COVID-19 ADULT Clinical Pathway Chart Description

The COVID-19 suicide risk clinical pathway provides guidance for screening adult medical patients for suicide risk via telehealth and over the phone using the Ask Suicide-Screening Questions (ASQ) and effectively managing patients who screen positive. This pathway serves as an adaptation of previous suicide risk screening pathways for the purposes of guiding clinicians in screening and assessing suicide risk during the COVID-19 pandemic. The ASQ is a four-item questionnaire that has been validated in pediatric and adult patients in medical settings. The pathway proposes a three-tiered approach to screening: 1) screening for suicide risk with the ASQ (≈ 20 seconds), 2) a brief suicide safety assessment (BSSA) to conduct a more in depth suicide risk assessment for patients who screen positive on the ASQ (≈ 10 minutes), and, if deemed necessary by the BSSA, 3) a mental health referral, initiation of safety precautions, and/or visit to an emergency department if absolutely necessary. The BSSA is critical in optimizing mental health resources and ensuring a viable screening program. The main change in the COVID-19 pathway is that it guides the assessing clinician in avoiding the Emergency Department and emphasizing lethal means safety counseling. Examples of guides for conducting the BSSA include the ASQ Brief Suicide Safety Assessment (www.nimh.nih.gov/asq) or the Columbia Suicide Severity Rating Scale.
This is a detailed description of a flowchart appearing on the [COVID-19 Adult Clinical Pathway] webpage.

• Provider calls/is called by patient. Screen all patients who meet any of the screening criteria.*

• *Screening criteria: 1. New patient; 2. Existing patient who has not been screened within the past year; 3. Patient had a positive suicide risk screen the last time they were screened; 4. Clinical judgement dictates screening

• Medically able to answer questions?

• No
• Screen at next visit
• Yes
• Administer ASQ. Assess whether patient is in a private place.
• YES on any question 1-4?
• No -> Negative Screen, Exit the Pathway
• Yes
• Yes to Q5?
• Yes -> Imminent Risk
• No -> Non-acute Positive Screen: Conduct Brief Suicide Safety Assessment (BSSA). Detailed instructions about the BSSA can be found at www.nimh.nih.gov/ASQ
• BSSA Outcome (3 Possibilities)
• Low Risk – No further evaluation needed at this time
• Would benefit from a non-urgent mental health follow-up?
• No -> No referral needed at this time
• Yes -> Referral to further telehealth care as appropriate; Continue medical care; Initiate safety plan for potential future suicidal thoughts
• Referral – to further mental health care as appropriate; continue medical care; initiate safety plan for potential future suicidal thoughts
• Safety Planning: Create safety plan for potential future suicidal thoughts, including identifying personal warning signs, coping strategies, social contacts for social support, and emergency contacts. Detailed instructions about safety planning can be found at https://www.sprc.org/resources-programs/patient-safety-plan-template; Discuss lethal means safe storage and/or removal with patient (e.g. ropes, pills, firearms, belts, knives); Provide resources: 24/7 National Suicide Prevention lifeline 1-800-273-TALK (8255), En Español: 1-888-628-9454, 24/7, Crisis Text Line: Text “START” to 741-741.
• If suicide risk becomes more acute, instruct patient/family/friends to contact outpatient healthcare provider to re-evaluate need for ED visit
• Schedule all patients who screen positive for a follow-up visit in 3 days to confirm safety and determine if a mental health care connection has been made. Future follow-up primary care appointments should include re-screening patient, reviewing use of safety plan, and assuring connection with mental health clinician.
• Further Evaluation Needed – Mental health referral needed as soon as possible via telehealth services or in person
• Make a safety plan with the patient to activate as needed
• Schedule a follow up with patient within 72 hours for safety check and to determine whether or not they were able to obtain a telehealth or in person mental health appointment
• Imminent Risk – Patient has acute suicidal thoughts and needs an urgent full mental health evaluation
• Patient to initiate safety precautions
• Safety Precautions: If available, family/friends can assist with implementing immediate safety precautions. Patient or family/friend to remove or safely store dangerous items. Provider can ask patient for permission to contact patient’s family/friend to instruct on how to implement safety precautions and to call the provider if worried about the patient.
• Assess need for ED visit versus patient’s ability to remain safe at home. Avoid ED visit if possible, balancing risk for exposure to COVID-19 versus suicide risk.
• Send to ED?
• Yes -> Advise patient to wear mask and call local ED before arrival
• No -> Safety Planning: Create safety plan for potential future suicidal thoughts, including identifying personal warning signs, coping strategies, social contacts for social support, and emergency contacts. Detailed instructions about safety planning can be found at https://www.sprc.org/resources-programs/patient-safety-plan-template; Discuss lethal means safe storage and/or removal with patient (e.g. ropes, pills, firearms, belts, knives); Provide resources: 24/7 National Suicide Prevention lifeline 1-800-273-TALK (8255), En Español: 1-888-628-9454, 24/7, Crisis Text Line: Text “START” to 741-741.
• If suicide risk becomes more acute, instruct patient/family/friends to contact outpatient healthcare provider to re-evaluate need for ED visit
• Schedule all patients who screen positive for a follow-up visit in 3 days to confirm safety and determine if a mental health care connection has been made. Future follow-up primary care appointments should include re-screening patient, reviewing use of safety plan, and assuring connection with mental health clinician.