Suicide ranks as the 11th leading cause of death in the United States, claiming 48,183 lives in 2021 alone—equivalent to one life lost every 11 minutes. For us, as clinicians, suicide prevention starts in our emergency department, where at-risk individuals often seek help in the days or weeks leading up to a suicide attempt. Unfortunately, in the ED, the opportunity to screen for suicide risk can be overlooked due to high patient values, the assumption that mental health is for psychiatry, or because we see the same patient multiple times. Still, screening for suicidal ideation (SI) in the ED, while challenging, can significantly improve patient outcomes and save lives.
In 2021, the CDC reported that 12.3 million adults thought about suicide, 3.5 million made a plan, and 1.7 million attempted suicide. These are alarming numbers, especially given that many patients won’t volunteer their suicidal thoughts unless prompted.
How to Identify At-Risk Patients in the ED
Many patients hesitate to share their suicidal thoughts unless specifically asked, making universal screening a critical step. While tools like the Patient Safety Screener 3 (PSS 3) and the ED SAFE Primary Screener can help identify at-risk patients, evidence on the effectiveness of universal screening versus targeting screening remains mixed. It isn’t clear if universal screening is more beneficial than a more targeted approach when it comes to identifying patients who have an elevated risk of harming themselves. Still, having a structured approach can help us ensure we’re not missing crucial signs.
We all recognize that certain risk factors, particularly substance use disorders, increase the risk of suicide. But did you know that a single ED visit for suicidal ideation puts a patient at 57 times higher risk of dying by suicide in the next 12 months? Self-harm presentations or unexplained accidents should also alert you to the potential for suicidal intentions.
ED SAFE Screening Tool: A Simple, Effective Approach
The ED SAFE screener is a standardized tool designed to identify suicide risk in the ED. It consists of two parts:
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Primary Screener: A three-question triage tool to identify patients at potential risk. A “yes” response to any question leads to the secondary screener.
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Secondary Screener: A detailed six-question assessment that evaluates intent, mood changes, substance use, and other high-risk factors, categorizing patients into:
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Mild risk (0-2)
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Moderate risk (3-4)
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High risk (5-6)
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Using a standardized screening tool like ED SAFE prompts us to ask the right questions and focus on key risk factors. The evidence is clear that screening leads to earlier intervention, safety planning, and follow-up care, all of which have been shown to reduce the risk of suicide.
Does Screening Work?
While universal suicide screening in the ED may not directly reduce patient mortality, it serves several critical functions:
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Early identification of at-risk patients
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Early identification counseling
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Safety planning and lethal means counseling, which has been shown to reduce suicide risk
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Facilitating follow-up care post-discharge, which also reduces suicide risk
Universal screening with tools like ED-SAFE isn’t perfect, but it’s a critical first step in identifying and helping at-risk individuals, paving the way for timely recognition and intervention.
Stay tuned for next month’s Emergency Medicine blog, where we’ll dive into the importance of the Medical Screening Exam in further supporting at-risk patients.
