Can mandatory suicide risk screenings in emergency rooms save lives? Researchers say yes.
Richard Clark in his book “Warnings: Finding Cassandras to Stop Catastrophes" warned us to pay serious attention to people like Dr. Edwin Boudreaux. He is a Cassandra shouting out a serious warning. As Clark said in this book Cassandra was a princess of Troy cursed by the god Apollo. “He gave her the ability to see impending doom, but the inability to persuade anyone to believe her.” Suicidologists have given the clinicians the ability to detect dangerous suicidal warning signs before others see it.
Decision-makers, (Hello Secretary of Health and Human Services) need to read Clark’s book and require their subordinates to do the same.
General Mattis, in his book Call Sign Chaos said, “If you haven’t read hundreds of books, you are functionally illiterate, and you will be incompetent, because your experiences alone aren’t broad enough to sustain you.” General Mattis said his Marines had to be “all in, all the time.” Dr. Boudreaux is saying the same thing to health field leaders.
Death by suicide is now a public health crisis that America is having an increasingly difficult time getting a grasp on. In the past two decades, the suicide rate has climbed 33 percent. Today, the average number of people who die by suicide each year has reached 47,000. More than a million people, additionally, attempt suicide.
Teens and adolescents are more at risk than any other age group. Guns are also involved in nearly half of all deaths by suicide, accounting for roughly 60 percent of all gun deaths in America.
Researchers argue for mandatory ER suicide risk screenings
Edwin Boudreaux, professor of emergency medicine and psychiatry at the University of Massachusetts Medical School, is pushing for mandatory emergency room suicide risk screens nationwide.
What started out as routine diabetes treatment revealed a suicide risk in one of Boudreaux's patients, according to an article in The Washington Post.
“She was so suicidal, I had to walk her from our clinic to the emergency department just to make sure nothing would happen in between,” Boudreaux recalled.
This one incident is only part of a large-scale problem. According to research produced by Boudreaux, suicidal thoughts in emergency room patients who are treated for unrelated health issues are alarmingly common. For this reason alone, death by suicide can be prevented in many cases when doctors and nurses simply ask if patients are having suicidal thoughts.
“You can save hundreds of lives doing this. But the amount of pushback has been frustrating,” said Boudreaux.
Boudreaux isn't alone. Other authorities in the medical industry, including the National Institute of Medical Health (NIMH), also argue that screening for suicide risks in health clinics and ERs could help bring down the staggering rate of death by suicide. During a screening, doctors or nurses would ask patients if they are having suicidal thoughts. They would then follow up with telephone counseling, referrals for additional treatment, as well as other interventions.
Opponents of screening argue that hospital resources are limited
NIMH has invested millions of dollars into researching suicide risk screening and has tried to garner support from physician groups, health-care companies, and regulators.
There has been pushback by many doctors and nurses, as well as The American College of Emergency Physicians (ACEP). Opponents claim not to have sufficient resources to deal with patients who are at risk of dying by suicide or suffer from mental illness. They said they would need more time and money to perform suicide risk screenings.
The Joint Commission, an agency that accredits hospitals, agrees that suicide risk screenings could help save lives, yet they have not made them mandatory. The commission’s Executive Vice President for Health Care Quality Evaluation David Baker said in an email that the decision not to mandate screening in hospitals and ERs was due to lack of effectiveness if follow-ups aren't conducted.
The proven life-saving benefits of suicide risk screenings in ERs
Dealing with suicide risks in hospitals and ERs may be challenging because of the lack of funding and staffing, according to other doctors and health experts. In some medical facilities, patients who suffer from mental illness may wait more than 24 hours to see a doctor, and potentially days before being admitted to a psychiatric ward.
Sandra Schneider, an emergency physician and former president of the ACEP explains.
“If I have a patient with appendicitis or a heart attack, I can get a surgeon on the phone and get the patient taken care of instantly,” said Schneider. “But if someone came in trying [to] kill themselves, in many hospitals in the country, the only person available is a psychiatric nurse or social worker or behavioral specialist on call that day. It’s not even a doctor.”
This leaves hospital staff with only two options: either hospitalize them when resources aren't available or send them off with a list of mental health clinics to consult (many of which have a prolonged waiting period).
In response, Boudreaux acknowledged these challenges while stressing the importance of suicide risk screenings. Over the past decade, Boudreaux has witnessed the life-saving benefits of the screenings in ERs across seven states.
“There are real barriers to implementation,” said Boudreaux. “No one denies that. But what’s the alternative? Would we rather not know that people want to kill themselves? Is it better to just not ask and not know?”
He, along with researchers from eight hospitals, took part in a $17 million federally funded study which found that screening in ERs revealed twice as many patients with suicidal thoughts. The true rate was found to be 5.7 percent of adult patients, as opposed to the previous rate of 2.9 percent.
In addition, researchers found that immediately responding with a brief telephone counseling after a screening resulted in a 30 percent reduction in suicide attempts over the course of 52 weeks, in contrast with standard emergency department care. Other types of intervention by ER staff were also found to be effective at preventing deaths by suicide.
ER staff and other medical professionals can save lives by implementing a safety plan. This includes providing patients with a list of people they can reach out to when the urge to attempt suicide arises. A safety plan should include a list of crisis lines and mental health providers, as well as providing coping strategies and limiting access to lethal materials.
Columbia University psychologist Barbara Stanley explains that the safety plan patients receive in the ER can have an impact.
“This may be the only time we have with them. So the idea was let’s give them something they can walk away with, even it’s small," said Stanley.
A guide for suicide risk intervention
Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments provides information ER staff can utilize when screening patients.
When conducting a screening using a risk assessment tool, ER staff should base intervention on:
- Disclosures and statements made by the patient
- Reports by friends, family, police, and other acquaintances
- Noticeable conditions that suggest a suicide risk is present, such as depression and drug use
- Primary screening conducted by healthcare professionals
The Decision Support Tool — a secondary screening tool — offers a basic guide for decision making, providing brief intervention, and properly discharging patients who are found to be at risk of suicide. It also provides a comprehensive risk assessment tool that helps ER staff determine if a patient is in need of a mental health evaluation or other inclusive treatment and monitoring.
The Decision Support Tool is a six-tier screening process which covers these crucial areas:
- Does a patient have thoughts about how he or she intends to attempt suicide?
- Does a patient have any intention of attempting suicide?
- Has a patient attempted suicide in the past?
- Does a patient suffer from any mental health problems, or has he or she been treated for mental health in the past?
- Has a patient recently consumed drugs or excessive amounts of alcohol?
- Has a patient recently been feeling irritable, agitated, or aggressive, or engaged in aggressive behavior such as getting into fights?
If a patient answers "no" on all six questions, then discharge may be necessary. However, if a patient answers "yes" on any of the questions, then intervention is a critical course of action.
For patients who are found to be at risk, ER staff should consider the following:
- Assess a patient's capacity to make healthcare decisions.
- If the patient can't make healthcare decisions, ER staff should continue with the assessment and provide treatment and monitoring as needed.
- If the patient can make healthcare decisions, staff should move on to secondary screening.
- Staff may then provide emergency department prevention intervention and refer patients to suicide prevention specialists upon discharge.
- If a patient's visit was due to attempted suicide, staff should consult with mental health specialists for further evaluation and assessment.
- Patients should then be considered for inpatient or outpatient treatment, depending on the level of care needed.
What should come after discharge?
Healthcare professionals may then follow up with ER-based suicide prevention interventions, which includes:
- Brief patient education: This step helps patients (and families of patients) understand the nature of their condition, as well as the treatment options available to them. This can include brochures, booklets, and other educational materials.
- Safety planning: Patients learning coping strategies they can use in the event of a crisis or urge to attempt suicide.
- Lethal means counseling: Healthcare professionals work with patients to assess lethal means of carrying out a suicide attempt. For example, does a patient have access to guns or prescription medication?
- Rapid referral: Patients are provided with a follow-up appointment after discharge. The ideal time frame is 24 hours after discharge, but no more than seven days.
- Caring contacts: ER providers and other medical personnel provide follow-up communication to help facilitate treatment plans after discharge. Communication may be conducted once or may be reoccurring. Patients should also be provided with a local crisis center phone number or the National Suicide Prevention Lifeline 1-800-273-8255 (TALK).
Texas suicide lawyer Skip Simpson fully endorses these ER suicide risk screenings and follow-up interventions. We place a great deal of trust in our medical professionals to save lives. The risk of suicide in patients should be addressed just as promptly and inclusively as any other potentially fatal condition.
If you lost a loved one because medical staff failed to act, or discharged a patient who was at high risk of dying by suicide, The Law Offices of Skip Simpson can help you in the pursuit of justice. We serve clients nationwide. To find out how we can help you, contact us online or call our law office at (214) 618-8222.