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

2. 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.

3. 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.

4. 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)

5. The Pathway

6. 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.

7. 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.

8. 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.

9. 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

10. 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

11. 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

12. 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

13. Go-Live is March 1, 2017

14. For Questions Contact:
Dr. Linda Lang, MD Chair, Dept. of Behavioral Health (302) Brady Shuert, BHS Behavioral Health Specialist/ Co-Project Manager Lori Jones, LCSW Program Coordinator of Psychiatric Services/ Co-Project Manager (302) Aliesha Rivera, MSN, RN-C Staff Development Specialist Department of Behavioral Health (302)

16. Where We Are Going
What Guides Us
How We Get There