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Suicide Risk Screening Pathway: Emergency Department Chart Description

The suicide risk clinical pathway provides guidance for screening pediatric patients for suicide risk in medical settings using the Ask Suicide-Screening Questions (ASQ) and effectively managing patients who screen positive. The ASQ is a four-item questionnaire that has been validated in pediatric 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 full suicide safety assessment that includes a broader mental health assessment. The BSSA is critical in optimizing mental health resources and ensuring a viable screening program. 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 Suicide Risk Screening Pathway: Emergency Department webpage.

  • Presentation to ED
    • Medically able to answer questions?
      • No
        • Screen when medically able
      • Yes
  • Administer ASQ (ideally separate from parents)
        • Patient refuses to answer
          • Yes
            • Non-acute positive screen: conduct brief suicide safety assessment (BSSA)
          • No
            • 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)
      • BSSA Outcome (3 Possibilities)
        • Low Risk – No further evaluation needed on the medical unit
          • Referral – to further mental health care as appropriate; continue medical care; initiate safety medication; communicate positive screen to PCP
              • Safety Education: Create safety plan for potential future suicidal thoughts; discuss suicide mean restriction; provide resources – 24/7 National Suicide Presentation lifeline 1-800-273-TALK (8255); En español: 1-888-628-9454, 24/7. Crisis Text Line: Text “START” to 741-741.
        • High Risk – Further evaluation of suicide risk is necessary; should not leave without a full safety assessment
        • Imminent Risk – Patient is at imminent risk for suicide with current suicidal thoughts
          • Initiate safety precautions; should not leave without a full safety assessment
          • Safety Precautions- per institution protocol; keep patient under direct observation, remove dangerous items, etc.
          • Notify family; Alert ED provider
          • Conduct Full Safety Assessment
          • Needs inpatient psychiatric hospitalization?
              • No
                • Referral – to further mental health care as appropriate; continue medical care; initiate safety medication; communicate positive screen to PCP
              • Yes
                • Initiate or maintain safety precautions; medically stabilize patient
              • Is patient being admitted for medical treatment?
                • No
                  • Handoff clinical risk assessment information to accepting psychiatric unit upon transfer from ED
                  • Transfer to psychiatric unit. Safety precautions to be followed throughout transfer process
                • Yes
                  • Handoff clinical risk assessment information to accepting medical unit upon transfer from ED
                  • Transfer to medical unit. Safety precautions to be followed throughout transfer process.