To identify potential emergency department (ED) visits prior to suicide deaths in North Carolina (NC) and describe pre-suicide care-seeking in EDs.
Suicide is a leading cause of mortality in the United States, causing about 45,000 deaths annually1. Research suggests that universal screening in health care settings may be beneficial for prevention, but few studies have combined detailed suicide circumstances with ED encounter data to better understand care-seeking behavior prior to death.
This project used data from the NC Violent Death Reporting System (NC-VDRS), a repository of all violent deaths in North Carolina, and the NC Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT), which includes all visits to 24/7, acute-care, civilian, hospital-affiliated EDs in NC. We identified all suicide deaths recorded in the NC-VDRS between 1/1/2014 – 9/30/2015, and all NC DETECT ED visits between 1/1/2013 – 9/30/2015. Descriptive analyses were conducted for each data source, separately. For all NC-VDRS suicides, we identified ED visits likely made by the same individual within the 48 hours prior to death. We identified these ED visits based on the variables arrival date, sex, date of birth (DOB), county of residence, and a chief complaint consistent with self-harm/suicide; we refer to these as suicide-related ED visits. For the subset of NC-VDRS suicides with a suicide-related ED visit, made within 48 hours of death, we identified all ED visits associated with the decedent made to the same facility or healthcare system in the year prior to death. We then categorized the pre-suicide ED visits according to the primary reason healthcare was sought by the patient (e.g. mental health problem, substance abuse/overdose, pain, etc.).
From 1/1/2014-9/30/2015, there were 2,953 suicide deaths captured in NC-VDRS data; 2,435 (82%) of these included DOB. Between 1/1/2013 – 9/30/2015, there were 13,463,345 ED visits captured by NC DETECT; 12,884,596 (96%) included DOB. For 961 suicides (32.5%), no ED visit was found with the same DOB, sex and county of residence. For the remaining 1,474 suicides, at least one ED visit was found for a patient with the same DOB, sex and county of residence and occurring on or before the date of death. For 406 suicides, a suicide-related ED visit was identified; 122 of these patients had at least one additional ED visit in the year prior to death. A total of 516 ED visits were identified for these 122 suicides, including the suicide-related ED visit, with an average of 3.2 (range: 1-25) visits.
For nearly a third of NC-VDRS suicides, no indication of any ED visit by a patient with the same DOB, sex, and county of residence was found. While it is likely we were unable to identify all ED visits prior to suicide, the findings from this pilot study suggest many suicide victims did not seek NC ED care in the year prior to death. Overall, a suicide-related ED visit was found for only 13.7% of NC suicides in the study period, indicating that most people who self-inflict fatal injury do not make it to an ED for care prior to death. ED visits in the year prior to death by suicide indicated a variety of diagnoses, but rarely depression or suicidality; this suggests that universal screening at ED visits would have been necessary to identify any suicide risk present. Limitations of this study include that we were unable to directly link suicide deaths and ED visits using patient identifiers. Additionally, we relied solely on secondary data used for public health surveillance and, therefore, had no access to medical record information that may have documented depression or suicidal ideation that was not coded as such. Findings from this pilot study can inform future work to identify ED visits prior to suicide.
1National Center for Injury Prevention and Control. Suicide Rising Across the US. Vital Signs, June 2018; Atlanta, GA: Centers for Disease Control and Prevention 2018. https://www.cdc.gov/vitalsigns/suicide/. Accessed Sept 25, 2018.