Train-the-Trainer Training

1. Screening Saves Lives! Train-the-Trainer Training Barry N. Feldman, Ph.D. ED-SAFE Training Director

2. Goal and Objectives • Goal: • Provide content to ED-SAFE trainers to train front-line ED staff to use the Patient Safety Screener • Objectives: • Discuss importance of attitudes/ values about suicide • Provide material for brief overview of suicide and importance of ED screening • Explain the ED-SAFE Patient Safety Screener • Present some common patient scenarios • Discuss some concerns re: universal screening Screening Saves Lives

3. Patient Scenario: Missed Chance Tom is a 51 y.o. with multiple minor trauma secondary to MVA. Alert, oriented, conversant. Treated for trauma, then discharged from ED. One week later, found dead by his neighbor. He had hung himself in his garage. The MVA was an unrecognized suicide attempt. Could Tom’s suicide have been prevented? Screening Saves Lives

4. Values and Attitudes About Suicide

5. Values and Attitudes • Values are beliefs and attitudes that guide actions • Values can often influence our decisions when decision-making powers are tested • “Clinical judgments and professional behaviors to a large extent are shaped by attitudes ” (Knesper, 2010) • You may have strong personal values, attitudes, and emotional reactions to suicide Screening Saves Lives

6. Common Attitudes and Reactions Toward Suicidal Individuals • They are weak • They are cowards • They are selfish • They are wasting ED resources • Anger • Pity • Fear • “Planting the idea” by asking patient about suicide • Could I get to that point someday? Screening Saves Lives

7. Screening Addresses Ambiguity “Nurses in the emergency department often are unclear about which types of patients are most vulnerable to suicide and focus more on the physiologic assessment rather than the psychosocial assessment that may give clear warning signs of suicidal ideation.” Screening Saves Lives

8. ED Front-line Staff Often lack formal mental health training Often do not have confidence in psychological assessment and intervention skills May often be uncomfortable treating this patient population Therefore, evaluations of suicidality may be particularly stressful or avoided Screening Saves Lives

9. Background on Suicide

10. Non-Suicidal Deliberate Self-Harm • Intentional self-injurious behavior without evidence of intent to die • Methods may include: • Self-cutting • Self-battering • Taking overdoses • Showing deliberately reckless behavior Screening Saves Lives

11. The Full Spectrum of Suicidality Ideation Attempts Survivors While it is virtually impossible to estimate empirically, we believe that literally millions of American have suicidal thoughts. It is estimated that there are approximately 816,000 suicide attempts per year in the U.S. If every suicide immediately affects 6 family members or friends, then 1 out of every 59 Americans loses someone to suicide each year There are an estimated 180,000 new “suicide survivors” each year in the US. Screening Saves Lives

13. Universal Suicide Screening in Emergency DepartmentsWhy screening is necessary

14. EDs: “Revolving Doors” for Suicidal Patients • Attempt survivors can be at greater risk for subsequent attempt(s) with more lethal means • Up to 25% of suicide attempters seen in ED will re-attempt (Beautrais, 2004) • 5-10% of attempters will eventually complete suicide (Owens et al., 2002) • Up to 39 % of people who later die by suicide will have attended an ED within year before their death (Gairin et al., 2003) • The majority of these visits are unrelated to suicide Screening Saves Lives

15. Suicide Risk in the ED Suicidal ideation common in ED patients who present for medical disorders Study of 1590 ED patients showed 11.6% with SI, 2% (n=31) with definite plans 4 of those 31 attempted suicide within 45 days of ED presentation Screening Saves Lives

16. The Joint Commission: Elements of Performance Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide Address the patient’s immediate safety needs and most appropriate setting for treatment When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as a crisis hotline) to the patient and his or her family http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=166&StandardsFAQChapterId=77 Screening Saves Lives

17. The Joint Commission Universal screening is not mandated by JC; only screening and assessment for people presenting with primary emotional or behavioral disorders However, universal screening is often viewed as providing a “safety net,” and is generally viewed positively by JC Screening Saves Lives

18. Benefits for Nurses and Clinicians “...having (a) screening tool was much preferred to the previous method of judging by intuition when and how to ask about suicidal behavior” With proper structured tools to guide them, non-mental health clinicians can increase their confidence and lower barriers to asking about suicidality Screening Saves Lives

19. Precedents for Universal Screening • Vital signs (e.g., blood pressure) • Routine assessment with all medical encounters • Not commonly done at all medical visits until the 1970s • Identification of possible hypertensive emergencies and other vital sign abnormalities that could affect patient outcome (i.e., hypotensive) • Potentially devastating consequences Screening Saves Lives

20. The Screening Tool: Patient Safety Screener

21. ED-SAFE Screening Method • 3-item screener • Question 1: Depressed mood - PHQ-2 • Question 2: Thoughts of killing yourself - C-SSRS • Question 3: Lifetime suicide attempt - C-SSRS • If yes, Question 4: How recent? • Positive screen • Question 2=Yes (or) • Question 3=Yes and Question 4=attempt within last 6 months Screening Saves Lives

22. Introductory Script “Because some topics are hard to bring up, we ask these same questions of everyone.” Rationale: To help reduce likelihood of a negative reaction to the screener questions To foster a non-threatening approach Use this segue as the introduction to administering the Patient Safety Screener Screening Saves Lives

23. Screen: Over the Past 2 Weeks… Item 1: Have you felt down, depressed or hopeless? Yes = Depressed mood Rationale: • Provides additional segue into the suicide questions • Depression is most common diagnosis associated with suicide • In the elderly, depression can be mistaken for natural effects of aging • In the young, depression may be masked by acting out behavior or hyperactivity • Physical distress can be a manifestation of depression • Hopelessness found to predict suicide ideation , attempts and completion Screening Saves Lives

24. Screen: Over the Past 2 Weeks... Item 2.Have you had thoughts of killing yourself? Yes = At least active ideation, general thoughts, requires assessment Rationale: Intent to die is the type of ideation thought to be most predictive of suicide Thoughts of suicide precede suicidal behaviors Determining presence of ideation key in suicide risk screening Screening Saves Lives

25. Screen: Previous Suicide Attempt Item 3. Have you ever attempted to kill yourself? Yes = Lifetime attempt (best single predictor) Rationale: People who have a history of suicide or self-harm fall within the high-risk group for suicide 30% to 40% of persons who complete suicide have made a previous attempt Suicide attempters have a high incidence of mortality, risk of repetition is highest immediately after the attempt and repetition is positively associated with subsequent suicide Screening Saves Lives

26. Screen: If “Yes” To Item 3 If positive for attempt by history, ask: “When did this last happen?” Within the past 24 hours (including today)? Within the last month (but not today)? Between 1 and 6 months ago More than a six months ago Recent attempt = If positive for attempt within 6 months Screening Saves Lives

27. Patient Safety Screener—Ambiguous Responses Screening Saves Lives

28. Suggestions for Screening Patients for Suicide Risk

29. When Screening Patients for Suicide Risk • Avoid acting “like a robot” while conducting screening • Important to convey you are interested in what patient has to say • Be empathizing, accepting, and understanding • Be non-judgmental re: patient’s history, situation, beliefs, sexuality, actions • Show you care with compassion, tone, and rate of speech • Be fully-attentive • Use appropriate active listening techniques Screening Saves Lives

30. Listening Techniques • Verbal & Non-Verbal Nodding • Verbal “Nodding” • Uh-huh • Oh my • Okay • Non-Verbal Nodding • Nod your head • Show compassion in facial expressions • Body language Screening Saves Lives

31. Listening Techniques • Validations - A statement that “validates” the person’s experience. • “That sounds really rough” • “That sounds upsetting” • “It seems like you have been going through a lot” • “I’m sorry to hear that” • Basic premise – listen without passing judgment or giving advice • Often best way to de-escalate someone in crisis Screening Saves Lives

32. Screening at Triage vs. Universal Screening

33. ED-SAFE Screening Patient Safety Screener not to be used with Children/Teens Patient Safety Screener was not specifically designed or validated with children/teens Children/teens can be screened in a manner decided by the site Screening Saves Lives

34. Intoxicated Patient Patient is intoxicated If the patient is currently intoxicated, but a clinical interview is initiated, the Patient Safety Screener should be administered per standard protocol Once the individual is clinically sober, the Patient Safety Screener should be re-administered If the patient is intoxicated but a clinical interview is not initiated until the individual is clinically sober, then the Patient Safety Screener should be administered at that point Screening Saves Lives

35. Other Patient Presentations • Patient is claiming to be suicidal but the clinical staff suspect it is simply to get into inpatient care • Patient is a prisoner or under state custody • Patient is a high utilizer of the ED • Patient is an active duty military service member or a veteran • Answer is the same: screen them in the same manner as you’d screen those who do not present this way Screening Saves Lives

36. Patient Scenarios

37. Scenario 1: Intoxicated Patient Bill, aged 42, is brought to the ED in police custody to be ‘checked out’ after driving his car at low-speed into a shallow ditch. Vital signs are within normal limits. He has no visible injuries but appears intoxicated, unable to keep his balance, slurred speech, glassy eyes and strong ETOH breath odor. During the patient safety screener, his eyes are closed and his responses are unintelligible. What would be the next step for completing the Patient Safety Screener? Screening Saves Lives

38. Scenario 1: Key Points • Bill was intoxicated at time of screening • Multiple risk factors and warning signs: • Middle aged-male • Intoxicated • In police custody • MVC as failed suicide attempt? ED-SAFE Protocol: • Patient should be re-screened when clinically sober Screening Saves Lives

39. Scenario 2: Collateral Information Sue, 30, is a walk-in accompanied by her sister for evaluation of an infected wound on her thigh. She is alert and oriented, takes no meds. Vital signs are WNL. Sue states she was preparing a sandwich and “the knife slipped”. There is a similar, healed wound on her other thigh; she shrugs her shoulders and does not respond to inquiry about the injury. Her sister states she is worried about Sue, who has missed a lot of work after the breakup of her marriage a few months prior. A few days ago Sue said that she “just can’t do it anymore”. How would this information relate to Sue’s responses to the Patient Safety Screener? Screening Saves Lives

40. Scenario 2: Key Points Patient denies previous suicidal behavior Patient’s denies current injury represents a suicide attempt Patient’s sister provides key information ED-SAFE Protocol: Although this may be a ‘negative screen’, because there is additional information suggestive of suicide risk, this indicates the need to follow standard risk management protocols Screening Saves Lives

41. Scenario 3: Ambiguous Patient Fred, 68, lives alone since his wife died 6. mos. prior, and is driven to the ED by his daughter, who thinks he may have accidentally taken too much blood pressure medicine today. When preparing his weekly medication holder she noticed ‘3 or 4 pills were missing’. He is pale, dry, with a low BP and heart rate around 50, however he is mentating well and denies pain or difficulty breathing, stating he is “a little dizzy”. He is unsure how much medication he took today and is embarrassed by the fuss his daughter is making. Fred states, “I’ve just been such a burden to everyone since my wife died”. What would you do about Fred ? Screening Saves Lives

42. Scenario 3: Key points • Multiple risk factors and warning signs: • Elderly male • Recent widower • Access to means • Indirect verbal clue – “I’ve been such a burden…” ED-SAFE Protocol: • Although this may be a ‘negative screen,’ because there are additional factors suggestive of suicide risk, this indicates the need to follow standard risk management protocols Screening Saves Lives

43. Suggested Responses for Concerns about Increased Psych Utilization

44. A Legitimate Concern! • ED-SAFE Study PIs concerned about this, too • We’re monitoring it at all 8 sites • If our intervention leads to a marked increase in psych consults, and slows the ED down, then it is highly unlikely to be adopted in clinical practice Screening Saves Lives

45. To Help Mitigate This Concern • Patient Safety Screener questions very carefully chosen • Positive screen only occurs if the individual is actively suicidal or has had a recent attempt (past 6 months)   • Represents a relatively high threshold • Would avoid identification of mild cases, like those with only passive ideation Screening Saves Lives

46. Universal Screening Already Happening Many EDs already do it, and have not found dramatic increases in psych consults or ED clogging Cooper Hospital example Screening Saves Lives

47. Patient Scenario: Successful Save Brenda is an 18 y.o. with CC of headache for 3 days. Alert, oriented, conversant. Screened for suicidal ideation by primary nurse. Admitted to current active ideation, previous attempt 2 months ago. Psychiatry consulted, provided with MH appointment. Received treatment for depression, anxiety. Reduced suicidal thoughts, improved psychological and overall functioning. Screening Saves Lives

48. In Summary– This Training • Provided content and materials for ED-SAFE trainers to train their front-line ED staff to use the Patient Safety Screener in Phase 2 of the study. Screening Saves Lives

49. Comments and Questions Screening Saves Lives