Asking Three Questions Can Identify Suicide Risk

When nurses asked three questions of patients who arrived in the Emergency Department (ED) with a nonpsychiatric chief complaint, screening for suicide risk significantly improved. A study underway in eight EDs is demonstrating that it is possible to dramatically increase the detection of suicide risk during routine ED care.

The study, known as ED-SAFE (Emergency Department Safety Assessment and Follow-up Evaluation) is funded by the National Institutes of Mental Health and is aligned with The Joint Commission’s call to identify patients who are at risk for suicide.

Universal screening in the ED can be especially productive because a greater percentage of ED patients with nonpsychiatric chief complaints has either considered or attempted suicide in the past as compared to the general population. Overall, the number of suicide attempts is increasing while the number of ED visits for attempted suicide and self-inflicted injury has more than doubled.

Resistance to screening, including resistance from clinical staff, has sometimes impeded the implementation of universal ED screening for suicide risk. Care providers may fear that if they screen for suicide risk and identify it, they need to take appropriate action, which can be complicated and not offer a real solution. Moreover, aftercare and referral options to specialty services are limited so, once the problem is identified, there may not be adequate resources to deal with it.

Question 1, 2, and 3

Using three screening questions, emergency nurses in the study were able to detect an increased risk of self-harm in 5.7% of all ED patients compared with a 2.9% detection rate without the screening questions.

The screening begins with a brief introductory script to establish a nonthreatening atmosphere followed by three questions:

  • Question 1: “Over the past two weeks, have you felt down, depressed, or hopeless?”
  • Question 2: “Over the past 2 weeks, have you had thoughts of killing yourself?”
  • Question 3: “Have you ever attempted to kill yourself? If ‘yes,’ then when did this happen?”

If the nurse receives a positive result on the screening, a physician is called in to ask additional questions and decide whether a consultation with a psychiatrist is needed.

Three Phases

  • The study is being conducted in three phases:
    Phase 1 (baseline): During the 12-month baseline phase of the study, 26% of patients who came to the ED with a nonpsychiatric chief complaint were screened for suicide risk; 2.9% of these patients were determined to have some level of suicide risk/self-harm.
  • Phase 2 (training phase): After emergency nurses received formal training in the effective use of the three-question screen, the number of ED patients with a nonpsychiatric chief complaint who were screened for suicide risk increased to 73%; 5.2% of these patients were determined to be at some level of risk for suicide or self-harm.
  • Phase 3 (intervention phase): The percentage of ED patients who were screened for suicide risk increased even further to 85%; 5.7% of these patients were identified as exhibiting some level of risk of self-harm.

Phase 3 of the study, which is currently underway, will determine whether universal ED suicide risk screening becomes policy. Any at-risk patients who are detected during screening will receive post-ED telephone counseling. They will be followed for 12 months to determine whether detection and intervention will affect the incidence of attempted or completed suicide.

To learn more about assessing for suicide risk, look into Mosby’s Handling Psychiatric Emergencies, an eLearning course, and Mosby’s Nursing Skills Mental Health Collection.

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