Use these tips if you suspect a suicidal patient
Use these tips if you suspect a suicidal patient
More than 200,000 patients are treated in EDs each year for self-inflicted injuries. Yet many of these patients do not receive a psychiatric assessment, says Debra Houry, MD, MPH, associate director for the Atlanta-based Center for Injury Control at Emory University.1,2 As a result, suicidal patients may leave EDs without getting appropriate care, which is dangerous for patients and legally risky for nurses, she adds.
"EDs are very busy places, and sometimes nurse and physicians do not assess a patient thoroughly enough to realize how suicidal they are," says Houry.
To improve assessment of potentially suicidal patients, do the following:
• Determine whether the patient is actively suicidal.
"We have spent many hours educating our staff about assessing suicidal patients," says Mary G. Kelley, MS, ARNP, CEN, triage coordinator for the ED at Carondelet St. Mary’s Hospital in Tucson, AZ. A psychologist gives inservices addressing suicidal assessment for ED nurses, and Kelley includes recognizing potentially suicidal patients in the triage class required of all new nurses.
Validated tools such as the Brief Psychiatric Rating Scale are too long and complex for practical use in the ED, says Houry. Instead, she recommends asking the patients if they’ve had any thoughts about hurting themselves or if they’ve been sad or depressed lately. If the answer is yes, use the "SAD PERSONS" mnemonic for assessing risk of suicide:
- Sex, male;
- Age, advanced;
- Depression, possibly recurrent;
- Previous suicide attempts;
- Ethanol abuse;
- Rational thinking loss;
- Social isolation;
- Organized plan to commit suicide;
- No spouse;
- Sickness.
"People with these risk factors are at greater risk for suicide completion," says Houry.
At Carondolet’s ED, all patients who present with a complaint of depression, detoxification from drugs or alcohol, agitation, or suicidal ideation are asked if they have thoughts of hurting themselves or others, says Kelley. "We follow up with addressing their behavior if it is incongruent with their answer," she says. "An example would be someone who is fidgety, with eyes that dart around the room as you talk to them."
In this case, Kelley recommends saying, "You seem anxious, is there something you are not telling me? I am here to keep you safe." If you give them another opportunity to respond, most patients will tell you what they are feeling, she explains.
The patient’s behavior is assessed and documented at triage, says Kelley. For example, if the patient is quiet, withdrawn, and without eye contact but denies suicidal ideation, that patient will be watched carefully and treated as if they were suicidal, she says. "The suicidal patient is considered high acuity, 1 on a 1 to 4 scale, and treated as such."
- Evaluate the need for restraint.
You need to make sure a suicidal patient doesn’t leave before psychiatric evaluation, and this step may require restraint, says Houry. "Any patient whose chief complaint is suicidal thoughts should be brought back immediately and assessed," she stresses. "In addition, anyone the nurse or physician feels is at imminent risk for harm should have suicide precautions including restraint and being placed in a locked room."
- Take patients out of the main ED if possible.
After a potentially suicidal or homicidal patient is medically cleared, they are placed in a quiet, safe place with security nearby, using an area staffed by a nurse and behavioral health technician, says Kelley. The annex is away from the ED, locked, safe, and quiet, she says. "They are still our patients, cared for by ED staff who are specially trained, but this keeps this population out of the ED. It provides better care for the patient and a safer environment."
This procedure has reduced use of behavioral restraints dramatically, she adds. "Frequently, we send the patient to the annex from triage," says Kelley. "The physician does an exam in triage, and the patient is sent up with orders." Any patient who is suicidal is not allowed to return to the waiting room unless they are with family, who will stay with the patient temporarily, until a room is available.
- Discourage the use of contracts in triage.
Kelley points to the American Psychological Association’s guidelines for management of suicidal behavior, which states that a "suicide prevention contract," which is a written or verbal agreement that the patient will not harm themselves, is not recommended in EDs, since they are dependent upon an established physician-patient relationship.3
"We assume they will attempt suicide and treat them as such," says Kelley. Patients are asked to remove their clothing and put a gown on, and belongings are taken from the patient, placed in a bag, and removed from the room. "This helps avoid any surprises, like someone having a cigarette lighter and trying to light the oxygen on fire," she says.
- Don’t make assumptions.
Sometimes when a patient is very old, suicide is not seriously considered by the nurse, but chronic health problems, the recent loss of significant other, financial problems, or lack of family support all put an elderly patient at risk, says Kelley. "They are less likely to express actual ideation but may discuss hopelessness or profound sadness," she says. "Frequent injuries or adverse drug reactions may actually be suicide attempts."
You also should have a high index of suspicion for very young patients, and consider factors such as the child’s environment and possible sexual abuse, recommends Kelley. "Is the child a straight-A student who is under a lot of pressure? Are they talking of death a lot?" she asks. "Frequent injuries may also be failed suicide attempts, as well as child abuse."
References
- Centers for Disease Control and Prevention. Nonfatal self-inflicted injures treated in hospital emergency departments — Unites States, 2000. MMWR 2002; 51:56-59.
- Hickey L, Hawton K, Fagg J, et al. Deliberate self-harm patients who leave the accident and emergency department without a psychiatric assessment. J Psychosom Res 2001; 50:87-93.
- Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 2003; 160:1-60.
Sources
For more information on assessment of suicidal patients in the ED, contact:
- Debra Houry, MD, MPH, Department of Emergency Medicine, Emory University, 1518 Clifton Road, #230, Atlanta, GA 30322. Fax: (404) 727-8744. E-mail: [email protected].
- Mary G. Kelley, MS, ARNP, CEN, Triage Coordinator, Emergency Department, Carondelet St. Mary’s Hospital, 1601 W. St. Mary’s Road, Tucson, AZ 85745. Telephone: (520) 872-2422. E-mail: [email protected].
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