“The first thing I would say to any clinician is that it’s never wrong to send a child to the emergency room,” said Amy Dryer, MD, pediatrician and REACH faculty member.
Having spent 10 years in a hospital emergency department, Dr. Dryer is intimately familiar with the criteria ER physicians use to decide to admit psychiatric patients: a medical condition, suicidal ideation with a lethal plan, homicidal ideation, or active psychosis.
However, she emphasized that your decision to refer to the ER doesn’t hinge on whether the patient is likely to be admitted. “If what they’re telling you makes you uncomfortable,” she said, “go ahead and refer them.”
In the REACH course Patient-Centered Mental Health in Pediatric Primary Care, Dr. Dryer and other faculty teach primary care providers to be more comfortable working with children who express suicidal ideation. Armed with knowledge and practice, clinicians can take a balanced approach to the decision to refer to the ER or not.
Suicidal ideation is high among teenagers. According to the Centers for Disease Control and Prevention, 18.8% of teenagers reported having considered suicide in 2019, though only 2.5% required medical intervention after a suicide attempt.
Using materials from the REACH course, Dr. Dryer outlined factors that make young patients more likely to complete suicide:
In addition, children of color (especially Black children) and LGBTQIA+ kids are at greater risk than others.
Dr. Dryer and The REACH Institute recommend the ASQ (Ask Suicide Screening Questions) five-question screening tool to help you assess whether a patient is in imminent danger.
“Suicidality exists on a spectrum, from passive ideation through having a plan to completed suicide,” said Dr. Dryer. “The trick is figuring out where this patient is on that spectrum—keeping in mind that, for one kid, that spectrum might be two football fields wide, while for another it’s only ten yards.”
Dr. Dryer also pointed out that self-harm behaviors like cutting, which have been treated as risk indicators, do not necessarily correspond to high risk of suicide. There are three reasons for cutting, she said: as a relief valve, as a distraction, or as practice for suicide. “That last is the one I worry about. The first two are coping mechanisms—not healthy ones, but also not pre-suicide behaviors.”
Here are the conditions Dr. Dryer wants to have in place in order to send a child home rather than to the ER:
Knowing how the ER will handle your patient and what other options are available in your community can help you better care for patients whose suicidal ideation concerns you.
If you haven’t already, investigate the ER(s) in your community, whether by asking colleagues or calling the attending physician. How long is the wait? What is the availability of beds for pediatric psychiatric patients—and are those beds on site or elsewhere?
“Hospital emergency rooms often don’t feel like safe places for LGBTQIA+ youth,” said Dr. Dryer. “Or the wait could be days. You would still send the patient if it’s the only way to keep them safe, but you wouldn’t submit them to that trauma if there are other options.”
In many communities, crisis intervention units provide another option. They often provide wraparound services, such as family support, that neither you nor the hospital can readily provide. To find out what’s available locally, start with your state health department’s website.
“I always do a warm hand-off” when referring to the ER, said Dr. Dryer. “I want to talk to the attending or admitting physician to tell them who this is and why I’m sending them.”
Furthermore, said Dr. Dryer, “I am 110% transparent with both the patient and the family. I tell them why I’m concerned and why it’s important for the patient to go straight to the ER.” If the patient and caregiver agree, great! But if the caregiver insists that the child will be okay at home, Dr. Dryer says, “I’m prepared to call 911 if need be.”
Screening tool: ASQ (Ask Suicide Screening Questions)
“The opportunity to learn information to help me manage psychiatric conditions in my patients in this time where demand clearly outweighs supply of services, is going to be excellent for me as a PCP in my community.”