PORTLAND, ORE. – A poster about suicide prevention that hung in four emergency departments in New York State – plus a two-page guide to reinforce its message – increased clinicians’ recognition and engagement of suicidal patients, according to Dr. Glenn W. Currier.
Surveyed after the poster hung for a month, clinicians in the four EDs were more likely than those in a fifth ED that did not get the poster and guide to ask patients they were worried about whether they were suicidal, and to ask them about risk factors. Providers who worked in the area of the poster also were more confident about detecting concealed ideation and managing suicidal patients.
"It did better than I would have expected in a thousand years for a brief intervention. It’s a project that has some practical value," said Dr. Currier, a psychiatrist at the University of Rochester (N.Y.) Medical Center.
The benefit seemed "to span across all types of providers – physicians, residents, midlevels, and nurses – and it was essentially a free thing to do. We don’t think there’s any downside to [doing] this at your local site," he said at the annual conference of the American Association of Suicidology .
The American Association for Emergency Psychiatry, American Association of Suicidology, Emergency Nurses Association, and other groups cooperated in developing the 11- by 17-inch poster and the guide, both of which were tested among various clinicians for utility. "It was a fairly rigorous formative evaluation process," said Dr. David A. Litts, director of science and policy at the Suicide Prevention Resource Center (SPRC), which funded the project.
Signs of acute risk listed on the poster, which is titled "Is Your Patient Suicidal?" include purposelessness, anxiety or agitation, substance abuse, and mood changes.
The poster then lists questions to ask when such problems are noted, including "Have you ever thought about death or dying?" and "Have you ever attempted suicide?"
If patients say they have never thought about dying, chances are, they are not being truthful, because death is a universal human concern, Dr. Litts said.
The poster includes the National Suicide Prevention Lifeline phone number (800-273-TALK [8255]) and concludes by noting that "10% of all ED patients are thinking of suicide, but most don’t tell you. Ask questions – save a life."
The accompanying guide, titled "Suicide Risk: A Guide for ED Evaluation and Triage," includes the poster information as well as advice on evaluation, triage, interventions, ED elopement, and discharge planning.
Posters were hung in the break rooms, chart rooms, or bathrooms of the four EDs, which spanned the spectrum from rural to academic departments. All of the EDs seemed to benefit. Guides were either handed out at staff meetings or placed in clinicians’ mailboxes. There was no additional training on suicide prevention.
Clinicians were surveyed before the posters and guides were distributed, then a month later. Their answers were compared with those from clinicians in the fifth, control ED. In all, 362 clinicians completed the initial survey, and 250 completed the follow-up survey.
In EDs that got the poster and guide, 73% of clinicians in the follow-up survey said they always ask patients they are concerned about whether they are suicidal; 59% in the control ED did likewise.
Similarly, 58% of clinicians in the poster-and-guide EDs said that when they are worried about a patient, they always ask about suicide risk factors; 41% in the control ED said they did the same.
Also, 52% of clinicians in the poster-and-guide EDs said they had suspected concealed suicidal ideation in a patient who presented in the past month without a mental health chief complaint, compared with 18% in the control ED.
In the poster-and-guide EDs, 74% of clinicians thought their department had good protocols for managing suicidal patients; 53% of clinicians in the control ED felt the same.
Clinicians in the poster-and-guide EDs also were more likely to ask family and friends for more information when they suspected that patients were suicidal; more likely to ask patients whether they were suicidal; and more comfortable talking to patients about suicide, among other findings, all of which were statistically significant.
About half of clinicians thought that the poster and guide "increased or improved knowledge and skills regarding identification and treatment of suicidality."
Dr. Currier and Dr. Litts concluded in their abstract that "significant improvements in self-reported practice patterns can be achieved through the simple intervention of hanging a wall poster and distributing a [two-] page clinical guide to ED clinicians."
The next step is "to get this into a pocket guide," Dr. Litts said.