• Suicide assessment in the ED is imprecise. 40% of patients who attempted or completed suicide had visited ED in the prior 12 months and up to 10% of patients with medical complaints endorse suicide ideation only when asked (US study).
• No rule is useful in isolation and no clinical summary can replace physician judgment but they may help physicians reach better decisions. Mental health resources are institutionally and geographically specific. Each center has to determine its own criteria for safety of discharge versus transfer to a higher level of intervention using the general principles described.

1. ASSESS for presence of acute medical conditions/impaired mentation/medical incompetence

1. Medical Rx for delirium, violence, altered mental status…
a. Vital signs, Toxidromes, Bloodwork/ECG/drug screen as indicated
b. Chemically restrain [and physically] if necessary for diagnosis/treatment

2. Involuntary Hold until medically cleared if (1) is present

3. Obtain collateral input/healthcare representative if medically incompetent/mentally impaired

2. BALANCE suicide risk factors [Chart 1 below]:

1. MILD: suitable to discharge after safety plan formulated/agreed by patient

2. MODERATE: requires psychiatry consult with involuntary hold as necessary

3. SEVERE: requires close monitoring for safety/elopement risks until psychiatry assessment

3. COMMUNICATE with staff, psychiatry if consulted, patient and his/her support of decision

4. DOCUMENT

1. Risk level rationale, treatment initiated, disposition plans

2. All involuntary hold and treatment forms if utilized

3. Communication with Psychiatry re: consult and expected time for psychiatry assessment

1. Apps or walls charts of risk factors serve as useful reminders
2. Beware of bias due to location of patient or past history of frequent visits/manipulative behavior
3. Chronic [e.g. drug use, socio-demographics] risk factors though less important should be documented
4. Defensive and de-escalation skills training should be available/encouraged for staff

1. Betz ME, Boudreaux ED. Managing Suicidal Patients in the Emergency Department.

   
   

2. Reshetukha, et al. Improving suicide risk assessment in the emergency department through physician education and a suicide risk assessment prompt.

   
   

3. CAMH Suicide Prevention and Assessment Handbook

   
   

4. Suicide Prevention Resource Center (US)

   
   

5. SuicideAssessment Five-step Evaluation and Triage – Substance Abuse and Mental Health Services Administration (US)