Basic Safety Planning Uncommon in Emergency Department Management of Self-Harm

Patients who present to an emergency room for self-harm are routinely assessed for suicide, but relatively few are offered basic safety planning, such as how to restrict access to lethal means or connect with available social supports.

Emergency departments (EDs) may not consistently employ evidence-based management practices in treating patients who present for self-harm, according to national survey data published in JAMA Psychiatry.

Investigators surveyed a random sample of 665 ED nursing directors selected from 2228 hospitals with 5 or more self-harm visits in the prior year. Surveys were mailed to participants between May 2017 and January 2018; the response rate was 77.1% (n=513). The survey assessed the availability of mental health services to ED patients presenting for self-harm, using a Likert-type scale. The scale classified responses as “on a routine basis” or “not on a routine basis,” with the latter category further delineated with “never or rarely,” “sometimes,” or “usually but not routine” options. Additional ED characteristics were collected, including patient volume, location, and mental health staffing levels.

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The majority of sampled EDs were urban (n=1669, 75.4%), nonteaching hospitals (n=1276, 57.6%) with high mental health staffing (n=1299, 58.3%). EDs provided a mean (SD) of 5.44 (0.14) of the 10 self-harm management practices described by the survey. The most commonly encountered patients were those who presented with self-harm for current suicidal intent/plans (n=2156, 97.6%), past suicidal thoughts/behaviors (n=1989, 90.6%), and access to lethal means (n=1708, 77.7%). The survey described 6 recommended safety planning elements to be administered to patients before discharge. However, just 2 of 6 elements were routinely provided by EDs: the provision of lists of professionals or agencies to contact in a crisis (n=1710, 79.2%) and helping patients to recognize the warning signs of suicide (n=1075, 52.2%). Just 15.3% (n=342) of departments routinely provided all recommended safety planning measures. No significant differences in emergency self-harm management practices were identified by urban/rural status, mental health staff availability, or hospital volume. However, EDs associated with teaching hospitals were significantly more likely than their nonteaching counterparts to provide professional contact lists to patients (P =.004).

These data suggest that although EDs often encounter patients who present with deliberate self-harm, few routinely employ proper safety planning before discharge. “Future research should evaluate whether specific aspects of emergency management of deliberate self-harm lower the risk of repeat self-harm and suicide,” the investigators concluded.

Disclosures: See source for complete disclosure information.


Bridge JA, Olfson M, Caterino JM, et al. Emergency department management of deliberate self-harm: a national survey [published March 13, 2019]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2019.0063