D219 Task 2 Practice Change Recommendation Example

Recommending Universal Suicide Risk Screening at Triage for Patients Aged 10 to 18 in a Community Emergency Department

Student Name

Leavitt School of Health, Western Governors University

D219: Scholarship in Nursing Practice, Task 2

Course Instructor

Month Day, Year

Recommending Universal Suicide Risk Screening at Triage for Patients Aged 10 to 18 in a Community Emergency Department

Introduction

In the composite community emergency department described here, a 30-bed adult and pediatric department in a suburban hospital, nurses screen for suicide risk only when a young patient arrives with a mental health complaint. A 14-year-old who comes in with a sprained ankle, abdominal pain or a headache is never asked. The evidence-based practice question for this work was: in patients aged 10 to 18 presenting to a community emergency department, does universal nurse-administered suicide risk screening at triage, compared with screening only patients with a psychiatric complaint, increase the proportion of at-risk youth identified during the visit? This paper summarizes the evidence, recommends a practice change and sets out who will carry it, what will get in the way and how success will be measured.

Summary of the Evidence

Four sources, all published within the last five years, shape the recommendation. A systematic review of 13 test accuracy studies in nonpsychiatric medical settings found that the Ask Suicide-Screening Questions (ASQ) had one of the strongest evidence bases of any pediatric screening tool, with satisfactory sensitivity and specificity (Lowry et al., 2024). A retrospective cohort study of 17,332 patients aged 10 to 18 in a large pediatric emergency department found universal screening completed in 84.8% of encounters, with 16.1% of screened patients at some level of risk; those identified as high risk who later returned were 15.5 times as likely as minimal-risk patients to have a suicide attempt within six months (Rogers et al., 2025). That study shows both that universal screening is workable in a busy department and that the screen identifies real risk.

Two further sources address implementation. A quality improvement project at a children's hospital raised screening compliance in the emergency department from 17% to 80% by pairing a clinical care guideline with decision support built into the electronic health record (Lund et al., 2025). A study of barriers in two pediatric emergency departments found that workflow problems and language or comprehension difficulties were the most common reasons screening failed (Seag et al., 2024). Together the evidence says the tool works, universal screening finds youth who would otherwise be missed, and success depends on how the screen is built into the nurse's workflow.

Recommended Practice Change

I recommend that every patient aged 10 to 18 presenting to the department, whatever the chief complaint, be screened with the ASQ by the triage nurse or, when the patient is sent straight to a room, by the primary nurse within one hour of arrival. Current practice is selective: screening happens only for mental health complaints. Proposed practice is universal, with the four ASQ questions asked privately, away from parents where possible, using a professional interpreter when the patient or family prefers a language other than English. A positive screen triggers the fifth question on current thoughts, a brief suicide safety assessment by the emergency physician or advanced practice provider, environmental safety precautions and, for imminent risk, a constant observer until evaluation is complete.

The change applies only to this department and this age group, and it begins with a 90-day pilot. Adults are outside the scope of this recommendation because they need a different tool and a different pathway.

Involvement of Three Key Stakeholders

The first stakeholder group is the emergency nurses who will ask the questions. Their involvement begins before launch: two nurses from each shift will join a working group that places the ASQ in the triage workflow, practice-scripts the questions with each other and helps build the electronic health record prompt. After launch, they will serve as unit resources who coach colleagues and report problems at each huddle.

The second is the emergency physicians and advanced practice providers, who must complete a brief safety assessment for every positive screen. The medical director will review and approve the positive-screen pathway, and a physician champion will present the evidence at the department meeting, because a nurse-driven screen that produces results no one acts on would erode trust in the program within weeks.

The third is the hospital's behavioral health team, including the social worker and the crisis clinician on call. They will agree on response times for positive screens, supply the list of outpatient resources given at discharge and join the monthly review of positive screens to confirm that each one received a safety plan or a referral.

Barrier to Implementation

The most likely barrier is triage workflow. Triage nurses in this department already complete a sepsis screen, a fall risk score, a domestic violence question and vital signs within minutes, often with parents in the room. Adding four questions for every patient aged 10 to 18 will feel like one more box on a crowded screen, and on busy shifts the easiest response is to skip it or to ask it quickly in front of a parent, which makes an honest answer less likely. This is the same workflow barrier identified as the leading cause of missed screens in pediatric emergency departments (Seag et al., 2024).

Strategy to Overcome the Barrier

The strategy is to build the screen into the electronic health record so it cannot be missed and is easy to finish, as the successful quality improvement project did (Lund et al., 2025). A hard prompt will appear at triage for every patient aged 10 to 18, with the four questions and scripted wording on screen. If triage is too busy or a parent cannot be asked to step out, the nurse may defer the screen once, which moves the prompt to the primary nurse's task list with a one-hour timer. A private script for asking parents to step away ('I ask every teenager a few health questions on their own') will be taught in a 15-minute in-service and printed on a badge card. A weekly report will show each shift its completion rate, so gaps are seen and discussed within days rather than months.

Outcome Measure

The outcome from the PICO question is the proportion of at-risk youth identified during the visit, measured as the number of positive ASQ screens among patients aged 10 to 18 without a psychiatric chief complaint, per 1,000 eligible visits. Before the change this figure is effectively zero, because these patients are not screened. During the 90-day pilot the figure will be reported monthly from the electronic health record, alongside two supporting measures: screening completion among eligible visits, with a target of at least 80%, and the proportion of positive screens that received a documented safety assessment before discharge, with a target of 100%. If completion stays below 60% after the first month, the working group will review deferred screens to find where the workflow is failing.

Conclusion

Current evidence supports universal suicide risk screening with the ASQ for young people in emergency care, and shows that screening only those with mental health complaints misses youth at real risk. Built into triage with nurses, providers and the behavioral health team each given defined work, and supported by an electronic prompt that answers the workflow barrier, the change can be tested in 90 days and judged by how many at-risk young people it finds.

References

Lowry, N. J., Goger, P., Hands Ruz, M., Ye, F., & Cha, C. B. (2024). Suicide risk screening tools for pediatric patients: A systematic review of test accuracy. Pediatrics, 153(3), e2023064172. https://doi.org/10.1542/peds.2023-064172

Lund, A., Denicolo, K., Tomko, S., Jones, R. C., Stephen, R. J., Olsen, M., Sarmiento, J., Jones, S., DiVenere, E., Sullivan, N., Nytko, A., & Hoffmann, J. (2025). Improving universal suicide risk screening rates at a children's hospital. Pediatrics, 155(5), e2024065901. https://doi.org/10.1542/peds.2024-065901

Rogers, S. C., Sacco, S. J., Volz, K., Chenard, D., Borrup, K., Chen, K., & Aseltine, R. H., Jr. (2025). Feasibility and importance of universal suicide screening in a pediatric emergency department. PLOS ONE, 20(6), e0321934. https://doi.org/10.1371/journal.pone.0321934

Seag, D. E. M., Cervantes, P. E., Narcisse, I., Wiener, E., Tay, E. T., Knapp, K., & Horwitz, S. M. (2024). Implementation barriers encountered during a universal suicide screening program in pediatric emergency departments. Pediatric Emergency Care, 40(10), 731-735. https://doi.org/10.1097/PEC.0000000000003221