Suicide risk: Solutions to rapid assessment and documentation
In November 2010, The Joint Commission issued a Sentinel Event Alert requiring all hospitals to screen patients who do not present with a primary mental health diagnosis and are treated in general hospitals in medical-surgical units and the ED, in addition to those patients who are admitted after a suicide attempt and are a known risk.
The alert comes after suicide has ranked in the top five most frequently reported events to The Joint Commission since 1995.
Of the 827 inpatient suicides reported to The Joint Commission's Sentinel Event Database since 1985, 14.25% occurred in the nonbehavioral health units of general hospitals (e.g., medical-surgical units, ICU, oncology, telemetry), 8.02% occurred in the EDs of general hospitals, and 2.45% occurred in other nonpsychiatric settings such as home care, critical access hospitals, and long-term care hospitals.
Based on these findings, the identification of individuals who are at risk for suicide while under the care of, or following discharge from, a healthcare organization has become an important step in protecting these at-risk individuals.
"You will see patients who have recently attempted suicide, and you will also see those patients who are suicidal who have not expressed any intent," Sharon Chaput, RN, C, CSHA, director of standards and quality management at Brattleboro (VT) Retreat, said during a March 31 audio conference entitled "Suicide Risk: Solutions to Rapid Assessment, Environment of Care, and Documentation Issues."
Chaput explained that many patients who kill themselves in general hospital inpatient units do not have a psychiatric history or a history of suicide attempts, and that most medical-surgical units and EDs are not designed to care for suicidal patients and do not routinely assess everyone who comes in their door.
According to Chaput, screening for suicide risk in the ED should include ordering a psychiatric consult to assess the immediate risk of individuals admitted for medical treatment following a suicide attempt, communicating suicide risk screening results at handoff, and interventions to prevent suicide in those patients at increased risk, which include:
- Checking the patient for contraband that could be used to commit suicide.
- Involving the patient in care planning and decision-making.
- Making sure age and cultural considerations are factored into care.
- Offering the patient the opportunity to be visited by a family member or volunteer (i.e., "sitter") who can alert staff to any warning signs that may indicate imminent action. Peer support can be provided by either a certified peer support specialist or someone who has had experiences similar to that of the patient.
- Involving the person at risk and his or her family in the discharge process and aftercare recommendations.
What are the suicide risk factors?
Some suicide risk factors may be difficult to spot in the ED, such as family history, genetics/neurobiology, access to weapons, severe medical illness, substance use/abuse, psychiatric illness, and psychosocial stressors, but screening is mostly about asking patients the right questions, said Kirk Woodring, LICSW, CGP, licensed independent clinical social worker and director of access, evaluation, and ambulatory services at Brattleboro Retreat. Woodring also spoke at the audio conference.
"There are so many types of different risk factors-biological, psych, social, and environmental factors," said Woodring. "The primary risk factor is previous suicide attempt. Were there previous attempts?"
According to statistics, men who are widowed, divorced, or single are more likely to commit suicide, he explained, and risk increases with age. Alcohol and substance abuse, while not in and of itself a primary risk factor, is a potentiating factor for suicide, he added.
"We always want to make sure we ask the question and look at the risks around the use of alcohol and the extent to which they're using it," said Woodring.
Woodring said statistics also show that affective disorders such as depression or bipolar disorder, especially among females, are part of a high-risk profile for suicide, along with a family history of suicide.
"It's interesting when you think about [the fact that] there's a fourfold increased risk when [a patient's] relatives have committed suicide or attempted in the past compared to non-suicidal subjects," he said. "It's always important to ask questions about family history. Is there a family history of suicide, and certainly is there a family history of attempted suicide?"
Life stressors and the loss of activities that were previously enjoyed are also big risk factors for suicide, said Woodring.
"It's interesting to note that in the past year, Brattleboro Retreat has seen an increase of 23% in admissions, and much of that is due to psychosocial factors such as the declining economy, job loss and the associated identity loss, and concordant use of alcohol and drugs," he said. "I also think it's important to note a higher suicide risk in patients with chronic diseases, and particularly unremitting pain. Folks who have chronic pain are more likely to become suicidal."
What do we document?
Suicide risk assessments should be composed of the elicitation of high-risk behavior and intent, the elicitation of statistical risk factors, and clinical decision-making based on criteria such as the severity of suicidal ideation and the presence of suicide risk factors.
Suicide risk assessments should include documentation of the risk level, the basis for the risk level, and the treatment plan for reducing the risk. They should also include the suicidality of the patient, whether the patient has a plan for how he or she would commit suicide, the lethality of the plan, and whether the patient has the means and resources available to him or her to commit suicide.
According to The Harvard Medical School Guide to Suicide Assessment and Intervention, essential components of a suicide assessment include:
- Identifying predisposing factors
- Elucidating potentiating factors
- Conducting a specific suicide inquiry
- Determining level of intervention, which includes estimating the acuteness or chronicity of the patient's suicidality and evaluating competence, impulsivity, and acting out
- Assessing the therapeutic alliance
- Planning the nature and frequency of reassessment
- Documenting the assessment
Some facilities have been known to use "no-suicide contracts," a document designed for careful and methodical exploration of the patient's thoughts and feelings in a psychotherapeutic relationship and the patient's sense of self-control. These are usually used pro forma in a psychiatric setting and are not considered legal documents.
"No-suicide contracts don't really decrease the chance of suicide," said Woodring. "In a long-term therapeutic relationship they can be helpful, but they don't discharge the liability of the treating professional, especially in an emergency department or a critical setting like that when you're doing a very quick risk assessment."
However, if a no-suicide contract is used, the terms ofthe contract should be documented in the patient's record.
When do we document?
Suicide risk assessment documentation should be continual. Assessments should be documented at the first psychiatric assessment or admission, with every occurrence of any suicidal behavior or ideation, whenever there is any noteworthy clinical change, or even if there is simply a general concern that someone may be suicidal. For inpatients, suicide risk assessments should especially be documented whenever there is an increase in patient privileges and before they are discharged.
It's also crucial to document when a patient has access to firearms, said Woodring. "We always want to be sure that we document the issue of firearms-whether or not they're present, and if they are present in the home, what instructions have been given to make sure that the firearms are out of reach," he said.
"Firearms are the most lethal method of attempting suicide," he continued. "While more women attempt suicide than men, men are four times more successful at suicide, and that's primarily because they're more likely to use a firearm. So it's really important to be asking questions about access to firearms and documenting when there is access."
Assessing suicide risk in the ED
Suicidal people usually ask themselves a few bottom-line questions when they are considering whether to commit suicide: "Will it work?" and "Is it the right thing to do?" Suicidal people commonly ask themselves whether committing suicide will end their pain and solve their problems, and they also ask themselves whether committing suicide hurts the people they care about or breaks underlying codes of ethics or religious beliefs.
Several protective factors influence answers to those questions, which could be useful in asking the right questions during a suicide risk assessment in the ED or other inpatient setting. It's helpful to look for and document the following protective factors if they come up, as well as the risk factors during a suicide risk assessment:
- Children in the home, except among those with postpartum psychosis
- Deterrent religious beliefs
- Life satisfaction
- Reality-testing ability
- Positive coping skills
- Positive social support
- Positive therapeutic relationship
ED patients who may be suicidal can be identified with critical thinking and a risk assessment tool designed for use by health professionals without a behavioral health background. The tool, which goes by the acronym SAD PERSONS, assigns one point to each of 10 items on a risk factor scale. A score of 7-10 indicates that the patient is a high risk for attempting suicide.
"Risk assessment tools are beneficial for quick assessment because it's easy to remember, it's easy to go back to when you're in a situation when you are considering risk and can help with remembering to ask the right questions," said Woodring. "However, it's important to recognize that while suicide risk scales can be helpful, in and of themselves they aren't helpful unless they are part of a really structured interview and a process of developing a therapeutic alliance with the individual."
Woodring added that in an ED or other general healthcare setting, it's important to assess for high-risk behavior and intent, statistical risk factors, and clinical decisions that are made.
"It's important to really pay attention to the clinical decisions that you're making in terms of risk and the severity of the suicidal ideation," said Woodring. "And then the most essential component of an assessment is documenting that assessment. We can do terrific interviews, we can use all the scales that we have available to us when we're doing an assessment, but making sure we document carefully is absolutely critical."
"Practical Guideline for the Assessment and Treatment of Patients With Suicide Behaviors." American Journal of Psychiatry (Suppl.) Vol. 160, No. 11, November 2003.
The Harvard Medical School Guide to Suicide Assessment and Intervention. San Francisco: Jossey-Bass Publisher, 1998.