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Suicides in the hospital: The liability risk nobody wants to talk about
Most prevention focused on psych care, but ED also is high risk for suicides
The phone on your desk can ring with news of a wide variety of events that will make your heart sink and yield trouble for the hospital for months to come, but few can rival being notified that a patient has committed suicide in your emergency department (ED).
It doesn't happen routinely, but it happens too much, and the risk manager can play a large role in reducing the likelihood of this tragedy and this huge liability risk for the organization. The challenge is that most health care providers don't want to talk about suicides in acute care.
It's not supposed to happen, and when it does the provider just wants the incident to go away with little attention.
That reluctance to discuss the risk of suicide stands in the way of prevention efforts, says Edwin D. Boudreaux, PhD, professor in the departments of emergency medicine and psychiatry at the University of Massachusetts Medical School in Worcester. Boudreaux is studying suicides in acute care settings, particularly the ED, and he says risk managers must acknowledge the risk and address it head on.
His research has shown that 8% to 10% of all patients in the ED have some level of suicidality a level that he says warrants serious attention.
"There aren't a lot of evidence-based strategies to recommend with research to back them up," Boudreaux says. "People have been risk-averse to doing research in this area because doing research with people who are suicidal is the least attractive to a researcher because of all the ethical, human subject, and investigational review issues that come up."
Patient jumps out window
In his career, Boudreaux has been witness to two suicides in another hospital in which he worked previously. The two instances illustrate how different suicides can be and how prevention efforts must be tailored to include both. In the first instance, a patient on a general medical floor became agitated and said he was going to kill himself.
"He ripped a TV off the wall, threw it through the window and then jumped after it," Boudreaux recalls. "He plummeted eight stories to his death."
The second suicide, in the same hospital, involved a patient who had a known psychiatric history but was not screened for suicide risk in the ED. The patient asked to go to the bathroom and hanged himself from the rafters there.
"So it can be very dramatic, the most dramatic exit you can imagine, or it can be someone realizing that the patient hasn't returned from the bathroom in an hour and going to check on him, only to find him hanging," he says.
Hospital increases screening
a.ter the suicide in the ED, the hospital conducted a sentinel event analysis and a root cause analysis. As a result, the hospital implemented a universal screening program for all emergency patients during the triage process the earliest opportunity to discover the risk. Waiting until the patient is seen for treatment is too late, because the patient may commit suicide while in the waiting room.
"The waiting room in the ED is a nightmare, and you don't want to throw someone who is suicidal into that," Boudreaux says. "Patients have killed themselves after waiting hours in the ED, so it doesn't help you much to wait until they are in the exam room to start asking about suicide risk."
The hospital also implemented a "wraparound safety system" for any individuals identified as a suicide risk by the triage nurse. From that point on, there is a warm handoff of the patient from point to point, so that the person is never left alone. The triage person walks to the patient to the treatment area and makes sure that another nurse is in the room before leaving. From that point on, the patient is never left alone until discharge or it is determined that the patient is not at immediate risk of suicide.
TJC calls for more attention
Within the behavioral health community, and on the psychiatric units of acute care hospitals, providers are much more oriented toward screening for suicide risks and taking the appropriate precautions, Boudreaux says. But in other health care settings, the risk of suicide receives little attention unless there is an overt threat and sometimes not even then, he says.
The Joint Commission recently addressed the risk in a Sentinel Event Alert that emphasized the need for more prevention efforts in inpatient settings other than behavioral health. "It is noteworthy that many patients who kill themselves in general hospital inpatient units do not have a psychiatric history or a history of suicide attempt they are 'unknown at risk' for suicide," according to the alert. " Compared to the psychiatric hospital and unit, the general hospital setting also presents more access to items that can be used to attempt suicide items that are either already in or may be brought into the facility and more opportunities for the patient to be alone to attempt or re-attempt suicide." (The entire Sentinel Event Alert is available online at http://www.jointcommission.org/assets/1/18/SEA_46.pdf.)
Suicide has ranked in the top five most frequently reported events to The Joint Commission (TJC) since 1995. The Sentinel Event Database includes 827 reports of inpatient suicides. Of the 827 reports, 14.25% occurred in the non-behavioral health units of general hospitals, and 8.02% occurred in the ED of general hospitals. Another 2.45% occurred in other non-psychiatric settings such as home care, critical access hospitals, long-term care hospitals, and physical rehabilitation hospitals.
TJC notes, however, that most of the events are voluntarily reported and represent only a small proportion of actual events. The actual incidence of suicide in non-behavioral health units likely is higher, according to TJC.
"Even though 827 is not a huge number, it's shocking that that many people committed suicide on the grounds of our hospitals," he says. "That's a sentinel event for sure, and when it happens, it shakes up the hospital in a big way the negative publicity, the lawsuits that are very likely afterward, and the impact it has on the staff who witnessed the suicide or could have prevented it."
a.ong the reported events, the location of the suicides included bathroom, bedroom, closet, shower and other locations, or they occurred after discharge or leaving the hospital against medical advice. The methods of suicide included hanging, asphyxiation by other than hanging, gunshot, jumping from a height, drug overdose, laceration, drowning, jumping in front of a moving vehicle, ingestion of poison, stabbing, and burning.
The alert from TJC should be taken seriously because it is prompted by the number of actual suicides and not just a theoretical risk, says Cindy Baldwin, RN, MS, CNP, director of risk management and patient relations at Sanford Health in Sioux Falls, SD. EDs are inherently unsafe for suicidal patients because it is impossible to remove all potentially dangerous items, she notes.
In her facility, the alert prompted a multidisciplinary meeting that included the risk manager, other administrators, environmental safety officers, physicians, and nurses to discuss what precautions already were in place and what additional improvements could be taken. The hospital already screened everyone in the ED for mental health issues, but the meeting served as a reminder that it is everyone's responsibility to be alert to suicidal risks, she says.
"Everyone who comes into contact with the patient and family is a resource, eyes and ears to alert us to any change in status or comments that could signal danger for that patient," Baldwin says. "We emphasize that we want to hear about anything, even a comment that sounds just random or not so serious, if it could mean the patient is suicidal."
If a patient is identified as a possible suicide risk, the ED staff take precautions such as removing items from the room that could be dangerous, assigning a staff member to be with the person at all times, and searching the patient's belongings for anything that could be used for harm. ED staff have access to a summary of the hospital's policy and procedures on patients at risk of suicide, which includes a checklist of items to remove from the exam room and a reminder that patients under suicide observation cannot be left alone even when using the restroom.
The recent meeting revealed another problem that needed attention.
"We can take away dangerous items from the high-risk patient, like the belt and shoelaces, but then the patient may call his family and ask them to bring new clothes, or a blow dryer or curling iron," Baldwin says. "The family wants to help and may not realize they are giving the patient something to harm himself with. So we increased our education for the family, explaining what items could not be brought into the room."
In addition, the Sanford Health ED now has a policy of considering every patient who comes in with a drug overdose to be high risk for suicide, whether the overdose was thought to be intentional or accidental.
Sometimes no obvious signs of risk
TJC's National Patient Safety Goal 15.01.01 requires behavioral health care organizations, psychiatric hospitals, and general hospitals treating individuals for emotional or behavioral disorders to identify individuals at risk for suicide. That suggests that hospitals are obliged to screen ED patients for suicide risk only when there is reason to suspect emotional or behavior disorders, but the alert clearly encourages liberal screening and a low threshold for suspicion.
Boudreaux says that touches on part of the problem: Sometimes you don't know that a patient being treated for a physical ailment is suicidal because he or she shows no outward signs of mental distress. "Sometimes hospitals assume that you only have to screen for suicidality with people who have obvious risks of being suicidal, such as people who come into the ED with a psychiatric problem," he says. "The vast majority of people who come into the ED are not being screened. Of the people who commit suicide in the ED, there's going to be some who were identified and adequate precautions weren't taken, but some significant percentage will be people who were never identified as a suicide risk."
a. a minimum, Boudreaux recommends broadening the conditions that would trigger a screening for suicide risk. Rather than screening only those patients with psychiatric conditions, for instance, you can also screen those with substance abuse problems, teenagers, those who are very upset, and anyone whose injury might be self-inflicted. The best option, however, would be to screen all patients in the ED for suicide risk, he says.
"Look at it like screening for hypertension. No one would come into the hospital and not get their blood pressure checked, regardless of whether they had any risk for high blood pressure," Boudreaux says. "Similarly, you could screen all patients for thoughts of harming or killing themselves, or whether they have ever made an attempt."
Boudreax acknowledges that ED staff and physicians will not welcome the addition of another screening to add to the long list of other required screenings. Many will question whether it is necessary to spend time and effort screening for something that doesn't happen often.
"They're right that too many people are urging them to screen for everything under the sun. But if they're going to prioritize screening, I'd say the ones at the top of the list are those that can potentially lead to death," he says. "A much larger proportion of patients in the ED are either thinking of killing themselves or have thought about it in the last 30 days than are hypertensive. In terms of risk reduction, suicide should be a priority because it can kill your patient imminently, not some time down the road."
Edwin D. Boudreaux, PhD, Professor, Departments of Emergency Medicine and Psychiatry, University of Massachusetts Medical School, Worcester, MA. Telephone: (508) 334-3817. E-mail: Edwin.Boudreaux@umassmed.edu.
Cindy Baldwin, RN, MS, CNP, Director of Risk Management and Patient Relations at Sanford Health, Sioux Falls, SD. Telephone: (605) 333-7484. Cindy.firstname.lastname@example.org.