Suicide is the 11th leading cause of death in the United States.1 Less than 30% of patients who receive a depression diagnosis are treated appropriately.2 Suicide of a patient while in a staffed, round-the-clock care setting has been the number one most frequently reported type of sentinel event since the inception of The Joint Commission's Sentinel Event Policy in 1996.2
Reportedly, 48% of suicides occurred in other areas outside the psychiatric unit of the hospital, most notably the ED.3 Patients will continue to die if healthcare organizations don't take action and appropriately assess patients at risk for suicide in general hospitals. To best comply with the Joint Commission's 2008 National Patient Safety Goal 15A—identifying those at risk for suicide—we initiated inpatient admission screening.
Through an interdisciplinary team, a prescreening tool/process was developed that identified medical patients with emotional or behavioral disorders at risk for suicide. Assessment and referral (A&R) is in the behavioral medicine center in the hospital. It's staffed by therapists and nurses who screen, assess, and triage individuals needing psychiatric services. (One hundred percent of patients admitted to the inpatient psychiatric unit for suicide risk are screened.) When the nursing staff identifies a patient at a higher risk for suicide, A&R is notified for an additional suicide assessment.
Nurses and other healthcare professionals often struggle with distinguishing which patients to screen because it's difficult to identify patients who have emotional and behavioral disorders when admitted to the general hospital. The interdisciplinary team decided that the screening would be most beneficial if completed on all patients admitted to our general hospital—a 400-bed acute care suburban community hospital, with a 22-bed inpatient psychiatric unit and a 36-bed ED that fields more than 40,000 visits a year.
The interdisciplinary team was selected to include all areas involved with the decision making and implementation of the final process. The team included nurses from labor and delivery, the ED, the breast care center, medical, surgery, the ICU, day surgery, preprocedures, A&R, and admissions. Other team members were from social work, nursing care coordination, computer clinical analyst, staff education, and management.
The team members were identified by their managers for skills in leadership and the ability to work through process improvement. Behavioral health experts were included on the team to help guide and provide suggestions for development of an appropriate tool. Those who developed the tool included a master's-degreed social worker who works specifically within the behavioral health team and a master's-degreed nurse who specializes in behavioral health nursing.
The interdisciplinary team met for an 8-hour work session and formulated five outcomes: develop an inpatient suicide risk screening tool, identify a process to implement the screening risk tool, define the sample group, identify education needs for specific areas for implementation of the tool, and define measures of success.
After reviewing relevant literature, the team decided that questions needed to document history of self-harm and previous suicide attempts. Research shows that the use of suicide-screening tools on admission to the hospital detects patients at risk and identifies patients who need further evaluation.4 Our screening tool included four target questions to assess patients' emotional/behavioral state. Historically, there has been inadequate inclusion of clinical features associated with inpatient suicide and similar deficiencies with respect to documentation of self-harm or history of past attempts.4,5 The questions developed for the tool were as follows:
- Have you been feeling sadness or anxiety?
- Have you been feeling overwhelmed or hopeless?
- Have you had thoughts of self-harm?
- Have you attempted to harm yourself?
It's difficult to identify a patient at risk for suicide if the patient was admitted for an illness or injury unrelated to a suicide attempt.6 The admission nurses involved in the pilot study completed the suicide screening on all patients they admitted to an inpatient unit. The time period for the pilot project was 60 days. The hospitals institutional review board granted permission to publish findings from the pilot study.
Education and coaching were provided to the A&R staff and the two admission nurses. The nurse manager of the inpatient behavioral health unit reviewed with the admission nurses different approaches to ask the suicide risk questions in a manner that was nonthreatening. The admission nurses began by asking the patients about abuse, which led to the four suicide risk questions. A&R developed a strategy within its own department on how to meet the needs of increased referrals from the admission nurses. The three measures of success from the pilot study included the number of patients screened, the number of referrals to A&R, and the number of psychiatric services that were provided following the assessment.
The admission nurses screened patients after a decision was made to admit the patient to the hospital. If a patient answered yes to question one, the admission nurse would document all stressors verbalized by the patient, which included pain, shortness of breath, frustration with life situations, and so on, but no A&R consult was triggered. Answering yes to questions two, three, or four triggered an A&R consult.
After 1 week, the team reviewed the process and the questions on the suicide risk tool. It was decided that question one needed to include the feeling of "overwhelmed," leaving question two screening specifically for hopelessness. This change was discussed because A&R was finding that patients could be overwhelmed without being suicidal or at an increased risk for suicide just from the nature of being admitted to the hospital. Questions were changed to: Have you been feeling sadness, anxiety, or overwhelmed? Have you been feeling hopeless? A&R would only consult on patients answering yes to questions two, three, and four. The team agreed this would be a better indicator of patients at risk.
The results of the pilot study included 177 admissions to the general hospital, who were screened for suicide risk. Seventeen patients (9.6%) answered yes to questions two, three, and four, which triggered a referral to A&R. Of the 17 referrals, 12 patients received psychiatric services (one patient was admitted to the inpatient psychiatric unit, one patient received a psychiatric consult, one patient was admitted to a partial hospitalization program, one patient was admitted to an alcohol and other drug abuse program, two patients received outpatient appointments, two patients were referred to the county mental health facility, and four patients received information on how to contact resources/services if needed). Five of the patients refused to meet with A&R staff for a more comprehensive screen.
Because of this intervention, nearly 7% of patients were able to receive needed psychiatric services. These patients wouldn't have been assessed, and it can be assumed that this population would have gone unrecognized in its need for psychiatric services. The data also demonstrated that 42% (5 of 12) of patients referred for services were elderly or over the age of 65. (Many illnesses place the elderly at risk for suicide. It's also important to note that most elderly patients who commit suicide visit a physician shortly beforehand, and many have clinically recognizable features of depression at that time.)7 Our pilot study suggests that patients screened for suicide risk on admission obtain increased opportunities to access resources and services for psychiatric needs.
Our study has several limitations. First, our suicide-screening tool wasn't tested for reliability or validity. Second, not all hospital admissions were screened, but only those admitted by the admission nurses. Third, the study was completed in a small community-based hospital for a short period, limiting generalizability. Finally, nurses' ability to communicate the screening questions in a nonthreatening manner so patients feel comfortable disclosing sensitive information may vary. Despite these limitations, screening of suicide risk on general hospital admissions is helpful for early identification. The screen identifies and offers services to patients who then have a choice to follow through on the recommendations.
Our pilot study suggests that screening suicide risk on admission to a general hospital helped identify patients in need of psychiatric services. Literature supports the use of suicide-screening tools on admission to the hospital, as doing so helps detect patients at risk and identifies patients who need further evaluation.
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