In what appears to be a first for a health system, Parkland Health & Hospital System in Dallas recently implemented suicide screenings for all patients.
The program is the first of its type in the United States, according to Kimberly Roaten, PhD, director of quality for safety, education, and implementation in the Department of Psychiatry at Parkland and associate professor of psychiatry at The University of Texas Southwestern Medical Center, also in Dallas. A clinical psychologist working with Parkland patients, Roaten is one of the leaders who developed the new program.
“The Joint Commission requires healthcare providers screen all patients with psychological problems for suicide risk,” Roaten notes. “But we believe it’s important to screen everyone because some of this risk may go undetected in a patient who presents for treatment of non-psychiatric symptoms.”
In 2014 Parkland dedicated the resources needed to make this possible. Those resources included hiring 12 psychiatric social workers, selecting a standardized and validated suicide screening instrument, building an algorithm in the electronic health record that triggers the appropriate clinical intervention depending on the patient’s answers to a few simple questions, and training all nursing staff to implement the program.
Parkland implemented suicide risk screening with all emergency department patients and hospital inpatients in February 2015, says Celeste Johnson, DNP, APRN, PMH CNS, director of nursing in psychiatric services at Parkland.
“In late May, we transitioned from the previous screening program to the standardized suicide risk screening at all Parkland community-oriented primary care health centers and also at the correctional health division for all inmates at the Dallas County Jail,” Johnson says. “Our goal is to screen every patient using proven screening tools that can help us save lives.”
Parkland has screened more than 100,000 patient encounters at the hospital and emergency department, and it has screened more than 50,000 patient visits in outpatient settings. Parkland uses the Columbia Suicide Severity Rating Scale (C-SSRS), a validated screening tool developed by Columbia University in New York City, with adults 18 and older and the ASQ (Ask Suicide Screening Questionnaire), developed by the National Institute of Mental Health in Bethesda, MD, with 12- to17-year-olds.
The Parkland algorithm sorts patients into three suicide risk categories based on their answers to the screening questions: no risk identified, moderate risk identified, and high risk identified. Those at high risk are immediately placed under one-to-one supervision, suicide precautions are implemented, and an evaluation by a behavioral health clinician is initiated. Patients at moderate risk are automatically referred to a psychiatric social worker and usually are seen during the same visit. If patients choose not to speak with a psychiatric social worker during the visit, they will receive a follow-up phone call to provide additional support and resources.
For example, a patient might come in with a sprained ankle or sore throat, but if his or her suicide risk screening shows moderate risk, Parkland’s clinical algorithm immediately alerts a member of the behavioral health team to come and speak with the patient. Before discharge, moderate- and high-risk patients also are given information about suicide warning signs, suicide crisis center hotline numbers, and Dallas County community mental health resources.
So far, the suicide risk screening in the emergency department and inpatient units at Parkland has found 1.8% of patients to be at high risk and approximately 4% at moderate risk for suicide.
“To our knowledge we are the first big hospital system in the U.S. to implement a universal screening program for suicide risk, and the data we are gathering will be significant for other organizations in the future,” Roaten says.
