Suicide Prevention at Sheppard Pratt. Sheppard Pratt Suicide Prevention Initiative Spokespersons: Camilla J. Rogers Robert Roca, M.D.

Transcription

1 Suicide Prevention at Sheppard Pratt Sheppard Pratt Suicide Prevention Initiative Spokespersons: Camilla J. Rogers Robert Roca, M.D. 1

2 Sentinel Events Reported to Joint Commission Demographics Prevalence in Men Risk increases with age Caucasians more than other races Nevada has the highest rate Most in the Spring Public safety officers Physicians Dentists 2

3 The Nursing Assessment Awareness of activities associated with suicide Making will, getting affairs in order Unexpected visiting Purchase of gun, rope or hose Characteristics Sense of isolation, withdrawal Emotional distancing History of mental illness Communication & Observation Documentation of the initial nursing and clinician assessment with attention to risk factors Communication of identified risk factors to the team with the identification of observation levels commensurate to the risk Awareness of environmental factors that would aid suicide 3

4 Suicide Prevention Suicide is intentional self-killing. While it has many meanings and motives, in our setting it is almost always a product of a psychiatric disorder; it is the most serious complication of psychiatric illness. We make extraordinary efforts to prevent it. Very rarely, we are unable to prevent it. Suicide Prevention Recent experience with inpatient suicide in our extended family of units prompted review of our practice. Root cause analysis Special attention to environment of care Eliminate platforms for hanging Launching of Suicide Prevention Initiative 4

5 Epidemiology of Suicide Accounts for 30,000 deaths yearly in U.S. 11 th leading cause of death in United States Worldwide more die by suicide than by homicide and war combined Elderly white males have highest rate in US Other risk factors include previous attempts, mood disorder, substance abuse, medical illness, pain, hopelessness, and social isolation In US larger birth cohorts have higher rates Prevention of Suicide: Limits of Predictability Risk factors identify populations at increased risk Low base rate of suicide (11 suicides per 100,000 or.01%) and the limited sensitivity/specificity of risk factors complicate prediction in individuals. Even if we had tests with only 1% FP and FN rates, only 20% of suicide predictions would be accurate (MacKinnon and Faberow, 1975). No test, measure, or interview technique is sufficiently sensitive or specific to provide reliable short-term prediction of suicide in individuals. 5

6 Five-year study of predicted v actual suicide in 4800 vets rated on 21 risk factors (Pokorny, Arch Gen Psy 1983;40:249) Predicted? Suicided? Yes No Total Yes 30 (TP) 773 (FP) 803 No 37 (FN) 3960 (TN) 3997 Total 67 died 4733 lived 4800 Axis I Diagnoses and Suicide (Jacobs, HGSAI, 1999:7) Diagnosis Lifetime Risk Percentage of Suicides High-Risk Profile Affective Disorders 15 percent percent Anxiety, panic alcohol Schizophrenia 10 percent percent High function, depression Alcohol and substance abuse 2-3 percent percent Personal loss, depression 6

7 Illness and Suicide Risk (Kelly, HGSAI, 1999: 502) ILLNESS HIV Huntington s disease Cancer (all) Head and neck Multiple sclerosis CRF (dialysis) Spinal cord injury SLE INCREASED RISK 6.6x 2.9x 1.8x 11.4x 2.4x 14.5x 3.8x 4.3x Preventing Suicide What we learned from RCAs Staff performed and documented good assessments. Patients did not disclose their intentions. Patients killed themselves despite levels of observation that were appropriate given the results of the assessments. 7

8 Preventing Suicide Salient features of the mental status of patients who committed suicide Intense psychological pain or anguish Intense self-loathing Delusions of guilt Agitation or perturbation Hopelessness Feeling that death would bring relief Preventing Suicide What we learned from study of environment of care Careful design eliminates many hazards Using breakaway or downsloping fixtures Avoiding breakable glass materials But a door is a potential gallows Self-asphyxiation does not require hanging Practically anything can become an instrument of self-harm 8

9 Suicide Prevention Initiative: Are we doing the most we can? Consultation with Douglas Jacobs, MD, Chair of APA Task Force on Suicidal Behaviors Review and revision of our observation policies Enhancement of clinical safety (nursing) rounds practices Development of pilot protocol for assessment of suicide risk Guide for clinical practice Template for staff training in suicide assessment Recommendations of Douglas Jacobs, Chair of APA Suicide Task Force Comments regarding observation policies: Change name of close observation to constant observation. Provide specific examples of when SO, ISO, CO and other levels are appropriate Consider an intermediate step between 15-min checks (SO) and ISO (arm s length) (e.g., 5-min checks) Patients at acute risk for suicide should never be left alone, e.g, should not be put in seclusion A RN should be able to increase observation level before getting order; MD order should be obtained before lowering observation level 9

10 Recommendations of Douglas Jacobs, Chair of APA Suicide Task Force Comments regarding RN practice/staffing: Nursing rounds Critical to maintaining safety with regard to suicidal behavior. Rounding is one of the most important jobs on each shift and staff should be rotated... to maintain attention and vigilance. An additional staff member should be assigned to a unit if ISO or CO is in use. Recommendations of Douglas Jacobs, Chair of APA Suicide Task Force Comments regarding training: There should be a clear understanding throughout the facility of what it means to do a suicide assessment and a minimum standard for what is expected. In-service training in suicide assessment should be provided annually to all direct care staff. 10

11 Preventing Suicide: Policy Highlights Suicide Observation (SO) Ordered when 15-minutes checks are considered sufficient to ensure safety Private bathrooms must be locked Seclusion is not permitted. Personal searches and room searches are required when SO is instituted or renewed Preventing Suicide: Policy Highlights Constant Observation (CO) Replaces close observation. Provides for continuous observation for any reason, including suicidality When CO is ordered because of concern for self-harm, seclusion is not permitted. Personal searches and room searches are advisable (not yet formally required by policy). 11

12 Preventing suicide: Policy highlights Intensive Suicidal Observation (ISO) Patients are monitored 1:1 and are kept within arm s length at all times Should be strongly considered when there is imminent intent and an actionable plan, unless an individualized but equally intensive plan is preferred. Personal searches and room searches are required when ISO is initiated or renewed. Preventing Suicide: Clinical Safety Rounds Enhancement of rounds performed by nursing every shift Certain elements will be common to all settings Accounting for all patients Proactive search for contraband and signs of imminent mischief Other elements will be specific to unit populations e.g., adolescent vs. geriatric 12

13 Standardizing the Minimum Suicide Assessment Draft: SPHS Inpatient Suicide Assessment Protocol 13 questions; 3 dimensions of risk: Expressed intentions regarding suicide Mental status findings pertinent to suicidality Aspects of history pertinent to suicidality Proposal: Complete protocol upon admission and whenever patient is being assessed for suicide risk, especially when reducing the level of observation Expressed Intentions: Words or Deeds Has there been a recent suicide attempt? Patient seriously attempted suicide immediately prior to admission Is there imminent suicidal intent? The patient is expressing a believable intention to harm self in hospital. Is there an actionable plan? The patient describes a specific plan that can realistically be acted upon in the hospital 13

14 Expressed Intentions: Words or Deeds If the answer to any of these three questions is yes, a high level of observation should be considered If the answer is yes to questions 2 (imminent intent) and 3 (actionable plan), then ISO or an individualized and equally intensive level of observation should be ordered. Mental Status Findings: Worrisome signs and symptoms Does the patient show Extreme psychological pain or anguish? Intense self-hatred? Hopelessness? Agitation or perturbation? Psychosis, especially delusional guilt? A wish for death? Presence of one or several of these may call for a high level of observation even if the patient denies suicidal thoughts 14

15 Selected Aspects of History Has there been a recent severely distressing loss, disappointment or threat? Does the patient lack social support from family, friends, church, and/or work? Is there a history of suicide among friends or family? Is there an active substance abuse problem? The presence of any of these may increase suicide risk The Safety Contract Patient provides assurance of current safety and promises to inform clinician if selfharm is imminent. Is this an adequate suicide assessment? Does it address all clinical dimensions of risk, or just expressed intentions? Does it release clinician from liability in the event of suicide? 15

16 Preventing Suicide: Summary of Minimum Assessment Risk should be evaluated upon admission & whenever there is concern about safety, especially when lowering observation level Risk should be evaluated in three dimensions: Expressed intentions Mental status findings Selected aspects of history Documenting a Safety Contract is not sufficient Suicide Prevention Initiative: Next Steps Finalize Clinical Safety (Nursing) Rounds protocol for Towson and Ellicott City campuses Pilot and revise the Suicide Assessment protocol Develop curriculum for mandatory annual inservice training on suicide assessment for all direct care staff Schedule lecture by Douglas Jacobs, MD, for fall