Suicide Risk and Prevention in the Outpatient Setting

Background: Suicide is a serious public health problem that can have lasting harmful effects on individuals, families, and communities. The ambulatory nurses in the neurology department identified a gap in care for patients who called or presented to the clinic with suicidal ideation. Both nursing and providers identified a need for a standardized workflow and policy to appropriately manage the high-risk patient population.

Purpose: To outline a systematic approach for assuring the safety of patients who present to ambulatory practices with a suicide attempt or possible suicidal ideation.

Objectives
• Screen for suicide severity using an evidence-based screening tool.
• Develop a sustainable standardized policy and patient care workflow with recommended interventions when managing suicide and/or suicide ideation.
• Deliver safe, effective, and timely care to the patient.
• Standardized documentation to enhance organizational communication and collaboration.

Methods: Ambulatory nursing developed a multidisciplinary committee chaired by a nurse. The committee included members from the following departments: nursing, social work, psychiatry, psychology, providers, access center, information systems, and security. Initially, the committee identified various problems/needs such as need for suicide severity screening tool, appropriate patient care interventions, a sustainable workflow, and integration with the electronic medical record. The committee performed a literature and suicide resource review of best practices to identify an evidence-based tool to evaluate suicide ideation severity. The committee reviewed the suggested interventions and developed program standards based on available resources. Finally, the committee developed a policy, education, and training for staff.

Results: The suicide prevention committee implemented the Columbia suicide severity rating scale (CSSRS), which is a tool utilized to identify the risk for suicide, assess the severity and immediacy of that risk, and gauge the level of support that the person needs. The tool and workflow was developed in the electronic medical record for ease and compliance of use by the providers and clinical staff. Education and training on the policy, CSSRS tool, and workflow were delivered via an online learning module, presentation, and open office hours allowing for open discussion and questions. The intervention workflow for patients identifying having low severity of suicidal ideation were routed to a social workers for follow-up within 7 days of their initial evaluation per the TJC recommendations and to establish any additional care or resources for the patient. After implementation, modifications were made to how patients were referred to the social work resources through the electronic medical record.

Discussion: Next steps involve running data to determine the volume of patient encounters involving suicidal ideation and the reviewing the common interventions ordered for the patients. Based on the data, further evaluation can be conducted to identify a need to develop any additional resources/services as well as collaborate and partner with community resources so patients can obtain advanced access to care around suicidal ideation within their local community aligning with the organization’s mission and vision.