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.