Patient Care, Training

Study Analyzes Effectiveness of Sending Follow-Up Postcards to Suicidal Patients

Issue 6 and Volume 38.

Powerful Postcards
Carter GL, Clover K, Whyte IM, et al. Postcards from the EDge: Five-year outcomes from a randomised controlled trial for hospital-treated self-poisoning. Br J Psychiatry. Epub ahead of print 2013 Mar 13.

We give kudos to these researchers for this longitudinal five-year study. In an original project, this Australian emergency department group showed that suicidal patients who received a personal follow-up postcard from the staff in the emergency department (ED) were half as likely to re-attempt suicide or return to the ED. In this follow-up study, the authors report on the same population five years later.

From April 1998 to December 2001, 378 patients (roughly 50% of total) receiving services from a regional toxicology service in New South Wales, Australia, were randomly selected to receive follow-up postcards. In addition to standard treatment, postcards were sent every two months for one year. Their rates of hospital readmission for self-poisoning, psychiatric hospital admission and death were compared with patients who received only standard treatment (control group).

Interestingly, a small group of seven patients (out of 76 who refused the intervention) accounted for 33 total repeat hospitalizations for self-poisoning. Over a five-year period, 484 individual events in the control group required re-admission for self-poisoning vs. 252 in the postcard group. Of patients readmitted, 61% overall required treatment for a pharmaceutical-only overdose.

The authors report that psychiatric hospital admissions were significantly less in the postcard group (447 vs. 710 per patient), resulting in 2,525 fewer hospital-bed days for patients who simply received a postcard.

This is an interesting, novel and inexpensive treatment that requires almost no face time and minimal follow up. Imagine what EMS might accomplish if we were to send follow-up postcards to our patients. We hope someone reading this column is inspired to try it, measure it and report it.

Stress in EMS
Bentley MA, Crawford JM, Wilkins JR, et al. An assessment of depression, anxiety, and stress among nationally certified EMS professionals. Prehosp Emerg Care. Epub ahead of print 2013 Feb 15.

It’s no secret that EMS takes a toll on providers. Previous research has shown the long hours and repeated exposure to high-stress situations that have led to an increase in substance abuse and missed work due to psychiatric health issues. In this study, the National Registry of EMTs (NREMT) set out to determine the prevalence of depression, anxiety and stress among EMS providers.

EMS professionals who applied for recertification through the NREMT in 2009 were given a self-administered questionnaire along with their recertification. The questionnaire asked demographic and work-related questions, along with a Depression Anxiety Stress Scale-21 (DASS-21). This was a cross-sectional study covering multiple variables.

A total of 23,451 study participants were included for review. Respondents were divided into nine groups based on certification level, the size of community the respondent works in, service type (fire-based, municipal, private, hospital-based or other), years of service, race, gender, education level, marital status, general health, exercise in the past month and whether the respondent is a smoker.

Of note is that just less than 64% of respondents are current smokers. In addition, 6.8% of respondents tested positive for some form of depression, with paramedics being more likely to have some form of depression, at 9.3%, than EMTs, at 4.4%. Anxiety and stress levels were similar, with 6% of respondents testing positive for anxiety and 5.9% testing positive for stress. Respondents indicating that they were of fair to poor health were most likely to test positive for some form of depression or anxiety. The respondents who indicated that they hadn’t exercised in the past month had the highest percentage for some sort of stress at 12.10%. Individuals who had never been married or were separated from their spouse were more likely to be depressed (9.42%) than those who were married (6.03%).

It should come as no surprise that people who care for themselves report much lower levels of depression, stress and anxiety. As the authors state, the design of this study leaves room for some self-reporting bias—which is why the statistics seem low. EMS is a family, from first responders to flight crews, medics to medical directors. We all need to keep in mind that there’s help available.

Reduced Admissions for Alcohol
Hughes NR, Houghton N, Nadeem H, et al. Salford alcohol assertive outreach team: A new model for reducing alcohol-related admissions. Frontline Gastroenter. 2013;4(2):130–134.

Last month, we praised American Medical Response Colorado Springs for its alternate transport disposition for intoxicated patients. This month, we praise the National Hospital Service trust, the national publicly funded healthcare system in the United Kingdom. This Salford, Greater Manchester group is taking an active approach in reducing the number of hospital admissions due to alcohol-related illness.

The group created an alcohol assertive outreach team (AAOT) composed of ED physicians and nurses, as well as psychologists, alcohol workers and social workers. The team set out to determine if aggressive intervention can effectively reduce hospital admissions by patients frequently admitted for alcohol related problems. They compared hospital admission three months prior to and after interaction with the AAOT.

There were 54 total patients who were case managed for a total of six months. There were no exclusion criteria. Although each patient received highly personalized care, the most commonly identified cares included psychological and alcohol support and access to detoxification and outpatient facilities, including rides to and from appointments. Hospital admissions in the three-month period following intervention by the AAOT were 50 in comparison to 151 in the three-month period prior to intervention. ED visits decreased to 146 from 360.

This is exciting news, because two-thirds of alcohol-related hospital admissions and more than half of ED visits disappeared with appropriate access to primary care resources. Like the first study mentioned earlier, this seems like a great opportunity for the growing field of community paramedicine in the U.S.

Bottom Line
What we know: Emergency department overcrowding is a frequent problem due to intoxicated patients.
What this study adds: With appropriate resources, such as community-based paramedics, emergency department admissions due to intoxication can drop dramatically.

Exclusion criteria: Predetermined variables set by the study authors that would preclude a particular piece of data from being added to the study. For example: an incomplete survey.
Cross-section: A large group of people from one particular population, regardless of multiple variables. A snapshot of that group which is then divided into groups based on research criteria.