Calc Function

    • Calcs that help predict probability of a diseaseDiagnosis
    • Subcategory of 'Diagnosis' designed to be very sensitiveRule Out
    • Disease is diagnosed: prognosticate to guide treatmentPrognosis
    • Numerical inputs and outputsFormula
    • Med treatment and moreTreatment
    • Suggested protocolsAlgorithm

    Disease

    Select...

    Specialty

    Select...

    Chief Complaint

    Select...

    Organ System

    Select...

    Patent Pending

    ED-SAFE Patient Safety Screener (PSS-3)

    Screens for suicidality in emergency patients.
    Favorite

    INSTRUCTIONS

    Use as an initial quick screen for suicide risk.

    When to Use
    Pearls/Pitfalls
    Why Use

    Emergency patients presenting for any complaint, even non-psychiatric complaints, to screen for suicide risk.

    • Dependent on the patient’s ability to answer the question; thus, it cannot be used in patients who cannot engage in conversation (e.g. if intubated or with altered mental status).

    • Has strong agreement with well-established but lengthier suicide risk assessments like the Beck Scale for Suicide Ideation (BSSI).

    • 3-12% of ED patients presenting with non-psychiatric chief complaints actually have suicidal ideation (Boudreaux 2013). Identifying these at-risk patients is an important first step in implementing an intervention to prevent death/sequelae from suicidal behavior.

    • Traditional suicide risk measures are lengthy and complex. ED-SAFE PSS-3 is a short, efficient screener that can be easily integrated into the existing ED clinical workflow.

    Ask the patient:
    No
    Yes
    Refused to answer
    No
    Yes
    Refused to answer
    No
    Yes
    Refused to answer

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    Patients screening positive should be further assessed by the treating physician to determine if a mental health professional should be consulted. A safety plan may also be considered.

    Management

    • The ED-SAFE PSS-3 is a screen and not an endpoint. A positive screen should prompt provider to delve deeper in assessing the patient for suicidality and to consider consulting a mental health professional for the patient.

    • More in-depth screens or assessments for suicide risk include the Beck Scale for Suicide Ideation (BSSI) and Columbia Suicide Rating Scale (C-SSRS).

    • Patients for whom providers have high concern for suicidality should be assessed by a mental health specialist.

    Critical Actions

    The ED-SAFE PSS-3 is meant to be a universal screening tool. Patients presenting to the ED, regardless of whether the primary complaint is psychiatric or not, can be screened with this universal screening tool.

    Formula

    Positive screen = selection of “Yes” to question 2 or 3 below:

    Variable

    Ask the patient:

    1. Depressed mood

    “Over the past two weeks, have you felt down, depressed, or hopeless?”

    No

    Yes

    Refused

    2. Active suicidal ideation

    “Over the past two weeks, have you had thoughts of killing yourself?”

    No

    Yes

    Refused

    3. Lifetime suicide attempt

    “In your lifetime, have you ever attempted to kill yourself?”

    No

    Yes

    Refused

    3a. Recent suicide attempt (if it happened within the last 6 months)

    “When did your last attempt occur?” (only ask if yes to question 3)

    Today

    Within 30 days

    Within 1-6 months

    >6 months

    Does not know

    Refused

     

    Evidence Appraisal

    Boudreaux et al (2013) set up the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Study to determine if universal screening of ED patients could improve detection of patients with suicide risk, and if an intervention initiated from the ED visit can improve outcomes related to suicidality. Given the high-risk nature of suicidality, the ED-SAFE investigators opted for a quasi-experimental multi-phase design instead of a randomized control trial.

    Patients presenting to eight EDs across seven states including large academic centers and small community hospitals were included. The objective of Phase 1, “Treatment as Usual” (TAU), was to obtain baseline data. Research assistants prospectively collected data from chart documentations of intentional self-harm, and patients received usual care. In Phase 2, “Universal Screening” (SO for “screening outcome”) was implemented with the 3-item Patient Safety Screener (PSS-3) by the primary treating nurse. In Phase 3, “Universal Screening Plus Intervention” (INT), those who screened positive had secondary screening by a physician to determine whether to consult a mental health specialist. Patients also received a safety plan and had up to seven subsequent telephone follow-up calls over the next year as part of their intervention. Outcomes were assessed by telephone interviews or medical record review at 6, 12, 24, 36, 52 weeks.

    The 3-item Patient Safety Screener (PSS-3), which this calculator reflects, is the universal screen that was used for the ED-SAFE Study. The original Patient Safety Screener consisted of 5 items (PSS-5) derived from the Patient Health Questionnaire-9 (PHQ-9) and Columbia Suicide Rating Scale (C-SSRS). PSS-5 assessed for anhedonia, depressed mood, passive suicidal ideation, active suicidal ideation, and lifetime suicide attempt.

    The primary study by Boudreaux et al (2013) compared a 2-item and 3-item Patient Safety Screener (PSS-2 and PSS-3, respectively) with the well-validated but much lengthier Beck Scale for Suicide Ideation (BSSI). The PSS-3 contained the questions of depression, active suicidal ideation, and prior lifetime attempt while the PSS-2 omitted the question related to depression. Patients unable to engage in conversation (intubated, altered, etc) were excluded. Patients tested positive if there was active ideation in the last 2 weeks or if there was lifetime history of suicide attempt. 951 participants were enrolled across three EDs; 459 participants were randomized into the PSS-2 group versus 492 participants in the PSS-3 group. Overall, 15.2% had a positive screen. There was strong agreement between the PSS-2 (Kappa 0.94) or PSS-3 (kappa 0.95) with the BSSI. However, the PSS-3 had stronger agreement with the BSSI compared to PSS-2 in regards to active ideation (kappa 0.61 versus 0.34, respectively).

    In a prospective observational cohort study (essentially Phase 1 in the larger ED-SAFE Study) Caterino et al (2013) summarized the baseline suicide risk screening rate. 94,354 charts were reviewed. One site had a version of universal screening as their “treatment as usual.” Excluding this site, overall, 12% of patients were assessed for self-harm. If this site were included, 26% of patients were assessed. In this Phase 1 study, only 2.7% of patients were documented as having current self-harm. In addition, Caterino et al found that younger men are more likely to be assessed for self harm and older adults are less likely to be assessed.

    To analyze the effect of “Universal Screening,” Boudreaux et al (2016) reviewed 236,791 charts. Documentation of suicide risk screening increased across the phases of the ED-SAFE study: 26% in Phase 1, 73% in Phase 2, 84% in Phase 3 (p <0.001). With increases in screening, there were also increases in detection: 2.9% in Phase 1, 5.2% in Phase 2, 5.7% in Phase 3 (p <0.001).

    Miller et al (2017) analyzed effects of implementing an ED-initiated intervention for patients screening positive on the universal screening. The intervention consisted of a secondary suicide risk screening by the treating ED physician, safety plan reviewed with the patient by nursing staff, and telephone follow-up calls by advisors trained on the Coping Long Term with Active Suicide Program (CLASP) protocol to reduce suicide risk. 1,376 participants were enrolled: 497 in TAU, 377 in SO, 502 in INT. They found that 89.4% had a secondary suicide risk assessment, but only 3.9% received the ED-SAFE designated secondary screening tool. 37.4% of the participants reported having received a written safety plan from the ED visit.

    Of the enrolled participants of the intervention group, 60.8% completed at least one CLASP telephone call. There was at least one suicide attempt in 20.9% of the participants over the study year: 22.9% in TAU, 21.5% in SO, 18.3% in INT. There was also a reduction in overall suicidal behaviors (suicide preparation, interrupted/aborted suicide attempt, suicide attempt, death by suicide): 46.3% overall, 48.9% in TAU, 49.6% in SO, 41.4% in INT. The intervention showed a small reduction in suicide risk and overall suicidal behaviors compared to “Treatment as Usual,” equating to an NNT of 22 and NNT of 13, respectively.

    Literature

    Dr. Edwin D. Boudreaux

    About the Creator

    Edwin Boudreaux, PhD, is a professor of emergency medicine at the University of Massachusetts Medical School in Worcester, MA. He is also the vice chair of research for the emergency medicine department. Dr. Boudreaux’s primary research is focused on suicide risk screening.

    To view Dr. Edwin D. Boudreaux's publications, visit PubMed

    Content Contributors
    About the Creator
    Dr. Edwin D. Boudreaux
    Content Contributors