DALLAS – Using a brief three-question screen, it’s feasible to increase dramatically the detection of suicide risk during routine emergency department care.
That’s the key message from phase II of ED-SAFE (Emergency Department Safety Assessment and Follow-up Evaluation), a National Institute of Mental Health–sponsored multicenter study of the impact of implementing universal suicide risk screening in the nation’s EDs.
The third and final phase of ED-SAFE, now underway, will determine whether universal ED suicide risk screening actually becomes policy. In phase III, patients detected as at-risk through screening will receive post-ED telephone counseling from a centralized center. They are being followed for 12 months to see if detection and intervention affects the incidence of attempted or completed suicide, Edwin D. Boudreaux, Ph.D., explained at the annual meeting of the Society for Academic Emergency Medicine.
ED-SAFE is taking place at eight EDs around the country. It has entailed review of more than 236,000 charts of patients presenting to participating EDs with a nonpsychiatric chief complaint.
During the 12-month baseline treatment-as-usual phase of the study, 26% of patients presenting to the ED with a nonpsychiatric chief complaint were screened for suicide risk as documented in the medical record. During phase II, when triage nurses underwent formal training in the effective use of the three-item ED-SAFE Patient Safety Screen, this rate jumped to 73%. And in phase III – the intervention phase – the proportion of ED patients documented as having been screened for suicide risk climbed further to 85%, reported Dr. Boudreaux, chair of the ED-SAFE steering committee and professor of emergency medicine, psychiatry, and quantitative health sciences at the University of Massachusetts, Worcester.
In the baseline phase, 2.9% of all patients presenting to the ED with a nonpsychiatric chief complaint were detected as having some level of suicide risk/self-harm, as recorded in their chart. In phase II, this figure rose to 5.2%, and in phase III, 5.7% of ED patients were identified through screening as having some level of self-harm.
While this virtual doubling of the rate of suicide risk detection through the use of the three-question screen is impressive, it nonetheless falls well short of the true prevalence of current or past suicidal ideation or behavior among ED patients based upon prospective studies, the psychologist noted.
"Those studies would suggest 15% of ED patients should screen positive using our definition," Dr. Boudreaux said.
He conceded the existence of substantial barriers to implementation of universal ED screening for suicide risk. EDs are already very busy places. Nationally there are more than 120 million ED visits per year, and they occur around the clock.
"You get lots of resistance from clinical staff for doing this kind of screening routinely," he explained. "It’s because of the Pandora’s Box phenomenon. People are afraid that if they start to screen for suicide they’ll actually detect suicide risk, and that means they’ll have to act on it. Many clinicians have told us that they just prefer not to ask because they really don’t want to have to take the next step because it’s complicated, it’s perceived to delay care, and there’s not a ready solution to the problem once it’s identified. There are limited aftercare and referral options to specialty services even if you want to try to do something."
Nevertheless, the Joint Commission has called for organizations to identify patients at risk for suicide. And the ED is a logical place to conduct universal screening for occult suicidality because there is abundant evidence that a much larger proportion of individuals who come to the ED for a nonpsychiatric chief complaint have some degree of suicidal ideation or have made a past attempt than is the case among the general population.
Moreover, the annual number of ED visits for attempted suicide and self-inflicted injury more than doubled in a recent 16-year period, as shown in a study by Dr. Boudreaux and coworkers (Gen. Hosp. Psychiatry 2012;34:557-65).
The three-question ED-SAFE Patient Safety Screener borrows from well-validated screening instruments. It begins with a brief introductory script designed to foster a nonthreatening atmosphere. Then comes question one, which screens for depressed mood: Over the past 2 weeks, have you felt down, depressed, or hopeless? Question two: Over the past 2 weeks, have you had thoughts of killing yourself? Then question three: Have you ever attempted to kill yourself? If ‘yes,’ then when did this happen? A recent attempt is defined as one within the past 6 months.
When the triage nurse gets a positive result on the three-question screen, an ED physician is then brought in to ask additional questions aimed at gauging the severity and acuity of the patient’s suicidality.