Suicide: Intervention Bundle

Despite the significant burden of youth suicidality on the healthcare system, the number of pediatric mental health professionals is significantly less than needed. The addition to the increased burden caused by suicidal behavior on the healthcare system, the American College of Child and Adolescent Psychiatry (AACAP) has reported a severe shortage of practicing pediatric psychiatrists. This shortage has caused a significant disparity in mental health care for children aged 0-17.4 In addition to the overall shortage of mental health professionals for children, a large disparity also exists by county and average age of child and adolescent psychiatrists per state.

The AACAP workforce map shows the pediatric psychiatrist coverage by geographic region. See: https://www.aacap.org/aacap/Advocacy/Federal_and_State_Initiatives/Workforce_Maps/Home.aspx

There are currently about 8,000 child and adolescent psychiatrists practice in the U.S., while estimates put the need at more than 30,000. This disparity between needs and access is especially true in rural areas.5,6,7,8 Hospital EDs serve as an important safety net for children and adolescents awaiting mental health services in the hospital or community.

Considering the limited access to a mental health professional in many communities, it is important for primary care clinics and EDs to identify professionals who can become familiar with how to conduct an initial suicide screening, as well as to assess the acuity and severity of suicide risk in a child or adolescent. Studies show that primary care pediatricians may feel comfortable with providing such assessment and referral, but they are not as comfortable providing treatment.26 In addition to strategies that help improve the clinic or ED assessment of a child or adolescent, specific considerations such as telehealth or collaboration with Pediatric Mental Health Care Access (PMHCA) programs play an important role in optimizing assessment and outcomes. Telemedicine, another useful approach, would entail an agreement to have a psychiatric-trained professional provide remote assessment and/or consultation with the ED physician.

Gathering data when implementing change to your system is important to both track how your implementation is going and also to assess whether your changes are moving towards your process measure goal. Data can help give insight into how the changes are being accepted or not accepted into your system.

There are a variety of ways to assess how your implementation project is progressing, some include:

• Chart audits to evaluate any of the process measures above:
  • Can be conducted in real time or retrospectively.
  • Can be all charts or some charts selected for surveillance using a sampling such as a random sample or systematic approach (e.g., every 5th pediatric patient over 10 years old), or all pediatric patients evaluated over a given time period.
• Survey staff on usage and/or comfort.
• Consider adding “survey staff experience/satisfaction” as a layer related to the implementation of any of your intervention strategies.
• Create a brief survey for families for any of the process measures above:

Some example numerical metrics you can calculate for each process measure are listed in the table below:

Below you will find suggested possible interventions, also called change strategies, for each process measure. These are suggestions on different steps that may assist your team in accomplishing the aim you are focusing on. Interventions or change strategies are often grouped into “Guidelines/Protocols, Education, Electronic Medical Records Optimization, and Resources (inclusive of personnel and equipment)”. As the local expert, you may have other ideas regarding how to best implement change in your hospital or ED. You should always feel free to reach out to your team leader and/or brainstorm these ideas with the other ED team leaders or participants working on similar aims in this collaborative.

Quality Measure: Percentage of patients who had a structured suicide screen

UTILIZE PROCESS OR GUIDELINE THAT USES A VALIDATED SCREENING TOOL

• Develop a process or guideline to use an identified validated screening tool to guide the screening of all children over the age of 10 to be assessed for risk (and level of risk) for suicide.

EDUCATION

Change Strategies

• Develop a training or education program that includes:
  • Learning Objectives: Components and importance of universal screening of pediatric patients for risk of suicide and instructions for use of identified/validated suicide screening tool.
• Determine a method of how to measure “high-level knowledge” through self-reports or use of a test with a percentage of knowledge score.

ELECTRONIC MEDICAL RECORD (EMR) OPTIMIZATION

Change Strategies

• Integrate suicide screening into the EMR.
• Implement standing physician orders or nursing form for nurses to complete.
• Develop an automated alert to remind the care team to use the identified screening tool(s) with links to the tool(s).

Quality Measure: Percentage of patients with a positive suicide screen who had a structured suicide assessment

WRITTEN PROCESS/GUIDELINE FOR HIGH-RISK PATIENTS TO RECEIVE STRUCTURED SUICIDE ASSESSMENT

Change Strategies

• Develop a written clinical process or guideline requiring a structured mental health assessment when pediatric patients screen for high-risk for suicide. The process or guidelines should include:
  • Informing the patient what can and cannot be kept confidential, including your obligation to inform appropriate people about immediate safety concerns.
  • Informing patients of next steps and what to expect.
  • Details on the process of which patients qualify for further assessments and next steps for providers.

EDUCATION

Change Strategies

• Develop a training or education program that includes:
  • Learning Objectives: Components and importance of the clinical pathway for full mental health assessment of pediatric patients determined to be at high risk for suicide

Quality Measure: Percentage of patients with a positive suicide screen who had a consultation with a licensed mental health professional

WRITTEN PROCEDURE/GUIDELINE FOR FULL SUICIDE ASSESSMENT

Change Strategies

• Develop a written procedure/guideline that provides instructions on how and when to consult a licensed mental health professional or social worker to assess pediatric patients at high risk for suicide in the ED.
• Include how to contact the correct personnel at what times, including social workers, psychiatrists, and telepsychiatric consult services (i.e., call social worker’s phone, place need for consult in EMR).
• Identify how best to access available community resources.

PROCESS TO OBTAIN 24/7 ACCESS TO LICENSED MENTAL HEALTH PROFESSIONALS

Change Strategies

• Meet with key stakeholders to develop a process to access mental health professionals 24 hours a day, 7 days a week.
• May include coverage from different personnel (i.e., social workers, psychiatrists, or telemedicine approaches) on certain days or during different times of day to increase to full coverage.
• Describe or compile information on the various crisis service models in the community.

Below you will find suggested possible interventions, also called change strategies, for each process measure. These are suggestions on different steps that may assist your team in accomplishing the aim you are focusing on. Interventions or change strategies are often grouped into “Guidelines/Protocols, Education, Electronic Medical Records Optimization, and Resources (inclusive of personnel and equipment)”. As the local expert, you may have other ideas regarding how to best implement change in your hospital or ED. You should always feel free to reach out to your team leader and/or brainstorm these ideas with the other ED team leaders or participants working on similar aims in this collaborative.

Quality Measure: Percentage of patients with a positive suicide screen that received a discharge safety plan

WRITTEN POLICY/PROCEDURE

Change Strategies

• Develop a written procedure or guideline that provides instructions on who should perform, and what should be included in discharge and safety planning of pediatric patients with a mental health condition, such as:
  • Scheduling the first follow-up appointment (ideally within less than 72 hours after discharge).
  • Facilitating a phone call/follow-up communication to the primary care provider/outpatient clinician.
  • Discussion of lethal means restriction: access to weapons, medications, etc.
  • Reviewing the discharge and safety plan, follow-up, and resources with the patient and family.
  • Provision of crisis cards with contact information.
  • Development of a personalized safety plan.
  • Considering a contract specific to safety issues.
  • Providing a family resource packet.
  • Ensure the family is aware they can always return to the ED when safety is compromised.
• Identify or develop a team of ED care providers (e.g., social workers, case managers, mental health consultants, or others) to arrange and support follow-up for patients with suicidality.

RESOURCES

Change Strategies

• Development of a family resource packet to help them navigate mental health follow-up and provide guidance on safety. Consider resources on:
  • Safe storage of medications and firearms.
  • Local resources for mental health services, medication disposal, and firearm storage.
  • How to talk to children/adolescents about suicidal feelings.
  • List of local outpatient mental health providers to consider for follow-up appointments.

EMR OPTIMIZATION

Change Strategies

• EMR documentation of safety planning and lethal means restriction counseling.
  • Integrate a discharge planning safety checklist into the EMR.
  • Document ED follow-up plan in the EMR.

EDUCATION

Change Strategies

• Educate staff on the process for ensuring that each high-risk pediatric mental health patient receives adequate safety planning prior to discharge follow-up after their departure.
• Offer training on how to conduct appropriate and thorough discharge and safety planning processes in the ED.
  • Learning objectives could focus on the importance of discharge/safety planning, lethal means safety counseling, and the importance of establishing follow-up plans.
  • Overview of the family resource packet and its importance.

KNOWLEDGE REINFORCEMENT TOOLS

Change Strategies

• Post the discharge and safety planning process in a readily visible place in the ED.
• Develop a written checklist for staff to use when discharging mental health patients.
• Create a badge card that includes suggestions for lethal means restriction and family counseling.

Disclaimer: The views and responses to these FAQ’s are recommendations from the subject matter experts who presented during the Suicide Fireside Chat on June 27th, 2023. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government

Q: “Will you please share these suicide fireside chat slides?”

A: These slides/recording of the fireside chat will be posted to: https://emscimprovement.center/collaboratives/prqc/2023/sessions

Q: “What is the recommendation for how often a screening should be redone in the ED?”

A: There is not necessarily one standard best answer to this question. You will often end up with a child who spends long enough in the ED where circumstances will change; however, one of the considerations is how much of a concern was the very first screening? If there is a child who screened very high risk, you will have to do more frequent reassessments especially to make sure it didn’t escalate more during their time in the ED. On average, reassess every 1-2 hours. One hour for the really concerned about children; 2 hours for the ones that raised less concern. Regardless of the concern level, at the minimum, some form of reassessment needs to occur. A tip to remember to make sure reassessment occurs is adding notes to your tracking board, “reassessment at this time”.

A: If a child is awaiting an inpatient bed, the recommendation is to conduct a full reassessment each day (every 24 hrs.), especially for those spending an extensive amount of time in the ED.

A: Conduct a reassessment before a new change occurs (i.e. about to discharge, about to relocate the child to a psych hospital, about to let a parent enter the room for the first time).

Q: “In your opinion, what is the most effective suicide screening tool for pediatric patients, ASQ or the C-SSRS? We utilize the CSSRS screening tool in my organization and if the C-SSRS screen is positive it will trigger the SAFE-T to be completed.” “How about for those under 12 years old?”

A: The two tools are slightly different but both have robust evidence behind them. The ASQ is a more sensitive tool so it works well as a primary screener. It will be very sensitive at identifying anyone with the risk, including anyone with related mental health issues that might be found due to a positive ASQ. The C-SSRS is used more as a secondary screener- it is a little bit longer; however, it can give a better idea of the severity of the suicidality and is able to classify it.

A: Found ASQ to be simpler and easier to conduct; Columbia allows for more detailed information to be received. Both tools are well-tested, validated screening tools but it depends on if you are looking for a quicker or a more in-depth answer and also being sure you may integrate this information into your EHR. For a deeper look at more validated screening tools, see Critical Crossroads Toolkit.

A: For universal screening, down to age 10 and targeted below 8 years of age – would use the same tools (ASQ best for universal and CSSRS as secondary)

Q: “Can you provide further information for the Stanley Brown Safety Planning intervention? I would be interested in implementing this in my organization as well.”

A: The Stanley Brown Safety Planning intervention will be posted as a resource in the Suicide Intervention Bundle Guide, which will be posted to the EIIC website.

Q: “Who does the screening and the safety planning in an ED that does not have access to SW or psych resources?”

A: Nurses typically do screenings, safety planning can be done by anyone who is trained; however, it does take time! That individual will need to have some time to sit with the patient and the family.

A: It helps if this was integrated into your EHR as part of your screening tool. The type of personnel conducting it doesn’t matter as much as the prompt to do it does. This would be a great opportunity for a QI project for this collaborative (creating content into your streamlined process by integrating it in the EHR).

Q: “Using a structured screening tool, that is one item that we can use and collect data on?”

A: Yes.

Q: “We also have pediatric patients coming to our community hospital for short procedure unit- would you have recommendations for screening with those encounters?”

A: Ideally, if you have the bandwidth and can do universal screening (especially with kids 12 and over), that can be integrated into your questionnaire. If a child is showing concerning behavior, then you can consider screening them if you don’t have the ability to implement universal screening. If there is not bandwidth for universal screening, there should be criteria for targeted screening.

Q: “Does this intervention bundle have a preference as to the age group for screenings?”

A: 12 years of age and over for sure for universal screening; however, recent data is showing children as young as 5 years old may be at risk, so the 5-9 age group can be targeted for screening based on behavior and chief complaint.

A: ASQ is validated down to 10 and CSSRS to 8.

We recommend universal screening above 10 and targeted below.

If you have any additional questions, please email collaboratives@emscimprovement.center

Screening and Assessment Resources:

Suicide Screening Tools

• Ask Suicide Risk Screening Tool (ASQ) ASQ Questionnaire
• Suicide Assessment Five-step Evaluation and Triage (SAFE-T)
• Columbia Suicide Severity Rating Scale (C-SRRS)

General Mental Health Screening Tools

• HEADS-ED
• Australian Mental Health Triage Scale

Suicide Assessment

• NIMH Toolkit: ASQ-Brief Suicide Safety Assessment
• NIMH Toolkit: ASQ-Brief Suicide Safety Worksheet
• Columbia Suicide Severity Rating Scale (C-SRRS)- Risk Assessment Version

Discharge and Safety Planning Resources:

• Stanley-Brown Safety Plan
• Child Mind Institute - My Safety Plan
• Seattle Children’s Hospital Coping Card
• The Bullet Points Project: Clinical Tools for Preventing Firearm Injury
• ZEROSUICIDE Counseling on Access to Lethal Means Online Training
• American Academy of Pediatrics Suicide Prevention Campaign Toolkit
• ZERO SUICIDE Safety Planning videos

Additional Consideration*

If you are interested in learning about ED-based interventions for boarding mental health patients, please contact Joyce Li, MD, MPH and Michael Goldman, MD, MHS-MEd for more information and resources.

References

1. Mancinelli-Hough K, Lucas Breda K, Karl C, Wentland BA. Don't Ask, Won't Tell: Suicide Screening in the Pediatric Perioperative Setting. Compr Child Adolesc Nurs. 2022 Dec;45(4):395-402. PMID: 36440865
2. Ruch DA, Heck KM, Sheftall AH, Fontanella CA, Stevens J, Zhu M, Horowitz LM, Campo JV, Bridge JA. Characteristics and Precipitating Circumstances of Suicide Among Children Aged 5 to 11 Years in the United States, 2013-2017. JAMA Netw Open. 2021 Jul 1;4(7):e2115683. PMID: 34313741; PMCID
3. https://www.cdc.gov/mmwr/volumes/72/su/pdfs/su7201a6-H.pdf
4. https://www.aacap.org/aacap/zLatest_News/Severe_Shortage_Child_Adolescent_Psychiatrists_Illustrated_AACAP_Workforce_Maps.aspx
5. Harris K, Aguila Gonzalez A, Vuong N, Brown R, Ciccolari Micaldi S. Understanding Pediatric Mental Health in Primary Care: Needs in a Rural State. Clin Pediatr (Phila). 2022 Nov 9:99228221136121. https://pubmed.ncbi.nlm.nih.gov/36352499/
6. Mongelli F, Georgakopoulos P, Pato MT. Challenges and Opportunities to Meet the Mental Health Needs of Underserved and Disenfranchised Populations in the United States. Focus (Am Psychiatr Publ). 2020 Jan;18(1):16-24. https://pubmed.ncbi.nlm.nih.gov/32047393/
7. Addressing Children’s Mental Health Workforce Shortage. American Association of Child and Adolescent Psychiatry. https://www.aacap.org/App_Themes/AACAP/docs/advocacy/advocacy_day/WORKFORCE_2018.pdf
8. Findling RL, Stepanova E. The Workforce Shortage of Child and Adolescent Psychiatrists: Is It Time for a Different Approach? J Am Acad Child Adolesc Psychiatry. 2018 May;57(5):300-301.https://pubmed.ncbi.nlm.nih.gov/29706155/
9. Bettencourt AF, Ferro RA, Williams JL, Khan KN, Platt RE, Sweeney S, Coble K. Pediatric Primary Care Provider Comfort with Mental Health Practices: A Needs Assessment of Regions with Shortages of Treatment Access. Acad Psychiatry. 2021 Aug;45(4):429-434. PMID: 33786779