Universal Screening Can Help Identify People at Risk for Suicide

Parkland Health & Hospital System in Dallas is one of the country’s largest public hospital systems, serving more than 1 million patients annually in the hospital and providing care at more than 20 community- and school-based clinics throughout the region. In 2015, Parkland was the first health system in the country to implement a universal suicide screening program across its facilities.

Courtesy of Dr. Kimberly Roaten

Kimberly Roaten is a licensed psychologist, professor of psychiatry at the University of Texas Southwestern Medical Center, and senior fellow for suicide prevention at the Meadows Mental Health Policy Institute. She’s also the director of quality for safety, education, and implementation in the Department of Psychiatry at Parkland Memorial Hospital and leads Parkland’s universal suicide screening program.

This interview has been edited for length and clarity.

Q: Why did Parkland Health & Hospital System implement universal suicide risk screening?

A: Parkland made the commitment in 2015 to expand suicide risk screening beyond the minimum requirements to improve patient safety and care. We recognized that many individuals who die by suicide have encounters with primary care or emergency medicine providers in the months before their death, and the risk is often undetected. In fact, people who die by suicide are more likely to be seen by primary care or emergency providers than by psychiatric clinicians—so if we limit our screening to patients seeking mental health treatment, we miss an opportunity for detection and prevention.

Q: What does “universal screening” mean to Parkland Health & Hospital System?

A: It means that we use a brief, standardized, evidence-based tool to screen every patient for suicide risk at every provider encounter, regardless of whether the patient is seeking care for psychiatric symptoms.

Q: How many people have been screened since the program began in 2015?

A: On average we screen 18,000 to 20,000 patients each month in our emergency department, urgent care, and inpatient units—and more than 25,000 in our 20 outpatient primary care clinics. We’ve completed nearly 4 million screenings to date.

Q: Who does the screening?

A: The screenings are typically completed by nursing staff during the triage or check-in process. If a patient is unable to complete the screening during the initial portion of the encounter, the electronic health record continues to display reminders until the questions are answered.

Q: What obstacles did you face when you began implementing this universal suicide risk screening?

A: Because this was the first program of its kind, one of the biggest challenges was that we didn’t know how many patients would screen positive for suicide risk. That made it difficult for us to estimate the resources that would be required.

Q: How did you address that challenge?

A: The key was embedding a clinical decision support system in our screening process in the electronic health record. That allowed us to quickly and efficiently deploy the appropriate resources for each patient without overusing or misusing intensive interventions, such as one-to-one observation.

We also identified ways to better utilize our existing staff to respond to and care for people who screened positive. For example, we recognized that our social workers have the expertise to respond to many patients with suicide risk, but they were being underused. So we collaborated with our social work leaders to create a standardized clinical response plan they could execute following screening. This step really optimized their skills and system resources while effectively connecting patients with the level and type of care they needed, based on their risk screening.

Q: Were there other challenges?

A: Initially, providers and staff members were hesitant to incorporate suicide screening into routine care for nonpsychiatric patients. Many were concerned about the patients’ potential reactions to suicide screening questions, particularly among pediatric patients.

Q: How did you respond to that one?

A: We helped our staff understand the prevalence of suicide risk among all patient populations, the data indicating that screening does not lead to increases in suicidal ideation or suicide attempts, and strategies for educating patients and their families about the process.

And once they had experience with the brief questionnaire and the standardized clinical response, their comfort level increased significantly. We also found that support grew once we were able to share “good catch” stories—instances where, without universal screening, a patient wouldn’t have received the help they needed.

Q: Those anecdotal good catch stories are important. And what about the data: What numbers do you have on the impact of universal screening on patient outcomes?

A: We’ve identified suicide risk in approximately 2.3% of pediatric and adult patients seeking nonpsychiatric care, a group that would have previously gone unrecognized. The vast majority of patients who screen positive are able to be discharged after receiving additional assessment and connection to outpatient behavioral health resources. Beyond that, we are also starting to collect state mortality data to examine long-term clinical outcomes and identify any areas of the program that might need improvement.

Q: What advice do you have for other hospitals that want to address suicide risk among their patients?

A: I would say, first, start using an evidence-based tool for suicide risk screening. Two of the most commonly used tools, the Ask Suicide-Screening Questions and the screener version of the Columbia-Suicide Severity Rating Scale, are brief, and they improve the quality of risk detection. To ultimately get to universal screening, it may be helpful to begin by expanding screening in clinical areas with patient populations at greater risk and identify clinician champions who are willing to help lead the universal screening implementation process.

Q: What about the resource question that a hospital may face?

A: Many health care systems have already implemented more robust screening practices and publicly shared their data about positive screening rates in a variety of settings and clinical populations, making it easier for other health systems to estimate what resources they’ll need. Hospitals must also thoroughly assess their existing resources to determine where there might be opportunities to use existing staff and expertise before adding additional personnel.

Q: A final word? 

A: Ultimately, education within hospitals and health systems is the key for raising awareness about the importance of suicide risk detection—and for allaying fears about changes to workflow, resource use, and patient responses.