Suicide Screening in the ED?

  1. 8

    AN discusses new suicide screening research from the Emergency Nurses Association.

    Suicide Screening in the ED?

    New research from the Emergency Nurses Association encourages more in-depth suicide screenings in the emergency department in an effort to better identify individuals at risk for suicide. The study, recently published in the Journal of Emergency Nursing, explores current screening procedures while identifying opportunities for improvement. Forty-one emergency nurses participated in two focus groups to share their experiences with suicide-risk assessments and current practice challenges for this study.

    All Nurses staff were recently fortunate to interview the lead researcher of the research study. Lisa Wolf, PhD, RN, CEN, FAEN, is the Director of ENA's Institute for Emergency Nursing Research.

    According to the Centers for Disease Control and Prevention, suicide is the tenth leading cause of death in the U.S., and research shows a substantial percentage of people who die by suicide present for healthcare in the year before their deaths. Screening for suicidality is a critical nursing function in the ED and provides healthcare professionals an opportunity to identify patients at risk for suicide and intervene appropriately.

    ED nurses, like all nurses today, are being tasked to do yet another assessment. How would you convince these nurses of the necessity of asking every patient about suicidal thoughts?

    It is estimated that about 3% of patients disclosed SI at triage (it's the reason they are there). However, it is also estimated that about 11% of patients actually are suicidal on presentation, so there's a significant percentage of patients who need care for SI, but don't immediately disclose it. This is why the Joint Commission recommends universal screening for SI in emergency departments. What our study suggests is that the assessment for suicidal ideation is a process that should extend across the ED visit, especially if the patient denies suicidal ideation, but has a concerning presentation. So, the onus is on the triage nurse to at least do the initial assessment and then pass on concern to other providers. This is a critical assessment that can really be a life or death matter, and it relies on the communication between nurses and other providers.

    What are some easy scriptings in order to fulfill this requirement?

    The initial question that is commonly asked is some version of "Do you have feelings of wanting to hurt yourself or anyone else?" Our study findings suggest that this question as a single data point may not be as useful and that some follow up questions for those who raise concern but do not disclose might include, "Are you feeling hopeless about things right now? Have you done anything recently that 's scared the people close to you? Or even more directly, "I am concerned that there's something you're worried about. Do you want to kill yourself?"

    Many small EDs at critical access hospitals don't have mental health resources. What advice would you give these nurses?

    It's really important to have post-licensure education in the care of patients presenting in behavioral health crisis; they are a significant percentage of the ED population, and correct management can yield lifesaving interventions. There are a number of courses in behavioral health nursing management available. If the CAH is part of a system, we would recommend ED staff requesting an in-service by psychiatric staff. Also, protocols for transfer of these patients who require inpatient care should be determined by the healthcare system to which the CAH belongs. Many rural or CAHs also do not have the resources to care for patients having cardiac events, but emergency nurses in these facilities receive education on how to identify and stabilize these patients, and there are processes for getting them to the care they need. Critical access hospitals without mental health resources should get the same type and targeted training to manage behavioral health emergencies that they get in managing cardiac emergencies. Recognition, stabilization, transfer are the three pieces. Mental health emergencies are as much of an emergency as a cardiac event in the sense that you still need to identify, stabilize and transfer to a higher/different level of care.

    Contingency plans for mental health care are at best hit and miss in the US. What kind of improvements would you like to see to increase mental health care availability to the US population?

    1. Better care available in communities, so BH patients have fewer crises that require emergency care
    2. Follow up and connection between acute care and primary care for BH
    3. Immediate availability of psychiatric assessment, treatment, stabilization, and disposition in emergency departments. In Australia, this is often done by MHPNPs (mental health/psychiatric nurse practitioners) who are in the ED or on-call with good results
    4. Expanded services for inpatient care and transitional care back to communities
    5. Improved and expanded training for emergency nurses in behavioral health
    6. Standardized protocols (core measures) for the care of behavioral health patients in emergency departments
    Last edit by Joe V on Jun 14
    Do you like this Article? Click Like?

  2. Visit traumaRUs profile page

    About traumaRUs, MSN, APRN, CNS Admin

    Joined: Apr '00; Posts: 52,860; Likes: 25,605
    allnurses Asst Community Manager, APRN; from US
    Specialty: 25 year(s) of experience in Nephrology, Cardiology, ER, ICU

    Read My Articles

    8 Comments

  3. by   Racer15
    The issue is that a lot of these folks know the right things to say. I was a recent psych patient, and I knew the words to say and the things to keep to myself if I wanted to avoid inpatient admission. I'm not saying I'm particularly clever, but I've been an ER nurse five years, I know the way this game plays out.
  4. by   traumaRUs
    ....but if it helps to deter even one person from suicide, its worth it, don't you think?
  5. by   Crs13an
    This is unfortunately too late for my son. He took his life 7 hours after the hospital ED discharged him. We obtained the copy of his 7 hour stay from admission to discharge from ED with questions asked and answered and vital signs and treatment , which was minimal, in my opinion. I must mention I am an RN with 46 years experience. he was 31 at the time so thanks to HIPPA we were excluded from information at the time he was in the ED. He was 4 times over the legal limit for alcohol. Alcohol toxic actually because he was seizing when we called the ambulance for him at his residence. My husband found him when he went to pick him up for Thanksgiving dinner with us. Sad to say they deemed him non-suicidal,and ok to discharge even though there were obvious "signs" in the charting., that I will not mention here. And physical symptoms such as hypertensive urgency. We tried several Lawyer firms but they declined the case. Stating" you will never get an impartial jury" when it comes to suicide. Our lives,our hearts remain broken. That was 11/23/2012.
  6. by   traumaRUs
    Quote from Crs13an
    This is unfortunately too late for my son. He took his life 7 hours after the hospital ED discharged him. We obtained the copy of his 7 hour stay from admission to discharge from ED with questions asked and answered and vital signs and treatment , which was minimal, in my opinion. I must mention I am an RN with 46 years experience. he was 31 at the time so thanks to HIPPA we were excluded from information at the time he was in the ED. He was 4 times over the legal limit for alcohol. Alcohol toxic actually because he was seizing when we called the ambulance for him at his residence. My husband found him when he went to pick him up for Thanksgiving dinner with us. Sad to say they deemed him non-suicidal,and ok to discharge even though there were obvious "signs" in the charting., that I will not mention here. And physical symptoms such as hypertensive urgency. We tried several Lawyer firms but they declined the case. Stating" you will never get an impartial jury" when it comes to suicide. Our lives,our hearts remain broken. That was 11/23/2012.
    I am so very sorry for this terrible loss! These kind of situations is what we are desperately trying to prevent.
  7. by   JKL33
    I don't wish to have my concern for those struggling called into question again so I will phrase differently this time around, which perhaps gets more to the heart of my misgivings anyway.

    I favor proper training of ED nurses, and I favor an environment where those triaging and screening are RNs operating at levels of proficiency and expertise. Protocolized screenings by those who have been advanced into the triage and screening role via brief orientations are not fool-proof - - I believe these patients can be overlooked and missed even with screenings - by those who have no context, a still-developing basic knowledge base, a minimal set of prior experiences from which to draw, and a not-yet-developed sense of nursing intuition. I suspect, but can't prove, that the 8% are those who can be prudently ferreted out - and that they may not be willing to answer a screening question or two affirmatively.

    I am aware of Parkland's initiative and some of the numbers and outcomes being reported and am mulling it over.

    Thank you for the article.
  8. by   3peas
    Quote from Crs13an
    This is unfortunately too late for my son. He took his life 7 hours after the hospital ED discharged him. We obtained the copy of his 7 hour stay from admission to discharge from ED with questions asked and answered and vital signs and treatment , which was minimal, in my opinion. I must mention I am an RN with 46 years experience. he was 31 at the time so thanks to HIPPA we were excluded from information at the time he was in the ED. He was 4 times over the legal limit for alcohol. Alcohol toxic actually because he was seizing when we called the ambulance for him at his residence. My husband found him when he went to pick him up for Thanksgiving dinner with us. Sad to say they deemed him non-suicidal,and ok to discharge even though there were obvious "signs" in the charting., that I will not mention here. And physical symptoms such as hypertensive urgency. We tried several Lawyer firms but they declined the case. Stating" you will never get an impartial jury" when it comes to suicide. Our lives,our hearts remain broken. That was 11/23/2012.
    I am so sorry for the death of your son. This should have never happened and as a nurse you know the Federal laws put in place to stop this from happening. The hospital is liable for any pt that walks out the ED's doors and dies immediately. This is exactly why I believe more should be done in ED's. I know ER nurses are overworked and overloaded, but MH pt's are told to go to ED's for help and most times they do not receive the help they deserve because it's deemed "not emergent." But it is! I firmly believe Ed's should be overhauled.
  9. by   Racer15
    Quote from traumaRUs
    ....but if it helps to deter even one person from suicide, its worth it, don't you think?
    Oh I wasn't arguing your point, quite the opposite. I was not seen in my ER, my NM took me to a crisis center for my evaluation because she would never make me be evaluated at my own ER. My mom is also a LCSW for the organization we use for crisis management, so I was a bit of a problem child when I was brought in, unfortunately. This is really good advice, truly! I guess I'm just talking out loud, what questions do you use to screen the people that know too much?
  10. by   bellini
    Quote from JKL33
    I don't wish to have my concern for those struggling called into question again so I will phrase differently this time around, which perhaps gets more to the heart of my misgivings anyway.

    I favor proper training of ED nurses, and I favor an environment where those triaging and screening are RNs operating at levels of proficiency and expertise. Protocolized screenings by those who have been advanced into the triage and screening role via brief orientations are not fool-proof - - I believe these patients can be overlooked and missed even with screenings - by those who have no context, a still-developing basic knowledge base, a minimal set of prior experiences from which to draw, and a not-yet-developed sense of nursing intuition. I suspect, but can't prove, that the 8% are those who can be prudently ferreted out - and that they may not be willing to answer a screening question or two affirmatively.

    I am aware of Parkland's initiative and some of the numbers and outcomes being reported and am mulling it over.

    Thank you for the article.
    This^^ and in relation to nursing generally, in any area. We need to get away from this task orientation and this checklist mentality, and move towards extensive knowledge acquisition and application in a variety of contexts through deliberate practice.

close