In the News

Suicide rating scale; hospitalists and the intensivist shortage.

Suicide rating scale offers insights into actions, intents of patients

A suicide assessment exam that quantifies suicidal ideation and suicidal behavior as distinct domains instead of a continuum of behavior is suitable for clinical use, a study recently concluded. The Columbia-Suicide Severity Rating Scale (C-SSRS) was designed to quantify the severity of suicidal ideation and behavior. To assess C-SSRS's validity compared to other measures of suicidal ideation and behavior, as well as the exam's internal consistency, researchers applied data from three previous studies:

  • a National Institute of Mental Health multisite study of 124 adolescents with a suicide attempt or interrupted attempt 90 days before enrollment;
  • an industry-sponsored multisite, double- blind, placebo-controlled, parallel-group, fixed-dose clinical trial to evaluate the efficacy of escitalopram relative to placebo in the treatment of major depressive disorder among 312 adolescents with a diagnosis of major depressive disorder; and
  • a study funded by the American Foundation for Suicide Prevention that evaluated the identification and classification of recent suicide attempts and nonsuicidal self-injurious behavior among 237 adults who presented to an emergency department for psychiatric reasons.

Results were published in the Dec. 1, 2011 American Journal of Psychiatry.

The authors found that the C-SSRS demonstrated good convergent and divergent validity with other suicidal ideation and behavior scales and had high sensitivity and specificity for suicidal behavior classifications compared with other assessment scales. Its ideation and behavior subscales were sensitive to change over time, the authors noted, and the intensity of ideation subscale demonstrated moderate to strong internal consistency.

Other important findings included the following:

  • The C-SSRS severity subscale is sensitive to clinical change. Similarly, the C-SSRS identified almost an identical number of cases with specific types of suicidal behavior as the Columbia Suicide History Form and the suicide evaluation board ratings in study 1.
  • The C-SSRS demonstrated predictive validity, while another scoring system for suicidal ideation did not predict near-term nonfatal suicidal behavior.
  • A history of severe ideation with at least some intent to die may confer a greater risk for suicidal behavior than a history of ideation with no intent to die.

The authors wrote, “The use of a standardized measure such as the C-SSRS that comprehensively assesses suicidal behavior and ideation permits comparison of findings across research and clinical populations, as well as trends over time, providing data to guide treatment recommendations for suicidal patients and suicide prevention efforts.”

Hospitalists can help alleviate intensivist shortage

There was no difference in adjusted mortality or length of stay between medical ICU patients cared for by a hospitalist-led versus an intensivist-led team, a recent study found, though intermediate- and high-acuity mechanically ventilated patients may benefit from care by intensivists.

In a prospective, observational study at an urban academic hospital, researchers compared 828 consecutive medical patients admitted to a hospitalist-led ICU team (with intensivist consultation/comanagement of 152 patients) with 528 patients admitted to an intensivist-led ICU teaching team. Assignment of patients to admitting teams followed existing referral patterns, meaning ED patients who required invasive ventilatory support were admitted to the intensivist-led team, as were those transferred from a hospital floor bed to the ICU by non-hospitalist physicians. Patients with respiratory failure requiring noninvasive ventilation were admitted to the hospitalist-led team, as were those transferred by hospitalist floor teams. Both teams participated in similar multidisciplinary rounds and used the same evidence-based protocols and order sets. (Patient assignment sometimes deviated based on ICU teams' census, however—intensivists had a strict limit of 20, while hospitalists had a preferred limit of 12.) Study results were published online Nov. 8, 2011 by the Journal of Hospital Medicine.

Patients admitted to hospitalists were more likely to have preexisting morbid obesity, while those admitted to intensivists more often had cancer, pulmonary disease and immunological disease (P≤0.05 for all). Hospitalist patients also had a significantly lower mean SAPS II (Simplified Acute Physiology Score), less use of noninvasive and mechanical ventilation, and fewer central venous catheters (P<0.001 for all). When adjusted for disease severity, in-hospital and ICU mortality rates didn't differ between teams, nor did adjusted length of stay (LOS). ICU readmission rates also were similar for both teams. In subgroup analysis, patients with intermediate illness severity who were on mechanical ventilation had lower hospital LOS (10.6 days vs. 17.8 days, P<0.001) and ICU LOS (7.2 vs. 10.6, P=0.02) in the intensivist-led group, as well as a trend toward lower in-hospital mortality (15.6% vs. 27.5%, P=0.10).

Patients assigned to the two teams differed substantially in illness severity and mechanical ventilation; though researchers tried to control for this via statistical techniques, residual confounders may have remained, they noted. Still, the study results are helpful in suggesting hospitalists can help alleviate the current shortage of intensivists by caring for lower acuity critical care patients, leaving intensivists to care for higher acuity patients—especially those that are mechanically ventilated, the authors concluded.