The Joint Commission issued a Sentinel Event Alert relating to suicides in 2010 with a focus on locations other than behavioral health units (see our December 2010 What’s New in the Patient Safety World column “ ”). This was an update to an earlier Sentinel Event Alert. The issue continues to be one of the hot buttons during Joint Commission surveys. They also recently released a BoosterPak relating to suicide.
We previously discussed multiple issues related to suicide on inpatient units in our Patient Safety Tips of the Week for January 6, 2009 “Preventing Inpatient Suicides” and February 9, 2010 “More on Preventing Inpatient Suicides”. Those contain numerous useful tips and links to valuable resources and should help you identify vulnerable aspects within your health care system.
A great new resource on suicide risk assessment was just released last week by the Canadian Patient Safety Institute and the Ontario Hospital Association (Perlman 2011). The Canadian guide addresses not only the general suicide risk assessment but also that in multiple different situations, including primary care, emergency care, and mental health settings.
The Canadian Guide stresses that the assessment must look not only at what risk factors are present but also at what protective factors may be present. They also discuss that some risk factors are long-term associations with suicide, others are potentiating factors, and others are warning signs in the short term.
They talk about the mental illnesses that are associated with suicide but also note that some patients who commit suicide have no mental illness at all. The concept of “predicament suicide” is discussed, in which the patient has a set of unacceptable circumstances from which he cannot find an acceptable alternative means of escape.
Their principle #1 in assessing suicide risk is to develop a therapeutic relationship with the patient, showing empathy, respect, and genuineness, with active listening. They stress that helping the patient see his or her strengths may help the patient regain his or her control over their situation. In principle #2 – communication and collaboration - they stress the importance of maintaining communication, not only with the patient but also with the support network, whether formal or informal, and the healthcare team.
Principle #3 relates to documentation of the assessment. They note that chart notes must clearly identify the patient’s level of risk and the plans for treatment and preventive care. They provide a detailed list of all the elements that need to be documented. Then they discuss the importance of documentation at transitions of care, particularly from the hospital back to the community. The importance of suicide risk assessment is essential when the timing of discharge is considered. Specifically, persons in hospital or the emergency department for suicidality should be discharged with a specific safety plan, with strategies for staying safe, early warning signs, grounding techniques, coping strategies and crisis contact numbers.
Principle #4 is cultural awareness. In some communities it is considered taboo to discuss suicide. Recognition of that is important in identifying barriers to implementation of a safety plan and support systems in the community.
The guiding principles for suicide risk assessment are presented in a tabular format with key bullet points highlighted.
They go on to discuss suicide assessment in specific settings. They note the challenges in the primary care setting, including time constraints and lack of systems for dealing with patients screened positive. They discuss the role of education, skills-based training, and collaboration for primary care practices to successfully approach the issues.
Time constraints are also problematic in the emergency setting, where a key role is identification of the true intent of the patient. It is extremely important to get information from collateral sources (families, friends, ambulance attendants, police, etc.) in such cases. They discuss the risk assessment in the mental health setting, then also discuss the issue relating to patients in long-term care settings.
Their discussion on the environment of care is thorough and informative. As we have discussed in our own prior columns on suicide risk, the hazards in the different settings vary considerably.
Risks in special circumstances, such as specific age groups, are dealt with in detail. In the young, “contagious” clusters of suicide can be problematic. Therefore, it is important in the risk assessment to know whether the youth knows anyone who has committed or contemplated suicide, how recent that was, and how the youth is coping with that. In older persons, somatic symptoms or feelings of despair rather than mention of suicidal ideation tend to predominate. In fact, older persons will seldom mention suicidal ideation to a healthcare professional unless specifically asked, though many will have mentioned it to their own family or friends. And they discuss issues specific to the gay and lesbian community, military personnel, and native populations.
The next section is a critical review of 15 suicide risk assessment tools from the literature. We obviously don’t have the time or space to discuss them here but it is a kind of “everything you wanted to know” presentation of these tools. They are quick to point out that there is no one “best” tool and that none can predict suicide. However, they point out the strengths of each in decision making and how to choose tools adapted to the particular setting of care. They also point out that “scores” to predict suicide are not very useful. Instead, they note that the specific information in the questions underlying the score may be more important. As an example they state that knowing a person has developed a specific suicide plan may be more important than knowing he scored x out of 20 on a tool.
The last section focuses on the quality improvement aspects related to suicide risk assessment. Elements discussed include the initial screening, the focused risk assessment, how the assessment is integrated into the collaborative care of the patient, care planning and intervention implementation, and monitoring and reassessment of the patient. It includes specific elements to be monitored in your quality improvement process.
In addition to suicidal ideation they do discuss the concept of self-harm, which is not always synonymous with suicidal intent. In fact, they note that the majority of patients who self-harm do not wish to die. Nevertheless, some who self-harm may inadvertently commit suicide. Note, however, a new paper on patients discharged from emergency departments after self-harm (Olfson 2011) finds that many do not get emergency mental health assessments or followup mental health care.
Whether you are a hospital with behavioral health units or a general hospital that must deal with potentially suicidal patients in your emergency department, med/surg units, or outpatient practices, you will find this Canadian resource to be both comprehensive and extremely informative.
Some of our prior columns on preventing hospital suicides:
· January 6, 2009 Patient Safety Tip of the Week “Preventing Inpatient Suicides”
· February 9, 2010 Patient Safety Tip of the Week “More on Preventing Inpatient Suicides”
· March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt”
· December 2010 What’s New in the Patient Safety World column “ ”
The Joint Commission. A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department. Sentinel Event Alert 2010; 46: 1-5 November 17, 2010
The Joint Commission. Inpatient Suicides: Recommendations for Prevention. Sentinel Event Alert 1998; 7: 1-2 November 6, 1998
New on Connect! Standards BoosterPak™ for assessing suicide risk
Joint Commission Online. June 22, 2011
Perlman C, Goy, M, Hirdes JP. Suicide Risk Assessment Inventory: A Resource Guide for Canadian Health Care Organizations. Toronto, Ontario: Canadian Patient Safety Institute (CPSI) and Ontario Hospital Association (OHA). 2011
Olfson M, Marcus SC, Bridge JA. Emergency Treatment of Deliberate Self-harm. Arch Gen Psychiatry. Published online September 5, 2011