Screening Saves Lives!
Barry N. Feldman, Ph.D.
ED-SAFE Training Director
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Goal:
 Provide content to ED-SAFE trainers to train front-line
ED staff to use the Patient Safety Screener
Objectives:
 Discuss importance of attitudes/ values about suicide
 Provide material for brief overview of suicide and
importance of ED screening
 Explain the ED-SAFE Patient Safety Screener
 Present some common patient scenarios
 Discuss some concerns re: universal screening
Screening Saves Lives
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Tom is a 51 y.o. with multiple minor trauma secondary to
MVA. Alert, oriented, conversant. Treated for trauma, then
discharged from ED. One week later, found dead by his
neighbor. He had hung himself in his garage. The MVA
was an unrecognized suicide attempt.
Could Tom’s suicide have been prevented?
Screening Saves Lives
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Values are beliefs and attitudes that guide actions
 Values can often influence our decisions when decisionmaking powers are tested
“Clinical judgments and professional behaviors to a large
extent are shaped by attitudes ” (Knesper, 2010)
You may have strong personal values, attitudes, and
emotional reactions to suicide
Screening Saves Lives
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They are weak
 They are cowards
 They are selfish
 They are wasting ED resources
 Anger
 Pity
 Fear
 “Planting the idea” by asking patient about suicide
 Could I get to that point someday?
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Screening Saves Lives
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“Nurses in the emergency department often are unclear
about which types of patients are most vulnerable to suicide
and focus more on the physiologic assessment rather than
the psychosocial assessment that may give clear warning
signs of suicidal ideation.”
Screening Saves Lives
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Often lack formal mental health training
Often do not have confidence in psychological assessment
and intervention skills
May often be uncomfortable treating this patient population
Therefore, evaluations of suicidality may be particularly
stressful or avoided
Screening Saves Lives
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Background on Suicide
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Intentional self-injurious behavior without evidence of intent
to die
Methods may include:
 Self-cutting
 Self-battering
 Taking overdoses
 Showing deliberately reckless behavior
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Ideation
While it is virtually
impossible to
estimate
empirically, we
believe that
literally millions of
American have
suicidal thoughts.
Attempts
It is estimated
that there are
approximately
816,000 suicide
attempts per year
in the U.S.
Screening Saves Lives
Survivors
If every suicide
immediately affects
6 family members or
friends, then 1 out of
every 59 Americans
loses someone to
suicide each year
There are an
estimated 180,000
new “suicide
survivors” each year
in the US.
11
12
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Attempt survivors can be at greater risk for subsequent
attempt(s) with more lethal means
Up to 25% of suicide attempters seen in ED will re-attempt
(Beautrais, 2004)
 5-10% of attempters will eventually complete suicide (Owens
et al., 2002)
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Up to 39 % of people who later die by suicide will have
attended an ED within year before their death (Gairin et al., 2003)
 The majority of these visits are unrelated to suicide
Screening Saves Lives
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Suicidal ideation common in ED patients who
present for medical disorders
 Study of 1590 ED patients showed 11.6% with SI,
2% (n=31) with definite plans
 4 of those 31 attempted suicide within 45 days of ED
presentation
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Screening Saves Lives
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Conduct a risk assessment that identifies specific patient
characteristics and environmental features that may increase
or decrease the risk for suicide
Address the patient’s immediate safety needs and most
appropriate setting for treatment
When a patient at risk for suicide leaves the care of the
hospital, provide suicide prevention information (such as a
crisis hotline) to the patient and his or her family
http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?
StandardsFAQId=166&StandardsFAQChapterId=77
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Universal screening is not mandated by JC; only screening and
assessment for people presenting with primary emotional or
behavioral disorders
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However, universal screening is often viewed as providing a
“safety net,” and is generally viewed positively by JC
Screening Saves Lives
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“...having (a) screening tool was much preferred to the
previous method of judging by intuition when and how to
ask about suicidal behavior”
With proper structured tools to guide them, non-mental
health clinicians can increase their confidence and
lower barriers to asking about suicidality
Screening Saves Lives
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Vital signs (e.g., blood pressure)
 Routine assessment with all medical encounters
 Not commonly done at all medical visits until the 1970s
 Identification of possible hypertensive emergencies and
other vital sign abnormalities that could affect patient
outcome (i.e., hypotensive)
 Potentially devastating consequences
Screening Saves Lives
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3-item screener
 Question 1: Depressed mood - PHQ-2
 Question 2: Thoughts of killing yourself - C-SSRS
 Question 3: Lifetime suicide attempt - C-SSRS
▪ If yes, Question 4: How recent?
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Positive screen
 Question 2=Yes
(or)
 Question 3=Yes and Question 4=attempt within last 6
months
Screening Saves Lives
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“Because some topics are hard to bring up, we ask these
same questions of everyone.”
Rationale:
To help reduce likelihood of a negative reaction to the
screener questions
To foster a non-threatening approach
Use this segue as the introduction to administering the
Patient Safety Screener
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Item 1: Have you felt down, depressed or hopeless?
Yes = Depressed mood
Rationale:
 Provides additional segue into the suicide questions
 Depression is most common diagnosis associated with
suicide
 In the elderly, depression can be mistaken for natural
effects of aging
 In the young, depression may be masked by acting out
behavior or hyperactivity
 Physical distress can be a manifestation of depression
 Hopelessness found to predict suicide ideation , attempts
and completion
Screening Saves Lives
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Item 2. Have you had thoughts of killing yourself?
Yes = At least active ideation, general thoughts, requires
assessment
Rationale:
 Intent to die is the type of ideation thought to be most
predictive of suicide
 Thoughts of suicide precede suicidal behaviors
 Determining presence of ideation key in suicide risk
screening
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Item 3. Have you ever attempted to kill yourself?
Yes = Lifetime attempt (best single predictor)
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Rationale:
People who have a history of suicide or self-harm fall within
the high-risk group for suicide
30% to 40% of persons who complete suicide have made a
previous attempt
Suicide attempters have a high incidence of mortality, risk of
repetition is highest immediately after the attempt and
repetition is positively associated with subsequent suicide
Screening Saves Lives
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If positive for attempt by history, ask:
“When did this last happen?”
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Within the past 24 hours (including today)?
Within the last month (but not today)?
Between 1 and 6 months ago
More than a six months ago
Recent attempt = If positive for attempt within 6 months
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Over the past 2 weeks, have you had thoughts of killing yourself?
Criteria for positive
response
Patient endorses
active ideation
Ambiguous Answer
Score Y or N?
“Well, I haven’t really
thought of killing
myself, but I have
wished that I just
wouldn’t wake up”
Score: NO
Patient endorses
passive rather than
active ideation
Have you ever attempted to kill yourself?
Criteria for positive
response
Ambiguous Answer
Score Y or N?
Patient endorses
attempt to kill self
“Well, I cut myself but I
wasn’t really trying to
kill myself”
Score: NO
Patient endorses nonsuicidal self-injury
Screening Saves Lives
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Avoid acting “like a robot” while conducting screening
Important to convey you are interested in what patient has
to say
 Be empathizing, accepting, and understanding
 Be non-judgmental re: patient’s history, situation, beliefs,
sexuality, actions
 Show you care with compassion, tone, and rate of speech
 Be fully-attentive
 Use appropriate active listening techniques
Screening Saves Lives
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Verbal & Non-Verbal Nodding
 Verbal “Nodding”
▪ Uh-huh
▪ Oh my
▪ Okay
 Non-Verbal Nodding
▪ Nod your head
▪ Show compassion in facial expressions
▪ Body language
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Validations - A statement that “validates” the person’s
experience.
 “That sounds really rough”
 “That sounds upsetting”
 “It seems like you have been going through a lot”
 “I’m sorry to hear that”
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Basic premise – listen without passing judgment or giving
advice
 Often best way to de-escalate someone in crisis
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Patient Safety Screener not to be used with
Children/Teens
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Patient Safety Screener was not specifically designed or
validated with children/teens
Children/teens can be screened in a manner decided by the
site
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Patient is intoxicated
 If the patient is currently intoxicated, but a clinical interview is
initiated, the Patient Safety Screener should be administered
per standard protocol
 Once the individual is clinically sober, the Patient Safety
Screener should be re-administered
 If the patient is intoxicated but a clinical interview is not
initiated until the individual is clinically sober, then the Patient
Safety Screener should be administered at that point
Screening Saves Lives
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Patient is claiming to be suicidal but the clinical staff suspect
it is simply to get into inpatient care
 Patient is a prisoner or under state custody
 Patient is a high utilizer of the ED
 Patient is an active duty military service member or a veteran
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 Answer is the same: screen them in the same manner as
you’d screen those who do not present this way
Screening Saves Lives
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Bill, aged 42, is brought to the ED in police custody to be
‘checked out’ after driving his car at low-speed into a shallow
ditch. Vital signs are within normal limits. He has no visible
injuries but appears intoxicated, unable to keep his balance,
slurred speech, glassy eyes and strong ETOH breath odor.
During the patient safety screener, his eyes are closed and
his responses are unintelligible.
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What would be the next step for completing the Patient
Safety Screener?
Screening Saves Lives
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Bill was intoxicated at time of screening
Multiple risk factors and warning signs:
 Middle aged-male
 Intoxicated
 In police custody
MVC as failed suicide attempt?
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ED-SAFE Protocol:
Patient should be re-screened when clinically sober
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Screening Saves Lives
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Sue, 30, is a walk-in accompanied by her sister for evaluation
of an infected wound on her thigh. She is alert and oriented,
takes no meds. Vital signs are WNL. Sue states she was
preparing a sandwich and “the knife slipped”. There is a
similar, healed wound on her other thigh; she shrugs her
shoulders and does not respond to inquiry about the injury.
Her sister states she is worried about Sue, who has missed a
lot of work after the breakup of her marriage a few months
prior. A few days ago Sue said that she “just can’t do it
anymore”.
How would this information relate to Sue’s responses to the
Patient Safety Screener?
Screening Saves Lives
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Patient denies previous suicidal behavior
Patient’s denies current injury represents a suicide attempt
Patient’s sister provides key information
ED-SAFE Protocol:
Although this may be a ‘negative screen’, because there is
additional information suggestive of suicide risk, this
indicates the need to follow standard risk management
protocols
Screening Saves Lives
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Fred, 68, lives alone since his wife died 6. mos. prior, and is
driven to the ED by his daughter, who thinks he may have
accidentally taken too much blood pressure medicine today.
When preparing his weekly medication holder she noticed ‘3
or 4 pills were missing’. He is pale, dry, with a low BP and
heart rate around 50, however he is mentating well and
denies pain or difficulty breathing, stating he is “a little
dizzy”. He is unsure how much medication he took today
and is embarrassed by the fuss his daughter is making. Fred
states, “I’ve just been such a burden to everyone since my
wife died”.
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What would you do about Fred ?
Screening Saves Lives
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Multiple risk factors and warning signs:
 Elderly male
 Recent widower
 Access to means
 Indirect verbal clue – “I’ve been such a burden…”
ED-SAFE Protocol:
Although this may be a ‘negative screen,’ because there are
additional factors suggestive of suicide risk, this indicates
the need to follow standard risk management protocols
Screening Saves Lives
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ED-SAFE Study PIs concerned about this, too
 We’re monitoring it at all 8 sites
If our intervention leads to a marked increase in psych
consults, and slows the ED down, then it is highly unlikely to
be adopted in clinical practice
Screening Saves Lives
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Patient Safety Screener questions very carefully chosen
Positive screen only occurs if the individual is actively
suicidal or has had a recent attempt (past 6 months)
Represents a relatively high threshold
 Would avoid identification of mild cases, like those with
only passive ideation
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Many EDs already do it, and have not found dramatic
increases in psych consults or ED clogging
Cooper Hospital example
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Brenda is an 18 y.o. with CC of headache for 3 days. Alert,
oriented, conversant. Screened for suicidal ideation by
primary nurse. Admitted to current active ideation, previous
attempt 2 months ago. Psychiatry consulted, provided with
MH appointment. Received treatment for depression,
anxiety. Reduced suicidal thoughts, improved psychological
and overall functioning.
Screening Saves Lives
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Provided content and materials for ED-SAFE trainers to train
their front-line ED staff to use the Patient Safety Screener in
Phase 2 of the study.
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Screening Saves Lives
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