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Bringing universal suicide screening to your hospital

With suicide rates high and getting higher, hospitals and clinics need to revamp how they work with suicidal patients. The first step is developing a system to identify struggling patients so they can get the care they need.

In 2014, the Parkland Health and Hospital System (PHHS) in Dallas became the first in the nation to establish a universal suicide screening program (SSP) in all its departments. The program screens every admitted patient for suicidal ideation, regardless of the patient’s chief complaint or estimated risk. The screening is incorporated into PHHS’ electronic health record (EHR), and the entire staff have been trained on suicide screening and prevention.

Since the go-live, PHSS has achieved almost 100% program compliance, screened over a million patients, collected invaluable suicidal ideation data, and helped countless patients get the care and treatment they need—all without slowing down hospital workflow or straining resources.
Celeste Johnson, DNP, APRN, PMH CNS, PHHS director of nursing and psychiatric services, and Kimberly Roaten, PhD, director of quality for safety, education, and implementation in the system’s department of psychiatry, were the driving forces behind PHHS’ universal SSP. The two presented an HCPro webinar on the topic in February (visit for more information).

“There’s many people out there who’ve contemplated suicide who may not voice that when they’re coming in for a medical complaint,” said Johnson. “We’re missing a lot of folks who are coming to us every day. That’s what the research shows.”

Suicide numbers 
According to the CDC, suicide is the seventh leading cause of death for American men, the 14th for American women, and the 10th overall. In 2013, the agency found that 9.3 million adults had suicidal thoughts, 1.3 million attempted suicide, and 41,149 died. In addition to the loss of life, suicides cost $51 billion annually in combined medical and work costs. Even more worrying is that the rate of suicides has increased 24% between 1999 and 2014.

At the healthcare level, there’d been limited information on the number of patients considering suicide who were seeking treatment for other issues. In that regard, the data gathered at PHHS has been eye-opening. Out of the 502,000 patients who visited the health system in 2015, 14,900 were screened as moderate suicide risk, and 5,249 were high risk. That's equal to one out of every 25 patients experiencing suicidal thoughts.

PHHS also found that people who commit suicide often have contact with the healthcare system before their deaths. Within the year prior to their death, 77% of people who committed suicide have contact with a primary care physician, 40% have contact with an ER physician, and 24% have contact with a mental health provider.

Pitching the idea
Roaten said a major concern for most facilities is that implementing universal screening would overload their systems—specifically, it would slow down hospital treatment times and expend resources to provide one-on-one observation for high-risk patients. These were concerns that leadership at PHHS had back in 2012, when Johnson and Roaten first proposed a universal SSP. 

“When I first suggested this, they asked me, ‘You’ve done a dissertation on suicide risk assessment (SRA); what do you think we should be doing?’ ” Roaten said. “And I said, ‘I think we should screen everyone.’ And the response was very clear: ‘Absolutely not.’ The medical director of the emergency room at the time said, ‘You will close us down if you try that.’ ”

The idea was revisited two years later after a Joint Commission survey cited PHHS for not completing an SRA on an inpatient with a history of substance use. Now with the support of administration, the system immediately started working on its universal SSP in August 2014.
“The conversations would get quite complex about resources and IT bills and all sorts of things,” Roaten said. “But fundamentally, at the end of the day, what works best is something easy to understand and follow. And that’s a mantra that we carried with us throughout the creation of this program.”

Since implementing its program, PHHS has conducted over 1 million screenings, without any delay in treatment or burden on resources. And by making the screening part of the electronic health record (EHR), they’ve sustained a 98% compliance rate. Roaten said they were only expecting 90% when they first started, but they’ve been able to do even better. 

“We gamed the system because we created a screening that you can’t skip,” she said. “So our compliance is really over 99% across the system, but that’s because we won’t let people be noncompliant.” 

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