The purpose of this study was to analyze the characteristics and factors of voluntary discharged patients after suicide attempt and analyze the effectiveness of follow-up measures.
Total 504 adult patients aged 14 years and over, who visited a local emergency medical center from September 1, 2013 to December 31, 2015 were enrolled and retrospectively reviewed. We analyzed the relationship with voluntary discharge group (VDG) among basic characteristics, suicidal attempt variables, outcome variables related to suicide attempts, and treatment related variables comparing with normal discharge group (NDG).
Of the total 504 suicide attempts, three hundred eleven (61.7%) patients were VDG and 193 (38.2%) were NDG. The proportion of patients who completed the community service linkage were 18.7% (36/193) in NDG, compared with 7.7% (24/311) in VDG (p<0.05). In addition, the ratio of the patients who visited psychiatric outpatient department in NDG were 57.0% (110/193), more than four times as likely as 14.5% (45/311) in VDG (p<0.05).
Over sixty percent of suicide attempters discharged against medical advice. Further various aspects of national supportive measures including strengthening case management service should be considered.
A suicide attempter is a patient who has survived a suicide attempt. Persons with suicidal thoughts are estimated to be approximately 25 times more likely to attempt suicide than the general population [
Among the Organization for Economic Co-operation and Development (OECD) countries with the highest suicide percentages from 1985–2001, Finland and Japan succeeded in decreasing their suicide percentages by conducting government suicide prevention projects and suicide comprehensive measures centered on “psychological autopsy” [
The purpose of this study was therefore to investigate the characteristics and factors related to the discharge of patients and the effectiveness of state-led case management for suicide attempts by hospital emergency departments.
Among 506 adult patients ≥14 years of age who visited the Soonchunhyang University Hospital Emergency Medical Center at Bucheon City, which is located in Gyeongi-do province in southern Korea, from September 1, 2013 to December 31, 2015, two patients were excluded from the study due to missing data about their medical severities. The medical records of 504 patients were then reviewed retrospectively.
The statistical relationship between the major variables of the four categories (basic characteristics, suicide attempt-related variables, outcome variables related to suicide attempts, and treatment-related variables) and the types of discharges were investigated. Independent variables were defined as variables that were necessary to predict a voluntary discharge. The type of discharge of the attempted suicide victim admitted to the emergency department was classified into the voluntary discharge group (VDG) and normal discharge group (NDG). Dependent variables were defined as VDG and NDG. The methods of attempted suicide were categorized as ingested poisoning, briquette gas poisoning, hanging, wrist cutting/puncture wounds, death leaps, and other causes. The state of consciousness at presentation was classified as alert, verbal, painful, and unresponsive.
Medical severity was defined as the extent of a serious injury. The medical severity was based on the medical records prepared by the emergency department nurse and interviews of two case management service team members. We classified cases where intensive care was required due to the severity of the injury, even after emergency department treatment, as “high.” After emergency department treatment, the patients who were admitted to the general ward or who needed medical attention even after discharge were classified as “moderate.” If there was no physical damage or very mild (abrasion) physical damage usually treated with a simple dressing, the case was classified as “low.” After emergency department discharge, the researcher completed the type of insurance by checking the medical records and classifying them as “health insurance,” “ordinary type,” “medical aid,” and “others.” Patients with a history of psychiatric disease were covered by health insurance and classified as “health insurance.” Other suicide attempters in the emergency department were recorded as “ordinary type” and were not covered by insurance. However, if the patient agreed to psychiatric treatment in the emergency department and conducted a psychiatric consultation, “ordinary type” was changed to “health insurance.” This was confirmed by reviewing the medical records of the authors after discharge of the patient and confirming the changed parts of the records. Even if the psychiatric consultation occurred in the emergency department, it was classified as “ordinary type” when the patient was not cooperating with the interview, when it was difficult to eliminate a diagnosis, or if psychiatric treatment was refused after discharge.
The classification of independent variables and dependent variables are listed below.
1) Baseline characteristics (demographic variables): sex, age, level of education, marital status, housemate, physical status, and the type of insurance.
2) Variables related to suicide attempts: drinking, a history of psychiatric disease, the method of the suicidal attempt, acknowledgment of the suicide attempt, and plans about a future suicide attempt.
3) Suicide attempt-related outcomes per type of discharge: awareness condition, medical severity, and plans for future suicide attempts.
4) Treatment modalities per type of discharge: medical request for neuropsychiatry (NP), case management service, links with community services, psychiatric treatment after the discharge, location of the discharge.
We used descriptive statistics to determine how these four categories of independent variables listed below were related to the voluntary discharge.
(1) Baseline characteristics (demographic variables)
(2) Variables related to suicide attempts
(3) Variables of suicidal attempt-related outcomes
(4) Treatment-related variables
The chi-square test was used to compare the main variables of the above four categories from (1) to (4) according to the type of discharge.
(5) Frequencies of emergency department voluntary discharge of patients according to visit and discharge time differences
Simple descriptive statistics (frequency and percentage) were applied for category (5).
(6) Voluntary discharge outcomes according to univariate logistic regression analyses
Univariate logistic regression analyses were performed for all variables included in the four categories in the suicide attempt group. The variables associated with voluntary discharge and the extents of association with statistical significance were also later examined.
(7) Voluntary discharge outcomes according to multivariate logistic regression analyses
After constructing an initial model of multivariate logistic regression using statistically significant factors in univariate logistic regression, we selected variables by backward selection and examined the variables associated with voluntary discharge and their associated strengths of statistical significance.
The collected data were analyzed using the R 3.1.3 program (codename, “Smooth Sidewalk”), (Comprehensive R Archive Network at
This study was supported by Soonchunhyang University and approved by the Institutional Review Board Committee of Soonchunhyang University Bucheon Hospital (IRB No. 2017-08-019-002).
Age, level of education, marital status, and physical status were statistically significant in terms of baseline characteristics (
Variables related to suicide attempts such as drinking, a history of psychiatric disease, the method of the suicidal attempt, acknowledgment about the suicidal attempt, and a plan for a future suicide attempt were all significantly associated with voluntary discharge (p<0.05) (
Variables of suicide attempt-related outcomes were the awareness condition, medical severity, and future suicide attempt plans (
The variables related to the treatment of suicide attempts were medical requests for NP, case management service, links with community service, psychotherapy after discharge, and the location when discharged. All these variables showed a statistically significant relationship with voluntary discharge (p<0.05) (
The total number of emergency department VDG patients was 242 (
In addition to treatment-related variables, univariate logistic regression was performed on variables that were significant using the chi-square test for baseline characteristics, variables related to suicide attempts, and suicide attempt-related outcome variables (
The level of education, physical status, psychiatric disease history, and medical severity were significant (p<0.05) using multivariate logistic regression analyses of variables that were significant using univariate logistic tests for voluntary discharge (
The voluntary discharge of patients accounts for approximately 2% of all hospital discharges, which results in a quality problem for health care [
Regarding demographic variables, the percentage of VDG patients was significant depending on the age, level of education, marital status, and physical health. The percentage of voluntary discharges of patients ≤20 years of age was high, and the percentage of normal discharges was high in patients ≥50 years of age. It was found that the younger the age, the higher the probability of voluntary discharge. In the case of elderly patients ≥50 years of age, the patient’s or caregiver’s concerns about the patient’s physical health may have caused an increase in the percentages of admissions and normal discharges. The percentage of voluntary discharge from the married group was the lowest in the VDG, which was presumed to be influenced by the emotional intervention of the spouse.
In the case of alcoholic patients related to suicide attempts, the percentage of drinkers was twice as high as that of nondrinkers in the VDG when the unmeasured patients were excluded. This was consistent with the finding that most past retrospective studies have consistently involved decisions to use a person’s discharge note if there was a drug or alcohol problem [
Awareness condition was not significantly associated with the voluntary discharge of the patient, in contrast to lower medical severity, which resulted in a significantly higher percentage of voluntary discharges. The unmeasured group with future plans for a suicide attempt had the highest percentage of patients in the VDG. In these patients, the non-responders were judged to be untreated patients, and because of the highest percentage of voluntary discharge of untreated patients, it was thought that a 24-h care system was needed to separately manage suicide attempters in the hospital. Suicide attempters were mostly impulsive. Excluding non-responders, impulsive patients were more likely to be voluntarily discharged.
The variables related to treatment, including psychiatric referral, consent, and intervention of a case management service; link with community service; post-discharge psychiatric treatment; and the location of the discharge (emergency department, general ward, or the ICU) were significantly associated with the type of discharge of the suicide attempter. Of the total of 311 voluntary discharge patients, 242 (77.8%) were discharged from the emergency department. The percentage of patients who refused psychiatric consultation in the VDG was more than twice that in the group who refused psychiatric consultation in the NDG. This was consistent with previous results from Holden et al. [
The percentages of the unmeasured or non-responder group involving variables such as the level of education, physical status, drinking status, psychiatric disease history, hospitalization history due to suicide attempts, plans for future suicide attempts, case management services, link with community services, and psychotherapy after discharge in the VDG were higher than those in the NDG. In VDG patients, there was a tendency not to accurately convey the condition of the patient or the coping process of the suicide attempter in the hospital care system could not be properly determined.
Whether the hospital had a psychiatric closed ward was also considered as a contributing factor for voluntary discharge of suicide attempters. In most of the admitted suicide attempters, in the course of the retrospective chart review of this study, after medical or surgical treatment was terminated, the patient was referred to a psychiatric department for treatment. In the course of this process, it was frequently found that patients and their caregivers were not compliant with the procedures and were discharged voluntarily from the hospital when they were told that they needed to be transferred to other hospitals with closed wards.
Interviews with the case management team staff at this research institute indicated that this team needed active participation by the medical staff. This meant that when the case management team was later contacted, the patient and caregiver showed a favorable attitude that led to post-management and community links with positive results.
Based on the results of the multivariate logistic regression analyses, the OR of the no response group relative to the college graduation or higher group, the physical status of the no response group relative to the healthy group, the psychiatric disease history group relative to the no psychiatric disease history group, and the low medical severity group relative to the high medical group were proportional to the percentages of voluntary discharges. It is anticipated that knowing the characteristics of the variables mentioned above and studying past investigations will help to reduce the voluntary discharge of patients from the hospital. Some studies have suggested that early detection, discussions, and counseling for communication are the preferred methods for reducing the percentage of discharges among patients with a history of drug or alcohol abuse [
This study was conducted based on a retrospective medical record survey at a single hospital, and it occurred during a specific period of time, so there was a possibility that there was selection bias and incomplete data discrimination. For example, patients recorded as “ordinary type” may have involved local enrollment or company enrollment, but it was impossible to distinguish between them. To overcome these limitations, future prospective multidisciplinary studies will be necessary.
Because suicide is caused by multiple causes, various forms of follow-up care are needed after discharge, and resources such as case management and community centers should be available.
In conclusions, three hundred eleven patients (61.7%) of the total 504 suicide attempters were discharged from the hospital. The non-response group relative to the college graduation or higher group, the physical status of the non-response group relative to the healthy group, the psychiatric disease history group relative to the no psychiatric disease history group, and the low medical severity group relative to the high medical severity group were all proportional. The VDG had a very low percentage of post-discharge intervention in the ongoing treatment methods of psychiatric outpatients, case management, and community links. Although case management services prevented and reduced the discharge of suicide attempters and increased the link between community and outpatient mental health services after discharge, it was not known whether at least 80% of the total suicide attempters were still linked to community services. Based on these results, further aspects of national supportive measures, including strengthening case management services, should be considered to reduce voluntary discharge of suicide attempters.
Treatment modality per type of discharge. *p<0.05. Self: voluntary discharge group, Normal: normal discharge group, NP: neuropsychiatry.
Psychiatric treatment after discharge. Self discharge: voluntary discharge group, Normal discharge: normal discharge group.
Baseline characteristics per type of discharge
Variable | Total (N=504) | Voluntary discharge group (N=311) | Normal discharge group (N=193) | p-value |
---|---|---|---|---|
Sex (%) | 0.15 | |||
Male | 175 (34.7) | 100 (32.2) | 75 (38.9) | |
Female | 329 (65.3) | 211 (67.8) | 118 (61.1) | |
Age (year) (%) | 0.022 | |||
<20 | 42 (8.3) | 29 (9.3) | 13 (6.7) | |
20–29 | 110 (21.8) | 75 (24.1) | 35 (18.1) | |
30–39 | 92 (18.3) | 53 (17.0) | 39 (20.2) | |
40–49 | 101 (20.0) | 68 (21.9) | 33 (17.1) | |
50–59 | 90 (17.9) | 55 (17.7) | 35 (18.1) | |
≥60 | 69 (13.7) | 31 (10.0) | 38 (19.7) | |
Educational level (%) | <0.001 | |||
High school or less | 169 (33.5) | 68 (21.9) | 101 (52.3) | |
≥College | 31 (6.2) | 11 (3.5) | 20 (10.4) | |
No response | 304 (60.3) | 232 (74.6) | 72 (37.3) | |
Marital status (%) | 0.007 | |||
Unmarried | 184 (36.5) | 120 (38.6) | 64 (33.2) | |
Married | 167 (33.1) | 87 (28.0) | 80 (41.5) | |
Married but without spouse | 153 (30.4) | 104 (33.4) | 49 (25.4) | |
Housemate (%) | 0.679 | |||
Existence | 426 (84.5) | 265 (85.2) | 161 (83.4) | |
None | 78 (15.5) | 46 (14.8) | 32 (16.6) | |
Physical status (%) | <0.001 | |||
Healthiness | 186 (36.9) | 102 (32.8) | 84 (43.5) | |
Acute disease | 13 (2.6) | 5 (1.6) | 8 (4.1) | |
Chronic disease/disability | 142 (28.2) | 66 (21.2) | 76 (39.4) | |
Unmeasured | 163 (32.3) | 138 (44.4) | 25 (13.0) | |
Type of insurance (%) | 0.096 | |||
Health insurance | 277 (55.0) | 181 (58.2) | 96 (49.7) | |
Medical aid | 26 (5.2) | 18 (5.8) | 8 (4.1) | |
Ordinary type | 191 (37.9) | 108 (34.7) | 83 (43.0) | |
Others | 10 (2.0) | 4 (1.3) | 6 (3.1) |
Data were reported as frequency (percentage). p-values were calculated by chi-square test or Fisher’s exact test as appropriate
Suicidal attempt related characteristics per type of discharge
Variable | Total (N=504) | Voluntary discharge group (N=311) | Normal discharge group (N=193) | p-value |
---|---|---|---|---|
Drinking (%) | <0.001 | |||
Yes | 256 (50.8) | 137 (44.1) | 119 (61.7) | |
No | 124 (24.6) | 74 (23.8) | 50 (25.9) | |
Unmeasured (no response) | 124 (24.6) | 100 (32.2) | 24 (12.4) | |
Psychiatric disease history (%) | <0.001 | |||
Yes | 194 (38.5) | 120 (38.6) | 74 (38.3) | |
No | 150 (29.8) | 70 (22.5) | 80 (41.5) | |
Unmeasured (no response) | 160 (31.7) | 121 (38.9) | 39 (20.2) | |
Method of suicidal attempt (%) | 0.015 | |||
Ingested poisoning | 283 (56.2) | 161 (51.8) | 122 (63.2) | |
Briquette gas poisoning | 36 (7.1) | 25 (8.0) | 11 (5.7) | |
Hanging | 24 (4.8) | 19 (6.1) | 5 (2.6) | |
Cutting wrist/pun |
144 (28.6) | 98 (31.5) | 46 (23.8) | |
Death-leaps | 12 (2.4) | 4 (1.3) | 8 (4.1) | |
Others | 5 (1.0) | 4 (1.3) | 1 (0.5) | |
Acknowledgment about suicidal attempt (%) | <0.001 | |||
Yes | 267 (53.0) | 145 (46.6) | 122 (63.2) | |
No | 42 (8.3) | 20 (6.4) | 22 (11.4) | |
Unmeasured (no response) | 195 (38.7) | 146 (46.9) | 49 (25.4) | |
Plan about suicidal attempt (%) | <0.001 | |||
Yes | 46 (9.1) | 21 (6.8) | 25 (13.0) | |
No (on impulse) | 271 (53.8) | 145 (46.6) | 126 (65.3) | |
Unmeasured (no response) | 187 (37.1) | 145 (46.6) | 42 (21.8) |
Data were reported as frequency (percentage). p-values were calculated by chi-square test or Fisher’s exact test as appropriate.
punctured wound
Variables of suicidal attempt related outcome per type of discharge
Variable | Total (N=504) | Voluntary discharge group (N=311) | Normal discharge group (N=193) | p-value |
---|---|---|---|---|
Awareness condition (%) | 0.134 | |||
Alert | 348 (69.0) | 222 (71.4) | 126 (65.3) | |
Verbal | 85 (16.9) | 54 (17.4) | 31 (16.1) | |
Pain | 62 (12.3) | 30 (9.6) | 32 (16.6) | |
Unresponsive | 9 (1.8) | 5 (1.6) | 4 (2.1) | |
Medical severity (%) | <0.001 | |||
Low | 244 (48.4) | 182 (58.5) | 62 (32.1) | |
Moderate | 161 (31.9) | 89 (28.6) | 72 (37.3) | |
High | 99 (19.6) | 40 (12.9) | 59 (30.6) | |
Suicidal attempt plan in future (%) | <0.001 | |||
Yes | 80 (15.9) | 40 (12.9) | 40 (20.7) | |
No | 160 (31.7) | 66 (21.2) | 94 (48.7) | |
Unmeasured | 264 (52.4) | 205 (65.9) | 59 (30.6) |
Data were reported as frequency (percentage). p-values were calculated by chi-square test or Fisher’s exact test as appropriate
Treatment modality per type of discharge
Variable | Total (N=504) | Voluntary discharge group (N=311) | Normal discharge group (N=193) | p-value |
---|---|---|---|---|
Medical request to NP (%) | <0.001 | |||
Request | 334 (66.3) | 199 (64.0) | 135 (69.9) | |
Patient refusal | 116 (23.0) | 92 (29.6) | 24 (12.4) | |
No request | 54 (10.7) | 20 (6.4) | 34 (17.6) | |
Case management service (%) | <0.001 | |||
Agreement | 238 (47.2) | 106 (34.1) | 132 (68.4) | |
Refusal | 70 (13.9) | 42 (13.5) | 28 (14.5) | |
Unmeasured | 196 (38.9) | 163 (52.4) | 33 (17.1) | |
Linkage of community service (%) | <0.001 | |||
Complete | 60 (11.9) | 24 (7.7) | 36 (18.7) | |
Unmeasured | 444 (88.1) | 287 (92.3) | 157 (81.3) | |
Psychiatric treatment after discharge (%) | <0.001 | |||
Outpatient visit | 155 (30.8) | 45 (14.5) | 110 (57.0) | |
Protection ward | 1 (0.2) | 0 (0.0) | 1 (0.5) | |
No therapy | 96 (19.0) | 65 (20.9) | 31 (16.1) | |
Unmeasured | 252 (50.0) | 201 (64.6) | 51 (26.4) | |
Place when discharging (%) | <0.001 | |||
Emergency room | 279 (55.4) | 242 (77.8) | 37 (19.2) | |
General ward | 225 (44.6) | 69 (22.2) | 156 (80.8) |
Data were reported as frequency (percentage). p-values were calculated by chi-square test or Fisher’s exact test as appropriate. NP: neuropsychiatry
Frequencies of emergency department voluntary discharge patients according to visit and discharge time difference
Total emergency department voluntary discharge group (N=242) | Time A |
Time B |
---|---|---|
Emergency department (%) | ||
Visit group | 43/242 (17.8) | 185/242 (82.2) |
Discharge group | 85/242 (35.1) | 157/242 (64.9) |
time from 8:00 am to 17:00 pm when direct case management service in emergency department was available,
time from 17:00 pm to 8:00 am when direct case management service in emergency department was unavailable
Univariate logistic regression analysis for voluntary discharge in subjects attempting suicide
Variable | Univariate |
|
---|---|---|
OR (95% CI) | p-value | |
Sex | ||
Male | 1 | |
Female | 1.34 (0.92–1.95) | 0.125 |
Age (year) | ||
<60 | 1 | |
≥60 | 0.45 (0.27–0.75) | 0.002 |
Educational level | ||
≥College | 1 | |
High school or less | 1.22 (0.56–2.8) | 0.619 |
No response | 5.86 (2.73–13.21) | <0.001 |
Marital status | ||
Married | 1 | |
Unmarried | 1.72 (1.12–2.65) | 0.013 |
Married but without spouse | 1.95 (1.24–3.09) | 0.004 |
Physical status | ||
Healthiness | 1 | |
Disease/disability | 0.7 (0.45–1.07) | 0.097 |
Unmeasured | 4.55 (2.75–7.73) | <0.001 |
Drinking | ||
No | 1 | |
Yes | 0.78 (0.5–1.2) | 0.258 |
Unmeasured | 2.82 (1.6–5.05) | <0.001 |
Psychiatric disease history | ||
No | 1 | |
Yes | 1.85 (1.2–2.86) | 0.005 |
Unmeasured | 3.55 (2.2–5.79) | <0.001 |
Method of suicidal attempt | ||
(Gas) Poisoning | 1 | |
Hanging/stang | 1.64 (1.11–2.45) | 0.015 |
Others | 0.64 (0.23–1.7) | 0.364 |
Acknowledgement about suicidal attempt | ||
Yes | 1 | |
No | 0.76 (0.4–1.47) | 0.42 |
Unmeasured | 2.51 (1.68–3.77) | <0.001 |
Plan about suicidal attempt | ||
Yes | 1 | |
No (on impulse) | 1.37 (0.73–2.59) | 0.325 |
Unmeasured | 4.11 (2.1–8.14) | <0.001 |
Medical lethality | ||
High | 1 | |
Moderate | 1.82 (1.1–3.04) | 0.02 |
Low | 4.33 (2.65–7.14) | <0.001 |
OR with 95% CI, p-values were calculated by univariate logistic regression analysis. OR: odds ratio, CI: confidence interval
Multivariate logistic regression analysis for voluntary discharge in patients attempting suicide
Variable | Multivariate |
|
---|---|---|
OR (95% CI) | p-value | |
Educational level | ||
≥College | 1 | |
High school or less | 1.13 (0.5–2.62) | 0.776 |
No response | 3.32 (1.47–7.82) | 0.004 |
Physical status | ||
Healthiness | 1 | |
Disease/disability | 0.67 (0.42–1.06) | 0.086 |
Unmeasured | 2.22 (1.23–4.07) | 0.009 |
Psychiatric disease history | ||
No | 1 | |
Yes | 1.62 (1.01–2.61) | 0.046 |
Unmeasured | 1.2 (0.67–2.15) | 0.54 |
Medical lethality | ||
High | 1 | |
Moderate | 1.26 (0.73–2.19) | 0.412 |
Low | 2.1 (1.21–3.65) | 0.008 |
OR with 95% CI, p-values were calculated by multivariate logistic regression analysis. OR: odds ratio, CI: confidence interval