.8 per 100,000. The rate of firearm suicides among males declined 2.9% from 2018 to 2019, and among females, the rate of suffocation decreased by 10.0%. The rate of poisoning among females decreased by 3.3%. Firearms were the most common method of suicide among all county levels in 2019. The percentage of suicides caused by firearms increased from 47.3% to 62.5% in rural areas, while the rate of suffocation and poisoning followed a similar pattern. The overall suicide rate decreased significantly in five states from 2018 to 2019. Among females, the rate declined significantly in Indiana, North Carolina, Virginia, and Massachusetts. The rate among males also declined in five states. The suicide rate declined in 2019 for the first time in 13 years, with significant declines among males and females. The rate declined in five states and in large fringe metropolitan areas. The decline in the suicide rate of gun suicides was especially encouraging. There is a link between mental illness and suicide, and it can be prevented through the identification and treatment of other risk factors. These factors include family and community barriers to suicide, employment barriers, and access to lethal means. As the world continues to grapple with the effects of the coronavirus disease 2019 pandemic, its long-term impacts are more critical than ever. This is evidenced by the rise in suicide rates following natural disasters and infrastructure disruption.