A quality improvement approach to developing and pre-implementation evaluation of a suicide risk screening and care continuity toolkit for rural American Indian youth

Abstract

Background: Suicide remains a leading cause of death among American Indian and Alaska Native youth, with rural and reservation communities experiencing disproportionately high rates. Local Problem: Limited access to behavioral health services, inconsistent screening practices, and fragmented care coordination contribute to gaps in early identification and intervention for at-risk youth in rural emergency department settings. Methods: This Doctor of Nursing Practice (DNP) project utilized a quality improvement framework to develop and evaluate a suicide risk screening and care continuity toolkit prior to implementation in a rural Indian Health Service emergency department. The toolkit was informed by evidence- based practices and structured using standardized clinical workflows. Intervention: The toolkit includes universal triage screening using the Ask Suicide-Screening Questions (ASQ), a Brief Suicide Safety Assessment (BSSA) for positive screens, standardized response protocols, and locally relevant referral pathways to support continuity of care. A multidisciplinary panel of four stakeholders evaluated the toolkit using the AGREE II instrument to assess quality, clarity, and applicability prior to implementation. Results: AGREE II evaluation demonstrated strong overall performance, with most domains meeting or exceeding the predefined 70% benchmark. Domains scoring below this threshold were revised based on stakeholder feedback to improve clarity, feasibility, and clinical usability within the rural tribal emergency department context. Conclusion: This project produced a high-quality, stakeholder-informed toolkit ready for implementation. Pre-implementation evaluation supports its potential to improve standardized suicide risk identification and strengthen care coordination for rural American Indian youth in emergency care settings.