ED Accreditation Update

To comply with new patient safety goal, here's how to assess patients for suicide risk

Do you have a process in place in your ED to identify patients at risk for suicide? If you don't have one in place by Jan. 1, 2007, you won't be in compliance with a new National Patient Safety Goal that requires hospitals to assess patients at risk for suicide.

In statistics released this year, the Joint Commission on Accreditation of Healthcare Organizations said the No. 1 sentinel event was patient suicide that accounted for 13.2% of sentinel events between January 1995 and March 31, 2006.

The most important thing for ED managers to remember is that there is are relatively significant rates of psychiatric illness and associated suicide risk among individuals who present to an ED, says Laura J. Fochtmann, MD, professor in the departments of psychiatry and behavioral sciences and former director of the Comprehensive Psychiatric Emergency Program at Stony Brook (NY) University School of Medicine. Fochtmann has written a section on emergency services for "Textbook of Suicide Assessment and Management."

It's important for ED staff to treat patients in a fashion so they're most likely to be open about those feelings, she says. Coming to an ED is stressful, especially if people have emotional and psychiatric issues, Fochtmann points out. "With the rush of trying to deliver care in an ED setting, oftentimes the urgencies there make it difficult for people to reach out to people with emotional difficulties," Fochtmann says. "That makes it hard to identify individuals who may be at risk for suicide or may have already had an attempt and may not be forthcoming about that."

The new patient safety goal is particularly challenging for EDs, acknowledges Gigi Acevedo, RN, MSN, associate director of standards interpretation at the Joint Commission. "It's not their primary focus," she says. "Also, the personnel there aren't primarily behavior health specialty personnel."

The process can be time-consuming to sit and talk to someone in psychiatric crisis, Fochtmann acknowledges. "It involves getting input from the family or other persons who have come with the patient to the ED," Fochtmann says. "That more detailed history-taking needed to identify someone at risk for suicide is difficult to fit into typical ED workflow."

To address this challenge, offer education and competency testing, Acevedo says. "There needs to be some internal training so the ED can do a good screenings," she says.

There's no rating scale that makes it easy to identify individuals who are potentially suicidal, Fochtmann warns. "You're left with evaluating individuals on a variety of risk factors and then coming to a clinical judgment on the overall level of risk, in terms of making a decision about hospitalization," she says.

Consider adding these areas to your ED assessment:

• Ask patients directly about suicidal thoughts.

Ask patients, "Are you feeling like you're going to hurt yourself or someone else?" suggests Shirley Goodman, MS, RN, director of psychiatric services, care management, and specialty school at Overlake Hospital Medical Center in Bellevue, WA. At Overlake, ED triage nurses bring any patients who seem suicidal to a back room, where they are assessed by a social worker who reports to Goodman.

Staff members ask patients who appear potentially suicidal whether they have made a previous suicide attempt, she says. They also ask the patients what suicide method they would use, in order to determine if the plan is imminent, firm, and/or lethal, she says. "The lethality of those previous attempts is also important," Goodman says. For example, has the patient tried to hang himself/herself or taken a very serious overdose? Such serious past attempts should raise the possibility that the patient is currently suicidal, she says. Also ask about a family history of depression and suicide attempts, Goodman advises. "Someone who has had a parent, brother, sister, or someone else fairly close attempt suicide, that would raise red flags," she says.

• Determine their current physical status.

At Overlake, patients who appear potentially suicidal are asked whether they are depressed, are abusing substances, are eating and drinking, "all the varied symptoms you'd see with someone who is depressed, psychotic, etc.," Goodman says.

Patients who are abusing alcohol or drugs do have an increased suicide risk, particularly with other psychiatric symptoms such as a psychotic disorder, says Fochtmann. "But even by themselves, they can increase suicide risk," she says.

Determine whether the patients are relatively healthy physically or have been under the care of a physician, Goodman says. Patients with chronic, painful, or terminal physical illness may be particularly at risk for suicide, Fochtmann says. Patients may have been diagnosed with a disease that runs in their family and has had poor outcomes, Goodman says.

• Examine their support system.

When assessing patients who seem potentially suicidal, ask questions that will reveal the strength of their support system, Goodman suggests. For example, ask what's going on with the patient that brought them to this situation. Is it interpersonal or job-related? The support network is critical, she notes. "Have they just moved to a new place or lost their job? Or can they not cope with their job?" Goodman says. "Do they have no family or friends to support them? Those are all things to take into consideration."

Also, determine whether patients are looking forward to events in their lives, she says. "If they're talking about their son's birthday party coming up or a vacation next month, those are positive things," Goodman says. "At least they're thinking there will be a tomorrow, vs. people who have nothing going for them."

• Identify safety risks inherent in the patient population.

The new patient safety goal requires EDs and other departments to identify safety risks inherent in the patient population.

Acevedo says, "The organization should do a proactive risk assessment and identify those areas that have high risk potential, based on a previous sentinel event or other data they already have."

Also keep in mind that certain patient populations are at a higher risk for suicide, including adolescents, older adults, and younger men, Goodman says. Look at who is presenting, she advises. "Is it a male, in his 30s or 40s, who has lost his job and his wife?" she asks. "It is a drinker who has a problem with depression? Those are all causes for you to stop and say, 'Whoa, what's going on here?'"

Also, closely examine postpartum women who have endured hormone changes and are sleep-deprived, Goodman warns. "They can get very, very depressed to the point of having psychotic symptoms and not being able to sleep," she says.

Resources

A Quick Reference Guide to assessing suicidal behaviors from the American Psychiatric Association is available at www.psych.org. The full guideline is available at www.psych.org. The full guideline contains tables of suicide risk and protective factors as well as a list of example questions to ask suicidal patients in assessing their risk.

The New South Wales Australia suicide guidelines include a version targeted to the emergency setting at www.health.nsw.gov.au.

The National Suicide Prevention Lifeline web site offers resources and a national crisis phone number [(800) 273-TALK (8255)]. Web: www.suicidepreventionlifeline.org.

The Textbook of Suicide Assessment and Management is available from The American Psychiatric Publishing in Washington, DC. The book includes a chapter on emergency services. The cost of the book (item 62213) is $85 plus $9.95 for shipping and handling. To order, call (800) 368-5777 or go to appi.org. Under "Books," click on "Featured Titles" and then "The American Psychiatric Publishing Textbook of Suicide Assessment and Management."

The publication Meeting the Joint Commission's 2007 National Patient Safety Goals, is available from Joint Commission Resources. The book includes a compilation of articles, book excerpts, and tips, including topics such as identifying safety risks inherent in patient populations, and encouraging the involvement of patients and families in patient care. Features include a matrix that identifies which 2007 goals are applicable to an organization, compliance solutions for each goal, tips and strategies for implementing the goals, answers to frequently asked questions, case studies from organizations that have successfully complied with the goals, and a summary of changes to the 2007 goals. The cost is $60 plus $12.95 for shipping and handling To order, call (877) 223-6866, 8 a.m. to 8 p.m. Central Time weekdays, or order on-line at www.jcrinc.com. Click on "Online Ordering," then "Publications and Multimedia" to search for the title.