THE JOINT COMMISSION (TJC) sentinel event alert calls for all accredited hospitals to screen patients—even those with no mental health diagnosis—for risk of self-harm and suicide to prevent suicides on medical-surgical units and in EDs. Its 2016 sentinel event summary, which includes data through 2015, shows that despite hospital efforts, suicides increased from the fourth most frequently reviewed sentinel event to the third.1 The good news is that TJC's updated quarterly reports show measurable improvements through the second quarter of 2017.2 However, because TJC data are voluntarily self-reported, the number of actual events is almost certainly higher.
Although a previous suicide attempt is considered the best predictor of a completed suicide, many patients who commit suicide in an inpatient hospital setting don't have a psychiatric history or a history of suicide attempts.3,4 This article describes who's at risk and steps clinical nurses on nonpsychiatric units can take to keep their patients safe.
Who's at risk?
Of voluntarily reported inpatient suicides, 14.25% occurred while a patient was on a medical-surgical, intensive care, oncology, or telemetry unit.5 Although estimates vary, the risk of suicide in patients with cancer and in cancer survivors is reportedly higher than that of the general population.6-8
The root cause of suicide attempts is a lack of initial assessment risk, lack of repeat assessments, and inadequate management of at-risk patients.1,9 (See Risk factors for suicide.)
Nurses know all too well that patients can receive devastating news about a new diagnosis or a poor prognosis during their hospitalization. Such news can affect patients' feelings about wanting to continue or discontinue their life. Depending on patients' support systems, they might begin to feel they'd be “better off dead.”10
Screening for risk
Identifying patients at high risk is the key to preventing inpatient suicides. Although no method can currently be used to reliably predict imminent suicide risk, many nurses use a standardized evidence-based screening tool at their hospitals to assess risk for self-harm on initial admission.9 (See Using a standardized tool to assess suicide risk.)
Many hospital computers incorporate suicide screening questions with dropdowns that nurses complete on admission, but what about later? How do nurses address suicide risk questions that arise during a hospitalization? No way is the wrong way; the only mistake is not asking at all.
Taking preventive steps
When patients say they're “better off dead,” nurses should then assess whether they're passively or actively suicidal (with a plan or intent). Patients are at high risk for suicide if they share a current plan of action to end their life. These patients should never be left alone. Initiate the hospital safety protocol, notify the healthcare provider, and contact the available mental health staff.11 Patients found to be acutely suicidal should be under continuous observation and have a psychiatric consult. Those at lower risk should be referred to an outpatient behavioral healthcare provider and given the national suicide prevention telephone number.
When sitters are provided for high-risk patients, be sure to remind the sitters that one-to-one supervision is exactly that. Even if patients ask for privacy to use the bathroom, the door must be kept unlocked and left open. Sitters should put on the call light rather than leave the patient room for quick patient requests, such as refilling a water pitcher or getting an extra blanket. Even if a patient has a sitter, nurses should continue their purposeful rounds to serve as a safety double check.12
Remind all staff to be alert for visitors who could bring in medications from home that the patient could use to self-medicate or overdose.
What doesn't work?
Although nurses can and have asked patients to sign no-harm contracts, the literature doesn't support this intervention because it can give staff a false sense of security and the evidence doesn't show that these contracts decrease risk.13
Avoiding the topic doesn't reduce the risk of suicide either. Some nurses believe the myth that asking a patient about suicide could “plant a seed” and trigger a suicide attempt.14 Nothing could be further from the truth. A literature review of 13 articles published from 2001 to 2013 found that talking about suicide can reduce suicidal ideation.15 Most patients encountering a shocking diagnosis or poor prognosis welcome the chance to share their anxiety, fears, and concerns, and they look forward to learning ways to get through it.15
How to start a conversation
Nurses can start a conversation by saying, “This is a hard topic to bring up, but as your nurse I need to ask these questions.” Some examples of conversation starters follow:
- “I heard you got the results of your biopsy today. How are you feeling about it?”
- “When you say you wish you were dead, I need to ask if you have a plan to do this.”
- “Do you feel safe here on the unit?”
- “Have you ever tried to kill yourself or thought about killing yourself in the past?”
Regardless of how patients answer, nurses need to remain nonjudgmental, calm, and compassionate. If patients have a history of suicide attempts, follow up to find out if they're feeling like harming themselves now. For instance: Are they actively suicidal? Do they have a plan or access to means? Are they presently in danger of harming themselves, or are they just experiencing passive thoughts without a plan?
Patients don't usually volunteer this information, so don't be afraid to dig deep and ask patients directly. Follow-up questions might include these:
- “How long have you felt this way?”
- “Does any stressor or trigger lead to these feelings?”
- “What things are worth living for?”
Direct patient quotes should be documented in the patient's medical record.
Nurses know how to quickly screen a room for fall risk; now it's time to take patient safety up a notch. In general, nurses need to explore patient-care areas for any concealed risks. Beyond initial and periodic assessments of suicide risk, nurses should do additional safety checks in patient rooms.
According to Mills et al., bathrooms in a medical-surgical area can be an unsafe environment because they contain potentially harmful objects.16 They recommend breakaway shower curtains, sealed grab bars (with no space between the wall and bar), and periodic room safety surveillance, which includes removing any anchor points that could be used for hanging.
If you notice any anchor items in rooms, talk to the nurse manager or risk management to get engineering to remove these items. One example we discovered was an empty metal cup dispenser next to a patient's sink that wasn't being used. It wasn't visible from the hallway even when the door was open, and it could be a potential anchoring device for hanging.
Closets can be changed to open format (without a door) with shelving for patients' clothing and personal items. Bathroom and shower doors should easily unlock so staff can enter quickly if necessary.
Recently our shared leadership council started looking at a clinical nurse suggestion to pilot the practice of rotating sitters every 4 hours. The goals of this plan are to enhance safety, keep sitters awake and alert (especially during the night shift), and prevent them from being unexpectedly overtaken by patients trying to harm themselves. We were concerned that long periods of sitting with one patient could cause sitters to burn out or become less focused. Rotating sitters can also give sitters a break from demanding or difficult patients.17
Sometimes staggering purposeful hourly rounds, instead of being exactly on the hour like clockwork, can mitigate risk. Some simple modifications of daily routines can also lower the risk. For example, when setting patient infusion pumps, turn the control panel away from patients so they don't learn how to adjust rates. Set the pump for the maximum volume to be infused, then push the lock key or button before leaving the room.
Finally, upon discharge, provide all patients with National Suicide Prevention hotline numbers (1-800-273-TALK or 1-800-273-8255) as well as community resources for patients and families.
Regardless of their specialty, nurses need to increase assessment and communication throughout a patient's hospital stay to successfully intervene to prevent patient suicides. By starting conversations with patients facing difficult diagnoses, protecting patients at risk for suicide, and creating a safe environment, nurses are taking steps to improve the climate for suicide prevention.
Risk factors for suicide6,18-29
Besides a cancer diagnosis or a history of cancer and access to lethal means, other risk factors for suicide include a history of:
- previous suicide attempts
- traumatic head injury
- HIV infection
- chronic pain or illness
- Parkinson disease
- multiple sclerosis
- bariatric surgery
- psychiatric illness
- hopelessness and impulsivity
- military service
- suicide in the family
- childhood abuse and other adverse childhood experiences.
Using a standardized tool to assess suicide risk
Many standardized tools, guidelines, and clinical practice screening questions are available. Depending on time constraints and other factors, some units may choose one of these:
- Patient Health Questionnaire-9 (PHQ-9). www.integration.samhsa.gov/images/res/PHQ - Questions.pdf.
- The Columbia-Suicide Severity Rating Scale (C-SSRS). http://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale.
- Suicide Assessment Five-Step Evaluation and Triage for Health Professionals (SAFE-T). www.integration.samhsa.gov/images/res/SAFE_T.pdf.
For more information about choosing a method of screening or assessing patients for suicide risk, see www.sprc.org/sites/default/files/migrate/library/RS_suicide_screening_91814_final.pdf.
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