Suicide screening for all is not needed - page 3

At my hospital every patient who comes in to the ER is supposed to be asked suicide screening questions. If they are admitted as an inpatient they are asked again. I don't think this is useful and... Read More

  1. by   MikeyT-c-IV
    I agree 100% But this is a NPSG... so ya know... It must be done no matter how repetitive or inadequate.
  2. by   JKL33
    Quote from elkpark
    Really? Because I work on the psych C&L service of a community hospital, we're the service that gets called for the consults when someone screens positive in the ED, and the experience here is that the ED nurses and physicians get caught by surprise all the time by the people who answer positively to the safety screening questions, and end up being mildly or seriously dangerous. I don't mind admitting that even I, as a psych CNS with >20 yrs experience, sometimes get caught by surprise by the people I am interviewing for some other psychiatric reason who endorse recent SI and are actually at risk. It's really not that simple or straightforward.
    And that is precisely not the type of "screening" I thought we were talking about. I am confident that is not what ED nurses are referring to in this thread.

    Can you elaborate? On what other types of patients are you consulted?

    And if you are able to share any of your ED's screening procedure, maybe that would help some of us struggling with this. It sounds like it is more effective than the experiences some of us are having.
  3. by   3peas
    Quote from thoughtful21
    They would rather just read the admission questions in a monotone voice and move on.
    Have you ever had this happen to you? How should I deal with it? I don't want to get over-involved or do more than I should. I do realize that psych issues are hard to work with, because they take extra time and don't have clear-cut answers. Also, I admit, like other people in this thread have said, that it can be hard to find enough time to form a good therapeutic relationship. And sometimes it's hard to even make a good referral for a patient, because of the lack of mental health care in rural parts of the country. And definitely in the ER it is hard to find time to address the issue properly. But I believe that it's very important, and I know that just taking a little time to talk with a patient, and showing that I care, can make a world of difference for them. Someone did this for me once, and made a world of difference for me.

    P.S. A related question...when does 'taking time to talk' and 'therapeutic nursing communication' cross the line to become 'counseling' and become out of my scope of practice?
    P.P.S. I welcome everyone's opinions/feedback, even if you disagree - they are all valuable!
    As an experienced emergency psych nurse when triaging your pt it's important to establish a relationship immediately by being professional, showing respect, not using a monotone voce, not rattling off questions like you've done 500 times that week (even though you have).

    Therapeutic communication does not equal counseling, that's not our role. As a psych nurse I'm there to gather data and give it to the necessary people. If I were an ED nurse and I were asking questions about self-harm/ideation or intent for self-harm (which should be asked in my opinion) and a pt confirmed one of those our job as a nurse is to find out if :
    1. they have attempted suicide recently?
    a.Last 7 days?
    2. Do they have a plan?
    a.Can they carry out that plan?
    b. Or is it ideation?

    Those questions give you an idea of their immediate danger. Then you MUST as a nurse report/refer this information to those who are trained to handle it. Social workers/ emergency psych RN assessment team/mobile assessment team. Then the 3 D's-Document, document, document because you are the advocate.

    If your hospital has not set up an appropriate system for MH referrals that would be something to talk to management about. But I would never ever not assess my patient properly or not provide an intervention properly.
  4. by   StatBlues
    I agree it is not needed for all!
    Patient comes in and is hurting or agitated.
    Needs help with the problem they come in with.
    Not asking anything about their mental status.

    Like, yea I am depressed , sad, and emotional...... I am in the ER Hello!!
  5. by   elkpark
    Quote from JKL33
    And that is precisely not the type of "screening" I thought we were talking about. I am confident that is not what ED nurses are referring to in this thread.

    Can you elaborate? On what other types of patients are you consulted?

    And if you are able to share any of your ED's screening procedure, maybe that would help some of us struggling with this. It sounds like it is more effective than the experiences some of us are having.
    My only point in referring to the full psychiatric evaluations I do in the hospital is that even experienced psychiatric professionals can not always, reliably, anticipate who is going to endorse recent SI based on their initial presentation, until they do when they're asked. Figuring out who is and isn't suicidal isn't that simple. The ED nurses at this hospital use a scripted safety screening that starts with two questions:

    "In past month, including today, have you had any thoughts or plans about hurting or killing yourself:"

    "In past month, including today, have you had any thoughts or plans about hurting or killing someone else:"

    If the individual answers "no" to both questions, that is the end of it (there, was that really so onerous?) If s/he answers "yes" to either question (or both), people are notified, some safety precautions are put in place, and additional questions are asked:

    "In past month, including today, have you tried to hurt or kill yourself:
    In past month, including today, have you tried to hurt or kill someone else:
    Do you have access to firearms:
    Do you have access to lethal means:
    Do you have a plan to harm/kill yourself or others:"

    The rest of the questions are really kind of superfluous because the reality is, when people answer "yes" to either of the initial questions, they usually get admitted (to a medical bed; we don't have a psychiatric unit) and a psych consult (with my service) is ordered to evaluate them further and make a decision about what kind of intervention is appropriate. Unless there's no medical indication for admission and the ED doc feels comfortable letting the person go (but that doesn't happen often; they prefer to let my service make those kind of decisions).
    Last edit by elkpark on Feb 7
  6. by   kaylee.
    At a hospital I worked at last year we had a medical patient commit suicide in his room. It turned out the suicide screening questions had not been done.

    I believe this is rare, but clealy it happens.

    Who knows if the questions would have caught this patient or not. But not asking is not the answer, IMO.
  7. by   Oldmahubbard
    So many good answers here, I don't really have a thing to add.

    A rare occurrence!

    Overall, our ability to intuitively know "who is at risk for what" is notoriously quite bad.

    There is a local case in my community, where an agitated young man was d/c from the ER. He then went home and killed his entire family.
  8. by   brandy1017
    Quote from Buckeye.nurse
    I agree that the nursing admission database can feel cumbersome at times. This is one question that I never skip over though. I've been surprised before at people who have answered yes to a depression/suicide screening question.

    In my 14 years as a nurse I have heard of patients who come in for a scheduled treatment, then screen positive, and had the round of chemo held while their increased depression and statements "I don't know if I want to keep fighting" or "I just want to die" are evaluated.

    It's kinda like the screening questions for domestic violence. Sometimes people won't say anything until asked. I make sure I ask.

    changed my mind
  9. by   Kooky Korky
    Quote from thoughtful21
    Beekee, sometimes I get flack from my coworkers for being "too involved" with patients about mental health issues. Patients often open up to me about things that they're struggling with. When I notice warning signs, I sit down and take extra time to talk with them. My coworkers sometimes seem a little irked about this... or maybe dismissive is a better word. One time when we were going into the room of a patient who had hinted at needing mental health help, I was told "don't ask." It seems like they would rather not know what's going on, so that they don't have to deal with it. They would rather just read the admission questions in a monotone voice and move on.
    Have you ever had this happen to you? How should I deal with it? I don't want to get over-involved or do more than I should. I do realize that psych issues are hard to work with, because they take extra time and don't have clear-cut answers. Also, I admit, like other people in this thread have said, that it can be hard to find enough time to form a good therapeutic relationship. And sometimes it's hard to even make a good referral for a patient, because of the lack of mental health care in rural parts of the country. And definitely in the ER it is hard to find time to address the issue properly. But I believe that it's very important, and I know that just taking a little time to talk with a patient, and showing that I care, can make a world of difference for them. Someone did this for me once, and made a world of difference for me.
    I guess to sum it up, I feel pressured about "wasting time" and "getting too involved" when trying to help patients with mental health issues, but I really want to help. Since I'm new (haven't even graduated yet, but I'm close), so I don't have much confidence yet, and I'm worried that my nursing judgment isn't very well developed. I was wondering if you'd ever had an experience like this, and if you could give me any advice?
    P.S. A related question...when does 'taking time to talk' and 'therapeutic nursing communication' cross the line to become 'counseling' and become out of my scope of practice?
    P.P.S. I welcome everyone's opinions/feedback, even if you disagree - they are all valuable!
    You have to do what you have to do. In other words, do what is right for you and don't give space in your head to coworkers. That goes for now while you're a student and after you are licensed.

    I don't know where the line is drawn. I can't really articulate it.

    That does lead, though, to the OP's expression of what to do when you get a positive response to questions of suicidal ideation, a patient not feeling safe at home, and similar topics. I assume each ER has a protocol that staff are to follow when getting someone saying he or she is depressed, suicidal, a victim of domestic violence, etc.

    Is a Psych consult to be obtained before the pt is discharged or transferred to a ward? Or what?
  10. by   Kooky Korky
    Quote from elkpark
    My only point in referring to the full psychiatric evaluations I do in the hospital is that even experienced psychiatric professionals can not always, reliably, anticipate who is going to endorse recent SI based on their initial presentation, until they do when they're asked. Figuring out who is and isn't suicidal isn't that simple. The ED nurses at this hospital use a scripted safety screening that starts with two questions:

    "In past month, including today, have you had any thoughts or plans about hurting or killing yourself:"

    "In past month, including today, have you had any thoughts or plans about hurting or killing someone else:"

    If the individual answers "no" to both questions, that is the end of it (there, was that really so onerous?) If s/he answers "yes" to either question (or both), people are notified, some safety precautions are put in place, and additional questions are asked:

    "In past month, including today, have you tried to hurt or kill yourself:
    In past month, including today, have you tried to hurt or kill someone else:
    Do you have access to firearms:
    Do you have access to lethal means:
    Do you have a plan to harm/kill yourself or others:"

    The rest of the questions are really kind of superfluous because the reality is, when people answer "yes" to either of the initial questions, they usually get admitted (to a medical bed; we don't have a psychiatric unit) and a psych consult (with my service) is ordered to evaluate them further and make a decision about what kind of intervention is appropriate. Unless there's no medical indication for admission and the ED doc feels comfortable letting the person go (but that doesn't happen often; they prefer to let my service make those kind of decisions).
    What if the pt figures the answer is no because it was more than a month ago? Seems best to not limit by time. At least not initially.
  11. by   CrunchRN
    It is ridiculous.

    My husband had an outpatient radiology procedure. Just an injection in the spine with local. Afterwards in "recovery" they screened for everything from alcohol/drug abuse, suicide, guns, domestic violence...... it just went on and an.

    I think these things can be useful, but only when used for some indication.
  12. by   elkpark
    Quote from Kooky Korky
    What if the pt figures the answer is no because it was more than a month ago? Seems best to not limit by time. At least not initially.
    I didn't write the screening questions, and my sharing them doesn't indicate any sort of endorsement -- I was just responding to the other poster who asked what the protocol was at my facility. That's the protocol.

    And how far back do you think is appropriate? If people have had thoughts of self-harm of suicide in the last six months (but not currently), is that something the ED needs to deal with? Within the last year? The idea is to identify acute risk.
  13. by   Neats
    I agree with you all here when I took my husband to the emergency room for a dog bite while he was out running they asked all the depression screening questions that include suicide. My husband answered all the question then while we were alone he said did I say something to think they thought I did this on purpose and think I am trying to harm myself? I assured him it is routine.

    We work and live in a society that is riddled with legalistic measures that are the cause of a change, get monies, retribution...the list can go on. Offenders in prison can start a lawsuit for next to nothing courtesy to our tax monies. We ask these questions to cover our liability professionally and business practice.

    When I am asking a patient about depression/sucide before I start I just say these are routine questions I have to ask everyone who comes in through that door. Our society makes things so complicated due to risk. To me it is no different than seeing the words printed on plastic: DO NOT PLACE OVER HEAD...some where something happened to a person who put a plastic bag over their head, they sued (or family sued) and now we have nice reminders not to be so abnormal. This is just another example of the 80/20 rule in that 20 percent of the people will do abnormal things but it effects 80 percent of our time trying to counteract those issue.

close