Eighteen patients committed suicide in an ED in the past six years, according to a new analysis from The Joint Commission.1

“Regulatory surveyors are beginning to expect thorough, validated suicide risk assessments to be charted for ED patients with behavioral health chief complaints that show positive risk for dangerousness to self,” says Scott Zeller, MD, vice president of acute psychiatric medicine at Vituity in Emeryville, CA.

A key component of evaluation of a psychiatric patient, especially in the ED, is an assessment of danger to self and others.

“Just writing something like ‘suicidal ideation present’ would be insufficient,” Zeller explains. Suicidality and danger to others in a mental status exam should include three different aspects: thoughts, intent, and plan.

Two examples of patients who present different degrees of risk:

  • a patient who thought about suicide occasionally but who expressed no intent to harm self or a plan of how to harm self;
  • a patient who was actively suicidal with clear intent and with a premeditated plan.

“Including patient quotes can be very helpful in documentation, both for establishing dangerousness but also for safety,” Zeller offers. Comments such as “I would never hurt myself, I have my children to think of” or “I’m going to kill myself when I leave here by jumping off a building” can be very revealing. These can serve to justify the EP’s decision-making.

“The better an ED documents that they did a careful assessment that shows their decision was supported by appropriate reasoning, the more difficult it would be for plaintiffs to argue they did not adequately assess risk,” Zeller adds.

Many traditional risk factors of suicidal behavior, such as previous suicide attempts, did not emerge as important in a recent study.2

“It is possible this is due to us examining future suicide attempts among those previously presenting with suicidal ideation,” acknowledges Brooke Ammerman, PhD, one of the study’s authors.

The researchers’ goal was to improve suicide risk prediction in EDs. “With approximately 40% of individuals who die by suicide presenting to the ED in the year prior to their death, the ED represents a unique environment for suicide risk management,” says Ammerman, an assistant professor of psychology at University of Notre Dame.

The researchers used information that ED providers would have readily available to them, such as the patient’s electronic medical record, to identify unique factors associated with suicide attempts among ED patients. “The long-term goal is to utilize findings from this study, combined with replication studies, to modify and improve how suicide risk is determined in the ED,” Ammerman explains.

It is important to keep in mind that these are findings from a single study with a relatively small sample. “The findings do suggest, however, that in making clinical judgments about suicide risk, it may be important for providers to consider factors that may not traditionally indicate risk, such as sleep disturbance and low energy,” Ammerman offers.


  1. Williams SC, Schmaltz SP, Castro GM, Baker DW. Incidence and method of suicide in hospitals in the United States. Jt Comm J Qual Patient Saf 2018; Sep 3. pii: S1553-7250(18)30253-8. doi: 10.1016/j.jcjq.2018.08.002. [Epub ahead of print].
  2. Knorr AC, Ammerman BA, Hileman B, et al. Influential predictors of suicide attempt among suicidal ideators following an emergency department visit. Presented at the American College of Emergency Physicians Scientific Assembly. San Diego; Oct. 1, 2018.