CSW Zero Suicide Initiative Pathway - Seattle Children's

Zero Suicide Initiative Pathway v2.0: Ambulatory ScreeningApproval & CitationSummary of Version ChangesExplanation of Evidence RatingsAMBULATORY SUICIDE RISK SCREENINGPrimary ReferencesNational Institute of Mental Health Ask Suicide-Screening Questions(ASQ)ASQ Toolkit Brief Suicide Safety Assessment(BSSA)BSSA Staff script to say to the parent/guardian and the patientInclusion Criteria All patients 10 years old In-person provider (MD, DOor APP) visits only!If parent/guardianrefuses to allowscreening questions,notify providerExclusion Criteria Unable to answer questionsdue to medical acuity ordevelopmental delayASQ1. In the past few weeks,have you wished youwere dead?2. In the past few weeks,have you felt that you orothers would be betteroff if you were dead?3. In the past week, haveyou been havingthoughts about killingyourself? If yes, do youhave a plan?4. Have you ever tried tokill yourself? If yes,when and how?5. Are you having thoughtsof killing yourself rightnow?CNA, MA or RN completes ASQ (#1 – 4)!Any “Yes” is aPositive ScreenAny “Yes” toASQ questions 1through 4?NoFurtherActionNoYesCNA, MA or RN completes ASQ (#5)!If “Yes” to #5,patient not to beleft alone“Yes” to ASQquestion 5?Yes CNA, MA or RN notifies provider(MD, DO or APP) Initiate policy for ManagingPatients, Family and Visitors atRisk of Self Harm (for SCH Only) Provider informs parent/guardianand provides handouts Provider orders Social WorkreferralNo CNA, MA or RN notifies provider(MD, DO or APP) Provider informs parent/guardianand provides handouts Provider orders Social Workreferral Continue with appointment Social Work does BSSA afterappointment Page Social Work SW Intake (8am to 4pm) SW On-Duty (afterhours) Or call Behavior Support Team Or transfer to nearest ED forevaluation (Regional ClinicsPatient Transport policy) (forSCH Only)! If parent/guardianrefuses BSSA, offer:Follow up phone call frommental health teamCrisis Prevention Planningwith PMHS IIResource listCall / notify PCPFor questions concerning this pathway,contact: ZeroSuicidePathway@seattlechildrens.org 2021 Seattle Children’s Hospital, all rights reserved, Medical DisclaimerLast Updated: May 2021Next Expected Review: March 2024

Zero Suicide Initiative Pathway v2.0: ED ScreeningApproval & CitationSummary of Version ChangesExplanation of Evidence RatingsED SUICIDE RISK SCREENINGPrimary ReferencesNational Institute of Mental Health Ask Suicide-Screening Questions(ASQ)ASQ Toolkit Brief Suicide Safety Assessment(BSSA)BSSA Nursing script to say to the parent/guardian and the patientInclusion Criteria All patients 10 years old!Exclusion CriteriaIf parent/guardianrefuses to allowscreening questions,notify medical team Unable to answerquestions due tomedical acuity ordevelopmental delayASQ1. In the past few weeks,have you wished youwere dead?2. In the past few weeks,have you felt that you orothers would be betteroff if you were dead?3. In the past week, haveyou been havingthoughts about killingyourself? If yes, do youhave a plan?4. Have you ever tried tokill yourself? If yes,when and how?5. Are you having thoughtsof killing yourself rightnow?RN completes ASQ (#1 – 4)Any “Yes” toASQ questions 1through 4?!Any “Yes” is aPositive ScreenNoNoFurtherActionYesRN completes ASQ (#5)“Yes” to ASQquestion 5?YesNoRN Notifies provider (MD or ARNP) Initiates ED MH GOC (for SCH Only)RNNotifies provider (MD or ARNP)ED medicaldisposition?ED medicaldisposition?AdmitDischargeAdmitProvider ordersPatient Watch 1:1Observation andPsych ConsultMHE doesevaluation in EDprior to dischargeSocial Work doesBSSA on AcuteCare Unit / ICU(include in shifthandoff)Psych Consultdoes evaluation onAcute Care Unit /ICU (include inshift handoff)Huddle with MHEregarding planprior to EDdischarge MHE does BSSAin ED prior todischargeHuddle with MHEregarding planprior to EDdischarge! DischargeIf parent/guardianrefuses MHEevaluation, offer:Follow up phone call frommental health teamCrisis Prevention Planningwith PMHS IIResource listCall / notify PCPFor questions concerning this pathway,contact: ZeroSuicidePathway@seattlechildrens.org 2021 Seattle Children’s Hospital, all rights reserved, Medical DisclaimerLast Updated: May 2021Next Expected Review: March 2024

Zero Suicide Initiative Pathway v2.0: Inpatient ScreeningApproval & CitationSummary of Version ChangesExplanation of Evidence RatingsINPATIENT SUICIDE RISK SCREENINGPrimary ReferencesNational Institute of Mental Health Ask Suicide-Screening Questions(ASQ)ASQ Toolkit Brief Suicide Safety Assessment(BSSA)BSSA Nursing script to say to the parent/guardian and the patientInclusion Criteria All patients 10 years old!Exclusion CriteriaIf parent/guardianrefuses to allowscreening questions,notify medical team Unable to answerquestions due tomedical acuity ordevelopmental delayASQ completedin ED?ASQNo1. In the past few weeks,have you wished youwere dead?2. In the past few weeks,have you felt that you orothers would be betteroff if you were dead?3. In the past week, haveyou been havingthoughts about killingyourself? If yes, do youhave a plan?4. Have you ever tried tokill yourself? If yes,when and how?5. Are you having thoughtsof killing yourself rightnow?RN completes ASQ (#1 – 4)YesAny “Yes” toASQ questions 1through 4?!Any “Yes” is aPositive ScreenNoNoFurtherActionYesRN completes ASQ (#5)“Yes” to ASQquestion 5?YesRN Notifies provider to order PatientWatch 1:1 Observation andPsychiatry Consult Notifies charge nursePsychiatry consultprior to dischargeNoRNNotifies providerSocial Work consult withBSSA prior to dischargeMILD RISKIf. Passive suicide ideation / no clear suicide plan No self-harm behavior(i.e. only ASQ #1 and #2 endorsed)Then. Offer option for Behavior Support Teamsupport of referrals and Crisis PreventionPlanning and Home Safety PlanningMORE THAN MILD RISKIf Frequent suicide ideation Specific suicide plan Self-harm behavior (i.e. non-suicidal self-injury suicide attempt) that is recent (within 3 months)or previously not identifiedThen. Consult PsychiatryFor questions concerning this pathway,contact: ZeroSuicidePathway@seattlechildrens.org 2021 Seattle Children’s Hospital, all rights reserved, Medical DisclaimerLast Updated: May 2021Next Expected Review: March 2024

CSW Zero Suicide Initiative Pathway Approval & CitationApproved by the CSW Zero Suicide Initiative Pathway team for March 20, 2019, go-liveCSW Zero Suicide Initiative Pathway Team:Psychiatry & Behavioral Medicine, OwnerPsychiatry & Behavioral Medicine, OwnerEmergency Medicine, StakeholderMedical Unit, Team MemberEmergency Medicine, Team MemberNursing Informatics, StakeholderMedical Unit, Team MemberSocial Work, StakeholderMolly Adrian, PhDErika Miller, BSN, RN-BCElaine Beardsley, MN, ACCNS-P, CPENChristine Delos Reyes, MN, RN, CPNSara Fenstermacher, MSN, RN, ACCNS-PLaura Graham, BSN, RN-BCEllie McMahon, MSN, RN, CPNDebra Roseberry, MSW, LICSWClinical Effectiveness Team:ConsultantProject ManagerData AnalystEHR AnalystEHR InformaticianLibrarianProgram CoordinatorLori Rutman, MD, MPHIvan Meyer, PMPNoah Espinoza, MPHMaria JeromeCarlos Villavicencio, MD, MS/MISue Groshong, MLISKristyn SimmonsClinical Effectiveness Leadership:Medical DirectorOperations DirectorDarren Migita, MDJaleh Shafii, MS, RN, CPHQRetrieval Website: initiative-pathway.pdfPlease cite as:Seattle Children’s Hospital, Adrian, M., Miller, E., Beardsley, E., Delos Reyes, C., Fenstermacher,S., Graham, L., McMahon, E., Roseberry, D., Migita, D., 2019 March. Zero Suicide InitiativePathway. Available from: initiative-pathway.pdfReturn to EDReturn to Inpatient

CSW Zero Suicide Initiative Pathway Approval & CitationApproved by the CSW Zero Suicide Initiative Ambulatory team for May 5, 2021, go-liveCSW Zero Suicide Initiative Pathway Ambulatory Team:Psychiatry Clinic, OwnerPsychiatry Clinic, OwnerAmbulatory, Team MemberSocial Work, Team MemberAmbulatory, Team MemberAmbulatory, Team MemberHematology/Oncology Clinic, Team MemberAmbulatory, Team MemberAdolescent Medicine Clinic, Team MemberNephrology Clinic, Team MemberMolly Adrian, PhDErika Miller, BSN, PMH-BCNicole Ardres, MN, RN, NPD-BC, CPNGretchen Bower, LICSW, MHP, CMHS, CCTPJulie Chase, MA-C, AAMAJose Estela, RN, MSN, NE-BCSarah McElvaine, LICSW, OSW-CSarah Storhoff, MSN, RN-BCJanet Sullivan, MSN, RNKaryn Yonekawa, MDClinical Effectiveness Team:ConsultantProject ManagerData AnalystEHR AnalystEHR InformaticsJeff Foti, MDIvan Meyer, PMPNoah Espinoza, MPHKelly FallinSaaliha Nawaz, MSN, RN, CPENClinical Effectiveness Leadership:Medical DirectorOperations DirectorDarren Migita, MDJaleh Shafii, MS, RN, CPHQRetrieval Website: initiative-pathway.pdfPlease cite as:Seattle Children’s Hospital, Adrian, M., Miller, E., Ardres, N., Bower, G., Chase, J., Estela, J.,McElvaine, S., Storhoff, S., Sullivan, J., Yonekawa, K., Migita, D., 2021 May. Zero Suicide InitiativePathway. Available from: initiative-pathway.pdfReturn to Ambulatory

Evidence RatingsThis pathway was developed through local consensus based on published evidence and expertopinion as part of Clinical Standard Work at Seattle Children’s. Pathway teams includerepresentatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, ClinicalEffectiveness, and other services as appropriate.When possible, we used the GRADE method of rating evidence quality. Evidence is first assessedas to whether it is from randomized trial or cohort studies. The rating is then adjusted in thefollowing manner ( from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):Quality ratings are downgraded if studies: Have serious limitations Have inconsistent results If evidence does not directly address clinical questions If estimates are imprecise OR If it is felt that there is substantial publication biasQuality ratings are upgraded if it is felt that: The effect size is large If studies are designed in a way that confounding would likely underreport the magnitudeof the effect OR If a dose-response gradient is evidentGuideline – Recommendation is from a published guideline that used methodology deemedacceptable by the team.Expert Opinion – Our expert opinion is based on available evidence that does not meet GRADEcriteria (for example, case-control studies).To BibliographyReturn to AmbulatoryReturn to EDReturn to Inpatient

Summary of Version Changes Version 1.0 (3/20/2019): Go live for ED and inpatient.Version 2.0 (5/5/2021): Go live for ambulatory. Aligned verbiage to correspond with Epic:patient watch. Corrected search methods.Return to AmbulatoryReturn to EDReturn to Inpatient

Medical DisclaimerMedicine is an ever-changing science. As new research and clinical experience broaden ourknowledge, changes in treatment and drug therapy are required.The authors have checked with sources believed to be reliable in their efforts to provide informationthat is complete and generally in accord with the standards accepted at the time of publication.However, in view of the possibility of human error or changes in medical sciences, neither theauthors nor Seattle Children’s Healthcare System nor any other party who has been involved in thepreparation or publication of this work warrants that the information contained herein is in everyrespect accurate or complete, and they are not responsible for any errors or omissions or for theresults obtained from the use of such information.Readers should confirm the information contained herein with other sources and are encouraged toconsult with their health care provider before making any health care decision.Return to AmbulatoryReturn to EDReturn to Inpatient