Improving suicide risk screening in the emergency department
Intended for healthcare professionals
Evidence and practice    

Improving suicide risk screening in the emergency department

Heather Englund Associate professor, University of Wisconsin Oshkosh, Oshkosh, Wisconsin, US

Why you should read this article:
  • To enhance your awareness and understanding of the Columbia-Suicide Severity Risk Scale

  • To learn about a project to improve suicide risk screening in three emergency departments in the US

  • To acknowledge the need to provide nurses with adequate training and tools on suicide risk assessment

Suicide is a significant and increasing public health concern. Research has shown that screening for suicide risk is inconsistent in acute care settings and that a variety of different tools are used for that purpose. The Columbia-Suicide Severity Risk Scale (C-SSRS) has emerged as a validated and recognised suicide risk screening tool. This article describes a quality improvement project designed to improve the screening of patients for suicide risk in a large hospital system in the Midwestern US. As part of the project, 97% of nurses working in the organisation’s emergency departments self-completed a 30-minute interactive learning module on the background, relevance and application of the C-SSRS. The C-SSRS enables nurses to classify the severity of suicide risk, which helps to provide interventions commensurate with patients’ level of risk. Following completion of the module, there was a significant increase in the percentage of patients screened for suicide risk.

Emergency Nurse. doi: 10.7748/en.2024.e2198

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

Correspondence

englundh@uwosh.edu

Conflict of interest

None declared

Englund H (2024) Improving suicide risk screening in the emergency department. Emergency Nurse. doi: 10.7748/en.2024.e2198

Published online: 26 March 2024

Suicide is defined as death caused by self-directed injurious behaviour with the intent to die as a consequence of that behaviour (National Institute of Mental Health (NIMH) 2024). In the US and globally, suicide is a significant and increasing public health concern that transcends factors such as gender, age, ethnicity and socioeconomic status (NIMH 2024). In the US, suicide was the 12th leading cause of death overall in 2020, with an estimated rate of 13.5 deaths per 100,000 individuals (NIMH 2024). Following a decline in 2019 and 2020, there was an approximate 5% increase in deaths by suicide in 2021. Recent provisional data show that the number of deaths by suicide rose by around 2.6% in 2022, from 48,183 overall in 2021 to an estimated 49,449 in 2022 (Centers for Disease Control and Prevention (CDC) 2023).

In the US, there are around 500,000 suicide-related visits to emergency departments (ED) every year and 25% of people presenting to the ED after a suicide attempt will make another attempt in the future (Dunlap et al 2019). Research has shown that the risk of suicide is at its highest in the 30 days after discharge from the ED or an inpatient psychiatric unit (Dunlap et al 2019). In a study examining clinicians’ assessment of the short-term risk of suicidal thoughts and suicidal behaviours among psychiatric outpatients, results suggested that approximately one third of people who had committed suicide had visited a healthcare professional in the preceding year (Barzilay et al 2019). The consequences of suicide extend beyond the loss of life. In the US, suicide-related incidents cost an estimated $70 billion per year in medical expenses and lost productivity (Stone et al 2018, CDC 2023).

Nurses in acute care settings are often responsible for the initial screening of patients for suicide risk and therefore have a crucial role in identifying suicidal ideation – which is defined as thinking about, considering or planning suicide (NIMH 2024). Screening for suicide risk should be a priority in all healthcare organisations, but studies have shown that suicide risk screenings are not conducted consistently across acute care settings (Barzilay et al 2019). In addition, there is significant variability in the tools used to assess patients for suicide risk (Horowitz et al 2018). By prioritising suicide risk screening and ensuring nurses are appropriately trained and equipped to undertake it, healthcare organisations can detect suicide risk in a timely manner and provide appropriate interventions to those who need them.

This article describes a quality improvement project conducted at a large hospital system in the Midwestern US to improve the screening of patients for suicide risk. The article shows how the care of patients at risk of suicide who present to the ED can be enhanced using a quality improvement process and education about a validated screening tool.

Key points

  • Nurses in acute care settings have a crucial role in identifying suicidal ideation at initial patient screening

  • In acute care settings, suicide risk screening is inconsistent and undertaken using a variety of tools

  • The Columbia-Suicide Severity Risk Scale (C-SSRS) is a validated and recognised tool for assessing suicide risk

  • The C-SSRS enables a precise categorisation of a patient’s risk of suicide by classifying risk into different levels

  • In a hospital system in the US, suicide risk screening rates increased after nurses completed a C-SSRS learning module

Screening for the risk of suicide

The Joint Commission is a US organisation that accredits healthcare organisations and programmes. It develops patient safety initiatives such as the National Patient Safety Goal for suicide prevention, which requires all Joint Commission-accredited hospitals to assess patients for their risk of suicide (The Joint Commission 2019). However, at present, that requirement only applies to psychiatric hospitals and to patients who are being evaluated for emotional or behavioural disorders (Roaten et al 2018).

Roaten et al (2018) noted that the risk of suicide among people who do not have a documented mental health condition is largely unknown. They cited a study on suicidal ideation showing that, among 1,590 non-psychiatric patients treated in the ED, 20% had active suicidal thoughts and nearly 2% had a specific suicide plan. Roaten et al (2018) further quoted a retrospective review of medical records indicating that almost 87% of patients with suicide plans had not been identified by healthcare professionals in the ED.

The lack of a clear classification of suicidal behaviours according to severity has hindered researchers’ ability to investigate the question of suicide risk screening systematically (Interian et al 2018). The absence of evidence-based guidelines for the development of suicide risk screening protocols has left many healthcare organisations in the US uncertain about how to proceed (Horowitz et al 2018). As a result, healthcare organisations use inconsistent approaches to suicide risk screening; some use validated tools while others use informal measures. Furthermore, many are concerned that screening all patients for suicide risk would yield excessively high rates of positive results and therefore lead to resource and capacity issues (Horowitz et al 2018).

Roaten et al (2018) conducted a quality improvement project involving the implementation of a universal suicide risk screening programme at a large hospital system in Texas, US. They developed an electronic health record screening protocol and provided clinical staff with education on the use of the Columbia-Suicide Severity Rating Scale (C-SSRS) to screen patients for suicide risk. Data on the prevalence of suicide risk were analysed for 328,064 adult patient encounters that had taken place in the first six months after implementation of the screening programme. Among the total number of screenings analysed as part of the project, around 50% had been completed in outpatient clinics, more than 40% had been completed in the ED and slightly less than 5% had been completed in inpatient units. Patients were found to be at risk of suicide in 6.3% of the screenings completed in the ED, 2.1% of the screenings completed in the outpatient clinics, and 1.6% of the screenings completed in the inpatient units. A qualitative analysis indicated that the screening programme did not disrupt workflows and did not place an undue burden on staff or resources (Roaten et al 2018).

In a cohort study conducted in eight EDs in the US, Dunlap et al (2019) examined whether the additional cost of implementing universal suicide risk screening followed by an intervention was justified by improvements in patient outcomes (that is, in decreased numbers of suicide attempts and of deaths by suicide). The study involved three sequential phases: treatment as usual, universal screening added to treatment as usual, and universal screening plus a telephone-based intervention delivered more than 12 months after patients’ visit to the ED. Data were collected for 1,376 participants across the three phases. Dunlap et al (2019) found that universal screening plus intervention was more effective, and potentially more cost-effective, in preventing suicide than treatment as usual and universal screening added to treatment as usual. They suggested that universal screening plus intervention could potentially lead to significant societal cost savings (Dunlap et al 2019).

Aim

The overall aim of this quality improvement project was to improve patient screening for suicide risk at a large hospital system in the Midwestern US. Specific objectives were to:

  • Educate nurses about the importance of consistent and standardised suicide risk screening in all patients.

  • Educate nurses about the clinical relevance and use of the C-SSRS.

  • Evaluate the effectiveness of a C-SSRS learning module in increasing nurses’ use of the C-SSRS.

  • Evaluate the effect of a C-SSRS learning module on the number of patients screened and the classification of patients’ suicide risk.

Method

The quality improvement project, which took place between 2021 and 2023, was targeted at nurses working in the ED. The ED had been chosen as the setting for the project because assessing patients’ suicide risk on arrival at the ED is part of routine nursing interventions. The quality improvement project was piloted in the organisation’s three EDs as a first step before potential implementation across the whole hospital system. All 173 nurses employed in the three EDs were approached to participate in the project. Among those 173 nurses, 168 participated, which represents a response rate of 97%.

Screening tool

Originally developed for screening suicide risk in adolescents, the C-SSRS (https://cssrs.columbia.edu) has been validated for use in adults (Posner et al 2011, Gipson et al 2015). It has been recognised as the gold standard for assessing suicide risk in all age groups and its use has been endorsed by the Joint Commission, the US Food and Drug Administration and the US Department of Defense (Interian et al 2018). Previous studies using the C-SSRS have shown that it has high internal consistency and reliability, with a Cronbach’s alpha of 0.93 (Posner et al 2011, Gipson et al 2015).

The C-SSRS comprises two subscales: suicidal ideation and suicidal behaviour. The person who is being screened starts by responding to the ‘suicidal ideation’ subscale, which is designed to assess the severity of their suicidal ideation – from a general desire to no longer live to active suicidal ideation with specific suicide intent and plan. If the person is found to have the most severe type of suicidal ideation, the intensity and characteristics of their suicidal ideation are further assessed through their responses to the ‘suicidal behaviour’ subscale, which enquires about suicidal and non-suicidal self-injurious behaviours (Gipson et al 2015).

The C-SSRS enables healthcare professionals to assess a broad range of behaviours related to suicidal intent, including subthreshold behaviours that are strong predictors of suicide risk (Interian et al 2018). The C-SSRS enables the evaluation of suicidal ideation and suicidal behaviour over a period of up to three months, thereby providing a more comprehensive understanding of the person’s suicide risk than screening tools using shorter timeframes. Another strength of the C-SSRS is that it offers a precise categorisation of the person’s risk by classifying risk into different levels – that is, ‘no risk’, ‘low risk’, ‘moderate risk’ and ‘high risk’ (Posner et al 2011).

Intervention

A 30-minute interactive learning module, which had been previously developed by Columbia University, was used to educate nurses about the importance of consistent and standardised suicide risk screening of all patients and about the clinical relevance and use of the C-SSRS. The module covers the background to, and clinical relevance and practical application of, the C-SSRS. It includes interactive patient scenarios for learners to engage with.

The C-SSRS learning module was integrated into the organisation’s IT system and implemented during a two-month period, during which participants were requested to self-complete the module. Participants’ knowledge was evaluated before and after completion of the module, but the outcomes of these evaluations are not reported here.

Source of data and data analysis

The organisation’s IT department provided comprehensive data on:

  • The numbers of patients screened for suicide risk in the six months before and in the 12 months after implementation of the learning module.

  • All suicide risk screenings completed by nurses in the six months before and the 12 months after implementation of the learning module, including screening tool used, outcomes and subsequent interventions.

Data analysis was conducted using SPSS Version 25.

Ethical considerations

The project was reviewed by the organisation’s institutional review board to ensure that it met its ethical standards, regulations and policies. It was deemed to be a quality improvement project and therefore exempt from institutional review board oversight. Participants consented to have their data included in the project. All data were collected anonymously and presented in aggregate form to reduce bias during data analysis.

Results

The analysis of data showed that there had been a significant increase in the rate of patients screened for suicide risk, from 71% in the six months before implementation to 93% in the 12 months after implementation of the learning module.

Of the 6,918 patients screened for suicide risk in the 12 months after implementation of the learning module:

  • 4% (n=266) had been identified as being at high risk of suicide; 71% (n=189) of these 266 high-risk patients presented with a mental health issue such as anxiety, depression or substance abuse.

  • 6% (n=412) had been identified as being at moderate risk of suicide; 69% (n=284) of these 412 patients presented with a mental health issue such as anxiety, depression or substance abuse.

All 266 high-risk patients received appropriate interventions, including continuous observation, evaluation by a mental health professional and consultation at the county crisis resource centre. Interventions implemented for moderate-risk patients included line of sight observation, safe room assessment, evaluation by a mental health professional, notifying the patient’s primary care provider of their moderate risk of suicide, and referral to a mental health care provider in the community.

Discussion

In this quality improvement project, the completion of an interactive learning module on the C-SSRS appeared to increase the overall rate of patients screened for suicide risk on arrival at the ED. This is important because nursing education programmes in the US often lack comprehensive education on suicide detection and prevention, leading to knowledge gaps and a higher risk of negative attitudes towards patients with mental health issues (Ryan et al 2017). For example, patients diagnosed with a mental health condition may not be appropriately assessed and diagnosed for physical health conditions because of diagnostic overshadowing, which can result in inadequate treatment (Carrara et al 2019). Such knowledge gaps and negative attitudes can have detrimental effects on patient care, patient outcomes and patient safety (Carrara et al 2019).

To address these challenges, it is crucial to involve nurses in quality improvement initiatives, empowering them to advocate for practice change and deliver high-quality, evidence-based care. Through training, healthcare staff can gain a deep understanding of the rationale behind practice change and become proficient in the use of validated tools and techniques. An interactive learning module can increase nurses’ confidence to broach sensitive topics, such as suicidal ideation and suicidal intent, with patients (Ryan et al 2017). Following the quality improvement project, the learning module has been incorporated into the organisation’s orientation process for newly recruited nurses.

Before the project, nurses working in the organisation’s EDs used a variety of screening tools to assess patients’ risk of suicide, including an informal tool consisting of three questions. Completing the learning module prompted nurses to use one tool consistently, rather than a variety of tools. Furthermore, using the C-SSRS enabled nurses to obtain a precise categorisation of patients’ level of suicide risk and therefore provide interventions commensurate with each patient’s level of risk.

The C-SSRS provides a standardised approach to assessment and classification of suicide risk (Posner et al 2011). By implementing the C-SSRS and training staff in its use, healthcare organisations can significantly improve the accuracy of suicide risk screening and enhance the quality of patient care, which in turn can have substantial positive effects on individual patient outcomes and on public health overall.

Limitations

It is important to consider several limitations when interpreting the results of this project. First, the project was limited to a single healthcare organisation and three EDs in the Midwestern US, which may restrict the generalisability of its results to other healthcare settings, regions and countries. In addition, the absence of a control group makes it challenging to determine whether the observed improvements in screening rates were solely attributable to the implementation of the learning module or were also influenced by other factors.

Furthermore, the project’s follow-up period of one year means that the intervention’s sustainability and long-term effects on suicide risk assessment and management and on patient outcomes could not be evaluated. The outcomes measured were limited to screening rates, risk classification and subsequent interventions, with no exploration of broader indicators such as number of suicides, patient satisfaction or healthcare professional practices beyond the ED. In addition, the project did not look into feasibility, availability of resources or potential implementation challenges.

These limitations mean there is a need for further research in a wider range of healthcare settings and with longer follow-up periods to validate and expand on the results of this project.

Recommendations for practice

The C-SSRS is a validated tool that has been recognised as the gold standard for assessing suicide risk (Posner et al 2011, Gipson et al 2015). Its implementation in healthcare organisations involves training staff and incorporating guidelines regarding its use into organisational policies and procedures. This can be achieved by developing quality improvement initiatives around suicide prevention using the C-SSRS as the screening tool.

To evaluate the effectiveness of C-SSRS implementation, regular audits and feedback mechanisms are crucial. These are needed to gather input and insight from stakeholders including healthcare staff, patients and families. Engaging with staff who are directly involved in the use of the C-SSRS is essential. Their feedback provides critical information on practical implementation challenges, areas of success and areas for improvement. Staff’s first-hand experience can help improve ongoing staff training programmes, C-SSRS integration into workflows and the overall usability of the tool. It is equally essential to engage with mental health specialists – including nurses, psychiatrists, psychologists and social workers – in the implementation process to ensure a comprehensive and multidisciplinary approach to suicide risk assessment and management.

Conducting long-term follow-up studies can allow healthcare organisations to monitor patient outcomes over time by looking at indicators such as number of suicide attempts, number of deaths by suicide, number of suicide-related hospitalisations and patient satisfaction. Follow-up studies can also allow organisations to determine whether staff’s attitudes and perceptions regarding suicide risk assessment and management change over time and whether the implementation of C-SSRS has an effect on staff burnout rates. Lastly, long-term studies can provide insight into the continued effectiveness and sustainability of suicide prevention initiatives.

Conclusion

Death by suicide is preventable but suicide remains a significant public health concern. Addressing the issue of suicide requires a comprehensive and systematic approach to suicide risk assessment and management that includes robust screening protocols providing consistency and accuracy.

The C-SSRS is a validated and recognised suicide risk screening tool, one of its strengths being that it enables to classify risk into different levels. This subsequently allows staff to provide interventions commensurate with each patient’s level of risk. The quality improvement project described in this article showed that educating ED nurses about the importance of consistent risk suicide screening and about the use of the C-SSRS can increase risk suicide screening rates. Nurses, as front-line healthcare providers, have a pivotal role in addressing suicide and need to receive adequate education and training so that they are equipped to effectively identify and support at-risk patients.

References

  1. Barzilay S, Yaseen ZS, Hawes M et al (2019) Determinants and predictive value of clinician assessment of short-term suicide risk. Suicide & Life-Threatening Behavior. 49, 2, 614-626. doi: 10.1111/sltb.12462
  2. Carrara BS, Ventura CA, Bobbili SJ et al (2019) Stigma in health professionals towards people with mental illness: an integrative review. Archives of Psychiatric Nursing. 33, 4, 311-318. doi: 10.1016/j.apnu.2019.01.006
  3. Centers for Disease Control and Prevention (2023) Suicide Data and Statistics. http://cdc.gov/suicide/suicide-data-statistics.html (Last accessed: 11 March 2024.)
  4. Dunlap LJ, Orme S, Zarkin GA et al (2019) Screening and intervention for suicide prevention: a cost-effectiveness analysis of the ED-SAFE interventions. Psychiatric Services. 70, 12, 1082-1087. doi: 10.1176/appi.ps.201800445
  5. Gipson PY, Agarwala P, Opperman KJ et al (2015) Columbia-suicide severity rating scale: predictive validity with adolescent psychiatric emergency patients. Pediatric Emergency Care. 31, 2, 88-94. doi: 10.1097/PEC.0000000000000225
  6. Horowitz LM, Boudreaux ED, Schoenbaum M et al (2018) Universal suicide risk screening in the hospital setting: still a Pandora’s box? Joint Commission Journal on Quality and Patient Safety. 44, 1, 1-3. doi: 10.1016/j.jcjq.2017.11.001
  7. Interian A, Chesin M, Kline A et al (2018) Use of the Columbia-Suicide Severity Rating Scale (C-SSRS) to classify suicidal behaviors. Archives of Suicide Research. 22, 2, 278-294. doi: 10.1080/13811118.2017.1334610
  8. National Institute of Mental Health (2024) Suicide. http://nimh.nih.gov/health/statistics/suicide (Last accessed: 11 March 2024.)
  9. Posner K, Brown GK, Stanley B et al (2011) The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry. 168, 12, 1266-1277. doi: 10.1176/appi.ajp.2011.10111704
  10. Roaten K, Johnson C, Genzel R et al (2018) Development and implementation of a universal suicide risk screening program in a safety-net hospital system. Joint Commission Journal on Quality and Patient Safety. 44, 1, 4-11. doi: 10.1016/j.jcjq.2017.07.006
  11. Ryan K, Tindall C, Strudwick G (2017) Enhancing key competencies of health professionals in the assessment and care of adults at risk of suicide through education and technology. Clinical Nurse Specialist. 31, 5, 268-275. doi: 10.1097/NUR.0000000000000322
  12. Stone DM, Simon TR, Fowler KA et al (2018) Vital signs: trends in state suicide rates – United States, 1999-2016 and circumstances contributing to suicide – 27 states, 2015. Morbidity and Mortality Weekly Report. 67, 22, 617-624. doi: 10.15585/mmwr.mm6722a1
  13. The Joint Commission (2019) National Patient Safety Goal for Suicide Prevention. http://jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_18_suicide_prevention_hap_bhc_cah_11_4_19_final1.pdf (Last accessed: 11 March 2024.)

Share this page

Related articles

Emergency assessment bay for cancer patients
The annual Quality in Care (QiC) Excellence in Oncology...

Focus on patients with a family history of cancer
The breast cancer risk assessment service (BCRAS) at Guy’s...

An assessment of the value of music therapy for haemato-oncology patients
The aim of this service evaluation was to assess the value...

Assessing the benefits of social prescribing
Social prescribing provides GPs and other healthcare...

Management of patients with low-risk febrile neutropenia
The National Institute for Health and Care Excellence in the...