Summary
- Health care providers have the opportunity to prevent suicide attempts and deaths by suicide. An American Foundation for Suicide Prevention-funded Learning & Action Network (LAN) has identified ways to support clinicians in closing the “know-do gap.”
Most people who attempt suicide are seen by a health care organization in the year before their death, most frequently in primary care or other outpatient medical settings. Nearly a third of those who die by suicide see a primary care physician or outpatient specialist in the week before their deaths.
With three testing partner organizations — Bon Secours Mercy Health, Ascension Health, and Providence Health — the Institute for Healthcare Improvement (IHI) identified three key drivers for initial focus: universal screening, lethal means counseling, and safe and timely transition to evidence-based treatment.
The following vignettes illustrate the impact that reliable implementation of recommended processes can have on the lives of patients and their families. All names and some details have been changed to protect patient anonymity.
Cecily arrived at the Emergency Department (ED) at Bon Secours Mercy Health Springfield, Ohio with mental health concerns: a friend noticed erratic behavior and expressions of paranoid thoughts and brought her in for evaluation. As is standard at Bon Secours Mercy Health, Cecily was screened using the Columbia Suicide Severity Rating Scale (C-SSRS) and was found to be at moderate risk, prompting the team to ask about her access to lethal means, including firearms, medications, sharp instruments, or other ways a person can inflict self-directed violence. She reported having no lethal means in the home and indicated she had no concerns about being discharged from the ED.
Though Cecily was medically cleared for discharge, an Emergency Department nurse involved in her care was concerned about sending her home. She had a sense that Cecily was not being fully forthcoming about her access to lethal means. She brought her concern to the attending physician and together they consulted a staff psychiatrist for decision support. Together they agreed that they should take further steps to protect Cecily in the short term. The nurse told Cecily that she was concerned about her safety and support and asked if she could phone her mother who was listed as her emergency contact. Cecily agreed. When reached, her mother reported that she shared concerns about her daughter’s safety because Cecily lived alone and had a firearm in her home.
In consultation with Cecily and her mother, the team recommended that Cecily be admitted under observation to allow time for a family member to secure the firearm. Cecily was able to return to a safer home environment during this difficult period, and due to the successful engagement of her mother during her ED visit, her family was aware of her need for additional support in the near term.
While we will never know what would have happened if the team at Bon Secours Mercy Health did not fully engage Cecily in lethal means counseling and family engagement, we do know that Cecily was discharged to a safer home. In addition to the multidisciplinary approach and family engagement, it is worth noting that the nurse with additional concerns had a team that supported her clinical judgement and experience. Their commitment to providing excellent care beyond the “requirement” was essential.
Support in the Primary Care Setting
Alex arrived at a Bon Secours Mercy Health Primary Care office in crisis. A clinician determined that, while Alex did not require further medical intervention, he was at moderate to high risk for suicide and should be admitted to an inpatient behavioral health setting. Typically, Alex and primary care patients like him would be advised to visit a local emergency department as an intermediary step to accessing further behavioral health support. Instead, as part of their work in the LAN, the Bon Secours Mercy Health team facilitated direct admission to an inpatient behavioral health setting, avoiding an unnecessary emergency department visit.
There are many benefits to direct admission. Most importantly, Alex received care from a behavioral health specialist without delay. He also avoided the extended wait and busy environment of an emergency department which could have exacerbated his agitation or anxiety. Also, with direct admission, there was no duplicative medical work-up in the ED as the primary care team sent their medical evaluation to the receiving inpatient team.
One hiccup occurred that was instructive for further testing of direct admission. The inpatient setting required a COVID test for admission and no rapid tests were immediately available. This led to a slight delay. Now the team is making rapid test availability standard. They also noted that it is helpful to speak directly with inpatient providers about the new process and address their concerns about direct admission.
The team is working to further test their direct admission workflow, including refining direct admission guidelines, and hope to spread the process to other primary care sites in the future.
Background
At the request of the American Foundation for Suicide Prevention (AFSP), IHI facilitated a Learning & Action Network with three health systems to test and refine a theory of change and implementation guidance for health care organizations to prevent suicide. The theory of change was developed by the IHI Innovation Team, with support from the AFSP, in a previous phase of work.
If you are in a crisis, please call or text 988 or text TALK to 741741.
Joelle Baehrend, MA, is a Senior Project Director at the Institute for Healthcare Improvement.
Photo credit: shapecharge, iStock
You may also be interested in:
How Health Care Can Help Prevent Suicides (about what was learned in the innovation phase of this work)
Resources from the American Foundation for Suicide Prevention