Althoff-VT-Suicide-Prevention-Symposium-Presentation-6-4-18

The heart and science of medicine UVMHealth.org/MedicalGroup Suicide Risk Assessments in Hospitals Using  Systematic Expert Risk Assessment for Suicide  (SERAS) Robert R. Althoff, MD, PhD Associate Professor of Psychiatry, Pediatrics, & Psychological Science Director of Adirondack Division of Psychiatry Larner College of Medicine at the University of Vermont VT Suicide Prevention Symposium June 5, 2018 Conflict of Interest Disclosure • Co-Inventor of SERAS (Systematic Expert Risk Assessment for Suicide) • Equity stake in WISER Systems, LLC – holds license from UVM to commercialize SERAS The Team William Cats-Baril, PhD William Hudenko, PhD Associate Professor, UVM Grossman School of Business; Founding Director of MBA on Sustainable Entrepreneurship Assistant Professor, Dartmouth College CEO Incente llc, Winner of the 2016 Dartmouth Entrepreneurial Forum StartUp Competition Isabelle Desjardins, MD General and Geriatric Psychiatrist, Associate Professor, UVM-COM; Chief Medical Officer, University of Vermont Medical Center Sanchit Maruti, MD Addiction Psychiatrist, Assistant Professor, UVMCOM; Medical Director, UVM-Medical Center Suboxone Program Robert Althoff, MD, PhD Child and Adolescent Psychiatrist; Associate Professor, UVM-COM; Director, Adirondack Division of Psychiatry, New York Michael Goedde, MD, MS UVM-COM graduate and training in psychiatry and research methods John Helzer, MD Professor Emeritus, UVM; 40 years of research experience and 15 years of eHealth approaches to alcohol assessment, smoking, ECT, and pain management Donna Rizzo, PhD Professor and Dorothean Chair, UVM College of Engineering and Mathematical Sciences Expert in complex systems Epidemiology of Suicide in Hospitals • 2nd most frequently reported of the five serious events reported to the Joint Commission since 1995 • Many patients who kill themselves in general hospital inpatient units are “unknown at risk” for suicide – No psychiatric history or – No history of suicide attempt • The Sentinel Event Database includes 827 reports of inpatient suicides: The Joint Commission, Sentinel Event Alert, Issue 46, November 17, 2010 Bostwick JM, Rackley, SJ: Completed Suicide in Medical/Surgical Patients:  Who is At Risk? Current Psychiatry Reports, 2007;9:242‐246 Joint Commission Sentinel Alert #56 • Detecting and treating suicide ideation in all settings; • Most individuals who die by suicide receive health care services in the year prior to death, usually for reasons unrelated to suicide or mental health • National Patient Safety Goal 15.01.01 requires General hospitals to identify individuals at risk for suicide • …requires…“general hospitals treating individuals for emotional or behavioral disorders, to conduct a risk assessment that identifies specific individual characteristics and environmental features that may increase the risk of suicide and to address safety needs such as placing a patient under constant observation if the patient exhibits warning signs.” Detection Tools PHQ2/PHQ9 • Detects Major  Depression ED‐SAFE Patient  Safety Screener SBQ‐R/ASQ • PHQ2 and  portions of C‐ SSRS • Holds  predictive  validity for  lifetime suicide  risk • Assesses  suicide related  thoughts and  behaviors • Differentiates  suicidal from  nonsuicidal patients overall Secondary Screening ED‐SAFE Patient  Safety Secondary  Screener for EDs SAFE‐T Pocket Card C‐SSRS • Assess dimensions of suicide risk to help the clinician come to a  risk assessment The Need • Tools to specifically assess imminent/near term risk • Tools that use accumulated risk factor information and also account for expert weighting of risk factors and clinical data Brown GK (2002) A review of suicide assessment measures for intervention research in adults and older adults Technical report submitted to NIMH under Contract No 263- MH914950 Hypothesis We can replicate the judgment of Board-Certified Psychiatrists in assessing the near-term risk of suicide (next 72-hours) and the associated expert intervention recommendations Phase 1: Model Development Expert Panel Case  Review/Revision Group  Consensus  Process • Convened Panel of National Experts • Comprehensive Literature Review • Discussed important components of an ideal suicide risk  assessment tool  • Revised and Added Cases to cover full range of suicide risk • Reviewed Cases • Rated patient profiles based on likelihood of Acute suicide  in the hospital setting in the next 72 hours • Utilized Nominal Group Technique (NGT) to identify risk variables,  ranges and weights on those variables and discussed aggregation  methods (compensatory/non‐compensatory, etc.) • Compared the experts’ rankings  and addressed inconsistencies  and disagreements • Created a preliminary model that included critical features that  should be in the computerized screening Suicide Risk Assessment Questions 11 Discovery Sample • Testing of algorithm against expert consensus in the ED patient population • Psychiatrists examining patients in ED were trained using the same cases as the Expert Panel 12 S Mean Age:  42.6 [SD 17 years] Male: 48% Primary Psych Complaint: 8% % Discovery Samplea2 Categories of Risk (RISK) High  Moderate Low Minimal Even considering  The combination of risk  Although there may be  The risk of suicide in  mitigating protective  factors and mitigating  suicide risk factors  the following 72 hours  factors, the acute risk  protective factors yield  present, the  is minimal of suicide – in the  a risk of suicide in the  combination of risk  following 72 hours‐ is  following 72 hours that  factors and mitigating  high  is only moderate  protective factors yield  a relatively low risk of  suicide in the following  72 hours Suicide Possible and   Suicide Possible, but  Likely Unlikely Suicide Very Unlikely Categories of Interventions (INT) TYPE OF  INTERVENTION Psychiatric  Assessment ROUTINE Environment of  Care Modification No No Routine Routine Environment of  care free of  harmful hazards Routine Routine Yes Yes Environment of  care free of  harmful hazards Constant  Observation Yes Yes Yes Yes Yes Level of  Observation After Care  Referral Education re  Suicide  Prevention  Resources at  Discharge No SPECIALIZED HIGHLY  SECURED SPECIALIZED Psychiatry or  Psychiatry or  Psychiatry or  Crisis Consultation Crisis Consultation Crisis Consultation Neural Neural Network Model ‐ RISK Model RISK Classification Errors: Psych Chief Complaint in 100% of cases Ne Neural Network Model ‐ INT r Model - INT Classification Errors: Psych Chief Complaint in 100% of cases Replication and Extension Samples ED Med-Surg Inpatient Psychiatry 18 Partnership 19 Partnership 20 EMR Integration 21 EMR Integration 22 Conclusions Novel Approach to Suicide Risk Assessment in hospitals – – – – Expert Systems Approach/ Neural Network mathematical model User Friendly – iPad based and patient self-administered Time Efficient Able to replicate the Risk Assessment and Intervention recommendations of expertly-trained clinicians for ED and MedSurg populations – Only predicts expert assessment of near-term risk (72 hours) – Risk assessment is contextual to the environment of care 23 Next Steps - Have just completed a new trial of 480 participants in emergency room setting who received SERAS, C-SSRS, expert risk assessment, and 72 hour follow up - Finalizing data analysis now - Can report that SERAS did again detect several individuals who had not reported suicidal ideation in any other format - We see SERAS as an easy to use general tool that can direct the need for more refined assessment - Integration with social media - Enhancement with VOI to include REACH – a mechanism for incorporating social supports 24 Acknowledgements • Funding: – Fletcher Allen Foundation – University of Vermont Medical Group (UVMMG) Research and Education Committee – SPARK-VT – National Institute of Mental Health • Contributors: – – – – – – – University of Vermont EMRAP program Jeffords Quality Institute Ms Diantha Howard Ms Abigail Wager Ms Chelsea Manning Conor Carpenter, MD Judy Lewis, MD, Isabel Norian, MD, Anne Rich, MD, Tobey Horn, MD for their contribution to the Expert Assessments 25