Good afternoon, and thank you for joining ENA's webinar, Using the iCare2 Tool to Care for Suicidal Patients in Emergency Settings, with presenter Lisa Wolf. Please note that you are currently muted by the organizer to diminish any background noise. Questions can be typed into the Q&A panel, and any typed questions will be answered at the end of the webinar. Shortly after the conclusion of the webinar, you will receive an email with a link to complete a post-webinar evaluation. This evaluation is required in order to receive CE credit for this webinar. And before we get started, I'd like to tell you a little bit about our presenter today. Lisa Wolf is a nationally and internationally known researcher with expertise in emergency – or, I'm sorry, with expertise in nursing environments and clinical decision-making. She has directed the Institute for Emergency Nursing Research at ENA since 2012, and with a team of researchers, has published studies using qualitative, quantitative, and mixed methods. Dr. Wolf is expert at identifying clinical problems and developing study methods to explore complex nursing and patient problems. And with that, I will hand it over to Lisa to start the presentation. All right. Good afternoon, everybody. We're going to talk a little bit today about the iCare2 tool, which is a process for identifying, assessing for risk, and managing the care of the suicidal patient in emergency settings. I'll talk a little bit more about how the tool was developed in a little bit, but what I want to start with is the work of the ENA and the IENR Advisory Council, who did – we did some collaborative research together on identifying suicidal patients at triage. It seems like with any process by which there is a protocol or some kind of bundle, it doesn't really matter how good that process is if no one is correctly identifying patients who should be plugged into it. So that's a lot of what we're going to talk about today, even though this tool was developed in conjunction with ASEP, and really, I think they had in mind more for the emergency physician in areas where there was minimal or delayed psychiatric consultation. I think that there is so much overlap here that emergency nurses will find this even more beneficial, really, than the targeted audience of emergency physicians. Hey, Lisa. Sorry, this is Julie. I just want to let you know that we cannot see your PowerPoint. You may have to minimize your PowerPoint and go back to the WebEx and then click Share Screen. Okay. Perfect. You got it? Yeah. Super. Thank you so much. I'm glad I have not yet moved on. All right. All right. So there's no conflict of interest. I don't get paid extra for this. So what I'm hoping that everybody can do at the end of this presentation is to identify barriers to the suicide screening process. And this is really important because unless we understand why we're struggling with something, it's really hard to fix it. I think we need to develop an understanding of different types of suicidal presentation and identify those processes by which the patient presenting to the emergency department can be assessed for suicide and kept safe as appropriate and necessary. So what I'm going to try to do today is explain this very systematic identification of patients who are at risk for suicide. This is a critical part of emergency care. About 12% of patients presenting to emergency departments are presenting with behavioral health complaints. We found in a previous study that was published in 2015 that 60% of emergency nurses report having had no behavioral health education since licensure. So you have your brief psychiatric content and maybe four or five shifts in a psychiatric setting. And that's about it. A lot of emergency departments don't have immediate access to psychiatric providers who we sort of depend on to stratify risk. I think we're all very uncomfortable in determining who is really at risk and who is not. And I'm also going to explain the way that both the ENA and the ENA in collaboration with the American College of Emergency Physicians yields this tool. And it's really useful as a practice guide in areas with delayed or absent psychiatric services. So we know that suicidality is a significant issue. It's a critical nursing function at the initial emergency department encounter, whether that is in a triage area or at the bedside. We screen for suicide because it's the 10th leading cause of death in the United States. And a substantial percentage of people who go on to die by suicide will present for healthcare in the year before their deaths. The emergency department provides us a critical opportunity to identify and intervene, especially in the area of access to lethal means. So the Joint Commission recommends screening every patient for suicidal ideation and risk in the emergency department. They have determined that schools, primary care settings, and emergency department settings are really appropriate places to screen for suicidality in young people. And suicidal ideation is estimated to be present in as many as 11% of our patients, but only 3% are identified by current screening methods. So when a patient presents with a complaint of suicidality, hi, I'm here, I'm feeling depressed, I'm feeling suicidal, that's easy. It's like the cardiac patient presenting clutching their chest, sweating, and complaining of chest pain. It's easy. But there's this substantial subpopulation of people who are in fact suicidal who present to the emergency department with other presentations, with other complaints. And so it becomes a real detective process to identify those patients. Now the ENA has a clinical practice guideline on suicide risk screening, kind of looking at different types of tools. And we have a couple that are recommended as being useful for practice in the emergency department, and that includes the ASK, the Ask Suicide Screening Questions, the Manchester Self-Harm Rule, and the Risk of Suicide Questionnaire. There's also a lot of places that are using the Columbia tool. The American College of Emergency Physicians recommends the PSS-3. So basically this is three questions. The first really is kind of a leader question, right? So you don't sort of jump into the meat of the matter. You sort of start very generally with, have you felt down or depressed or hopeless? And the possible answers are yes, no, the patient's unable to complete or the patient refused to complete. The real question, right, the question we really want to ask is, have you had thoughts of killing yourself? That is a high, a yes answer to that obviously puts the patient in a high-risk category. However, the answer to number three also puts a patient in a high-risk category. So that question is, have you ever attempted to kill yourself? Now the most, I think the best predictor of future behavior is past behavior. And so people who have a history of attempts are at higher risk, like no matter what. And so when we get a yes answer to that, we want to ask about timelines. So within the last 24 hours, including today, this month, but not today, a few months ago, more than six months ago, and then patient unable to complete, patient refused. So this PSS3 is a tool that people are trying to use. It's a little more specific and it has some well-known predictors involved. However, what we know, we know two things. One is that people don't want to ask about suicidal ideation. Even if it's a mandatory question in the department, what tends to happen is that people either don't ask the question, it tends to be a hard stop in a lot of EHRs. And so people just will put in an answer. They don't want to ask about suicidal ideation because they don't have a lot of training in how to ask the question in a way that is open to an honest response. There is a lack of protocol. If someone says, yes, I do feel suicidal, we don't really know what to do. And the third piece is that if somebody discloses suicidal ideation as part of a direct question, they immediately become high-risk, they're an ESI-2, they have to come back and have a one-to-one. And that, for overcrowded emergency departments, poses a problem. And so rather than ask the question, get an answer, and not do what's right for the patient, because none of us want to do that, I think people tend to hedge the question or not ask it at all. And so in that sense, they are triaging the emergency department and not the patient. And things that come into play there are crowding, who the provider is, and the number of available beds. So if you're just having a slamming night in your emergency department, and you don't have any beds available, and you're getting all kinds of sick people and gunshots and heart attacks and whatever, there is a definite feeling that this patient might not warrant your last bed. So they do not ask the question and appropriately triage the patient. And that is a systemic issue. That is not any particular nurse at any particular time. This is a systemic problem that feeds into all the issues that we deal with every day, crowding and boarding. What we know about assessing and caring for suicidal patients comes from studies of emergency department behavioral health practices. And what we find out, again, is that 60% of respondents receive no specific post-licensure education. We're very undereducated and uncomfortable dealing with behavioral health patients. And nurses will report that they lack the skills to assess risk severity, provide brief counseling or negotiate a safety plan. Patient contracts for safety is not a safety plan. The vast majority of patients, there's a study out there that suggests that 78% of patients who go on to complete their suicide attempt successfully categorically deny suicidal ideation at their last health encounter. So as House says, everybody lies. So what we did at the ENA was we did a qualitative exploratory study to describe the process by which nurses identify patients with risk for suicide, even if those patients don't declare that as a presenting complaint. Because again, we have that fairly substantial subset of patients who are suicidal yet do not identify that as their primary complaint. But we wanted to find out what nurses were doing with that. So we asked them, we convened some focus groups at the national conference. So we asked nurses from all over the country, what behaviors raise concern about suicide? How do you understand and interpret those behaviors? What action do you take in response to your understanding of risk? So the end point of a clinical decision is not a thought, it's an action. So what action do you take? And how do you determine whether your response was effective or not? And lastly, we asked people what they thought were the facilitators and barriers to effective triage of patients with either overt or occult suicidality. So our participants reported a feeling that there are unstated and unmet patient needs. And so they reported that when they asked questions about suicidality, they paid less attention to the actual answer that the patient gave and more toward the patient's response to the question, their reaction to being asked the question. So the nurses in this study reported that patients who wouldn't make eye contact or hesitated before answering the question, they reported those as very significant cues that did not sort of clinch it for them that the patient had issues of suicidality, but kind of raised a red flag that further investigation was required. So the themes from this piece were hesitation at disclosure. In other words, if you hesitated in answering the question, that was almost as good as disclosing suicidal ideation. Patient mismatch, or a patient who presented with injuries that did not match the story at all. And gathering courage. So when nurses talked about patient behaviors, again, they talk a lot about lack of eye contact and hesitancy to answer. And they talk about that as a cue for further investigation. So red flags are reported as disengagement, right? So people are just not having a conversation, not responding to your questions. The patient who is agitated, or again, the mismatch between the presenting complaint and the patient's description of mechanism or the situation. So no one of these things is conclusive. But in constellation, our nurses reported that that prompted concern about occult suicidality. And we understood that idea of occult suicidality is a suicidal ideation that is not stated by the patient. It is not the presenting complaint. But because of the patient's presentation, conversation, affect, whatever, it becomes a primary focus of the nurse's attention. So the nurse starts really thinking like, okay, you're telling me this is your problem, but I really am concerned about this. So they reported things like patients who complained about a scratch that looks self-inflicted, but they're telling you a different story. You see cut marks and scars, and the patient is giving you a story that doesn't match what you're seeing. Kids who come in and say, I've cut myself, or I fell down the stairs. And so those nurses would say that at some point in the encounter, they really wanted to, or did a lot of times, ask the patient, like, did that really happen? Or is this something else? Like, what are you trying to tell me? And there's this recognition that the patient is presenting to you something to save face or to cover up their true intent, but it is our obligation to pursue that line of inquiry. Another theme that arose from this data was gathering courage. And so the nurses in our study reported a recognition of patterns of presentation. So the patient who comes in over and over again over a short period of time with very vague complaints, they saw that as kind of a somaticization of anxiety or depression or discomfort that caused the patient to repeatedly present to the emergency department looking for help for a need that perhaps they didn't even realize was present. So one nurse was saying that the SI patients check into the emergency department every day once a week. You see a whole bunch of minor complaints ahead of time when they're trying to get up the courage to say what they're really here for. And so nurses began to note that pattern of presentation. So what was really important, again, we talk about the end point of clinical decision-making as action. So we wanted to know how did the nurses interpret these behaviors and what did they do in response? So what they saw was that the understanding and interpretation of these patient behaviors was very much dependent on the nurse's level of experience. Newer nurses really didn't have the breadth of experience or the education, the behavioral health-specific education, to recognize some more subtle cues. So the patient who doesn't outright declare their suicidality or suicidal ideation becomes really challenging for people with not a lot of experience. So they said the patient behaviors can be mediated or interpreted looking at the overall patient presentation. So they're looking at hygiene, appearance, the patient's social support system or lack thereof. Is the patient there all by themselves? Is there somebody with them? Is there someone who brought them in? So what they did when they started becoming suspicious that the patient might in fact have some suicidal intent or ideation is they would do one of three things that they told us about. One was to pass on the concerns to a colleague. So that could be another nurse, that could be the physician, someone else down the line who could do either a more thorough assessment or just ask some more questions, right? Not necessarily a specific assessment for suicidality, especially if the patient had denied it initially. But just to sort of discuss the situation, kind of talk a little bit about their concerns. The triage environment is not really conducive to that kind of conversation. So what people really wanted to do was have someone to hand that patient off to who would continue to pursue this line of inquiry. They also talked about providing a safe space for patients to disclose more information. And then the last thing that they did we called probing further. So they would either alert a provider or seek out more information through other channels like the chart. So handing off described the process by which a nurse in that triage role had some suspicion that more follow-up was required. And the nurses in our study said that even if the patient specifically denied, categorically denied suicidality, but had behaviors that prompted concern, they would continue to alert the next provider. Like, hey, how about you talk to this patient a little bit more? I'm concerned about this. What we're hoping for is that third person on the match phenomenon, which we're all familiar with where the patient won't tell person one, won't tell person two, and then the physician walks in the room and they're like, oh, yeah, and they'll talk for 10 minutes about the thing that they denied to both you and your colleague. So we're kind of in that case, in this case, we're kind of hoping that they will do that if people keep asking that perhaps they will disclose and we can conclusively identify them. So the nurses in our study talked a lot about how triage was so fast paced that they were much more willing to hand off to another nurse and pass it on. Or they'll put them in another room and very clearly say to the primary nurse, please get somebody to see them. We had a couple of nurses from Australia in our sample and they said we would make a referral at triage to the mental health worker even if the patient did not disclose suicidality. Because they wanted a professional assessment. Our nurses also reported that if they could, they would try to create an opportunity for patients to give more information. So of course, the triage area is not super private. It's not quiet. It's really not conducive to a conversation about suicidality. So what they would try to do was create some space to get the patient to feel a little more relaxed, a little more cared for, to develop sort of an initial therapeutic relationship with the patient and allow that information to emerge. So some people talk about kind of putting people out of the way in a quiet place to just give them a chance to kind of think a little bit and keep an eye on them. So as long as they were safe and they could hand them off to a safe spot, they were okay. Another nurse, and a lot of people agreed with this nurse about this technique, was she said I would walk the patient to the bathroom. So I would separate them from whoever was with them, walk down the hall, let's get your urine sample, and then in that space where there's some quiet and some privacy, they would ask directly about suicidal intent. This other part, probing further, was this very iterative process. Allows the nurse to seek further detail from the patient with an emphasis on providing care to the patient in a personally and professionally caring way. So looking at things that might either support, challenge, or confirm the initial suspicion, give you something to go on as you present this to a provider. Again, if the nurses stated that if they felt uncomfortable during the triage process, it's a real red flag. And they'll keep further questions that they can ask in this particular department. This nurse, the second nurse, was saying that you have a high degree of suspicion, the patient denies, you'll look through their chart and you'll see previous suicide attempts, depression, suicidal ideation, or you'll see a lot of psychiatric medications. And they get flagged, right? So it's not like we're going to immediately put that patient on a one-to-one. They're not going to be deemed a suicide risk. But this is a way that nurses are reporting that they are continuing to gather information and not just letting it go with a single denial at triage. And that's important because the care of this patient really takes place over the entire ED stay. So there are certain patients that are going to provoke a high level of suspicion, certainly, and they're probably going to be few and far between. But I think it's really important to note that there is people who are really plugging into this process, this iterative, continuous process of assessing for risk, which turned out to be really important. Now, when we think about effective nursing care and going to the way back machine to nursing theory, Ida Jean Orlando defines effective nursing care as recognizing and meeting the needs of the patient, even if the patient doesn't state them explicitly. So our nurses reported that it was really difficult for them to really determine effectiveness because for most of us, if you triage a patient, and then they go in the back, and then they're gone, right? So you don't really know what happened to them. So it's really hard to determine whether or not your handoff was successful or necessary, or if, in fact, the patient was just having a bad day and not feeling like interacting rather than suicidal, right? So as long as someone, it's tough to determine whether you were right or not. So in the short term, there are participants described the effectiveness of their nursing care as creating that window of opportunity to reach the patient. What they were really kind of the overarching theme of this was ensuring safety for now. So everybody participating in the study understood that you can't keep patients safe forever. You can't stop people necessarily who are very determined to die by suicide. But for the time that they are under our care, we kept them safe, and the really great success is when you can plug them into social services or psychiatric care. So the nurses had said, you know, this is just getting them through the stage. We want to get them safely to the next part, right? They're safe here. And there was a recognition that sometimes patients come to the emergency department just to be safe, whether they acknowledge it explicitly or not. And so when they feel okay, then they go, they accept discharge without ever having to really disclose suicidality. And so there was some recognition of that. We found that barriers to good identification of suicidal patients, either overt or occult, were deficits in time, experience, education, and training. So this totally makes sense. Especially when we're talking about the patient who doesn't overtly declare their suicidal intent, these are very subtle cues, and it takes some experience and some education to really get the hang of noticing those subtle cues. Because there is so much over-reliance on checkboxes now that all of us are pretty much using electronic health records, you're triaging people while you're staring at a computer. And that, unless you are really, really good at what you do, or really able to separate those checkboxes from the person in front of you, right, where there's this big emphasis on throughput of patients over assessment. And this is where I think a lot of patients can fall through the cracks. Another barrier is a lack of community resources. I think a lot of nurses feel like, why does it matter if I identify this patient when there's nothing to do for them, right? I have no community resources to hook them up with. There's no way to keep them safe. Facilitators included the availability of behavioral health nurses within the emergency department. So nurses that understand and are trained specifically to deal with behavioral health crisis. Other facilitators were adequate training and experience to detect those subtle cues. And also the availability of safe spaces within the emergency department for the patient to be further assessed. So these are all the things that come out of the ENA study on assessing for suicidality. We know that the 2016 Sentinel event alert, the SE56, this reports over 1,000 suicides in the acute care setting or within 72 hours of discharge from an emergency department. So this is a big problem. The most common root cause for this was inadequate psychiatric assessment. So you've got, like, not just emergency nurses that don't have any post-licensure education. Emergency physicians don't either. And I think most of us are familiar with the intense discomfort with which physicians will reluctantly prescribe psychiatric medications. It's not their area of expertise. They're really uncomfortable with it. So patients tend to kind of languish in the emergency department. So out of this, the Joint Commission recommends using clinical judgment tools for the final determination of safety. We would all love for there to be some kind of acid test that can definitively say whether a person is at risk or not. It would be great to have a troponin for behavioral health. But there isn't. And so the final determination of safety is really challenging. And so the Joint Commission says that the vast body of research suggests that a screening tool can identify individuals at risk more reliably than a clinician's personal judgment. Okay. So that totally makes sense. However, if the triage nurse doesn't recognize the problem, the screening tool never gets used. So even if we have great tools, even if we have great processes, if the nurse that encounters that patient at the front end of the visit is not able to identify them properly, then it doesn't matter that we have these great tools and these great processes. So what our participants reported is that when they assess suicide risk at triage, it was usually by asking just one question. And I know that certainly in the emergency departments in which I work, there is sort of a checkbox about, you know, does the patient have any suicidal thoughts or homicidal thoughts? The nurses in our study really expressed concern about the effectiveness of asking just that one question because it is so tied up with the nurse's perception of risk, even in the way the question is asked. So if you're having a busy, busy night and you have somebody in front of you who's twisted their ankle, the way that the question tends to get asked is, you're not feeling suicidal, are you? And so the patient gets a very clear message that the answer to that question is no. And so the way that we are asking the question, I think, perhaps in a way, we're asking it to kind of soften the question a little bit. But I think that can backfire in terms of effectiveness. So what our participants describe is this effort to improve screening across the landscape of the patient's ED state. So there's this iterative process of assessment that, you know, includes further probing and eliciting, evaluating, reacting, pulling in other people, checking the chart, looking at other resources to really make sure that that patient is safe. And again, I can't stress enough, these are patients who raise red flags. This is not every patient who says, no, I really don't feel suicidal at all. That's not a patient that you're going to really put this enormous effort into determining risk. It's the patients who make you nervous because they're unkempt or because they look so depressed or because they're not making eye contact. You know, those are the patients that we're really worried about. So this triage decision is very, very critical. The decision to hand off is really important because it is that initial decision that can lead to the use of a decision-making tool farther along down the road. So all those things that the Joint Commission wants physicians to do, a lot of times they will do them because we tell them that it needs to be done. So this is really important. The nurse's role in this is incredibly important. The other thing that we worry about, I think, is false positives. So patients who might disclose suicidality or whom we think are suicidal and identify as such, we're really worried that false positives lead to frustration from providers. If everybody's suicidal, then nobody gets the care that they need. However, what's really important to keep in mind is that, as I said before, there are studies that find that most patients who die by suicide deny suicidality. And so looking at these other cues is super important. And what our nurses want to do in response to suspected suicidality is to allow more information, to dig up further information, to engage the patient, to really clarify what the patient's true state is with respect to their suicidal intent. So the conclusions of this particular study suggests that the effectiveness of asking a single question to determine suicide risk in a public triage area is questionable. Whether or not the same question asked in a quiet, private space is more effective, we can only imagine. Our participants report that engaging in this process, the iterative process that they want to conduct, is not well served by the conditions of any emergency department, which is chaotic and loud and busy and not private at all. Our nurses report that they are motivated to probe further based on behaviors that raise suspicion. If suicidality is identified, they take very specific actions to keep patients safe while they are in the emergency department. And we know that future efforts to improve triage assessment need to include screening tools that are not administered just at the front end, but throughout the course of the ED visit. And those tools should have some non-verbal items incorporated to further weight suicidality. So non-verbal like hygiene, like engagement, like social support. So that's a whole lot of stuff that comes out of this study. Now there's a lot that feeds into this eye care tool. So the purpose of this tool was to provide emergency physicians with a framework to assess patients for suicidal ideation while they're in the emergency department. And kind of a template for what to do, how to respond once risk is ascertained, because they can't necessarily keep everybody in their department for four days waiting for the psychiatrist to come to their critical access hospital. So emergency nurses are a critical piece of this, both in identification and care of the suicidal patient. So the tool was developed as an expert consensus document. So the contributors were an emergency physician, an emergency nurse, that was me, an emergency psychiatrist, and a psychiatrist. So it was a good, varied group of people who are all invested in the identification and care of suicidal patients. The tool is a mnemonic. The I is for identify suicide risk, and this is where the emergency nurse comes in very prominently. Communicate, assess for life threats, and ensure safety. Risk assessment, reduce the risk, and extend care beyond the ED visit. So I'm going to go through each piece of this, and I'm going to talk a little bit about how the work of the Emergency Nurses Association kind of feeds into how this works and how most emergency nurses are already doing a lot of these things, and we should be encouraging our physician colleagues to get into this as well. So in identifying suicide risk, the patient who presents with a complaint of suicidal ideation, as we talk about, is the primary target and the easiest to identify. But other presentations that should heighten your suspicion around suicidality include the patient who comes in with an overdose, either overtly accidental or overtly not accidental. A single-car MVC can be indicative of suicidal intent. A hanging injury, burns, cutting or other self-harm, depression, psychotic symptoms, including command hallucinations, and patients who present for changes in sleep, behavior, or substance use. Either they're not sleeping or they've ramped up their substance abuse or use. These all should make us think about risk. Other nonverbal clues. Now, this comes directly from our study. Poor engagement, so not making eye contact or hesitancy in asking, poor hygiene, flat affect, reports by family or friends that the patient is gathering lethal means, so firearms or medications. The family or friend who reports concerns, who brought them to the emergency department and may pull you aside and say, hey, I just want you to know. A discrepant history of presenting event or complaint and concerns from other providers. So if you're, this is, again, for our physician colleagues, if the nurse comes to you, social worker comes to you and says, hey, you know, I think we're worried about this patient. This communicate piece directly aligns with the theme that emerged from our study of creating caring spaces for more information to emerge. So this really fed into how we all structured this process. So again, we know that having a conversation in a crowded, loud emergency department does not really encourage people to disclose this information. So we want to try to have, to encourage our physician colleagues to have these conversations in private, comfortable spaces. You want to have food, blanket, make people comfortable so that they will disclose. The emergency department is here for patients with health problems. Mental health is one type of health problem. So the idea in this communication is to reassure the patient that mental health concerns are legitimate reasons to come to the emergency department, that there's some normalization in that conversation so that people won't feel like they're aberrant in their feelings of suicidality. So these are some suggestions for physicians, but frankly, I think nurses have these conversations all the time. So we want to assess for life threats and assure safety. So this is our big thing, right? Is the environment free of potential means, right? Potential lethal means. So do we have the sharps out of the way? Do we have cords out of the way? Ligatures, tubes, glass, anything that a patient could use to hurt themselves. So this aligns very much with the theme of insurance safety for now. So keeping our patients safe in the emergency setting is totally under the purview of nursing. So this, while this is a sort of a checklist for physicians, this happens, nurses do this, right? So it's really important to kind of have this as a process or a structure in your department as well. So we want to create a safe environment. We consider one-to-one observation, try to get a patient to change into a gown or be checked with a security wand to remove any metal objects. We want to make sure that there are no sharps and cords, any ligatures. And then, I think most departments have a process by which they search patients and remove weapons, pills, ligatures, anything else that the patient could use to hurt themselves or somebody else. The first R is for risk assessment. So once we have sort of this idea that, okay, here's a patient who might be at risk. We want to, you know, there's definitely some depressions, definitely a behavioral health component to this visit. Now we want to get a sense of their current risk for suicide as opposed to, I mean, there are a lot of people who walk around with suicidal ideation who will never attempt. And so those are the people who don't need to be hospitalized. And so we want to kind of separate those people out from the people who will benefit from inpatient care. So this idea of risk assessment aligns really well with the nursing response of probing further, which we found in the previous ENA study. So we're looking at psychiatric illness, history, and current symptoms. Are there any uncharacteristic behaviors? Are there changes in mood or anxiety or sleep patterns? Is the patient starting or increasing their use of alcohol? Is the patient previously sober and is now no longer sober? What was the precipitating event for that? What kind of physical health conditions does the patient have in addition to their possible depression and suicidal ideation? How many previous attempts for suicide were made and what were the consequences of these attempts? So was the patient hospitalized or did they swallow a couple of pills and then stop? What were the circumstances of those previous attempts and are they present currently? So all of those things can increase the risk that the patient will die by suicide. A very important piece here is assessing for access to lethal means, and that is critical to assess for the presence of firearms in the home. 90% of people who attempt suicide with firearms will be successful. It is an impulsive act, and if we can intervene at this point where the patient is safe in the emergency department, this is a super important assessment to make. So access to lethal means, which can include firearms, which can include prescriptions, other medications, drugs, other substances, and other methods that might be specified by the patient, including gathering means. So any patient who has access to lethal means or is deliberately seeking access is very high risk. So not all suicidal patients benefit from inpatient care. And in fact, patients who are hospitalized when they don't need to be have no reduced risk of suicide. In fact, they feel very out of control. It makes it almost worse. So how do we figure out who needs inpatient care and who can go home with community support? So patients who have very few risk factors and many protective factors might be able to be discharged from the emergency department for follow-up. So patients who are feeling depressed with some suicidal ideation who also have some of these life stressors on the left there. So job loss, financial stress, recent death of a spouse, a child, a parent, divorce, other issues that might lead to more depression. So legal problems, bullying, harassment, homelessness, recent life transitions. So those are some stressors that you can kind of, there's really no way to weight them. It's not like if you have three or more of these, you're more at risk. It's sort of looking at the totality of the patient presentation. Protective factors, however, will really be a good support. And those people are generally, all other things being equal, able to be discharged back to the community. So people with a really good support system, people who have mental health care already established so they have a therapist and the patient is engaged with them. So are they presenting to the department because they don't feel safe and they will disclose that to you and when they can engage with a plan to remain safe, which is not the same as contracting for safety, but somebody who's really able to engage and plan and I have an appointment tomorrow, I'm going to go tomorrow. Those people generally have, we would consider that protective. Reasons for living, you know, and it's important to ask patients, you know, what do you have to look for? Do you have a new baby? Do you have, are you in school? Are you, you know, all those sorts of things. Connection to community and support systems and cultural or spiritual beliefs that would foster connection and asking for help. So all of those things are very protective and can be taken into account. So if discharge is possible, right? So if the decision is taken that this patient, yeah, has some suicidal ideation, but is not a very high risk patient, if we can discharge them to the community, we want to go to the second R, which is reduce the risk. So we want to counsel them to reduce access to firearms and other lethal means. We ideally want to have someone else move the means out of the home, right? So it's not good for the patient to remove their own lethal means. So if the patient has firearms at home, you might want to have a plan by which the patient's friends or their brother or their parents, you know, go to the house, remove the firearms for the time being to keep them safe through this time. We can establish a safety plan. We can communicate that safety plan and the lethal means plan with family or friends as possible. So if people have come to the emergency department with the patient and we're talking about removing lethal means, then we share that plan with family and friends so everybody's on the same page. We share the medication as indicated for these patients. So we want to, however, patients who do not have a lot of protective factors, who have access to lethal means, who have previous suicide attempts, these are people who probably need to be admitted to inpatient care. So they're likely to attempt suicide. They don't engage with the discharge process. They don't cooperate with safety planning. Or they're just unable to manage outpatient care. Those are the people who need inpatient care. But in general, you can discharge a lot of people home. When we discharge patients back into the community, we move to the last part of the tool. So we're extending care beyond the emergency department visit. So if we're going to discharge people, we need to have a planning process that looks at high-risk conditions, such as their substance abuse disorders or their underlying psychiatric conditions. We need to be able to connect people with available resources. Ideally we'd set up that appointment from the emergency department and set it up for very soon after discharge. Another piece of this is follow-up care after discharge. So reaching out with phone calls or postcards and just asking people how they are, how they're feeling, how they're doing. There's actually a growing body of evidence that this idea of post-discharge communication reduces risk of suicide, especially in the Netherlands they do this a lot. And it seems to significantly reduce the risk of suicide. So this tool was developed for emergency physicians without immediate access to psychiatric providers. But the process outlined in the tool really mirrors the process by which emergency nurses described in our study managing suicidal patients over the course of the emergency department stay. So this tool, again, although developed for emergency docs, really becomes a good blueprint for emergency nurses in not just identification, but also assessment of risk, discharge planning, and talking with emergency care providers around the disposition decision. So it allows us really to advocate and anticipate the trajectory of the patient care visit for patients for whom we are concerned about suicidal ideation. So I will take any questions if there are any. You can access the ICARE-2 tool on the ASAP website. And it goes through all of these things as well. So thank you for your attention. And I'm happy to answer any questions I think my first question is. Hi, Lisa. Thank you for your presentation. It was very informative and gave me some interesting ideas to think about. One is I needed some clarification. You mentioned kids coming in and being cutters or cutting certain body parts. Do you see this tool applicable for pediatric patients? No. No. I'm sorry. This tool is designed for adults. I think of anybody under 30 as a kid. So that I misspoke in that. I don't mean pediatric patients. Did you say 30? Three zero? I think of anybody under 30 as a kid. But no. This tool is very specifically for patients over the age of 18. Okay. And then you, of course, mentioned that this tool was developed for physicians with your input as an ED nurse. So how do you anticipate ED nurses starting to use it? Well, funny you should mention. So I was working in the emergency department a few weeks ago. And we had a patient. And I referred the emergency physician to the tool. I'm like, are you aware of this tool? Do you know what to do with it? And so he looked it up and he was like, wow, this is really great. Like this is a terrific checklist to make sure I'm thinking about all these things. So for me, I think having a sense of what the trajectory looks like, what the assessment process looks like, and issues of identifying and reducing risk allow me to have that conversation with my colleagues, with my physician colleagues, and also say, hey, your own organization suggests you do it this way. So it's informational for me. It gives me some backing for what I'm advocating for. And it allows the physician to feel like, oh, okay, this is what my professional association says. And so I can kind of hang my hat on this a little bit. And do you see it taking a while to roll out into an ED environment if you've got a champion? Or do you think you need a champion to get it going? I think just making people aware that it exists will give, because this is a free tool. Anybody can access it. And so I've been talking to my colleagues with whom we developed this. And so I've just kind of been sharing it everywhere. Because I think this is very much, except for the disposition decision, this is all totally under the purview of nursing as well. Excellent. So we're hoping that anyone on this webinar is able to share the tool with their colleagues and physician colleagues particularly, and make them aware of it. And then, as you said, up to the disposition point, nurses can certainly not own it, but certainly encourage use of it. So thank you, Seth. Are there any other questions? If so, you can type them into the Q&A tab. All right, while we wait for any questions to come in, I just wanted to remind you that after this webinar, you will be receiving a link to the evaluation. You'll receive your CE credit after completing that evaluation. I do see that there are a few users on this webinar who called in on their phone. So I'm not able to see who you are. So if you are called in on your phone and you're not logged in via your computer, please send me an email. My name is Julie. You probably received some reminder emails from me. Just send me an email and let me know your name so that I can send you that evaluation. And I'm not seeing any more questions come in. I'd say thank you to Lisa for providing this very valuable information and the tool website so people can start using it. You'll be awarded one hour of C&E after you complete your evaluation. And we will follow up with an evaluation a couple months later to see if you've been able to use the tool in your environment. So hopefully some of you, even if you're not able to use it, you're able to share it with physicians who start using it. So thank you and have a great afternoon. And anyone on the Northeast or Midwest, keep safe from the snow and the frigid cold coming our way. Cheerio. Thank you. Thank you. Thank you, Lisa.

iCare2 tool

suicidal patients

emergency settings

identifying cues

assessing patients

managing care

emergency nurses

non-verbal cues

creating a safe environment

ongoing assessment