After reading this article you will be able to:
- Describe the document used at Brattleboro for assessing patients at risk for suicide
- Identify the importance of suicide contracts
Identifying patients at risk for suicide has been a requirement of the National Patient Safety Goals since 2007. Since that time, inpatient suicide remains the second most frequently reported sentinel event to The Joint Commission, after wrong-site surgery.
Those patients who arrive at the hospital with a primary diagnosis of an emotional or behavioral disorder must be assessed for their suicide risk, and it’s important to document well that the assessment occurs, Sharon Chaput, RN, C, CSHA, director of regulatory and quality management at the Brattleboro (VT) Retreat, said during a recent HCPro audio conference.
“We all know documentation is critical for risk management and legality issues, but it’s also a communication vehicle, and we want to ensure that all members of the treatment team have a very clear picture of the patient’s risk level,” said Chaput.
Chaput and Tasha Farrar, MD, medical director of outpatient services at the Anna Marsh Clinic, Brattleboro Retreat, spoke on the HCPro program titled “Suicide Risk Assessment: Comply with The Joint Commission’s National Patient Safety Goal and Keep Your Patients Safe.”
The components of a suicide risk assessment, as recommended by the American Psychiatric Association, include looking at whether the patient has any psychiatric illness, family history of suicide or personal history of attempted suicide, individual strengths and vulnerabilities, as well as looking at the patient’s psychosocial situation. Surveyors will look at when and what you documented.
Times to document a suicide risk assessment include:
- At the first psychiatric assessment or admission
- With the occurrence of any suicidal behavior, ideation, or statements
- Whenever there is a noteworthy clinical change
In addition, for those working in an inpatient psychiatric setting, documentation is important prior to increasing privileges, issuing passes, and discharge, said Chaput. Also, documenting whether firearms are present in the home is of the utmost importance.
“It’s extremely important if [firearms] are present to always remember to document the instructions given to family or guardians, such as ‘Removal of guns from the home,’ ” said Chaput. “If the patient or client states that they do not have firearms or access to firearms, please be sure to also document that you were informed during the assessment that there were no firearms available to the patient after discharge.”
To help staff members remember what to document in a suicide risk assessment, Chaput recommended using the acronym SLAP, which stands for:
- Suicidality: Does a patient have active or passive suicidal ideation?
- Lethality: How lethal/serious is the suicide plan?
- Availability: Is the patient’s plan for suicide available to him or her?
- Plan: What is the plan of action for the patient’s team of caregivers?
To learn other ways to assess suicide, click here.
Suicide risk scales
Suicide risk scales can be great tools for caregivers who do not specifically have a behavioral health background to assess a patient’s suicide risk. These tools work well for patients who are admitted through the ED.
Chaput recommended using the well-known SADPERSONS scale, an acronym originally developed by William Patterson and published in the journal Psychosomatics, which assigns a point for each positive response for certain risk factors.
Although suicide contracts are commonly used, they have not been proven to reduce suicide, said Chaput, and cannot be considered a legal document. However, if there is a positive therapeutic relationship, contracts can be helpful.
“Suicide contracts can be a very useful tool to help you determine risk and also to counsel the patient, but they do not necessarily protect you or your organization from citation or reduce liability issues,” said Farrar. A suicide contract is really a method for gathering information as well as a way of measuring the patient’s risk of committing suicide.
Farrar gave the example of a patient expressing depressed and suicidal thoughts. Farrar would ask that patient about her thoughts and also whether she could commit to seeking care when she has strong thoughts about hurting herself before acting on them.
“Now what I just asked her to do is, in a roundabout way, a suicide contract,” said Farrar. “But it is primarily an information-gathering tool. She may say, ‘Yes, Dr. Farrar, I do have these thoughts, but I don’t think I’m going to act on them. They build up slowly, but I do know that if they came back, I would call you or an emergency hotline or go to an emergency room.’ She has, by definition, just contracted for safety.”
To learn more on suicide contracts, click here.
Parasuicidal behavior is an epidemic among teens and young adults, said Chaput. It’s likely some of your patients will exhibit these behaviors, such as wrist-cutting or self-mutilation.
One thing to keep in mind when assessing the suicide risk of these patients is that the same action can have entirely different meaning depending on the person and circumstance. “There could be any number of explanations which require very different responses and represent very different risk levels,” said Farrar.
To learn more on parasuicidal behavior and teen suicide, click here.
Survey focus for 2010 and beyond
For those facilities that may be surveyed by The Joint Commission and CMS this year or in the future, there are some specific areas on which surveyors tend to focus, said Chaput and Farrar.
Environment of care (EC) will likely be a focus this year, said Chaput. Environmental suicide risk assessments should really be at a minimum, part of an annual EC risk assessment. EC.02.01.01, which requires hospitals to manage safety and security risks, is often cited as well, she said.
Specifically, surveyors cite element of performance (EP) 1, which requires hospitals to identify safety and security risks associated with the EC using internal sources such as ongoing monitoring and root cause analysis. Also, watch out for EP 3, which requires hospitals to take action to eliminate or minimize any identified safety and security risks in the physical environment.
“There is no specific requirement from The Joint Commission at this time for how often to complete this risk assessment, but the key wording is ‘ongoing monitoring of the environment,’ ” said Chaput. “One easy way to accomplish this is to use an environment of care suicide risk assessment tool … round on the units with a multidisciplinary team ... at a minimum of every six months.”
There has also been a push from CMS in some Northeastern states to create a totally risk-adverse environment. It’s imperative to clearly articulate psychiatric standards of care at survey time, Chaput said. For example, parasuicidal behavior is a hot topic among CMS surveyors, she noted.
“Surveyors often have no psychiatric background,” said Chaput. “They have a really hard time differentiating between a suicide attempt and self-mutilation.”
If a CMS surveyor attempts to cite you for something like this, Chaput recommended informing the surveyor that it is not clinically therapeutic to create a clinically adverse environment. Patients are going to be discharged into a world with pens and staplers, for example, and ridding the hospital of these items will not facilitate the hospital in helping patients identify their feelings associated with hurting themselves and teaching them how to cope. It’s helpful to have some literature on hand to back up these points, said Chaput.
Source: Patient Safety Monitor (Briefings on Patient Safety), April 1, 2010.
- NewYork-Presbyterian at http://nyp.org/health/mentalhealth_teensuic.html.
- Suicide.org at http://www.suicide.org/no-suicide-contracts.html.
- Training Institute for Suicide Assessment & Clinical Interviewing at http://www.suicideassessment.com/web/top-level/case.html.