Sounding the Alarm About Suicide Risk
The Joint Commission (TJC) issued a Sentinel Event Alert, noting that in too many instances healthcare providers are not recognizing signs of suicide risk in patients who present for care. While the agency calls on all frontline providers to screen for suicide risk, experts note the issue is of particular importance to EDs because this is one of the most likely places for patients at high risk for suicide to present. Beyond identifying risk, experts note emergency providers and staff must receive training to effectively manage patients at risk for suicide. Further, TJC calls for the development of appropriate referral sources and mechanisms for follow-up contact.
- TJC reports that between 2010 and 2014, its Sentinel Event Database received 1,089 reports of suicides. The most common root cause was inadequate assessment. According to TJC, in 2014 more than 21% of accredited behavioral health organizations and 5% of accredited hospitals were non-compliant with conducting a risk assessment to identify patient characteristics or environmental factors related to suicide risk.
- Beyond instances of obvious risk, strong tipoffs that suicide is a concern include signs of hopelessness or evidence that the patient has no sense of the future. Further, experts note the strongest indicator of a future suicide attempt is a past attempt, so evidence in the record of a past suicide attempt, or a family history of suicide, should be taken very seriously.
- Researchers found that a three-item instrument, dubbed the Patient Safety Screener-3, can double the number of patients identified as at risk for suicide over usual care in a busy emergency setting. Experts recommend asking screening questions during the primary nursing assessment for most patients, and at triage for patients who present with a primary psychiatric complaint.
- Some experts suggest regionalizing mental health care, much like the country does with trauma care. However, communities must ensure they maintain adequate funding for such endeavors.
Three questions to recognize suicide risk
Edwin Boudreaux, PhD, uses a three-item suicide risk screen, dubbed the Patient Safety Screener-3, to effectively identify suicide risk, doubling the number of patients identified as at risk over usual care when applied universally in a busy ED setting.1,2 The first question asks patients if they have felt down, depressed, or hopeless in the previous 2 weeks. The second question asks if patients have had suicidal thoughts in that same period. The third question asks if patients have ever attempted suicide. Answering “yes” to two questions suggests a patient is at risk. If the screen is to be applied universally to all patients, at what point in the workflow is the best time to ask patients the three questions? While Boudreaux hasn’t studied that issue specifically, he believes for most EDs the best time to review these questions with patients who present with a non-psychiatric problem is during primary nursing assessment. “Many facilities want triage to be as fast as possible, and to be very focused on the problem that the patient is presenting with,” he explains. “Any other kind of screening — public health, behavioral health, or anything related to metrics that are reported — really have a better utility once the patient is back [in a treatment room] and a more comprehensive assessment is performed.”
For patients presenting with a psychiatric problem or emergency, Boudreaux advises screening at triage. “You’ve got two [screening] tiers that work,” Boudreaux notes, indicating that the same screen is effective at both stages of the workflow. “My site has made the decision to implement the screen at triage rather than during the primary nursing assessment because it fits in with the workflow of the ED acceptably.”
While there are no data on this point, Boudreaux suggests patients may not be as comfortable discussing or disclosing thoughts of suicide during triage as they are in a more private location. “You may get more false negatives if you do it that way,” he says. The most private method may be through self-reporting via an electronic device. “When you administer a computerized self-assessment, you get as good or better results than when [the screen is administered] by an interviewer,” Boudreaux offers. “The more sensitive the information, the more likely you are to get better information from the computer because you don’t have … social issues influencing responsiveness.” Additionally, computers ask questions exactly the same way every time, eliminating variability. Busy nurses often blend screening questions together, making the instrument less effective at determining risk. “You don’t want a patient who screens positive for suicide risk leaving the waiting room before being seen,” Boudreaux notes. “If you are going to screen for suicide in the waiting room, you specifically have to make sure there are procedures and protocols in place for reviewing those results quickly, identifying patients, bringing them in quickly to prevent elopement.”
- Boudreaux E, et al. The patient safety screener: Validation of a brief suicide risk screener for emergency department settings. Arch Suicide Res 2015;19:151-160.
- Boudreaux E, et al. Improving suicide risk screening and detection in the emergency department. Am J Prev Med 2015;50:445-453.
The Joint Commission urges universal screening and increased efforts to link at-risk patients to appropriate care.
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