Head to toe practice: Implementation and outcomes of a suicide screener in pediatric hospital inpatient units



Suicide remains the second leading cause of death in Canadian children and youth (Public Health Agency of Canada, 2019). Recent studies show that 50-80% individuals who die by suicide have had contact with a healthcare provider within one month prior to their death (Ahmedani et. al., 2014; Vasiliadis et. al., 2015). Unfortunately, these patients often present solely with physical complaints and infrequently discuss suicidal thoughts and plans unless asked directly. Those with medical conditions are also at a higher risk of experiencing mental health difficulties.

Following a critical incident in our hospital, the corporate leadership committee addressed opportunities for improvement, and recommended the integration of routine suicide screening into standard care for all pediatric patients admitted to hospital.


Prior to implementation of the transformative Head to Toe (term coined by a family caregiver during stakeholder interviews) initiative, suicide screening was routinely part of the admission assessment in the inpatient mental health units and for patients presenting to the emergency department with mental health concerns. In February 2019 we began a step-wise implementation of the Head to Toe suicide screening for all youth 12 and older admitted to the medical and surgical inpatient units at out institution using a psychometrically validated tool, the Ask Suicide Screening Questionnaire (ASQ) (Horowitz et. al, 2012).


During the admission process, the nurse administers the ASQ and documents patients’ eligibility for screening and their responses on the ASQ items in the electronic health record. If a patient positively endorses an ASQ item(s) the nurse communicates this to the most responsible physician, who initiates a consult to mental health. Youth who endorse a positive screen receive a brief mental health risk assessment within 24 hours conducted by a mental health nurse. Patients who disclose active suicidal thoughts on the ASQ are assessed directly by psychiatry as soon as possible and actions are taken to ensure patient safety.

A framework was developed for continuous evaluation of key components of the Head to Toe practice. Since the end of July 2019, when all medical/surgical units went live with the Head to Toe project, we have monitored compliance with the screening protocol on a daily, weekly, and monthly basis.


We are the first pediatric hospital in Canada to implement systematic screening for suicide risk in medically or surgically hospitalized children and youth. Initial data indicate that during the first six months of the full implementation of the Head to Toe suicide screening, 72% (396) of eligible patients were screened with 14% (57) of these identified as having thoughts of suicide or a previous attempt and proceeding to further mental health assessment.

Daily review of compliance rates on each unit allows us to identify omissions in patient screening and provide one-on-one support to staff to facilitate timely completion of the ASQ, while the weekly and monthly compliance reports are reviewed with unit staff and leadership to identify and address factors impeding compliance with Head to Toe care pathways and monitor change in adherence patterns. This ensures the sustainability of the Head to Toe initiative and provides opportunities for celebrating successes. We are also currently collecting qualitative feedback from youth and families about their experiences participating in the Head to Toe process.


This presentation will describe the steps to ensure successful implementation of suicide screening in our hospital setting, the challenges encountered and possible solutions. The hope is that this new practice will reduce emergency hospital visits for mental health crises and facilitate early access to mental health services. This initiative can be used to support other hospitals in implementing their own suicide prevention screening programs, along with informing policy about ways to help prevent suicide in youth populations.

Lead Researchers

Link to Publication


  1. Melanie Buba

    Investigator, CHEO Research Institute

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