Early Detection Can Reduce Suicide Risk in Ambulatory Care

Purpose: To create a standardized process for screening, assessment, reassessment, and safety planning for patients who present to an ambulatory care clinic with behavioral health concerns or identify as potentially having suicidal ideation while being cared for within primary care and specialty care clinics.
Background: Suicide is the 9th leading cause of death in individuals ages 10-64 (CDC, 2022). Most people who die by suicide visit a healthcare provider within months before their death (NIMH, n.d.). In 2019, The Joint Commission updated the National Patient Safety Goals to include suicide screening. In April 2022, the hospital system successfully implemented a standard evidence-based approach to suicide screening on all non-behavioral health units, pre-procedural areas, and the emergency department. Since April 2022, the suicide prevention steering committee (SPSC) continued collaboration to expand suicide screening in ambulatory care that is scalable organization wide.
Methods: The SPSC developed an algorithm to screen for suicidal ideation for patients who present with a behavioral health concern in the ambulatory care setting. The algorithm utilizes four evidence-based tools based on patient age and current clinic workflow including the PHQ-2, PHQ-9, PHQ-A, and ASQ to assess for suicide ideation and risk. Standardized assessment and management of patients at risk for suicide was established using the SAFE-T protocol with CSSRS. Two clinics were identified to trial this new process, including one primary care office and one specialty care office. Onsite suicide screening education was provided to nurses, medical assistants, and social workers. All providers were required to view 2 training modules focused on suicide assessment. An optional Q&A session was made available for all providers to attend. For the pilot, both offices were provided with an iPad for integrated behavioral health (IBH) that allows team members to request an urgent virtual behavioral health referral for further assessment and safety planning.
Results: Over the course of two weeks, primary care completed a total of 750 PHQ-2 screens and 41 PHQ-9 screens. Of this, 33 patients scored negative for suicide ideation while 8 patients scored positive for suicide ideation. A total of 7 patients were further assessed using the ASQ and screened non-acute positive for suicide risk. No patient screened imminent risk. Two IBH referrals were made, and safety plan developed. All but one of the remaining non-acute positive patients had no active safety plan documented. Specialty care had one patient present to clinic with a behavioral health concern and scored non-acute positive for suicide risk. The patient was referred to IBH. Data collection will be ongoing and three additional pilot sites will be included for analysis.
Conclusion: The mental health crisis has escalated since the COVID-19 pandemic. Since mental health providers are at capacity, it is essential that non-behavioral health staff are appropriately trained to detect early warning signs of suicide. These pilots have demonstrated that implementation of suicide screening in patients who present to ambulatory care can be achieved with positive outcomes.