Daily Evidence-Based Suicide Screening Improves Patient Safety

How did the inpatient psychiatric unit become one of the first to adopt the Columbia Protocol as a daily practice?

For the first time in a pediatric inpatient psychiatric unit, team members at the Children's Hospital Colorado Pediatric Mental Health Institute start each day by administering an evidence-based suicide assessment tool, the Columbia-Suicide Severity Rating Scale (C-SSRS). 

Up until this year, clinical staff asked patients about suicidal thoughts on a scale of 1-10. While helpful, the practice wasn’t evidence-based.

The Columbia screening consists of a series of questions that evaluate an individual's thoughts and behaviors related to suicide, including the presence and intensity of suicidal ideation, the extent of planning and any previous attempts.

“We wanted to standardize our process to ensure every patient is asked the same questions in the same format and then consistently have a workflow to respond to and track responses,” says Jessica Hawks, PhD, a child and adolescent psychologist at Children’s Colorado.

The Children’s Colorado inpatient pediatric psychiatric unit is one of the first in the nation to adopt an evidence-based suicide assessment tool for daily use. Inpatient units are focused on stabilizing kids so they can safely return home and to outpatient care, and a standardized screening hadn’t yet become a regular practice. Screenings like the C-SSRS are more commonly administered in other settings, such as pediatric visits or counseling sessions.

Today, patients at Children’s Colorado use an iPad to answer six questions on suicidal ideation and behavior. Nurses administered the screening 1,850 times since implementing the daily practice in the first half of 2024. 

“Asking more specific questions in an intentional, standardized way helps us improve our abilities to individualize the support and intervention we provide to patients in our inpatient unit, which ultimately should improve treatment outcomes for our patients,” says Dr. Hawks.

Why an evidence-based daily screening tool was necessary for inpatient care

The inpatient unit at Children’s Colorado serves close to 800 patients a year, typically for six to eight days.

Before the Columbia Protocol was adopted in January 2024, nurses asked patients daily about suicidal thoughts, but guidelines for capturing responses weren’t standardized. This lack of standardization meant that patients could give different answers depending on how nurses asked the question. The information wasn't documented in a way that could always be communicated well to the team and used in clinical decision-making.

Assessing patients daily to determine whether they still meet the criteria for an inpatient unit admission is critical to keeping them safe and discharging them. “Our intention is always to stabilize and get them back home as soon as they are safe to discharge,” says Dr. Hawks.

Since beginning the daily Columbia Protocol, approximately 9% of respondents identify as high risk every day. High risk in an inpatient setting is someone who positively endorses question number six, which asks about doing anything or preparing to end your life in the last 24 hours. This is further evidence of the importance of standardized daily screening.

That nearly one out of 10 patients answered positively to this question was most surprising to Dr. Hawks. Even though children in an inpatient unit might experience suicidal thoughts, their ability to create a suicide plan in that restrictive setting should be low.

“This measure provides us with an opportunity to know who’s at imminent risk so we can do something about it. The whole intention of this measure is that the data drives clinical decision-making,” says Dr. Hawks.

Identifying the right suicide assessment tool

The Columbia Protocol is one of several evidence-based suicide assessment tools the team considered. 

They chose the C-SSRS because it’s simple and comprehensive, making it ideal to adopt as part of the daily routine in the inpatient psychiatric unit to assess the severity and immediacy of suicide risk. Plus, many providers already used the tool in other clinical settings at Children’s Colorado. 

“What I like about it is its simple, plain language that's easy for our patients to understand. It's easy to administer, and it's a measure that most of our clinicians throughout the hospital are familiar with because it's so frequently used in the community,” says Evadine Codd, PhD, the inpatient unit attending psychologist at the Pediatric Mental Health Institute.

The tool is simple enough to be used by anyone, including primary care providers, schools and law enforcement. Its standardized format allows for consistent evaluation across diverse populations, facilitating early detection and prevention efforts.

With its adoption on the inpatient unit, now the Columbia Protocol is used across teams providing mental and behavioral health at Children’s Colorado. Children often need to move through different levels of care and departments, so using a coordinated and consistent screening tool across all departments helps compare and track patients’ care.

Making evidence-based suicide screening a daily routine in the psychiatric unit

Key to adopting the Columbia Protocol was to build it into the unit’s daily routine. Nurses are asked to use the screener at the start of the day. They provide patients with an iPad every morning, allowing them to respond to the questions with some privacy. That information is then communicated to the treatment team through Epic. “We can use that data to support clinical decision-making, make changes to treatment plans, approach readiness for discharge, or identify baseline suicidality in our patients,” says Dr. Codd.

While the Columbia Protocol is frequently used in emergency or outpatient settings, administering it daily in an acute care setting is a newer use for this instrument.

Making the Columbia screener part of the daily routine on the inpatient floor meant 150 staff members needed to access iPads and bring them to morning assessments. “Our approach was to implement this process into the staff’s existing routine. Our nurses were already doing morning verbal assessments, so we incorporated that into using an iPad instead,” says Dr Codd. 

The timeframe referenced in the questions needed to be adapted to accommodate daily usage, but otherwise the screening questions remain the same. Responses are entered into an Epic flowsheet that is populated into clinicians’ notes and can be tracked over time. 

The Columbia tool serves as a guide for suicide assessment, but it’s not a replacement for clinical observation and expertise. “There's always the caveat that it has to be part of a comprehensive evaluation to determine the risk level,” says Dr. Codd.

Standardizing other screening tools

When it comes to administering daily screening tools, the clinical team identified suicide risk assessment as the top priority. Now that the Columbia screening has been successfully adopted on the inpatient unit, they plan to assess other evidence-based screening tools to use as part of routine daily assessments, such as the Patient-Reported Outcomes Measurement Information System (PROMIS) to measure anger, anxiety and depressive symptoms.

Beginning in fall 2024, additional screening tools will be administered upon admission and discharge, including a trauma screener, a distress tolerance assessment, a mindfulness assessment and a client satisfaction questionnaire. “The goal is to look more at the mechanisms driving emotional disorders rather than just the symptom burden,” says Dr. Codd.

When considering new tools, Dr. Codd and Dr. Hawks identify ones already being used in other mental health care settings in the hospital, such as the eating disorder program or outpatient clinic. The goal is to standardize measures across care levels. “When patients step up to inpatient or step down to lower levels of care, we need consistent measures to track their progress over time and inform our clinical decision-making,” says Dr. Codd.

Standardizing measurement over time for individual patients helps improve the overall quality of care. “It's important that these measures help us determine whether the treatment we provide on the inpatient unit is effective or whether we need to make changes,” says Dr. Codd.

Standardizing daily assessment tools into routine care across the organization is still new, but Drs. Codd and Hawks hope implementing daily suicidality screening can become a model for other health systems. The two plan to track and publish their findings in what may provide a roadmap for other facilities. “I’m hopeful we'll be able to positively inform the field, and not only be able to help our own patients, but those across the country,” says Dr. Hawks.