The Emergency Nurses Association is the premier professional nursing association and resource for emergency nursing, as well as for other emergency clinicians. Due to constraints of time and personnel in the emergency department (ED), screening within the ED must be brief and easily administered by the staff. The initial suicide screening tool should efficiently identify those at risk for self-harm and be easily integrated with the current clinical assessments performed by clinicians in the ED. For that reason, this clinical practice guideline has restricted recommendations to tools with five or fewer screening questions to improve compliance with the universal screening requirement of the Joint Commission.
The Emergency Nurses Association has outlined in this resource the most appropriate tools for screening for self-harm or suicidal ideation during an initial emergency assessment of patients across the lifespan. They utilize CDC’s terms: suicidal, non-suicidal, undetermined self-directed violence, suicide attempt, interrupted self-directed violence (by self or other), other suicidal behavior including preparatory acts, and suicide. They evaluated existing tools for their strength of evidence and present appropriate tools for use in emergency settings for the goal of universal suicide screening. The goal of universal screening is to identify the population at risk for self-harm that currently goes undetected, and allows for providers to complete a more in-depth lethality or depression screening to assist with placement or discharge planning.
An example of a suicide risk assessment tool recommended by this guideline for use in the ED is the Ask Suicide-Screening Questions (ASQ). An example specific for use in evaluating lethality for discharge planning is the Behavioral Health Screening-Emergency Department (BHS-ED).
View the guidelines below.
Clinical Practice Guideline: Suicide Risk Assessment (Emergency Nurses Association)
This resource was selected by SMI Adviser content partners and approved by the SMI Adviser clinical expert team for inclusion in the knowledge base.