Clinical Severity Alone Does Not Determine Disposition Decisions for Patients in the Emergency Department with Suicide Risk

Background Boarding of patients with suicide risk in emergency departments (EDs) negatively affects both patients and society. Factors other than clinical severity may frequently preclude safe outpatient dispositions among suicidal patients boarding for psychiatric admission in the ED. Objective To determine the extent to which nonclinical factors preclude safe outpatient discharge from the ED among patients boarding for psychiatric admission based on suicide risk. Methods A survey regarding the importance of 13 clinical and 19 nonclinical barriers to safe outpatient disposition was administered in the ED to 40 adults who were determined by psychiatrists to require inpatient level of psychiatric care due to suicide risk. A second survey regarding whether addressing the nonclinical factors would have enabled a safe outpatient disposition in each case was administered to the psychiatrists who evaluated each patient participant. Results Out of 40 patient participants, 39 cited at least one nonclinical factor that could have enabled a safe outpatient disposition had it been correctable in the ED. According to the psychiatrists who made the decision to hospitalize, 10 (25%) of the patient participants could have been discharged had social support become available. Conclusion Both clinical and nonclinical factors affect disposition from the ED after an evaluation for suicide risk. Attention to nonclinical factors should be considered in programmatic efforts to reduce ED boarding of patients with suicide risk.