Alert addresses patient suicides
When the situation warrants it, The Joint Commission will re-visit a topic that it previously has covered in a Sentinel Event Alert to look at it from a different point of view. That clearly was the case as it once again has made patient suicide an alert topic, according to Robert Wise, MD, medical advisor to the Division of Health Quality Evaluation.
"The [sentinel event] database is a voluntary database, so we don't know what the specific rates are, but when we look at what's reported to us, there are suicides connected to the psych unit and those connected to the ED and the med/surg unit, and the latter two are different kinds of issues," says Wise, who explains that the latest alert focuses on the ED and inpatient units. "What we're trying to get across is that these are different environments, and they need to be thought about separately."
The ED is a rapid-paced, high-volume environment with high acuity patients, Wise notes. "You have a lot of life-and-death situations, and you have personnel really focused on trying to quickly understand what the potentially serious med/surg issues are," he says. A number of these patients also could have suicidal issues associated with their medical problems, Wise points out. "It is a secondary issue, but it could turn out to be a deadly one," he says. "It's easy to sort of miss that secondary one because of how fast things are moving."
An example might be a cancer patient who comes to the ED because he or she is experiencing new pain or shortness of breath that is probably indicative of some spread, Wise says. "You also have a good chance the person is more despondent or feels hopeless," he says. "That's not what they present, with, but it is clearly there also."
What if patients don't volunteer info?
Bill Fiebig, RN, BSN, CEN NREMT-P, the ED manager at the Rose de Lima Campus of St. Rose Hospital in Henderson, NV, agrees. "It's easy to pick up the person who says 'I want to kill myself,' because they have declared," Fiebig says. "But it's very different with people with chronic illnesses, who go through body image or lifestyle changes, who may not be earning the same amount of money any longer or who are unable to work, or who are not functioning in daily life."
EDs do not do a good job of discovering that patients have a previous psychiatric illness when they don't volunteer that information in their history, he says. "We do not pry as much because our environment is so fast-paced," Fiebig says. "The truth is we are most likely the worst place in the world for patients with mental illness to come." Still, he adds, "we have to do a better job in screening patients and looking at their case in a multi-dimensional way."
Offering your staff inservices on this topic as a matter of course might not be all that effective, says Wise.
"Close calls or real events are more likely to be teaching moments," he says. "It becomes valuable then to do a root cause analysis, understand what happened, and then not blame the person in charge but use it as a teaching experience."
If you just do an inservice out of the blue and share the Sentinel Event Alert, for example, "People's eyes will glaze over because it does not have any meaning to their reality," says Wise. "However, if you have a near miss or, heaven forbid, a completed suicide, you can then bring in the inservice, and the alert is more likely to come alive for the staff," he says.
Fiebig says, "I couldn't have said it better myself. People need to have a relevant explanation given to them. We tend to inservice, inservice, inservice, and all you get are lost messages. If you have a real-life event, the staff is more likely to pay attention." (It's also important that your staff learn to recognize suicide risk factors. See the story, below.)
Sources
For more information on preventing patient suicide in the ED, contact:
- Bill Fiebig, RN, BSN, CEN NREMT-P, ED Manager, St. Rose Hospital, Rose de Lima Campus, Henderson, NV. Phone: (702) 616-4348.
- Robert Wise, MD, Medical Advisor, Division of Health Quality Evaluation, The Joint Commission. E-mail: [email protected].
Recognize risks, take precautions ED managers and their staffs should be aware of the risk factors for patient suicide, says a recent Sentinel Event Alert from The Joint Commission. Experts agree and add that it's also important to take precautions when you believe patients might be a danger to themselves. There are two types of patients who might present such a risk, says Robert Wise, MD, medical advisor to the Division of Health Quality Evaluation. "Some people have cognitive problems: dementia or other things that might affect their judgment," Wise notes. "They're a lot more likely to be despondent and make a suicide attempt if they're intoxicated or if they have some sort of dementia because they're not able to grasp or understand the consequences." The other group of patients is at risk because of the way in which they react to their medical problems, he says. "Suicidality may come from the patient's perception of their illness," Wise says. "You have to understand what the person is perceiving about what you're telling them." Gregory Henry, MD, FACEP, risk management consultant at Emergency Physicians Medical Group, Ann Arbor, MI, says, "I have never had someone successfully go from looking normal to killing themselves in my department. The crime is concentrating on the wrong thing." ED managers and their staffs should be on guard for subtle signs of problems such as agitation, Henry says. "Look for patients who pace the floor or those who are so monumentally depressed they sit there and say life is not worth living," he advises. Once you've determined a patient is at risk, you should do the "simple" things that can help avoid a more serious situation, says Henry. "Make sure the patient is in the ED proper, and have them closer to the nursing station," he advises. "Obviously, remove harmful objects from the room." He also says that ED staffs should check for any instruments or materials with which the patient might harm themselves or others, because patients who are suicidal also might be homicidal. If nurses see warning signs, they should notify the physicians that precautions need to be taken, says Henry. "What's more, get in touch with somebody who's invested in the well-being of the patient," he adds. Bill Fiebig, RN, BSN, CEN NREMT-P, the ED manager at the Rose de Lima Campus of St. Rose Hospital in Henderson, NV, says, "The big thing is you have to make sure nurses are assessing the psychodynamics of their patients, although it's easier said than done sometimes. We're helped by having chaplains round regularly [because St. Rose is a faith-based health system], and we also do our own rounding in the ED." If caregivers suspect another dimension to a patient's illness, "we encourage our nurses to get chaplains involved in difficult circumstances and to look at the family dimension as well," says Fiebig. Source For more information on patient suicide risk factors, contact:
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