3 Steps to Assess and Respond to Suicide Ideation in Acute Care Settings

National Suicide Prevention Week has been observed every year since 1975. This year’s observation occurs September 9 through 15 and corresponds with World Suicide Prevention Day on September 10.

The American Foundation for Suicide Prevention (AFSP) estimates that suicide in the U.S.:

• Is the 10^th leading cause of death
• Claims 42,773 lives each year — that’s 117 lives per day
• Costs $44 billion annually in lost work and medical costs
• 6+ million years of life are lost due to suicide

Taking Steps to Prevent Suicide at the Point of Care

While psychiatric settings are designed to be safe for suicidal patients and have staff with specialized training, non-psychiatric units in hospitals and emergency departments are not designed for suicide risk and often do not have staff with training to deal with suicidal patients. In these areas patients often have access to items that can be used, and have more opportunities to be alone to attempt suicide.

To identify patients at risk for suicide and assure their safety, The Joint Commission urges clinicians in all settings to:

1. Review each patient’s personal and family medical history for suicide risk factors (see below for risk factors)
2. Screen all patients for suicide ideation, using a brief, standardized evidence-based screening tool
3. Review screening questionnaires before the patient leaves the appointment or is discharged

When assessment results require immediate safety measures, behavioral health clinicians are added to the care team to take one of the following actions:

1. Keep patients in acute suicidal crisis in a safe environment under one-on-one observation
2. For patients at lower risk, make personal and direct referrals to outpatient behavioral health and other providers within one week of the initial assessment
3. For all patients with suicide ideation, give them a number to the National Suicide Prevention Lifeline (800-273-TALK), conduct safety planning and restrict access to lethal means

Suicide Risk Factors

Suicidal risk factors are characteristics that make it more likely that an individual will consider, attempt or die by suicide. Physicians, nurses, and other healthcare professions should be aware of risk factors, warning signs, and common characteristics of individuals at risk for suicide and take appropriate steps to ensure patient safety.

Per the National Suicide Prevention Lifeline, risk factors include:

• Depression, schizophrenia, anxiety disorders and certain personality disorders
• Alcohol and other substance use disorders
• Impulsive and/or aggressive tendencies
• History of trauma or abuse
• Major physical illnesses
• Previous suicide attempt
• Family history of suicide
• Job or financial loss
• Loss of a relationship
• Lack of social support

Suicide Warning Signs

Most people who die by suicide exhibit warning signs. Up to 80 percent of suicidal people signal their intentions to others, or display other types of warning signs. The more signs a person shows, the greater the risk. A change in behavior or the presence of entirely new behaviors, especially those related to a painful event, loss or life change carry the greatest concern. Some signs to look for include:

• Talking about wanting to die
• Looking for a way to kill oneself, such as searching online for materials or means
• Talking about feeling hopeless or having no purpose
• Talking about feeling trapped or in unbearable pain
• Talking about being a burden
• Increasing the use of alcohol or drugs
• Acting anxious, agitated or reckless
• Sleeping too little or too much
• Withdrawing from others
• Showing rage or talking about seeking revenge
• Displaying extreme mood swings

When risk factors or warning signs are noted, it is important to make specific inquiries using a compassionate, non-judgmental tone with questions such as:

• Do you ever feel like life isn’t worth living?
• Have you ever thought about ending your life?
• Have you ever attempted suicide?
• Are you currently thinking about ending your life?
• Do you have a suicide plan?
• Can you tell me about your plan?

Responding to Imminent Risk for Suicide

Risk factors and warning signs should be immediately communicated to a clinical manager, supervisor, or primary physician. Hospitals typically have policies which address the care of suicidal patients. The Joint Commission recommends hospital staff be empowered to call a mental health professional or other resource who can assess a person at risk, and act to prevent suicide in those patients with imminent warning signs.

If a patient is in imminent risk for suicide, secure the environment and facilitate rapid psychological evaluation and treatment. The safest environment is a room or unit designated for behavioral health patients. If not available, or until available:

• Ensure there is one-to-one constant staff observation and/or security.
• Assess the area for items that might increase the risk of suicide by hanging, such as door hinges, plumbing fixtures, privacy partitions, clothing hooks and closet or curtain rods.
• Eliminate, to the extent possible, all means of hanging such as sheets, pants, belts, shoelaces, cords, electronic equipment and curtains or blinds.
• Use plastic utensils and disposable dishes for meals.
• Minimize access to glass and framed artwork.
• Eliminate materials that present a smothering hazard, such as plastic shower curtains, trash liners and disposable gloves.
• Prevent elopement. Assign the patient to a room that allows easy observation and access for staff, yet away from exits. Keep patient attire limited to a hospital gown.
• Check for the presence of weapons, medications and any other items that can be used for self-harm. Organizational policies may require a search of personal belongings to be witnessed by or delegated to designated staff, such as security personnel. Any potentially harmful items should be documented and secured away from the patient.

Patients Needing Further Evaluation

Suicide risk is highest within the month immediately following discharge from an emergency department or psychiatric hospital, with the greatest number of suicides occurring within one week of discharge.

If a patient is NOT considered to be in imminent risk for suicide, but needs further evaluation, effective strategies to assist individuals in connecting with outpatient services and providing support during this high-risk time are critical.

According to SPRC, these include:

• Making a follow-up appointment for the patient before discharge (ideally within 48 hours)
• Involving family, friends and other loved ones in the care transition plan
• Making follow-up contacts with the patient and checking with providers to make sure the person is receiving follow-up care
• Developing agreements among hospitals, behavioral health providers, crisis centers and others to facilitate safe transitions between settings
• Transmitting patient health information to referral providers in a timely manner

Final Thoughts

The rate of suicide is increasing in the U.S.  Although a large portion of individuals who die by suicide receive health care services in the year prior to their death, oftentimes, clinicians do not have the correct training on appropriate assessment to identify and take immediate action.

Provide education to all staff in patient care settings on how to assess and respond to patients with suicide ideation in a way that is appropriate to their role and experience level, as well as training on proper discharge and follow-up care for at-risk individuals.

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