Columbia Suicide Severity Risk Scale C-SSRS Pathway The Department of Behavioral Health

Goal To instruct and empower the nurse on administering Columbia Suicide Severity Risk Scale (C-SSRS), identify patients at risk for suicide, understanding when to initiate and utilize the Suicide Prevention pathway appropriately.

Objectives By completion of education, the nurse will be able to: Identify signs and symptoms of Suicidal Ideation Administer Columbia Suicide Severity Risk Scale utilizing the appropriate terminology and verbiage. Demonstrate process of initiating the C-SSRS Pathway Articulate the importance of patient/family care regarding follow up treatment and safety plan.

Importance of the C-SSRS Provides consistent language to enable tracking and measurement of suicide prevention efforts and patient population risk over time. Allows for multiple sources of information (subject, family members, caregivers, records, etc.) Meets Accreditation and regulatory requirements It is well-validated and reduces false positives, enabling us to focus on the right patients. (Foote, M., Intermountain Healthcare, 2014)

The Pathway

The Pathway Patient is admitted to the floor with no prior C-SSRS completed OR admitted patient indicates suicidal ideation. The Nurse would begin the Columbia Suicide Severity Rating Scale via Powerchart Admission Referral Process or Ad Hoc a C-SSRS if the ARP was previously completed. The Ad Hoc Screener looks and functions like the ARP version.

The C-SSRS Screener in ARP Please ask questions exactly as written. If “NO” to both Questions 1 & 2, the C-SSRS, you then ask Question 6. If “NO” to Questions 1, 2 & 6 the screener is complete. There is no risk.

The C-SSRS Screener in ARP This patient said “YES” to Question 2This second form automatically pops up  ask questions 3,4,5, AND 6. 6 is always required.

Moderate Risk Protocol The C-SSRS Screener Based on the patient’s answers to questions 3, 4, 5 and 6 the system will generate a risk level indicating the specific protocol to initiate. Low Risk Protocol Moderate Risk Protocol High Risk Protocol

Low Risk Protocol Notify Primary Care Provider Provide Mental Health Referral List which can be located in Exitcare Provide patient education via Exitcare: Patient Safety Plan How you can help someone who is suicidal Suicide: Caring for yourself

Moderate Risk Protocol Place patient on Elopement Precautions Rescreen Daily This task will be done daily until patient scores low risk Notify Attending, consider: Safety Companion Psychiatric Consult Suicide Precautions Provide Mental Health Referral List which can be located in Exitcare Provide patient education via Exitcare: The Patient Safety Plan How you can help someone who is suicidal Suicide: Caring for yourself

High Risk Protocol Patient is placed on: Notify Attending Elopement Precautions Suicide Precautions This is automatic via Powerchart Safety Companion (automatically ordered)- RN’s must facilitate an order for a Safety Companion Psychiatric Consult (automatically ordered) Notify Attending Rescreen Daily This task will be done daily until patient scores low risk Provide Mental Health Referral List which can be located in Exitcare Provide patient education via Exitcare: Patient Safety Plan How you can help someone who is suicidal Suicide: Caring for yourself

Go-Live is March 1, 2017

For Questions Contact: Dr. Linda Lang, MD Chair, Dept. of Behavioral Health (302) 320-6263 LLang@ChristianaCare.org Brady Shuert, BHS Behavioral Health Specialist/ Co-Project Manager Bshuert@Christianacare.org Lori Jones, LCSW Program Coordinator of Psychiatric Services/ Co-Project Manager (302) 320-4755 LoJones@Christianacare.org Aliesha Rivera, MSN, RN-C Staff Development Specialist Department of Behavioral Health Arivera@ChristianaCare.org (302) 320-4601

Where We Are Going What Guides Us How We Get There