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UNC Suicide Screening (ASQ and BSA)

SUICIDE SCREENING - Brief Safety Assessment (BSA)

★Who is screened for suicide?

  • All patients 12 years and older that present to the Emergency Department and on admission
  • For those determined to be at risk for suicide,re-assessments will occur every shift in the ED and daily in all other areas

Can a nurse implement/order Suicide Precautions?

  • Yes, at any point that a patient is thought to be at risk for suicide; the nurse will implement Suicide Precautions along with the Suicide PrecautionsStanding Order

Brief Safety Assessment (BSA)

NO to ALL 1-4

ASQ

Ask Suicide Screening Questions

Usually done by RN 4 initial questions 5 th question if YES to any of 1-4

3 possible outcomes

YES to ANY of 1-4 NO 5

BSA

(Basic Safety Assessment)

  • 1) completed by a Licensed Independent Practitioner (LIP) w/in 12 hours of ASQ
  • 2) Four options for recommended next steps (a-d)

d

Recommend safety planning & outpatient mental health referral Recommend evaluation by mental health clinician prior to discharge

Screening complete

ASQ QUESTIONS

  1. In the past few weeks, have you wished you were dead? 2. In the past few weeks, have you felt that you or your family would be better off if you were dead? 3. In the past week, have you been having thoughts about
  2. killing yourself?
  3. Have you ever tried to kill yourself?

If the patient answers yes to any of the above, ask the following question:

  1. Are you having thoughts of killing yourself right now?

Full mental health evaluation Psychiatric consult

Imminent risk :

  • 1) Requires suicide safety precautions order
  • 2) 1:1 sitter
  • 3) psychiatric evaluation

ASQ Outcomes -Provider Actions

RN has completed the ASQ → 3 possible outcomes

  • 1 If patient answered ' No ' to ALL questions 1-4:
  • Screening complete & no further action needed by provider
  • 2 If patient answered ' Yes ' to ANY of questions 1-4 AND ' No ' to question 5 ( potential risk ):
  • Order suicide precautions 1
  • Order level of supervision 2
  • Frequency: 1:1 (close)
  • Reason: Suicidal/SIB
  • RN to contact Clinician
  • Clinician to complete BSA (within 12 hours)
  • 3 If patient answered ' Yes ' to question 5 ( imminent risk ):
  • Order suicide precautions 1
  • Order level of supervision 2
  • Frequency: 1:1 (close)
  • Reason: Suicidal/SIB
  • RN to contact Clinician
  • Clinician to Order Inpatient Psychiatry Consult & page Inpatient Psychiatry Consult Service
  • BSA is not required

Suicide Precautions Order 1

Level of Supervision Order 2

Completing the BSA

Step 1

Navigate to the BSA by clicking the Potential-Risk banner on the left side of the patient's chart, then hit "BSA Navigator" and "Accept":

COVID-19: Link to previous

test results

ASQ Suicide Screen-

Potential Risk

Completing the BSA

Step 2

  • With the navigator, check the boxes that apply to the patient. Appropriate sources that the clinician may use when completing:
  • Patient responses
  • Collateral (information about the patient gathered from others)
  • Chart review
  • If certain factors do not apply to the patient, you may leave blank/boxes unchecked .
  • Questions are just to guide your conversation; they are not a mandatory checklist that needs to be completed in its entirety.

Click on the pencil beside "BSA Documentation" to open the flowsheet:

Complete the relevant components of the flowsheet to address risk and protective factors:

Based on the information collected above, make a clinical decision and click the appropriate button reflecting your recommendation

Step 4

Once BSA is completed, navigate to the "BSA Complete" tab and check "yes"