Suicide screening for all is not needed - page 4

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   OldDude
    Quote from 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.
    this bag is not a toy
  2. by   JKL33
    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 expect people 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?)
    Thanks for the reply and writing everything out; sorry it took me awhile to put my thoughts together here.

    What you wrote is the general routine I'm familiar with as well. I don't know if this is part of your ED's initial triage process or not, but that may make a difference. It's tempting to say it's not so onerous. But then, neither is the tetanus shot question, or the way you arrived at the ED question, or the recent travel question, or the English vs. other question or the home safety question, or the queries about whether anyone is hurting you or....etc. All of these questions (and more) are being asked for one particular reason or another. Questions come and go; sometimes they're mandated for awhile until somebody decides they aren't and then we don't have to ask them any more (seatbelts, marijuana). [This, too, has an effect on staff over time.] I've already posted the basic/general triage query routine - roughly, say, 75% or so of the "triage" (and I use that term ever-so-loosely, as it is commonly used these days) is information not directly related to the CC. It has become "massive information collection session," not sorting.

    I'm not exaggerating when I say that I don't receive surprise answers to these two questions as part of a triage screening of all ED patients. Due to my own belief that the situation and setting heavily influences responses and to give the benefit of the doubt to the idea that maybe it's true (maybe many individuals in the masses are struggling and we could find out if we just asked them), I've experimented with various tones of voice, I always make eye contact, I've even experimented with prefacing by gently/kindly saying, "We've found that sometimes there are other issues going on when someone comes to the ER, so we like to ask if...." I get no "hits" with these questions, no matter how asked, outside of situations where the CC is loosely or possibly related. Generally-speaking, patients come to the ED with a problem that they are willing to verbalize and when that problem isn't remotely/loosely related to social or psychiatric concerns, I have gotten zero affirmative answers. From both triage and charge nurse perspective my experience has been that patients just aren't "turned up" that way.

    Quote from elkpark
    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).
    Interesting. Around here, patients who present with psychiatric concerns or are determined to be at risk during triage (or are noticed to have one of several other background or presentation-related situations going on) will be roomed immediately in the ED and safety protocol initiated. They receive their MSE and consults are undertaken to determine need for psychiatric admission. This is a very, very frequent occurrence - - but still, these patients aren't "turned up" when they come in for their cough/SOB/chest pain/abd pain/kidney stone/sore throat/twisted ankle/headache and just out of the blue answer a screening question or two. I guess what I mean is, the ones who end up answering the screening questions affirmatively are the ones who were already headed to an ED safety bed anyway.

    So I guess I could summarize all that to say that in my experience the two screening questions appear to be of exceedingly low value when there is no index of suspicion.

    I don't know what to say except that I sincerely still don't understand how so many people are walking into your ED with all the various run-of-the-mill complaints and are coincidentally also having SI that is turned up by these screening questions. If I could politely voice some doubt - are you positive of the manner in which your team's patients eventually make contact with your service? It honestly sounds to me like you're talking about the same type of patients that I am assigning immediately to a secure bed - not the hundreds of other patients with their un-related complaints. Yes, the patients you consult may have answered the questions affirmatively. But you may not have been consulted solely because the answers to those questions suddenly changed the patient's course of care.

    In other words, I think we are talking about two separate/different groups of patients. You're saying that your ED comes up with these patients for you to see, and you believe it is related to the two questions because the two questions are asked of everyone. But I'm telling you that it's possible that your ED has already determined these patients' needs and the screening questions are neither here nor there. [I'm not trying to be snotty, I'm just trying to write out enough detail that we can each know what the other is talking about. ]

    Meanwhile....(sorry, I know this is getting lengthy) - the role of the triage nurse is first and foremost to sort through large groups of people and screen out the ones who are at serious risk of dying or immediately deteriorating. Not tonight, tomorrow, or next week, but NOW.

    If I believed that ED 2-question screening could be useful, it would not be a duty that is assigned to the person responsible for sorting through groups of people looking for anyone who might be dying (to put it simply).

    People want to think this is useful, we all do. We all want to believe that we can do some simple thing that will save people - - because the only thing we truly know is that the opposite is not useful as pointed out in post #31. But because other patients in the ED are at risk, too, this should rightfully become more than a 'feel-good' initiative that is tacked on to a very specific task the triage nurse is trying to do.


    To all - these are issues that ED nurses ponder about and deal with every single day. They do wear on the mind. It's slightly possible that we do actually have some idea of what is effective and helpful and what isn't.

    For those of you who aren't familiar with what an ED nurse is talking about when we refer to screening questions, we're talking about two very brief and "out of the blue" questions asked amidst the rest of the info collection at triage. We aren't talking about the services and additional screenings provided by teams like elkpark's - - which are utterly crucial and critical and are routinely (daily, multiple times per day) provided to any patient that is remotely at-risk. The degree of "at-risk" is not determined by the screening questions (in my experience).
  3. by   ElvishDNP
    12 years ago I went to the ED for a self-inflicted (accidental) stab injury in my LFA. (Always cut plastic zip ties with scissors, not with a knife, people!) It was a terribly embarrassing injury to have, and I was definitely not attempting suicide, but the ED physician asked me anyway if I had been or had ever thought about it. I was on Zoloft at the time for postpartum depression. He may or may not have known that, but I'm glad he asked. I was fine, just embarrassed. Got my stitches and went home to call out from work - an extremely embarrassing callout.

    My point is that it seemed like a pretty straightforward treat & street situation, but the ED doc still covered his bases. New(ish) mom, stab wound. Glad he asked. He did his job at making sure I was safe.

    I know it seems like a bunch of extra busy work but you really don't ever know. I used to work in a community health center and we screened all our physicals for DV and suicidal ideations....I was amazed at the answers I got from people I'd have never expected.
  4. by   Have Nurse
    I think you've just answered your own question.
  5. by   alex1214
    You're right, having too many SI/depression questionnaires is not necessarily a good thing sometimes. Unfortunately though this is done due to joint commission requirements, which are pretty strict.
  6. by   Susie2310
    Quote from JKL33
    The paradox here is that while the ED seems like a great opportunity because of the sheer number of people we see, that itself, along with the setting, makes for an extremely poor screening procedure (to the point of being embarrassing and awkward because of the glaring lack of time to develop rapport). Unfortunately it's not uncommon for screening to be made part of the triage process, to make matters worse. So here's how that goes:

    There's a list of questions. Basically you need to get through them AFAP. A general expectation for most triages is that they will take a few minutes or less. So, while getting vitals and double-checking the name/DOB:

    Basic relevant med/surg hx
    How did you get to the ED today?
    Ever been a smoker?
    Any chance you could be pregnant?
    Recent travel/been out of the country?
    Is English your primary language? If not, what is?
    Are you living in a safe place/any concerns about your living situation?
    Anyone hurting you?
    Any thoughts of hurting yourself or anyone else?

    No? Ok, great, have a seat and we'll call you when we have a bed.

    Mind you, I am trying to make eye contact, trying to convey my interest and attention, but the bottom line is to keep things rolling.

    I, too, have never had anyone surprise me with a response. Really....not once. That's not to say there are not depressed, suicidal or homicidal patients that I triage. Just that no one has ever surprised me with a response to the rapid-fire question routine, which was not thought up by anyone currently doing the job of triage, I can promise you.
    No, not everyone should be asked this question (among others) at triage. Triage used to be (is supposed to be) quick! I was with a family member at triage recently who had serious physical symptoms and really should have gone to the ER by ambulance. Their vital signs, physical symptoms and co-morbidities, together with their chief complaint, put them at much greater risk from dying from their illness in the very near future than from committing suicide or homicide. They would have benefitted from triage being expedited and care being started quickly, but instead unnecessary time went to asking the suicidal ideation/homicidal ideation questions along with other questions that could have waited until later. And as others have mentioned, when they were admitted they were asked the SI/HI, abuse and risk assessment questions etc. again.
    Last edit by Susie2310 on Feb 8
  7. by   Buckeye.nurse
    JKL33, I understand your point of view better after the last post. Thank you for taking the time to explain things from an ER nurse perspective. I've always worked as a floor nurse. We get at most 2 admissions in a 12 hour shift. It can sometimes feel difficult to work the admission database into the ongoing care of our other patients, but I still have some time luxury compared with your day.

    I have had patients I admit surprise me a few times with their answers. They immediately have their risk assessed by the MD service, get a 24 hour sitter, and a psych consult. The yes answers that really surprise me happen at the outpatient infusion clinic. Those nurses see many more patients per day (although still not quite so many as an ER nurse). Patients that screen positive there have their chemo held, and are admitted to the floor for evaluation.

    I can say, assuredly, that for the practice areas for which I have experience, the screening questions have meaning.
  8. by   admc4444
    I find this conversation is a perfect example of Benners stages of clinical competence. The novice/beginner is asking "why do I have to ask questions about suicide in a ED" and the competent ,proficient and expert nurses are trying to help a beginner nurse rise to a higher level of nursing.
  9. by   Susie2310
    Quote from admc4444
    I find this conversation is a perfect example of Benners stages of clinical competence. The novice/beginner is asking "why do I have to ask questions about suicide in a ED" and the competent ,proficient and expert nurses are trying to help a beginner nurse rise to a higher level of nursing.
    If you read the OP's bio below her post you'll see that she has 23 years of experience. I hardly think she is asking her question as a naive beginner nurse.
    Last edit by Susie2310 on Feb 10
  10. by   OldDude
    Quote from admc4444
    ...Benners stages of clinical competence...
    ...eyes glaze over...

    how insightful and cutting edge...stating the obvious.
  11. by   /username
    Quote from OldDude
    ...eyes glaze over...

    how insightful and cutting edge...stating the obvious.
    I think I threw up a little.
  12. by   JKL33
    Quote from admc4444
    I find this conversation is a perfect example of Benners stages of clinical competence. The novice/beginner is asking "why do I have to ask questions about suicide in a ED" and the competent ,proficient and expert nurses are trying to help a beginner nurse rise to a higher level of nursing.
    And yet it was Benner who noted that

    "The rule-goverened behavior typical of the novice is extremely limited and inflexible. The heart of the difficulty lies in the fact that since novices have no experience of the situation they face, they must be given rules to guide their performance. But following rules legislates against successful performance because the rules cannot tell them the most relevant tasks to perform in an actual situation" (Benner, 2001, p. 21).

    I will not comment further except to say that your attempt at provocation is laughable.


    Benner, P. (2001). From novice to expert - Excellence and power in clinical nursing excellence (Commemorative ed.). Upper Saddle River, NJ: Prentice Hall.
  13. by   Lexi McDonough
    I agree that it a complete suicide/mental health assessment is not necessary unless there is some indication for it, but every patient should get a quick mental health assessment (we ask 4 questions to screen for depression and suicide/violence).

    Other than that, we should really just be trying to establish trusting relationships with our patients and paying attention to their moods, document significant things, etc.

    The fact is, most depressed patients are not going to admit they are depressed to you when you first meet them.

    That said, I work in a SICU. Most of my patients are sedated, unable to answer questions, or able to answer questions but are too critical to be worrying about mental health at this point. Sometimes I get a medical patient when I'm working a 5 day stretch and get them back every day, and thats when I'll dive deeper into their mental health. They wont tell you much unless they trust you.
    Last edit by Lexi McDonough on Feb 11