Assessing Suicide Risk in Triage

Emergency nurses are often the first health care providers to interact with patients, so they need the necessary skills to identify, assess and treat suicide-risk patients. And considering an estimated 12 percent of patients presenting to the ED annually are there because of suicidality and self-harm, the need has never been greater.

ENA is doing its part today to help bring home the need for honing such suicide assessment skills with a session titled “Finding the Suicidal Patient: Triage Processes for Safe Passage.”

Finding the Suicidal Patient: Triage Processes for Safe Passage

10:15 – 11:15 a.m.


Room 413, 414, 415

The session this morning describes and discusses findings from an Institute for Emergency Nursing Research study aimed at better understanding the initial assessment process for suicidality in patients who present to the ED for non-psychiatric reasons. The study, “Assessing for Occult Suicidality at Triage: Experiences of Emergency Nurses,” published in the September issue of the Journal of Emergency Nursing, explores the methods emergency nurses employ to assess patients for suicidal ideation during the initial encounter and how they respond once risk is ascertained.

The authors found that facilitators and barriers to effective at-risk patient triage were individual and environmental. 

Lisa Wolf

“Inadequate time, experience, education and training were identified as the most significant barriers to effective identification at triage,” said session leader and IENR Director Lisa Wolf. “Participants also discussed bypassing or over-reliance on check boxes in electronic record screening tools and the emphasis on patient throughput procedures that may preclude the type of assessment that requires nursing presence.”

Another reported barrier was lack of community resources, which was viewed as a challenge for managing patient care and a contributing factor to colleagues’ unwillingness or inability to recognize and respond to the needs of patients at risk for suicide.

Meanwhile, facilitators of effective triage included EDs with dedicated behavioral health nurses, nurses with adequate experience and training to detect a patient’s subtle cues and safe places within EDs for patients to be adequately assessed. 

But nothing is as effective as a well-designed screening tool, Wolf explained.

“Research findings suggest a screening tool can identify individuals at risk for suicide more reliably than a clinician’s personal judgment,” she said. “Our participants reported that when they assessed suicide risk at triage, it was usually by asking a single question, such as ‘Do you have thoughts or plans to harm yourself?’ But they were concerned about the effectiveness of the single-question approach.”

Regardless of how the process is designed, Wolf said arming emergency nurses with the tools and skills to assess and treat at-risk patients effectively is imperative.

“The emergency nurse is absolutely critical in raising the alarm about a patient who presents with a complaint or injury pattern suggestive of self-harm,” she said.