Improved suicide risk assessment screening in a youth treatment facility: a quality improvement project

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Montana State University - Bozeman, College of Nursing


Research suggests that youth receiving mental health treatment are at increased risk for suicidal ideation or suicide attempts. Thus, youth admitted to a psychiatric treatment facility must receive appropriate suicide risk assessments. The Columbia-Suicide Severity Rating Scale (C-SSRS) is a well-researched, evidence-based, tool which has been endorsed by multiple agencies, including The Joint Commission, as an effective instrument to screen for suicide risk in youth populations. This quality improvement project aimed to improve the overall safety of patients admitted to the designated clinical site by implementing a standardized suicide assessment screening process using the C-SSRS as the identified screening tool. The Model for Improvement was the framework chosen for this quality improvement project. The clinical site selected was a licensed therapeutic group home and school specializing in relational-based trauma-informed care, treating children and adolescents aged 5 to 15 years. Five licensed therapists and one registered nurse received formal training to administer the two identified versions of the C-SSRS. Data pertaining to completion rates for assessments and interventions implemented per protocol were collected over three PDSA cycles. 100% (n=19) of baseline and admission assessments were completed and documented in the EHR within 24 hours of assessment completion. Additionally, 100% (n=19) of the patients assessed completed a safety plan as part of the organization's identified suicide risk-reduction interventions. During the data collection period, no patients presented with possible suicidal ideation, and no patients screened in the "high-risk" category. Therefore, no data were collected related to these objectives. This quality improvement project aimed to improve the overall safety of patients admitted to the designated clinical site. Despite several limitations, all patients received baseline suicide assessments and completed a safety plan. The long-term hopes for this process change include improving the ability of clinicians to accurately assess suicide risk and intervene appropriately, leading to fewer patients presenting with suicidal behaviors and overall improvements to patient safety.




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