As psychiatrists, University of Vermont College of Medicine faculty members Isabelle Desjardins, M.D., and Sanchit Maruti, M.D.’10, deal with patients experiencing suicidal thoughts on a daily basis. A recent alert on national patient safety from non-profit health care organization accreditor The Joint Commission prompted Desjardins and Maruti to consider the safety of a much larger group of patients: the entire hospital population.

In hopes of reducing the more than 1,000 suicides that occur each year nationwide in non-psychiatric units in hospitals across the country, The Joint Commission is calling for hospitals to screen all in-patients and every patient treated in the emergency room, seen for an outpatient procedure, or who has been admitted to the hospital for their likelihood to commit suicide in the hospital.

In order to deal with the massive mandate, Desjardins, associate professor of psychiatry and medical director of inpatient psychiatry at Fletcher Allen Health Care, called on long-time collaborator Willy Cats-Baril, Ph.D., UVM associate professor of business, who develops predictive risk models for the medical community and specializes in health care management, to figure out how to create an effective suicide risk assessment tool. With $20,000 from the Fletcher Allen Foundation, they brought four of the most highly recognized suicidologists in the country to Fletcher Allen and the UVM School of Business Administration on October 8 and 9, 2012, to help develop an electronic algorithm designed to simulate the thinking of an experienced psychiatrist in the evaluation of imminent suicide risk.

The algorithm, which will eventually be an electronic questionnaire on a tablet, will allow for the assessment of a large volume of patients in an efficient manner, and provide short-term guidance to clinicians in identifying high-risk patients that require expert attention from psychiatrists.

“When Isabelle told me about the new requirement, I said, ‘Let’s try to replicate what psychiatrists would do,’” says Cats-Baril, who points out that if hospitals were to fulfill the regulatory mandate by hiring more psychiatrists they would require such a large number as to make it financially infeasible. “The panelists commended us for our innovative approach to address a regulatory requirement in a clinically meaningful way and suggested that if we are able to implement our model, we could have a significant national impact on public health.”

Putting the tool into practice

The charge of the panel over the two-day meeting was to create an assessment tool that incorporates suicide risk factors in a weighted manner; is clinically relevant and informed by suicide risk data; creates uniformity of suicide risk assessment among the medical, surgical and intensive care units, the emergency department and in-patient psychiatric units; is user-friendly and can be efficiently administered by all health professionals. The idea is that the assessment tool will optimize resource utilization by focusing psychiatric expertise where it is most needed and by using the existing electronic medical record infrastructure; and will improve quality assurance by systematically documenting suicide risk of every patient.

Cats-Baril says the panel of experts assembled at UVM brought expertise in each of the key areas necessary to develop an effective and efficient tool. These experts included Jan Fawcett, M.D., professor of psychiatry at the University of New Mexico, member of the American Psychiatric Association Guidelines on Suicide Work Group, and chairperson of the DSM-V Mood Disorders Work Group; Peter D. Mills, Ph.D., adjunct associate professor of psychiatry at Dartmouth, director of the VA National Center for Patient Safety Field Office and member of  the Joint Commission Sentinel Event Alert Panel; Morton Silverman, M.D., clinical associate professor at the University of Chicago and senior advisor at the National Suicide Prevention Technical Resource Center; and David A. Jobes, Ph.D., professor of psychology at The Catholic University of America. Robert Althoff, M.D., UVM assistant professor of psychiatry, psychology, and pediatrics, was also a member of the panel.

“From a business perspective, I was thinking in terms of how to meet a regulatory demand with scarce human resources while trying to maintain quality of care and spend the least amount of money,” says Cats-Baril. “I thought we could develop an effective solution by leveraging the expertise of experienced psychiatrists with information technology.”

In practice, the evaluation process would start when a patient arrives at the hospital for registration. After a medical record number is assigned, key demographic and hospitalization information would automatically populate the tool. For example, in the case of a patient coming through the Emergency Room, the triage nurse would ask initial screening questions, and depending on the answers, would assign the patient to a specific room and level of observation. The remaining questions would be administered by emergency medicine research associates, prompting the tool to generate a "risk suicide score" and associated stratification for the patient. This information would then be reviewed by an emergency medicine provider to determine if further psychiatric evaluation is required.

Addressing a growing concern

Since 1995, suicide has ranked among the top five most frequently reported events to The Joint Commission, an organization responsible for accrediting and certifying more than 19,000 health care organizations and programs in the United States, and it's the eleventh leading cause of death in the U.S., accounting for 33,300 fatalities in 2006. Although some suggested actions have been offered by The Joint Commission, like educating staff about the risk factors for suicide, few guidelines for developing an assessment tool were offered. Desjardins anticipates some hospitals addressing the regulation by simply asking patients if they feel suicidal. That won’t suffice when patients come to the hospital with a minor injury and find out they have a much more serious illness like cancer, causing them to fall into a deep depression that could lead to suicidal thoughts, she says.

“We have so many regulatory bodies today that regulations are becoming burdensome and causing low satisfaction for employees and patients,” Desjardins says. “We have a lot of opportunities to just check a box to meet a regulation or we can try to make it clinically relevant and show a positive outcome that makes the work meaningful.”

Cats-Baril hopes to extend the results of the project by conducting a multi-center testing of the tool to measure its usability and usefulness by tracking quality of patient care, time spent, staff satisfaction and resource utilization. Desjardins, Althoff and Maruti and Cats-Baril will seek funding from the National Institutes of Mental Health, which has outlined the importance of the development of clinical risk assessment instruments that encompass multiple domains as one of the areas of strategic research priority.

“The panelists unanimously thought the meeting was a breakthrough, asked us to keep them involved, encouraged us to go for funding at the national level and said that they would support us in that quest. It’s exciting," Cats-Baril says.