Intentional self-harm (suicide) is listed as the 11th leading cause of death in the United States according to the latest statistics available from 2007.1 Men take their lives at nearly four times the rate as women, and men age 75 and older have the highest rate of suicide (35.7 per 100,000).2 The highest incidence of reported suicide attempts occurs in the 18 to 24 age-group, and suicide is the third leading cause of death among 15- to 24-year-olds.3 Of the adults who attempted suicide in 2008, 62.3% (678,000) received medical attention for their suicide attempts and 46% (500,000) stayed overnight or longer in a hospital for their suicide attempts.2
Suicide is ranked in the top five most frequently reported events to The Joint Commission (TJC) since 1995. The sentinel event database includes 827 reports of inpatient suicides, but because most of these events are voluntarily reported, and represent only a small proportion of actual events, no conclusions should be drawn about the actual relative frequency of events or trends in events over time.2 Mills and colleagues state that about 1,500 suicides take place in inpatient hospital units in the United States each year.4 Although psychiatric hospitals are designed to be safe for suicidal patients and have staff with specialized training, typically, CCUs and medical-surgical units of general hospitals aren't designed to care for suicidal risk patients and don't have staff with specialized training to deal with suicidal individuals.2 Not surprisingly, suicidal individuals are often admitted to general hospitals immediately following suicide attempts.
Nurses in my general hospital's CCU often care for patients following suicide attempts; however, we didn't begin to develop a routine protocol for suicide prevention until a little over 2 years ago. At one of our unit-based clinical practice meetings, one of the staff members recounted that the admitting physician was alarmed that a patient who'd been admitted with an intentional drug overdose hadn't been placed on a suicide risk 1:1 (one staff member assigned to one patient). The physician assumed that our practice was to assign a suicide risk 1:1 with every patient who overdosed. We did have algorithms and guidelines for 1:1 coverage for the confused patient; however, outside of the behavioral health unit (BHU), we had nothing for the patient at risk for suicide.
As we talked, we realized that in the absence of a specific physician prescription, staff were using their professional judgment as to the need for a suicide risk 1:1. Given the statistics and the importance of our patients' safety and well-being, the need for a suicide prevention protocol became obvious.
Looking at the research
As a first step, we decided to investigate existing research in this area to see how we could best apply it to our hospital and patient population.
Our initial research review was quite disappointing—few articles were available on the subject. Of those available, the majority were out of date by more than 5 years or were very specific to psychiatric facilities, which wouldn't be suitable for implementation in our not-for-profit, rural community hospital. Despite these challenges, we were able to take snippets of ideas from the articles, mostly related to securing the patient's belongings and creating a safe environment for the patient. Unfortunately, we didn't find any articles that were specific to implementation of a comprehensive process. To gather more of the information we were seeking, we sent surveys to other hospitals in our buying consortium to find out what protocols and processes they had in place. Regrettably, we didn't gain much more information than we did from our research review.
As our final step in the development process, we reviewed current policies and procedures in place on our inpatient BHU and ED, which deal with suicide prevention on an almost daily basis. We obtained quite a bit of useful information from our BHU; however, at that point, our ED didn't have anything definitive in place.
The final result was a hodgepodge of information gathered from various sources and mixed with some common sense, which we then transformed into a process that would work for us and our patients.
Identifying at-risk patients
The first step in the process was to identify patients who had a coherent, lethal suicide plan as determined by a suicide risk assessment. Originally, our group wanted to simply ask patients “Did you really want to die?” and “Do you still want to?” We wanted to keep it clean and straightforward. However, to establish consistency throughout our organization, our inpatient BHU and our clinical information teams encouraged us to use an assessment tool that the BHU was using (see Suicide risk screening tool). The version we use in our hospital is in electronic format, so that a suicide risk score can be automatically generated. The tool is based on a previously developed paper tool.
Each response has a preassigned point value. For example, if the intent is clear, that's an automatic score of 6; same with lethality, if it's potentially lethal, it's an automatic 6. The other responses have point values from 0 to 5.
All patients admitted to an acute inpatient unit, such as ours, with an intentional overdose receive a score of 6 due to the potential lethality of their attempt and are automatically placed on a suicide risk 1:1. The risk assessment is repeated every shift; however, typically, the original baseline score doesn't change because of the lethality component.
The staff doing the suicide risk 1:1 must be within arm's length of the patient at all times, including when the patient uses the bathroom, is off the unit, and has visitors (including family). The staff assigned to these patients usually are certified nursing assistants (CNAs) who've had training in nonviolent physical crisis intervention. The initial 8-hour course is followed by a 3-hour renewal course every year. If a CNA isn't available, an RN may be used. Routine sitters who typically sit with confused patients may not be used in this role. At our institution, routine sitters don't have training in crisis intervention and have little training in patient care. Their main job is sitting with the confused patient and keeping that patient safe from falls and pulling at medical equipment. Based on the job description and typical role of the sitter position, suicidal patients aren't an appropriate delegation to sitters.
Every 4 hours, a behavioral assessment is completed on these patients. The behavioral assessment includes documenting patient behaviors such as agitation, anxiety, confusion, crying, delusions, lethargy, or socially inappropriate behavior; documenting environmental interventions provided to assist in treating and improving any behavioral issues; documenting specific emotional support provided; and documenting the patient's response to provided interventions.
A secure environment
The patient's room is made as secure as possible. Telephones and any unnecessary equipment with cords are removed. All sharp or hazardous objects (including safety pins, scissors, gloves, and plastic bags) are removed from the room. The patient's belongings are reviewed, checked for contraband, and the belongings present in the room are documented in the patient's medical record. All of the patient's belongings are sent home with the family if present. If no family is present, patient belongings are secured at the nurses station.
An order is placed to the dietary department to serve the patient's food on paper and plastic without a knife. The family is instructed not to bring in anything, and told that any item brought to the hospital must be inspected by nursing staff. At the beginning of each shift, an RN and another staff member check the patient's room for potentially dangerous articles or any unnecessary equipment.
Meeting TJC goals
About the same time that we began to develop our plan for implementing the suicide prevention process, our hospital's quality management department approached our clinical practice group and asked about the suicide risk protocol that we were developing. This interest was sparked by TJC's recent publication of its National Patient Safety Goal on identifying patients at risk for suicide. Elements of performance for this goal include:
1. Conducting a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk of suicide.
2. Addressing the patient's immediate safety needs and most appropriate setting for treatment.
3. Provide suicide prevention information (such as a crisis hotline number) to the patient and family when a patient at risk for suicide leaves the care of the hospital.5
The process that we were about to implement addressed all the elements except number three. This was a fairly easy fix for us due to our electronic discharge note. To the general discharge note we added the reminder option: “Provided to patient at discharge for crisis care” that includes the following components: instructions to get help, card for local crisis, and suicide hotline number.
The goal of our unit-based clinical practice council from the outset had been to make this a facility-wide inpatient protocol; however, in addition to the TJC patient safety goal related to suicide identification and prevention our hospital went through a “mock” TJC survey by an outside consulting firm. One of the areas for improvement identified in this survey came from our ED. The surveyors identified the lack of a consistent, safe approach to the potentially suicidal patient in the ED. The ED now had interest in tapping into what we were doing. After discussion among quality management, ED, inpatient nursing units, and inpatient BHU, the process was rolled out hospital-wide to all inpatient and outpatient nursing-care areas.
We did several things to educate staff and prepare for implementation. One of the things that our unit-based clinical practice council did was develop a skit. Members of our unit-based clinical practice council were the actors. The skit first showed a patient admitted with a drug overdose going through our current process, perhaps a bit exaggerated to add some drama; the second half of the skit showed the same patient going through the new suicide protocol. The skit was videotaped and put on the hospital's home page for staff to view.
The education department developed a mandatory competency-based training (CBT), which was also put on the hospital's home page for staff to complete. The CBT reviewed the process, including how to complete the assessment tool, how to secure the room, specifics related to the role of the suicide risk 1:1, and how to complete the required documentation. Questions at the end were designed to ensure that the viewer understood what was presented. All new nursing employees must complete the CBT and view the video. We also put bulletin boards in staff break rooms with the above information.
Having a suicide protocol provides consistency in the assessment and care of patients at risk for suicide, helps assure that these patients are kept safe from any further self-harm while under our care, and assures compliance with TJC standards related to care and safety of this patient population.