Suicide Risk Assessment

Emergent, RN · Mar 16, 2014

We use the one that is more annoying than our last one. Five intrusive questions instead one, totally unrelated to the sore throat or chest pain that the patient presented with. And then some level 1-5 complicated thing that no one does.

Just another example of some person in an office saving the world through one sized fits all, computer generated, mandatory fields of inquiry.

"And can you describe your chest pain. Are these your meds, are you suicidal?"

"NO, I'M NOT SUICIDAL, DO I LOOK SUICIDAL? I'M HERE TO HAVE YOU SAVE MY LIFE, FOR THE LOVE OF GOD!"

CodeteamB · Mar 16, 2014

We don't have a formalized tool, and we certainly don't ask about suicidal ideation unless the patient is presenting with a mental health concern.

Actually, once past triage our psych patients are evaluated by a separate emergency crisis team of psychiatric nurses, so maybe they have a tool they use, I'll have to ask.

zmansc, ASN, RN · Mar 16, 2014

Love it Emergent! My main facility we only do a suicidal assessment on behavioral patients or if the nurse thinks their may be a reason to believe the patient is depressed/suicidal/homicidal. My PRN job, does it on every patient. When I first got there I was like ***** And many times it got entered into the 'puter w/o questions because of exactly what Emergent said. However the PRN job people claim the facility gets rated on how many pt's get asked the questions so they are mandatory. Therefore in the nurses note documenting my initial assessment it would say "SI assess done visually". I'm guessing no one actually read the note part because I was never asked to explain this. lol

Sassy5d · Mar 17, 2014

I can't tell ya how many pts, there for whatever reason, start saying yes when u ask about si/hi/voices.

emtb2rn, BSN, RN, EMT-B · Mar 17, 2014

Suicide prevention, especially in the ed, has been a jc goal for years. Go to http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=166&ProgramId=47 for details.

We do an 11 question screen on every pt that presents to our er. The answers to most questions for most pts is "no". Any score less than 4 has no impact while 4-6 simply generates a recommendation to add depression to the care plan. A score of 6 up auto generates a 1:1 order which needs to be co-signed by a doc. Fast and effective.

emtb2rn, BSN, RN, EMT-B · Mar 17, 2014

I can't tell ya how many pts there for whatever reason, start saying yes when u ask about si/hi/voices.[/quote']
"Are the voices telling you to do anything?" I always ask what the plan is when si/hi is expressed.

ChristineN, BSN, RN · Mar 17, 2014

"Are the voices telling you to do anything?" I always ask what the plan is when si/hi is expressed.

This. Some people (like a relative of mine who is psychotic) hears voices all the time, but knows how to block them out when she is stable.

If they are suicidal, I also always ask if they have a plan, and what that plan is. My facility has a 12 or so question form that pops up if they screen positive for suicide risk. The questions in the form include have they ever attempted suicide, do they have a support system, substance abuse, feelings of low self esteem/ hopelessness, age over 70, recent life stressors. The form is supposed to be filled out in triage

TheGooch · Mar 18, 2014

"NO, I'M NOT SUICIDAL, DO I LOOK SUICIDAL? I'M HERE TO HAVE YOU SAVE MY LIFE, FOR THE LOVE OF GOD!"

That one fits into the PEOPLE ASK THE DUMBEST QUESTIONS Category on Jeopardy!

Anna Flaxis, BSN, RN · Mar 18, 2014

Let me clarify. I'm referring to a tool that you use to assess severity of suicide risk on patients that present with a CC of SI, not the basic suicide screening that we do on everybody.

We use the SAD Persons Scale. I like it because it's brief and not cumbersome at all (too much cumbersome paperwork as it is), but I dislike it because it doesn't seem like a really accurate tool- plus the SAD scale is not recommended for use in the ED by the ENA.

I'm trying to find a tool to suggest to management, but I can't seem to find anything available online. The ENA recommends the following:

Beck's Suicide Intent Scale (SIS)

Depressive Symptom inventory-Suicidality Sub-scale

Geriatric Depression Scale (GDS)

Risk Assessment Matrix (RAM)

Suicidal Ideation Questionnaire (SIQ)

Suicidal Ideation Questionnaire (SIQ-JR)

Violence and Suicide Assessment Form (VASA)

Nurses Global Assessment of Suicide Risk (NGASR)

Risk of Suicide Questionnaire (RSQ)

I can't find any of these anywhere online so I can at least look at them and find one or two that don't look like they'd be too cumbersome to ask nursing staff to use, but that will also be more helpful in assessing suicide risk, and I was curious what others are using.

MrChicagoRN, RN · Mar 18, 2014

At an APNA conference I went to, the Cleveland assessment was recommended by the speaker.