EXECUTIVE SUMMARY
The Joint Commission’s Sentinel Event Alert on preventing suicide in healthcare says that the information applies to all patients in all settings.
- Parkland Memorial Hospital in Dallas has universal suicide screenings, including at outpatient clinics. The hospital has found 1.8% of patients to be at high suicide risk and up to 4.5% to be at moderate risk.
- Review each patient’s personal and family medical history for risk factors, screen all patients for suicide ideation, and review screening questionnaires before patients leave.
- Take immediate action for patients in acute suicidal crisis, and conduct safety planning for all patients with suicide ideation.
- Manage evidence-based treatments and discharge plans that directly target suicide, educate staff about how to identify and respond to at-risk patients, and document decisions on care and referral.
The Joint Commission has issued a Sentinel Event Alert on preventing suicide in healthcare settings. The Alert says that the information applies to all patients in all settings.
“It’s imperative for health care providers in all settings to better detect suicide ideation in patients, and to take appropriate steps for their safety and/or refer these patients to an appropriate provider for screening, risk assessment, and treatment,” the Alert says.
The Alert points out that Parkland Memorial Hospital in Dallas became the first hospital in the United States to have universal screenings to determine whether patients are at risk for suicide. (For more information, see “Health system is thought to be first to provide universal suicide screenings” that ran in Healthcare Risk Management, also published by AHC Media, at bit.ly/1Rawpen.)
“Through preliminary screenings of 100,000 patients from its hospital and emergency department, and of more than 50,000 outpatient clinic patients, the hospital has found 1.8 percent of patients there to be at high suicide risk and up to 4.5 percent to be at moderate risk,” says the Alert, basing its figures on a report in The Dallas Morning News.1
The Alert aims to assist providers in better identifying and treating individuals with suicide ideation. The Alert also provides screening, risk assessment, safety, treatment, discharge, and follow-up care recommendations for at-risk individuals.
The Joint Commission is bringing attention to this issue because its Sentinel Event Database received 1,089 reports of suicides occurring from 2010 to 2014. The most common root causes documented were shortcomings in assessment, most commonly psychiatric assessment. In addition, 5.14% of Joint Commission-accredited hospitals, for which a related National Patient Safety Goal (NPSG) was applicable, were non-compliant in 2014 with conducting a risk assessment that identifies specific patient characteristics and environmental features related to suicide risk. (For more on that NPSG, see the Same-Day Surgery article “New Patient Safety Goals added for next year” at bit.ly/24TzsSz.)
“We are shining a light on this issue because the tragic reality is that many healthcare providers do not detect suicidal thoughts of individuals who eventually die by suicide, even though most victims of suicide received healthcare services in the year prior to death,” said Ana Pujols McKee, MD, executive vice president and chief medical officer at The Joint Commission. “As a result, it is crucial for at-risk patients to receive timely and supportive care. Healthcare organizations are encouraged to develop clinical environment readiness by identifying, developing, and integrating comprehensive behavioral health, primary, and community care resources to ensure the continuity of care for at-risk individuals.”
STEPS TO TAKE
All healthcare providers play an important role in detecting suicide ideation, according to the Alert. It recommends these steps.
• Review each patient’s personal and family medical history for suicide risk factors, screen all patients for suicide ideation, and review screening questionnaires before patients leave or are discharged.
The Joint Commission says providers can use a waiting room questionnaire including a question asking if the patient has had thoughts about killing himself or herself.
Some practices use the Patient Health Questionnaire 2 (PHQ-2),2 which asks about depression symptoms, and some providers add another question about suicidal thoughts. If a patient answers “yes” to any of these questions, providers can administer the PHQ-9.3 Another brief screening tool mentioned in the Alert includes the Suicide Behaviors Questionnaire-Revised (SBQ-R).
• Take immediate action for patients in acute suicidal crisis, and conduct safety planning for all patients with suicide ideation.
Patients in acute suicidal crisis should be observed continuously. Give them immediate care through an emergency department, inpatient psychiatric unit, respite center, or crisis resources, the Alert says. Check the patient, as well as their visitors, for items that could be used to hurt or attempt suicide. Don’t let these patients near anchor points that could be used for hanging. Also, keep them away from materials that could be used for self-injury, including bell cords, bandages, sheets, restraint belts, plastic bags, elastic tubing, and oxygen tubing.
Patients who are at lower risk of suicide should be given personal, direct referrals and links to outpatient behavioral health and other providers, to be seen within one week. Don’t leave it to the patient to make the appointment, the Alert advises. Also, give each of these patients the number to the National Suicide Prevention Lifeline (800) 273-TALK (8255).
“For patients who screen positive for suicide ideation and deny or minimize suicide risk or decline treatment, obtain corroborating information by requesting the patient’s permission to contact friends, family, or outpatient treatment providers,” the Alert says. “If the patient declines consent, HIPAA permits a clinician to make these contacts without the patient’s permission when the clinician believes the patient may be a danger to self or others.”
• Manage evidence-based treatments and discharge plans that directly target suicide, educate staff about how to identify and respond to at-risk patients, and document decisions regarding care and referral.
The education should cover environmental risk factors, how to find help in emergencies, and policies for patients at risk of suicide. The Clinical Workforce Preparedness Task Force of the National Action Alliance for Suicide Prevention developed Suicide Prevention and the Clinical Workforce: Guidelines for Training.4 Other resources recommended in the Alert are TJC’s Standards BoosterPak Suicide Risk for National Patient Safety Goal 15.01.01 for accredited organizations (Web: bit.ly/1u6pY4z) and the QPR Institute and the VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide (2013).5
Providers should document decisions about patients with suicide risk. “Thoroughly document every step in the decisionmaking process and all communication with the patient, his or her family members and significant others, and other caregivers,” the Alert says. “Document why the patient is at risk for suicide and the care provided to patients with suicide risk in as much detail as possible ... .”
A documentation checklist is available on page 21 of Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments.6
REFERENCES
- Jacobson S. Parkland’s suicide-risk screening finds more patients need preventive care. Dallas Morning News. The Scoop Blog. Sept. 8, 2015 (accessed Nov. 6, 2015).
- Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener. Med Care 2003; 41:1284-1292 (accessed Aug. 17, 2015).
- Zero Suicide in Health and Behavioral Health Care. Screening for and assessing suicide risk. Web: bit.ly/1V7f63R (accessed July 27, 2015).
- National Action Alliance for Suicide Prevention: Clinical Workforce Preparedness Task Force. Suicide prevention and the clinical workforce: Guidelines for training. 2014. Washington, DC.
- VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. Department of Veterans Affairs, Department of Defense, June 2013. Web: 1.usa.gov/250tSxE (accessed Jan. 10, 2016).
- Suicide Prevention Resource Center. Caring for Adult Patients with Suicide Risk. A Consensus Guide for Emergency Departments. Web: http://www.sprc.org/ed-guide.
RESOURCE
The full Alert, an infographic, and a chart of related standards from The Joint Commission can be accessed at bit.ly/1h0HsER.
RISK FACTORS FOR SUICIDE
- Mental or emotional disorders, particularly depression and bipolar disorder
- Previous suicide attempts or self-inflicted injury
- History of trauma or loss, such as abuse as a child, a family history of suicide, bereavement, or economic loss
- Serious illness, or physical or chronic pain or impairment
- Alcohol and drug abuse
- Social isolation or a pattern/history of aggressive or antisocial behavior
- Discharge from inpatient psychiatric care, within the first year after discharge and particularly within the first weeks and months after discharge
- Access to lethal means coupled with suicidal thoughts.
SOURCE: The Joint Commission. Detecting and treating suicide ideation in all settings. Sentinel Event Alert 2016; 56. Accessed at bit.ly/1R2riNr.
The Joint Commission has issued a Sentinel Event Alert on preventing suicide in healthcare settings. The Alert says that the information applies to all patients in all settings.
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