a b s t r a c t

Background: It is estimated that as many as 1 in 10 individuals who complete suicide had been seen in emergency departments within the prior 2 months. However, very little evidence underlies the current recommendations on managing patients with suicidal ideation presenting to the emergency department. The American College of Emergency Physicians (ACEP) and Veterans Affairs/Department of Defense (VA/DoD) have developed clinical practice guidelines for the screening and treatment of patients with suicidal ideation who present to emergency departments. In this study we investigated the extent to which new and ongoing studies are being conducted to address the current limitations in suicide screening in emergency departments.

Methods: We identified low-level recommendations in clinical practice guidelines that have been set forth by the ACEP and VA/DoD. PICO questions were then created to help identify relevant studies pertaining to screening pa- tients with suicidal ideation in the emergency department. PICO questions were used to develop search strings, which were then used to locate studies from ClinicalTrials.gov and the World Health Organization’s International Clinical Trials Registry Platform.

Results: Seventeen PICO questions were created for this study. We found 11 studies addressing gaps identified in the clinical practice guidelines. Of the 17 PICO questions created, 10 were being addressed by 11 studies.

Conclusions: Little research is being done to improve suicide risk assessment tools in the emergency department. Further research in this area may decrease health care costs, improve patient care, and save the lives of those at risk of dying by suicide.

(C) 2017

Introduction

Suicidal ideation is a continual problem for emergency physicians, accounting for 1% of all adult emergency department (ED) visits [1]. It is estimated that as many as 1 in 10 individuals who complete suicide had been seen in ED within the prior 2 months [2]. From 2006 to 2013, the rate of ED visits related to suicidal ideation among adults in- creased by 12% on average annually. Additionally, the total number of ED visits related to suicidal ideation in 2006 was 388,100 compared with 903,400 in 2013, an increase of 132.8%. From 2006 to 2013, total ED and inpatient costs for patients presenting with suicidal ideation in- creased from $600 million to $2.2 billion. Patients presenting in 2013

? The authors report no financial conflicts of interest.

* Corresponding author at: Oklahoma State University, Center for Health Sciences, 1111

W. 17th St., Tulsa, OK 74107, United States.

E-mail address: [email protected] (C. Meyer).

with suicidal ideation to the ED were 3 times less likely to experience a routine discharge and 2.5 times more likely to be admitted. This leads to an increased stay of half a day and an increase of $1000 in costs over the same period of stay [1].

The American College of Emergency Physicians (ACEP) and the Vet- erans Administration in partnership with the Department of Defense (VA/DoD) have developed clinical practice guidelines (referred to as clinical policies by ACEP) for the screening and treatment of patients with suicidal ideation presenting to the ED and other Acute care settings. These guidelines were created through comprehensive literature re- views and were also based on expert opinion when supporting evidence was unavailable. Recommendations for both guidelines were classified according to levels of supporting evidence. The ACEP guideline contains grades ranging from Grade A (high) to C (low), whereas the VA/DoD guideline grades range from Grade A (high) to I (inconclusive). Recom- mendations based on insufficient evidence from these guidelines may serve to identify areas that need additional research. Conducting studies

https://doi.org/10.1016/j.ajem.2017.09.044

0735-6757/(C) 2017

to fill these research gaps may ultimately lead to a more rigorous evi- dence base and greater clinical certainty in Guideline recommendations [3,4].

In 2017, the ACEP released its latest clinical policy for patients with suicidal ideation presenting to EDs. One of the recommendations, rated as Level C, states that, “In patients presenting to the ED with sui- cidal ideation, physicians should not use currently available risk- assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psy- chiatric assessment and good clinical judgment, taking patient, family, and community factors into account.” Upon reviewing the evidence, the ACEP panel concluded that the current studies contained methodo- logical flaws. They recommended that future studies focus on identify- ing screeners that can best predict suicide completion in an at-risk population with a low prevalence rate while also being applicable to all age groups. They further recommended that such Screening tools have at least 90% sensitivity and specificity for patients at high suicide risk in the next 30 days. Similar limitations were noted in the VA/DoD guideline. Others have questioned the application of universal screening tools for patients presenting to EDs, acknowledging that there are no good-fit, well-validated screening tools for suicide risk. Furthermore, traditional suicide assessment tools are too lengthy and complex for emergency department staff to administer universally [5]. In this study, we identify guideline recommendations that are based on insuf- ficient evidence from the ACEP and VA/DoD related to suicide screening. We also search for new and ongoing studies catalogued in clinical trial registries to determine the extent to which new and ongoing studies are being conducted to address the current limitations in suicide screen- ing in EDs.

Methods

Oversight and reporting

This study was not subject to Institutional Review Board oversight since it did not meet the regulatory definition of human subject research as defined in 45 CFR 46.102(d) and (f) of the Department of Health and Human Services’ Code of Federal Regulations. We applied relevant Sta- tistical Analyses and Methods in the Published Literature reporting guidelines for reporting descriptive statistics. We carefully reviewed several sources when developing the methodology for this study [6].

Clinical practice guidelines

We located the latest clinical policy for the Management of the Adult Psychiatric Patient in the Emergency Department from the ACEP and the clinical practice guideline, Assessment and Management of Patients at Risk for Suicide, from the VA/DoD [3,4].

Recommendations from the ACEP clinical policy are rated as follows [3]:

Grade A: Generally accepted principles for patient care that reflect a high degree of clinical certainty (e.g., based on evidence from one or more Class of Evidence I or multiple Class of Evidence II studies).

Grade B: Recommendations for patient care that may identify a par- ticular strategy or range of strategies that reflect moderate clinical certainty (e.g., based on evidence from one or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).

Grade C: Recommendations for patient care that are based on evi- dence from Class of Evidence III studies or, in the absence of any ad- equate published literature, based on expert consensus.

For interpretation of these recommendations, evidence is classified into the following levels [3]:

Class I: Randomized, controlled trial or meta-analysis of randomized trials.

Class II: Non-randomized trial. Class III: Case series.

Recommendations from the VA/DoD are as follows [4]:

Grade A: A strong recommendation that the clinicians provide the intervention to eligible patients. Good evidence was found that the intervention improves important health outcomes, and it concludes that benefits substantially outweigh harm.

Grade B: A recommendation that clinicians provide (the service) to eligible patients. At least fair evidence was found that the interven- tion improves health outcomes, and it concludes that benefits out- weigh harm.

Grade C: No recommendation for or against the routine provision of the intervention is made. At least fair evidence was found that the in- tervention can improve health outcomes, but it concludes that the balance of benefits and harms is too close to justify a general recommendation.

Grade D: Recommendation is made against routinely providing the intervention to asymptomatic patients. At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.

Grade I: The conclusion is that the evidence is insufficient to recom-

mend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or con- flicting, and the balance of benefits and harms cannot be determined.

Development of PICO questions

Investigators then constructed one or more research questions using the Participants, Intervention, Comparator, Outcome (PICO) format for grades C, D, and I recommendations from both guidelines involving the use of suicide Risk assessment tools (SRATs). This method is used to identify clinical components for systematic reviews and is endorsed by the Cochrane Collaboration [7]. It was chosen over the Participants, Intervention, Comparator, Outcomes, Study Design (PICOS) and the Sample, Phenomenon of Interest, Design, Evaluation, Research type methods (SPIDER) because evidence suggests that the PICO method produces searches with greater sensitivity [8]. Two investigators (MB, SH) constructed all initial PICO questions.

Development of the search strings

PICO questions were reviewed to identify high-yield keywords. These keywords were then used to design search strings for the ques- tions. Search strings are part of a search strategy for finding information in databases. According to Gillespie and Gillespie [9], a search strategy is the process used to translate a clinical query (i.e., research question in PICO format) into a format that can be correctly understood by the search engine. The goal of a search string is to strike a balance between retrieving relevant studies and excluding irrelevant ones. For this study, we used a highly sensitive search strategy. Our searches retrieved a large number of false-positive results to ensure that important studies were not missed.

Using these keywords, a medical librarian consulted Cochrane Sys- tematic Reviews, Medical Subject Headings (MeSH), and PubMed Auto- matic Term Mapping to determine relevant synonyms, entry terms, and variant word forms. A search string was formulated leveraging Boolean operators (e.g., OR, AND) and parenthetical groupings to optimize the use of key terms to retrieve as many relevant records as possible in the clinical trial registries. Although both ClinicalTrials.gov and the World Health Organization’s International Clinical Trials Registry

Platform (ICTRP) databases employ the Unified Medical Language Sys- tem to enhance interoperability of vocabularies, their search engines work differently. For this study, 2 search strings were created, one for ClinicalTrials.gov and a second for ICTRP. We consulted Glanville et al.

[10] to accurately translate these search strings between the trial regis- tries. We also consulted an expert in searching these trial registries to verify the accurate translation of our search strategy between the regis- tries (personal communication).

Searching the trial registries

Using the search string for ClinicalTrials.gov, we retrieved studies using the expert search feature. After conducting our searches, the stud- ies and their registry-listed information were downloaded to a Microsoft Excel spreadsheet. Registry-listed information included study identification number, title, recruitment status, condition, inter- vention, phase, enrollment status, study type, date completed, and funding agency.

Using the search string for ICTRP, we retrieved studies using the basic search function. By performing a basic rather than advanced search, we were able to achieve a more sensitive search [10]. We planned a priori that studies that were returned from the ICTRP search would also be downloaded as a Microsoft Excel file. Ultimately, no search results were returned from the ICTRP search, and this step was not necessary.

Screening studies for eligibility

Two investigators (AB, CM) screened studies for relevance. First, AB and CM evaluated whether studies retrieved from the searches were relevant to adult patients with suicidal ideation presenting in the ED. Studies that were not relevant were excluded. Studies relevant to the PICO questions were retained, and studies that were unclear were reviewed for relevance by 3 other investigators (BR, MB, SH). AB and CM then screened relevant studies by completion date. Only studies registered between November 2011 and June 2017 were considered.

Searching the EMF database

We evaluated studies funded by the EMF to determine if any recent- ly funded studies addressed the research gaps we identified. We used the “Past Grantees” feature of the EMF’s website [11]. Furthermore, we used the NCT of each clinical trial to further investigate funding and sponsorship.

Results

Two search strings were developed to identify trials addressing our PICO questions. The PICO questions, search string, and number of rele- vant trials addressing each question are listed in Table 1.

The ClinicalTrials.gov search string yielded 86 results, whereas the ICTRP search string yielded 0 results. All 86 studies were then screened for relevance to PICO questions. Of these, 11 studies addressed gaps identified in the 2 guidelines (Table 2).

Seven studies addressed the predictive value of SRAT post-ED dis-

charge (PICO 3). Nine studies addressed the effectiveness of different SRATs (PICO 4). These same studies also evaluated whether SRATs had utility in guiding clinician assessment or management (PICO 8, 9) and whether SRATs contributed to Patient harm (PICO 10). Two studies ad- dressed factors affecting the Predictive validity of SRATs (PICO 16, 17). No studies addressed the use of SRATs to aid in discharge or admission decisions (PICO 1, 2); the tools most appropriate for patients from dif- ferent social, cultural, economic, or psychological backgrounds (PICO 5); whether SRATs were more cost efficient than clinician assessment (PICO 7); the extent to which evidence is still needed to develop an ef- fective standardized rating scale for suicide risk (PICO 13); or if clinician

factors associated with Predictive ability of suicide risk assessment scales (PICO 15).

One study in our sample was being funded by the Va/DoD [12], and no studies were funded by ACEP. Four were funded by the National In- stitutes of Health, and the remaining studies were funded by other insti- tutes and agencies.

Discussion

Our study found significant research gaps in the evaluation of SRATs for patients in the ED. We found no studies that addressed whether SRATs could help physicians make patient discharge decisions. We also found no current or ongoing research related to psychometric com- parisons of SRATs, comparisons of cost effectiveness between SRATs and clinician assessment, or patient and clinician factors influencing the ef- ficacy of SRATs. These areas are important for future research that may improve suicide risk assessment in the emergency department.

We did, however, identify some current and ongoing studies that provide some insight into research on suicide screening in EDs. Some researchers are developing new screeners. In France, one research team is developing a tool that includes neurocognitive measures and psychological measures hypothesized to be predictive of future suicide attempts (NCT03026387). Another study is developing a multidimen- sional assessment of suicide risk because the team expects a multidimensional scale to have improved predictive properties to unidi- mensional scales (NCT3072875). Due to the lack of evidence-based practice guidelines, the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study was developed to increase suicide detection and Prevention efforts (NCT01150994). This study is assessing a practical approach to suicide screening for the ED and will assess its effect on suicide detection and outcomes. Furthermore, ED- SAFE 2 (NCT02453243) is currently being conducted to test the long- term use of a universal screening process implemented from the origi- nal ED-SAFE study. The VA/DoD is currently funding the SAFE VET pro- ject (NCT01334541) on suicide risk assessment and interventional programs for military service members and veterans with suicidal ideation.

For many patients with suicidal ideation, the ED is the default option for treatment, and emergency medicine physicians are the first care providers that these patients encounter. Mills et al. found that in the VA health care system, more patients with suicidal ideation present to the ED than to outpatient psychiatric care [13]. Over 10% of ED visits are psychiatry related; however, ED physicians often are not adequately trained in psychiatry [14,15]. To help ED physicians, SRATs were devel- oped to provide Optimal care for patients who are at risk to complete suicide [16]. However, many different tools exist, and there is no con- sensus among ED physicians regarding tool choice. Chan et al. found that the current tools are inadequate, which could give physicians a False sense of security [17].

Furthermore, suicide risk can be difficult to accurately assess due to some individuals attempting to conceal their suicidal thoughts and due to false positives [18]. For example, Nelson et al. found that current tools have a high rate of false positives, limiting their clinical utility and in- creasing health care cost [19]. The ACEP reports that screening is posi- tive for 42% of patients, but only 1.5% of cases are true positives [20]. While it is critical to have a sensitive test to minimize the potentially fatal risk of a false negative, the cost of false positive results is crippling. Patients assessed with a false-positive result drive up health care costs and leave people at true risk without care [21]. Development of an accu- rate risk assessment tool would decrease hospital admissions for pa- tients pending psychiatric evaluation and ease the overall burden on EDs and inpatient psychiatric facilities.

The Consensus-Based Standards for the Selection of Health Measure- ment Instruments (COSMIN) initiative aims to improve the selection of health assessment tools [22]. The COSMIN checklist evaluates the meth- odological quality of studies on measurement properties of health

Table 1

PICO question, search string, and number of trials relevant.

No. PICO question Search string Trials in

ClinicalTrials.gov ICTRP

progress (n)

Which risk assessment tool for suicide is able to identify patients presenting to the ED with suicidal ideation that can be safely discharged home?

P: Patients with suicidal ideation I: Risk assessment tool

C: Other risk assessment tools

O: Can be safely discharged home

Which risk assessment tool for suicide is able to identify patients presenting to the ED with suicidal ideation that need inpatient psychiatric care?

P: Patients with suicidal ideation I: Risk assessment tool

C: Other risk assessment tools

O: Need to be admitted to inpatient psychiatric care

Which risk assessment tool for suicide is able to identify patients presenting to the ED with suicidal ideation that carry out suicide within 30 days?

P: Patients with suicidal ideation I: Risk assessment tool

C: Other risk assessment tools

O: Detect patients who will carry out suicide within 30 days

For adult patients presenting with suicidal ideations in an acute care setting, what is the most effective standardized tool for assessing risk of suicide?

P: Patients with suicidal ideation I: Risk assessment tool

C: Other risk assessment tools

O: The tool that is best suited to assess suicide risk

For adult patients presenting with suicidal ideations in an acute care setting, which suicide risk assessment tool is best utilized across all different social, cultural, economic or psychologic populations (i.e. military, native American, homeless, etc.)?

P: Patients with suicidal ideation I: Risk assessment tool

C: Other risk assessment tools

O: Stable prediction of suicide risk across social, cultural, economic, psychologic adult populations

For adult patients presenting with suicidal ideations in an acute care setting, are suicide risk assessment tools more effective than clinician assessment?

P: Patients with suicidal ideation I: Risk assessment tool

C: Other risk assessment tools

O: Accurate prediction of suicide risk

For adult patients presenting with suicidal ideations in an acute care setting, are suicide risk assessment tools more cost-efficient than clinician assessment?

P: Patients with suicidal ideation

I: Risk assessment tool

C: Alternatives to suicide risk assessment tools O: Cost effective prediction of suicide risk

For adult patients presenting with suicidal ideations in an acute care setting, do current suicide risk assessment tools have any utility in guiding clinician assessment? (If cannot be utilized for SRA prediction, can SRAT assist ED clinician in guiding assessment interview etc.?)

P: Patients with suicidal ideation I: Risk assessment tool

C: Other risk assessment tools

O: Guidance in clinical assessment/interview

For adult patients presenting with suicidal ideations in an acute care setting, do current suicide risk assessment tools have any utility in guiding clinician management? (if cannot be utilized for SRA prediction, can SRAT assist ED clinician in determining next step or appropriate care?)

P: Patients with suicidal ideation I: Risk assessment tool

C: Other risk assessment tools

O: Guidance in patient care management

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room O(Suicide OR suicidal OR self violence OR self harm) AND adult

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

Suicide AND adult AND emergency OR suicidal 0

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 0

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 7

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 9

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 0

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 1

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 0

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 9

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 9

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

(continued on next page)

Table 1 (continued)

No. PICO question Search string Trials in

ClinicalTrials.gov ICTRP

progress (n)

For adult patients presenting with suicidal ideations in an acute care setting, do current suicide risk assessment scales have any patient harm associated?

P: Patients with suicidal ideation I: Risk assessment tool

C: Alternatives to risk assessment tools O: Patient harm

For adult patients presenting with suicidal ideations in an acute care setting, do current suicide risk assessment scales have any clinician/ED harm associated? (time, cost, failure to think of risks outside of scale)

P: Patients with suicidal ideation I: Risk assessment tool

C: Alternatives to risk assessment tools

O: Clinician/ED harm (time, cost, thinking outside box)

For adult patients presenting with suicidal ideations in an acute care setting, how can current suicide risk assessment tools be improved to more effectively identify patients most likely to engage in suicide behavior? When coupled with a needs and psychosocial assessment, would outcomes improve?

P: Patients with suicidal ideation I: Risk assessment tool

C: Improved suicide risk assessment tools (+/- needs assessment, +/- psychosocial assessment)

O: Accurate prediction of suicide risk

For adult patients presenting with suicidal ideations in an acute care setting, what evidence is still needed to develop an effective Standardized Rating Scale for Suicide Risk?

P: Patients with suicidal ideation I: Risk assessment tool

C: Lacking evidence

O: Identification of evidence needed to develop a quality/effective suicide risk assessment tool

Is there scope for using global estimation of risk scales as a useful part of routine ED assessments?

P: Patients with suicidal ideation I: Risk assessment tool

C: SRAT utilization on adult patients not presenting with SI in acute care setting

O: Increased identification of suicidal ideations that can be managed in acute care setting

For adult patients presenting with suicidal ideations in an acute care setting, do clinician factors affect the predictive ability of suicide risk assessment scales (level of experience, professional background, etc.)?

P: Patients with suicidal ideation

I: Suicide risk assessment tool given by ED clinician C: Suicide risk assessment tool given by psychiatric clinician

O: Prediction of suicide risk

For adult patients presenting with suicidal ideations in an acute care setting, do patient factors affect the predictive ability of suicide risk assessment scales (history of Suicidal behaviors, psychiatric treatment, etc.)?

P: Patients with suicidal ideation

I: Suicide risk assessment tool given to one adult patient population

C: Suicide risk assessment tool given to other adult patient populations

O: Prediction of suicide risk

If current suicide risk scales do not improve assessment of suicide for adults presenting to an acute care setting with suicidal ideations, what factors are affecting the predictive ability of these scales?

P: Patients with suicidal ideation

I: Suicide risk assessment tool given to one adult patient population

C: Alternatives to suicide risk assessment tools O: Prediction of suicide risk

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

(Suicide OR suicidal OR self violence OR self harm) AND adult AND (emergency room OR ER)

Suicide AND adult AND emergency OR suicidal 9

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 1

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 1

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 0

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 1

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 0

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 0

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Suicide AND adult AND emergency OR suicidal 2

AND adult AND emergency OR self violence AND adult AND emergency OR self harm AND adult AND emergency

Table 2

Trials identified that address research gaps in suicide risk assessment tools

Trial title Registry

number

Recruitment status

Recommendation addresses

Evaluation of the risk associated with impulsivity and other neuropsychological factors on suicidal relapse within NCT03026387 Not yet recruiting 3, 4, 6, 8, 9, 10, 12

hospital emergencies
Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE)	NCT01150994	Active, not	3, 4, 8, 9, 10
		recruiting
Emergency Department Safety Assessment and Follow-up Evaluation 2	NCT02453243	Enrolling by	3, 4, 8, 9, 10, 14
		invitation
A brief intervention to reduce suicide risk in military service members and veterans- study 1	NCT01334541	Active, not	3, 4, 8, 9, 10
		recruiting
The genetic and affective prediction study	NCT02625818	Recruiting	3, 4, 8, 9, 10
CAMS-RAS: for suicide prevention	NCT03072875	Enrolling by	11
		invitation
Self reported level of agitation of patients presenting to an emergency department	NCT02713100	Recruiting	16, 17
A System of Safety (SOS)	NCT03104504	Enrolling by	3, 4, 8, 9, 10
		invitation
A comparative effectiveness trial of optimal patient-centered care	NCT02274688	Active, not	3, 4, 8, 9, 10
		recruiting
The effectiveness of interactive discussion group intervention about suicide risk identification and assessment for	NCT02033915	Completed	4, 8,9 10
clinical nurses Agitation in the acute psychiatric department	NCT01415323	Completed	4, 8, 9, 10, 16, 17

outcome measurement instruments [23]. The COSMIN taxonomy is made up of three quality domains: reliability, validity, and responsive- ness. Each quality domain is further divided into sub-domains. The COSMIN initiative established consistent terminology and definitions regarding measurement properties and a taxonomy of the relationships of measurement properties of health research. For this reason, we rec- ommend that investigators use COSMIN in the design of future research on SRATs. COSMIN also produced a guideline for the selection of out- come measurement instruments [24]. We recommend that the ACEP and VA/DoD use the COSMIN checklist to evaluate current research on SRATs and use the COSMIN guideline to select the best outcome mea- surement instrument when developing future clinical practice guidelines.

The Emergency Medicine Foundation, which is the research arm of the ACEP, provided over $2.5 million to further emergency medicine re- search from 2015 to 2017. Since publication of its clinical policy, 52 pro- jects have been funded [25,26]. Of these 52, none address the research gap in suicide risk-assessment tools. The research arm of the VA is ac- tively involved in research to explore risk factors associated with suicide risk and improve risk assessment tools [27]. In 2014, a study was funded by the VA to identify risk factors specific to veterans that should be in- cluded in future SRATs [28]. Furthermore, in 2015 another VA-funded study focused on objective biological and genetic markers that could be implemented in SRATs [29]. We recommend that funding organiza- tions such as these prioritize funding for research studies that hold promise for improving the current state of suicide screening in EDs.

Limitations

Based on the recent publication of the ACEP clinical policy, we did not perform searches of research databases like MEDLINE or Embase. Such databases were very recently searched by the guideline develop- ment panel, and we made the assumption that our searches would have resulted in a similar set of source literature. It is possible that searches conducted by the guideline panel did not retrieve all relevant studies, and we note this limitation here. We felt that searches of the trial registries would provide greater insight into current and ongoing research related to screening for suicidal ideation in the ED. We also ac- knowledge that while all study types are catalogued on the trial regis- tries, a majority of registered studies are clinical trials. Likely, there are ongoing psychometric studies of SRATs that are not registered in either of these trial registries. Furthermore, although we took precautions to ensure that the search strings would be sensitive, search terms may have been inadvertently omitted, possibly resulting in additional

relevant trials being missed. We surveyed both ClinicalTrials.gov [30] and the WHO’s ICTRP [31] to increase the thoroughness of our search.

Conclusions

The creation of a SRAT to support Clinical decisions regarding pa- tients with suicidal ideation is of high importance. Because of the risks of inappropriate discharge of patients with potential suicidal ideation, physicians keep and monitor at-risk patients for long periods of time. These patients occupy ED beds that could be actively used to evaluate and treat other patients. In many facilities, patients with suicidal idea- tion are admitted and occupy a bed while awaiting placement in an in- patient psychiatric facility. Development of accurate SRATs can help physicians confidently make triage decisions in this difficult situation. In cases in which patients are deemed stable with a low risk of adverse outcome, discharge and outpatient treatment would decrease resource utilization [32]. Given the current climate in medicine, which demands accuracy from physician risk assessment, the Emergency Medicine com- munity would greatly benefit by having SRATs on which to base clinical decisions regarding suicidal ideation. Research in this field could sup- port physician decisions that are otherwise driven by fear and often lead to high resource utilization.

References

1. Emergency Department Visits Related to Suicidal Ideation, 2006-2013 #220. [[Inter- net]. [cited 8 Jun 2017]. Available] https://www.hcup-us.ahrq.gov/reports/statbriefs/ sb220-Suicidal-Ideation-ED-Visits.jsp.
2. Gairin I, House A, Owens D. Attendance at the accident and emergency department in the year before suicide: retrospective study. Br J Psychiatry 2003;183:28-33.
3. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on the Adult Psychiatric Patient, Nazarian DJ, Broder JS, MEW Thiessen, Wilson MP, Zun LS, et al. Clinical policy: critical issues in the diagnosis and manage- ment of the adult psychiatric patient in the emergency department. Ann Emerg Med 2017;69:480-98.
4. [PDF]Suicide Risk – VA/DoD Clinical Practice Guidelines. Available https://www. healthquality.va.gov/guidelines/MH/srb/VADODCP_SuicideRisk_Full.pdf.
5. Boudreaux ED, Jaques ML, Brady KM, Matson A, Allen MHCONTENTREMOVED. The patient safety screener: validation of a brief suicide risk screener for emergency de- partment settings. Arch Suicide Res 2016;21:52-61.
6. Lang TA, Altman DG. Basic statistical reporting for articles published in biomedical journals: the “Statistical Analyses and Methods in the Published Literature” or the “SAMPL Guidelines”. Handbook, European Association of Science Editors; 2013.

   p. 23-6.

   Higgins JPT. Green S. Cochrane handbook for systematic reviews of interventions: John Wiley & Sons; 2011.

7. Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi SPICO. PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res 2014;14:579.
8. Gillespie LD, Gillespie WJ. Finding current evidence: search strategies and common databases. Clin Orthop Relat Res 2003:133-45.
9. Glanville JM, Duffy S, McCool R, Varley D. Searching ClinicalTrials.gov and the Inter- national Clinical Trials Registry Platform to inform systematic reviews: what are the optimal search approaches? J Med Libr Assoc 2014;102:177-83.
10. Emergency Medicine Foundation. [[Internet]. [cited 30 Aug 2017]. Available] https:// www.emfoundation.org/Content.aspx?id=85.
11. A Brief Intervention to Reduce Suicide Risk in Military Service Members and Veterans- Study 1 – Full Text View – ClinicalTrials.gov. [[Internet]. [cited 31 Jul 2017]. Available] https://clinicaltrials.gov/ct2/show/NCT01334541.
12. Mills PD, Watts BV, DeRosier JM, Tomolo AM, Bagian JP. Suicide attempts and com- pletions in the emergency department in Veterans Affairs Hospitals. Emerg Med J 2012;29:399-403.
13. Centers for Disease Control and Prevention (CDC). Emergency department visits by patients with mental health disorders–North Carolina, 2008-2010. MMWR Morb Mortal Wkly Rep 2013;62:469-72.
14. Zun L. Care of Psychiatric patients: the challenge to emergency physicians. West J Emerg Med 2016;17:173-6.
15. Large M, Galletly C, Myles N, Ryan CJ, Myles H. Known unknowns and unknown un- knowns in suicide risk assessment: evidence from meta-analyses of aleatory and ep- istemic uncertainty. BJPsych Bull 2017;41:160-3.
16. Chan MKY, Bhatti H, Meader N, Stockton S, Evans J, O’Connor RC, et al. Predicting suicide following self-harm: systematic review of risk factors and risk scales. Br J Psychiatry 2016;209:277-83.
17. Freedenthal S. Assessing the wish to die: a 30-year review of the suicide intent scale. Arch Suicide Res 2008;12:277-98.
18. Nelson HD, Denneson LM, Low AR, Bauer BW, O’Neil M, Kansagara D, et al. Suicide risk assessment and prevention: a systematic review focusing on veterans. Psychiatr Serv 2017 [appips201600384].
19. Is universal suicide screening in the emergency department saving lives or wasting time? – Page 2 of 3 – ACEP NOW. In: ACEP Now [[Internet]. [cited 26 Jul 2017]. Avail- able: http://www.acepnow.com/article/is-universal-suicide-screening-in-the- emergency-department-saving-lives-or-wasting-time/2/]
20. Horowitz LM, Ballard ED, Pao M. Suicide screening in schools, primary care and emergency departments. Curr Opin Pediatr 2009;21:620-7.
21. Mokkink LB, Prinsen CAC, Bouter LM, Vet HCW de, Terwee CB. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and how to select an outcome measurement instrument. Braz J Phys Ther 2016;20:105-13.
22. Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measure- ment properties of health status measurement instruments: an international Delphi study. Qual Life Res 2010;19:539-49.
23. Prinsen CAC, Vohra S, Rose MR, King-Jones S, Ishaque S, Bhaloo Z, et al. Core Out- come Measures in Effectiveness Trials (COMET) initiative: protocol for an interna- tional Delphi study to achieve consensus on how to select outcome measurement instruments for outcomes included in a ‘core outcome set’. Trials 2014;15:247.
24. Emergency Medicine Foundation. [[Internet]. [cited 8 Jun 2017]. Available] https:// www.emfoundation.org/grantees/.
25. Emergency Medicine Foundation. [[Internet]. [cited 8 Jun 2017]. Available] https:// www.emfoundation.org/Content.aspx?id=318.
26. Suicide Prevention. [[Internet]. 1120 [cited 26 Jul 2017]. Available] https://www. research.va.gov/topics/suicide.cfm.
27. Schoenbaum M, Kessler RC, Gilman SE, Colpe LJ, Heeringa SG, Stein MB, et al. Predic- tors of suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiat 2014;71:493-503.
28. Niculescu AB, Levey DF, Phalen PL, Le-Niculescu H, Dainton HD, Jain N, et al. Under- standing and predicting suicidality using a combined genomic and clinical risk as- sessment approach. Mol Psychiatry 2015;20:1266-85.
29. Home – ClinicalTrials.gov. [[Internet]. [cited 26 Jul 2017]. Available] https:// clinicaltrials.gov.
30. WHO. Welcome to the WHO ICTRP. World Health Organization; 2016[Available: http://www.who.int/ictrp/en/].
31. Rothberg MB, Class J, Bishop TF, Friderici J, Kleppel R, Lindenauer PK. The cost of de- fensive medicine on 3 hospital medicine services. JAMA Intern Med 2014;174: 1867-8.