Standardization of Suicide Risk Assessment and Risk-Aligned Interventions Across a Multisite Health Care Network

Suicide is a leading cause of death in the United States for individuals aged 10-64. Emergency departments (EDs) and inpatient units represent critical points for prevention. In non-behavioral health settings, suicide risk assessment and observation practices are often inconsistent. Additionally, only about half of individuals who die by suicide have a documented mental health diagnosis, increasing the risk of missed identification without universal screening. Baseline network review identified inconsistent documentation of risk assessment, substantial overuse of continual 1:1 observation, and repeated regulatory findings. These gaps presented an opportunity to standardize suicide risk assessment, interventions, and observation practices across the network.

A chartered, multidisciplinary suicide prevention performance improvement committee implemented a network wide standardization strategy using Plan Do Check Act (PDCA) methodology. Key interventions included universal suicide risk screening in ED and inpatient settings; standardized policies for observation, secure hold, and virtual patient observation (VPO); mandatory education supported by role specific checklists; optimization of electronic health record workflows and order sets; expansion of ligature assessed secure hold rooms; scaled deployment of VPO for low and moderate risk patients; and routine audits supported by real time analytics.