Train-the-Trainer Training

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Train-the-Trainer Training

• Screening Saves Lives!

Barry N. Feldman, Ph.D. ED-SAFE Training Director
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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

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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 Toms suicide have been prevented?

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Values and Attitudes About Suicide
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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

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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?

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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.

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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

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• Background on Suicide

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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

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The Full Spectrum of Suicidality
Survivors
Ideation
Attempts
It is estimated that there are approximately
816,000 suicide attempts per year in the U.S.
While it is virtually impossible to estimate
empirically, we believe that literally millions
of American have suicidal thoughts.

• 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.

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Universal Suicide Screening in Emergency
DepartmentsWhy screening is necessary
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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

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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 (n31) with definite plans
• 4 of those 31 attempted suicide within 45 days of
  ED presentation

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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 patients 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_informati
  on/jcfaqdetails.aspx?StandardsFAQId166StandardsF
  AQChapterId77

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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

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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

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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

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The Screening Tool Patient Safety Screener
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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 2Yes
• (or)
• Question 3Yes and Question 4attempt within last
  6 months

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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

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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

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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

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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

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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

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Patient Safety ScreenerAmbiguous Responses
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Suggestions for Screening Patients for Suicide
Risk
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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 patients history,
  situation, beliefs, sexuality, actions
• Show you care with compassion, tone, and rate of
  speech
• Be fully-attentive
• Use appropriate active listening techniques

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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

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Listening Techniques

• Validations - A statement that validates the
  persons experience.
• That sounds really rough
• That sounds upsetting
• It seems like you have been going through a lot
• Im sorry to hear that
• Basic premise listen without passing judgment
  or giving advice
• Often best way to de-escalate someone in crisis

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Screening at Triage vs. Universal Screening

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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

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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

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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 youd screen those who do not present
  this way

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Patient Scenarios

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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?

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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

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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 cant do it anymore.
• How would this information relate to Sues
  responses to the Patient Safety Screener?

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Scenario 2 Key Points

• Patient denies previous suicidal behavior
• Patients denies current injury represents a
  suicide attempt
• Patients 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

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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, Ive just been such a
  burden to everyone since my wife died.
• What would you do about Fred ?

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Scenario 3 Key points

• Multiple risk factors and warning signs
• Elderly male
• Recent widower
• Access to means
• Indirect verbal clue Ive 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

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Suggested Responses for Concerns about Increased
Psych Utilization
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A Legitimate Concern!

• ED-SAFE Study PIs concerned about this, too
• Were 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

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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

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Universal Screening Already Happening

• Many EDs already do it, and have not found
  dramatic increases in psych consults or ED
  clogging
• Cooper Hospital example

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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.

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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.

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Comments and Questions