Evaluation of a Universal Suicide Risk Screening Program in a Large Non-Profit Health System

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Introduction: In 2019, the Joint Commission updated National Patient Safety Goal 15.01.01, which details regulations for the prevention of suicide in the hospital setting. Specifically, the “elements of performance” include a mandate for hospitals to screen individuals presenting with behavioral health conditions for suicide risk using an evidence-based screening tool. While this update represented an improvement in suicide safety, hospitals may achieve compliance with the standard while failing to identify all individuals at risk for suicide. We evaluated the implementation of a project regarding this mandate in a large non-profit health system that deployed a Universal Suicide Risk Screening Program across 22 facilities. Method: Program leaders conducted a retrospective evaluation, using pre-intervention and post-intervention data, to determine compliance with the program’s screening requirements and to assess the program’s effectiveness in detecting high suicide risk compared to “care as usual.” Results: During a 2-year post-implementation period, the health system achieved 94.56% compliance with universal suicide risk screening across nearly 1.3 million unique patient encounters. Analysis revealed a statistically significant increase in the percentage of total encounters determined to be high risk for suicide in the post-intervention period compared to the pre-intervention cohort. Post-intervention, individuals presenting with non-behavioral health conditions accounted for 23.88% of the encounters determined to be at high risk for suicide. Discussion: The first step in preventing in-hospital suicides is identifying individuals at risk for suicide. Widespread compliance with universal screening for suicide risk was achieved and sustained in a diverse set of hospitals and care settings. Universal screening can be an effective strategy to detect high suicide risk, especially in individuals presenting with non-behavioral health complaints.

Suicide Risk Screening, Universal screening, Suicide prevention