Adolescent Suicide Screening and

Nursing Practice

Presented by: Leah J. Dahlstrom & Devin R. Steidler

Nursing Division, University of Mary
NUR 435: Research & Evidence Based Practice
Sarah Berreth, MSN, RN
 Introduction

 Suicide is an epidemic
 North Dakota ranked 12th in 2017
 Suicide in adolescents
 Second leading cause of death
 Increased 52.2% between 2000-2021
 Highest rates of emergency department
(ED) visits for self-harm
 Someone commits suicide every 11 minutes
 Suicide is preventable

(Centers for Disease Control and Prevention, 2023)

 Suicide Screening History and Evolution
Related to Nursing

 Suicide has occurred for more than 2000 years (Lu et al.,
2020)

 First screening tool implemented in 2001 (The Joint

Commission, 2019)

 Seven screening tools endorsed by The Joint Commission (The Joint

Commission, 2019)

 Local hospital uses questions based off the Columbia-Suicide

Severity Rating Scale (C-SSRS) (K. Mathern, personal
communication, April 19, 2023)
Clinical Significance of
Suicide Screening to
Nursing

 First health care

professional patient may
encounter
 Duty to ensure patient
safety
 Administer suicide risk
screening assessments
 Identify patient needs
and coordinate care
 Screening is a pathway
for further evaluation
and treatment
 P: Adolescent patients in the hospital
emergency department

PICOT I: Suicide risk screening tool

Question C: No suicide risk screening tool

O: Decreasing suicide rates

 Clinical Question

 In adolescent patients in the hospital emergency

department (ED), does utilization of suicide risk
screening tools decrease the rates of suicide?
 Effectiveness of Two Psychiatric Screening
Tools for Adolescent Suicide Risk
By: Weatherly, A.H., & Smith, T.S.

 Quantitative Study
 Retrospective convenience sample
 Aim
 To discuss the outcomes of an evidence-based practice project that assessed the
effectiveness of using the C-SSRS and the PHQ-9 in identifying adolescents at
higher risk for suicidality warranting inpatient psychiatric hospitalization
 Methods
 Verbally administered the C-SSRS and PHQ-9 modified for teens
 Guardians were not required to leave the room
 Some voluntarily left

(Weatherly & Smith, 2019)

 Effectiveness of Two Psychiatric Screening
Tools for Adolescent Suicide Risk
By: Weatherly, A.H., & Smith, T.S.

 Findings
 C-SSRS and PHQ-9 modified for teens congruent accuracy of 62.2%
 65% had a previous diagnosis of depression and scored accurately
 There was no 2-week return visit for 92% of discharged patients
 Conclusion
 The goal: reduce suicide completion and attempts
 Evaluation process
 Time efficient method for improving adolescent safety
 C-SSRS and PHQ-9 are ideal for acute care
 Less than 5 minutes

(Weatherly & Smith, 2019)

 Identification of At-Risk Youth by Suicide
Screening in a Pediatric Emergency Department
By: Ballard, E. D., Cwik, M., Van Eck, K., Goldstein, M., Alfes, C., Wilson, M. E., Virden, J. M., Horowitz, L. M., & Wilcox, H. C.

 Quantitative Study
 Retrospective cohort
 Aim
 “Examine nursing compliance with administration of screening and patient
characteristics impacting compliance
 Describe the relationship between screening results and primary complaint,
demographics, and disposition
 Identify value of ASQ in detecting suicide risk that may have otherwise gone
unnoticed
 Evaluate the relationship between screening results and repeat visits to ED for
suicide-related reasons”
(Ballard et al., 2016, p. 175)
 Identification of At-Risk Youth by Suicide
Screening in a Pediatric Emergency Department
By: Ballard, E. D., Cwik, M., Van Eck, K., Goldstein, M., Alfes, C., Wilson, M. E., Virden, J. M., Horowitz, L. M., & Wilcox, H. C.

 Findings
 Nursing compliance with screening was 79%
 Over half screened positive for suicide risk (448/768, 58%)
 53% of patients who screened positive did not come to the ED with a suicide-related presenting
complaint
 288 (30%) were hospitalized or transferred to another facility after their visit
 Conclusions
 ED suicide screening may identify at-risk youth who are important targets for suicide prevention
efforts
 Can be incorporated into standard of care with a relatively high nursing compliance rate
 Study demonstrates that many more patients are experiencing suicidal thoughts than patients who
report suicidal behavior as a presenting complaint
 Important to ask these questions directly as adolescents may not otherwise disclose these
thoughts
(Ballard et al., 2016)
Comparing the predictive value of screening to the use of EHR
data for detecting future suicidal thoughts and behaviors in
urban pediatric ED: a preliminary analysis
By: Haroz, E. E., Kitchen, C., Nestadt, P. S., Wilcox, H. C., DeVylder, J. E., & Kharrazi, H.

 Quantitative Study
 Retrospective cohort
 Aims
 Compare a brief screening measure to an EHR-based predictive modeling
approach on accuracy, sensitivity, and utility for identifying those at risk of returning
to the pediatric ED for suicide related reasons
 Measuring the added value of integrating EHR data with the ASQ
 Identifying subsequent pediatric ED suicide related visits
 Identifying how best to recognize individuals at risk for suicide, as well as
implications of implementing such approaches in clinical care settings

(Haroz et al., 2021)

Comparing the predictive value of screening to the use of EHR
data for detecting future suicidal thoughts and behaviors in
urban pediatric ED: a preliminary analysis
By: Haroz, E. E., Kitchen, C., Nestadt, P. S., Wilcox, H. C., DeVylder, J. E., & Kharrazi, H.

 Findings
 N=13,420 individuals, n=141 subsequent suicide related pediatric ED visits
 63% identified as high risk
 ASQ and EHR data resulted in a sensitivity of 0.783 and an AUC of 0.885
 ASQ alone sensitivity of 0.667 AUC of 0.754
 EHR alone sensitivity of 0.601 AUC of 0.755
 Conclusions
 The addition of EHR data to brief suicide screening in the pediatric ED
setting considerably improves accuracy of identifying individuals at risk of future
suicidal behaviors
 Further research is needed

(Haroz et al., 2021)

 Successful Suicide Screening in the Pediatric Emergency
Department: Youth, Parent, Researcher, and Clinician
Perspectives
By: Vaughn, L. M., Sunny, C. E., Lindquist-Grantz, R., King, C., Brent, D., Boyd, S., & Grupp-Phelan, J.

 Quantitative & Qualitative

 Mixed methods study
 Utilized concept mapping
 Six step process
 Aim
 To compare and contrast perspectives from youth, parents, researchers, and
clinicians about potentially effective suicide screening tools in the pediatric
emergency department setting

(Vaughn et al., 2020)

 Successful Suicide Screening in the Pediatric Emergency
Department: Youth, Parent, Researcher, and Clinician
Perspectives
By: Vaughn, L. M., Sunny, C. E., Lindquist-Grantz, R., King, C., Brent, D., Boyd, S., & Grupp-Phelan, J.

 Findings
 Prompt 1: “I believe the most important result of suicide screening for teens in the ED is…”
 7 clusters of ideas
 Short and long-term follow-up and treatment as most important (26%)
 Rated suicide prevention and education most feasible
 Prompt 2: “Successful suicide screening for teens in the ED should include…”
 6 clusters of ideas
 Rated comfortable, safe screening environment as most important (25%)
 Rated provision of resources and information as most feasible
 Conclusion
 Screening tools can address risk for suicide
 Provide opportunities for addressing further treatment and services
 Study collectively identifies successful screening practices
(Vaughn et al., 2020)
 Synthesis

 Suicide screening tools should be implemented

in clinical practice
(Ballard et al., 2016; Haroz et al., 2021; Weatherly & Smith, 2019; Vaughn et al., 2020)

 Specific screening tools recommended:

 Columbia-Suicide Severity Rating Scale (C-SSRS)
(Weatherly & Smith, 2019)
 Patient Health Questionnaire (PHQ-9)
(Weatherly & Smith, 2019)
 Ask Suicide-Screening Questions (ASQ)
(Ballard et al., 2016; Haroz et al., 2021)

 Provides opportunity to receive important

treatments and services
(Ballard et al., 2016; Haroz et al., 2021; Weatherly & Smith, 2019; Vaughn et al., 2020)

 Addresses risks that might otherwise go unnoticed

(Ballard et al., 2016; Haroz et al., 2021; Weatherly & Smith, 2019; Vaughn et al., 2020)

 More research needs to be conducted

(Ballard et al., 2016; Haroz et al., 2021; Weatherly & Smith, 2019; Vaughn et al., 2020)

https://www.simplypsychology.org/wp-content/uploads/Questionnaire-1536x1024.jpeg
 Recommendations &
Suggestions for Clinical
Impact and Change

 Implementing the ASQ screening tool

into the Electronic Medical Record
(EMR) for standard use in adolescent
admission assessment
 Ease of use
 Time efficient
 Does not require extensive training
 High compliance rate
 Recognizing those at risk
(Ballard et al., 2016; Haroz et al., 2021)

https://i0.wp.com/keepkidshealthy.com/wp-content/uploads/2020/10/asq-suicide-screening-questions.png?w=960&ssl=1
 Model Chosen:
Lewin’s Three Step
Model for Change

 Experts assert that

Lewin’s theory
provides the
fundamental
principles
for change

 Historically, many
nurses utilize this
specific model for
change
(Wojciechowski et al., 2016) https://online.visual-paradigm.com/repository/images/f703210a-5dca-44c6-9f7c-e0a53e618d78/lewins-change-model-design/lewins-3-stage-
model.png
 Lewin’s Three Step Model for Change

Unfreeze Change Refreezing

 Prevalence of adolescent  Inservice about upcoming  Incentivization

suicide changes  Quarterly meetings
 Need for age-appropriate  Discuss importance of change  Employee feedback
screening tools  Educate on facility protocols  Performance checks
 Strong support from peers and  Informatics team incorporates  Continuing education
management ASQ into EMR
 Dispel doubts, inspire desire  Goal: 90% compliance rate
with administering ASQ after
for change two months of initial
implementation
 Conclusion

 Suicide is the second leading cause of death for adolescents

(Centers for Disease Control and Prevention, 2023)

 ED visit is an opportune time to screen for suicide risk

(National Institute of Mental Health, 2020)

 Screening tools are endorsed by The Joint Commission

(The Joint Commission, 2019)

 Successfully detects risk for suicide

(Ballard et al., 2016; Haroz et al., 2021)
https://baylorlariat.com/wp-content/uploads/2019/09/suicide-prevention.jpg
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