Could a suicidal patient be discharged from ED?

Some come with unrelated complaints

While assessing a 40-year-old male who complained of abdominal pain, nurses did a routine mental health screening, which included asking if he was currently suicidal. "He answered 'yes' to all of the questions," says MaryEllen Swanson, RN, a senior staff nurse in the ED at Hennepin County Medical Center in Minneapolis. "It would have been missed if the screening had not been done."

In fact, the patient had no medical problems that needed to be addressed, she reports, and instead was admitted to the mental health unit for treatment.

"Patients presenting to the ED for vague complaints often are seeking help for something other than their original complaint," says Swanson, adding that patients have returned to hospitals and committed suicide in ED waiting rooms.

To address this, a task force of ED and psychiatric nurses and physicians developed a set of questions to ask every adult at triage in May 2011, with the exception of patients with altered mental status due to alcohol or substance abuse, who are screened once they are sober. ED nurses first ask, "Are you suicidal?" (See clinical tip, below, on the importance of asking this question.)

If the patient answers yes, he or she is asked, "Do you have a plan for harming yourself?" "Have you ever harmed yourself?" and "Have you ever been hospitalized for this?"

If the patient reports being suicidal, these steps are taken:

  • Patients are immediately placed in a direct observation room and all items that they may attempt to use to harm themselves are removed, including blood pressure cuffs and monitor cables.
  • If the ED physician believes the patient is at risk after an initial screening, he or she is placed on a "hold." "Once the medical issues have been addressed, the patient is transferred to our Emergency Acute Psychiatric Services area," says Swanson.
  • The patient is then evaluated further by a mental health counselor and a psychiatrist. "They will either admit the patient or place them in a day treatment program, based on the risk for harming themselves," says Swanson.

Triage assessment

Erin Cavanagh, RN, BSN, MBA-HCM, clinical coordinator in the ED at Henry Ford Hospital in Detroit, says she sees a significant number of patients with suicidal ideation in her ED.

"We have a dedicated six-bed psychiatric area in our ER," she says. "This is frequently occupied due to economic issues and limited mental health outpatient services for the underinsured."

With a quick glance, says Cavanagh, you might notice that a patient doesn't make eye contact, appears withdrawn, and lacks personal hygeine. He or she may not want to talk in detail about why they came to the ED, and instead tell you, "I just want to talk to the doctor."

These are all signs your patient is possibly suicidal, says Cavanagh, adding that patients are at higher risk if they're using drugs and alcohol. "Never make decisions based on the patient's personality," she adds. "Patients at most risk might be the most difficult to work with."

Patients who come to the ED frequently while intoxicated may routinely make comments about suicide, notes Cavanagh, but you need to take all such statements seriously.

"Nurses can never be complacent on these threats," warns Cavanagh. "If you believe a patient could be at risk, advocate for the patient. Nurses must stop a discharge of an at-risk suicidal patient."

Sources

For more information on suicidal ED patients, contact:

Erin Cavanagh, RN, BSN, MBA-HCM, Emergency Department, Clinical Coordinator, Henry Ford Hospital, Detroit. E-mail: ecavana1@hfhs.org.

MaryEllen Swanson, RN, Senior Staff Nurse, Emergency Department, Minneapolis, MN. Phone (612) 873-3573. Fax: (612) 904-4242. E-mail: maryellen.swanson@hcmed.org.

Clinical Tip

Ask this simple question of patients

The single best tool you have available to determine if a patient is suicidal is a simple question, according to Erin Cavanagh, RN, BSN, MBA-HCM, clinical coordinator in the ED at Henry Ford Hospital in Detroit. Simply ask patients in a nonjudgmental manner, "Are you suicidal? Have you ever had thoughts of harming yourself?"

"Nurses should never be afraid to ask," she says. "Patients are often relieved to have the subject opened up."