Suicide Risk Screening Pathway: Inpatient Medical Unit 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 the flowchart appearing on the Suicide Risk Screening Pathway: Inpatient Medical Unit webpage.

• Patient presents to Inpatient Medical Unit
• Handoff of risk info received from ED
• Has the ASQ been completed?
  • Yes
    • Are any safety measures already in place due to prior safety concerns?
      • Yes
        • Continue safety care as established previously
      • No
        • Consider re-screening
  • No
    • Initiate Inpatient Suicide Risk Screening
    • Medically able to answer questions?
      • No
        • Screen when medically able
      • Yes
  • Administer ASQ (ideally separate from parents)
    • Patient refuses to answer
      • 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
    • 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
      • Safety Precautions- per institution protocol; keep patient under direct observation, remove dangerous items, etc.
      • Initiate safety precautions; should not leave without a full safety assessment
      • 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
            • 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.
        • 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.