Inpatient Suicidality: Detection and Maintaining Patient Safety

Introduction

Class Purpose:  To engage clinicians in an inquiry-based learning exercise to refine nursing understanding and skill in assessing for and documenting the suicidality of patients admitted to the hospital.  A case study will be presented followed by a logical progression through the assessment and actions to keep the patient safe.  Suicidality was selected based upon the inability or inconsistency with which staff can articulate the true risks for suicide as an inpatient, the frequency of omission or error, and to demonstrate the clinical decision support built into the electronic health record (EHR).

Class Structure:  Participants will work as individuals to complete the WebQuest.

     

    Task

    Objectives:

    At the conclusion of this activity, participants will be able to:

    1. Articulate the incidence of suicide in the inpatient setting.
    2. Articulate how to screen and if required, assess for suicidality of hospitalized patients.
    3. Articulate the risks to suicidal patients when hospitalized.
    4. Describe the actions necessary to maintain the safety of suicidal patients.
    5. Describe the environmental risks and considerations for the suicidal patient in the inpatient setting.
    Process

    Case Study: 

    Mrs. Sara Robinson is an 80-year-old female who was admitted directly from the cardiologist’s office.  Sara was seeing her cardiologist for a routine evaluation/follow-up regarding hypertension and valvular heart disease.  Sara was noted to be in congestive heart failure based on physical exam findings as well as a recent CT scan of the abdomen and pelvis showing bilateral pleural effusions and anasarca.  Last week she began noticing progressive weight gain and lower extremity edema.  Patient's weight last week was 240 lb and today is 250 lb.  Patient denies orthopnea, cough and dyspnea.  She reports generalized fatigue and heaviness in her legs.  Sara states she is “sick of being sick” and “it is too difficult to keep fighting, I could just take too many pills”.  Sara said she has been feeling hopeless and overwhelmed with health problems and with trying to manage them.

    Sara’s past medical history is significant for heart failure, type 2 diabetes, mild dementia, valvular heart disease, hypertension, CVA, hyperlipidemia, vascular disease.  She has a poorly healing left heel wound.  Sara sustained a coccyx pressure injury during a previous hospitalization that has healed completely.

    Sara demonstrates confusion regarding daily medication dosages and times.  She also confuses her prn and scheduled medications.  The daughters are involved in their Mom’s care but Sara does not see a daughter or caregiver daily.  Sara’s husband, Bill, is also involved but he has some memory issues.

    How will you follow up on the patient's comments regarding "being sick of being sick"?

    For this WebQuest, read or watch each of the hyperlinks below. Consider our patient Sara.  She was not admitted as a risk for suicide but as her admitting nurse was learning her story, Sara’s risk for suicide became clear.  Review the first three hyperlinks to understand the incidence of deaths due to suicide in the inpatient setting.  When included, review the essential points reiterated before or after each hyperlink.

    Inpatient Suicide Statistics

    https://www.beckershospitalreview.com/quality/5-stats-on-hospital-suici…

    https://www.jointcommissionjournal.com/article/s1553-7250(18)30253-8/fu…

    https://www.psychiatrictimes.com/view/inpatient-suicide-identifying-vul…

    National Patient Safety Goal – Suicide Prevention

    https://dfwhcfoundation.org/wp-content/uploads/2019/08/DFWHCF-Safety-Su…

    In the non-psychiatric inpatient setting, there are instances of incomplete adherence to the clinical practice guidelines for suicide prevention.  This incomplete adherence is demonstrated as inadequate communication and handoff education, omissions in the adherence to the requirements of the environmental safety checklist, and gaps in constant observation due to individual lapses or department activity.  These omissions and gaps must be identified and eliminated.  The environmental safety checklist ensures that the patient’s environment does not provide any opportunities for the patient to be successful in attempting suicide.  Small group discussions have revealed that nurses doubt whether any patient can be successful in the non-psychiatric inpatient setting at completing a suicide attempt. Reflect on the statistics from The Joint Commission.  These deaths are real and avoidable.

    Depression as a Major Contributing Factor

    https://sapienlabs.org/15-depression-assessment-tools-and-their-differe…

    Depression Screen

    https://patient.info/doctor/patient-health-questionnaire-phq-9#:~:text=….

    From the above article:  “When screening for depression the Patient Health Questionnaire (PHQ-2) can be used first (it has a 97% sensitivity and a 67% specificity).  If this is positive, the PHQ-9 can then be used, which has 61% sensitivity and 94% specificity in adults.”

    Suicide Risk Assessment

    Suicide Risk Screening Training: How to Manage Patients at Risk for Suicide

    As you listen to the link below, please pay particular attention to the difference between screening (quick to identify if further assessment is needed) and assessment (comprehensive testing that confirms and estimates risk and very importantly, determines next steps).

    https://www.youtube.com/watch?v=P4_-SF9lQuc

    Environmental Assessment for Suicide Risk

    According to The Joint Commission’s R3 Report (November 27, 2018), regarding required environmental assessments:

    “For non-psychiatric units in general hospitals: The organization implements procedures to mitigate the risk of suicide for patients at high risk for suicide, such as one-to-one monitoring, removing objects that pose a risk for self-harm if they can be removed without adversely affecting the patient’s medical care, assessing objects brought into a room by visitors, and using safe transportation procedures when moving patients to other parts of the hospital.  Note: Non-psychiatric units in general hospitals are not expected to be ligature-resistant environments.  Nevertheless, these facilities should assess clinical areas to identify objects that could be used for self-harm and should be routinely removed when possible from the area around a patient who has been identified as high risk for suicide. This information can be used for training staff who monitor high risk patients (for example, developing checklists to help staff remember which equipment should be removed when possible).”

    https://www.jointcommission.org/-/media/tjc/documents/resources/patient….

    Patient Experience

    https://video.search.yahoo.com/yhs/search?fr=yhs-norton-ext_onb&hsimp=y…

    Note the patient experience and the lack of cohesive and consistent patient education in the above video.

     

    Evaluation
    Rubric for Inpatient Suicidality:  Detection and Maintaining Patient Safety WebQuest
    Criterion Mastery (4 points) Articulate (3 points) Adequate (2 points) Needs Assistance (1 point)

    Does Not

    Meet (0 points)

    Total Points Achieved
    Articulate the incidence of suicide in the inpatient setting. Demonstrates complete mastery of criterion essential content. Demonstrates most of the key points with significant insight into clinical application. Demonstrates some key points with limited description of applicability to the clinical setting. Demonstrates only one or two key points with minimal insight for application to patient care. Work lacks understanding of essential content or applicability to the clinical setting.  
    Articulate how to screen and if required, assess for suicidality of hospitalized patients. Demonstrates complete mastery of criterion essential content. Demonstrates most of the key points with significant insight into clinical application. Demonstrates some key points with limited description of applicability to the clinical setting. Demonstrates only one or two key points with minimal insight for application to patient care. Work lacks understanding of essential content or applicability to the clinical setting.  
    Articulate the risks to suicidal patients when hospitalized. Demonstrates complete mastery of criterion essential content. Demonstrates most of the key points with significant insight into clinical application. Demonstrates some key points with limited description of applicability to the clinical setting. Demonstrates only one or two key points with minimal insight for application to patient care. Work lacks understanding of essential content or applicability to the clinical setting.  

    Describe the actions necessary to maintain the safety of suicidal patients.

    Demonstrates complete mastery of criterion essential content. Demonstrates most of the key points with significant insight into clinical application. Demonstrates some key points with limited description of applicability to the clinical setting. Demonstrates only one or two key points with minimal insight for application to patient care. Work lacks understanding of essential content or applicability to the clinical setting.  
    Describe the environmental risks and considerations for the suicidal patient in the inpatient setting. Demonstrates complete mastery of criterion essential content. Demonstrates most of the key points with significant insight into clinical application. Demonstrates some key points with limited description of applicability to the clinical setting. Demonstrates only one or two key points with minimal insight for application to patient care. Work lacks understanding of essential content or applicability to the clinical setting.  
    Point Totals            

    All points earned are multiplied by 5 to derive the final score.

    Conclusion

    The risk of inpatient suicide is real and significant.  We are responsible to understand the risk, universally screen, assess as needed, provide a safe environment, and provide unfailing supervision in compliance with the clinical practice guidelines for suicide risk.

    The student participant will address each of the five objectives by writing two-three paragraphs for each objective.  These paragraphs are expected to demonstrate your knowledge and how you will apply the knowledge from that objective to your daily practice to enhance patient safety.  Provide specifics for each objective.