In 2013, more than 41,000 individuals died of suicide in the United States, and while that number has been declining, suicide remains the second leading cause of death among teenagers and young adults. It is the tenth leading cause of death for all ages.Í These deaths often leave family, friends, and health professionals with guilt, searching for missed clues and interventions that might have prevented the untimely, tragic death. Recently, many emergency departments have started screening all patients for suicide risk. This practice is not only unnecessary but may not be successful and places additional burden on emergency staff.
Explore This IssueACEP Now: Vol 34 – No 12 – December 2015
Many emergency department managers and hospital administrators falsely believe The Joint Commission requires screening all emergency patients for suicide risk. In actuality, The Joint Commission National Patient Safety Goal (NPSG) 15.01.01 states, “Identify patients at risk for suicide.” The NPSG also includes a note that states, “This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.” The elements of performance for NPSG 15.01.01 are:
- Conduct a risk assessment that identifies specific individual characteristics and environmental features that may increase or decrease the risk for suicide.
- Address the individual’s immediate safety needs and most appropriate setting for treatment.
- When an individual at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the individual and his or her family.2
The NPSG goes on to clarify in the FAQ section that screening should occur for “any patient who has a primary diagnosis or primary complaint of an emotional or behavioral disorder.”2 The Emergency Nurses Association (ENA) states in its “Clinical Practice Guideline: Suicide Risk Assessment” developed in 2012, “The Joint Commission [NPSG] requires facilities to ‘Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.’”3 That statement may be interpreted to mean that all patients need to be screened for suicide ideation. However, later in that document, the ENA clarifies that screening is only required for patients seeking mental health care. Therefore, there is no requirement to screen all emergency department patients for suicide risk.
One argument for universal screening is the fact that many patients who later commit suicide are seen in the ED in the weeks and months prior to an attempt. In fact, in a recent retrospective study on a large patient population in the United States, 38 percent of patients who attempted suicide had a health care visit in the week prior to their attempt; 95 percent had a health care encounter in the year prior.4 Of those visits, primary care and emergency department visits were most common. In a similar study looking at suicide deaths, 80 percent of patients had contact with some type of health care provider within the year prior to their suicide.5 Again, primary care and emergency visits were most common. Approximately 25 percent visited their primary care provider within that year for mental health issues; 65 percent, for other reasons. For the emergency department, 20 percent visited for mental health issues; 35 percent, for other reasons. However, it is not clear that patients who commit suicide would screen positive 12 months earlier during a routine health visit. The same study also examined visits within the prior four weeks.5 The percent who visited their primary care provider was 8 percent for mental health issues, 0.7 percent for chemical dependence, and 21 percent for other reasons. In contrast, except for patients with chemical dependency, patients were less likely to visit the ED, with 7.5 percent going to the ED for mental health, 1.4 percent for chemical dependency, and 12.8 percent for other reasons.
For the emergency department, 20 percent visited for mental health issues; 35 percent, for other reasons. However, it is not clear that patients who commit suicide would screen positive 12 months earlier during a routine health visit.
While these numbers may give some credence to screening in the ED, it is important to note that patients who commit suicide are more likely to visit primary care providers than the ED. This fact is important since the U.S. Preventive Services Task Force does not recommend screening for suicidality in primary care practices.6 The data would suggest EDs should not routinely screen for suicidality as well.