Eventos centinelas predictores de suicidio en hospitalización psiquiátrica

8/2/2019 Eventos centinelas predictores de suicidio en hospitalizacin psiquitrica

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PRIMARY RESEARCH Open Access

Sentinel events and predictors of suicide amonginpatients at psychiatric hospitalsYi-Lung Chen1, Dong-Sheng Tzeng1,2* , Ting-Sheng Cheng1 and Chien-Hung Lin3

Abstract

Background: The objective of this study was to assess sentinel event analysis and relative factors in differentmental healthcare settings. In addition, the occurrence of sentinel events in different hospital settings wascompared and potential risk factors contributing to sentinel events identified.Methods: A total of 75 consecutive adult subjects were enrolled from 2 psychiatric units, 1 within a general

hospital and 1 at a psychiatric hospital in southern Taiwan. A retrospective chart review of the psychiatricinpatients was conducted for patients that met the criteria for a sentinel event between July 2004 and May 2011.A comparison of the hospital settings was made and differences between suicidal and non-suicidal sentinel eventsstudied.Results: Psychiatric patients that received general hospital psychiatric services (1) appeared to experience asentinel event soon after admission, (2) the time between the sentinel event occurrence and patient death wasshorter, (3) there was a higher probability of potential medical illness than among inpatients treated at aspecialized psychiatric hospital, (4) the sentinel event subjects that committed suicide were younger, had a shorterhospital stay, shorter time to occurrence of the sentinel event followed by an unexpected death than the non-suicidal group, and (5) a younger age, higher education level, previous suicide attempt and family psychiatrichistory were important predictors of suicide among psychiatric inpatients.Conclusions: The results of this study suggest that psychiatric inpatients treated at a general hospital require

careful examination for potential physical illness and greater efforts to prevent suicide. A younger age, highereducation level, history of a previous suicide attempt and family psychiatric history are additional risk factors forsuicide among these patients.

Keywords: retrospective study, sentinel event, suicide

IntroductionIn order to improve patient safety, there have been sig-nificant changes in the way health services are providedin the hospital setting [ 1]. The delivery of mental healthservices is very complicated; it requires action at alllevels of the healthcare organization that is coordinated

and integrated in accordance with the principles of clini-cal governance [ 1].The terms sentinel event and medical error are not

synonymous; not all sentinel events occur because of anerror and not all errors result in sentinel events. The

Joint Commission on Accreditation of Healthcare Orga-nizations (JCAHO, now the Joint Commission) updatedtheir definition of a sentinel event in 2007; the currentdefinition is as follows: a sentinel event is an unex-pected occurrence involving death or serious physical orpsychological injury, or the risk thereof . The phrase or

the risk thereof

includes any variation for which arecurrence would carry a significant chance of a seriousadverse outcome. Such events are called sentinel

because they signal the need for immediate investigationand response [ 2].

Many medical and health service managers haveimplemented a sentinel event policy to strengthen thereporting, monitoring, and management of major inci-dents . Such a pol icy mus t be implemented in

* Correspondence: [email protected] of Psychiatry, Kaohsiung Armed Force General Hospital,Kaohsiung, TaiwanFull list of author information is available at the end of the article

Chen et al . Annals of General Psychiatry 2012, 11 :4http://www.annals-general-psychiatry.com/content/11/1/4

2012 Chen et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0 ), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.
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accordance with the underlying healthcare system,human activities, work processes, and technical factorsthat may contribute to the occurrence of sentinel events[3].

Suicide occurrence in a hospital setting is one of themost commonly reported adverse events (12.4%), secondonly to surgical errors; about half (52%) of the suicidesoccur in psychiatric wards [ 4]. Previous reports haveindicated that the range of inpatient suicide is 5 to 15and 100 to 400 every 100,000 admissions to psychiatricand general hospitals, respectively. Patient characteristicssuch as male gender, depressive disorders, violent behavior, history of previous suicide attempts, absence with-out official leave and the rapid occurrence of suicideafter admission are known risk factors for inpatient sui-cide in psychiatric or general hospitals [ 5-14].

A review of the current published literature shows a

lack of data on comparison of sentinel events betweenadmissions to psychiatric hospitals and admissions topsychiatric units in general hospitals; little is knownabout the associated suicidal characteristics and predic-tors of suicide among these inpatients, especially in Tai-wan. The primary goal of this study was to assesssentinel event reporting in different mental healthcaresettings. In addition, the occurrence of a sentinel eventat one psychiatric hospital was compared to one psy-chiatric unit in a general hospital in southern Taiwan by retrospective chart review (between July 2004 and July 2011) to identify potential risk factors contributing tothe sentinel event.

MethodsParticipantsThe redesigned care network model was used to recruitconsecutive adults from two hospital settings, a psychia-tric hospital and a psychiatric unit in a general hospital,in southern Taiwan. A network of mental health serviceshas been created by coordinating services at a generalhospital, a psychiatric hospital, 10 outpatient clinics, andcommunity programs [ 15]. Inpatients that met the cri-teria of a sentinel event, according to the definitionreported by JCAHO were recruited for this study. The

criteria for the psychiatric diagnosis of the subjects wasbased on the Diagnostic and Statistical Manual of Men-tal Disorders, Fourth Edition (DSM-IV).

MeasurementsThe hospital s institutional review board approved thisstudy. A retrospective chart review of the psychiatricinpatients that met the definition of a sentinel event wasperformed between July 2004 and May 2011. The demo-graphics for all patients were reviewed. Patients thatcommitted suicide were defined as cases and comparedto other sentinel events. The definition of a sentinel

event not associated with suicide was an unexpectedsentinel event not associated with suicide.

The variables that were compared included: gender,age, disease duration, level of education, smoking, alco-hol use, drug misuse, medical history, previous suicidalhistory, committed suicide or not, hospital stay beforeoccurrence of the sentinel event, the time of occur-rence of a sentinel event followed by an unexpecteddeath, a result of death or serious disability, transfer tothe intensive care unit (ICU) or not, nursing care timeand the seniority of attending doctors. In addition,patients that experienced a sentinel event were cate-gorized as suicidal or non-suicidal for comparison of characteristics.

Statistical analysisSPSS V.15.0 (SPSS Inc., Chicago, IL, USA) was used for

the demographic, descriptive, exploratory c2

analyses. AStudent s t test was carried out to compare the differ-ences between patients in the psychiatric unit of a gen-eral hospital and those at a psychiatric hospital todetermine whether there were significant differences.For further analysis, a logistic regression model wasused to identify important predictors of suicide after asentinel event.

ResultsA total of 75 sentinel events were reported from the 2hospital settings studied; 52 patients were from a psy-chiatric unit within a general hospital and 23 patientswere from a psychiatric hospital. Among them, schizo-phrenia was the most common diagnosis (n = 38,50.67%), followed by bipolar disorder (n = 18, 24%), andmajor depressive disorder (n = 7, 9.33%), substance-related disorder (n = 6, 8%), depressive disorder (n = 3,4%), and dementia (n = 3, 4%). The comparison of demographic data between two different psychiatricmental healthcare settings is shown in Table 1.

There were three demographic variables comparedbetween the two different hospital settings found tohave a significant difference. Firstly, the mean occur-rence time of the sentinel event after admission for psy-

chiatric inpatients from the general hospital was 52.7 65.6 h, and for patients from the psychiatric hospitalwas 152.9 206.8 h. Secondly, the mean occurrencetime of a sentinel event followed by an unexpecteddeath for psychiatric inpatients from the general hospitalwas 5.5 14.4 h, and for inpatients from the psychiatrichospital was 21.9 80.9 h. Thirdly, the mean nursingtime for psychiatric inpatients from the general hospitalwas 2.2 0.8 h/day, and for inpatients from the psychia-tric hospital was 2.0 1.4 h/day. There was no statisti-cally significant difference found for the otherdemographic variables with regard to the sentinel events


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had a past history of a suicide attempt. Previous epi-sodes of self-abusive behavior and a history of suicideattempts, especially during the index admission, werealso significant predictors [ 17-19]. The findings of thisstudy are consistent with a previous report that showedthat psychiatric inpatients with a history of suicidalbehavior were mainly young patients with a previoussuicide attempt [ 20]. Previous studies have demonstratedthat younger patients were found to have higher rates of suicidal ideation or attempts than older age groups[21-24]. Although these study subjects were collectedfrom the general population in the community. It is wellknown, based on retrospective survey data, that over90% of suicides have a diagnosable mental illness[25,26]. The findings of this study confirm that youngage is a risk factor for suicide following a sentinel event.

In contrast to earlier findings, however, there was no

evidence of an association between the duration of men-tal illness and suicidal events [ 27,28]. Since the defini-tion of a sentinel event is an unexpected occurrenceinvolving death, physical or psychological injury, a possi-ble explanation for this result is that some suicidalevents are associated with less violent methods andc au se minor physi ca l i nju ri es that ma y beunderreported.

A logistic regression analysis was performed to iden-tify the potential predictors of suicidal events associatedwith a sentinel event. The variables studied includedage, gender, education level, marital status, and family psychiatric history. In addition to younger age and previous suicide attempt, other significant predictors identi-f ied were a higher education level and a family psychiatric history. A study demonstrated that a family history of a psychiatric disorder was strongly associatedwith psychiatric inpatient suicide [ 29]. A review of thecurrently published literature showed positive priorreport of a correlation between education level andinpatient suicide [ 30]. One explanation might be the younger age of suicide cases with regard to educationlevel compared to the non-suicidal group. Anotherexplanation is the selective bias associated with a smallsample size.

Another issue is that all study subjects were part of anintegrated care model of psychiatric service, either in apsychiatric unit within a general hospital or a psychiatrichospital [15]. These two psychiatric hospital settingshave the same integrated care model and provide anintensive care experience for their psychiatric patients.A suicide assessment protocol was thoroughly per-formed to identify subjects and the appropriate psychia-tric services provided. This would include 24 hourmonitoring, high levels of nursing care, routine assess-ment of mental symptoms and security screens in orderto minimize the occurrence of a serious sentinel event.

Since there is little data in the literature for comparison,different care models must be considered in the future.

This retrospective study had several limitations. Theretrospective chart review methodology limited a moredetailed recording of demographic information. The cor-relation of physical and mental illness with the reportedsentinel event could not be clearly linked based on achart review. Objective assessment tools should be pre-sented on charts to help in this matter. The characteris-tics associated with suicidal and non-suicidal sentinelevents, in patients admitted for integrated psychiatricservices, may not be applicable to a traditional psychia-tric care model. The relatively small sample size alsocauses wide 95% confidence intervals for the odds ratios,which make the predictors and estimates less reliable.

Conclusions

Based on the comparative results of two different psy-chiatric hospital settings, hospitalized psychiatric inpati-ents treated at a general hospital appear to haveunidentified critical medical conditions more frequently than the inpatients treated in a psychiatric hospital set-ting. The goal of this study was to identify factors thatmight help predict suicidal behavior associated with sen-tinel events. Such factors might help prevent suicide,and improve patient care.

Author details1Department of Psychiatry, Kaohsiung Armed Force General Hospital,Kaohsiung, Taiwan. 2Hyperbaric and Undersea Institute, National DefenseMedical Center, Taipei, Taiwan. 3Calo Psychiatric Center, Pingtung County, Taiwan.

Authors contributionsDr. DT contributed to the conception and design of the study. Dr YCcontributed to the data collection process and assembling of data. Dr. TCcontributed to overlooking the data collection and data analysis. Dr. CL alsocontributed to the analysis of the data and further interpretation of the data.Dr. YC was involved in the overall research process. All authors contributedto the drafting of the manuscript and approved of the final manuscript.

Competing interests The authors declare that they have no competing interests.

Received: 30 December 2011 Accepted: 16 February 2012Published: 16 February 2012

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doi:10.1186/1744-859X-11-4Cite this article as: Chen et al .: Sentinel events and predictors of suicideamong inpatients at psychiatric hospitals. Annals of General Psychiatry 2012 11:4.

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Eventos centinelas predictores de suicidio en hospitalización psiquiátrica

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