7.2 Core Workflows and Decision Points

7.2 Core Workflows and Decision Points

The central workflow in behavioral emergencies is risk stratification for self-harm and violence. The Emergency Nurses Association (ENA) Clinical Practice Guideline on Suicide Risk Assessment supports universal screening of ED patients, because many people who die by suicide were seen in an ED for an unrelated complaint shortly before death.

Suicide risk screening tools

The Columbia-Suicide Severity Rating Scale (C-SSRS) is the most widely used ED tool. A nurse administers the brief screen at triage; questions move from passive ideation ("wish you were dead") to active ideation, then to method, intent, and plan. Any affirmative on the behavior items or a higher ideation level escalates the patient to a full risk assessment by the evaluator. The older SAD PERSONS mnemonic is still tested as a way to remember risk factors:

The single strongest predictor of a future attempt is a prior attempt. The most acutely dangerous combination is a specific plan plus access to lethal means plus stated intent.

Stratifying and acting on suicide risk

Classify the patient as low, moderate, or high risk and match the environment to the risk:

• High risk (active ideation with plan, intent, or means; recent attempt): immediate one-to-one (1:1) continuous observation, a ligature-resistant room, removal of belongings (belts, cords, sharps, medications, shoelaces), patient placed in a gown, and search per policy. The patient may not leave AMA and may require an involuntary hold.
• Moderate risk: close observation, means restriction, prompt psychiatric evaluation, and reassessment.
• Low risk: structured safety planning, means restriction counseling (e.g., lock up firearms and medications), crisis-line information, and a warm handoff for outpatient follow-up.

Homicidal ideation and duty to warn

When a patient expresses homicidal ideation, the nurse assesses the same elements used for suicide: ideation, plan, means, intent, and identified target. Escalate security and provider involvement early. If the patient names a specific, identifiable intended victim, clinicians may have a Tarasoff duty to warn/protect — a legal obligation that can require notifying the potential victim and law enforcement. This breaches confidentiality lawfully because preventing serious harm outweighs privacy. Document the threat verbatim and the notifications made.

The leaving-against-medical-advice trap

A patient who has voiced suicidal or homicidal ideation, or who is gravely disabled or psychotic, cannot simply walk out. They lack the decisional capacity to refuse care safely, so the team initiates an involuntary psychiatric hold under state law, secures the patient, and removes means of self-harm. Letting such a patient sign out AMA is the classic wrong answer.

Capacity vs. competence

Capacity is a clinical, decision-specific judgment the ED team makes: can the patient understand the situation, appreciate consequences, reason, and communicate a choice? Competence is a legal status decided by a court. The ED works on capacity. Suicidal intent, acute psychosis, or severe intoxication generally negate capacity for the decision to refuse life-saving care.

Workflow checklist

1. Screen every patient (C-SSRS) and document the result.
2. Stratify risk (low / moderate / high).
3. Match environment to risk — 1:1 and ligature-safe for high risk.
4. Restrict means; remove belongings and search per policy.
5. Hold the patient if they cannot leave safely; involve security.
6. Address duty-to-warn for named targets.
7. Safety-plan and arrange follow-up for those discharged.

Documentation and handoff

The legal and clinical record protects the patient and the nurse. Document the screening tool result, quoted patient statements about ideation, plan, and intent, the risk level assigned, the interventions (1:1 initiated, means removed, room searched), provider notifications, and any duty-to-warn actions. At handoff to the psychiatric evaluator or accepting facility, communicate the risk level, the precautions in place, the medical-screening status, and pending labs.

A frequent miss is discharging or transferring a behavioral patient before the EMTALA medical screening exam is complete or before an emergency medical condition is stabilized.

Protective factors and reassessment

Risk is dynamic, not a one-time score. Protective factors — strong social support, moral or religious objection to suicide, responsibility for children, future-oriented plans, and engagement in treatment — lower risk but never eliminate it in a patient with active intent and means. The nurse reassesses risk after de-escalation, after sedation wears off, and before any disposition decision, because a patient who initially denied ideation may disclose it once rapport is built, and a previously calm patient may decompensate.

Never read a suddenly peaceful, resolved demeanor in a despairing patient as safety; it can signal that the patient has settled on a plan.

Voluntary vs. involuntary status

Know the difference between a voluntary patient, who requests evaluation and may generally request discharge, and an involuntary hold (often called an emergency or 72-hour hold under state law), which authorizes detaining a patient who is a danger to self or others or is gravely disabled. The involuntary hold does not by itself authorize forced treatment beyond emergency stabilization; that may require a separate legal step. The nurse implements the hold by securing the patient and environment, removing means, and documenting the behavior that justified it.

Even under a hold, the patient retains rights to dignity, the least restrictive setting, and the EMTALA medical screening exam — a hold is never a reason to skip the medical workup or to use restraint without meeting the separate restraint criteria.