Research In Action

My colleagues at CHOP’s PolicyLab recently blogged about the need for depression and suicide screening in autistic teens, as they are at higher risk for endorsing, attempting, and dying from suicidal thoughts and actions. In our Developmental and Behavioral Pediatric Clinic (DBP) at CHOP, where we care for children and teens with different developmental conditions (including autism, ADHD, genetic differences, and intellectual disability), we recognize this urgent need and recently implemented a new workflow to implement suicide screening in all patients age 12 and older.

The process to create this workflow has taken over a year. Barriers to implementing a universal standardized screening workflow in our clinic in the past have included:

• Lack of training on how to use suicide screening and assessment measures
• Lack of a standardized workflow for how to respond if a child or teen reports suicidal thoughts
• Concern that our existing electronic medical documentation and personnel structure do not support universal screening

We knew that to implement suicide screening successfully and efficiently for all our adolescent patients, all three of these barriers would need to be addressed.

Training the Providers

We started with training providers on how to administer/interpret suicide screening and assessment measures, as well as how to develop a formal suicide safety plan with the family. Fortuitously, our intention to begin this process coincided with a PCORI study led by researchers at the University of North Carolina at Chapel Hill that compared two ways to help autistic youth manage thoughts of suicide -- an autism tailored suicide plan with and without follow-up care. Because CHOP is one of the sites participating in this study, our providers were able to receive formal training on developing the tailored safety plan with families. Concurrently, providers received training on using the Ask Suicide-Screening Questions (ASQ) screening tool, as well as an adapted Columbia Suicide Severity Rating Scale (CSSRS) for assessment in patients who screen positive for suicidal thoughts.

Creating A New Workflow

The training for suicide assessment and planning gave providers confidence to use the tools in clinic, but what we needed to address next was the daily integration of these tools into our already busy workflow. Ultimately, we knew that we wanted the suicide screening questions to be completed while patients were in the office with us (rather than at home) so that we could do an assessment in the case of a positive screen. In a busy clinic, though, any additional step or question can feel very difficult to add on without disrupting efficiency. In addition, this new step requires coordination with not just providers, but also the front desk registration, medical assistants, and nurses in clinic.

We are currently trialing a system where the patient completes the ASQ (5 questions) in the waiting room, and then the providers review the questions at the start of the visit. For privacy, we carved out a space within the waiting room for teens to complete the questionnaires. We are currently soliciting feedback from patients and families to understand whether this workflow feels acceptable and comfortable for them.

Electronic Support Tools

Finally, we needed to build tools in our electronic health record (EHR) system to facilitate documentation of screening, assessment of suicide risk level, and creation of the safety plan for youths to take home. Neither the ASQ nor the Adapted CSSRS existed within our EHR so we needed the support of our IT team to build these tools. It took months of planning and revision to build these tools in our system.

We used the time it took to build these electronic tools to conduct multiple pilots to work out any “kinks” in our workflow. First, we limited suicide screening to a small group of providers/patients and used paper forms of the questionnaire, getting feedback from providers and patients about the process along the way. Then we opened the screening process to all providers at our Center City location but still used only the paper forms. Finally, we will soon open screening using the electronic version of the questionnaires and new EHR tools to all providers at all of our DBP satellite sites.

Some of the improvement changes that we made or plan to address as part of this iterative feedback cycle include:

• Carving out dedicated space in the waiting room to give patients privacy to complete the questionnaires
• Creating a way for providers to indicate that the family was unable to complete screening due to patient limitations with understanding/answering the screening questions
• Providing patient/family education about why we are implementing suicide screening for all adolescents (still in progress)

Next Steps

We are planning quality improvement projects regarding both the implementation of screening (e.g., frequency among eligible patients), the patient/family experience with screening, and the provider experience with screening (e.g., its impact on the clinician’s ability to address other patient concerns in a timely fashion). We are excited to have finally built the infrastructure within our clinic to implement this important step in care for our adolescent patients.