[sidebar]Image Credit: © SHUTTERSTOCK.COM[/sidebar]
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.
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.
Despite the facts, suicide screening is taking place in a number of emergency departments, often done by the triage nurse. Suicide screening tools are embedded in some electronic medical records. There is no “best practice” screening tool. Many use a four-question tool (Are you here because you tried to hurt yourself? In the past week, have you been having thoughts about killing yourself? Have you ever tried to hurt yourself in the past? Has something very stressful happened to you in the past few weeks?).7 Any single positive answer is considered a positive screen. A recent study of this tool in an emergency department setting demonstrated a very high false-positive rate, though it did appear to be successful in identifying individuals who had suicidal ideation. Overall, nearly 42 percent of all patients screened positive, but with secondary screening, only 1.5 percent were true positives. Among adolescents, 51 percent screened positive, but only 5 percent were true positives. Although the numbers screened were low, all patients with mental health complaints screened positive, but none of them were determined to be suicidal.8 Other tools developed since then and currently under development now may have better sensitivity and specificity and may be better accepted by providers.9
Screening positive has significant implications for emergency physicians and staff. Should all patients who screen positive be cleared by psychiatry? Should all patients who are discharged receive referral to mental health resources? Should patients who screen positive, particularly those screening positive for more than one question, have 1:1 observation, at least until they can be assessed by the emergency physician? What are the legal implications of sending home patients with positive screens, particularly if they, sometime in the future, attempt or complete a suicide? All of these issues remain unclear.
Mental health treatment is not universally successful. Successful suicides during inpatient mental health treatment are not uncommon. More important, suicide risk is highest in the first few weeks after discharge from a mental health facility. Inpatient treatment itself has been questioned. David J. Knesper, MD, of the department of psychiatry at the University of Michigan in Ann Arbor, noted “there is no evidence that psychiatric hospitalization prevents suicide” in the immediate postdischarge period.10 The stress that led to the patient’s decompensation is often still present in the community, with the addition of the stigma of being in a mental health facility.
There is no necessity for universal screening, though screening of “high-risk” populations is a recommendation of The Joint Commission. Current screening tools are imperfect, and referral options for inpatient and outpatient assessment are not able to absorb a large influx of false positives. Treatment, once available, has limitations. Screening is potentially valuable in high-risk patients. Suicide is an important and serious public health problem. We need better screening tools and better referral systems before universal screening of all patients in the emergency department can be embraced.
Dr. Schneider is director of EM practice at ACEP and a member of the ACEP Now editorial advisory board.
- Suicide facts. Suicide Awareness Voices of Education website. Accessed Oct. 16, 2015.
- Suicide risk reduction FAQs. The Joint Commission website. Accessed Oct. 16, 2015.
- Brim C, Lindauer C, Halpern J, et al. Clinical practice guideline: suicide risk assessment. Emergency Nurses Association website. Accessed Oct. 16, 2015.
- Ahmedani BK, Stewart C, Simon GE, et al. Racial/ethnic differences in health care visits made before suicide attempt across the United States. Med Care. 2015;53:430-435.
- Ahmedani BK, Simon GE, Stewart C, et al. Health care contacts in the year before suicide death. J Gen Intern Med. 2014;29:870-877.
- LeFevre ML, US Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and older adults in primary care: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160:719-726.
- Davis KN. Detecting suicide risk in adolescents and adults in an emergency department: a pilot study. Illinois Wesleyan University website. Accessed Oct. 16, 2015.
- Folse VN, Eich KN, Hall AM, et al. Detecting suicide risk in adolescents and adults in an emergency department: a pilot study. J Psychosoc Nurs Ment Health Serv. 2006:44:22-29.
- Betz ME, Arias SA, Miller M, et al. Change in emergency department providers’ beliefs and practices after use of new protocols for suicidal patients. Psychiatr Serv. 2015;66:625-631.
- Knesper DJ, American Association of Suicidology, Suicide Prevention Resource Center. Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths subsequent to discharge from the emergency department or a psychiatry inpatient unit. 2010. Newton, MA: Education Development Center, Inc.