Suicide Risk Screening Pathway: Outpatient Flowchart Description

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Presentation to Outpatient Primary Care & Speciality Clinics. Screen all patients ages 10 above who meet any of the screening criteria.*
* Screening Criteria

1. New patient
2. Existing patient who has not been screened within the past 30 days
3. Patient had a positive suicide risk screen the last time they were screened
4. Clinical judgement dictates screening 

Suicide Risk Screening Pathway

• Medically able to answer questions?
  • No
    • Screen at next visit
  • Yes
    • Administer the ASQ (ideally separate from parents)
      • Yes on any question 1-4 or refuses to answer?
        • No
          • Negative Screen. Exit pathway
        • Yes
          • Yes to Q5?
            • Yes
              • Acute Positive Screen; Imminent Risk. Patient has acute suicidal thoughts and needs an urgent full mental health evaluation.
                • Initiate Safety Precautions1 Until able to obtain full mental health evaluation
                • 1Safety Precautions. Per institution protocol; keep patient under direct observation, remove dangerous items, provide safety education, etc.
                • Send to emergency department for full mental health/safety evaluation
              • 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 (three 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 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 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 both parent/guardian and child (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/parent/guardian to contact outpatient healthcare provider to 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
  • Make a safety plan with the patient and parent/guardian to activate as needed. If mental health evaluation
    is not available within practice, refer to outpatient mental health clinician.
  • Schedule a follow up with patient within 72 hours for safety check and to determine whether or not they were able to obtain a mental health appointment
  • Safety Planning
    • Create safety plan for potential future suicidal thoughts, including identifying personal warning signs, coping strategies, social contacts for 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 both parent/guardian and child (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/parent/guardian to contact outpatient healthcare provider to 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

• Imminent Risk. Patient has acute suicidal thoughts and needs an urgent full mental health evaluation
  • Initiate Safety Precautions1 Until able to obtain full mental health evaluation
    • 1Safety Precautions. Per institution protocol; keep patient under direct observation, remove dangerous items, provide safety education, etc.
  • Send to emergency department for full mental health/safety evaluation