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Conteúdo (article):

ELABORAÇÃO DE DIRETRIZES PARA ATENDIMENTO HOSPITALAR DE TENTATIVAS DE SUICÍDIO NA ADOLESCÊNCIA
Development of guidelines for hospital care of suicide attempts in adolescence
Simone Scheibe
Hospital Infantil Joana de Gusmão, Serviço de Psicologia (Joana de Gusmão Children’s Hospital, Psychology Service)
Florianópolis-SC
scheibehijg@gmail.com
ORCID: 0000-0003-3364-1966

Ivânia Jann Luna
Universidade Federal de Santa Catarina, Professional Master’s Program in Mental Health and Psicosocial Attention, Public Health Department / Graduate Program in Psychology
Florianópolis-SC
ivaniajannluna@gmail.com
ORCID: 0000-0003-1758-0892

Resumo
Objetivo: este artigo visa descrever um estudo qualitativo e quantitativo de construção e validação de diretrizes para atendimento hospitalar de adolescentes com tentativa de suicídio Método: o percurso metodológico implicou a realização de revisão integrativa de literatura com análise temática de conteúdo de 27 artigos, o qual gerou 3 categorias: avaliação do comportamento suicida em contexto de urgência e emergência hospitalar; intervenção diante do comportamento suicida e equipe multiprofissional hospitalar. O conteúdo destas categorias fundamentou a construção de um instrumento com 15 afirmativas sobre a atuação com adolescentes em crise suicida atendidos no contexto hospitalar. Este instrumento foi aplicado com 20 profissionais de saúde selecionados em duas instituições hospitalares do sul do Brasil, os quais atuaram como juízes/avaliadores das afirmativas propostas. Resultados: O conteúdo das 15 afirmativas foi validado como diretrizes através do Cálculo de Porcentagem de Concordância e do Cálculo do Escore. Conclusão: As diretrizes construídas podem auxiliar as equipes multiprofissionais hospitalares, diante dos adolescentes com tentativas de suicídio, a fundamentarem suas condutas a partir de critérios que norteiam ações de acolhimento, avaliação, intervenção e encaminhamento.
Palavras-chave: Tentativa de suicídio; Adolescência; Serviço hospitalar de emergência.
Abstract
Objective: This article aims to describe a qualitative and quantitative study of the construction and validation of guidelines for hospital care of adolescents with suicide attempts. Method: the methodological approach involved an integrative literature review with thematic content analysis of 27 articles, which generated 3 categories: assessment of suicidal behavior in the context of the emergency department; intervention in suicidal behavior, and hospital multidisciplinary team. The content of these categories was the basis for the construction of an instrument with 15 statements about the performance of adolescents in suicidal crisis assisted in the hospital setting. This instrument was applied with 20 healthcare professionals selected from two hospital institutions in southern Brazil, who acted as judges/evaluators of the proposed statements. Results: The content of the 15 statements was validated as guidelines through the Percentage of Concordance Calculation and the Score Calculation. Conclusion: The constructed guidelines may help multidisciplinary hospital teams when facing adolescents with suicide attempts, to base their conduct on criteria that guide actions of reception, assessment, intervention, and referral.
Keywords: Suicide Attempt; Adolescence; Emergency Department.
INTRODUCTION
Suicide is a phenomenon that accompanies the history of humanity, with various meanings according to the cultural and historical context in which it occurs¹. It is characterized as a multifactorial phenomenon resulting from a complex interaction of biological, psychological, sociological, cultural, and environmental factors2,3. It is not limited to a single field of knowledge, which means that disciplines such as philosophy, anthropology, sociology, medicine, and psychology contribute to the analysis of the theme. Shneidman, an American psychologist, considered the father of suicidology, defined suicide as “[...] a conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which the suicide is perceived as the best solution”4 (p. 203). The same author emphasizes that suicide is an attempt to stop the flow of unbearable psychological pain4. Nowadays, suicide is circumscribed to a broader phenomenon called "suicidal behavior "2,3,5, which is considered a non-adaptive behavior with multiple determinants that presents itself on a scale of severity that includes at least three types of phenomena associated with suicide: suicidal ideation, attempted suicide, and suicide itself3,6.
Suicidal ideation encompasses ideas, wishes, and manifestations of the intention to die. It can also include planning how, when, and where to do the act: Suicide attempt, as clarified by Bertolote et al5, has the same phenomenological characteristics as suicide, differing only in the outcome, which is not fatal, and they propose that suicidal behavior should be differentiated from other self-destructive behaviors, in which there is no intention of ending one\'s life.
According to the World Health Organization (WHO), adolescence is circumscribed to the period between 10 and 19 years7 and is characterized by an accelerated rate of growth and body, biological, social, psychological, and cognitive changes, in which the social context has a primary influence on the development of potentialities and vulnerabilities7,8. It is important to emphasize that there is no universal standard for adolescence so this stage should be understood as a social construction8, historical-dialectical9, the result of the subject\'s appropriation of their experiences, social relations, living conditions, and values present in his culture9,10. In this process, the teenager may experience impasses and weaknesses, developing complications in the mental health sphere. These complications are related to the constitutional path of their singularity, which is dialectically processed in their lives of relationships on the one hand, and with the social and historical context on the other9,10. Suicide attempts in adolescence are associated with the search for relief from intense psychological suffering11. The WHO2 considers factors such as dysfunctional family life, neglect and lack of social support, inability to cope with academic challenges, poor problem-solving skills, low self-esteem, conflicts over gender identity, loss of love relationships, situations of mistreatment, physical and sexual abuse, family psychiatric disorder, and substance abuse or dependence associated with depression may increase the risk of suicide among adolescents. The suicide of prominent and reference figures or someone the adolescent knows personally is pointed out as an additional risk factor at this stage.
Adolescent suicidal behavior is characterized as a growing public health problem in Brazil. According to data released in the latest epidemiological bulletin from the Ministry of Health in September 202112, there has been a significant increase in mortality rates for adolescents and a sustained increase in deaths by suicide in those under 14 years of age. It is estimated that for every death by suicide there are more than 20 attempts3. In turn, Rigo13 warns that half of those who commit suicide have made a previous attempt, making previous suicide attempts an important risk factor for self-extermination. It is important to emphasize that the analysis period of the epidemiological bulletin data is before the new coronavirus Covid-19 pandemic, which was a potentiating variable in the aggravation of mental health for everyone14.
Given the data found, the epidemiological bulletin emphasized the need for healthcare networks to be trained in the reception and care of child and adolescent mental health. There is a lack of national research to formulate an effective approach for users in suicidal crisis, highlighting the lack of development of specific intervention strategies for people who have attempted suicide and arrive at the emergency services5,15.
The WHO has been articulating a series of actions, since 1999, aimed at the global prevention of suicide3. In line with this policy, the Brazilian Ministry of Health has also been articulating a strategic suicide prevention agenda with states and municipalities, which has translated into the definition of national16, state, and municipal prevention guidelines. Despite these initiatives around suicide prevention and the publication of guidance content, there is still little material directed to the specifics of the adolescent public, especially regarding the intervention of health professionals who work at emergency hospital entrances.
In this context, the adequate assessment and management of adolescents who have attempted suicide that arrives at emergency rooms, aiming at the prevention of new attempts, becomes more urgent. This paper aims to describe a qualitative and quantitative study of the construction and validation of guidelines for multidisciplinary hospital care of adolescents who have attempted suicide.
METHOD
This research was planned and carried out in line with the ethical procedures of resolution No. 466, December 12, 2012, and was submitted to the Ethics Committee on Research with Human Beings.
Regarding the methodological path, the study was conducted in seven (7) stages, four related to the construction of the guidelines and three related to their validation. The first step was the bibliographic research through an integrative literature review, which allows the synthesis of multiple published studies and the development of conclusions about a specific study area17. The review’s starting point was the following guiding question: "How to assess and manage suicidal behavior in adolescents seen in the context of hospital urgency and emergency?" This directed the definition of the search terms, which were chosen based on the descriptors standardized by the Descriptors in Health Sciences (Decs) and the Medical Subject Headings Terms (MeSHTerms). To search the databases, the terms "adolescence," "adolescent," "suicidal behavior," "suicide attempt," "suicidal ideation," "suicide," "emergency hospital service," "emergency medical services," "emergency room" were used, with their synonyms, in Portuguese, English, and Spanish, using the Boolean operators "OR" and "AND." Inclusion criteria were: articles available in full; in Portuguese, English, and Spanish languages; with a period of five years (2014-2018); contributing to answering the research question; preferably covering the adolescent audience; having the context of hospital urgency and emergency as locus. The integrative review took place from March to May 2019, and the following databases were consulted: BVS/Bireme, Scopus, Web of Science, PsycINFO, Medline/Pubmed, CINAHL, Pepsic, Index Psi, SciELO. A total of 1,595 articles were identified, and after reading the titles, 463 articles remained. The abstracts of these articles were read, and 27 articles were included.
The second stage of the study was defined by the content analysis of the 27 articles selected according to Bardin\'s thematic categorization18. From this analysis, 3 categories emerged (Assessment of suicidal behavior in the context of hospital urgency and emergency; Intervention in suicidal behavior in the context of hospital urgency and emergency; Hospital multidisciplinary team), which were the basis for the identification of the contents for the preparation of the statements that later comprised the guidelines. Fifteen statements were prepared in the third stage of the study, based on the mentioned categories. A Likert-type scale was built with the 15 statements in the fourth stage. The instrument with the Likert scale presented 5 (five) options: totally disagree; partially disagree; neither agree nor disagree; partially agree; totally agree; reserving an optional space at the end for comments and suggestions.
Next, the fifth stage consisted of selecting the judges/evaluators to validate the content of the statements contained in the instrument. We adopted the definition of 20 (twenty) participants and this number was determined based on the criteria presented by Alexandre and Coluci19, who refer to the number of six to twenty experts for participation in content validity processes. The judges/evaluators were recruited based on the criterion of working in the hospital urgency and emergency context in the care of adolescents with suicide attempts. Twenty judges/evaluators were selected from two hospital institutions in southern Brazil, which are references as hospital urgency and emergency gateways in the care of adolescents in suicidal crisis. All judges/evaluators had from 4 to 35 years of professional training. The distribution among the professional categories was: 7 psychologists, 5 physicians (being 3 psychiatrists and 2 pediatricians), 5 nurses, and 3 social workers, totaling 20 (twenty) participants.
The sixth stage was characterized by the quantitative analysis of the answers to the Likert scale through the Percentage Agreement Calculation19 and by Score Calculation20. The percentage of agreement is the simplest measure of interobserver agreement, and when using this method, a significant agreement rate must be considered 90% 19. The calculation of the Score20 makes it possible to identify the direction of the answers of all the judges/assessors for the agreement or disagreement concerning each proposed statement. For this, different weight is determined for each of the alternatives contained in the Likert scale based on the values 1, 2, 3, 4, and 5. Then, the Score Calculation20 formula is applied to each statement. The final score of each statement is reached from the sum of the values found for each of the five response options on the Likert scale. To interpret the results, a statement is considered to have a "high" agreement score when the value is equal to or higher than 4 (four), and when the value is equal to or lower than 3 (three), it has a "low" agreement score.
The results obtained regarding the agreement rates of the statements from the Percentage Agreement Calculation (12 statements with 100% agreement, 2 with 90%, and 1 statement with 85%) and the Score Calculation (all statements with scores between 4.5 and 5) allowed us to consider that the content of the 15 statements was validated regarding the assessment and management of suicidal behavior in adolescents in hospital emergency setting. Thus, we reached the seventh and last stage of the study, which was the final presentation of the validated guidelines’ content for in-hospital care of adolescent suicide attempts. Next, the guidelines are presented in their qualitative and content aspects, as well as the discussion of these guidelines based on the literature.
RESULTS AND DISCUSSION
According to Table 1, guidelines 1 to 7 were built from the first category of analysis, with their respective subcategories and thematic units, and refer to the relevant aspects that need to be included in the scope of the evaluation of the adolescent who attempted suicide and is in the hospital setting.

Table 1

In the first guideline, the execution of emergency actions in the hospital context was pointed out based on the thematic units; first aid and physical and laboratory exams. In this sense, the clinical exam (physical and laboratory) of the patient at the moment of admission is highlighted as decisive in defining the emergency procedures that need to be taken to ensure the patient\'s clinical stabilization, ruling out possible complications21,22.
As a second guideline, the promotion of ambiance was highlighted, based on the thematic units; safe physical space and privacy conditions. Ambiance is one of the National Humanization Policy’s (PNH, or Política Nacional de Humanização in Portuguese) guidelines and comprises not only the physical space, but also the social space, the interpersonal relationships that are aligned with a welcoming, caring, and humane care23. Gutierrez24 emphasizes that welcoming the person who has attempted suicide to hospital care must be done safely, promptly, and with quality to promote patient acceptance and adherence to treatment. Chun et al21, Margret and Hilt22, and Kuczynski25, also point out the safety and privacy conditions of where the adolescent will be evaluated and kept under observation, as well as an approach that includes comprehensiveness and care.
The topic related to the welcoming/communicational approach with the adolescent and their parents/caregivers was highlighted as a third guideline, based on the thematic units of empathy, listening, and absence of judgment. According to Gutierrez24, reception represents the most important technology in an emergency service, as it enables integral care through active and empathetic listening. In this context, it is essential to avoid judgment and censorship, but to adopt a continent approach based on tranquility, empathy, and resoluteness25,26. Botega and Rapeli6 have also pointed out the importance of trying to establish a bond that allows the patient\'s trust, especially at this moment when he is fragile and not always willing to collaborate with the interview.
The fourth guideline refers to the conduct of the clinical interview for the assessment of suicidal behavior and points to crucial aspects to be observed as described below.
The first aspect is the lethality of the suicide attempt, which is usually an indication of the intentionality of the act. However, it is necessary to be alert, because children and adolescents can misjudge the lethality of their actions. An adolescent whose suicide attempt had a low lethality may conceal a significant desire for self-injury or suicide25, 27, 28. Suicide planning, according to the stages of suicidality29, is one of the factors considered when defining a high risk of suicide. The frequency and intensity of suicidal ideation show the degree to which the adolescent is suicidal21, 22, 25, 28, 30.
The history of suicidal/self-mutilation behaviors delimits whether the risk of suicide is chronic or more current. Regarding the history of self-harm, the research of Pettit, Buitron, and Green28, Asarnow et al31 found the importance of assessing and monitoring self-harm regardless of suicidal intent in adolescents, as it is an important predictor of suicide attempts, especially in girls. Chun, Mace, and Katz27 indicate that the existence of signs of self-mutilation should be verified in the clinical examination of the patient, since these signs may be hidden under the patient\'s clothing. Another important item to be listed in the clinical interview refers to the identification of precipitating events associated with the suicidal crisis. Chun et al21, Kuczynski25, Chun, Mace, Katz27, and Ginnis et al32 define precipitating factors as triggers for the suicidal crisis. Bertolote, Mello-Santos, and Botega5 define precipitating events as proximal factors that trigger the suicidal crisis and are also called stressors associated with the risk of suicidal behavior.
Obtaining information from family members and people close to them about the life situation of the adolescent who attempted suicide was shown to be an important aspect of measuring the suicide risk, considering that the adolescent frequently minimizes the severity of their symptoms or the intention behind their acts21, 22, 26, 33. This fact may be related to the adolescent\'s fear that reporting suicide risk and self-harm may lead to hospitalization. Identifying risk and protective factors is a key aspect in evaluating suicide attempts and indicates the adolescent’s degree of vulnerability. But it is necessary to emphasize that none of the isolated factors has the power to provoke or prevent suicidal behavior5. Pesce34 emphasizes that the protective factors can modify the subject\'s response to risk factors, and they must be analyzed interconnectedly since they are not static entities and change according to the person and their life context. The studies included in the research described many risk factors and few protective factors, as described in Table 2:

Table 2

The fifth guideline addresses the need for conducting the clinical interview also with a focus on the risk classification of adolescents in a suicidal crisis. However, Ambrose and Prager35 consider this classification an imprecise task since suicide risk is not static. Pettit, Buitron, and Green28 emphasize that even when the risk level is considered low, a suicidal crisis can arise and the risk of suicide in some situations can be high. They also advise that healthcare professionals need to be vigilant in monitoring suicide risk during the year following an attempt and consider that the first 3 to 6 months represent the highest risk for a new attempt.
The sixth guideline refers to assessing suicide risk using auxiliary means during the clinical interview by applying standardized instruments. Margret and Hilt22, Kuczynski25, Berk and Asarnow33, King et al36, and Ambrose and Prager35 suggest the inclusion of screening instruments to assess suicide risk and support the decision to hospitalize or discharge for outpatient follow-up. There are many internationally validated instruments, but Silva et al37 point out the need for investment in cross-cultural adaptation and validation of these instruments for use in Brazil, since there is a limitation of psychological assessment instruments in our country specifically directed to suicidal behavior in children and adolescents.
The seventh guideline concerns another aspect to be observed in the clinical interview, which is the presence of self-injury as a risk factor for a suicidal crisis that was advocated by some authors of the included studies27, 28, 31, 35, 38.
According to Chart 3, guidelines 8 to 13 were built on the second analysis category, which was intervention in the face of suicidal behavior in an urgent and emergency hospital setting. This category is comprised of 3 subcategories: preventive approach, use of criteria for hospital admission, and use of criteria for hospital discharge.

Table 3

The eighth guideline addresses the need to consider care related to suicidal behavior in the hospital emergency setting as an opportunity to implement effective strategies for suicide prevention for those who are at risk of committing it. Several studies have emphasized the importance and possibility of a preventive approach that begins in the emergency setting, offering brief therapeutic interventions that will positively impact treatment adherence and, consequently, suicide prevention22, 26, 28, 30, 32, 35, 36, 38, 39, 40, 41, 42, 43, 44. Among these interventions, the safety plan, family counseling, and co-responsible counter-referral to outpatient mental health services21, 22, 26, 28, 30, 32, 36, 38, 39, 41, 42, 43 stand out.
A relevant aspect of the eighth guideline that will be addressed in more depth in the tenth guideline is the issue of developing a "safety plan" with the adolescent and their parents/caregivers. This type of intervention is highlighted in the eighth guideline, as is the welcoming and guidance of parents/caregivers. Parents and caregivers need individual attention during care because they are often in shock and find it difficult to deal with their adolescent\'s suicidal crisis; in addition to being part of the context in which the young person lives, they are the people that the adolescent will turn to in other moments of crisis. The articulation of the adolescent\'s mental health follow-up is another crucial point of the preventive approach, and it is present in the eighth guideline. Health professionals have an ethical commitment to articulate the continuity of care, especially in suicidal crises. This topic is corroborated by other authors, such as Ferreira and Gabarra45, who reinforce the need for communication with the psychosocial care network and describe ongoing telephone contact with the network points as a means to articulate the outpatient follow-up.
Regarding the ninth guideline, the studies highlighted some options that are applied used in the emergency context of American hospitals as brief therapeutic interventions, such as CALM (Counseling Access to Lethal Means)39, FISP - Family Intervention for Suicide Prevention41, Family-Based Crisis Intervention32, TOC - Teen Option for Change36, COPES (Coping, Problem-solving, Enhancing life, and Safety planning)46 and several coping strategies that can compose the safety plans21, 22, 26, 28, 30, 32. An Irish study that proposes a specific approach to self-harm behaviors was also found: National Clinical Programme for Assessment and Management of patients presenting to the emergency departments after self-harm38.
The ninth guideline aims to bring attention to the importance of the multidisciplinary teams\' conducts in the management of adolescents in suicidal crisis and their families/caregivers in the context of hospital urgency and emergency. The preventive approach implies an overview of the subject’s situation in line with the logic of psychosocial care, in which the expanded clinic (clínica ampliada in Portuguese), the welcoming, the incentive to the leading role of patients, and social inclusion are some of the aspects involved47.
The tenth guideline specifically addresses the issue of developing a safety plan with the adolescent in a suicidal crisis treated in a hospital setting. Chun et al21 clarify that "safety plans" typically include: a) Identification of warning signs and possible triggers for recurrence of suicidal ideation; b) Coping strategies that the patient can use; c) Healthy activities that can distract from or suppress suicidal thoughts; d) Supports that the patient can seek if the suicidal impulse return; e) Contact information for professional support, including instructions on how and when to call for emergency services; f) Restriction of access to lethal means. This plan is usually first made with the adolescent, who writes the plan on a standard sheet of paper, retaining a copy. Afterward, the plan is worked on with the parents/caregivers, especially regarding the aspects that involve them, such as when they are people that the teenager will signal to ask for help when faced with triggers for the suicidal crisis.
In turn, the eleventh guideline emphasizes the importance of an approach with the parents/caregivers of the adolescent in a suicidal crisis. Gutierrez24 emphasizes that health professionals should offer support, care, and clarification to family members at this time since they are people who can collaborate in suicide prevention. Babeva et al41 stress that family involvement aims to increase family support, emphasizing the importance of restricting access to lethal means in the home environment and the need for protective monitoring, empowering parents to support adolescents in using their safety plans, and obtaining a parental commitment to engage in follow-up treatment after discharge.
Regarding the twelfth guideline, the studies pointed to the use of previously established criteria for hospital discharge. Chun, Mace, and Katz27 point out that the decision for "inpatient" vs. "outpatient follow-up" depends on many factors, including a careful assessment of suicide risk and should include consultation with a mental health professional. Betz et al30 describe the 5 steps for the discharge plan and follow-up in the network that are associated with the execution of the safety plan, psychoeducation for family members, and provision of emergency telephones. The 5 steps are: identify risk factors, identify protective factors, conduct suicide inquiry, determine risk level, perform brief intervention and guidance.
Regarding the thirteenth guideline, it establishes the need to articulate follow-up care after patient discharge. Rothes and Henriques42 point out that health professionals should promote a chain of care provided by a multidisciplinary team, allowing the integration of pharmacological and psychological therapy. In Brazil, according to the logic of network care advocated by SUS (Unified Health System or Sistema Único de Saúde in Portuguese), all points of care are bound to the principles of the Unified Health System, such as the guarantee of universality, equity, and comprehensiveness of care, humanization of care, and guarantee of implementation of the multidisciplinary care model. Thus, suicidal behavior assessment and management in adolescents seen at hospital urgent care or emergency rooms should be guided by this logic of care. This guideline is also aligned with what is recommended in the National Policy of Child and Youth Mental Health48, which, among other principles, provides for implicated and co-responsible referral. This principle requires that the referring professional included themself in the referral and take responsibility for the demand, following the case until its new destination. The Psychosocial Care Network (RAPS)49 exists since 2011 and has been changing over the years but establishes an articulation and integration flow between the network points.
The fourteenth guideline emphasizes the issue of hospitalization criteria, which can be a necessary strategy for the moment of crisis aiming at patient safety. Wolff et al46 proposed that hospitalization can be an opportunity for interventions focused on improving adolescent coping skills and problem-solving around the factors that led to their hospitalization. It also allows professionals to better evaluate the family\'s protective capacity and conduct psychoeducation with family members to help them better manage the situation with the adolescent.
The ninth and fifteenth guidelines, according to Table 4, include the theme of the multidisciplinary hospital team under different aspects, but at the core of these guidelines are the contents related to the promotion of comprehensive care and continuing education. Table 4 reveals the following results.

Table 4

The ninth guideline addresses the promotion of integrality of care so that the actions that align with suicide prevention for adolescents seen in the hospital setting must be comprehensive and conducted by a multidisciplinary team. Gutierrez24 emphasizes that integrality is offered through a network and that professionals need to consider the biopsychosocial aspects of the patient and their families. The National Policy of Child and Youth Mental Health48 also emphasizes the relevance of permanently building the network and of intersectionality. As previously highlighted, suicidal behavior is multifaceted and a result of a complex interaction of factors2,3, and cannot be solely understood as an individual issue. In this sense, the approach of a multidisciplinary hospital team articulated with the psychosocial care network and with other social, justice, and child and adolescent protection agencies are compliant with the complexity of the phenomenon. The fifteenth guideline addresses the need for hospital health team training and qualification based on technical and scientific criteria in their conduct. The studies emphasized that there are scientifically proven interventions for adolescents seeking emergency services who are at risk for suicide. Gutierrez24 reminds us that permanent education is a strategy for the consolidation of SUS (Unified Health Care, or Sistema Único de Saúde in Portuguese), recommending that an in-service education project be carried out in the area of mental health.
FINAL CONSIDERATIONS
The guidelines that were constructed and validated aim to help the emergency hospital teams based on criteria in their conduct, guiding actions of welcoming, assessment, intervention, and referral. In this sense, the proposed guidelines aim to guide and build effective practices when facing an adolescent in a suicidal crisis, since weaknesses were highlighted regarding the assessment and management of suicidality in urgent and emergency hospital settings.
Among the aspects that fragilize the care of these adolescents is the lack of training among teams, generating insecurity and a certain discomfort for health professionals since they are trained to deal with life rather than with people in intense psychic suffering who are placing their existence at risk.
The adolescent and their family need welcoming and qualified action in mental health.
In addition to the role of guiding, the validated guidelines contribute to the prevention of suicide risk in adolescents, because as was revealed in the studies selected in the integrative review, the conduct of the multidisciplinary team in hospital services can be preventative if based on scientifically supported interventions and criteria. Therefore, urgency and emergency services can offer suicide prevention care that effectively saves lives. It is understood that, in this way, the multidisciplinary team at hospital emergencies can perform one of the "indicated" suicide prevention actions recommended by the World Health Organization50, which is directed to the person who presents a high risk of suicide.
Considering the above, the guidelines developed and validated in this study are considered not only as possible guidelines for the care of adolescents in suicidal crisis seen in the context of hospital urgency and emergency but as guidelines that can promote the prevention of new suicide attempts.
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