Suicide Risk Screening in the Emergency Department: Should we be doing this in PreOP?
Myron Yaster MD and David G. Nichols MD, MBA
At this year’s SPA meeting, my best friend, Dr. David Nichols, challenged us during his AAP lecture entitled: “Past, Present, and Future: The Impact of Pediatrics on Pediatric Anesthesia - The Diseases, The Workforce, and The Training” to think of ourselves as perioperative pediatricians. In the face of the current pediatric mental health public health emergency, in his lecture he suggested that the preoperative evaluation was one more touchpoint in the healthcare system to identify adolescents suffering from major depression and suicide risk.
Suicide is now the 2nd leading cause of death in children and adolescents aged 10-18 years. Screening tools exist, and the AAP recommends that they be used in ALL health care encounters. In today’s PAAD, we’ll review how these screening tools are being used in the Pediatric Emergency Departments (PED). I am not an expert by any means on this topic nor for that matter on other pediatric mental health issues like depression and anxiety. I asked Dave to assist me in today’s PAAD. For those of you who don’t know him, David was trained and is Board certified in pediatrics, anesthesiology, pediatric anesthesiology, and pediatric critical care medicine. He served as Division Chief at Hopkins and vice-dean of education at the Medical School, and went on to become President of the American Board of Pediatrics. Myron Yaster MD
Original article
Rachel Cafferty, Lilliam Ambroggio, Jan Leonard, Sarah Schmidt, Maya Haasz. Evaluating Provider Documentation of Suicide Risk Factors Among Youth Screening Positive for Suicide Risk in a Pediatric Emergency Department. Pediatr Emerg Care. 2022 Jul 1;38(7):317-320. PMID: 35608523
Suicide is now the 2nd leading cause of death in children and adolescents aged 10-18 years. The American Academy of Pediatrics recommends that health care providers discuss suicidal thoughts and the risk factors associated with suicide when obtaining a patient's medical history throughout adolescence. The objective of today’s PAAD was to determine whether PED physicians routinely documented the risk factors for suicide among PED patients who presented to the PED for non-psychiatric reasons. PED patients at this single institution were routinely screened for suicide risk using the validated Ask Suicide-Screening Questions (ASQ) tool. Based on an a priori literature review for risk factors, the authors searched the eligible patients' electronic medical records for documentation of the following risk factors: presence or absence of current Suicide Ideation (SI), sexual orientation, gender identity, bullying, substance use, access to lethal means including firearms, history of self-harm, and prior parental Suicide Attempt (SA) for each patient encounter.1
The ASQ2 is quick and simple and consists of the following 4 Yes/No screening questions:
(1) In the past few weeks, have you wished you were dead?
(2) In the past few weeks, have you felt that you or your family would be better off if you were dead?
(3) In the past week, have you been having thoughts about killing yourself?
(4) Have you ever tried to kill yourself (if yes, how and when)?1, 2
Of the eligible patients in this study, 7484 (87.7%) were screened for SI, and 524 (7%) were flagged as at modest or high risk for suicide (393 patients and 131 patients, respectively) (YIKES!).3 An emergent mental health evaluation was required in 11.4% of patients, and 32% of these required hospitalization at a psychiatric facility.
This article throws down the gauntlet and presents us with both a challenge and an opportunity. The National Institute of Mental Health (NIMH) Youth Screening Pathway4 calls for suicide screening in all patients ages 10 and above who present to a specialty clinic and have not been screened negative within the past 30 days. This mandate affects us since the preop evaluation clinic is a pediatric specialty clinic!
Approximately 5 million children undergo surgery every year in the United States, of whom at least a quarter or more are adolescents. Extrapolating the data from this study to the Preop Evaluation Clinic, it’s conceivable we could be flagging nearly 90,000 adolescents for suicide risk annually. In this study, 41% of patients with a positive suicide screen had no documented prior mental health comorbidities, suggesting that standardized screening for suicide in this population is essential. Not doing this screening in our preop evaluation is therefore a missed opportunity. However, if we instituted this screening into our preop evaluation, what would we do with a positive result? Cancel surgery? Make a referral? Are there even enough (or any) mental health professionals within your institution to deal with this? And, if we didn’t do anything with a positive result, what is our liability? Each institution would need clear answers to these questions as part of a screening system. Blitz et al. have demonstrated reduced perioperative mortality associated with a preoperative evaluation.5 Dustin et al. offer specific recommendations for managing suicide screening during the adolescent’s preoperative clinic visit.5
This is a lot to think about and absolutely takes us out of our comfort zone. After reading this article and some of its source documentation, I (MY) contacted SPA’s informatics committee leadership to ask them to pre-review this PAAD and to consider developing a pilot project to see if and how the ASQ could be added to our preop evaluations in the electronic medical record. If you have an interest in this, please email me (myasterster@gmail.com), and I will circle back as we create a working group to develop this project. Hopefully, we will have it up and running by the time of SPA’s annual meeting in New Orleans.
References
1. Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Archives of pediatrics & adolescent medicine. Dec 2012;166(12):1170-6. doi:10.1001/archpediatrics.2012.1276
2. National institute of mental health. ASQ; Ask suicide- screening questions: screening tool. Accessed 08/04/2022,
3. Cafferty R, Ambroggio L, Leonard J, Schmidt S, Haasz M. Evaluating Provider Documentation of Suicide Risk Factors Among Youth Screening Positive for Suicide Risk in a Pediatric Emergency Department. Pediatric emergency care. Jul 1 2022;38(7):317-320. doi:10.1097/pec.0000000000002753
4. National institute of mental health. Youth suicide risk screening pathway: Outpatient primary care and specialty clinics Accessed 08/4/2022, https://www.nimh.nih.gov/sites/default/files/documents/research/research-conducted-at-nimh/asq-toolkit-materials/youth-outpatient/Suicide_Risk_Screening_Pathway_Outpatient_Youth_Nov_10_2021.pdf
5. Blitz JD, Kendale SM, Jain SK, Cuff GE, Kim JT, Rosenberg AD. Preoperative Evaluation Clinic Visit Is Associated with Decreased Risk of In-hospital Postoperative Mortality. Anesthesiology. Aug 2016;125(2):280-94. doi:10.1097/aln.0000000000001193