Given that EDs are among the most likely places for patients at risk for suicide to present, experts say training staff to recognize and manage such patients is critical.

In its latest Sentinel Event Alert, The Joint Commission (TJC) spotlights the inescapable fact that in too many instances, healthcare providers are not recognizing signs of suicide risk in patients who present for care. It is a critical lapse, as most people who go on to commit suicide have interacted with the healthcare system in the year before their deaths, according to TJC.

The agency notes that between 2010 and 2014, its Sentinel Event Database received 1,089 reports of suicides. The most common root cause cited in these cases was inadequate assessment. According to TJC, in 2014 more than 21% of accredited behavioral health organizations and 5% of accredited hospitals were noncompliant with conducting a risk assessment to identify patient characteristics or environmental factors related to suicide risk.

As a result of these findings, TJC is calling on healthcare providers to review every patient’s personal and family history for suicide risk factors, and to screen all patients using an evidence-based tool that includes questioning about suicidal thoughts. Further, TJC notes professionals should review these screens before discharge. Patients who screen positive for potential suicide risk should be subjected to more in-depth evaluations.

Know when to probe further

In issuing this alert, TJC encourages all healthcare organizations to develop “clinical environmental readiness” by developing and integrating the kind of behavioral, primary, and community care resources that ensure patients who are at risk for suicide continue to receive appropriate care when they transition back to the community or to the next healthcare setting.

While TJC’s Sentinel Event Alert targets providers in all healthcare settings, expertise in both identifying the risk of suicide and managing this risk effectively is particularly important in the emergency environment.

“If there is a crisis involving someone who is suicidal, the most common advice is to call 911 or bring someone to the ED. Every year, hundreds of thousands of people who have made suicide attempts [and] many others who are thinking about suicide arrive at EDs,” explains Richard McKeon, PhD, MPH, chief of the suicide prevention branch in the division of prevention, traumatic stress, and special programs in the Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services. “The ED is one of the most likely places for people at high risk for suicide to be encountered.”

Further, while TJC highlights shortcomings in assessment as one of the most common root causes for suicide in patients who have recently visited a healthcare setting, McKeon observes that the problem of identifying risk is not even an issue in many patients who present to the ED.

“While screening is a good thing that can identify additional people, when someone is brought to the ED because of a suicide attempt or because the person has been talking about suicide and has been brought in by a family member, for example, then the issue of how to identify them is not present,” he says. “You already know the person is at risk. Then the issue is assessing their risk and determining what needs to happen next.”

Beyond the obvious instances of risk, there are strong tipoffs that should prompt providers to probe further.

“The strongest predictor of future behavior is past behavior, so the absolute strongest indicator of a future suicide attempt or death by suicide is a past suicide attempt,” explains Cheryl McCullumsmith, MD, PhD, an associate professor in the Department of Psychiatry and Behavioral Neuroscience at the University of Cincinnati. “Certainly, if you have in the record that someone has had a past suicide attempt or a family history of death by suicide, those are very specific things that people should be taking quite seriously.”

Other indications that a person may be at risk for suicide can be picked up by questioning, but too often providers don’t take this extra step, McCullumsmith notes. For instance, simply asking a patient whether he or she has had thoughts of self-harm or whether he or she feels that life is not worth living often yields critical information regarding risk.

“There are other things that we consider strong warning signs. Hopelessness has been very much associated with suicide attempts and death by suicide, so someone who just has no sense of the future or has no future plans” should alert the provider of potential risk, she says. McCullumsmith also notes that impulsivity and substance use are significantly underplayed as warning signs for suicide risk, but she acknowledges these issues are more difficult to address.

Whether patients will actually disclose they are thinking about suicide is a tougher question, but McCullumsmith suggests there is evidence that many people at risk for suicide do reach out for help, and that more active probing could make a difference.

“We do know that many people who have died by suicide have sought care from a primary care provider or someone else in the month or two before their death,” she says. “It is unclear whether these people told their providers [about their plans], but a lot of people do seek help.”

McCullumsmith is collaborating with colleagues at Cincinnati Children’s Hospital to identify linguistic and auditory patterns associated with suicide risk, but this work is in early stages of development.

Develop approach for follow-up

McKeon estimates that about half of patients seen in EDs for a suicide attempt are not admitted but rather discharged, setting off a time period of critical importance.

“Typically, when someone walks out of an ED, the ED’s responsibility ends. Someone may be referred to an outpatient department or a community mental health center, but the community mental health center’s responsibility typically doesn’t begin until the person walks through their door. There is a lethal gap between the ED and the outpatient department unless there is a system in place to pay attention to that,” McKeon explains. “The rates of follow-up care can be poor, so it is vitally important that EDs are linked to community systems that can do a better job of improving these kinds of care transitions.”

McCullumsmith agrees, noting she worked with colleagues at the University of Cincinnati and previously at the University of Alabama at Birmingham to set up programs to follow people within 1 or 2 days of discharge from an ED to make sure they are stable, and that they are able to connect with appropriate care. She stresses that this follow-up can involve phone calls or in-person visits, and physicians don’t have to be the ones conducting these follow-ups.

“It can be done by a trained social worker, a psychologist, or a therapist,” she says.

However, there is no question that putting such systems in place can be challenging, given the demands that are placed on busy EDs every day.

“Emergency medicine is under siege in this country. You go to any urban ED and people are stacked to the rooftops. There are stretchers in the hallway,” says Glenn Currier, MD, MPH, chair and professor in the College of Medicine Psychiatry and Behavioral Neurosciences at the University of South Florida. “There is this notion that ED boarding of psych patients is one of the problems. Even if you find people who are at some elevated risk for suicide, the question is, what do you do with them? Then it often involves an involuntary commitment to a hospital. Make sure that you know what you’re treating before you detain people and strip them of their civil rights in what, in many communities, is a very long wait for a psych bed.”

Currier points out that the Washington State Supreme Court ruled last year that the boarding of psych patients violates peoples’ inherent constitutional rights, but the court offered no suggestions on how to address the problem.

“Psych beds in this country are about one-tenth of what they used to be, so it is a complex problem,” he says, noting that solutions must address how to safely and effectively manage patients who are found to be at some elevated risk of suicide in the ED. “It is not just a cost question. It is a rights question for the patient.”

Currier observes that he has spent most of his life working in large EDs where demand for psychiatric services was so high that the health systems incorporated freestanding psychiatric components to meet the needs of mental health patients in the emergency setting. With this setup, Currier found traditional emergency providers are willing to take on mental health issues once they learn how to provide evidence-based care.

“However, it is really incumbent on mental health to come up with protocols, algorithms, and treatments that work,” he notes.

“Regionalization of this, similar to what we have done with trauma care, makes a whole lot of sense,” Currier adds, noting that what he is referring to is a centralized receiving facility that makes optimal use of community assets to care for patients with mental health issues. Such programs often employ mobile crisis teams, shelter beds, and an array of resources that can help them maintain patients in the community. But such models often suffer over the long term.

“As long as [these programs] are attached to a hospital system, they work great. However, once you carve them off and put them in the community ... the support behind them tends to dwindle. Regionalization is a great idea; it just has to be done well.”

Directing a psychiatric emergency service for many years gave McKeon empathy for emergency providers, many of whom are already overwhelmed with responsibilities.

“I know what a busy medical emergency room is like, and there is no question that it is important to figure out how to best integrate suicide prevention activities into the ongoing workflow of an ED,” he says.

Screening for suicide risk is one of the issues, but McKeon suggests this may not be as big a barrier as some people think.

“People spend a lot of time waiting in EDs, so patients may well have time for screening,” he says. “What is needed is the kind of systems that are able to communicate that [screening] information to emergency physicians and nursing staff quickly so that they can consider it in their dispositions.”

McKeon acknowledges that connecting patients with appropriate mental healthcare is typically an easier task for EDs that are affiliated with major teaching hospitals.

“Then you may have the availability of psychiatric residents to come down to the ED, but the average ED doesn’t have that. Particularly in rural or remote areas, there may not be the availability of any kind of mental health resources to the ED,” he says.

In these cases, EDs must partner with community mental health resources, McKeon notes. For instance, he explains that there are currently 165 crisis centers that are participating with the National Suicide Prevention Lifeline, many of which are funded through SAMHSA. Another option is to link with a telepsychiatry provider so that an informed suicide risk assessment or psychiatric assessment can be provided while patients are still in the ED.

“Trying to establish these relationships is key,” McKeon says. “There isn’t a substitute for it unless an ED is part of a hospital that is fortunate enough to have its own comprehensive system where an ED is able to refer to its own [psychiatric] service within the hospital or health system. If you don’t have that, then there is a need for partnering.”

Provide staff training

Access to referral sources for mental healthcare is critical, but traditional providers also need training on how to effectively identify and manage patients who are at risk.

“The issue of suicide makes many people — both traditional providers and mental health providers — anxious,” McKeon says. “If you haven’t been trained about what to do, then your anxiety is even higher ... people need to know what steps that they can take.”

Also, knowing that there is someone who can follow up quickly if a patient is discharged is a key piece because otherwise you can get into a vicious cycle, McKeon adds.

“If the answer is always needing a hospital bed, and there are no hospital beds available, and the patient is just going to wait and wait for a bed to come available, then that ends up being a disincentive [to the provider] for looking too closely,” he says. “The fundamental issue is one of anxiety, which is why it is important for people to be trained in risk assessment, trained in treatment options that are available, trained in how to collaboratively work with a patient toward keeping themselves safe, and [training] in how to work with families.”

McKeon acknowledges emergency providers have a limited amount of time with patients.

“We are certainly conscious of the fact that if you urge people in EDs to do things, you have to be [aware of] what the work flow actually is and what can realistically be done,” he says.

Consequently, SAMHSA works with emergency providers and emergency psychiatrists to develop consensus steps for how to manage patients at risk of suicide in the ED. This work happened through the Suicide Prevention Resource Center (SPRC), and is available through the SPRC’s website at:

Also available to frontline providers is what is called the Safe-T Card, a tool that actually walks providers through the fundamental steps of a suicide risk assessment, at:

Much of the same basic information from the Safe-T Card is also available in electronic form as the Suicide Safe App.