DOI: https://doi.org/10.21203/rs.3.rs-51267/v2
Background Suicide is a significant public health problem. Individuals are estimated to make up to 20 suicide attempts before suicide. The emergency department (ED) is the first location where individuals are brought after a suicide attempt. This study investigated the factors related to delays in the medical hospitalization of patients who attempted suicide and aimed to provide criteria for hospitalization decisions for physicians.
Methods This study included who had deliberately self-harmed (age ≥19 years) and who presented at the EDs of two tertiary teaching hospitals between March 2017 and April 2020. Those for whom relevant demographic and clinical information were unavailable and those who were admitted to the psychiatric wards were excluded.
Results This study included 414 patients in the hospitalization group and 1,346 in the discharged group. The mean patient age was 50.3 ± 20.0 years and 40.7 ± 17.0 years in the hospitalized and discharged groups ( p <0.001), respectively. The mean ED length of stay (LOS) was 4.2 ± 12.3 and 11.4 ± 18.8 h in the hospitalized and discharged groups, respectively . In the hospitalized group, the odds ratio and confidence interval for aged 35~64 (2.222, 1.343–3.678), aged over 65 (2.788, 1.416-5.492), sex -male (2.041, 1.302–3.119), and consciousness (1.840, 1.253–2.466). The Risk-Rescue Ratio Scale (RRRS) was (1.298, 1.255–1.343). A receiver operating characteristics analysis of RRRS for the decision to hospitalize patients who attempted suicide showed a cut-off value of 42, with sensitivity, specificity, and area under the curve being 85.7%, 85.5%, and 0.924, respectively.
Conclusion The level of consciousness and the RRRS of patients who attempted suicide can be the factors to decide medical hospitalization and reduce ED LOS and crowding.
Suicide is a significant public health problem. South Korea has a high suicide rate [1], which has ranked first among the member countries of the Organization for Economic Cooperation and Development (OECD) during 2003–2017 and second since 2018 [2]. South Korea has seen a rapid increase in the suicide rate which has triple since the nineties [3]. Moreover, individuals are estimated to make up to 20 suicide attempts before suicide [4]. The emergency department (ED) is the first contact point providing management for patients who have attempted suicide, when primary care institutions or outpatient clinics are inaccessible [5]. Patients with physical injuries or altered mental status, besides psychiatric issues, inevitably tend to visit the ED [6]. The hospitals and EDs are readily accessible through South Korea’s universal healthcare system [7].
In 2018, according to the statistics issued by the Korea Suicide Prevention Centre, based on information from the death certificates in Statistics Korea and the Emergency Department Information System, there were 13,670 deaths by suicide and 33,451 patients who attempted suicide [8].
Most of the patients who attempted suicide receive medical care through the ED, and both domestic and international research on these individuals are frequently based on injury-monitoring data or medical records from the ED and ED patients [8-11]. The patients who require only psychiatric care are typically, either discharged after a psychiatric consultation or admitted to a psychiatric ward, while those with an altered mental status, in need of intensive care or surgery, due to physical injuries, may need medical hospitalization. The hospitalization decision is based on the clinician’s judgement. Suicidal patients may be discharged or hospitalization after being assessed according to available guidelines. However, these guidelines are not universally accepted [13]. During the management of patients who attempted suicide, the decision for hospitalization is as crucial for the as acute stabilization of their concurrent injuries [14]. There are some studies regarding the variables associated with only psychiatric hospitalization [15,16] as well as those both medical and psychiatric hospitalization [17].
Furthermore, ED crowding is a significant patient safety concern that is associated with poor quality of care [18], and a significant positive relationship between ED crowding and patient mortality has been reported [19, 20]. Henneman showed that both hospitalized and discharged patients who stayed in ED for 6 hours were associated with ED crowding [21]. There is an ongoing investigation into ED crowding and ED capacity in South Korea [22]. In the ED, emergency medicine physicians ,depending on the severity of the patient’s condition, evaluate and treat those who attempt suicide and decide upon their subsequent care.
This study investigated the factors related to delays in medical or surgical hospitalization of patients who attempted suicide and aimed to provide criteria for assist the physicians’ rapid decision. This can be helpful to shorten the decision time for hospitalization and the ED length of stay (LOS), assist proper treatment for patients.
Study population, data collection, and variables
This retrospective cohort study included adult patients who attempted suicide (≥19 years) and visited the EDs at two tertiary teaching hospitals from March 2017 to April 2020. These patients had deliberately self-harmed with overdoses (drugs, pesticides, herbicides, chemicals), and injuries (fall, drowning, hanging, cutting, collision). At each study centre, there were two coordinators, certified by the South Korean Psychologic Counseling Association. The research team comprised a psychologist, an emergency medicine specialist, and the two coordinators. The research team surveyed all patients who visited the ED after a suicide attempt. The initial assessment forms were designed under the supervision of psychiatrists. The patient data were collected prospectively, and the researchers retrospectively reviewed the data.
Each hospital provided healthcare services to a population of approximately 700,000 individuals and was located in a metropolitan area, with an annual average of 60,000 patient visits at each hospital. The hospitalization process was as follows. If a patient needed surgery, then the surgery department hospitalized the patient. If a patient was in a state of shock or had an altered mentality (such as drug overdose, carbo-monoxide poisoning, hanging and etc.), the emergency medicine department hospitalized the patient. All the patients or their guardians were consulted by the psychiatrist on-duty. If the patient did not require hospitalization, psychiatric department decided on psychiatric admission or discharge. Coordinators also met with the patients and their guardians. The case management team held regular conferences every two weeks to discuss data biases and improvements. All these details are uploaded onto the data collecting site of the Ministry of Health and Welfare, the project host.
The assessment, designed in consultation with psychiatrics, collected demographic and clinical information, including age, sex, vital signs (systolic blood pressure, diastolic blood pressure, and heart rate), time from suicide attempt to ED visit, location where the suicide was attempted, patients’ marital status, religion, employment status, income level (with reference to the average monthly income of Korean workers, classified on the basis of 1.5 and 2.5 million KRW), education level (with reference to the mandatory education in South Korea), cohabitant, consciousness (alert–verbal response–pain response–unresponsiveness), method of suicide attempt, alcohol ingestion before the suicidal attempt, request for help, history of suicidal attempts, history of psychiatric care, psychiatric drug use, history of psychiatric admission, and suicidal attempt plan.
In addition, information on ED outcomes (intensive care unit [ICU] admission, general ward [GW] admission, discharge, and death), presumptive psychiatric diagnosis (depression, psychiatric disease other than depression, and no intervention or inability to diagnose), and physical status at the time of visit to the ED (chronic disease, acute disease, and physically healthy) was collected.
The Risk-Rescue Ratio Scale (RRRS) was calculated with the formula: [Risk rating/(Risk rating + Rescue rating)] × 100 (risk and rescue ratings are presented in Appendix).
The data were collected, and the RRRS was determined by a senior emergency medicine resident under the supervision of an emergency medicine specialist and the on-duty psychiatrists. The psychiatric diagnoses were made by psychiatric residents by using the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders-IV (American Psychiatric Association, 2000).
Statistical analysis
The patients were assigned to two groups: the hospitalization group and the discharge group. The hospitalization group included all patients who were admitted to the ICU and GW. The mean with standard deviation and median with 25th and 75th percentiles were expressed as the continuous variables. The number of patients and percentage were expressed as the noncontinuous variables. For items requiring statistical verification, an independent T-test were used for the continuous variables and Chi-squared tests were used for the non-continuous variables. A p-value <0.05 was considered statistically significant. We selected all variables that proved to be statistically significant (p < 0.05) from the univariate analysis and performed multivariate logistic regression analysis using backward stepwise selection (likelihood ratio); variables with p <0.05 are listed in the table. Statistical analyses were conducted using the Statistical Package for the Social Sciences (version 21) for Windows (International Business Machines Corporation, Armonk, NY, USA), and 95% confidence intervals with statistically significant p-values were reported.
Ethic statement
This study was approved by the institutional review boards of Ewha Womans’ University Mok-dong Hospital and Sangye Paik Hospital, and the requirement for informed consent was waived by the approving authority in view of the retrospective use of anonymized patient information.
During the study period, 2,772 individuals attempted suicide, out of which 319 were paediatric patients and 602 were patients who were either transferred or who had died in the ED were excluded. Furthermore, out of the remaining 1,851 patients, 91 patients who were admitted to a psychiatric ward were also excluded. After the exclusions, a total of 414 and 1,346 patients were included in the hospitalized and discharged groups, respectively (Figure 1).
Comparison of general characteristics of suicide attempted patients between hospitalized and discharged groups
Table 1 presents the general characteristics of patients who attempted suicide and visited the ED during the study period. In the hospitalized and discharged groups, the mean age was 50.3 ± 20.0 and 40.7 ± 17.0, respectively and the number of males was 183 (44.2 %) and 420 (31.2 %) , respectively (p <0.0001). In the age groups into <34 years old, 35–65 years old, and over 65 years, there were significant differences were observed (p <0.0001). There were more patients in the hospitalized group, in the 35–65 year age group (47.1%) and the over 65 years age group (27.1%) than in the discharged group. There was also a significant intergroup difference in the marital status (p <0.001). Single status was more prevalent (45.7%) in the discharged group compared with the hospitalized group (35.2%). In discharged group 48.3% had the highest income (>2.5 million KRW/month) compared with 38.1% in the hospitalized group, while 28.7% in discharged group was lowest income (<1.5 million KRW/month) compared with 43.7% in hospitalized group. Educational status, religion, cohabitant, insurance, time from suicide attempt to ED visit, and location of suicide attempt did not show significant between-group differences. The ED LOS significantly differed between the hospitalized and the discharged groups (11.4 ± 18.8 h vs 4.2 ± 12.3 h; p <0.002). ED LOS subgroup (~2 hours, 2–6 hours, over 6-hours) showed that longer ED LOS, the greater the possibility of hospitalization (p <0.001).
Comparison of suicidal attempt-related patient characteristics
Table 2 showed the differences between the study groups with regards to the characteristics of the patients who attempted suicide. There was a significant between-group difference in the degree of mental alertness at the time of ED visit (p <0.001). Patients who did not request help a higher rate of hospitalization (p <0.026). Patients with a previous suicidal attempt had a higher rate of discharge. Previous suicidal attempts were 2.5±2.9 in the discharged group and 1.7±1.4 in the hospitalized group (p <0.009). Alcohol ingestion before self harm were 50.4% in discharged group and 42.8% in hospitalized group (p<0.011) There was no significant intergroup differences in the histories of psychiatric ward admissions, current psychiatric medication use, and psychiatric tentative diagnoses. The motivation for the suicidal attempt (p<0.001) and the method of the suicidal attempt (p <0.001) differed significantly between the groups.
Multiple logistic regression analysis for prediction of hospitalization
In the hospitalized group, the logistic regression showed statistically significant differences between the age subgroup and ED LOS subgroup. The odds ratio (OR) and confidence interval (CI) of the age subgroups 35–65 and over 65 years old were 2.222 (1.343–3.678) and 2.788 (1.416–5.492), respectively, while the ED LOS subgroups 2–6 and over 6-hours were 1.674 (0.998–2.808) and 1.771 (1.017–3.083), respectively. The OR and CI of the study variables for Sex (male) and consciousness (alert vs. verbal response, pain responses, and unresponsiveness) were 2.041(1.302–3.119) and 1.840(1.253–2.466). The Risk-Rescue Ratio Scale (RRRS) was 1.298 (1.255–1.343). (Table 3). The OR of The receiver operating characteristics analysis of RRRS for the association with the hospitalization decision with regard to suicidal patients showed a cut-off value of 42.9, with an 85.7% sensitivity, 85.5% specificity, and an area under the curve of 0.924 (Figure 2).
The findings of this study demonstrated that the methods of suicide attempt had an effect on the need for hospitalization. Among the OECD countries, South Korea has the highest suicide rate, which is two times higher than that in the United States [23]. While suicide ranks as the 13th leading cause of life lost with 800,000 deaths worldwide annually [24] , it is the 5th leading cause of death in South Korea [25]. The ED is an important point-of-care in the healthcare process for patients attempted suicide. In this study, drug overdose was the most common method of suicide (52.4% of the total patients), and had similar rates in both the hospitalized and discharged groups. Walker et al had reported drug overdose to be a strong predictor of ICU admission [26] while Kim et al classified stabbing, hanging, drowning, and jumping off a height as clinically serious, lethal methods, and severe depression, psychological disturbance, and repetitive suicidal ideation as factors that indicated high medical severity [27]. This study excluded patients who died while in the ED or within 24 h of hospitalization. Those patients represented less than 10% of all suicide attempted patients.
Those who were discharged from the hospital in this study were younger by approximately 10 years and were more likely to be female (68.8%). Age may be a factor in that the younger are discharged because they are healthier and recover better. Gender as a risk factor for suicide has been studied extensively. Female attempted non-fatal suicide behavior [28, 29]. Several studies have highlighted the concept of non-suicidal self-harm (NSSI) and have distinguished between suicide attempts and NSSI [30, 31]. It has been reported in NSSI attempts consists of patients that are younger and more frequently female and that these attempts less fatal with a more frequent use of cutting methods [32]. Data in this study included all patients whip deliberately self-harmed without questioning the authenticity of the suicide attempts. Further research is needed on whether there are many NSSI patients in the discharged group.
Studies have shown associations between alcohol use disorder and suicide behavior [33, 34]. Salles et al reported that an alcohol use disorder was not associated with hospitalization for inpatient psychiatric care, whereas depression was a clearly associated factor [13]. This present study also showed that alcohol use was not associated with hospitalization; rather, alcohol use before suicidal behavior was higher in the discharged group. The higher rate of alcohol use rate in discharged group may show that the alcohol causes non-serious impulsive suicide behavior.
Mortin J reported that in the elderly with suicide intentions alcohol use disorder showed a strong association with hospital-treated suicide [35] In Baltic countries, there was a high suicide rate, but due to their restrictive alcohol policy there was a lower the annual male suicide rate during 1986-80 [36].
South Korea ranks first in suicide rate and twenty-three in alcohol consumption.[37] Thus the association of suicide rate and alcohol consumption may not clear. However, this study only investigated whether the patients consumed alcohol and not whether the patients were diagnosed with an alcohol use disorder. The amount of alcohol consumed and the blood alcohol concentration was not ascertained. These aspects need to be evaluated in future research.
One in eight patients who visit the ED are psychiatric patients, contributing to ED overcrowding [38, 39]. The ED LOS is associated with increased ED crowding. The walk-out rate was 0.34 patients/hour when the ED LOS was less than 6 hours and 0.77 patients per hour when the patients’ ED LOS was more than 6 hours [21]. In this study, the average ED LOS in the hospitalized group was 11.4 ± 18.8 hours vs 4.2 ± 12.3 hours in the discharged group, which significantly contributed to the ED crowding. The overall ED LOS of patients with psychiatric emergencies and suicidal/self-harm patients showed a median duration of 2.4 h, which showed that the duration has been maintained at a similar value for 3 years, with local differences [40].
In this study, the hospitalized group had a significantly longer ED LOS than the discharged group, with the average duration being well over 6 hours. Besides the time for assessment and treatment, the time to take hospitalization decision contributed to the long ED LOS. Both of the hospitals where this study was conducted left the hospitalization decision for patients who attempted suicide via drug overdose, hanging, and drowning to the department of emergency medicines. South Korea does not have a dedicated toxicology department at hospitals, leaving the hospitalization decision to the department of emergency medicine or internal medicine physicians. Therefore, the ED LOS is extended when the patients cannot be admitted to a psychiatric ward due to physical injuries and is even longer with ED crowding.
In this study, the ORs for hospitalization based on mental status at presentation were 2.027 for verbal response, 6.200 for pain response, 39.931 for unresponsiveness. The OR for consciousness was 1.840, indicating that in order to avoid ED crowding and improve the ED occupancy ratio, emergency physicians should not delay the hospitalization decision when the patients were not alert. Jo et al reported that ED crowding was associated with a higher mortality rate in critically ill patients [41]. In addition to the level of alertness, the socioeconomic status can affect the hospitalization decision. Even in alert patients, a report estimates that approximately 25% of patients could have been discharged if they had social support, and that clinical severity alone does not determine the need for hospitalization [42]. In this study, consultancy care was provided to the caregivers when hospitalized patients had altered mental status, and for unconscious patients who received a psychiatric consultation after they regained consciousness. All hospitalized patients were transferred or discharged after the psychiatric follow-up consultation.
The RRRS had high sensitivity and specificity for the hospitalization decision of deliberated self harm in this study. The RRRS was validated for its psychometric properties [43] and has been used to determine the lethality of suicide attempts [44]. Oh et al showed that deliberate self-poisoning was included in the high-risk/low-rescue group [45]. Kim et al analyzed several psychologic scales that were used to determine the hospitalization need of suicidal patients in the ED and reported that RRRS was the most useful factor for predicting hospitalization in the ED setting. Baca-García et al reported that psychiatrists appear to rely on patients' self-report to decide on hospitalization rather than demographic, diagnostic, or psychosocial factors [15]. A few previous studies have suggested that suicide mortality can be lowered if individuals at risk of suicide are effectively identified and appropriately treated. Emergency physicians evaluate and treat patients who attempted suicide and make decisions to admit patients to the medical ward and not to the psychiatric ward. Weiland et al reported that emergency physicians were uniformly confident in their decision to shift patients at risk of suicide or self-harm to the inpatient department [46]. In the busy ED, physicians do not use scoring systems. Emergency physicians have limited time and high patient volumes [12]. Therefore, a guideline for early decision-making for hospitalization of suicide attempted patients would be helpful to avoid ED crowding.
In the RRRS, the absence of loss of consciousness, confusion, and coma are assigned 1, 2, and 3 points, respectively. It does not have a large effect on the total score. Based on a regression analysis, the level of consciousness should be considered as a single factor for the hospitalization decision.
Planned suicide attempt was twice as frequent in the hospitalization group than in the discharge group (OR 1.728). A previous report indicated that planned suicidal attempts have more severe medical consequences for serious suicidal attempts [47]. For patients with a planned suicidal attempt, a psychiatric follow-up after initial care is especially important.
In this study, the history of psychiatric care or current psychiatric medication usage did not differ significantly between the study groups. This may suggest that suicidal behavior was present regardless of psychiatric treatment, or that psychiatric treatment was inadequate to prevent suicidal attempts. Harada et al reported that females tended to be over-represented in the psychiatric consultation group, and males in the non-consultation group. Poisoning by prescription drugs was used more frequently as a method of suicide in the consultation group. Moreover, the prevalence of adult personality disorders and schizophrenia and related disorders were higher in the consultation group than in the non-consultation group [48].
Shepard et al reported that based on the reported numbers alone, the national cost of suicides and suicidal attempts in the United States in 2013 was $58.4 billion. After adjustment for under-reporting, the cost increased to a total of $93.5 billion, which was 2.1–2.8 times that reported in previous studies [49]. In South Korea, statistics on suicidal attempts are only available through ED data. Furthermore, the cost of medical care and related indirect costs have not been investigated. Considering the high prevalence of suicide in South Korea, if the direct and indirect costs of ED use by deliberated self harm and by under-reporting of suicide attempts are studied, the national cost of suicide is likely to be very high. Further research is needed to assess the national costs associated with suicide.
The limitations of this study include the fact that many patients refused to participate in the data collection or were excluded due to missing data. Moreover, the study was conducted at tertiary teaching hospitals in metropolitan areas and may not be representative of ED situations in more rural areas. Further research should include multiple levels of hospitals nationwide to identify other issues in the medical hospitalization process of patients who attempted suicide.
In this study, patients in the ICU and GW were grouped together in the hospitalized group and compared with those in the ED discharged group. Since close observation is available in the ICU, in both of the study hospitals, patients who attempted suicide by drug overdose, hanging, and drowning were hospitalized from the ED, were admitted to the ICU if they had a high risk of suicide re-attempt even if their physical injury was treatable in the GW. Therefore, the hospitalization rate for the ICU and GW was difficult to determine, and it was more appropriate to include both as the total hospitalized group. Furthermore, continuous psychiatric consultation is not provided during hospitalization, and is only provided following discharge. Another limitation is that bed availability at the time of hospitalization was not assessed. It may be possible that an early hospitalization decision was made, but a bed was not immediately available. But this may not add a significant bias as patients are typically transferred to another hospital when the bed is unavailable soon after the hospitalization decision.
This study included 2.6% of ED visits by patients who were 19 years of age or older without an existing illness in South Korea. When suicidal/self-harming patients desired medical hospitalization due to physical injury, there is an extra barrier to the hospitalization decision for departments other than psychiatry due to the combination of the patients’ psychiatric condition, with their physical injury. The present study demonstrates that the level of consciousness and RRRS scores can be used as factors for the hospitalization in patients who attempted suicide.
Suicidal patients often end up in the ED, and they frequently require medical hospitalization rather than psychiatric admission due to their physical injury. ED overcrowding increases the mortality risk in critical patients and reduces the quality of care. When considering medical hospitalization of patients who attempted suicide, assessing their level of consciousness and the RRRS can be the factors to decide medical hospitalization in order to reduce the ED LOS and crowding.
ED = Emergency Department
ED LOS = Emergency department length of stay
RRRS = Risk-Rescue Rating Scale
OECD = Organization for economic cooperation and development
LOS = Length of stay
CI = Confident Interval
GW = General ward
ICU = Intensive care unit
Ethics approval
This study was approved by the institutional review board (IRB) of Ewha Womans’ University Mok-dong hospital and Sangye Paik hospital. The requirement for informed consent was waived by the approving authority in view of the use of anonymized patient information.
Consent to publish
NA
Availability of data and materials
There are ethical restrictions on sharing a dataset because the data contain potentially identifying information. Suicide case management team can be contacted for data access via e-mail ([email protected]) or by calling 82-2-2650-5296.
Competing interests
The authors declare that they have no competing interests.
Funding
This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. 2018R1C1B5046096). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Authors’ contributions
Duk Hee Lee performed the experiments, analyzed the data, prepared figures and/or tables. Hye Jin Kim conceived and designed the experiments, performed the experiments, contributed reagents/materials/analysis tools, authored or reviewed drafts of the paper, approved the final draft.
Acknowledgments
We thank Young-ho Shin and Ji-young Lee (Sanggye Paik Hospital case management team) for data management support, and Hye Ah Lee. Ph.D. for helping with statistical analysis.
Clinical trial registration: Not applicable
Table 1. Comparison of the general characteristics of patients who attempted suicide between the hospitalized and discharged groups
|
Discharge (n=1346) |
Hospitalization (n=414) |
Total (n=1760) |
p-value |
|
Age (years, mean±SD) |
40.7±17.0 |
50.3±20.0 |
42.7±18.1 |
0.000 |
|
Sex, n (%) |
0.000 |
||||
Male |
420 (31.2) |
183 (44.2) |
603 (33.9) |
||
Female |
926 (68.8) |
231 (55.8) |
1163 (66.1) |
||
|
|||||
Marital status, n (%) |
0.001 |
||||
Single |
615 (45.7) |
146 (35.2) |
761 (43.6) |
||
Married |
572 (42.5) |
201 (48.5) |
773 (43.7) |
||
Separated |
116 (8.6) |
38 (9.3) |
154 (8.8) |
||
Widowed |
43 (3.2) |
29 (6.9) |
72 (3.9) |
||
|
|||||
Education status, no. (%) |
0.305 |
||||
Elementary school and lower |
75 (5.6) |
37 (9.0) |
112 (6.3) |
||
Middle school |
61 (4.5) |
21 (5.0) |
82 (4.6) |
||
High school |
605 (44.9) |
179 (43.2) |
784 (44.6) |
||
University and higher |
605 (44.9) |
177 (42.8) |
782 (44.5) |
||
Religion, n (%) |
0.409 |
||||
Yes |
392 (29.1) |
137 (33.1) |
529 (30.0) |
||
No |
954 (70.9) |
277 (66.9) |
1231 (70.0) |
||
Employment, n (%) |
0.021 |
||||
Yes |
594 (44.1) |
152 (36.6) |
746 (42.6) |
||
No |
752 (55.9) |
262 (63.4) |
1014 (57.4) |
||
Cohabitant, n (%) |
0.186 |
||||
Yes |
937 (69.6) |
305 (73.6) |
1242 (70.4) |
||
No |
409 (30.4) |
109 (26.4) |
518 (29.6) |
||
Health status, n (%) |
0.000 |
||||
Healthy |
993 (73.8) |
257 (62.1) |
1250 (71.4) |
||
Acute disease |
24 (1.8) |
11 (2.6) |
35 (2.0) |
||
Chronic disease without disability |
125 (9.3) |
48 (11.7) |
173 (9.8) |
||
Chronic disease with disability |
204 (15.1) |
98 (23.5) |
299 (16.9) |
||
Income, n (%) |
0.003 |
||||
|
<1.5 million KRW/month |
386 (28.7) |
181 (43.7) |
567 (31.4) |
|
1.5–2.5 |
310 (23.0) |
76 (18.3) |
386 (22.2) |
||
>2.5 |
650 (48.3) |
157 (38.1) |
807 (46.4) |
||
Insurance, n (%) |
0.057 |
||||
National health insurance |
1176 (87.4) |
373 (90.8) |
1549 (88.1) |
|
|
Medicaid beneficiary |
141 (10.5) |
33 (8.0) |
174 (10.0) |
|
|
Self-pay (uninsured) |
29 (2.1) |
8 (1.3) |
37 (1.9) |
|
|
Time from attempting to ED visit (hours) |
7.1±33.1 |
5.9±21.4 |
6.81±31.0 |
0.518 |
|
ED Length of stay (hours, mean±SD) |
4.2±12.3 |
11.4±18.8 |
5.4±13.7 |
0.002 |
|
|
|||||
Location of suicide attempt, n (%) |
0.778 |
||||
Home |
1170 (86.9) |
350 (84.6) |
1520 (86.4) |
||
School |
1 (0.1) |
0 (0.0) |
1 (0.1) |
||
Workplace |
10 (0.8) |
3 (0.8) |
13 (0.8) |
||
Lodging |
22 (1.6) |
17 (4.0) |
39 (2.2) |
||
Car |
16 (1.2) |
2 (0.5) |
18 (1.1) |
||
Group living facility |
1 (0.1) |
2 (0.5) |
3 (0.2) |
||
Healthcare facility |
7 (0.5) |
1 (0.3) |
8 (0.4) |
||
Commercial facility |
23 (1.7) |
10 (2.5) |
33 (1.9) |
||
River |
51 (3.8) |
12 (3.0) |
63 (3.7) |
||
Public facility |
10 (0.8) |
7 (1.8) |
17 (1.0) |
||
|
Others |
35 (2.4) |
10 (2.1) |
45 (2.3) |
|
ED LOS, emergency department length of stay
Table 2. Comparison of the characteristics of the patients who attempted suicide who visited the ED
|
Discharge |
Hospitalization |
Total |
p-value |
|
Consciousness, n (%) |
0.001 |
||||
Alert |
1004 (74.6) |
189 (45.7) |
1193 (68.3) |
||
Verbal response |
249 (18.5) |
95 (22.9) |
344 (19.5) |
||
Pain response |
93 (6.9) |
107 (25.8) |
200 (10.9) |
||
Unresponsiveness |
0 (0.0) |
23 (5.6) |
23 (1.3) |
||
Vital signs |
|
|
|
|
|
|
Systolic blood pressure(mmHg) |
122.6±21.8 |
118.5±28.8 |
121.0±25.4 |
0.007 |
Diastolic blood pressure(mmHg) |
74.5±15.1 |
70.2±18.0 |
73.3±17.1 |
0.001 |
|
Pulse rate(beat/min) |
91.5±19.6 |
91.1±23.4 |
90.9±21.8 |
0.421 |
|
Respiratory rate(/min) |
19.9±2.0 |
20.0±2.9 |
19.8±2.9 |
0.297 |
|
Body temperature (℃) |
36.6±1.1 |
36.2±2.7 |
56.3±3.0 |
0.035 |
|
Request for help |
|
0.026 |
|||
Yes |
701 (52.1) |
188 (45.5) |
889 (50.7) |
||
No |
645 (47.9) |
226 (54.5) |
871 (49.3) |
||
|
|||||
Previous suicidal attempt |
|
0.001 |
|||
Yes |
568 (42.2) |
118 (28.5) |
686 (39.3) |
||
No |
778 (57.8) |
296 (71.5) |
1074 (60.7) |
||
Number of previous suicidal attempts (n=686) (mean±SD) |
2.5±2.9 |
1.7±1.4 |
2.3±2.6 |
0.009 |
|
Past psychiatric consultation |
0.017 |
||||
Yes |
758 (56.3) |
206 (49.8) |
964.0 (55.0) |
||
No |
588 (43.7) |
208 (50.2) |
796.0 (45.0) |
||
History of psychiatric admission |
0.078 |
||||
Yes |
253 (18.8) |
58 (14.0) |
311 (17.9) |
||
No |
1093 (81.2) |
356 (86.0) |
1449 (82.1) |
||
Current psychiatric medication use |
0.544 |
||||
Yes |
810 (60.2) |
240 (58.0) |
1050 (59.7) |
||
No |
536 (39.8) |
174 (42.0) |
710 (40.3) |
||
Alcohol ingestion before suicidal attempt |
|
|
|
0.011 |
|
Yes |
678 (50.4) |
177 (42.8) |
855 (48.9) |
||
No |
668 (49.6) |
237 (57.2) |
905 (51.1) |
||
Planed suicidal attempt |
|||||
Yes |
109 (8.1) |
72 (17.5) |
181 (9.9) |
0.001 |
|
No |
1237 (91.9) |
342 (82.5) |
1579 (90.1) |
||
Motivation of the suicidal attempt |
0.001 |
||||
Psychiatric |
1147 (48.8) |
303 (52.3) |
1450 (49.5) |
||
Interpersonal |
442 (18.8) |
84 (14.5) |
526 (18.0) |
||
Job-related |
122 (5.2) |
26 (4.5) |
148 (5.1) |
||
Economic |
131 (5.6) |
36 (6.2) |
167 (5.8) |
||
Illness-related |
129 (5.5) |
46 (8.0) |
175 (6.0) |
||
Death of family member or pet |
42 (1.8) |
11 (1.9) |
53 (1.8) |
||
Legal problem |
19 (0.8) |
2 (0.3) |
21 (0.7) |
||
Loneliness |
25 (1.1) |
6 (1.1) |
31 (1.1) |
||
Fighting or punishment |
233 (9.9) |
54 (9.4) |
287 (9.8) |
||
Other traumatic event |
54 (2.5) |
11 (1.9) |
65 (2.2) |
||
Method of the suicidal attempt |
0.001 |
||||
Medication poisoning |
709 (52.7) |
219 (53.0) |
929 (52.7) |
||
Pesticides and herbicides |
28 (2.1) |
32 (7.8) |
61 (3.3) |
||
Gas poisoning |
50 (3.7) |
9 (2.2) |
59 (3.4) |
||
|
Chemical exposure |
28 (2.1) |
17 (4.1) |
45 (2.6) |
|
Hanging |
67 (5.0) |
23 (5.6) |
90 (5.2) |
||
Drowning |
20 (1.5) |
4 (1.0) |
24 (1.4) |
||
Cutting and piercing |
326 (24.2) |
70 (17.0) |
396 (22.7) |
||
Fall/jumping from a height |
20 (1.5) |
18 (4.4) |
38 (2.1) |
||
Collision/burns |
4 (0.3) |
1 (0.2) |
5 (0.3) |
||
Others |
93 (6.9) |
19 (4.6) |
112 (6.4) |
||
Psychiatric tentative diagnosis in ED |
|
0.430 |
|||
Depressive disorder |
1118 (83.1) |
343 (82.8) |
1461 (83.0) |
||
Bipolar disorder |
66 (4.9) |
16 (3.8) |
82 (4.7) |
||
Adjustment disorder |
63 (4.7) |
21 (5.0) |
84 (4.7) |
||
Schizophrenia and schizotypal and delusional disorders |
57 (4.2) |
21 (5.0) |
77 (4.4) |
||
Substance-use disorder |
15 (1.1) |
5 (1.3) |
20 (1.2) |
||
Anxiety disorder |
11 (0.9) |
0 (0.0) |
11 (0.7) |
||
Personality disorder |
9 (0.7) |
3 (0.8) |
13 (0.7) |
||
Organic mental disorder |
3 (0.2) |
3 (0.8) |
6 (0.3) |
||
Somatoform disorders |
3 (0.2) |
2 (0.4) |
4 (0.2) |
||
Disorders of psychological development |
1 (0.1) |
0 (0.0) |
1 (0.1) |
||
Risk-Rescue Ratio Scale score |
36.7±8.3 |
50.4±8.8 |
39.4±9.8 |
0.001 |
Table 3. Early decision factors identified in the hospitalized group by multivariate logistic regression analysis
Variables |
Univariate |
Multivariate |
||||||||
OR |
(95% CI) |
p-value |
OR |
(95% CI) |
p-value |
|||||
Age subgroup (Years) |
|
|
|
|
|
|
|
|
|
|
(≤34) |
1.000 |
Reference |
- |
1.000 |
Reference |
- |
||||
(35–64) |
1.722 |
(1.330 |
- |
2.228) |
0.000 |
2.222 |
(1.343 |
- |
3.678) |
0.002 |
(65≤) |
5.014 |
(3.639 |
- |
6.908) |
0.000 |
2.788 |
(1.416 |
- |
5.492) |
0.003 |
|
|
|
|
|
|
|
|
|
|
|
Sex, male |
1.750 |
(1.402 |
- |
2.284) |
0.000 |
2.041 |
(1.302 |
- |
3.119) |
0.002 |
|
|
|
|
|
|
|
|
|
|
|
ED LOS (hours) |
|
|
|
|
|
|
|
|
||
(~1.5) |
|
Reference |
- |
1.000 |
Reference |
- |
||||
(1.5–6) |
1.481 |
1.048 |
- |
2.093 |
0.026 |
1.674 |
(0.998 |
- |
2.808) |
0.051 |
(6~) |
1.933 |
1.333 |
- |
2.802 |
0.001 |
1.771 |
(1.017 |
- |
3.083) |
0.043 |
|
|
|
|
|
|
|
|
|
|
|
Consciousness |
3.499 |
(2.792 |
- |
4.385) |
0.000 |
1.840 |
(1.253 |
- |
2.466) |
0.000 |
|
|
|
|
|
|
|
|
|
|
|
RRRS |
1.275 |
(1.245 |
- |
1.305) |
0.000 |
1.298 |
(1.255 |
- |
1.343) |
0.000 |