Phase 3: Intervention Site Training Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Phase 3: Intervention Site Training 1

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

Overview In all phases: Similar to Phase 2, for Phase 3: 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 4 4

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 5 5

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 6 6

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) Slide 7 7

Outline of Presentation Phase overview New information for Phase 3 Changes in REDCap databases Reminders

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 9 9

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 10 10

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 11 11

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 12 12

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 13 13

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 14 14

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 15 15

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 16 16

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 Slide 17 17

Outline of Presentation Overview New information for Phase 3 Changes in REDCap databases Reminders

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 19 19

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 20 20

REDCap Screening Logs New Questions #2-4 (in yellow): Any documented thoughts or behaviors related to intentional self-harm, including suicidal and non-suicidal, on patient chart? Yes, past self-harm ideation/behavior only (patient screened and endorsed self-harm ideation/behavior in past, but not currently) Yes, current self-harm (patient screened and endorsed self-harm ideation/behavior 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 21 21

REDCap Shift Summary No change to Shift Screening Summary Database Enter Phase 3 data into existing database Slide 22 22

Longitudinal Database No change to the Longitudinal Database Enter Phase 3 data into existing database Slide 23 23

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 24 24

REDCap Fidelity Interview No change in Fidelity Interview database Enter Phase 3 data into existing database Slide 25 25

Outline of Presentation Overview New information for Phase 3 Changes in REDCap databases Reminders

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 27 27

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 28 28

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 29 29

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 30 30

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 31 31

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 32 32

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 33 33

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 34 34

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 35 35

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 36 36

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 37 37

Chart Review In each phase, 2 groups have chart reviews: Enrolled subjects (performed after index ED visit) 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 38 38

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 39 39

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 40 40

Questions? REDCap inquiries: Mardi Coleman (mardia.coleman@umassmed.edu) General ED-SAFE or AE inquiries: Sarah Ting (sting@partners.org) Slide 41 41