Implementation of a Health and Hospital System Nurse Driven Suicide Screening Protocol Disclosure The speakers have no conflicts of interest to disclose. Kimberly Roaten, PhD Celeste Johnson, DNP, APRN, PMH CNS Russell J. Genzel BSN, RN Objectives Discuss the process for implementation of a hospital wide suicide screening protocol driven by nurses Examine the impact of a standardized suicide screening protocol on identification of at risk patients Discuss lessons learned for future implementations BACKGROUND Parkland Health & Hospital System (PHHS) Mission: Dedicated to the health and well being of individuals and communities entrusted to our care. Vision: By our actions, we will define the standards of excellence for public academic health systems. Parkland Health & Hospital System Founded in 1894 Licensed for 862 beds >10,000 employees 3,500 nurses >159,000 Emergency Department encounters annually 20 community based clinics More than 1 million outpatient encounters annually Primary teaching hospital for The University of Texas Southwestern Medical Center BSN, RN 1
Celebrating 120 years of providing medical care to Dallas County residents First Level I Trauma Center in North Texas First Level III Neonatal Intensive Care Unit in Dallas Second largest civilian Burn Center in U.S. Leader in disaster preparedness; disaster plans adopted worldwide As of August 20, 2015, largest hospital in the U.S. (2.1 million square feet) Scope and Significance According to the CDC suicide was the 10 th leading cause of death among American adults in 2013 7 th leading cause of death for adult men 14 th leading cause of death for adult women More than 41,000 suicide related deaths in the US in 2013 Age adjusted rate of 12.57/100,000 More than 494,000 patients treated for selfinflicted injuries in 2013 Health Care Contact Prior to Suicide Contact with health care professionals is common in the days, weeks, and months leading up to a suicide However, patients who later die by suicide are often seen by non behavioral health providers: Emergency Department Primary Care Provider Mental Health Provider 40% had contact within 1 year before death ~10 20% of patients who present to the ED for a non behavioral health CC acknowledge SI 77% had contact within 1 year before death 45% within 1 month prior to death 24% had contact within 1 year before death 19% within 1 month prior to death SCREENING AND RISK ASSESSMENT Screening vs. Risk Assessment Suicide Screening: a procedure in which a standardized instrument or protocol is used to identify individuals who may be at risk for suicide Completed independently or as part of a comprehensive health screening Universal: applied to everyone in a population, regardless of estimated risk Selective: applied to a group that research has shown is at increased risk Suicide Risk Assessment: a comprehensive evaluation done by a clinician to confirm suspected suicide risk, estimate the danger, and decide on a course of treatment BSN, RN 2
Evidence to Support Universal Screening (or not) Limited predictive value of existing screening tools Convergent validity, no mortality data U.S. Preventative Services Task Force 2004: Insufficient data to make a recommendation for or against standard suicide screening practices in primary care 2014: Insufficient data to make a recommendation for or against standard suicide screening practices in primary care Emergency Department Safety Assessment and Follow Up Evaluation (ED SAFE) Standardized screening (primary and secondary), provider training, telephone follow up Established feasibility Timeline Ash Wednesday 2012: I think we should be screening everyone. NOPE. You will close us down. August 2014: Renewed interest in suicide screening Universal screening recommended Weekly meetings scheduled to plan resources and implementation Support from administration, Concern from clinicians The Joint Commission action plan System wide suicide screening 90% compliance Resource allocation Phases Inpatient/Emergency Department All Outpatient and Correctional Health Choosing an Instrument Something brief Something free Something that does not require mental health training Columbia Suicide Severity Rating Scale (C SSRS) 3 6 items Clinician administered, but no mental health training required In the public domain Free standardized online training Multiple languages Ask Suicide Screening Questions (ASQ) For patients ages 12 to 17 4items Clinician administered, but no mental health training required In the public domain Electronic Health Record Clinical Response How do we create a screen in the EHR that guides appropriate clinical care? Nothing existed in Epic and nobody had tried before Branching logic? Cascading logic? Assign scores in the background Weighted scores based on clinical importance Consulted with multiple behavioral health providers Consulted with Columbia research group and NIMH group Clinical Response Algorithm No Risk Identified Screen complete and documented in the chart Moderate Risk Identified Screen complete and documented in the chart No 1:1 required Psych SW evaluation: focused psychosocial eval, safety plan After Visit Summary with resources High Risk Identified Screen complete and documented in the chart Initiate 1:1 and suicide precautions Psych Activation (ED) or Consult Psychiatry/Psychology (Inpatient) After Visit Summary with resources BSN, RN 3
ELECTRONIC HEALTH RECORD IMPLEMENTATION & STAFF EDUCATION Epic since 2007 All clinical areas except for Correctional Health Includes Provider, Nursing, and Allied Health documentation 7 Epic IT teams with 79 employees Goals of Epic build: 1. Share documentation with all clinical areas 2. Use Epic functionality to lead staff to ask the correct questions based off responses from patient 3. Use Epic functionality to generate interventions based off answers and location of screening Sharing documentation with all clinical areas Important to standardize Documentation follows patient through areas Less IT build time Epic functionality allowed for sharing Correctional Health not using Epic; used paper intake form No issues with standardization Building the Screen in the EHR Listing all questions in EMR would cause error and confusion Goal: screening questions open up based off previous answers Question 6 being asked by everyone; the last question was the issue IT team worked 2 months on solution Solution found minutes before a meeting Intervention based on location displayed at the end of screening When patients moved from ED to IP, the intervention display changed 2015 Epic Systems Corporation. Used with permission BSN, RN 4
EMR based reminders created to catch: Patients not screened Incomplete screenings (not all questions answered) Correct interventions not ordered EMR notifications added automatically for high risk patients Banner in patient chart Staff unable to print After Visit Summary for high risk patients unless cleared by team Psychiatry must clear the patient in EMR Patient track board list based on risk level AMA list for SW follow up Community resources added to After Visit Summary of all patients scoring moderate or high Suicide Screening After Visit Summary Available in Spanish and English Prints in language identified in EHR Suicide Screening Flag & Banner 2015 Epic Systems Corporation. Used with permission 2015 Epic Systems Corporation. Used with permission Administrative Concerns ADMINISTRATIVE CONCERNS & RESOURCE ALLOCATION Do we have enough resources? How to activate psych resources? Which level of clinician will see patient? Will screenings cause delays in ED throughput? Impact on Emergency Detentions/1:1s? How to track screening compliance? Ebola plan What will we see with levels of risk? Who needs education? How to provide? BSN, RN 5
Resources Engaged stakeholders met weekly VPs of nursing and physician leaders involved Psych consult teams in place for EDs and IP 3new PMH NPs and one PA hired October March 2015 for ED consult team 12 additional psych SW hired prior to roll out IT support Education & Marketing Educational plan: Free Columbia training video Parkland specific scenarios and processes Reinforced education through Single Point Lessons Marketing Plan Emails Hospital publications Huddles Implementation Resources 12 new psych social workers 4 new advanced practice providers EHR Build Weekly meetings with Epic team Go Live Decision to separate Community Oriented Primary Care Clinics (COPC) and Outpatient Clinics (OPC) Phase I: All inpatient units (new screens for PM&R and Inpatient Psychiatry admissions) + Emergency Department Phase II: All COPCs + Correctional Health (provider visits only) Phase III: OPCs + ASC (provider visits only) Screening Data Emergency Department and Inpatient Units Screening Data Community Oriented Primary Care Clinics (COPCs) Compliance since go live >98% 85% of screens completed in the ED Compliance since go live >98% Majority of high risk identification in the homeless outreach program BSN, RN 6
Challenges Outpatient clinic implementation delayed $2 million budget (shockingly) not approved No available social workers, PMH NPs, or psychologists Social workers are very, very busy Quality of initial screens? Repeated screens despite education not to do so Clearing suicide risk flags at/after discharge Big Wins The hospital has not closed We have not quit our jobs We have opened the conversation regarding mental health issues Identification of patients who needs help regardless of whether or not they are at risk for self directed violence We implemented a universal screening program that will allow us to fill gaps in the suicide research literature Good Catches 52 yo female seen by psychiatric social worker for moderate risk. No psychiatric chief complaint. Wanted to go to sleep and not wake up. Patient revealed that male companion had been keeping her locked up in a truck for several months. Patient was referred to Victim Intervention Program (VIP) and was seen in psychiatry ED. Police were notified. At discharge patient was sent to a safe place outside of the Dallas area. Good Catches 16 yo female, seen by psychiatric SW for moderate risk; no psychiatric chief complaint. Discovered that she was discharged from an IP psych facility two weeks before. Attempted suicide post discharge but not did not seek treatment. Could not get away from drug using peer group. Transferred to IP psych facility for treatment. Future Directions Acknowledgements OPC implementation COPC data collection and analysis Publish algorithm and pilot data ASAP Begin outcomes research: ED recidivism Engagement in outpatient mental health follow up Mortality IT/Epic Team: In Mouracade Angie Sanders Dr. Brett Moran, MD Physician advocates: Dr. Bill Griffith, MD Dr. Esmail Porsa, MD, Chief Medical Officer PHHS Nursing Leadership: Jacqueline Brock, MSN, APRN, VP of Nursing Surgical Services Clifann McCarley, RN, BSN, MBA, VP of Emergency, Trauma, and Behavioral Health Services Social Work: Mary Berger, LCSW, BCD David Herman, LCSW Jana Creech, LMSW Psychology/Psychiatry: Dr. Jessica George, PhD Dr. Celia Jenkins, MD Dr. Fuad Khan, MD Dr. Laura Howe Martin, PhD Dr. Karen Frey, PhD Dr. Jacqualene Stephens, PhD BSN, RN 7
Questions & Contact Information Kim Roaten, PhD Associate Professor Department of Psychiatry University of Texas Southwestern Medical Center Parkland Health & Hospital System 5323 Harry Hines Blvd Dallas, Texas 75390 8898 Phone: (214) 648 8726 Email: Kimberly.Roaten@utsouthwestern.edu BSN, RN 8