Parkland administrators had considered implementing universal suicide risk screening before, but they became especially interested in 2014, when an accreditation survey by The Joint Commission found that a medical inpatient who had a substance use disorder was not given a full suicide risk assessment. “I suggested that we start screening every patient at every point of entry in order to not miss patients who were showing up for medical treatment who might also have occult suicide risk,” said Kimberly Roaten, PhD, director of quality for safety, education, and implementation in the department of psychiatry.
How it works
Although such screening tools as the Columbia-Suicide Severity Rating Scale (C-SSRS) and the Ask Suicide-Screening Questions (ASQ) were available to use, a triage system did not exist for a large hospital setting, she said. So the system built into its electronic health record the Parkland Algorithm for Suicide Screening (PASS), which gives numerical weightings to each item in the C-SSRS and the ASQ, Dr. Roaten said. “The screenings happen everywhere: in our ED, in our urgent care center, all of our inpatient units, and in all 20 of our community-oriented primary care clinics,” she said.
A nurse asks screening questions during triage, inputs the yes or no responses, and then the PASS prompts the appropriate clinical response, explained Dr. Roaten, who is also an associate professor of psychiatry at the University of Texas Southwestern Medical Center. There are three levels of risk stratification: no risk, moderate risk, and high risk. Patients at moderate risk are seen by social workers, receive a printed list of suicide warning signs and crisis hotline numbers, and are connected with outpatient mental health care resources in the community. High-risk patients (who typically report active suicidal ideation with intent or a recent suicide attempt) receive the same resources but are also seen by behavioral health clinicians, are placed under one-to-one observation, and are not allowed to leave without being evaluated.
Throughout 2015, the program rolled out in phases, and results from the first six months were published in January 2018 by the Joint Commission Journal on Quality and Patient Safety. Of more than 328,000 adult encounters in the ED, inpatient units, and clinics that involved screening, about 96% had no risk identified. About 50% of screenings occurred in outpatient clinics (2.1% positive), more than 40% occurred in the ED (6.3% positive), and fewer than 5% occurred in the hospital's inpatient units (1.6% positive).
The positive rate was slightly lower than Dr. Roaten anticipated, although she didn't know exactly what to expect. “We had no idea what to expect because nothing like this had been done before,” she said. “We're the first large hospital system in the nation to implement universal suicide screening.”
This uncertainty was an initial challenge. “The concern was, how many people would we actually identify, and then how many professionals would we need to see them?” said Celeste Johnson, DNP, APRN, PMHCNS, vice president of nursing for behavioral health at Parkland. Although the health system did not have to hire additional clinicians, it did add psychiatric social workers to care for the moderate-risk patients and assist with discharge planning for those at high risk, she said.
Another concern was that patient flow in the ED would slow down, but this didn't happen. “That is always a concern to EDs. The screening process only takes a few minutes. However, health care systems need to consider how they are going to provide mental health evaluations to those identified at risk for suicide,” Dr. Johnson said.
There was also concern about giving an additional task to nurses, but program administrators regularly shared good catches and data to enhance motivation, she said. “We continue to do that so that they can see that they're making a difference in people's lives and that their work has a lot of purpose to it,” Dr. Johnson said.
How patients benefit
The suicide screening opens the conversation for patients to speak about other mental health issues or social concerns, Dr. Roaten said. “They may say no in response to suicide screening questions but might mention that they're out of their antidepressants and need an appointment with a psychiatrist or...acknowledge that there's some sort of abuse situation at home,” she said.
Words of wisdom
Dr. Roaten said that any system that is considering implementing a universal suicide screening program has to be knowledgeable and realistic about its clinical resources. “We had the luxury of having a very big campus with a lot of employees, but if you're in a smaller setting, you'll have to be more creative about how you respond to the clinical needs from this program,” she said.