Improving Suicide Risk Screening and Detection in the Emergency Department

Abstract

Introduction: The Emergency Department Safety Assessment and Follow-up Evaluation Screening Outcome Evaluation examined whether universal suicide risk screening is feasible and effective at improving suicide risk detection in the emergency department (ED).

Methods: A three-phase interrupted time series design was used: Treatment as Usual (Phase 1), Universal Screening (Phase 2), and Universal Screening + Intervention (Phase 3). Eight EDs from seven states participated from 2009 through 2014. Data collection spanned peak hours and 7 days of the week. Chart reviews established if screening for intentional self-harm ideation/behavior (screening) was documented in the medical record and whether the individual endorsed intentional self-harm ideation/behavior (detection). Patient interviews determined if the documented intentional self-harm was suicidal. In Phase 2, universal suicide risk screening was implemented during routine care. In Phase 3, improvements were made to increase screening rates and fidelity. Chi-square tests and generalized estimating equations were calculated. Data were analyzed in 2014.

Results: Across the three phases (N=236,791 ED visit records), documented screenings rose from 26% (Phase 1) to 84% (Phase 3) (χ(2) [2, n=236,789]=71,000, p<0.001). Detection rose from 2.9% to 5.7% (χ(2) [2, n=236,789]=902, p<0.001). The majority of detected intentional self-harm was confirmed as recent suicidal ideation or behavior by patient interview.

Conclusions: Universal suicide risk screening in the ED was feasible and led to a nearly twofold increase in risk detection. If these findings remain true when scaled, the public health impact could be tremendous, because identification of risk is the first and necessary step for preventing suicide.

Trial registration: Emergency Department Safety Assessmentand Follow-up Evaluation (ED-SAFE) ClinicalTrials.gov: (NCT01150994). https://ichgcp.net/clinical-trials-registry/NCT01150994?term=ED-SAFE&rank=1.

Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1. CONSORT flow diagram

Note: This was an interrupted time series trial that used data collected during an index emergency department visit; therefore, there was no follow-up or attrition.

Figure 2. Time series plot of screening rates by site across the three phases

Lines represent the percentage of patients that were screened for intentional self-harm. One site (dark blue) achieved 95% screening in Treatment as Usual, because hospital administration interpreted the Joint Commission Patient Safety Goal 15 as requiring universal screening. This site implemented the screening after site selection had been completed for the study but before Treatment as Usual began. In Phase 2, this site switched over to the PSS-3 and continued universal screening.