Head to Toe is a new practice that helps with early identiﬁcation and management of patients at elevated risk for suicide in pediatric medical and surgical units.
All youth 12 and older admitted to the medical and surgical inpatient units at the Children’s Hospital of Eastern Ontario (CHEO) are screened for suicidal thoughts and actions by their admitting nurse, using a psychometrically validated tool, the Ask Suicide Screening Questionnaire (ASQ).
During the admission process, the nurse administers the ASQ within 4 hours. Scripting has been developed for nurses about how to introduce the screening and explain the limits of confidentiality. Nurses document patients’ eligibility for screening and their responses on the ASQ items in the electronic health record. Patients are deemed non-eligible if they are developmentally delayed, cognitively impaired, admitted for psychiatric reasons, non-verbal, or are participating in active end of life care. Special considerations were also made to address the unique needs in individual inpatient units.
If a patient positively endorses an ASQ item(s) the nurse communicates this to the MRP, who initiates a consult to mental health. The nurse additionally documents whether the patient consents to disclose the findings to caregivers, and have further mental health assessment.
Youth who endorse a positive screen receive a brief mental health risk assessment within 24 hours conducted by a mental health nurse. Patients who disclose active suicidal thoughts on the ASQ are assessed directly by psychiatry within 4 hours, and actions are taken to ensure patient safety.