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Prev Sci (2017) 18:174–182 DOI 10.1007/s11121-016-0717-5 Identification of At-Risk Youth by Suicide Screening in a Pediatric Emergency Department Elizabeth D. Ballard 1 & Mary Cwik 2,3 & Kathryn Van Eck 4,5 & Mitchell Goldstein 5 & Clarissa Alfes 2 & Mary Ellen Wilson 6 & Jane M. Virden 6 & Lisa M. Horowitz 7 & Holly C. Wilcox 2,4 Published online: 27 September 2016 # Society for Prevention Research (outside the USA) 2016 Abstract The pediatric emergency department (ED) is a critical location for the identification of children and adolescents at risk for suicide. Screening instruments that can be easily incorporated into clinical practice in EDs to identify and intervene with patients at increased suicide risk is a promising suicide prevention strategy and patient safety objective. This study is a retrospective review of the implementation of a brief suicide screen for pediatric psychiatric ED patients as standard of care. The Ask Suicide Screening Questions (ASQ) was implemented in an urban pediatric ED for patients with psychiatric presenting complaints. Nursing compliance rates, identification of at-risk patients, and sensitivity for repeated ED visits were evaluated using medical records from 970 * Elizabeth D. Ballard Elizabeth.Ballard@nih.gov 1 Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Building 10, CRC Room 7-3345, MSC 1282, Bethesda, MD 20892, USA 2 Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA 3 Center for American Indian Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 4 Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 5 Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA 6 Pediatric Emergency Department, The Johns Hopkins Hospital, Baltimore, MD, USA 7 Office of the Clinical Director, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA patients. The ASQ was implemented with a compliance rate of 79 %. Fifty-three percent of the patients who screened positive (237/448) did not present to the ED with suicide-related complaints. These identified patients were more likely to be male, African American, and have externalizing behavior diagnoses. The ASQ demonstrated a sensitivity of 93 % and specificity of 43 % to predict return ED visits with suiciderelated presenting complaints within 6 months of the index visit. Brief suicide screening instruments can be incorporated into standard of care in pediatric ED settings. Such screens can identify patients who do not directly report suicide-related presenting complaints at triage and who may be at particular risk for future suicidal behavior. Results have the potential to inform suicide prevention strategies in pediatric EDs. Keywords Suicide . Emergency department . Screening . Pediatrics Introduction Suicide is now the 2nd leading cause of death in both 10–14year olds and 15–19-year olds, with rates remaining relatively stable since 1990 (Centers for Disease Control and Prevention (CDC) (2016b)). According to the most recent data from the Youth Risk Behavior Survey, 8.6 % of American high school students report that they have attempted suicide in the last year and 3 % made a suicide attempt that required medical treatment (CDC 2016a). Across all ages, adolescents aged 15 to 19 years visit the ED for self-harm behaviors more frequently than any other age group (Ting et al. 2012). Given the relationship between past history of suicidal thoughts and behaviors with death by suicide, it is possible that intervening with adolescents who think about and attempt suicide may result in a reduced suicide rate, reduced healthcare burden, and, Prev Sci (2017) 18:174–182 because of their developmental stage, a significant number of life-years saved. The pediatric ED is an important setting for identifying children and adolescents at risk for suicide in order to intervene ideally before youth attempt or die by suicide (Horowitz et al. 2009). Not only do many children and adolescents present to the ED for treatment of their suicidal thoughts or after a suicide attempt, ED patients without suicide-related complaints often report suicide risk factors, such as depression, anxiety, aggression, and drug or alcohol abuse (Mahajan et al. 2009; Sheridan et al. 2015). Furthermore, subgroups of children and adolescents use the ED as their primary source of medical care and may not utilize primary care or mental health services; therefore, the ED clinician may be the sole healthcare provider able to detect suicidal thoughts (Wilson and Klein 2000). Even when these patients report thoughts of self-harm, they may not receive needed assessments and resources; reviews of Medicaid records suggest that only 39 % of youth who present to the ED for self-harm receive a mental health evaluation before discharge and only 43 % are linked to mental health outpatient resources (Bridge et al. 2012). Standard of care in the ED may also be heterogeneous, with different levels of access to mental health providers across EDs (Grupp-Phelan et al. 2009; Cappelli et al. 2012). Thus, the pediatric ED population forms a particularly underserved population of youth who experience high risk for suicidal behavior. Screening in the ED is therefore a unique opportunity for suicide prevention. Screening creates a context with at-risk youth and their families to discuss suicide risk, identify risk levels, and engage them in prevention efforts. Through screening, ED clinicians can initiate early prevention strategies, such as linkages to treatment, in order to prevent later suicide attempts and potentially save lives. Many ED settings use informal assessments practices; standardized assessment allows clinicians to link positive responses to specific clinical interventions and permits researchers to track the prevalence of acute suicide risk in their ED population. All of these reasons have led the National Action Alliance for Suicide Prevention (NAASP), the group charged with implementing the National Suicide Prevention Strategy, as well as the Joint Commission, to recommend screening for suicide risk in EDs as critical patient safety and suicide prevention initiatives (National Action Alliance for Suicide Prevention Research Prioritization Task Force 2014; The Joint Commission 2010; The Joint Commission 2016). In fact, the NAASP has identified suicide screening efforts that can be easily incorporated into healthcare settings as an Burgent priority^ for prevention efforts. Suicide risk screening in pediatric EDs requires validated instruments and effective screening procedures which fit the needs of the healthcare setting (Boudreaux and Horowitz 2014). Few, if any, analyses have addressed the implementation of suicide screening instruments in real-world settings. This study is a systematic examination of suicide risk 175 screening as routine care for patients presenting to the ED for psychiatric reasons using a brief screen (Ask Suicide Screening Questions or ASQ) in an urban ED (Horowitz et al. 2012). ED screening for suicidal behavior may be particularly relevant for urban environments, in which many children and adolescents are exposed to violence, trauma, and stress, which may lead youth to seek emergency treatment (Breslau 2009). In particular, screening interventions that can identify African American youth are sorely needed. Most research on suicidal behavior has focused on European-American youth, yet the suicide rates in African American children have recently increased (Bridge et al. 2015). These youth are particularly hard to reach with services, are less likely to seek mental health treatment when needed, and are more likely to isolate from supportive social groups when distressed (Goldston et al. 2008; Langhinrichsen-Rohling et al. 2009; Molock et al. 2006). There is the potential that through such screening, youth with suicidal thoughts can be identified before they go on to make attempts. This study had several goals: (1) to examine nursing compliance with administration and the degree to which patient characteristics impact nursing compliance; (2) to describe the relationship between screening results and primary complaint, demographics, and disposition; (3) to identify the added value of the ASQ in identifying children and adolescents for whom suicide risk may have otherwise gone undetected; and (4) to evaluate the relationship between ASQ screening results and repeat visits to the ED for suicide-related reasons. Methods This was a retrospective cohort study of a consecutive case series of patients in the Johns Hopkins Hospital Pediatric ED from March 2013 through August 2014 (76 weeks/ 18 months), where the ASQ was implemented as a selective prevention strategy. ED nursing staff used the ASQ as a standard of care during intake procedures for patients entering the ED for psychiatric reasons. The Johns Hopkins Pediatric ED is part of an urban academic pediatric medical center with approximately 30,000 patient visits per year. Eligible patients for this analysis were ages 8 through 18 years and presented with a psychiatric presenting complaint. No patients were excluded on the basis of sex, minority status, or insurance type. This medical record review was approved by the Johns Hopkins School of Medicine Institutional Review Board. Screening Assessment The Ask Suicide Screening Questions (ASQ) is a four-item non-proprietary suicide screening instrument that can be administered to patients in the ED for psychiatric or non- 176 psychiatric reasons, aged 10 to 21 years, by nurses regardless of psychiatric training (Horowitz et al. 2012). All questions are asked to the patient, and a Byes^ response to any of the four items is considered a positive screen. The four items are the following: BIn the past few weeks, have you wished you were dead?^, BIn the past few weeks, have you felt that you or your family would be better off if you were dead?^, BIn the past week, have you been having thoughts about killing yourself?^, and BHave you ever tried to kill yourself?^ The ASQ was developed from a study of 524 patients across three pediatric EDs using the Suicide Ideation Questionnaire (SIQ) as the criterion standard (Reynolds 1987). In the initial development study, for psychiatric patients, the ASQ was found to have a sensitivity of 97.6 %, a specificity of 65.6 %, and a negative predictive value of 96.9 % compared with the SIQ. Evaluations are underway to determine if other scoring methods, including adding the number of Byes^ responses, would be a beneficial screen, but no empirical data has been published as of yet. Implementation Procedures This screening effort involved an interdisciplinary team with trans-disciplinary collaboration, including emergency medicine physicians, emergency department nurses, epidemiologists, and psychologists involved in the creation of the screening instrument. After discussion among the team, the ASQ was presented to a hospital-wide multidisciplinary group charged with monitoring changes to the electronic medical record (EMR). Once the group agreed to adopt the ASQ as standard of care, the screen was built into the EMR. Several factors facilitated ASQ implementation and sustainability in this setting including the Joint Commission’s National Patient Safety Goal requiring behavioral healthcare organizations, psychiatric hospitals, and general hospitals treating individuals for emotional or behavioral disorders to identify individuals at risk for suicide. The characteristics of the screen also contributed to the decision to implement as the ASQ is very brief, easily scored, and in the public domain. The ASQ was added to the EMR in the pediatric ED for patients presenting with psychiatric concerns in March of 2013. Before implementation, the nurses were trained via a series of brief in-services on the floor of the ED; charge nurses were given additional training in order to facilitate monitoring of the screening efforts. The nursing department for this ED is around 60 individuals; over 35 are specifically trained on triage assessment. The trainer was a clinical psychology postdoctoral fellow who was part of the team that developed and conducted validation studies of the ASQ instrument. After a few months of implementation, an additional presentation was made to the charge nurses in June 2013 to share initial compliance rates and problem-solve any administration concerns. While the trans-disciplinary team was involved throughout to Prev Sci (2017) 18:174–182 trouble-shoot any concerns, the continued use of the ASQ was primarily due to the nursing and physician champions, who ensured that screening continued to be done throughout the year. The ASQ was administered at triage with the triage nurse, in front of the parent/guardian who brought the patient into the ED. Information on positive screens on the ASQ was relayed to ED physicians, nurses, and social workers. Of note, the ASQ was developed on patients aged 10 to 21 years. Given feedback from nursing staff that suicidal patients often present to the ED who are younger than 10 years of age, it was agreed that the ASQ would be administered to patients ages 8 to 18 years. Age 8 years had been the lower age limit used for an instrument that was the precursor to the ASQ (Horowitz et al. 2001). Study Procedures The retrospective chart review was conducted by querying the ED’s electronic health record database to identify patients who presented to the ED with psychiatric complaints over the 76 weeks of review. The patient’s arrival date, gender, age, race, insurance status, presenting complaint, ASQ responses, disposition, and discharge diagnoses were extracted from the medical record. Only the index visit was used during the study period; repeat visits were excluded from initial analyses. As there were 16 discrete presenting complaint and 16 discharge diagnosis categories, these classifications were collapsed into clinical categories through the consensus of two licensed clinical psychologists and one psychology postdoctoral fellow. Presenting complaints were mutually exclusive (a patient had only one presenting complaint), but patients could receive more than one discharge diagnosis. Patients under age 8 and over 18 years were excluded from the analysis, in addition to patients with a recorded diagnosis of mental retardation, developmental delay, and autism/Asperger’s. Although these individuals may have been at risk for suicide, no validated suicide screening instruments currently exist for this population (Ludi et al. 2012; Segers and Rawana 2014). In an additional analysis, the relationship between ASQ response on index visit and repeat visits in the subsequent 6 months after index ED visit was evaluated. In order to be included in this subanalysis, patients had to have at least 6 months of follow-up data available in the study period; therefore, only patients with index visits before February 2014 were included. Statistical Analysis Univariate analyses were used to describe (1) nursing compliance rates, (2) characteristics of patients with dichotomized screening results (positive or negative) on the ASQ, and (3) characteristics of patients who screened positive on the ASQ Prev Sci (2017) 18:174–182 by presenting complaint to identify youth whose suicide risk may have otherwise been undetected during the visit. Sensitivity and specificity analyses were used to evaluate the relationship between ASQ response on index visit and repeated visits for psychiatric and suicide-related reasons in the 6 months after index visit. SPSS version 21.0 was used for all analyses, and statistical significance was considered at p < .05. Results During the study period, there were 1484 consecutive patient visits for psychiatric reasons in the 8–18-year age range. Of these patient visits, 400 were repeated visits (27 %), resulting in 1084 unique patients. One hundred fourteen patients were excluded from analysis due to diagnoses of mental retardation, developmental delay, and autism/Asperger’s. In total, 970 patients were included in the analysis. The average age was 13.4 years (SD = 2.6); the sample was 53 % female and 66 % African American. Of this sample, 288 (30 %) were hospitalized or transferred to another facility after their visit. Nursing Compliance with Screening Over three fourths of patients were screened (768/970), resulting in a 79 % nursing compliance rate. Characteristics of patients who were and were not screened during their visit are presented in Table 1. There was no significant age difference between patients who were and were not screened. Nurses were more likely to screen females, patients with suicide-related chief complaints, and patients who presented with emergency petitions for a mental health evaluation. Nurses were less likely to screen patients with internalizing symptoms, alcohol or drug overdoses, and bizarre behavior or hallucinations. Characteristics of Patients Who Screened Positive on the ASQ Of the psychiatric patients screened, over half screened positive for suicide risk (448/768, 58 %). Demographic and clinical characteristics of patients who screened positive as compared to negative on the ASQ are presented in Table 2. Patients who screened positive were more likely to be older, female, have a suicide-related presenting complaint, and be hospitalized or transferred on their visit compared to those who screened negative. Patients who screened positive were less likely to present to the ED with an externalizing behavior or emergency petition/mental health evaluation presenting complaint. 177 Characteristics of Patients Who Screened Positive on the ASQ by Presenting Complaint Of those 448 psychiatric patients who screened positive on the ASQ, 237 (53 %) presented without suicide-related chief complaints. In order to focus on patients who may have been identified by the screening procedures, Table 3 displays patients who screened positive on the ASQ by presenting complaint. Patients who did not have a presenting complaint related to suicide, but screened positive on the ASQ (and may have gone undetected had they not been screened), were older, more likely to be male, African American, have bipolar disorder, ADHD, CD, ODD, or aggression noted in the medical record. These patients were less likely to endorse the first three items of the ASQ, which are primarily related to suicidal thoughts, and were more likely to endorse the final item, which relates to past suicidal behavior. In addition, they were less likely to be hospitalized or transferred postdischarge. Subsample Analysis of Sensitivity/Specificity Of the subsample of patients with 6 months post-ASQ screening follow-up data available (n = 618), 131 made at least one repeated visit to the ED for psychiatric reasons (21 %). Thirtytwo of these patients (32/618 or 5 % of sample with follow-up data) made a repeat visit to the ED with suicide risk as the presenting complaint. Of those 32 patients with repeat visits for suicide-related reasons, 28 had screened positive on the ASQ on index visit, 2 had screened negative on the ASQ, and 2 were not screened. Due to the two individuals who were not screened with the ASQ on index visit, the overall sensitivity of the entire patient population was 88 %, 95 % CI 71– 96 %. As a further subanalysis, we focused on patients that did not have a presenting complaint of suicide risk on index visit (n = 329). Of these patients, seven made a repeat visit to the ED with suicide as the presenting complaint (7/329 or 2 %), five of which had screened positive on the ASQ on index visit, one had screened negative, and one was not screened. Sensitivity and specificity values are presented in Table 4 for all patients with follow-up data. Sensitivity values for suiciderelated outcomes ranged from 83 to 93 %, while specificity values were lower from 43 to 58 %. Including the one patient who was not screened, sensitivity values fell to 71 %, 95 % CI 31–95 %. As males were less likely to be screened than females, a subanalysis of sensitivity/specificity for repeated ED visit for suicide-related complaints was conducted. Screening positive on the ASQ was associated with 100 % sensitivity in predicting repeat ED visits for suicide-related complaints and 58 %, 95 % CI 55–99 %, specificity in males. For females, there was 90 %, 95 % CI 69–98 %, sensitivity and 32 %, 95 % CI 30–33 %, specificity for the same outcome. 178 Prev Sci (2017) 18:174–182 Table 1 Pediatric ED patients with psychiatric complaints: comparing those who were screened with the ASQ to those who were not screened Not screened with ASQ Screened with ASQ (n = 202) (n = 768) Mean 13.4 SD 2.9 Mean 13.4 SD 2.5 t −0.3 n % n % ORa p Males African American race 112 137 55 68 341 507 44 66 0.64 0.92 .005 .63 Medicaid insurance Presenting complaint 138 68 536 70 1.07 .69 Suicide ideation or attempt Externalizing: aggression, ADHD, violence 24 44 12 22 230 147 30 19 3.17 0.85
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Week 4 | Part 4: Research Analysis
I have identified one topic of interest for further study. I have researched and identified
one peer-reviewed research article focused on this topic and have analyzed this article.
The results of these efforts are shared below.
Directions: Complete Step 1 by using the table and subsequent space below identify
and analyze the research article you have selected. Complete Step 2 by summarizing in
2-3 paragraphs the results of your analysis using the space identified.

Topic: "Identification of At-Risk Youth by Suicide Screening in Pediatric Emergency Department."

Step 1: Research Analysis
Complete the table below
Topic of Interest:

Identification of At-Risk Youth by Suicide Screening in
Pediatric Emergency Department

Research Article:
Include full citation
in APA format, as
well as link or
search details (such
as DOI)
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