Posted: 9/6/2016
Identifies at-risk adults, adolescents, provides immediate help
It’s a little discussed but anguishing reality – suicide in the U.S. has surged to the highest rate in nearly 30 years. Overall, the suicide rate rose by 24 percent from 1999 to 2014 according to a study by the National Center for Health Statistics released in April. Addressing this mental health crisis is a national challenge. Now, experts at Parkland Health & Hospital System are sharing an innovative program developed at Parkland with U.S. health leaders that could become a template for other health systems.
In 2015, Parkland launched a unique Universal Suicide Screening Program to identify those at risk and help save lives by intervening immediately. Parkland has more than 250,000 Emergency Department patient encounters and more than 1 million outpatient encounters annually.
“To our knowledge we are the first big hospital system in the U.S. to implement a universal screening program for suicide risk and the data we are gathering will be significant for other organizations in the future,” said Kimberly Roaten, PhD, Director of Quality for Safety, Education and Implementation, Department of Psychiatry at Parkland and Associate Professor of Psychiatry at The University of Texas Southwestern Medical Center.
A clinical psychologist working with Parkland patients, Dr. Roaten developed the screening program, along with Celeste Johnson, DNP, APRN, PMH CNS, Director of Nursing, Psychiatric Services and Russell Genzel, MSN, RN, CEN, Director of Nursing, Emergency Room at Parkland.
“Patients who later die by suicide are often seen by non-behavioral health providers in the days, weeks and months prior to death,” Dr. Roaten said. “U.S. data shows that 77 percent of people who die by suicide had contact with a primary care provider and 40 percent had contact with an emergency department provider in the year prior to death. We want to use every patient encounter at Parkland as an opportunity to identify those at risk.”
Dr. Roaten and Dr. Johnson were invited to share Parkland’s innovative suicide screening program with more than 500 Joint Commission surveyors at a meeting in Chicago on Sept. 7 as an example of the type of program the Joint Commission hopes will become widely used across the nation. The Joint Commission accredits and certifies nearly 21,000 healthcare organizations and programs in the U.S.
In 2014 Parkland dedicated the resources needed to make the universal suicide screening program possible, hiring additional psychiatric social workers, selecting a standardized and validated suicide screening instrument, building the Parkland Algorithm for Suicide Screening (PASS), an algorithm in the electronic health record that triggers the appropriate clinical intervention depending on the patient’s answers to a few simple questions, and training all nursing staff to implement the program.
Parkland implemented suicide risk screenings with all Emergency Department (ED) patients and hospital inpatients in February 2015. In May 2015, standardized suicide risk screening was added at all Parkland Community Oriented Primary Care health centers (COPCs) and at the Correctional Health division for all inmates at the Dallas County Jail.
In the first year of the program, Parkland screened 310,000 patients in the ED and 348,000 patients in the outpatient health centers and correctional health unit. Parkland uses the Columbia Suicide Severity Rating Scale (C-SSRS), a validated screening tool, with adults 18 and over and the ASQ (Ask Suicide Screening Questionnaire) with 12- to17-year-olds.
The Parkland algorithm sorts patients into three suicide risk categories based on their answers to the screening questions: no risk identified, moderate risk identified and high risk identified. Those at high risk are immediately placed under one-to-one supervision, suicide precautions are implemented, and an evaluation by a behavioral health clinician is initiated. Patients at moderate risk are automatically referred to a psychiatric social worker and usually are seen during the same visit. If a patient chooses not to speak with a psychiatric social worker during the visit, they receive a follow-up phone call to provide additional support and resources.
So far, the suicide risk screening in the ED at Parkland Memorial Hospital has found approximately 2 percent of patients to be at high risk and 4 percent at moderate risk for suicide. In the inpatients units 0.2 percent of patients were high risk and 0.8 percent were moderate risk. Patients screened at Parkland COPCs were found to have 1.8 percent at moderate risk and 0.15 percent at high risk of suicide.
“Patients may come in with a sprained ankle or sore throat, but if their suicide risk screening shows that they are at moderate risk, Parkland’s clinical algorithm immediately alerts a member of the behavioral health team to come and speak with them,” said Genzel. Before discharge, both moderate and high risk patients also are given information about suicide warning signs, suicide crisis center hotline numbers, and Dallas County community mental health resources.
“Experts know that suicidal crises tend to be brief,” Dr. Johnson said. “When suicidal behaviors are detected early, lives can be saved. Within the first 19 days of implementing the screening program, we screened 272 patients deemed high risk in the ED. Our nurses quickly recognized that this was making a difference, not just another task for them to do.”
More than twice as many adults in the U.S. die by suicide each year than homicide. Suicide is the 10th leading cause of death in the United States with one suicide occurring on average every 12.3 minutes. The elderly make up 14.5 percent of the population, but comprise 18 percent of all suicides. And suicide is the second leading cause of death among 15- to 24-year-olds. An estimated 4.8 million Americans are survivors of suicide of a friend, family member or loved one.
Dr. Roaten added that most people who are depressed or suicidal will benefit from “just the fact that someone asked them about their feelings. By simply showing concern, we are probably saving lives.”
Suicide Prevention Week is Sept. 5-11, and its 2016 theme is “Connect. Communicate. Care,” raising awareness that suicide is a major preventable cause of premature death on a global level.