Digital Repository Doctoral Projects Spring 2021 Introduction of a Universal Suicide Risk Screening Tool and Follow Up Care in the Emergency Department of a Rural Hospital: A Quality Improvement Project Catherine Harmston MSN, APRN, FNP-BC Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Harmston, C. (2021). Introduction of a Universal Suicide Risk Screening Tool and Follow Up Care in the Emergency Department of a Rural Hospital: A Quality Improvement Project. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Introduction of a Universal Suicide Risk Screening Tool and Follow UP Care in the Emergency Department of a Rural Hospital: A Quality Improvement Project by Catherine Harmston A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 25, 2021 Mary Anne Hales Reynolds PhD, RN, ACNS-BC_ Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Graduate Programs Director 1 Introduction of a Universal Suicide Risk Screening Tool and Follow Up Care in the Emergency Department of a Rural Hospital: A Quality Improvement Project Cathy Harmston MSN, APRN, FNP-BC Annie Taylor Dee School of Nursing, Weber State University April 8, 2021 2 Acknowledgements I would like to dedicate this project to Mike, Dave and Travis for whom life ended too soon. They are missed. I would like to thank the following people for the support and encouragement they rendered during the planning, implementation, and evaluation of my Doctor of Nursing Practice (DNP) project: Dr. Mary Anne Reynolds, RN, PhD, ACNS-BC, Associate Professor Annie Taylor Dee School of Nursing at Weber State University, John Williams CEO Nell J. Redfield Memorial Hospital in Malad, Idaho, and Rhonda D’Amico Suicide Prevention Program Coordinator Southeastern Idaho Public Health. These individuals have all inspired and mentored me throughout this project. Above all I would like to thank my family for their love and support. Over the last two years they have listened to my thoughts and ideas with patience and understanding. They were respectful of my time and championed my project 100%. I love them, and my life is all the better with them in it. 3 Abstract The purpose of this Doctor of Nursing Practice project was to determine if the use of a universal suicide risk screening tool and the provision of suicide care resources in a rural emergency department would reduce suicide rates in Oneida County. For the purposes of this project, all patients presenting to the Nell J. Redfield Memorial Hospital emergency department in Malad, Idaho, were universally screened for suicide risk using the Patient Safety Screener (PSS-3) tool. If patients screened positive, lethal means and safety were discussed. Then, an individualized plan of care was created for the patient, and if necessary, referrals were made. It was found that after introducing the screening tool, 26-47% of all emergency department patients were screened. All patients who screened positive were either transferred to a behavioral health facility, admitted to the hospital, or discharged with mental health resources and referrals. Findings indicate that screening for suicidal risk allows clinicians to identify individuals who require intervention. Once they are identified as high risk, an individual plan of care can be created, and the appropriate referrals can be made. This project demonstrated that a better screening process could be implemented, and individuals at risk can be appropriately identified. By identifying and intervening, suicide rates in Oneida County should decline. Keywords: prevention, rural, screening, suicide, risk factors 4 Introduction of a Universal Suicide Risk Screening Tool and Follow Up Care in the Emergency Department of a Rural Hospital: A Quality Improvement Project Suicide in both urban and rural populations creates a profoundly negative emotional and financial impact on both families and communities. According to the World Health Organization [WHO] (2020), nearly 800,000 people in the world die by suicide each year. In the United States suicide is the tenth leading cause of death, and on average there are 132 suicides per day in the United States alone (AFSP, 2020b). These staggering numbers provide sufficient cause for concern. The emotional and financial consequences of suicide can be staggering for individual families and communities. The average cost of one suicide in the United States is $1,329,553. The largest part of this cost is due to lost productivity followed by incurred medical treatment (Suicide Prevention Resource Center [SPRC], n.d.-a). Suicide and suicide attempts cost the United States almost $70 billion per year in lifetime medical and work-loss costs alone (CDC, 2020b). Oneida County, Idaho is a rural community that has a high suicide rate. From 2014-2018 there were 23 suicide deaths per 100,000 in Oneida County (D’Amico, 2019). Suicide is problematic in rural locations due to social isolation, poor economics, and the lack of access to mental health services. Social isolation is a well-documented risk factor of suicide (Monk, 2000). Living in isolation can create a feeling of loneliness and eliminate an individual’s sense of belongingness. Poor economies in isolated rural regions often lead to unemployment. Unemployment is also strongly associated with suicide death (Blakely et al., 2003) and contributes to financial stress creating a sense of burdensomeness for some individuals. Suicides in rural populations are more often carried out using lethal means such as a firearm (Idaho 5 Department of Health & Welfare, 2018), and finally, limited funding and the lack of sufficient mental health services prevents the rural resident from receiving adequate suicide care (Cohen Veterans Network, 2018). In order to reduce suicide rates in rural settings, it is vital that programs be implemented that promote improved suicide screening and access to mental health services in rural communities. Zero Suicide is an initiative formed by The Action Alliance, a national level public-private partnership dedicated to suicide prevention (National Action Alliance for Suicide Prevention, 2020) that focuses on assessment, intervention, treatment and prevention for high risk suicidal individuals. This doctor of nursing practice project was modeled after the Zero Suicide Initiative. This purpose of this doctor of nursing practice (DNP) quality improvement project was to implement and evaluate the impact of utilizing a universal screening risk screening tool in a rural emergency department to identify high risk individuals. Review of Literature Several search engines were used including Google Scholar, Medline, PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to gather pertinent evidence-based research data for the literature and full-text search. Peer reviewed articles were reviewed at length for meaningful information and data. The following keywords proved useful in the search for empirical literature on suicide: suicide, rural, risk factors, means, emergency department, treatment, prevention, hospital admission, discharge, and Zero Suicide. Suicide Suicide is a highly complex problem with a variety of contextual components. Klonsky (2016) defined suicide as “death caused by self-directed injurious behavior with an intent to die. A suicide attempt is defined as a nonfatal, self-directed, potentially injurious behavior with the 6 intent to die” (p.309). According to the WHO (2020), every 40 seconds someone in the world commits suicide. Approximately 79% of suicides occur in low and middle-income countries and 1.4% of deaths worldwide are caused by suicide. Suicide rates among males are approximately four times those among females, and by age group, suicide rates were highest among those aged 35-64 years and ≤75 years. By race/ethnicity, non-Hispanic whites and American Indian/Alaska Natives had the highest rates of suicide (Kegler, 2017). Means of completing suicide vary. The use of firearms account for 50.57% of all suicide deaths (AFSP, 2020b). There are multiple other external and interpersonal factors that contribute to suicidal behavior. Recognizing and acknowledging these external and interpersonal factors leads to a better understanding of suicide risk. Risk Factors External Factors External risk factors are characteristics of a person’s environment that increase the likelihood of suicidal behavior. These include a history of mental illness, prior suicidal behavior, substance misuse, and unemployment (McClatchey et al., 2017). People suffering from mental illness are often perceived to be a burden on society. Mental health disorders often inhibit an individual’s ability to cope appropriately. Depression is the most common condition associated with suicide (AFSP, 2020a). Other conditions such as schizophrenia, psychotic disorders, personality disorders, and anxiety disorders can all affect an individual’s ability to think, feel and behave. A meta-analysis conducted by Too et al. (2019) found that people with mental health disorders have an eight-fold increased risk for suicide when compared to those who have no history of mental illness. 7 Substance abuse poses a significant suicide risk factor in rural areas. Alcohol is considered a depressant and is known to lower inhibitions. Approximately 30-40% of suicide attempts occur while the person is under the influence of alcohol. Rates of alcohol abuse are higher in rural adults when compared to urban adults (Rural Health Information Hub [RHIB] n.d.). Low-income status has a direct correlation to suicide rates across the globe. Iemmi et al., (2016), found that eight of the ten countries with the highest suicide rates in the world are low-middle income countries. Unemployment increases financial stress and feelings of inadequacy. Blakely et al., (2003), found a strong association between unemployment and suicide. Using a firearm is the most lethal method of completing suicide in the United States (SPRCb). In the United States in the year 2017, suicide by firearms accounted for 23,854 total deaths, more than any other means including poisonings and suffocations (National Center for Health Statistics, 2016). Drug poisoning is the most common means of attempting suicide but less lethal than the use of a firearm. According to Conner et al. (2019), drug poisoning accounts for 59.4% of attempts, but only 13.5% of deaths. Other common lethal means of completing suicide include poisoning by gas, jumping, and drowning. Interpersonal Factors Interpersonal risk factors for suicide are characteristics of an individual that increase the likelihood of suicide. Thomas Joiner (2005) developed The Interpersonal Theory of Suicidal Behavior (ITSB) that describes three critical interpersonal factors or constructs that are central to understanding suicidal behavior. These constructs include first a feeling of thwarted belongingness, second, perceived burdensomeness, and third capability or the capacity to complete the act (Van Orden et al., 2010). The ITSB asserts that when an individual experiences social alienation in association with a feeling of burdensomeness, they develop the desire for 8 death. Joiner theorized that self-preservation is a powerful instinct and few can overcome it by force of will. The ITSB suggests that individuals who develop a fearlessness of pain, injury, and death, acquired through a process of repeatedly experiencing painful events, have the capacity to perform self-harm with the intent to die (Ribeiro & Joiner, 2009). Belonging is a human need that means acceptance as a member or a part of something. Hatcher & Stubbersfield (2013) performed a systematic review of suicide associated with a sense of belonging and found that individuals who have a low sense of belonging, or inclusion, have a higher risk of having suicidal thoughts or a history of suicide attempts. Hatcher also concluded that the association is more important when other factors, such as feeling a burden and being depressed, are also present. When an individual has a sense of belongingness, they see value in life and in coping with intensely painful emotions (Hall, 2014). When an individual feels isolated, the feelings of sadness perpetuate withdrawal from social situations, which reinforces feelings of disconnectedness (Santini et al., 2020). In adults over the age of 60 social isolation leads to increased suicidal ideation (Bennardi et al., 2019). Thus, older adults living in isolated settings pose a higher risk of suicidal behavior. Kposowa (2000) found that divorced and separated persons were over twice as likely to commit suicide as married persons. Divorced men were more likely to commit suicide than were married men. Stack (1980) looked at suicide rates using five independent variables and the results suggested that social isolation, hurt, and guilt, which are prominent characteristics of divorced populations, influence suicide rates. Many suicidal persons believe that they are a burden to their friends and families. Feeling like a burden feeds into a pattern of being an outsider. Men and women living in poverty often 9 perceive themselves as burdensome and are at higher risk of committing self-harm. The WHO (2020) found that more suicide deaths occur in low and middle-income countries. According to Joiner (2005), experiencing a sense of burdensomeness and low belongingness may instill a desire for suicide, but together they are not sufficient to ensure that desire will lead to a suicide attempt. In order for an individual to be capable of lethal self-harm, they must struggle with terminating the fight with self-preservation motives. Joiner believes that habitual patterns of behavior such as repeated attempts at self-harm lower an individual’s threshold for self- preservation allowing them to successfully complete a final, lethal act of self-harm. It is usually a combination of both external and interpersonal risk factors that create a high risk scenario that triggers vulnerable persons to attempt or complete an act of suicide. Impact of Suicide Suicide has a profound negative impact on families and their communities. In the United States, the average cost of an individual suicide is approximately 1.3 million dollars. The largest part of this cost is due to lost productivity (SPRC, n.d.-a). According to the National Funeral Directors Association (2019), the average cost of an adult funeral with viewing and burial in the United States is approximately $7,000. The annual cost in the United States for both suicides and suicide attempts is $70 billion per year in lifetime medical and work-loss costs (CDC, 2020b). These costly consequences create a heavy financial burden for families and associated communities. While the financial costs of suicide can be devastating, the emotional toll that suicide takes on families and communities can have equally negative consequences. The loss of a loved one by suicide is typically shocking, painful, and often unexpected (SPRC 2019c). There are stigmas that surround death by suicide. Family members and friends who knew and loved an individual 10 who lost their life to suicide, are often left with feelings of guilt, sadness, anger, and sometimes shame. People within the community such as emergency medical personnel, law enforcement, clergy and others who provide support to survivors can all potentially be impacted by suicide (Sandler, 2018). Social networks are interrupted within communities when fellow members commit suicide leading to the loss of the familiar sense of well-being commonly associated with living in close-knit rural communities. Suicide in Rural Communities The United States Department of Agriculture [USDA](n.d.) defines rural as any “area that is made up of open country and settlements, with fewer than 2,500 residents or areas with populations of less than 50,000”. Rural America has higher suicide rates than urban America does (Helbich et al., 2017). According to the CDC (2018a), since 2007 the gap in suicide rates between rural and urban areas began to widen more quickly. While there are multiple risk factors that contribute to overall increased rates of suicide the primary risk factors that contribute to higher suicide rates in a rural setting include isolation, financial hardship, unemployment, mental health disorders, and a lack of mental health services. These risk factors are a significant cause of concern for residents in rural locations. Isolation occurs in rural locations secondary to geographical distancing. Adults in rural areas were also more likely to live in single-family homes (78.3 percent compared with 64.6 percent) (United States Census Bureau [USCB], 2016c). Living in a rural setting and suffering divorce or separation are also factors that contribute to a sense of thwarted belongingness. Feelings of isolation can lead to feelings of depression and anxiety. Living in a rural setting while suffering from mental illness greatly increase an individual’s risk for suicide. The rate of suicide using firearms is also much higher in rural areas than it is in urban regions. Of adults in rural areas, 11 nearly half (46%) report owning a gun, and as opposed to urban adults, and rural adults more often store their guns loaded and easily accessible (RHIB, n.d.). In Idaho, 60% of suicides are committed using a firearm (Idaho Department of Health & Welfare, 2018). Historically rural communities have been at the margins of healthcare. Rural communities often have more uninsured patients who live in poverty. High-risk behaviors such as tobacco use, excessive alcohol intake, and obesity are often identified in the rural setting (Gaston & Walker 2018). Rural settings, because they are distantly located from towns and cities, often lack access to mental health care and behavioral health (CDC, 2018a). The National Advisory Committee on Rural Health and Human Services, (2017), found that sixty-five percent of rural county residents had no psychiatrist (compared to 27 percent of metropolitan counties). Forty-seven percent of rural counties have no psychologists (versus 19 percent). Social workers and counselors are also less available than they are in urban settings. Limited funding and the lack of sufficient mental health services prevents the rural resident from receiving adequate suicide care (Cohen Veterans Network, 2018). Common factors that prevent people from obtaining adequate mental health treatment are the cost of services, perceived stigma, concerns about confidentiality, busy schedules, shortage of psychiatrist physicians in rural/underserved areas, and lack of transportation (Singh, 2017). Early Detection According to the American Foundation for Suicide Prevention (2020a), there is no single cause of suicide. Suicide occurs more often when stressors and health issues coincide. It is vital that suicide risk be detected early, and that both short- and long-term treatment plans includes 12 individual counseling for individuals who experience suicidal ideation or who have attempted suicide. Approximately 50% of persons who complete suicide accessed healthcare in the month prior to their death and over 25% in the week prior to death (Ribeiro et al., 2017). Suicide risk however, often remains undetected by healthcare providers. Early detection is a critical component of a successful suicide prevention strategy (National Institute of Mental Health [NIMH], n.d.). Identifying individuals at risk includes knowing what behaviors are associated with suicide as well as identifying those at risk through screening. Suicide Behaviors Healthcare providers in both outpatient and inpatient facilities need to be able to recognize suicidal behaviors. Behaviors associated with suicide include persons who have a history of depression or demonstrate symptoms of depression such as frequent crying, fatigue, difficulty focusing, and hopelessness (Anxiety and Depression Association of America, 2020). Patients who appear to be under the influence of alcohol or illicit substances or who have substance abuse problems could also potentially be at risk for suicide. It is also important for healthcare provides to recognize that patients who have previously attempted suicide present a higher risk for another, potentially fatal attempt (AFSP, 2020a). Screening The key to reducing suicides in both rural and urban settings is to assess and identify at-risk individuals early on so that appropriate suicide care can be provided to those individuals. Using screening tools can help identify people who are experiencing suicidal thoughts and behaviors. Many validated and reliable screening tools have been developed that help identify a person who is at risk for suicide. If an individual scores positive (at risk for suicide) on the 13 screening tool, evidence-based interventions can then be implemented. Screening can be done with the assistance of a screener (who asks the questions) or independently by the individual in question (SPRC, 2016d.). It is recommended that the screening tool of choice be easy to administer, and have a high degree of sensitivity (Thom et al., 2020). Screenings can easily be administered in primary care settings as well as health care settings such as hospitals. Healthcare organizations can administer screening tools universally to all patients or to a select few who present with a behavioral health complaint. Screening patients for suicidal risk in the hospital emergency department setting has been found to have a twofold increase in detection (Boudreaux et al., 2016). Treatment In the healthcare setting a medical assessment should be completed including both a thorough history and physical examination followed by an evaluation of the patient’s cognitive function (Betz & Bordreaux 2017). Determination then needs to be made whether the patient requires inpatient care or if they can be safely discharged to home with follow up, outpatient care. Inpatient. Once a patient has been identified at risk or is actively suicidal, the plan of care includes inpatient or residential care. Inpatient psychiatric care is designed to reduce immediate risk, start a treatment program, and prepare for preventative strategies following discharge (National Action Alliance for Suicide Prevention, 2020). If the patient has a current plan or intent to harm self with available lethal means, recent severe self-harming behavior or suicide risk with continued imminent risk due to poor impulse control, and the inability to plan for their safety, they meet criteria for inpatient admission. The patient who is imminently unable to care for their own physical needs or participate in a treatment plan, because of disorganized 14 behavior, would also meet criteria for inpatient admission (Hardy, 2014). Once a patient is stabilized, they are discharged home and monitored in an outpatient setting. Individual counseling with referrals to other community services are critical components of the discharge plan of care. Outpatient Care. Mental health counseling should be the primary focus of outpatient care for high risk suicidal individuals. Suicide counselors have the obligation to do their utmost to provide safety for their clients. Suicide counselors offer a strong message of hope based on several effective treatment strategies. Behavioral Therapy (CBT) is one of the most widely studied forms of therapy. CBT is a behavioral health treatment that has proven to be effective in treating a range of problems including depression and suicidal ideation. CBT is used to change the way a patient perceives their situation and to produce an altered, productive response (Hofmann, Asmundson, & Beck, 2013). Licensed mental health professionals provide CBT in private settings. CBT has been found to be as effective, and potentially more effective, than other forms of psychological therapy, including psychological medications (American Psychological Association, 2017). Safety is a crucial element in the discharge planning of any suicidal individual. Safety planning lowers the imminent risk for suicide by developing coping strategies and referring to a list of contacts in the event of a crisis (O’Brien et al., 2014). Stanley et al. (2018), found that safety planning along with structured follow up was associated with about 50% fewer suicidal behaviors over a 6-month follow up and increased the odds of patients engaging in outpatient mental health programs. Community and religious organizations can offer resources and support to the suicidal person. Faith communities offer opportunities for the development of relationships with others. 15 They provide a sense of belonging and connectedness. Community support groups can organize meetings and allow for individuals to convene together in a safe, shared space to share similar stories of survival and hope (MentalHealth.gov, 2020). Other resources such as suicide hotlines, which consistently reduce a caller’s distress in the moment of crisis, are widely used. Hotline operators are typically trained volunteers. There is little evidence however as to their success. There have been no comprehensive studies that demonstrate suicide hotlines prevent death by suicide over time (Gould et al., 2007). Follow-Up When a high-risk patient is discharged and they receive a series of supportive follow-up phone calls, the risk of suicide goes down (Miller et al., 2017). Vaiva et al (2006) conducted a study and found that contacting people by telephone one month after discharge from an emergency department helped reduce the risk of further suicide attempts. These telephone calls consisted of efforts to review the discharge treatment plan and if the patient was not compliant, or the treatment failed, schedule an urgent appointment to reformulate an effective treatment plan. Theoretical Framework The Interpersonal Theory of Suicidal Behavior model developed by Thomas Joiner (2005) suggests that in order to improve care for high risk suicidal individuals, the healthcare team should provide individualized assessments, interventions, treatment and prevention plans. This model will be used to organize this DNP Project. Assessment is the process of gathering information in order to develop a better understanding. Joiner (2005) identifies assessment as scientific and theoretical clinical decision making which includes an integration of both theory and application. He also believes that 16 assessing suicidal risk, should be weighted on a history of multiple suicide attempts and the character of current suicidal symptoms. For this quality improvement project, assessment will take place in the emergency room by screening all admitted emergency room patient. From the results of this screening, intervention will be determined based on their risk. Interrupting a suicide attempt is often referred to as a crisis intervention that focuses on belonging and recognizing distorted thoughts. Joiner introduces a technique titled ICARE which he has found to be beneficial during the intervention and treatment phase of caring for suicidal individuals. This technique involves identifying negative thought patterns (I), connecting (C), assessing (A), restructuring (R), and executing (E) a plan to change the distorted, negative thought process. Joiner recommends focusing this technique on themes involving a sense of burdensomeness and failed belongingness. Intervention for this project includes referrals for inpatient care or outpatient mental health treatment. Joiner defines prevention for suicidal persons as enhancing a protective sense of belongingness. Prevention is seen as actions that are going to decrease the chances that suicidal ideation will re-occur. He defines prevention as behaviors that will eliminate further attempts. Prevention strategies will include education and resources to community behavioral health organizations. Project Implementation Expected Outcomes/Goals The primary goal of implementing universal suicide risk screening in the emergency room setting of the Nell J. Redfield Memorial Hospital was to reduce the number of suicide deaths and suicide attempts in Oneida County, Idaho. The Patient Suicide Risk Screener (PSS-3), an evidence-based suicide risk screening tool, administered universally to emergency room 17 patients would identify those individuals who were high-risk for suicide. Implementation of an evidence-based protocol for appropriate referral could then be coordinated. Educating the healthcare team about how to deliver and score the screening tool as well as familiarizing them with the components that improve suicide must take place prior to implementation. (See Appendix A). Population The state of Idaho lies in the Pacific Northwest region of the United States and has a population of 1,787,065 (USCB, 2019a). The landscape of Idaho is picturesque. Agriculture, manufacturing, and tourism are Idaho’s major industries. The total landmass of Idaho totals 83,557 square miles, and there are 3,500 river miles, more than almost any other states in the union (Visit Idaho, n.d.). Of the almost two million residents of Idaho, approximately one third live in what is considered to be a rural location (RHIB, n.d.). Oneida County is in the Southeastern region of the state of Idaho and has one of the highest suicide rates in the state of Idaho. According to the U.S. Census Bureau (2019b), in 2018 Oneida County had a population of 4,488 persons, and the median age of the Oneida county resident was 39.5 with a median household income in 2017 of $43,491. Malad City is the most populated region of Oneida County and provides healthcare services for residents living in the immediate area and neighboring communities. Idaho is consistently among the states with the highest suicide rates. In 2016, Idaho had the 8th highest suicide rate in the U.S. with a rate of 20.8, 50% higher than the national average. The 2nd leading cause of death for Idahoans ages 15-34 is suicide. The suicide attempt rate in adults in the years 2012-2016 was 686 per 100,000 (Idaho Department of Health & Welfare, 2018). Every two years in Idaho the youth are surveyed in grades 9-12 in order to identify high-risk 18 behavior. Results from the 2019 survey identified concerning trends with the increased use of e-cigarettes, suicidal thoughts, and feelings of hopelessness (Idaho State Department of Education, 2019). Setting According to the John Williams, the Chief Executive Officer (CEO) of the Nell J. Redfield (personal communication Feb. 5, 2020), the hospital, located in Malad, Idaho is the largest employer in Oneida County. The Nell J. Redfield Hospital is considered a Critical Access Hospital (CAH) that lies in a designated rural area that serves 4500 people in and around the county as well as approximately1000 persons from surrounding communities. The hospital in Malad provides emergency services to those in immediate danger of life-threatening injuries. The emergency department is typically staffed with 1 healthcare provider (Medical Doctor [MD], Physician Assistant [PA], or Nurse Practitioner [NP]), and two Registered Nurses [RN]. A social worker is available on a limited basis. Patients who have attempted suicide or are suicidal are often stabilized and transferred to a facility staffed with a board-certified Psychiatrist. Prior to implementation of this project, the Nell J. Redfield Memorial Hospital in Malad, Idaho had no suicide protocol in the emergency department setting. Screening tools were not routinely used, and suicide management treatment plans did not include evidenced-based suicide prevention strategies. Based on the high incidence of suicide within the county, lack of an established protocol inhibited implementation of best suicide care. Nell. J. Redfield Memorial Hospital administration identified the need for establishing evidence-based guidelines and protocols in order to reduce suicidal deaths within the county. 19 Plan Project Model This quality improvement project was modeled after The Zero Suicide Initiative which was formed by The Action Alliance, a national level public-private partnership dedicated to suicide prevention (National Action Alliance for Suicide Prevention, 2020). The Zero Suicide Initiative has a foundational belief that suicide deaths for individuals under the care of healthcare systems are preventable. Zero Suicide is a program that promotes a practical framework for system-wide transformation toward safer suicide care. This system wide change includes the following components: assessment, intervention, treatment, and prevention. It is expected that implementation of a quality improvement project modeled after the Zero Suicide will improve outcomes and closes gaps in healthcare systems (Zero Suicide, 2020). A quality improvement implementation team consisting of four members from Nell J. Redfield Memorial Hospital in Malad, Idaho were charged with leading the organizational change. The team members attended regular team meetings, changed policies and procedures, were responsible for evaluation quality improvement efforts, and budgeted to support improved suicide care implementation. The implementation team then provided training to hospital emergency room personnel (MD’s, PA’s, NP’s, and RN’s). The healthcare team learned about the Zero Suicide philosophy and essential elements of assessment, intervention, and the treatment plan (Zero Suicide, 2020). Timeline: See Appendix C Assessment The key to reducing suicides in both rural and urban settings is to assess and identify at-risk individuals early on so that appropriate suicide care can be provided to those individuals. The use of screening tools can help identify people who are experiencing suicidal thoughts and 20 behaviors. Screening patients for suicidal risk in the hospital emergency department setting has been found to have a twofold increase in detection (Boudreaux et al., 2016). The Patient Safety Screener 3 (PSS-3) (see Appendix B) is a validated suicide screening tool developed for use in the Emergency Department (ED). This tool consists of three short questions administered to patients upon arrival to the ED. The PSS-3 helps identify patients who are feeling suicidal or who have attempted suicide in the past (Patient Safety & Quality Healthcare, 2018). The use of this tool helps healthcare teams to develop an individualized plan of suicide care for each patient. Intervention The emergency department healthcare team attended one of two training sessions prior to implementation of this project. A total of six full-time medical providers, which included three medical doctors, two physician assistants, and one nurse practitioner, attended the first 45-minute training session. During this training session the suicide risk screening tool was introduced and instructions on scoring were covered in detail. Lethal means counseling was also discussed in-depth. Eight nurses attended a second 45-minute training session. Identical instructions were delivered to the nurses. A letter with detailed instructions about implementation date, delivering and scoring the PSS-3 screening tool was emailed to all staff who were not in attendance at either of the two training sessions. Upon implementation, when a healthcare provider reviewed the PSS-3 screening tool and identified a high-risk individual, intervention would take place on behalf of the patient. Crisis intervention included identifying disruptive symptoms and feelings in an attempt to reduce the intensity of the crisis. Healthcare providers were taught to engage with the patient in a non-threatening manner and address the patient’s feelings of thwarted belongingness and 21 burdensomeness. While this does not solve the problem completely, it has the potential to reduce the pain of the crisis (Joiner, 2005). During the intervention phase the provider was advised to address access to lethal means with the patient. If the patient has access to a firearm within the home, arrangements need to be made to remove the firearm from within reach, for a period of time, until the patient is no longer considered high risk. This intervention occasionally required collaboration with the patient’s family members or friends. Treatment and Prevention The National Action Alliance’s’ Clinical Care and Interventional Task Force (2011) identified essential components of successful suicide care systems. These components include leading system-wide culture change committed to reducing suicide rates, training a caring workforce, identifying high risk suicidal individuals, engaging suicidal individuals using a suicide care management plan, and transitioning suicidal individuals through care with thoughtfulness and support. Rural locations often lack mental health services, specifically board certified psychiatrists, and in-patient psychiatric services. Patients who are considered high-risk for suicide are transferred to an urban facility that has the capability of caring for inpatient mental health patients. The healthcare provider (after conferring with the patient and family for location/transfer preference) contacts a representative via telephone at a receptive facility. The provider then offers the receiving facility a verbal, individualized report with patient case details. It is then determined what mode of transport is safest. Emergency medical services (EMS) have been utilized depending on the risk level of the patient. Compliant patients can be transferred via private vehicle. 22 Patients who are not in immediate danger can be provided with suicide-specific outpatient care which could potentially include working with community agencies. Low risk patients benefit from being connected with crisis center hotline support and follow-up, and tele-mental health options. These resources are available to hospital staff, the patient, and the patient’s family and friends in the form of a handout. Telephone follow-up contact with patient after discharge is another recommended effective suicide prevention strategy (National Action Alliance: Clinical Care and Intervention Task Force 2011). Project Issues Patients who presented to the Nell J. Redfield Memorial Hospital emergency department involved in this quality improvement project were provided evidenced-based best suicide care. There was minimal risk to patients involved in the implementation of this project. Suicidal patients are vulnerable and confidentiality was carefully protected. Protective factors were in place that limited identifying information such as patient demographic data and other protected health information. This project was approved by Weber State Universities Internal Review Board (IRB) and determined safe for patients prior to implementation. Barriers to the success of this project included organizational and/or individual elements that prevented compliance with delivering and scoring the suicide risk screening tool. Unfortunately, at the Nell J. Redfield Memorial Hospital in Malad, Idaho, the screening tool was not able to be embedded into the electronic health record. If the screening tool had been embedded, with a prompt that notified healthcare provider when a patient screened positive, it is expected that more patients would have been screened, and positive screens would not have gone unrecognized. For this project, the screening tool was, and continues to be, delivered via paper and pencil. Completed screening tools are then uploaded into the patient’s electronic record. 23 The other primary barrier was not in control of the healthcare team. That barrier was the potential for patients to avoid answering the screening questions with honesty. Male gender, older age, poor social connectedness, and those with a lower education level are associated with greater odds of non-disclosure (Husky et al., 2016). If patients chose to falsify answers on the screening tool, they were not properly identified and the treatment plan did not indicate a need for suicide care. The cost of implementation this quality improvement was not burdensome and did not present as a barrier. For implementation of this project, the DNP graduate student completed and was awarded a grant from Sigma Theta Tau International Honor Society of Nursing Nu Nu Chapter. This funding was used to create and supply a pamphlet that was given to all discharged patients who screen positive but were considered stable. This pamphlet provided a listing of suicide hotline numbers and available community resources. This project had a large amount of support from both the Southeastern Idaho Public Health Department, and the administration team of the Nell J. Redfield Memorial Hospital. These stakeholders live within the community and desire improved outcomes for their family members, neighbors and friends. Evaluation and Data Analysis The impact of this quality improvement project was evaluated by using both formative and summative evaluation processes performing primarily chart reviews. The data was collected over a period of four consecutive months. Following implementation, electronic health records (EHR) were used to determine the number of patients admitted to the emergency department, over a four-month period of time. Each month, charts were reviewed in order to evaluate which patients presented via ambulance and which patients entered via wheelchair or ambulation. 24 Charts were then reviewed to determine which patients had been screened for suicide using the PSS-3 screening tool. If screening tools were completed in full, and the patient scored positive, charts were reviewed further to determine if an individualized plan of care took place and if the patient was admitted, transferred or discharged to home. Quantitative data was analyzed at the conclusion of each consecutive month. The total number of completed screening tools were divided by the total number of patients in the emergency department to come up with a total percentage of patients screened each month. Findings The total number of ED patients admitted each month ranged from 96-131. These numbers included both those who arrived ambulatory and via ambulance. The average percentage of patients that present via ambulance to the ED over the 4-month period was 12%. Less than 2% of those patients were screened for suicide. Pediatric patients were not excluded from the data. Chart reviews reflect that following implementation of this quality improvement project, 26-47% of patients evaluated in the emergency department were screened monthly. Prior to implementation of this project, universal screening was not taking place in the emergency department of the Nell J. Redfield Memorial Hospital. The screening tool results summarized below show what percentage of patients were screened months 1-4 consecutively. 25 Two positive suicide risk screening tools completed in the month of February, 2021 were not addressed by the medical provider. Provider notes did not identify an individualized plan of care for these two patients. One patient was admitted with respiratory distress/hypoxia, the other was discharged home following a work-up for flank pain. These findings indicate that healthcare teams can be taught and motivated to improve screening for suicide risk in rural emergency departments. Findings also indicate that identifying patients who are high risk for suicide improve significantly when universal suicide screening is performed. Discussion, Recommendations, and Conclusions Discussion Prior to implementation of this quality improvement project, patients admitted to the emergency department of the Nell J. Redfield Memorial Hospital were not being universally screened for suicide risk. Suicidal individuals were not being properly identified. With the implementation of the suicide screening risk took, 26-47% of the people presenting to the emergency department are now being screened. Once high-risk individuals are identified, intervention can take place. Clinicians are motivated to intervene knowing that approximately 0% 10% 20% 30% 40% 50% Nov-20 Dec-20 Jan-21 Feb-21 Administration of Suicide Screening Tools Percentage of ER Admission Screenings 26 50% of individuals who commit suicide, access healthcare in the month prior to their death (Ribeiro et al., 2017). A significant portion of unscreened patients presented to the ED via ambulance. In rural settings, high acuity patients, who present via ambulance, require an intense level of care from a limited number of medical personnel. It is thought these patients are often not screened because the primary focus in on delivering immediate life saving measures. It is not recommended that screening be forced upon patients who are experiencing acute, life saving measures. Screening tools can be implemented at a later date for those individuals. Officials from the state of Idaho Health and Human Services have expressed interest in this quality improvement project. A suicide prevention team has been organized with the intent of identifying interventions that can be easily implemented around the state to reduce suicide deaths in Idaho. Collectively the community of Malad, Idaho will benefit from the efforts of the healthcare team at the Nell J. Redfield Memorial Hospital because suicide rates should decline. By identifying patients at risk, there is improved potential to identify high risk individuals and intervene. Intervention reduces the threat of suicide thus reducing community suicide rates. The direct reduction in suicide rates prevents community members from experiencing the grief and pain associated with the suicide death of a loved one. Recommendations One of the largest barriers to the success of this quality improvement project was the inability to place the screening tool in the electronic health record program at the hospital. The tool is currently delivered via paper and pencil, then scanned into the patient’s chart. If the screening tool were available in each patient chart, and a system was put into place that would 27 alert the provider of a positive screen, it is thought that more patients would be properly screened, and fewer positive screening tools would fail to be addressed. Emergency departments are well positioned to universally screen for suicide risk. Evidence demonstrates that universal screening identifies high risk individuals thus allowing for early intervention. It is recommended that the healthcare team at Nell J. Redfield Memorial Hospital continue to universally screen emergency department admits for suicide risk. Conclusion Suicide rates in rural Idaho are high secondary to feelings of isolation, the use of guns as lethal means, and a lack of mental health resources. These high suicide rates are devastating to surviving family members and communities. The Zero Suicide Initiative is a systems organizational framework that requires transformative changes within an organization intended to improve suicide care and reduce suicide rates. This quality improvement project, led by a doctor of nursing practice (DNP) student in collaboration with an educated healthcare team and organizational and state leaders, demonstrated that universal suicide screening, based on an evidence-based program such as the Zero Suicide Initiative, improves the odds of identifying individuals who are high risk for suicide. Once high-risk individuals are identified, the healthcare team can intervene. Intervention reduces risk thereby saving families and communities from experiencing the loss that is felt when a loved one completes suicide. DNP’s bring value to healthcare organizations. Leadership training provided by quality DNP programs prepare the graduate to navigate convoluted systems and solve complex problems. Suicide is indeed a complex problem. With continued efforts on the part of DNP’s and healthcare teams, transformative initiatives can continue to be implemented with a focus on 28 identifying and appropriately treating high risk suicidal individuals in an effort to reduce suicide rates everywhere 29 References American Foundation for Suicide Prevention. (2020a). Risk factors and warning signs. https://afsp.org/risk-factors-and-warning-signs#suicide-risk-factors American Foundation for Suicide Prevention. (2020b). Suicide statistics. https://afsp.org/about-suicide/ suicide-statistics/ American Psychological Association. (2017). What is cognitive behavioral therapy? https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral Anxiety and Depression Association of America. 2020. Symptoms. https://adaa.org/understanding-anxiety/depression/symptoms Bennardi, M., Caballero, F. F., Miret, M., Ayuso‐Mateos, J. L., Haro, J. M., Lara, E., Arensman, E., & Cabello, M. (2019). Longitudinal relationships between positive affect, loneliness, and suicide ideation: Age-specific factors in a general population. Suicide and Life- Threatening Behavior, 49(1), 90–103. https://doi.org/10.1111/sltb.12424 Betz, M. E., & Boudreaux, E. D. (2016). Managing suicidal patients in the emergency department. Annals of Emergency Medicine, 67(2), 276–282. https://doi.org/10.1016/j.annemergmed.2015.09.001 Blakely, T. A., Collings, S. C. D., & Atkinson, J. (2003). Unemployment and suicide. Evidence for a causal association? Journal of Epidemiology & Community Health, 57(8), 594–600. https://doi.org/10.1136/jech.57.8.594 Boudreaux, E. D., Camargo, C. A., Arias, S. A., Sullivan, A. F., Allen, M. H., Goldstein, A. B., Manton, A. P., Espinola, J. A., & Miller, I. W. (2016). Improving suicide risk screening and detection in the emergency department. American Journal of Preventive Medicine, 50(4), 445–453. https://doi.org/10.1016/j.amepre.2015.09.029 30 Centers for Disease Control and Prevention. (2018a). Suicide in rural America. https://www.cdc.gov/ruralhealth/Suicide.html Centers for Disease Control and Prevention (2020b). Violence prevention: Preventing suicide. https://www.cdc.gov/violenceprevention/suicide/fastfact.html Cohen Veterans Network. (2018). America’s mental health: 2018. https://www.cohenveteransnetwork.org/AmericasMentalHealth/ Conner, A., Azrael, D., & Miller, M. (2019). Suicide case-fatality rates in the United States, 2007 to 2014. Annals of Internal Medicine, 171(12), 885–895. https://doi.org/10.7326/M19-1324 D’Amico, R. (2020). Suicide prevention gaps and needs analysis [Unpublished Manuscript]. Southeastern Idaho Public Health & Community Suicide Prevention Collection. Gaston, S. M., & Walker, B. W. (2018). Critical access hospitals: Meeting underserved community needs. Nursing2020, 48(5), 51–54. https://doi.org/10.1097/01.NURSE.0000531889.16311.c9 Gould, M. S., Kalafat, J., HarrisMunfakh, J. L., & Kleinman, M. (2007). An evaluation of crisis hotline outcomes. Part 2: Suicidal callers. Suicide and Life-Threatening Behavior, 37(3), 338–352. https://doi.org/10.1521/suli.2007.37.3.338 Hall, K. (2014, March 24) Create a sense of belonging: Finding ways to belong can help ease the pain of loneliness. http://www.psychologytoday.com/blog/pieces-mind/ 201403/create-sense-belonging Hatcher, S., & Stubbersfield, O. (2013). Sense of belonging and suicide: A systematic review. The Canadian Journal of Psychiatry, 58(7), 432–436. https://doi.org/10.1177/070674371305800709 31 Health Resources & Services Administration. (2020). Defining rural population. https://www.hrsa.gov/rural-health/about-us/definition/index.html Helbich, M., Blüml, V., de Jong, T., Plener, P. L., Kwan, M.-P., & Kapusta, N. D. (2017). Urban–rural inequalities in suicide mortality: A comparison of urbanicity indicators. Int J Health Geogr, 16, 39. https://doi.org/10.1186/s12942-017-0112-x Hofmann, S. G., Asmundson, G. J. G., & Beck, A. T. (2013). The science of cognitive therapy. Behavior Therapy, 44(2), 199–212. https://doi.org/10.1016/j.beth.2009.01.007 Husky, M. M., Zablith, I., Alvarez Fernandez, V., & Kovess-Masfety, V. (2016). Factors associated with suicidal ideation disclosure: Results from a large population-based study. Journal of Affective Disorders, 205, 36–43. https://doi.org/10.1016/j.jad.2016.06.054 Idaho Department of Health & Welfare (2018). Suicide in Idaho: Fact sheet. http://healthandwelfare.idaho.gov/Portals/0/Users/145/93/2193/Fact%20Sheet_February %202018.pdf Idaho State Department of Education. (2019). Idaho youth risk behavior survey. https://www.sde.idaho.gov/student-engagement/school-health/files/youth/Youth-Risk- Behavior-Survey-Results-2019.pdf Iemmi, V., Bantjes, J., Coast, E., Channer, K., Leone, T., McDaid, D., Palfreyman, A., Stephens, B., & Lund, C. (2016). Suicide and poverty in low-income and middle-income countries: A systematic review. The Lancet Psychiatry, 3(8), 774–783. https://doi.org/10.1016/S2215-0366(16)30066-9 Joiner, T.E. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press 32 Kegler, S. R. (2017). Trends in suicide by level of urbanization—United States, 1999–2015. MMWR. Morbidity and Mortality Weekly Report, 66. https://doi.org/10.15585/mmwr.mm6610a2 Klonsky, E. D., May, A. M., & Saffer, B. Y. (2016). Suicide, suicide attempts, and suicidal ideation. Annual Review of Clinical Psychology, 12(1), 307–330. https://doi.org/10.1146/annurev-clinpsy-021815-093204 Kposowa, A. J. (2000). Marital status and suicide in the national longitudinal mortality study. Journal of Epidemiology & Community Health, 54(4), 254–261. https://doi.org/10.1136/jech.54.4.254 McClatchey, K., Murray, J., Rowat, A., & Chouliara, Z. (2017). Risk factors for suicide and suicidal behavior relevant to emergency health care settings: A systematic review of post- 2007 reviews. Suicide and Life-Threatening Behavior, 47(6), 729–745. https://doi.org/10.1111/sltb.12336 MentalHealth.gov. (2020). For community and faith leaders. https://www.sprc.org/settings/faith-communities Miller, I. W., Camargo, C. A., Arias, S. A., Sullivan, A. F., Allen, M. H., Goldstein, A. B., Manton, A. P., Espinola, J. A., Jones, R., Hasegawa, K., & Boudreaux, E. D. (2017). Suicide prevention in an emergency department population: The ED-SAFE study. JAMA Psychiatry, 74(6), 563–570. https://doi.org/10.1001/jamapsychiatry.2017.0678 Monk. A. (2000). The influence of isolation on stress and suicide in rural areas: An international comparison. Rural Society, 10:3, 393-403. 33 National Action Alliance: Clinical Care and Intervention Task Force. (2011). Suicide care in systems framework. https://theactionalliance.org/resource/suicide-care-systems-framework National Action Alliance for Suicide Prevention. (2019). Best practices in care transitions for individuals with suicide risk: Inpatient care to outpatient care. https://www.samhsa.gov/sites/default/files/suicide-risk-practices-in-care-transitions- 11192019.pdf National Action Alliance for Suicide Prevention. (2020). Our story. https://theactionalliance.org/about-us/our-story National Advisory Committee on Rural Health and Human Services. (2017). Understanding the impact of suicide in rural America: Policy brief and recommendations. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/ rural/publications/2017-impact-of-suicide.pdf National Center for Health Statistics. (2016). Suicide and self-inflicted injury. https://www.cdc.gov/nchs/fastats/suicide.htm National Institute of Mental Health. (n.d.) Ask suicide-screening questions (ASQ) toolkit. https://www.nimh.nih.gov/research/research-conducted-at-nimh/asq-toolkit-materials/ index.shtml National Funeral Directors Association (2019) Statistics. https://www.nfda.org/news/statistics O’Brien, K. H. M., Singer, J. B., LeCloux, M., Duarté-Vélez, Y., & Spirito, A. (2014). Acute behavioral interventions and outpatient treatment strategies with suicidal adolescents. International Journal of Behavioral and Consultation Therapy, 9(3), 19–25. 34 Parry, G., Coly, A., Goldmann, D., Rowe, A. K., Chattu, V., Logiudice, D., Rabrenovic, M., & Nambiar, B. (2018). Practical recommendations for the evaluation of improvement initiatives. International Journal for Quality in Health Care, 30, 29–36. https://doi.org/10.1093/intqhc/mzy021 Patient Safety & Quality Healthcare. (2018). PSS-3: Three-question suicide screener for the er. https://www.psqh.com/analysis/pss-3-three-question-suicide-screener-for-the-er/ Ribeiro, J. D., Gutierrez, P. M., Joiner, T. E., Kessler, R. C., Petukhova, M. V., Sampson, N. A., Stein, M. B., Ursano, R. J., & Nock, M. K. (2017). Healthcare contact and suicide risk documentation prior to suicide death: Results from the army study to assess risk and resilience in service members (Army STARRS). Journal of Consulting and Clinical Psychology, 85(4), 403–408. https://doi.org/10.1037/ccp0000178 Ribeiro, J. D., & Joiner, T. E. (2009). The interpersonal-psychological theory of suicidal behavior: Current status and future directions. Journal of Clinical Psychology, 65(12), 1291–1299. https://doi.org/10.1002/jclp.20621 Rural Health Information Hub (RHIB) (n.d.). Risk factors for suicide. https://www.ruralhealthinfo.org/toolkits/suicide/1/risk-factors Sandler, E.P. (2018). The ripple effect of suicide. National Alliance on Mental Illness. https://www.nami.org/Blogs/NAMI-Blog/September-2018/The-Ripple-Effect-of-Suicide Santini, Z. I., Jose, P. E., York Cornwell, E., Koyanagi, A., Nielsen, L., Hinrichsen, C., Meilstrup, C., Madsen, K. R., & Koushede, V. (2020). Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): A longitudinal mediation analysis. The Lancet Public Health, 5(1), e62–e70. https://doi.org/10.1016/S2468-2667(19)30230-0 35 Singh, R. (2017). Rural mental health: Technology, collective intelligence, and community. Academic Psychiatry, 41(1), 135–137. https://doi.org/10.1007/s40596-016-0550-y Stack, S. (1980). The effects of marital dissolution on suicide. Journal of Marriage and Family, 42(1), 83–92. JSTOR. https://doi.org/10.2307/351936 Stanley, B., Brown, G. K., Brenner, L. A., Galfalvy, H. C., Currier, G. W., Knox, K. L., Chaudhury, S. R., Bush, A. L., & Green, K. L. (2018). Comparison of the safety Planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department. JAMA Psychiatry, 75(9), 894–900. https://doi.org/10.1001/jamapsychiatry.2018.1776 Suicide Prevention Resource Center.(n.d.-a). Costs of suicide https://www.sprc.org/about-suicide/ costs Suicide Prevention Resource Center. (2018b). Means of suicide. https://www.sprc.org/scope/means-suicide Suicide Prevention Resource Center. (2019c). Resources for suicide loss survivors. https://www.sprc.org/resources-programs/resources-suicide-loss-survivors Suicide Prevention Resource Center. (2016d). Suicide screening and assessment. http://www.sprc.org/sites/default/files/migrate/library/RS_suicide%20screening_91814% 20final.pdf Suicide Prevention Resource Center. (2018e). Talking about lethal means safety in health care settings. https://www.sprc.org/news/talking-about-lethal-means-safety-health-care-settings The Joint Commission. (2019). National patient safety goal NPSG 15.01.01, EP2: reduce the risk for suicide. https://www.jointcommission.org/- 36 /media/tjc/documents/resources/patient-safety-topics/suicide-prevention/ r3_18_suicide_prevention_hap_bhc_5_6_19_rev5.pdf?db=web&hash=88718 6D9530F7BB8E30C28FE352B5B8C Thom, R., Hogan, C., & Hazen, E. (2020). Suicide risk screening in the hospital setting: A review of brief validated tools. Psychosomatics, 61(1), 1–7. https://doi.org/10.1016/j.psym.2019.08.009 Too, L. S., Spittal, M. J., Bugeja, L., Reifels, L., Butterworth, P., & Pirkis, J. (2019). The association between mental disorders and suicide: A systematic review and meta-analysis of record linkage studies. Journal of Affective Disorders, 259, 302–313. https://doi.org/10.1016/j.jad.2019.08.054 United States Census Bureau (2019a). Quick facts: Idaho. https://www.census.gov/quickfacts/ID United States Census Bureau (2019b). Quick facts: Oneida County, Idaho. https://www.census.gov/quickfacts/oneidacountyidaho United States Census Bureau. (2016c). New census data show differences between urban and rural populations. https://www.census.gov/newsroom/press-releases/2016/cb16-210.html United States Department of Agriculture. (n.d.). What is rural? https://www.ers.usda.gov/topics/rural-economy-population/rural-classifications/what-is-rural/ Vaiva, G., Vaiva, G., Ducrocq, F., Meyer, P., Mathieu, D., Philippe, A., Libersa, C., & Goudemand, M. (2006). Effect of telephone contact on further suicide attempts in patients discharged from an emergency department: Randomised controlled study. BMJ : British Medical Journal, 332(7552), 1241–1245. 37 Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S., Selby, E. A., & Joiner, T. E. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600. https://doi.org/10.1037/a0018697 Visit Idaho (n.d.) About Idaho. https://visitidaho.org/about-idaho/ World Health Organization (2020). Suicide data. https://www.who.int/mental_health/prevention/suicide/suicideprevent/en/ Zero Suicide in Health and Behavioral Healthcare. (2020). What is zero suicide? https://zerosuicide.edc.org/about 38 Appendix A 39 Appendix B 40 Appendix C Quality Improvement Project Gantt Chart January- March 2020 April 2020 May 2020 June 2020 July 2020 August 2020 Sept. 2020 Oct. 2020 Nov. 2020 Dec 2020 Jan- April 2021 Identify problem & population: Suicide in Oneida County, Idaho Complete Literature Review Identify project lead & project consultant Develop project proposal Present Project Proposal Complete application for Southeastern Idaho Public Health Zero Suicide Initiative (ZSI) pilot program Implementation of ZSI at Nell J. Redfield Memorial Hospital. Collection of data Data analysis and evaluation Dissemination of results