Suicide Prevention Strategies and Risk Factors

1. Suicide Prevention

2. Suicidal Ideation: thinking or talking about committing suicide (making a will, getting affairs in order, buying a gun or rope, writing a suicide note). Also includes a patient stating they wished they were dead, but would never intentionally try to commit suicide. Suicidal Gesture: making an unusual, but nonfatal, behavioral bid for help. Includes cutting and attempting to overdose. Suicide Attempt: an intentional act that causes self-harm. Will be fatal if direct intervention does not occur. A suicide attempt is not a harmless effort to gain attention, it is an extreme expression of distress. Definitions

3. 10th most frequent cause of death in US; about 36,000 deaths per year 3rd leading cause of death between ages 15-24 About 1500 suicides take place in inpatient hospital units in the US each year, with 1/3 of these taking place while the patient is on 15-minute checks 90% of those who die by suicide had an underlying mental illness and/or substance abuse disorder Veterans are twice as likely as nonveterans to die of suicide Suicide has been the most frequently reported type of sentinel event for patients in a “staffed, around-the-clock care setting” since 1996. Suicide Statistics

4. Many patients who kill themselves in general hospital inpatient units do not have a psychiatric history or a history of suicide attempt – they are “unknown at risk” for suicide. The general hospital setting also presents more access to items that can be used to attempt suicide and more opportunities for the patient to be alone to attempt or re-attempt suicide. General Hospital Inpatients

5. Clinical assessment and reassessment remains the single best method for identifying individuals at risk for hurting themselves or others More specific plans that the patient has indicate greater risk. Most hospital suicides occur on the 2nd and 3rd shift so this staff must be actively involved in risk assessment Identifying At-Risk Patients

6. Elderly (65+) Young adult (18-24 yo) Unmarried Caucasian & American Indian/Alaskan Native populations Male (commit suicide 4x as freq as women, but women attempt suicide about 3-4 x more than men) Living alone Current alcohol/drug use Chronic physical disorder or pain including traumatic brain injury, delirium, dementia, poor prognosis, cancer Owns a firearm History of abuse Same sex sexual orientation (youth 2-6x more likely than heterosexual adolescents) Poverty Lower income Rural western states (Wyoming, Montana, Nevada, Alaska, NM) are the top five states March/April: More attempts among young & college students August: More attempts among elderly December/January: Other ages Risk Factors:Social & Demographic

7. Those at highest risk for suicide are patients with a combination of substance abuse and mood disorder Past history of attempts in 20-50% of individuals Recent suicide attempt, suicidal thoughts or behaviors, family history of suicide or psych illness, antidepressants Social isolation Loss of health, job, money, home, family member, self-esteem, personal security, discharge from service, divorce Alcohol/drug abuse Psychiatric disorders Any sudden change in symptoms of depression Risk Factors

8. Development of a suicidal plan Para-suicidal gestures or self inflicted injuries (cuts, burns, head banging, etc) Of all the factors to consider, the recent death of a family member or friend by suicide is the strongest life event linked to the act of committing suicide. Risk Factors

9. Hanging Jumping Cutting with sharp object Intentional drug overdose Strangulation 75% of inpatient suicides involved hanging 20% resulted from patients jumping from a roof or window Others included patients that committed suicide while on pass or eloping from hospital Methods of Self-Harm Most Frequently Used in Health Care Environments

10. Door or door knobs, door hinges Cabinet Bed or bed rail Shower Grab bar or handrail Bathroom stall Exposed pipes under sink Window Nightstand Fire sprinkler Ceiling mounted IV pole Ceiling vent Flag pole Hanging Anchor Points for Inpatient Suicide

11. Bedding Belt Shoelaces Clothing Wire coat hanger Wound dressing or sling Balloons with strings/ribbons Nasal cannula tubing Medical equipment Rope TV cable Towel Window blind cord Restraints Bandages Plastic bags Materials Used As A Noose For Inpatient Suicide

12. Irritability, increased anxiety, agitation Refusing visitors, crying, declining medications Requesting early discharge Impulsivity Decreased emotional reactivity C/O unrelenting pain Helplessness, hopelessness, worthlessness Decreased interest in treatment or prognosis Refusing to eat Alcohol/drugs Chronic illness/pain Delirium/dementia Warning Signs Associated with Increased Desperation & Imminent Risk

13. Medications • There are numerous medications that are associated with increased risk of suicidal thoughts and behaviors, including antidepressants, antiepileptic or anticonvulsant medications, and antipsychotic agents.

14. How to Ask the Question, “Are you thinking of killing yourself?” • To effectively determine if a patient is suicidal, one needs to interact in a manner that communicates concern and understanding. One also needs to know how to mange personal discomfort in order to directly address the issue.

15. Ask the question in such a way that is natural and flows with the conversation. Remain calm Listen more than you speak Act with confidence Do not argue Use open body language Use supportive and encouraging comments Be as honest and “up front” as possible How To Ask The Question

16. How To Ask The Question • Most patients appreciate having the clinician ask them about suicidal ideation as they tend to perceive this as evidence that the clinician cares about the patient.

17. How Not to Ask the Question • Do not just blurt out, “Are you going to kill yourself?” • Do not ask the question as though you are looking for a ‘no’ answer. For example, “You aren’t thinking of killing yourself, are you?” • Do not ask the question as a statement of surprise or amazement.

18. Show the patient that you are following what they are saying You are not passing judgment Let them know that the situation is serious and deserving of attention A person having suicidal thoughts may want the opportunity to ventilate his/her feelings Show concern by your tone of voice and manner Let him or her know you are there to help Explain that there are trained professionals to help them Explain that treatment works Explain that getting help for this problem is no different than seeing a specialist for other medical problems If the patient tells you that they have had treatment before and it didn’t help, try asking, “What if this is the time it does work?” Validation of Feelings

19. Must conduct a risk assessment that identifies specific patient characteristics (patient questions on next slide) and environmental features (found in our policy) that may increase or decrease the risk for suicide Address the patient’s immediate safety needs (remove all items that are a safety risk) and most appropriate setting for treatment (follow policy). National Patient Safety Goal:Suicide Prevention

20. All adults who present to ALH on 2E, 3E, ICU, MBU, ODA, and ED shall be assessed for risk of self-harm/suicide. Only those pediatric patients who are being treated for emotional or behavioral disorders shall also be screened. Ask the following questions to adult: Currently taking an anti-depressant? History of depression? Have a terminal/long-term chronic illness? Have a recent life-altering event (loss of loved one, divorce, injury, etc.)? History of mental illness? History of attempted suicide or history of suicide ideation? Current thoughts of suicide/homicide or current attempt? Risk Assessment

21. How To Ask the Question for a Pediatric Patient • Let the parent know that this is a routine safety screening question that is asked (5-13 years old with behavioral or emotional disorder) • “Are you thinking of hurting yourself?”

22. If there are signs of potential risk and a “yes” answer to any of the listed questions, the patient may be in need of a mental health assessment. Discuss with charge nurse and/or supervisor Document results and contact Decatur General West as indicated ‘Yes’ to Any of the Listed Questions

23. If there is a ‘yes’ answer to ‘history of attempted suicide or history of suicide ideation OR ‘yes’ to pediatric question: Case management is automatically notified of a ‘yes’ answer ED nurses will notify physician MBU nurses will notify Case Management History of Attempt or History of Suicide Ideation

24. If there is a ‘yes’ answer to current suicidal attempt or current thoughts of suicide for pediatric or adult: Notify physician Notify Decatur General West Arrange for transfer to appropriate facility Current Attempt or Thoughts(High Risk)

25. Patients are considered ‘high risk’ if current attempt or current thoughts of suicide/homicide: ED patient: Must be placed in secure room and continuously monitored by staff Document every 15 minutes High Risk Patients in ED

26. Medically Unstable patient: Placed in ICU for continuous monitoring Curtains must stay open unless nurse at bedside Patient must be visible to nurse at all times Use only plastic eating utensils and have staff verify removal at end of meal Document every 15 minutes All gifts and personal items must be inspected by staff prior to giving to the patient All belongings must be inventoried and hazardous items such as knives, medications, items with long cords must be stored in secure area Eliminate belts, shoelaces, safety razors (use only electric razors while watching patient) High Risk Patients in ICU

27. Medically stable and still considered at risk: 1:1 observation is required Observer must not leave the room Observer must not become distracted Observation may be done by PCA, Nurse, or trained contracted caregiver/sitter Use only plastic eating utensils and have staff verify removal at end of meal All gifts and personal items must be inspected by staff prior to giving to patient All belongings must be inventoried and hazardous items such as knives, medications, items with long cords must be stored in secure area Document every 15 minutes High Risk Patients on Med-Surg Unit

28. Patient must be in line of sight at all times Patient must never be left alone This includes when patient showers or uses toilet Desirable to use same gender staff If a patient is in imminent danger of hurting self, use restraint measures necessary to control the situation Count all plastic ware used for eating before and after use (no plastic knives left with patient) One-on-One Observation

29. After evaluation by Decatur General West and if indicated: Have patient sign ‘no harm contract’ Transfer may be made to Med/Surg unit with every 1 hour observations Family should not be used as observer except in special circumstances, which shall be documented in record by supervisor High Risk Patients After Evaluation by DGW

30. When a patient at risk for suicide leaves the care of the hospital, provide suicide prevention information (such as crisis hotline) to the patient and his/her family. National Suicide Hotline1-800-273-TALK (8255) National Patient Safety Goal:Suicide Prevention

31. Be clear and avoid making inferences or hypothesizing Report your clinical judgment based on facts from the assessment Assessment should lead clearly to the intervention and plan (follow policy) Document risk factors assessed Document what you did and why Document who was consulted Need a physician order to stop suicide precautions Discharge instructions need to include suicide hotline and ‘Self Harm’ patient education document Documentation

32. During Hospitalization • If at any time the patient verbalizes, plans, or has warning signs of suicide ideation or attempt, assess patient, follow policy, and intervene as indicated.