Injury Prevention Quarter
Kimberly Roaten, PhD, CRC
Director of Quality for Safety, Education, and Implementation
Associate Professor – Department of Psychiatry
The University of Texas Southwestern Medical Center
Alexander L. Eastman, MD, MPH, FACS
Medical Director and Chief — The Rees-Jones Trauma Center at Parkland
Assistant Professor – Division of Burns, Trauma, and Critical Care
The University of Texas Southwestern Medical Center
Suicide is a significant public health issue and the 10th leading cause of death in the United States with more than 44,000 suicides per year, half of which involve firearms. In 2016, there were more than half a million emergency department encounters related to self-inflicted injuries, with more than 200,000 of those requiring hospitalization, resulting in more than 9 billion dollars in lifetime costs. Even more alarming, despite increased national attention on suicide prevention, these rates have been steadily increasing for the past two decades. Although older white men remain the highest risk demographic group, recent data revealed that rates of self-directed violence are increasing particularly rapidly among young people. In 2014, suicide rates exceeded the rates of death due to motor vehicle collisions and homicide for the first time among children aged ten to fourteen.
Historically, the majority of the efforts to decrease suicide have focused on identifying and reducing risk in patients who seek treatment for psychiatric illness. The Joint Commission’s National Patient Safety Goal (NPSG.15.01.01) regarding identification of suicide risk applies only to patients treated at psychiatric hospitals and patients being treated for psychiatric symptoms in general healthcare settings. However, individuals who die by suicide are much more likely to be evaluated by primary care and emergency providers for non-psychiatric complaints in the months prior to death than by a behavioral health specialist. How do we address this gap? What is the solution to identifying risk in overburdened health care systems with limited access to behavioral health resources?
One promising solution is the implementation of standardized suicide risk screening with clinical decision support. Standardized screening leads to more accurate identification of patients at risk for suicide than relying on clinician judgment or vague queries about suicidal ideation. Parkland Health & Hospital System (PHHS) in Dallas, Texas implemented a universal standardized screening program in early 2015. Patients aged ten and older are screened for suicide risk during every provider encounter in the system. Nursing staff complete the screenings and the system allows for temporary silencing of the screening prompts if the patient is in the midst of resuscitation or is otherwise unable to complete the screening. The screening process is integrated into the electronic health record using the Parkland Algorithm for Suicide Screening, which leads to, as appropriate, automatic prompts for clinical interventions including environmental safety and escalation to behavioral health specialists. At-risk patients automatically receive printed information about suicide warning signs, local mental health resources, and crisis hotlines. More than two million screenings have been completed since the program began.
Screening during the initial emergency department encounter may be particularly important for trauma patients as they often have variable follow-up rates. During the first six months of the PHHS screening program, more than 3,600 trauma patients were screened for suicide risk, and approximately 4 percent screened positive. Of those who were positive, nearly half endorsed only one low acuity item and therefore did not require resource intensive interventions such as 1:1 observation or involuntary detention.
Screening is an important risk identification strategy, but it must be accompanied by interventions targeted at reducing imminent risk. One of the most effective strategies for reducing suicide risk is restriction of lethal means, particularly limiting access to firearms — an intervention consistent with strategies set forth by the American College of Surgeons Committee on Trauma to reduce firearm-related injuries and death. The combination of standardized screening, clinical decision support, and means restriction is an important and efficient strategy for reducing suicide risk in all healthcare settings, but particularly for trauma patients.
Centers for Disease Control and Prevention. Fatal Injury Data. 2018; Web-based Injury Statistics Query and Reporting System. Available at: http://www.cdc.gov/injury/wisqars/. Accessed May 15, 2018.
Imran, J.B., Richmond, R., Madni, T.D., Roaten, K., Clark, A.T., Huang, E., Mokdad, A.A., Taveras, L.R., Abdelfattah, K., Cripps, M.W., & Eastman, A.L. (2018). Determining suicide risk in trauma patients using a universal screening program. Journal of Trauma.
Roaten, K., Johnson, C., Genzel, R., Khan, F., & North, C.S. (2018); Development and Implementation of a Universal Suicide Risk Screening Program in a Safety-Net Hospital System. The Joint Commission Journal on Quality and Patient Safety, 44(1), 4–11.
Stewart R.M., Kuhls D.A., Rotondo M.F., Bulger E.M. Freedom with Responsibility: A Consensus Strategy for Preventing Injury, Death, and Disability from Firearm Violence. Journal of the American College of Surgeons.