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New set of emergency department standards may help identify patients at high risk for suicide

Christopher Palmer, M.D.
MinnPost photo by Andy Steiner
Christopher Palmer, M.D., medical director of North Memorial Health Hospital’s ED, says that he considers suicide-risk screening to be a form of preventive medicine.

It’s a common scenario in emergency departments (EDs): A person comes in complaining of a painful stomachache, a crushing migraine or another acute medical condition. While health care providers work to address the patient’s physical symptoms, further observation reveals that there’s more going on than meets the eye — the physical pains that brought the individual into the ED are actually signifiers of deeper psychological pains.

In the not-so-distant past, busy ED providers may have discharged patients like this after addressing their physical ailments: The psychological roots were someone else’s problem. But today, with more and more people turning to EDs for mental health care, and state rates of suicide up by 40.6 percent since 1999, Minnesota emergency medicine providers are acknowledging that change needs to happen.

This spring, members of MN Health Collaborative, a group of state health care organizations convened by the Bloomington-based Institute for Clinical Systems Improvement (ICSI), announced a new set of shared standards designed to address suicide prevention and intervention in Minnesota’s EDs.

One key element of the recommendations is establishing a set of screening tools that emergency health care providers can use to determine if patients — even those who come in for seemingly unrelated issues — are at risk of suicide.

The group’s focus on EDs is intentional: According to studies published in The British Journal of Psychiatry and Emergency Medicine Journal, 40 percent of patients who die by suicide were seen in an ED within 12 months of their death. By screening ED patients for suicide risk and offering mental health treatment when appropriate, Collaborative members hope to reduce suicide deaths statewide.

Suzanne Witterholt, M.D., a psychiatrist and medical director for mental health practitioners in Allina Health’s EDs, said she believes that standardizing suicide-risk screenings may help save lives.

“Most people who kill themselves have seen a health care provider in the weeks before they die,” she said. “Screening is a mechanism that might help catch something early, before someone dies.”

Suzanne Witterholt, M.D.
Suzanne Witterholt, M.D.
Christopher Palmer, M.D., medical director of North Memorial Health Hospital’s ED, said that he considers suicide-risk screening to be a form of preventive medicine.

“The goal would be to use these screenings to catch people prior to their being in serious crisis,” Palmer said. “Similar to screening for cancer or diabetes, if you wait until somebody manifests the worst of their symptoms, the amount of effort and resources required to put them on a corrective action is markedly more intensive. This type of screening has the potential to catch people that otherwise may get past and commit suicide.”

Last year, North Memorial’s ED adopted a universal screening policy mandating that all patients, except those admitted with acute, life-threatening conditions, should be screened for suicide risk.

Patients whose screens show that they are at risk of suicide are presented with options for follow-up mental health care.

“We try to create warm handoffs where we can set up outpatient appointments for people,” Palmer explained. “At North Memorial, we have the benefit of being a larger facility and having access to psychiatric physicians who assist us with long-term ED and help prescribe medicines if that’s what’s needed. And we have a partial hospitalization program that we can get people into with reasonable functionality.”

This “warm handoff” approach is a central component of MN Health Collaborative’s new suicide prevention standards, said Claire Neely, M.D., ICSI president.

“Screening is important, but it is not enough,” she said. “We are working to improve how we also intervene in the ED and prevent suicide deaths.” 

Another avenue for intervention at North Memorial is a partnership the hospital has forged with Vail Place, a clubhouse and community center for people with serious and persistent mental illness. When a North Memorial patient is identified as being at risk for suicide, North Memorial ED providers can set up appointments for follow-up care with social workers at one of Vail Place’s two Twin Cities locations. The appointments are scheduled within 24 hours of hospital discharge.

Ruth Johnson, LICSW, clinical services manager at Vail Place, said that her nonprofit’s collaboration with North Memorial means that people in serious mental health crisis will have a support system that they may have been missing.

“I think every human benefits from having someone in their corner, some sort of cheerleader, someone to support them,” she said. “Hopefully we can do that for people.”

Benefits of universal screening

Instituting a universal screening policy may sound like an overreaction, but Palmer said that he and his colleagues have seen too many situations where people at high risk for suicide come into the ED complaining of conditions seemingly unrelated to their mental health. Without screenings, those patients may get overlooked.

“You’re surprised at times by the answers you get to questions from people with unrelated or seemingly unrelated complaints,” Palmer said. Asking patients a series of simple screening questions helps a care provider quickly get beneath the surface. “With a screen,” Palmer said, medical professionals are able to unpack patients’ stories, to see the truth that lies just beneath the surface, and, he added, “to prevent a catastrophe.”  

This takes us back to those ED patients with migraines and stomachaches. Common physical ailments are also common symptoms of mental illness.

“People often manifest their mental anguish and emotional state in physical complaints that take them to the ED,” Palmer said. “It’s a fairly common response.” This is where screening can be helpful: “If you can ask those questions early, sometimes you can get past the initial barriers and get to treating the root cause.” Sometimes a stomachache is just a stomachache. Other times it’s more.

Establishing universal screening standards helps ensure that people don’t fall through the cracks, Johnson said. Not everyone is able or willing to articulate the depth of their psychological pain. Screening questions can make it clear.

“I think that when you go to the emergency department you are interacting with health providers there because you want some sort of help,” Johnson said. “You don’t always volunteer that you have a mental health condition or you are experiencing suicidal ideation.”

At North Memorial, screening is typically conducted early in the course of the ED visit, and usually done by a nurse or physician’s assistant.

“The appropriate timing of the questions is paramount,” Palmer said. “Our nursing staff does a very good job of introducing the why of asking the questions. Certainly there are a few people who are taken back by them. Sometimes people refuse to answer, which is perfectly fine. But as a whole most people answer our questions easily and appropriately.”

Ruth Johnson LICSW
Ruth Johnson
The screen usually lasts just a few minutes. The care provider asks the patient a list of screening questions based on the Columbia Suicide Severity Rating Scale (C-SSRS).

“It starts with questions like, ‘Have you ever wished you were dead?’” Palmer said. “Many people answer yes to that first question. It’s not an uncommon feeling. Further questions escalate the risk stratification.”

A yes answer to subsequent questions, like, “Have you ever thought about how you would kill yourself?”; “Have you decided how or when you would kill yourself?” or “Did you ever do anything to try to kill yourself?” add to the patient’s risk level, Palmer explained.

“The tool itself is actually pretty simple,” he said. “It’s not a treatment tool. It’s not a diagnostic tool. It’s a screening tool. And 80 percent of patients are going to screen out in two questions or less. If the first few answers are no, we take a patient off the risk grid.”

During the screening process, a provider may discover an opportunity for further evaluation and discussion, Palmer said. “If we feel that the main thing that we really need is additional patient resources and referrals, we would do that. If they need a more in-depth evaluation, then we have behavioral health specialists in our ED and they would do a more comprehensive visit and help determine next steps.”

Policy in some EDs is to only screen patients who have already been identified as behavioral health clients, Witterholt said. She supports the universal screen approach.

“By starting with everyone who comes in, by trying to make sure we don’t miss someone who might be already down that road, we greatly reduce our chances of missing someone,” Witterholt said. And research has shown that screening questions don’t give people ideas that weren’t already in their heads, she added: “Asking people if they want to kill themselves doesn’t increase their chance of suicide. If a screening uncovers that a person is having suicidal thoughts and you respond appropriately with ways of helping them get through, you have opened up a chance for their survival.”

Follow-up saves lives

All the suicide-risk screening in the world won’t make a significant dent in suicide rates if it isn’t tied to long-term follow-up programs, Palmer said. A patient identified as at risk for suicide needs to be connected to appropriate programs that can help them find reasons to want to keep living.

The North Memorial/Vail Place partnership tries to do just that. By connecting ED patients with Vail Place social workers, they are building a bridge to the world outside of the hospital. In the community, patients become people, and that’s where the real healing can begin.  

In the past, ED staff wasn’t always aware of all the outside support options that exist for people struggling with mental illness, Johnson said. The new partnership offers high-risk patients discharged from the ED 2-4 months of services that help connect them with community-based providers.

“This partnership has been innovative,” Johnson said. “It has improved our collaborative communication between North Memorial’s ED social workers and behavioral health staff. Now they are more familiar with us as community partners. They understand that we might be able to step in and provide extra support. It has globally improved communication and collaboration between North Memorial and Vail Place, hopefully to the betterment of someone’s life.”

After ED discharge, the risk of suicide increases, so community connections are key, Johnson said.

“If there is better collaboration between the ED and an organization like Vail Place, people get better help overall,” she said. “The ED staff is not going to come out and make sure a person is taking their medications. Their job ends at discharge, and that’s when our job begins.”

Vail offers wraparound supports for clients, including emotional support and building connections with key community service organizations.

“What we try to do is work on two different levels,” Johnson explained. “The ED is such a short-term service. Their focus is on what is happening right now. There is this huge gap for many patients after discharge. We try to fill that.”

Palmer said that the partnership with Vail Place helps his ED staff feel better about sending a patient in mental health crisis home.

With the right referrals to appropriate community-based organizations, Palmer said, “There are people who are suicidal who may be safely discharged. Suicidality is not a chronic condition for most folks. It’s a transient response to a particular situation. If you can help people connect with resources that could help them resolve that situation in a way that suicide is no longer the answer, then they can be redirected back to get care for that chronic condition.”

The impact on EDs

The marked increase in patients with mental illness has caused staff at many of the state’s EDs to rethink the way they do business.

“You can look at trends in emergency departments,” Witterholt said. “Of the population of people coming in we’ve had a surge in the last 10 years of patients with mental health or behavioral health problems. More people are coming to the ED as a place to help with their crises because they don’t know where else to turn. We want to be prepared to help them.”

Palmer has worked at North Memorial’s ED for 16 years. When he started, there was just one room set aside for patients needing special observation or treatment for mental illness. “It was frequently vacant,” he said.

But in recent years the number of people coming to North Memorial with mental health concerns has grown. “When we remodeled our ED in 2005 or so we went to two mental health rooms with several other rooms that could flex back and forth,” Palmer explained. “Our capacity continues to outgrow that. Based on volumes, we’ve needed to make physical changes to other rooms in order to be able to use them for safe management for patients who may be at risk of harming themselves.”

Treating mental illnesses in the ED “slows everything down,” Palmer said. “It takes much longer to do an evaluation for a mental health condition than it does for a physical health condition.” Because of that, staff members in his department sometimes struggle to make sure that all patients are cared for appropriately.

“It is certainly taxing on caregivers, nurses, techs and other providers to see people in continued mental crisis and feel a bit handcuffed in the resources we have to actually intervene,” he said.  

Palmer believes that the increase in mental health cases in EDs is a sign of a larger societal crisis, one that may be harder even than opioid epidemic to turn around. With opioids, at least, prescribers can cut the number of pills they offer to patients. But there is no obvious way to heal people’s mental anguish.

“All of us in the health care profession chose it because we wanted to improve the quality of life of patients,” Palmer said. “If you don’t feel like you’re seeing that impact, it can be challenging to see the reward on the opposite side.”

Palmer said that working with other health care leaders to establish shared standards through MN Health Collaborative gives him a bit of hope for the future.

“It has been a nice step forward,” he said. Collaboration across a broad spectrum of providers, “makes movement a little bit more challenging, but when you finally come together, you can make broader strokes toward improvement, and that’s an encouraging step.”

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