Clinical practice guideline: suicide risk assessment


Guideline Developer(s)

Emergency Nurses Association

Date Released

2012 Dec

Evidence Supporting the Recommendations

References Supporting the Recommendations

Aseltine RH Jr, Schilling EA, James A, Glanovsky JL, Jacobs D. Age variability in the association between heavy episodic drinking and adolescent suicide attempts: findings from a large-scale, school-based screening program. J Am Acad Child Adolesc Psychiatry. 2009 Mar;48(3):262-70. PubMed
Bergen H, Hawton K, Waters K, Cooper J, Kapur N. Psychosocial assessment and repetition of self-harm: the significance of single and multiple repeat episode analyses. J Affect Disord. 2010 Dec;127(1-3):257-65. PubMed
Bergen H, Hawton K, Waters K, Ness J, Cooper J, Steeg S, Kapur N. How do methods of non-fatal self-harm relate to eventual suicide?. J Affect Disord. 2012 Feb;136(3):526-33. PubMed
Bilen K, Ottosson C, Castren M, Ponzer S, Ursing C, Ranta P, Ekdahl K, Pettersson H. Deliberate self-harm patients in the emergency department: factors associated with repeated self-harm among 1524 patients. Emerg Med J. 2011 Dec;28(12):1019-25. PubMed
Choo EK, Ranney ML, Aggarwal N, Boudreaux ED. A systematic review of emergency department technology-based behavioral health interventions. Acad Emerg Med. 2012 Mar;19(3):318-28. PubMed
Cooper J, Kapur N, Dunning J, Guthrie E, Appleby L, MackwayJones K. A clinical tool for assessing risk after self-harm. Ann Emerg Med. 2006 Oct;48(4):459-66. PubMed
Cooper J, Murphy E, Webb R, Hawton K, Bergen H, Waters K, Kapur N. Ethnic differences in self-harm, rates, characteristics and service provision: three-city cohort study. Br J Psychiatry. 2010 Sep;197(3):212-8. PubMed
Coristine RW, Hartford K, Vingilis E, White D. Mental health triage in the ER: a qualitative study. J Eval Clin Pract. 2007 Apr;13(2):303-9. PubMed
Currier GW, Litts D, Walsh P, Schneider S, Richardson T, Grant W, Triner W, Robak N, Moscati R. Evaluation of an emergency department educational campaign for recognition of suicidal patients. West J Emerg Med. 2012 Feb;13(1):41-50. PubMed
DeMaso DR, Martini DR, Cahen LA, Bukstein O, Walter HJ, Benson S, Chrisman A, Farchione T, Hamilton J, Keable H, Kinlan J, Schoettle U, Siegel M, Stock S, Ptakowski KK, Medicus J, AACAP Work Group on Quality Issues. Practice parameter for the psychiatric assessment and management of physically ill children and adolescents. J Am Acad Child Adolesc Psychiatry. 2009 Feb;48(2):213-33. PubMed
Diefenbach GJ, Woolley SB, Goethe JW. The association between self-reported anxiety symptoms and suicidality. J Nerv Ment Dis. 2009 Feb;197(2):92-7. PubMed
Dolan MA, Fein JA. Pediatric and adolescent mental health emergencies in the emergency medical services system. Pediatrics. 2011 May;127(5):e1356-66. PubMed
Dube P, Kurt K, Bair MJ, Theobald D, Williams LS. The p4 screener: evaluation of a brief measure for assessing potential suicide risk in 2 randomized effectiveness trials of primary care and oncology patients. Prim Care Companion CNS Disord. 2010;12(6) PubMed
Fein JA, Pailler ME, Barg FK, Wintersteen MB, Hayes K, Tien AY, Diamond GS. Feasibility and effects of a Web-based adolescent psychiatric assessment administered by clinical staff in the pediatric emergency department. Arch Pediatr Adolesc Med. 2010 Dec;164(12):1112-7. PubMed
Gardner W, Klima J, Chisolm D, Feehan H, Bridge J, Campo J, Cunningham N, Kelleher K. Screening, triage, and referral of patients who report suicidal thought during a primary care visit. Pediatrics. 2010 May;125(5):945-52. PubMed
Gaynes BN, West SL, Ford CA, Frame PS, Klein J, Lohr KN. Screening for suicide risk: systematic evidence review for the U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2004 May 1. 100 p. (Systematic Evidence Review; no. 32).  [99 references]
Haney EM, O'Neil ME, Carson S, Low A, Peterson K, Denneson LM, Oleksiewicz C, Kansagara D. Suicide risk factors and risk assessment tools: a systematic review. Washington (DC): Department of Veterans Affairs, Veterans Health Administration; 2012 Mar. 137 p.
Happell B, Summers M, Pinikahana J. The triage of psychiatric patients in the hospital emergency department: a comparison between emergency department nurses and psychiatric nurse consultants. Accid Emerg Nurs. 2002 Apr;10(2):65-71. PubMed
Holden RR, Kerr PS, Mendonca JD, Velamoor VR. Are some motives more linked to suicide proneness than others?. J Clin Psychol. 1998 Aug;54(5):569-76. PubMed
Horesh N, Sever J, Apter A. A comparison of life events between suicidal adolescents with major depression and borderline personality disorder. Compr Psychiatry. 2003 Jul-Aug;44(4):277-83. PubMed
Horowitz L, Ballard E, Teach SJ, Bosk A, Rosenstein DL, Joshi P, Dalton ME, Pao M. Feasibility of screening patients with nonpsychiatric complaints for suicide risk in a pediatric emergency department: a good time to talk?. Pediatr Emerg Care. 2010 Nov;26(11):787-92. PubMed
Ilgen MA, Walton MA, Cunningham RM, Barry KL, Chermack ST, De Chavez P, Blow FC. Recent suicidal ideation among patients in an inner city emergency department. Suicide Life Threat Behav. 2009 Oct;39(5):508-17. PubMed
Jacobs D, Baldessarini R, Conwell Y, Fawcett J, Horton L, Simon R. Practice guidelines for the assessment and treatment in patients with suicidal behaviors. Psychiatry Online; 2003.
Joe S, Niedermeier D. Preventing suicide: a neglected social work research agenda. Br J Soc Work. 2006 Nov 8;38(3):507-530. PubMed
Kuo WH, Gallo JJ, Tien AY. Incidence of suicide ideation and attempts in adults: the 13-year follow-up of a community sample in Baltimore, Maryland. Psychol Med. 2001 Oct;31(7):1181-91. PubMed
Murphy E, Kapur N, Webb R, Cooper J. Risk assessment following self-harm: comparison of mental health nurses and psychiatrists. J Adv Nurs. 2011 Jan;67(1):127-39. PubMed
National Institute for Clinical Excellence (NICE). Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. Manchester (England): National Institute for Clinical Excellence (NICE); 2011.  (NICE Clinical guideline; no. 16). 
Oude Voshaar RC, Cooper J, Murphy E, Steeg S, Kapur N, Purandare NB. First episode of self-harm in older age: a report from the 10-year prospective Manchester Self-Harm project. J Clin Psychiatry. 2011 Jun;72(6):737-43. PubMed
Pailler ME, Cronholm PF, Barg FK, Wintersteen MB, Diamond GS, Fein JA. Patients' and caregivers' beliefs about depression screening and referral in the emergency department. Pediatr Emerg Care. 2009 Nov;25(11):721-7. PubMed
Randall JR, Colman I, Rowe BH. A systematic review of psychometric assessment of self-harm risk in the emergency department. J Affect Disord. 2011 Nov;134(1-3):348-55. PubMed
Royal College of Nursing. Mental health in children and young people: an RCN toolkit for nurses who are not mental health specialists. London (England): Royal College of Nursing; 2009.
Royal College of Psychiatrists. Self-harm, suicide and risk: helping people who self-harm. Final report of a working group. London (England): Royal College of Psychiatrists; 2010.  (College report; no. CR 158). 
Steeg S, Kapur N, Webb R, Applegate E, Stewart SL, Hawton K, Bergen H, Waters K, Cooper J. The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule. Psychol Med. 2012 Nov;42(11):2383-94. PubMed
The Joint Commission. Hospital accreditation program. National patient safety goals. Oak Brook (IL): The Joint Commission; 2012.
Ting SA, Sullivan AF, Miller I, Espinola JA, Allen MH, Camargo CA Jr, Boudreaux ED. Multicenter study of predictors of suicide screening in emergency departments. Acad Emerg Med. 2012 Feb;19(2):239-43. PubMed
Vergare MJ, Binder RL, Cook IA, Galanter M, Lu FG. Practice guideline for the psychiatric evaluation of adults. 2nd ed. Arlington (VA): American Psychiatric Association; 2010.
Warner CH, Appenzeller GN, Grieger T, Belenkiy S, Breitbach J, Parker J, Warner CM, Hoge C. Importance of anonymity to encourage honest reporting in mental health screening after combat deployment. Arch Gen Psychiatry. 2011 Oct;68(10):1065-71. PubMed
Zhang J, McKeown RE, Hussey JR, Thompson SJ, Woods JR. Gender differences in risk factors for attempted suicide among young adults: findings from the Third National Health and Nutrition Examination Survey. Ann Epidemiol. 2005 Feb;15(2):167-74. PubMed

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Quick Reference Guides/Physician Guides

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate suicide risk assessment to determine which patients are in emergent or urgent need of mental health care so that appropriate safety interventions can be implemented

Potential Harms

Not stated

Rating Scheme for the Strength of the Recommendations

Levels of Recommendation for Practice

Level A Recommendations: High
  • Reflects a high degree of clinical certainty
  • Based on availability of high quality Level I, II and/or III evidence available using Melnyk & Fineout-Overholt grading system* (see the "Rating Scheme for the Strength of the Evidence" field)
  • Based on consistent and good quality evidence; has relevance and applicability to emergency nursing practice
  • Is beneficial
Level B Recommendations: Moderate
  • Reflects moderate clinical certainty
  • Based on availability of Level III and/or Level IV and V evidence using Melnyk & Fineout-Overholt grading system* (see the "Rating Scheme for the Strength of the Evidence" field)
  • There are some minor flaws or inconsistencies in quality of evidence; has relevance and applicability to emergency nursing practice
  • Is likely to be beneficial
Level C Recommendations: Weak
  • Level V, VI and/or VII evidence available using Melnyk & Fineout-Overholt grading system* (see the "Rating Scheme for the Strength of the Evidence" field)
  • Based on consensus, usual practice, evidence, case series for studies of treatment or screening, anecdotal evidence, and/or opinion
  • There is limited or low quality patient-oriented evidence; has relevance and applicability to emergency nursing practice
  • Has limited or unknown effectiveness
Not Recommended for Practice
  • No objective evidence or only anecdotal evidence available; or the supportive evidence is from poorly controlled or uncontrolled studies
  • Other indications for not recommending evidence for practice may include:
    • Conflicting evidence
    • Harmfulness has been demonstrated
    • Cost or burden necessary for intervention exceeds anticipated benefit
    • Does not have relevance or applicability to emergency nursing practice
  • There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. For example:
    • Heterogeneity of results
    • Uncertainty about effect magnitude and consequences
    • Strength of prior beliefs
    • Publication bias

*Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams, & Wilkins.

Qualifying Statements

Qualifying Statements
  • The Emergency Nurses Association (ENA)'s Clinical Practice Guidelines (CPGs) are developed by ENA members to provide emergency nurses with evidence-based information to utilize and implement in their care of emergency patients and families. Each CPG focuses on a clinical or practice-based issue, and is the result of a review and analysis of current information believed to be reliable. As such, information and recommendations within a particular CPG reflect the current scientific and clinical knowledge at the time of publication, are only current as of their publication date, and are subject to change without notice as advances emerge.
  • In addition, variations in practice, which take into account the needs of the individual patient and the resources and limitations unique to the institution, may warrant approaches, treatments and/or procedures that differ from the recommendations outlined in the CPGs. Therefore, these recommendations should not be construed as dictating an exclusive course of management, treatment or care, nor does the use of such recommendations guarantee a particular outcome. CPGs are never intended to replace a practitioner's best nursing judgment based on the clinical circumstances of a particular patient or patient population. CPGs are published by ENA for educational and informational purposes only, and ENA does not approve or endorse any specific methods, practices, or sources of information. ENA assumes no liability for any injury and/or damage to persons or property arising out of or related to the use of or reliance on any CPG.

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Via a comprehensive literature search, all articles relevant to the topic were identified. The following resources were searched: PubMed, Google Scholar, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), OVID, TRIP Data Base, HAPI, Cochrane - British Medical Journal, Agency for Healthcare Research and Quality (AHRQ; www.ahrq.gov), and the National Guideline Clearinghouse (www.guideline.gov). Searches were conducted using a variety of different search term combinations. These included initial psychiatric emergencies, behavioral health emergency and mental health emergency. Additional search terms were assessment, management with the filters "and" and "or" added. Finally, the topics searched included suicide, suicidal ideation, suicide assessment, suicide scales and/or tools, and suicide predictors. Initial searches were limited to English language articles from 2000 to 2012. The reference lists in the selected articles were hand searched for additional pertinent references. Research articles from emergency department (ED) settings, non-ED settings, emergency care settings, position statements and guidelines from other sources were also reviewed. Articles that did not address the Population, Intervention, Comparison and Outcomes (PICO) question were excluded for the purpose of this systematic review of evidence. Other articles that evaluated specific medications or mental health pathology, such as schizophrenia were not included.

Articles that met the following criteria were chosen to formulate the clinical practice guideline (CPG): research studies, meta-analyses, systematic reviews, and existing guidelines relevant to the topic of suicide risk assessment.

Number of Source Documents

53 documents were included in the evidence tables.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Grading the Levels of Evidence*

  1. Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on systematic reviews of RCTs
  2. Evidence obtained from at least one properly designed RCT
  3. Evidence obtained from well-designed controlled trials without randomization
  4. Evidence obtained from well-designed case control and cohort studies
  5. Evidence from systematic reviews of descriptive and qualitative studies
  6. Evidence from a single descriptive or qualitative study
  7. Evidence from opinion of authorities and/or reports of expert committees

Grading the Quality of the Evidence

  1. Acceptable Quality: No concerns
  2. Limitations in Quality: Minor flaws or inconsistencies in the evidence
  3. Major Limitations in Quality: Many flaws and inconsistencies in the evidence
  4. Not Acceptable: Major flaws in the evidence

*Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams, & Wilkins.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

The clinical practice guideline (CPG) authors used a standardized reference table to collect information and assist with preparation of tables of evidence ranking each article in terms of the level of evidence, quality of evidence, and relevance and applicability to practice. Clinical findings and levels of recommendations regarding patient assessment were then made by the 2012 Emergency Nursing Resources Development Committee according to Emergency Nurses Association (ENA)'s classification of levels of recommendation for practice, which include: Level A High, Level B Moderate, Level C Weak or Not recommended for practice (see the "Rating Scheme for the Strength of the Recommendations" field).

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

This clinical practice guideline (CPG) was created based on a thorough review and critical analysis of the literature following Emergency Nurses Association (ENA)'s Guidelines for the Development of Clinical Practice Guidelines (see the "Availability of Companion Documents" field).

Conference calls with Subcommittee members and staff are held as necessary to discuss progress and facilitate the Subcommittee's work. All members of the Subcommittee independently complete an exhaustive review of all identified literature, complete a separate evidence table for each topic (if possible), and then reconvene to reach consensus. Each Subcommittee prepares a description of the topic, definition, background, significance, and evidence table. The Subcommittee identifies and assigns preliminary scores for quality and strength of evidence, and describes conclusions based on the review of the body of evidence. Each Subcommittee also serves as "second readers" for another topic; this assures an in-depth look at the literature by two Subcommittees. The entire Committee reads the articles and reviews the evidence-appraisal tables for each topic and then finalizes implications for practice and the level of recommendation.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

The Institute for Emergency Nursing Research (IENR) Advisory Council reviews the final document for overall validity and provides feedback as appropriate using the Clinical Practice Guidelines (CPGs) Evaluation Worksheet. Reviews and feedback are sent to the Subcommittee to evaluate and incorporate, as appropriate. Emergency Nurses Association (ENA) staff creates the final products for publication with input from the Committee.

Identifying Information and Availability

Bibliographic Source(s)

ENA Emergency Nursing Resources Development Committee. Clinical practice guideline: suicide risk assessment. Des Plaines (IL): Emergency Nurses Association; 2012 Dec. 15 p. [45 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

Emergency Nurses Association

Guideline Committee

2012 ENA Emergency Nursing Resources Development Committee

Composition of Group That Authored the Guideline

Committee Members: Carla Brim, MN, RN, CEN, CNS; Cathleen Lindauer, MSN, RN, CEN; Judith Halpern, MS, RN, APRN; Andrew Storer, DNP, RN, ACNP, CRNP, FNP; Susan Barnason, PhD, RN, APRN-CNS, CEN, CCRN, FAAN; Judith Young Bradford, DNS, RN, FAEN; Sherry Leviner, MSN, RN, CEN; Vicki C. Patrick, MS, RN, SRPN, ACNP, CEN, FAEN; Jean A. Proehl, MN, RN, CEN, CPEN, FAEN; Jennifer Williams, MSN, RN, CEN, CCRN, CNS

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Emergency Nurses Association Web site.

Availability of Companion Documents

The following are available:

  • Requirements for the development of: clinical practice guidelines, clinical practice guidelines synopsis, and translation into practice (TIP) recommendations. Des Plaines (IL): Emergency Nurses Association; 2013 Dec. 40 p. Electronic copies: Available in Portable Document Format (PDF) from the Emergency Nurses Association Web site.
  • Clinical practice guideline: suicide risk assessment. Synopsis. Des Plaines (IL): Emergency Nurses Association; 2012 Dec. 1 p. Electronic copies: Available in PDF from the Emergency Nurses Association Web site.
  • CPG evidence table: suicide risk assessment. Des Plaines (IL): Emergency Nurses Association; 2012 Dec. 34 p. Electronic copies: Available in PDF from the Emergency Nurses Association Web site.
  • CPG other resources table: suicide risk assessment. Des Plaines (IL): Emergency Nurses Association; 2012 Dec. 1 p. Electronic copies: Available in PDF from the Emergency Nurses Association Web site.
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on February 13, 2014. The information was verified by the guideline developer on March 27, 2014.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's restrictions.

Scope

Disease/Condition(s)

Suicidal ideation

Guideline Category

Prevention
Risk Assessment
Screening

Clinical Specialty

Emergency Medicine
Nursing
Psychiatry
Psychology

Intended Users

Advanced Practice Nurses
Emergency Medical Technicians/Paramedics
Hospitals
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers

Guideline Objective(s)

To evaluate what risk assessment tools and predictors are effective in screening for self-harm or suicidal ideation during initial assessment of patients across the life span in the emergency care setting

Target Population

Patients who present to the emergency setting who have suicidal ideation or after attempted suicide and/or those patients at high risk for future attempts of suicide

Interventions and Practices Considered
  1. Training to improve the confidence of emergency department (ED) personnel in screening patients for suicide risk
  2. Instruments used to assess potential suicide/self-harm risk*
    • Mental Health Triage Scale (MHTS)
    • Behavioral Health Screening-Emergency Department (BHS-ED)
    • Manchester Self-Harm Rule
    • ReACT Self-Harm Rule
    • P4 screener
  3. Awareness and consideration of predictors for suicide, including demographics, prior psychiatric and medical history, and significant life events

*A summary of additional instruments may be viewed in Appendix 1 in the original guideline document; the "Major Recommendations" field of this summary also provides a list of instruments that are recommended/not recommended for ED use.

Major Outcomes Considered
  • Accuracy, sensitivity, and specificity of suicide risk assessment instruments
  • Risk factors for suicide
  • Prevalence of suicidality

Recommendations

Major Recommendations

The grades of recommendations (A–C, Not Recommended), levels of evidence (I–VII), and quality of evidence (I–IV) are defined at the end of the "Major Recommendations" field.

Description of Decision Options/Interventions and the Level of Recommendation

Please note that the references listed after each recommendation represent the evidence considered when making the recommendation. This does not mean that the evidence in each individual reference supports the recommendation.

Initial Suicide Assessment

  1. Suicide screening tools should be used as a part of the assessment process for appropriate emergency department (ED) patients (based upon presentation). Level A – High (Coristine et al., 2007; Gaynes et al., 2004; Holden et al., 1998; Jacobs et al., 2003; National Institute for Health and Care Excellence [NICE], 2011; Royal College of Nursing [RCN], 2009; Royal College of Psychiatrists [RCP], 2010; The Joint Commission [JC], 2012; Vergare et al., 2010)
  2. The use of computer based tools for suicide risk assessment in the ED is feasible and acceptable to staff and for patients ages 11 and older. Level C – Weak (Choo et al., 2012; Fein et al., 2010; Gardner et al., 2010)
  3. Screening for risk of suicide in pediatric patients over age 10 based upon presentation, is appropriate, feasible and practical in the ED. Level B – Moderate (DeMaso et al., 2009; Dolan & Fein, 2011; Gardner et al., 2010; Horowitz et al., 2010; NICE, 2011; Pailler et al., 2009)
  4. Training ED personnel improves confidence in screening for suicide risk. Level B – Moderate (Currier et al., 2012; Dolan & Fein, 2011; NICE, 2011; RCN, 2009; RCP, 2010)

Suicide Risk Instruments

  1. The Behavioral Health Screening-ED (BHS-ED); Mental Health Triage Scale (MHTS); Manchester Self-Harm Rule (MSHR); P4; and ReACT Self-Harm Rule are valid and feasible for initial assessment of suicide risk in the ED. Level B – Moderate (Cooper et al., 2006; Cooper et al., 2010; Dube et al., 2010; Fein et al., 2010; Happell, Summers, & Pinikahana, 2002; Randall, Colman, & Rowe, 2011; Steeg et al., 2012)
  2. The following instruments are feasible, valid and reliable measures for use assessing risk for suicide in the ED setting. Level B – Moderate (see Table A, Appendix 1 in the original guideline document for further details):
    • Beck's Suicide Intent Scale (SIS)
    • Depressive Symptom Inventory-Suicidality Sub-scale (DSI-SS)
    • Geriatric Depression Scale (GDS) GDS-30/GDS-15/GDS-5
    • 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)
  3. The following suicide risk instruments are not recommended for assessment of risk in the ED setting. Not recommended for practice (see Table B, Appendix 1 in the original guideline document for further details):
    • Beck Hopelessness Scale (BHS)
    • Beck Scale for Suicide Ideation (BSS)
    • Behavioral Activity Rating Scale (BARS)
    • Centers for Epidemiologic Studies Depression Scale (CES-D)
    • Centers for Epidemiologic Studies Depression Scale for Children (CES-DC)
    • Columbia Suicide Screen (CSS)
    • Death/Suicide Implicit Association Test (IAT)
    • General Health Questionnaire (GHQ-12)
    • Geriatric Suicide Ideation Scale (GSIS)
    • Modified SAD Persons Scale (MSPS)
    • Patient Health Questionnaire for Adolescents (PHQ-A)
    • SAD Persons Scale (SPS): S=Sex, A=Age, D=Depression, P=Previous Attempt, E=Ethanol Abuse, R=Rational Think Loss, S=Social Support lacking, O=Organized Plan, N=No Spouse, and S=Sickness all items = 1 point
    • Scale for Suicide Ideation (SSI)

Suicide Risk Predictors

  1. Previous episodes of deliberate self-harm are a strong predictor of future suicide attempt. Level A – High (Bergen et al., 2010; Bilen et al., 2011; Haney et al., 2012; NICE, 2011; Steeg et al., 2012)
  2. Screening for suicide risk should be a part of the assessment process based upon patient presentation, is appropriate, feasible and practical in the ED. Patients with the following presentations should be considered for screening:
    1. History of major depressive disorder (MDD) or post traumatic stress disorder (PTSD). Level B – Moderate (Bergen et al., 2010; Diefenbach, Wooley, & Goethe, 2009; Dube et al., 2010, Gardner et al., 2010; Haney et al., 2012, Warner et al., 2011)
    2. Chronic illness in adults. Level C – Weak (Haney et al., 2012; Ilgen et al., 2009; Oude Voshaar et al., 2011)
    3. Young female. Level C – Weak (Cooper et al., 2010; Diefenbach, Wooley, & Goethe, 2009; Gardner et al., 2010; Kuo, Gallo, & Tien, 2001)
    4. Males over 55 years of age. Level C – Weak (Joe & Niedermeier, 2006; Oude Voshaar et al., 2011)
    5. Lethal methods of self-harm with self-cutting being significantly associated with repeat episode. Level C – Weak (Bergen et al., 2010; Bergen et al., 2012; Haney et al., 2012; Steeg et al., 2012)
    6. Substance abuse. Level C – Weak (Haney et al., 2012; Ilgen et al., 2009; Ting et al., 2012)
    7. Binge or high episodic drinking for adolescents and young adults. Level C – Weak (Aseltine et al., 2009)
    8. Recent negative life events. Level C – Weak (Coristine et al., 2007; Horesh, Sever, & Apter, 2003; Joe & Niedermeier, 2006)
    9. Living alone. Level C – Weak (Ilgen et al., 2009; Steeg et al., 2012)
    10. Lower socioeconomic status. Level C – Weak (Ilgen et al., 2009; Murphy et al., 2011; Zhang et al., 2005)

Definitions:

Levels of Recommendation for Practice

Level A Recommendations: High
  • Reflects a high degree of clinical certainty
  • Based on availability of high quality Level I, II and/or III evidence available using Melnyk & Fineout-Overholt grading system* (see the "Rating Scheme for the Strength of the Evidence" field)
  • Based on consistent and good quality evidence; has relevance and applicability to emergency nursing practice
  • Is beneficial
Level B Recommendations: Moderate
  • Reflects moderate clinical certainty
  • Based on availability of Level III and/or Level IV and V evidence using Melnyk & Fineout-Overholt grading system* (see the "Rating Scheme for the Strength of the Evidence" field)
  • There are some minor flaws or inconsistencies in quality of evidence; has relevance and applicability to emergency nursing practice
  • Is likely to be beneficial
Level C Recommendations: Weak
  • Level V, VI and/or VII evidence available using Melnyk & Fineout-Overholt grading system* (see the "Rating Scheme for the Strength of the Evidence" field)
  • Based on consensus, usual practice, evidence, case series for studies of treatment or screening, anecdotal evidence, and/or opinion
  • There is limited or low quality patient-oriented evidence; has relevance and applicability to emergency nursing practice
  • Has limited or unknown effectiveness
Not Recommended for Practice
  • No objective evidence or only anecdotal evidence available; or the supportive evidence is from poorly controlled or uncontrolled studies
  • Other indications for not recommending evidence for practice may include:
    • Conflicting evidence
    • Harmfulness has been demonstrated
    • Cost or burden necessary for intervention exceeds anticipated benefit
    • Does not have relevance or applicability to emergency nursing practice
  • There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. For example:
    • Heterogeneity of results
    • Uncertainty about effect magnitude and consequences
    • Strength of prior beliefs
    • Publication bias

Grading the Levels of Evidence*

  1. Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on systematic reviews of RCTs
  2. Evidence obtained from at least one properly designed RCT
  3. Evidence obtained from well-designed controlled trials without randomization
  4. Evidence obtained from well-designed case control and cohort studies
  5. Evidence from systematic reviews of descriptive and qualitative studies
  6. Evidence from a single descriptive or qualitative study
  7. Evidence from opinion of authorities and/or reports of expert committees

Grading the Quality of the Evidence

  1. Acceptable Quality: No concerns
  2. Limitations in Quality: Minor flaws or inconsistencies in the evidence
  3. Major Limitations in Quality: Many flaws and inconsistencies in the evidence
  4. Not Acceptable: Major flaws in the evidence

*Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott, Williams, & Wilkins.

Clinical Algorithm(s)

None provided

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Living with Illness
Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness
Timeliness

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Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion-criteria.aspx.

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.

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