This article covers:
Platform's history of patients expressing thoughts of self-harm
In 2020, we reviewed how eConsult manages the risks of patients expressing thoughts of self-harm during an online consultation. This is a difficult area, and suicidal thoughts cause alarm to both patients and clinicians alike.
We discussed this extensively within our team of primary and emergency care clinicians, and externally with our Liaison Consultant Psychiatrist and medico-legal advisor. The mitigation we currently have in place went live on 19/03/21.
Until 2020, we used to stop every consultation where a patient expressed thoughts of self-harm when they were asked:
In the PHQ-9: 'Over the last 2 weeks, how often have you had thoughts that you would be better off dead, or of hurting yourself in some way?' And answered 'Nearly every day'.
Or to the direct question: 'In the last few days, have you had thoughts of suicide or self-harm, or have you had thoughts about hurting someone else?’ the patient replied 'Yes'.
However, we would see consultations where patients wrote alarming words in the free-text box but answered 'No' to the closed question above.
We started interrogating our system through searching the data logs and found that patients were changing their answers from acknowledging to denying thoughts of self-harm. We surmised that they probably changed their answers to enable them to complete and submit the online consultation to their GP, or maybe they judged that their symptoms did not warrant a same-day call to the GP.
Our medico-legal advice was that where possible, GPs should be appraised of their patient’s true thoughts. We also, between clinicians, agreed that ideas of self-harm are not uncommon (and not only in patients diagnosed with depression), but that if a patient has made plans to take action on those thoughts, for example, by writing a note or setting a date, then that consultation needs to be stopped.
We have also listened to feedback from our GP users on our community groups. The consensus was that any individual answer in the PHQ-9 or GAD-7 questionnaires should not stop the consultation, including the question about ideas of self-harm. Again, this was because this was invaluable information for the GP, and as long as we asked a final closed question, then this was safe enough.
Mitigating the risks of patients with suicidal thoughts on the eConsult platform
This will be explained in two stages:
Which are the risk areas in the online consultation, i.e. where might patients be able to express these ideas.
How eConsult manages the risk, using a common ‘suicide pathway’.
There are three places in the online consultation where a patient can express suicidal thoughts.
In a free text answer to the first question: ‘Before we ask you detailed questions about your condition, please tell us what you would like to achieve from this consultation?’. This question appears at the start of all condition templates, not only in mental health templates. We have a tool that picks up any one of 39 synonyms of self-harm and suicide in the patient’s answer to this question. If this tool detects a trigger word, the patient is directed down the ’suicide pathway'.
In the PHQ-9 Depression questionnaire (appears in all mental health templates), we ask: ‘Over the last two weeks, how often have you had thoughts that you would be better off dead, or of hurting yourself in some way?’. The answer options are: Not at all / Several days / More than half the days / Nearly every day. For the reasons described above, none of these answers stops the consultation.
In all the mental health templates, we ask: ‘In the last few days, have you had thoughts of suicide or self-harm, or have you had thoughts about hurting someone else?’. If the patient answers 'Yes', we direct them down the 'suicide pathway’.
How we manage thoughts of self-harm/suicide: 'the suicide pathway’
If a patient is directed down the 'suicide pathway' by concerning answers in questions 1 and 3 above, they are then shown the follow-up screen:
If the patient answers 'No', they are allowed to continue with the consultation.
If the patient answers 'Yes', we stop the consultation and show patients the following screen:
Written by Dr Richard Wrigley, eConsult Clinical Governance team.
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