Suicide assessment team in the ED

Understanding those at risk

Michelle Buckman, RN, MSN, is a psychiatric clinical nurse specialist working as a consultant to the Loma Linda University Medical Center emergency department. Since The Joint Commission issued its Sentinel Event Alert on preventing suicide, Loma Linda has created a suicide assessment team, with Buckman as a consultant.

"We're looking at best practices, and we're just wanting to make sure we have not missed a single dot on the 'i' or a cross on the 't', and that there's just nothing anywhere we couldn't improve on within the behavioral medicine center [BMC] and emergency room," she says.

The team began with everyone bringing in what they were doing on their specific unit, with Buckman organizing the ED standards and policies, the best practices in place. "We're all going to look through that and see if there's anything we should add or change or take. We're looking at cases. We're looking at the near suicide cases we've had. Thank goodness, we've never in the BMC or in the ED, that we know of, had a completed suicide."

Not that patients haven't tried. "We've found people with shoestrings around their neck, and we've found people in the act of trying to hurt themselves," she says.

She says the team will review those cases and see what could have been done differently; they're also looking at job descriptions, shift duties, and the environment of care for any risks. "We are really working on awareness, awareness, awareness. And going through with a fine-tooth comb everything we do at all times to make sure that we can't be better at finding any missing pieces where a patient could slip through and hurt themselves or kill themselves," Buckman says.

Who's at risk

"You want to look at the general demographics that have been standardized by researchers, and that is men over 65, adolescents. The third leading cause of death for people age 15 to 25 in this country is suicide. So those people. When you add that with things like a romantic breakup, loss of a job, mental illness, traumatic events, they're at very high risk," she says.

Other high-risk triggers: homelessness, low socioeconomic status, and drugs and alcohol. Elderly people also are high risk. "When they talk about suicide, don't take that lightly. Take it seriously because the means of suicide that they use are very violent. They shoot themselves in the head, they takes overdoses, and wrap their faces in plastic," she says. Elderly men who have lost many friends, independence, and good health use serious means to end their lives, so being aware of this is important, Buckman says.

American Indians are at higher risk, as well as homosexuals, she says. And those addicted to drugs or alcohol, who also suffer from chronic pain should also be watched. "Another group of people are those with chronic medical or terminal illness. [People with cancer or end-stage diseases.] Somebody who has been in a lot of pain or suddenly just can't take a new diagnosis," she says. Another group is people who have been in accidents and are left with disfigurements.

She says to first look at demographics and those groups automatically at high risk. "And then on top of that, are they getting a bad diagnosis? Or are they somebody who has a history of mental illness? Are they somebody who you've noticed is not having any visitors at all, they have no family come, they have no friends come, they're wrapped up in a blanket and they don't care what pills the doctor prescribes for them, they just do what they're told without any participation in their treatment," she says.

A person who is 40, has a supportive family, and strong faith is not at a high risk for suicide, Buckman says.

It's important staff also understand what patients' behavior may be signalling. "Do they look depressed? Do they have a flat affect, no interest in treatment, have they stopped eating? Have they stopped grooming? If family was coming to visit, have they now refused that?"

As far as keeping the environment of care safe, that, too, took a lot of awareness and education, she says, from kitchen workers to engineers. She says often items such as nails or pieces of wire will fall from engineers' tool belts. Cleansers should be kept inconspicuously in carts. Watch for breakaway bars in showers and check on patients in the shower, she suggests. Don't let them bring in long pants or gowns that they could use to hang themselves. Watch IV poles, IV needles. She says med/surg physicians and nurses might not be used to thinking this way, but they have to.