CLINICAL ASSESSING SUICIDE RISK: THE FACTS

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CLINICAL June 2016 Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA Regional Chief Clinical Officer,

01 states Find out which patients are most likely to try to commit suicide.

are an essential part of nursing assessments. The statistics are staggering!

1 CLINICAL June 2016 Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA Regional Chief Clinical Officer, HealthTechS3 ASSESSING SUICIDE RISK: THE FACTS The National Patient Safety Goal (NPSG) states Find out which patients are most likely to try to commit suicide. Whether your hospital is accredited by the Joint Commission that promulgates the NPSGs, suicide risk assessments are an essential part of nursing assessments. The statistics are staggering! From a comparison standpoint, the data suggest a steady increase in the number of suicides each year. According to the CDC, in the age groups from 10-34, suicide is the number 2 cause of death, and number 4 for ages

Further data reveal an estimated 43.6 million (18.1%) Americans ages 18 and up experienced some form of mental illness. In the past year, 20.2 million adults (8.4%) had a substance use disorder.

2 Further data reveal an estimated 43.6 million (18.1%) Americans ages 18 and up experienced some form of mental illness. In the past year, 20.2 million adults (8.4%) had a substance use disorder. Of these, 7.9 million people had both a mental disorder and substance use disorder. (Source: SAMHSA s 2014 National Survey on Drug Use and Health (NSDUH) (PDF 3.4 MB). Recent data about opioid overdoses suggest that we have a crisis that is difficult to wrap one s arms around. So why all the data, you ask? The questions that one must ask regarding suicide risk during a nursing assessment are difficult at best, and oftentimes not asked at all. Let s explore why. The most obvious reason is discussion about mental illness which is uncomfortable for most. Second, many health care professionals believe that mental illness/substance abuse does not have a place in the emergency department since the psychological aspects of care and management take valuable time away from those who have serious medical conditions like MIs, CHF, strokes, etc. Third, patients coming to the ED may be friends and neighbors, and they probably won t answer honestly or frankly, it s none of my business. Lastly, there may be the general opinion that these frequent flyers are just looking for more drugs, and I don t have time for this. All of these thoughts were a running thread in this writer s mind when working as an ED nurse. If you are aware of the Diagnostic and Statistical Manual V (DSM-5), there are hundreds of diagnoses that can contribute to being a precursor to suicide ideation and/or suicide gesture. If one reviews the previously cited data, for every people one encounters, regardless of location, at least one person is affected by mental health and/or substance abuse problems. Health care professionals are committed to doing no harm. Most often, the altruism that all of us have in our core value system is unconscious, especially when it comes to routines like suicide risk assessments. Clearly, none of us want to be involved in a disastrous situation like a suicide or an attempt while at work or in our private lives. We must be committed to assuring that each individual we care for receives the same empathy and understanding regardless of chief complaint. Mental illness IS as important as MIs, CHF and stroke. 2 HTS3 June 2016 Page 2

Pragmatic Approach to Suicide Risk Assessment As health care professionals, we are in a key position for identifying people at risk of suicide and preventing suicide.

3 Pragmatic Approach to Suicide Risk Assessment As health care professionals, we are in a key position for identifying people at risk of suicide and preventing suicide. Oftentimes, the signs of suicide ideation are not overt, but subtle. Therefore, it is important to delve into the potential risk based on the following: Voiced feelings of hopelessness Depression or history of depression Taking antidepressants and/or change in medication History of abuse Inability to make eye contact Exaggerated nervousness during assessment S p ouse or s i g n i f i c a n t o th e r responding to questions, not the patient Suspicion of domestic violence Answering all or most questions negatively, for example, I do not have any feelings of hopelessness, I am not depressed and never have been, etc. Living alone without support; isolationism Previous history of suicide attempts Males are three times more likely to commit suicide than females (Source: CDC, 2010) If any of these triggers are present, it is important to conduct a complete suicide risk assessment, to include: 1) Developing a rapport with the person. 2) Maintain a calm demeanor and make eye contact. Be present in the moment. 3) Determine the level of risk such as norisk, low-risk, moderate risk or high risk. I f y o u c a n n o t m a k e t h a t determination seek assistance from a social worker, physician, NP or mental health professional. 4) Assess lethality. a. Does the person have suicidal thoughts? b. How long has the person had these thoughts? c. Does the person have a plan? Weapons, pills, etc. d. Is there imminent danger to committing suicide? 5) Assure a safe environment while in the hospital. May require 1:1 observation. 6) Develop a safe discharge plan or refer to a community agency if available. 3 HTS3 June 2016 Page 3

4 Tools There are a number of tools/instruments that can be used to conduct a suicide risk assessment. No tool is perfect. One example that may be beneficial to carry in your pocket is offered by the Department of Health & Human Services. 4 HTS3 June 2016 Page 4

5 Tools Another tool that sometimes makes it easier for the clinician and the patient is the Columbia-Suicide Severity Rating Scale (C-SSRS). The scale addresses all aspects of suicidal behavior and thinking, but includes only researched, evidence-based items required for the assessment. The scale is widely used for assessing suicidal thinking and behavior in both psychiatric and non-psychiatric settings. 5 HTS3 June 2016 Page 5

6 Tools Another tool that many have used is the SAD PERSONS scale. This is a simple scale that can be used by almost anyone. The scale assigns one point to each of 10 items identified as risk factors for suicide: Sex (male) Age less than 19 or greater than 45 years Depression (patient admits to depression or decreased concentration, sleep, appetite and/or libido Previous suicide attempt or psychiatric care Excessive alcohol or drug use Rational thinking loss: psychosis, organic brain syndrome Separated, divorced, or widowed Organized plan or serious attempt No social support Sickness, chronic disease A score of one or two points indicates low risk, three to five points indicates moderate risk, and seven to 10 signals high risk. Note that the first letter of each of the questions spells out the acronym SAD PERSONS. Summary Regardless of the tool used, it is incumbent on health care professionals to conduct a suicide risk assessment as a means of doing no harm. It is an ethical responsibility that helps to mitigate risk for your organization, and most importantly, decreasing risk for a patient entrusted to our care. Resources are scarce, especially in rural communities, so it is important that we as health care professionals provide the necessary management and safety for people at risk. The data indicate that there is an uptick in suicide, and we must pay attention to this medical illness as difficult as the conversation may be. Education is essential for all levels of providers as a means of assuring that there is increased knowledge and comfort in having the crucial conversations, and that the label of mental illness is just that, an illness needing empathic treatment. 6 HTS3 June 2016 Page 6

It s no coincidence that four of the six letters in health are heal. --Ed Northstrum HealthTechS3 hopes the information contained herein will be informative and helpful on industry topics.

7 It s no coincidence that four of the six letters in health are heal. --Ed Northstrum HealthTechS3 hopes the information contained herein will be informative and helpful on industry topics. However, please note this information is not intended to be definitive. HealthTechS3 and its affiliates expressly disclaim any and all liability, whatsoever, for any such information and for any use made thereof. Recipients of this information should consult original source materials and qualified healthcare regulatory counsel for specific guidance in healthcare reimbursement and regulatory matters. For more information, please contact Diane Bradley: Call: (Office) (Cell) diane.bradley@healthtechs3.com Mail: 75 Angels Path Webster, NY Website: HealthTechS3 is an award-winning healthcare consulting and hospital management firm based in Brentwood, Tennessee with clients across the United States. We are dedicated to the goal of improving performance, achieving compliance, reducing costs and ultimately improving patient care. Leveraging consultants with deep healthcare industry experience, HealthTechS3 provides actionable insights and guidance that supports informed decision making and drives efficiency in operational performance. Building Leaders Transforming Hospitals Improving Care 7 HTS3 June 2016 Page 7

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