PC3030: From Child Fatality Review to Zero Suicide

Purpose/Objectives: Suicide is the second leading cause of death among youth 10 to 19 years and rates have risen in this population since 2009. A county-level child fatality review team in a large urban area reported 191 pediatric suicide deaths from 2008 to 2017. A local healthcare system (system) in the county, comprised of 3 hospitals, ~50 primary care clinics, and 12 urgent care centers, used child fatality review and health claims data to help guide a system-wide response. The purpose of this quality improvement study was to: (1) identify children seen in the system who later died by suicide in the county, (2) use system-wide data to examine recent suicide-related healthcare utilization, and (3) to develop a system-wide response to suicide response and prevention.

Design/Methods: In this mixed methods quality improvement study, we conducted individual chart reviews to determine if youth who died by suicide from 2016-2020 received care in the system and describe the nature of the last service received. Additionally, we used system-wide claims data to create a pareto chart to display the distribution of suicide-related encounters across all locations from 2015-2021. Finally, we presented results to key system-wide leaders to inform key decisions in the ongoing system-wide suicide response.

Results: From 2015-2020, 152 youth died by suicide in a large urban county. Our chart review identified 56 of the 152 (37%) youth to be patients in the system within 5 years prior to death, 33 (22%) within 1 year, and 19 (13%) within 6 months of their death, respectively. For 13% of the youth, their last contact was with a primary care provider, specialty clinic, or emergency center in the system. More broadly, from 2015-2020, there were 9,204 encounters with a suicidal ideation or suicide attempt diagnosis in the emergency center, primary care, and urgent care settings (see Figure 1). There were 5,528 and 2,594 encounters with a diagnosis of suicidal ideation in the emergency center and primary care settings, respectively, accounting for 88% of the suicide-related encounters. We shared this information with key leaders. In September 2021, they founded the system-wide Suicide Response and Prevention (SRP) workgroup and its six committees – Research, Training, Internal Response, Family Response, Community Engagement, and Zero Suicide – to respond along the continuum of care from prevention to suicide care and response.

Conclusion/Discussion: These quality improvement efforts are an integral component of an ongoing effort to use data to inform and guide a unified system-level response to prevent, identify, and care for youth who experience suicidal thoughts and behaviors, and support their families and providers. The SRP will continue to monitor trends in data as specific committees collaborate with stakeholders and prioritize areas for a multi-pronged upstream and downstream approach.