Beyond Risk Identification: Adherence to a Pediatric Suicide Prevention Pathway in Primary Care

To evaluate adherence to a structured suicide prevention pathway in pediatric primary care and characterize management practices following suicide risk assessment.

We conducted a retrospective cross-sectional study of well-child visits among adolescents aged 12-21 years at an urban academic pediatric clinic from 2022-2024. The pathway incorporated the Patient Health Questionnaire-9 Modified for Adolescents (PHQ-A) for suicide risk identification and the Columbia-Suicide Severity Rating Scale (C-SSRS) for risk assessment. Electronic health record (EHR) data assessed adherence to pathway components, and supplemental chart review characterized management practices, including safety planning and emergency department referral. Multivariable regression examined patient-, provider-, and system-level factors associated with adherence.

Among 3440 visits, the PHQ-A was completed in 84.8%. Suicide risk was identified in 8.6%, and 57.8% received a C-SSRS. When an EHR alert was triggered, 79% completed the C-SSRS compared with 11% without an alert (p < 0.001). Older adolescents were less likely to receive a C-SSRS assessment (aRR=0.93; 95% CI: 0.89-0.97). Among adolescents with low or moderate C-SSRS risk levels, 20.8% had documentation of a complete six-step collaborative safety plan. Manual chart review identified additional suicide-related management practices beyond the adherence metric, including partial safety planning, behavioral health involvement, referral to mental health services, and ongoing mental health treatment.

Suicide prevention pathways can support identification, assessment, and management of suicide risk in pediatric primary care. EHR-based decision support may improve adherence. Defining evidence-based components of pediatric suicide prevention remains critical.