Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE)

1. Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Phase 2: Universal Screening Site Training

2. Outline of Presentation • Phase overview • Fidelity Interview • Reminders • Changes in REDCap databases

3. Outline of Presentation Phase overview Fidelity Interview Reminders Changes in REDCap databases

4. Phase 2 In all phases: Patient enrollment in ED 5 follow-up phone calls Timing differences in Phase 2: 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 Slide 4

5. 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

6. 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  Administer eligibility screening questions in Phase 2 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

7. 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

8. New in Phase 2 Subject ID numbers start in the 200s (3-digit site # + sequential # starting with 201) Example  Subject ID for 3rd subject enrolled at site 200 = 200203 Slide 8

9. New in Phase 2 Use the Phase 2-specific consent form Fidelity interview of 60 randomly selected ED patients who have no documentation of positive screen for current suicidal ideation or suicide attempt in the last week Slide 9

10. Outline of Presentation Phase overview Fidelity Interview Reminders Changes in REDCap databases

11. Fidelity Interview Purpose: to determine the proportion of patients who were actually asked the suicide screening questions Brief interview with random subset of ED patients with an absence of suicidality You will not actually assess suicidal ideation, only if the patient was asked the universal screening questions Slide 11

12. Fidelity Inclusion Criteria Age ≥18 years No documentation of any self-harm screening OR the individual was screened, but had no SI and no SA Slide 12

13. Fidelity Exclusion Criteria Medically/cognitively unable to participate Currently in state custody Pending legal action Insurmountable language barrier Already enrolled into ED-SAFE during current ED visit Slide 13

14. Fidelity Interview Goal 60 patients 30 patients in first 2 weeks of phase 30 patients in last 2 weeks of phase Slide 14

15. Fidelity Interview You will receive randomly selected numbers for each day of the 2-week period Order patients triaged during shift by triage time Approach the patient with the randomly selected number that corresponds to presentation order, if the patient appears eligible based on chart review. Slide 15

16. Fidelity Interview (cont'd) If patient not eligible (e.g., + SI), approach the next eligible, triaged patient If patient approached, but does not want to participate, enter this into REDCap (Are you willing to answer some questions?  No) Then, approach the next eligible, triaged subject Slide 16

17. Selection Example Random number = 7 Review the ED chart of the 7th person triaged during your shift If eligible  approach If not eligible  approach 8th patient (if he/she appears eligible) Approach patients based on randomly selected numbers until you complete an interview with 3 eligible patients on a single day Slide 17

18. Fidelity Interview Before starting the interview, complete the following: Was any suicide screening documented on the ED chart? If yes, indicate what was documented: SI documented as negative SA documented as negative Slide 18

19. Fidelity Interview (cont'd) Ask clinical staff if you can approach patient Read introductory script Obtain verbal informed consent If patient refuses, enter this in REDCap Slide 19

20. Fidelity Interview Questions Today’s date: __ __ / __ __ / __ __ Interview start time: __ __: __ __ RA initials: __ __ __ Slide 20

21. Fidelity Interview Questions (cont'd) Gender Current age If age >89, record age as 89 Ethnicity Race (check all that apply) Highest grade you completed in school Slide 21

22. Fidelity Interview Questions (cont'd) Major reason patient came to ED Summarize response if narrative given During your ED visit today, …did someone ask you if you had been feeling depressed? …did anyone ask you if you were having thoughts of suicide? …did anyone ask you if you had ever attempted to kill yourself? Slide 22

23. Fidelity Interview Questions (cont'd) If yes to any, ask “who asked you?” Triage nurse Primary nurse Physician Other ED staff End interview by thanking the patient for their time. Slide 23

24. Fidelity Interview You will not actually assess if the patient is suicidal If patient spontaneously reports SI or SA, communicate this to clinical staff treating patient immediately and document this in the notes section in REDCap. Slide 24

25. Fidelity Interview Results Summary of data will be given to site PI after first 2-weeks of interview after last 2-weeks of interview Summary should be shared with performance improvement team Slide 25

26. Outline of Presentation Phase overview Fidelity Interview Reminders Changes in REDCap databases

27. 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

28. 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

29. 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

30. Screening Log (cont'd) Review all documentation available in the ED for the current ED visit At minimum, review the triage nursing notes 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

31. 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

32. 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

33. Wallet Card All patients approached – regardless of whether or not they are enrolled – receive a wallet card with a national hotline phone # Slide 33

34. 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

35. Baseline Assessment (cont'd) 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

36. 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

37. 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

38. 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 Phase 2, the chart review will be done after patient enrollment complete. Slide 38

39. 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 2 to discuss random selection of charts Slide 39

40. Outline of Presentation Phase overview Fidelity Interview Reminders Changes in REDCap databases

41. REDCap Screening Logs Each cohort (2 sites) will have its own screening log (“ED-SAFE Screening Log PHASE 2_Cohort [#]”) Goal is to eliminate the need to “split” the screening logs during the phase No change in the way data are entered Slide 41

42. REDCap Shift Summary No change to Shift Screening Summary Database Enter Phase 2 data into existing database Slide 42

43. Longitudinal Database No change to the Longitudinal Database Enter Phase 2 data into existing database Slide 43

44. Chart Review Database No change to chart review form/ functionality However, enter Phase 2 data into Phase 2-specific database No change in the way data are entered Slide 44

45. REDCap Fidelity Interview New database for fidelity interview (“ED-SAFE Fidelity Assessment”) Important to record every patient approached for an interview, regardless of whether or not they agree to the interview REDCap will automatically assign an ID to the record Slide 45

46. 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 46

47. Questions? Slide 47

48. Questions? REDCap inquiries: Mardi Coleman (mardia.coleman@umassmed.edu) AE inquiries: Sarah Ting (sting@partners.org) All other inquires: Ashley Sullivan (afsullivan@partners.org) Slide 48