Warning Signs in the Emergency Department

Life and death emergencies are typical in a hospital emergency room. Yet some crises are not readily apparent in an ER, for instance a teenager that drank too much alcohol because he is extremely depressed or a mother with such severe insomnia that she is ready to take an overdose of sleeping pills. Both are suicidal but unless the warning signs of suicide are detected, they could be discharged from the hospital without anyone knowing.

According to EDC’s David Litts, this scenario is not uncommon. “A patient might mention having not slept for days, but what they’re not saying is, ‘If I don’t get some sleep soon, I might kill myself,’” says Litts. The reality is that 1 in 10 patients in an emergency department is harboring thoughts of suicide, and many medical personnel don’t realize it.

As a result, EDC’s Health and Human Development division, in collaboration with leading emergency department doctors and nurses, developed “Is Your Patient Suicidal?” This simple, quick checklist, displayed in poster format, includes signs of suicide such as substance abuse, insomnia, recklessness, and social withdrawal.

“Historically, a large portion of patients in the emergency department who are suicidal get little to no care for that aspect of their problem because staff don’t recognize they are suicidal,” says Litts. “We’re hoping these materials help improve their odds.”

The information on the poster grew out of a curriculum called Assessing and Managing Suicide Risk, developed by the Suicide Prevention Resource Center at EDC, which has been presented at workshops in 40 states and on 45 Air Force bases around the world. The poster is accompanied by a guide addressing how to detect whether a patient in an emergency department is suicidal and how to direct those patients to further treatment once they are discharged.

These materials have been distributed to hundreds of hospitals across the country. The Emergency Nurses Association distributes the posters to hospitals nationwide. And in Washington State, the Department of Health supplies the posters to emergency departments in all hospitals in that state, free of charge.

The effectiveness of the poster has been evaluated by the University of Rochester in New York with very encouraging results. After the poster was hung in the department for 30 days, a large portion of clinicians said they recalled seeing it and learning from it. They said that their skills in asking patients about underlying or concealed thoughts of suicide had improved. They were also more likely to seek additional information from family members and close friends when treating a patient for a suicide attempt or for suspected suicidal ideation.

In addition, there were significant changes in clinicians’ confidence and comfort asking patients without mental health complaints about depression and suicidal ideation. This is especially important in the emergency department setting because so many patients harboring thoughts of suicide come in for other problems and will not mention their emotional pain if they are not asked directly.

“What we’re finding here is that very real changes in knowledge, attitudes and actual practice can result from a very simple intervention that requires very little in terms of cost, effort, or staff time,” says Litts. “It is not unrealistic to think that by disseminating these materials to a few thousand more emergency departments we could prevent hundreds or even thousands of deaths and injuries stemming from suicide attempts,” he added.