Another unnecessary screening process has been proposed by Edwin Boudreaux, MD, et al. (“Suicide Risk: To Screen or Not to Screen,” EMN 2012;34:5; http://bit.ly/UD7rK7.) They are correct about one thing: screening will delay a patient's flow through the emergency department. The benefit, though, is unproven.
Compelling data do not exist that routine screening of patients in the ED reduces the suicide rate or the rate of attempts at suicide. Yet we are being asked to spend our time on this unproven and extremely low-yield intervention. Emergency physicians deal with outcomes in the seven- to 30-day range, not the one-year range that was suggested by the reference to the study in the British Journal of Psychiatry, which found that up to 40 percent of those who commit suicide visited an ED in the year before their death. This gives time for the patient to be identified and assessed in follow-up by someone trained in this process.
Most emergency physicians are not trained in suicide risk assessment, and are correctly not willing to take the risks of assessment upon themselves. That is why we have mobile psychiatric crisis units or in-house psychiatric personnel available to perform this work. Identifying a patient at risk will require a psychiatric evaluation, especially if one believes that the data presented in this article are strong enough to warrant screening. This will add hours to a patient's stay in the emergency department.
Anecdotally, our participation in the ED-SAFE study has already cost at least one of our patient's hours more in the ED. He had made a suicide attempt several years earlier, and he therefore screened positive even though he was not currently suicidal. Instead of being admitted to his inpatient bed for his COPD exacerbation, he stayed in the ED an extra nine hours because the hospital did not have a sitter available for him until after the morning shift began.
If we really want to perform all of these unnecessary screenings (and I don't), then I suggest the museum model. We are steered through the gift shop when we exit a museum w. When a patient is discharged from the ED, the patient can be sent to the “screening center” where a physician or midlevel provider trained in primary care can assess the patient's risk for diabetes, hypertension, HIV, suicide, and all the other possible things for which patients can be screened. Alternatively, after being seen by the emergency physician but while still in the ED, a “screening provider” can visit the patient and do all of these screening assessments. Patients will get all of the screenings by someone who has the time and ability to do them.
John Sarko, MD Phoenix, AZ