Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) Booklet

Step 5: Document
 Risk level and rationale; treatment plan to address/reduce current


Suicide Assessment Five-Step
risk; firearms instructions, if relevant; follow-up plan. For youths,
treatment plan should include role for patient/guardian
Evaluation and Triage (SAFE-T)
 Documentation should occur at first assessment and/or triage,
A Quick Guide for Clinicians
whenever there is a change in clinical state, with any major shifts in
treatment plan, at any change in the level of care, and before
terminating a relationship.
Step 1: Identify Risk Factors

Question-Asking Strategies Note those that can be modified to reduce risk
 Other people have similar problems sometimes lose hope; have
you?
 Are you feeling hopeless about the present or future?
Step 2: Identify Protective Factors
 This must be a hard time for you; what do you think about when
Note those that can be enhanced
you’re feeling down?
 With this much stress, have you thought of hurting yourself?
 Have you had thoughts about taking your life?
 When did you have these thoughts and do you have a plan to take Step 3: Conduct Suicide Inquiry
your life? Suicide thoughts, plans, behaviours, and intent
 What would happen to your family or significant others if you did
that?
 What has kept you from acting on these thoughts? Step 4: Determine Risk Level/Intervention
 Have you ever had a suicide attempt? Determine risk. Choose appropriate intervention to address and reduce
risk
Step 5: Document
Assessment of risk, rationale, intervention, and follow-up
Material has been adapted from SAFE-T pocket card from www.sprc.org
Suicide assessment and documentation should occur at first assessment Step 3: Conduct Suicide Inquiry
and/or triage, whenever there is a change in clinical state, with any  Ideation: frequency, intensity, duration (in the last 48 hours, past
major shifts in treatment plan, at any change in the level of care, and month, and worst ever)
before terminating a relationship.  “What kinds of thoughts have you been having?”
 “How long have you been having these thoughts? When did they first
start?”
Step 1: Identify Risk Factors  Suicide Plan: timing, location, lethality, access to means,
 Suicidal behaviour: history of prior suicide attempts or self-
preparatory acts
directed violence
 “Do you have a plan of how you would kill yourself?”
 Current/past psychiatric disorders: especially mood disorders,  “Do you have any firearms or other weapons at home?”
psychotic disorders, alcohol and substance abuse, ADHD, PTSD
 Key symptoms: anhedonia, impulsivity, aggression, hopelessness,  Intent: extent to which the patient (1) expects to carry out the plan
anxiety, insomnia and (2) believes the plan/act to be lethal or self-injurious
 Family History: of suicide, attempts, child maltreatment, or Axis I  “In the next 24-48 hours, how likely is it that you will act on your
suicide plan?” (Ask the patient to rate the likelihood on a scale of 1 to
psychiatric disorders requiring hospitalization
10, with 1 being very unlikely and 10 being certain.”
 Stressors: triggering events leading to humiliation, shame, or
 Explore ambivalence: reasons to die vs. reasons to live.
despair. Ongoing medical illness. Intoxication. Family distress.
History of physical or sexual abuse. Social isolation. Loss of primary
relationships, culture, or sense of community. Step 4: Determine Risk Level/Intervention
 Access to firearms, pesticides, or other lethal means  Assessment of risk level is based on clinical judgment, after
completing steps 1-3
Step 2: Identify protective factors RISK LEVEL RISK/PROTECTIVE SUICIDALITY POSSIBLE
 Family and community support, feelings of connectedness FACTORS INTERVENTIONS
HIGH
 Support from ongoing medical and mental health care relationships Psychiatric
Potentially lethal
Admission generally
suicide attempt
 Skills in problem solving, conflict resolution, and nonviolent ways disorders with indicated unless a
or persistent
severe symptoms, significant change
of handling disputes and coping with stress ideation with
or acute reduces risk. Suicide
strong intent or
 Cultural and religious beliefs that discourage suicide and support precipitating event precautions.
rehearsal
instincts for self-preservation MODERATE Admission may be
Suicidal ideation necessary depending on
 Responsibility to children or beloved pets Multiple risk
with plan, but no risk factors. Develop
factors, few
intent or crisis plan. Give
protective factors
behaviour emergency/crisis
numbers
LOW
Thoughts of Outpatient referral,
Modifiable risk
death, no plan, symptom reduction.
factors, strong
intent, or Give emergency/crisis
protective factors
behaviour numbers.

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Step 5: Document

 Risk level and rationale; treatment plan to address/reduce current

Step 1: Identify Risk Factors

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