‘Screening should be followed by steps that match the level of risk identified’
ACLP News asked Colin Harrington, MD, FANPA, DFAPA, FACLP, of Rhode Island Hospital—one of the four hospitals contributing to the National Institute study on the ASQ tool—questions raised by other Academy members through their special interest group listservs.
Is screening sufficient? Should there be interventions tied to each risk level?
Screening is screening. This and related tools were developed to capture possible suicidality in a population identified at higher risk than the general population for suicide—namely, patients who have visited a medical hospital in the months before attempted suicide. But the risk in this group remains, in absolute terms, limited/low.
Screening should be followed by steps that match the level of risk identified and by the patient’s interest in follow-up. For patients in our institution who screen positive and who report more active suicidality/psychiatric distress in step 2 of the screen, a fuller assessment follows and generates decisions about implementation of immediate safety measures (sitter, SP) and subsequent decisions re level of care (inpatient, part-hospitalization, outpatient). For those d/c to outpatient levels of care, full safety planning is performed.
How have requirements for suicide risk screening impacted C-L Psychiatry services?
Requirements for universal suicide screening of medical-surgical patients, well-intentioned, generated some concern in emergency department and C-L Psychiatry services that they would not have the resources to match the identified demand.
Our experience, consistent with that of colleagues, is that screening has not overwhelmed clinical services. While identifying patients with a history of suicidality, the ASQ [Ask Suicide-Screening Questions] empowered frontline clinicians to perform follow-up assessment that reliably identified those who were more acutely ill and/or potentially unsafe and in need of more immediate care. This represented a relatively small percentage of patients screened and did not outstrip the resources of consulting psychiatry services. We found the ASQ considerably easier to use than the Columbia-Suicide Severity Rating Scale (C-SSRS) tool—and noted that it was readily accepted by our incredibly hard-working and talented nursing colleagues.
Physicians determining safety of discharge appear to have had the final say on follow-up to suicide screening in hospitals to date. How far does C-L Psychiatry have a collaborative impact on the decision?
Our medical-surgical colleagues have both the obligation and ability to serve as frontline evaluators of suicidality in their patients. Screens such as the ASQ actually empower them to engage this important assessment. We (and most C-L Psychiatry services) have a robust and collaborative relationship with our medical-surgical colleagues, and while these clinicians will occasionally make the determination that formal psychiatric consultation is not needed, they routinely engage the floor social work team to perform a follow-up assessment of patients who screen positive.
Our social work colleagues have the training and expertise to perform a fuller psychiatric assessment and risk assessment—and to order formal psychiatric consultation for those patients identified to be in acute need. This represents a true sharing of the evaluation and treatment of these patients while all clinicians are “working to their licenses.”
How are hospitals allowed by law to respond to patients who screen positive?
The Joint Commission is mandating the use of a validated tool for suicide screening. Beyond that, institutions are able and obligated to more fully assess and manage positive screens as clinically indicated. I am unaware of any national mandate for a specific clinical path for positive screens.
Our and related institutions have generated clear clinical pathways for the follow-up assessment and treatment of positive screens with specific safety measures implemented per policy for patients identified as acutely suicidal or deemed to be an acute safety risk. Our C-L Psychiatry service is at the center of clinical decision-making around these issues and cases—by the nature of our work and mission; less so by any imposed “legal” directive.
We also asked ACLP member, June Cai, MD, Walter Reed National Military Medical Center—another of the four hospitals in the National Institute study—to respond to a further question from Academy listservs:
How do we follow up to ensure that suicide risk screenings are making a difference to the patient? What metrics should we use and who should take ownership of that data?
At Walter Reed National Military Medical Center, we have been routinely screening patients for suicidality daily. With every positive screen, we provide a close monitoring on site until psychiatric safety evaluation. We also ensure that patients do have appropriate follow-up care even after discharge.
This study provides another quick tool that seems to be more pertinent as it is originated from our own population. The relatively lower reporting rate of suicidal ideation in the study from our hospital could also reflect the relatively more stable socioeconomic status and fewer substance abusers among our patient population. But we remain vigilant about the active duty members’ general concern for reporting suicidal ideation affecting their careers. We hope to continue making efforts to improve mental health care and safety for our service members and families to maintain our strength in national defense.
As a safety screening tool, the key metrics will be the incidences of suicide attempts and complete suicides of the service that uses the instrument. The incidences should be monitored by the service chief or the person in charge of the safety data in the department.
The views expressed in this abstract are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or US Government.