Webinar for Nurses - How to Use the ASQ to Detect Patients at Risk for Suicide

Transcript

>> LISA HOROWITZ: Hello. My name is Lisa Horowitz. I'm a clinical psychologist and staff scientist at The National Institute of Mental Health, the NIH. And today, we're going to talk about suicide risk screening with the ASQ, the ask. And we're going to focus on training for nurses. Before I get started, I want to tell you that because I work for the government, I'm going to put up this disclaimer slide. And I have no financial conflicts to disclose. So the objectives of the training, today, will be to identify suicide and suicidal behavior as a national and global public health crisis. And we're going to look at the importance of screening youth and adult patients for suicide risk in the medical setting. And then, we're going to talk about appropriately administering the ASQ suicide-risk screening tool for all patients that meet the criteria of your individual hospital.

So I always like to start with my last slide and that my take-home message is going to be I'm a big advocate for universal suicide-risk screening for all patients in medical settings. And whether or not you're screening the medical patients or the behavioral health patients, asking directly is the most important part of the screening. Clinicians require population-specific and site-specific validated instruments. And so the ASQ has been tested in the medical setting with both children and adults. And I'm going to talk about a clinical pathway, which is a three-tiered system for implementing suicide-risk screening in a hospital. And it starts with a brief screen, which should take 20 seconds and, then, follows with the brief suicide-safety assessment, which should take about 10 minutes. And that determines whether or not a patient needs a full psychiatric safety evaluation, which will take 30 minutes. Now, today, we're going to focus-- and this is the training for the nurses. We are just going to focus on the brief screen, administering the ASQ. It's recommended that all patients be discharged with a safety plan, resources like the Suicide Lifeline and the Crisis Text Line, and they receive means-restriction and safe-storage education.

So just to give you some background of why suicide is such an important public health problem, it's actually an international public-health problem right now. And upwards of 800,000 people, every year, around the world, kill themselves. And it is the second leading cause of death for young people in the United States and worldwide. In 2008 the World Health Organization did a study that showed more people died by suicide than homicide and war combined, so more people killing themselves than are killed. In the United States, it is the 10th leading cause of death among all ages. Nearly 47,000 Americans kill themselves every year. And, as you can see, that suicide rate, over time, just keeps rising. For youths, it is the 2nd leading cause of death for kids 10 to 24. And in 2017 there were 6,769 deaths of young people by suicide. And that makes up a quarter of all deaths in this country for that age group. And, again, the suicide rate, over time, for young people, looks very much like the one I just showed you. And it just keeps creeping up. We have not been able to make it go down. And, in fact, more young people die of suicide than the seven other leading medical causes combined. Now, suicide's still a relatively rare event. What's more common than suicide is suicidal behavior and suicidal ideation so in 2017 for adults over the age of 26, almost 739,000 adults attempted suicide. And then, even more common, you can see just a staggering number of 7 million adults had serious thoughts of suicide with almost 2 million making a plan. For young people, the numbers are even higher, with almost 2 million adolescents attempting suicide every year. And these data are from the National Youth Risk Behavior Survey that goes into just your average high school and asks young people to self-report on all kind of teenage behavior like drinking and smoking, but it asks about suicide. And a little over 7% of your average high school student reported that they tried to kill themselves in the past year, and 3% went as far as making attempts that resulted in medical treatment. And then, even more common is thinking about suicide, suicidal ideation, with 17% of high school students self-reporting that they seriously considered attempting suicide in the past year, and 13% making a plan.

There's a myth that younger children don't think about suicide. But actually, children under 12 do plan, attempt, and die by suicide. It's actually the fourth leading cause of death for the age group 8 to 12 years old. And actually, in the 10 to 14-year-olds, death by suicide has just exceeded death by motor vehicle accidents, and that's the first time that's happened. We just looked into some of our data from the emergency department and we just published this study in hospital pediatrics, and we found that in our study, looking at 10 to 12-year-olds, 29% had screened positive for suicide risk and 17% of them reported a past attempt. So you can imagine if a 10, 11, or 12-year-old is reporting a past attempt, that's happening at a very young age. So this is just a tremendous public health crisis.

These are the risk factors for suicide. I'm not going to go through every one, but I highlighted previous attempts because this is the most potent risk factor. We have a saying in psychology. Anyone who's tried to kill themselves in the past is at risk for killing themselves in the future. Past behavior is the best predictor of future behavior, and this is absolutely true for suicide. Mental illness, so 90% of people who kill themselves have a diagnosable mental illness. And then, I wanted to highlight medical illness because this is an often-overlooked risk factor. Anyone who has a medical illness is at elevated risk for suicide. So I want to talk about warning signs and the reason-- so let me just go back for a minute to the risk factors. So most people who have these risk factors-- and there's many who do-- will not die by suicide because they're risk factors. And if you were a triage nurse in an emergency department, which some of you may be-- let's say somebody came in with risk factors for heart attack and they had family history and they were obese and they were a smoker with high blood pressure and high cholesterol. When they walked up to your triage desk, you would not think they were having a heart attack. But if they came in with warning signs for a heart attack, if they were sweating profusely clutching their chest in pain and pain radiating down their left arm, you might say that's a warning sign for a heart attack. Well, the same goes for suicide. There's risk factors and there's warning signs. So these are the warning signs that someone might be at imminent risk for suicide. So the obvious one is they're talking about wanting to kill themselves. That should always be taken seriously. But if they're feeling hopeless or trapped or like they're a burden, or they're increasing their use of alcohol or drugs or acting agitated and increasingly anxious, sleeping too little or too much or withdrawing, showing rage or mood swings, these are all signs that someone could be at imminent risk for suicide. So our research group has looked at can we save lives by screening for suicide risk in the medical setting, and I'm hoping that by the end of this training, you will be convinced that we can. So suicide in the hospital is a very rare but devastating event. It actually ranks as the top five most frequently reported sentinel event in the joint commission. So in the last 18, 20 years, there's been over 1,300 in-hospital suicides reported to the joint commission, and this is most likely an underrepresentation because reporting is sometimes underreported. So this comes out to about somewhere between 70 and 90 suicides per year. And what most people think is that these suicides happen on behavioral health units only, but the truth is is that 25% of these suicides, a quarter, occur on non-behavioral health units, so those are places like the emergency department, the ICU, the med-surg unit, the cancer wards. These are happening all over in hospitals. In 2007, the joint commission put out national patient safety goal stating that all behavioral health patients in psychiatric hospitals and in general medical settings should be screened for suicide risk, and this goal has just been confirmed recently and updated. In 2016, the joint commission issued a sentinel event recommendation, recommending that all medical patients be screened for suicide risk, and that is not yet a mandate, but that's a recommendation. So that was a big deal for suicide prevention in the medical setting and that was in February of 2016. If we look at the joint commission most frequently reported sentinel events for the past three years that we have data on, you can see that suicide is listed within the top five.

Now, I also highlighted falls. These are fatal falls, because a sentinel event is when a patient dies unexpectedly. So I highlighted falls to show that hospitals have routinized way of screening for falls risk, but they do not have a routinized way of screening for suicide. When you look at the root cause analyses of these suicide sentinel events, the number one root cause is lack of assessment. So that's very important, that underdetection is a really difficult problem, especially in the hospitals. So if you look at death registry studies, the majority of people who die by suicide have had contact with a medical professional within three months of killing themselves. And sometimes it's even a shorter period of time. So 72% of adults in the last few months had visited a healthcare provider or medical setting, and for young people, 38% had contact with a healthcare system within four weeks. Now the problem is is that a lot of times, people don't walk in and say, "I'm thinking of killing myself." They frequently present with somatic complaints and if they're not asked directly, "Are you thinking of killing yourself?" They will not talk about it. So that is why it is so important because the majority of suicide attempters go unrecognized because the majority of healthcare settings do not screen. So it's really important to ask directly okay. So I wanted to show you this Mayo Clinic video that they've given me permission to use in my presentations. But it's, actually, one of the most powerful public-service announcements there is. And anyone can use it. It's on YouTube, so anyone can google this and get it. But I wanted to show it to you now. It's geared towards talking to adults about kids. But it really pertains to either youth or adults. So I'd like you just to spend the next few minutes and play this video.

[music]
I had my ups and downs just like anybody else.
Maybe more than anybody else.
I can be hard to figure out.
And I like my privacy.
I don't want you looking over my shoulder all the time.
But you know your kid better than anybody else. And if you think he's acting different than usual.
Acting really down, crying all the time for no good reason.
Or getting really mad.
Not able to sleep or sleeping too much.
Shutting her friends out or giving her stuff away.
Acting reckless, drinking, using drugs, staying out late.
Suddenly, not doing stuff he used to love.
Or doing stuff that's just not like him.
It might be nothing to worry about. It might just be high school.
Or it might be something more. He might be depressed.
Not just feeling down, really depressed.
It might be that your kid is thinking about killing himself.
It happens more than you think, more than it should.
And people say, "I had no idea."
"I thought it was just a phase he was going through."
"I never thought she'd do it."
"I wish he'd come to me."
"I wish she'd said something."
"I wish I'd said something."
Then, it's too late. So if you think your kid's acting different, if she seems like a different person, say something.
Say, "What's wrong? How can I help?"
And ask straight out, "Are you thinking about killing yourself?"
It doesn't hurt to ask. In fact, it helps.
When people are thinking about killing themselves, they want somebody to ask.
They want somebody to care.
Maybe you're afraid you'll make it worse if you ask. You'll put the idea in their head.
Believe me, it doesn't work that way.
It doesn't hurt to ask.
In fact, the best way to keep a teenager from killing herself is to ask, "Are you thinking about killing yourself?"
And what if they say yes?
Or maybe.
Or sometimes.
Well, here's what you don't say.
"That's crazy."
"Don't be such a drama queen."
"You're making too much of this."
"That boy's not worth killing yourself over."
"That's not going to solve anything."
"You're just trying to get attention."
"You're not going to kill yourself." What you do say is--
"I'm sorry you're feeling so bad."
"How can I help?"
"We'll get through this together."
"Let's keep you safe."
A lot of people think about killing themselves, adults and kids.
Most of them never try it, but some of them do. So if your kid says--
"I'd be better off dead."
"I can't live with this."
"I'm going to kill myself."
Take her seriously. FInd someone she can talk to about it, someone who knows how to help.
Sometimes kids want to kill themselves because something happened, a breakup, a failure.
But sometimes it goes deeper, and it's not going to go away by itself.
Get some help. Talk to your doctor.
Or a counselor at school.
Or your minister.
But don't just let it drop.
And make sure that your kid always has someone to turn to, someone he trusts.
Make a list together, right then, three, four, five names.
Put the suicide hotline number on there too.
Have him keep that list in his wallet so he always knows where to turn.
Be sure your home is safe.
If you have pills she could use to hurt herself, lock them up.
If you have a gun, don't just lock it up. Get it out of the house, bullets too.
And one more thing, if you think your kid might be about to hurt himself, don't leave him alone.
Take him to the emergency room.
Call 911 if you have to.
We all have our ups and downs, but sometimes it's more than that.
If you think something's wrong, the only way to find out is to ask.
Ask straight out, "Are you thinking about killing yourself?"
Don't wait until you're sure. Trust your gut because it never hurts to ask.
And it can make a big difference.
All the difference.
Your kid's life.
[music]

Okay. So they talk about asking directly about suicide in that video. And I just want to talk about the way to ask directly and the difference between a screening tool and an assessment tool because what the nurses will be doing will be administering a screening tool. So a suicide-risk screening is, really, meant to identify an individual at risk. It's meant to flag someone who needs further assessment. The screening tool should be brief and rapid and only take 20 seconds. And that is what the ask does. It does not predict who's going to kill themselves. It is just meant to flag who needs further evaluation. And the further evaluation comes in the suicide-risk assessment. So the assessment is a more comprehensive evaluation. It confirms the risk, and it guides the next steps. So in your case, the nurses will just be doing the screening.

So what are the valid questions that nurses and physicians can use to screen patients for suicide risk in the medical setting? Well, what we did was we launched a study. And the ask was born out of a multi-site study from three children's hospitals in Boston, Washington, and Columbus, Ohio. And I'm not going to get into details of the study too much, but we included medical patients and psychiatric patients in our study. And what we came up with was the Ask Suicide-Screening Questionnaire. So these are, what we consider, the most efficient and effective questions to screen for suicide risk. The first one, "In the past few weeks, have you wished you were dead? In the past few weeks, have you felt that you or your family would be better off if you were dead? In the past week, have you been having thought about killing yourself? Have you ever tried to kill yourself?" If the patient answers yes to any one of those four questions, then you ask the fifth question, the acuity question, "Are you having thoughts of killing yourself right now?" These questions have been tested. They have a high sensitivity, which is a true positive rate of almost 97%. They have a high specificity, which is the true negative rate, which limits false positives of 87%, and good negative predictive values almost 100%.

Okay. I wanted to show you, in our study, what kids said when we did study evaluation questions. Why should nurses ask kids about suicide in the hospital setting? And I'm going to show you some kid responses. But I will tell you, in our adult studies, the adults said very similar things. So 95% of young people were in favor of nurses screening for suicide risk because a lot of kids, especially teenagers, get sad and don't have anyone to talk about it with. So if a teen is already in the ER and with people who are trained, it's a good time to talk because a lot of them are dying, running away, feeling stressed out because of their parents and don't know what to do. Sometimes when no one asks them, they feel no one cares. When someone asks, they know someone cares about them. And then, just to look at the negative responses - so this was 5% of the kids who thought nurses shouldn't ask - they said things like, "You should only ask kids that have mental health problems because it's not something you should ask because it will make kids think about suicide. And not everyone feels comfortable about  people about their problems. Sometimes, they can lie. Okay. So over 95% of the kids were in favor and over 85% of the adults. The ask has now been validated in the inpatient medical-surgical unit, the outpatient primary care specialty clinics, being validated in these other places, and it's available in these 14 different languages. So the common concern. Can asking patients questions about suicidal thoughts put ideas into their heads? I will tell you that this is a myth and it's been refuted by four research studies showing that asking questions about suicide does not put the idea into someone's head. And in fact, as you heard in that video, the best way to stop someone from killing themselves is to ask them directly: Are you thinking of killing yourself? So we have an ask toolkit available and it's divided up by venue in the medical setting. And so we provide scripts for nurses or medical assistants, whoever is screening, and the scripts look something like this. So for an adult, we ask that you ask these questions in private to either the adult patient or the child patient. And so we have this script. "We have a few questions we ask in private. I'm going to ask you to step out of the room for a few minutes." So just so you know, the screening should take about 20 seconds, and most of the time, it will be negative. And when it's positive, it takes a little bit more, but maybe just a couple of minutes more. So the visitor doesn't have to leave and go to the cafeteria or get-- the visitor just literally has to step out of the room for a few minutes. And then, you turn to the patient and you say, "At our hospital, we're committed to patient safety. Many things, including medical problems, can cause emotional distress. Sometimes, [many people?] have thoughts of suicide. Therefore, we are asking all patients a few questions about suicide." Now, I should pause here and say that every hospital has individualized their script, so your script might not be exactly like this and you should follow the scripts of your own institution. If a patient screens positive, it's important to say something like, "It's important that you spoke up about this. I'm going to talk to your medical team and someone who's trained to talk to patients about suicide is going to come speak with you," because the patient's going to receive a further evaluation.

For kids, it's also similar. "National safety guidelines recommend that we screen all kids for suicide risk. We ask these questions in private, so I'm going to ask you to step out of the room for a few minutes. If we have any concerns about your child's safety, we will let you know." So that's what you say to the parents. For kids, it's very important that you do not ask the child if it's okay to ask their parent to step out and that's because it puts too much burden on the patient. So you really, in a very normal this-is-the-way-we-do-things kind of attitude, you just say to the parent, "I'm going to ask you to step out for a few minutes because we ask these questions in private." Now, I will tell you from doing nurse trainings that one of the number one things nurses get anxious about is asking the parent to leave the room. They are worried the parent won't want to do that. So I have real evidence to show that most of the time, this is not an issue. Most of the time, the parent just steps out. Sometimes, a parent does not want to step out and it is okay to ask the questions with the parent in there because then, you're modeling how to talk to kids about suicide risk. You're more likely to get a better response from the child, a more frank response if the parent's not in the room. But if you have to, you can ask the questions with the parent in the room. And then, you turn to the child and you say, "Now, I'm going to ask you a few more questions," and you administer the ask verbatim. This could also be a time when you  after you administer the ask that you adminster the domestic violence questions or any other questions you want to ask in private. If the patient screens positive you praise them. I'm so glad you spoke up about this. I'm going to talk to your parent and your medical team. Someone who's trained to talk with kids about suicide is going to come speak with you and you say to the parent, we have some concerns about your child's safety that we would like to further evaluate. It's really important that he or she spoke up about this. I'm going to talk to your medical team and someone who is trained to talk with kids about suicide is going to come speak with you and your child. Now, I want to highlight what you don't do here because this is a brief screen you do not turn to either the parent or the child and say you are suicidal or your child's suicidal because this is a brief screen. So we just say that we have some concerns about your safety and we want to further evaluate and that's really important. So again, those are the four ask questions and it's really important that you ask them verbatim. When we have done debriefings with some nurses they have told us that they changed the questions because they didn't really like them and I could see how they're blunt and direct but every one of these questions has been tested statistically in a research study and so it's really important that you ask them verbatim just as they are and what nurses tell us is that after practicing these and saying them with their patients after a few weeks they get very comfortable. All right.

What happens when a patient screens positive? So what's considered a positive screen on the ASQ? Well, there's two ways to screen positive. So remember that most of your patients and I'm going to say somewhere over 90% of your patients are going to screen negative. So most of the time this is going to be just a no, no, no, no. When they do screen positive it will be a non-acute yes to one of the four questions. For young people, if they refuse to answer then you count that as a non-acute positive and that's because we have some data showing that 85% of the people who won't answer have very significant psychiatric histories that put them at a higher risk for suicide. So it's important to count them as non-acutes. For the adults, if they don't want to answer, then they're an adult and they're allowed to refuse like they would any other medical test. The provider, whoever that is in your hospital, I think in your hospital it's social workers will conduct a brief suicide safety assessment to determine if more extensive psychiatric evaluation is necessary and patient may not leave until this brief suicide safety assessment is completed. The less common way is the acute answer yes to number five. Are you having thoughts of killing yourself right now? So in your hospital, you're going to be screening behavioral health patients and so the non-acutes will be actually a little bit higher rate than 90%. I want to correct that and for the acute positives, you might have more acute positives as well. The patient should not be left alone. They should be placed on safety precautions according to the standard of care in your hospital and for out-patient settings, emergency services will need to be contacted. In these acute cases, the brief suicide safety assessment is not necessary because the patient is automatically deemed at imminent risk and so what we have found from data and overseeing and consulting with hospitals that have screened for suicide is that the screening does not overburden the system. That it actually is if you follow a good implementation plan that it's an effective and efficient way to manage suicide risk in your hospital setting.

So this is just a reminder of the screening. It's going to be a three-tiered pathway and the nurses are going to be responsible for the brief 20-second screen. That's just what the pathway looks like. Each institution adapts it according to how they want to do it. I'm not going to go through that but it starts with the administering the ask. There are brief suicide safety assessments that the social workers will receive to do the follow up of all positive screens and they vary depending on medical setting. We can discharge all patients with resources so they can get these mental health resources and the most important ones are the National Suicide Prevention Lifeline and the Crisis Text Line and those are manned 24-7 by trained professionals and anybody can use that and that can be someone who's at risk for suicide or someone who's worried about someone at risk for suicide and then we have some links to videos that we showed you today. Here are some additional considerations.

What if a patient refuses to answer the questions? So for adults, they're allowed to decline medical tests. For youth, you count them as a positive screen. Do I contact for safety with the patient? So this is something we used to do. We used to call them safety contracts. They are no longer valid. We do not contract for safety. That used to be when you said to the patient, do you promise you won't kill yourself and I'm going to step out for a minute or you're going to go home and then that made the provider feel better when they signed it. We don't think these are valid. Now, instead we do safety planning and we say what are you going to do if it's 2:00 AM and these suicidal thoughts come to you? But that's not something that we're asking the nurses to do. Can asking questions about suicide make the patient suicidal? That is a myth and it's not true.

What if the patient does not seem like they are suicidal? Do I still need to ask? So when you do a screening it needs to be systematic and it needs to happen every time. You can't see suicidal ideation and you can't know who's at risk for suicide unless you ask directly. What if patient starts talking to the nurse about suicidal thoughts in detail? This might happen and if this happens you sit down and you say I'm so glad you want to talk about this. I'm going to get someone who's trained to talk to people about suicide who's going to come talk with you. We really didn't want to put that on the nurses. You are the bridge to getting them the mental healthcare that they need. For youth, some additional considerations.

What if the parent refuses to leave the room? You proceed with the questions anyway. Or what if the parent or guardian won't cooperate with the disposition plan? If you say I'm going to call someone who's going to do a further evaluation. We have seen this on rare occasions. You will treat this as any other intervention that was going to happen in your hospital that had to happen that was denied against medical advice. So it's like an AMA and you treat that according to the laws of your state and the guidelines of your hospital. Okay.

Important considerations for pediatrics is that we think fliers should be given to parents and guardians at the triage, at the unit clerk's desk upon admission, upon registering. Don't forget to ask the parent or guardians and tell them, not ask them to step out for a couple of minutes. No response is treated as a positive screen and after a patient screen positive if they're under 18 they need to be told that their answers will be shared with their parents and that's because suicide is not covered by confidentiality we're all mandated reporters. So just some implementation examples: Parkland Health and Hospital Systems screened over two million adults and young people for suicide risk, and what they have found is that it did not overburden their system, and it helped them take better care of patients. So you can make a difference.

There are things any individual can do right now to prepare to save a life: that's the National Suicide Hotline, that's the Crisis Text Line, the NIMH has a website, and we basically talk about, ask, keep them safe, be there, help them connect and stay connected. I want to pause right now to show you a video, and this is from our partners at Mercy Children's Hospital in Kansas City. And this is about young people, but it really pertains, I think, for nurses who are screening for young people or adults.

[music] Suicide is the second leading cause of death for young people ages 10 to 24, claiming more than 5000 lives each year in the United States. As many as one million teens a year attempt suicide. Children's Mercy is dedicated to doing something about that.
Teenagers are very concrete, and if you don't address it directly with them they won't bring it up.

To me, it is a piece of being very holistic in our care. It's very easy to become centered on a diagnosis or the exact problem, but this is a person, and we need to do what we can to reach out to them, especially for younger people. They don't even know how to express what's going on in their head.

That's why we implemented a screening process in hopes of identifying patients at risk for this preventable cause of death.
I've never had a patient just say they were suicidal or had ever thought of suicide, and me go in the room and go, "Oh, that patient obviously looks like they've thought of suicide." It doesn't correlate. There's no good way to look at them to just outwardly say, "This patient obviously is a risk for suicidal ideation or suicidal thoughts." Really, it's that direct questioning. It needs to be there, and if it's not asked we don't know the answer.

In the Children's Mercy screening program--
The parents are not in the room when we ask these questions, just because teenagers, or any kids, they're not going to always be honest if their parents are there.

But we do not keep secrets and always inform the family of concerns.

There are questions you ask. As soon as you have those questions you're done.

The vast majority of parents are more than happy to have us do it. The kids who have these thoughts want somebody to know, so they are more than willing to tell you.

It starts a topic of conversation. I've had numerous families afterwards contact me and say, "This was something that at first I was kind of offended you were even asking, but then on the car on the way home they brought it up."

Children's Mercy has screened thousands of patients and identified hundreds of teens at elevated risk for suicide. Last year alone we had about 300 positive screens from youth ages 12 to 21. Mental health care providers respond to positive screenings and determine next steps to keep patients safe. Families leave with the resources they need should further mental health services be necessary. The social work staff not only connects patients with resources and services, they help the family build a safety plan for home and school.

The suicide screening's an extra 15 seconds and it's a really important 15 seconds.

So in closing, we don't have a crystal ball. We don't know who is going to go on to complete suicide and who is not. But it's safety first as best you can,  just err on the side of caution. There is nothing simple about this, but once you start screening it will become more routine. I, who have been trained to evaluate people for suicide risk, every time, it's hard. I have a great sense of humility. There is nothing easy about this because you never know. Best predictor of future behavior is the past behavior, but there are limits in our ability to predict. We just need to err on the side of caution and do the best you can.

And I just want to end with this patient example of a clinic that was screening in their outpatient clinic, and they started their pilot with just well visits. And so the nurses were only supposed to screen well visits, and so one day a mother brought an 18-year-old male in presenting with fatigue. She thought he had mono. And the nurse was not supposed to screen him, but the nurse's intuition told her that something wasn't right. And I can't tell you-- I'm sure I don't have to tell you how many lives have been saved because the nurse had a bad feeling about something and went above and beyond, because I think nurses save the day. So the nurse screened this child, or this 18-year-old, with the ask. And this is what she found, "In the past few weeks have you wished you were dead? Yes, yes to two, yes to three, and have you ever tried to kill yourself? No. Are you having thoughts of killing yourself right now? Yes." So this was a child who was a scholar-athlete, socially well connected, had everything going for them. No one suspected they were at risk for suicide, but he had been at a party a few weeks before and he got caught for underage drinking and he was in jeopardy of losing his scholarship. And then, something else happened at school that put his standing in jeopardy, and this kid was going to kill himself. And the pediatrician that screened him later told me that he-- had this nurse not screened this patient for suicide risk, because the nurse had a bad feeling about it, he probably would have been someone you read about in the newspaper the next day. And the doctor said to him, "I'm worried about releasing you. Can you convince me that it's okay to let you go?" And the patient said, "Well, before I came in here I had no hope, but now because we're talking about this I have some hope." And I'll tell you that that child, now, or that 18-year-old, is now a junior in college and thriving. He got the mental health care he needs, so this was a really nice success story, a screening.

So the common concern from healthcare providers is, "How am I going to manage the extra kids I'm going to identify or the extra adults that are at risk for suicide." And I'm going to end with this little 28-second snippet of Dr. Abernathy, who is a pediatrician in Richmond, Virginia and he's the one that-- his practice, I believe, saved that kid's life.

No one deserves to die by suicide. No one. And one thing that motivated our group more than anything in the world when we started talking about doing this was-- it wasn't how many were we going to catch, it was how are we going to deal with one that we don't catch. And how are we going to handle the death of one of our patients by suicide? And that we couldn't live with.

There's a huge number of people that go into creating the suicide risk screening tool and implementing it and studying it. And so I just want to thank, including all the nurses and patients and their families, that went into helping us hone this so that it's a more effective and efficient screening tool. Thank you for your attention. If you have any questions anyone is welcome to email me.