SEA 56 Suicide


1 A complimentary publication of The Joint Commission Issue 5 2016 24, 6, February Detecting and treating suicide ideation in all settings th 1 Now the 10 leading cause of The rate of suicide is increasing in America. Published for Joint 3 2 suicide claims more lives than traffic accidents and more than twice death, -accredited Commission 4 organizations and interested At the point of care, providers often do not detect the as many as homicides. health care professionals, suicidal thoughts (also known as suicide ideation) of individuals (including Sentinel Event Alert identifies children and adolescents ) who eventually die by suicide, even though most of and specific types of sentinel 5 usually for them receive health care services in the year prior to death, and high risk events adverse 5-7 Timely, supportive continuity reasons unrelated to suicide or mental health. conditions , describes their 8 ide is crucial, as well. of care for those identified as at risk for suic common underlying causes, recommend s steps to and future reduce risk and prevent Through this alert, The Joint Commission aims to assist all health care occurrences. organizations providing both inpatient and outpatient care to better identify and and treat individuals with suicide ideation. Clinicians in emergency, primary Accredited organizations behavioral health care settings particularly have a crucial role in detecting information in should consider suicide ideation and assuring appropriate evaluation. Behavioral health a Sentinel Event A lert when professionals play an additional important role in providing evidence- based designing or redesigning -up c are. For all clinicians working with patients with treatment and follow processes and consider implementing relevant suicide ideation, care transitions are very important. Many patients at risk for suggestions contained in the suicide do not receive outpatient behavioral treatment in a timely fashion alert or reasonable alternatives. following discharge from emergency departments and inpatient psychiatric 6 The risk of suicide is three times as likely (200 percent higher) the settings. Please route this issue to 9 and continues to be high first week after discharge from a psychiatric facility appropriate staff within your 11 6,10 and through the first four years after especially within the first year Sentinel Event organization. discharge. Alert may be reproduced if The Joint credited to Commission . To receive by This alert replaces two previous alerts on suicide (issues 46 and 7). The email, or to view past issues, suggested actions in this alert cover suicide ideation detection, as well as the visit www.j screening, risk assessment, safety, treatment, discharge, and follow -up care of at -risk individuals. Also included are suggested actions for educating all staff about suicide risk, keeping health care environments safe for individuals at risk for suicide, and documenting their care. 12 n suicide prevention. Some organizations are making significant progress i The "Perfect Depression Care Initiative" of the Behavioral Health Services consecutive Division of the Henry Ford Health System achieved 10 calendar without an instance of suicide among patients participating in the quarters program . The U.S. Air Force’s suicide prevention initiative reduced suicides by third over a six one- Over a period of 12 years, Asker and Bærum -year period. Hospital near Oslo, Norway implemented continuity -of-care strategies and risk population with achieved a 54 percent decline in suicide attempts in a high- -up. Additionally, the hospital’s a history of poor compliance with follow __________________________ multidisciplinary suicide prevention team accomplished an 88 percent success 8 rate for getting patients to the aftercare program to whi ch they were referred. Dallas’ Parkland Memorial Hospital became the first U.S. hospital to implement universal screenings to assess whether patients are at risk for suicide. Through preliminary screenings of 100,000 patients from its hospital and emergency department, and of more than 50,000 outpatient clinic patients, the hospital has found 1.8 percent of patients there to be at high 13 suicide risk and up to 4.5 percent to be at moderate risk.

2 Issue Sentinel Event Alert 56 Page 2 these patients to an appropriate provider for Who is at risk for suicide? screening, risk assessment, and treatment. Much of what we know about the profile of individuals who have died by suicide and those Assessing suicide risk remains a challenge who have attempted suicide comes from looking The Joint Commission’s Sentinel Event database* in the rearview mirror – at data compiled about has reports of 1,089 suicides occurring from 2010 suicide victims and attempts. S uicide may affect 14 to 2014 among pat ients receiving care, treatment, such as military veterans certain demographics – and services in a staffed, around- the clock care men over age 45 – . It’s more than others and setting or within 72 hours of discharge, including important to identify the risk factors, rather than from a hospital’s emergency department. The membership in a group, when considering suicide most common root cause documented during this risk. Paying attention to risk factors matters time period was shortcomings in assessment, because patients may not disclose suicide ideation most commonly psychiatric assessment. In k factors for suicide include: voluntarily. Ris addition, 21.4 percent (165) of Joint Commission- • Mental or emotional disorders, particularly accredited behavioral health organizations and 15 Up to 90 depression and bipolar disorder. 5.14 percent (65) of Joint Commission- accredited percent of suicide victims suffer from a mental hospitals (for which the requirement was 16 or emotional disorder at the time of death. compliant ated non- were r applicable) in 2014 with Previous suicide attempts or self • -inflicte d National Patient Safety Goal 15.01.01 Element of injury; the risk of suicide is twice as high (100 Conduct a risk assessment that Performance 1 – percent higher) than general suicide rates for identifies specific patient characteristics and 6,15 and one year following a suicide attempt environmental features that may increase or 6,11 The the higher risk continues beyond that. decrease the risk for suicide. risk is even higher the first few weeks 8 immediately following a s uicide attempt. Acti ons suggested by The Joint Commission To accomplish the following suggested actions, , such as abuse as a • History of trauma or loss 17 17 The Joint Commission urges all health care a family history of suicide, child, 18 18 to develop clinical environment organizations or economic loss. bereavement 18 readiness by identifying, developing and or physical or chronic pain or • Serious illness, 18 th, integrating comprehensive behavioral heal impairment. 15 primary care and community resources to assure • Alcohol and drug abuse. 19 continuity of care for individuals at risk for or a pattern/history of • Social isolation 12,25 20 Many communities and health care . suicide aggressive or antisocial behavior. organizations presently do not have adequate 21,22 Discharge from inpatient psychiatric care, • suicide prevention resources, leading to the low 10 and particularly within the first year after detection and treatment rate of those at risk. As a within the first weeks and months after result, providers who do identify patients at risk for 23 While some depressed patients discharge. suicide often must interrupt their workflow and who attempt or die by suicide after inpatient to find treatment disrupt their schedule for the day psychiatric hospitalization express suicide and assure safety for these patients. ideation before or during hospitalization, other depressed patients who have received DETECTING SUICIDE IDEATION IN NON- inpatient psychiatric treatment develop suicide ACUTE OR ACUTE CARE SETTINGS 24 ideation after discharge. Primary, emergency and behavioral health • Access to lethal means coupl ed with suicidal clinicians all play crucial roles in detecting suicide 18 . thoughts ideation through the following three steps , which acute or acute care settings: can be taken in non- However, there is no typical suicide victim. Most individuals having these risk factors do not attempt ’s personal and family 1. Review each patient suicide, and others without these conditions medical history for suicide risk factors. These sometimes do. Therefore, there is a danger in are listed in the “Who is at risk for suicide?” h certain conditions considering only individuals wit section of this alert. or experiences in certain health care settings as ______________________ being at risk for suicide. It’s imperative for health * The reporting of most sentinel events to The Joint Co mmission to better detect settings all providers in care is voluntary and represents only a small proportion of actual ideation in patients suicide , and to take these data are not an epidemiologic data set events. Therefore, and no conclusions should be drawn about the actual relative appropriate steps for their safety and/or refer frequency of events or trends in events over time.

3 Issue Sentinel Event Alert 56 Page 3 During the following two steps, behavioral health Screen all patients for suicide ideation, 2. clinicians are generally added to the care team via using a brief, standardized, evidence -based consultation or referral. The care team should: A waiting room questionnaire screening tool. including a question specifically asking if the 4. Take the following actions, using patient has had thoughts about killing him or assessment results to inform the level of herself may help identify individuals at risk for safety measures needed. ay not have been suicide who otherwise m • in a Keep patients in acute suicidal crisis Research shows that a brief screening identified. 11,26-32 to- safe health care environment under one- tool can identify individuals at risk for suicide one observation. Do not leave these patients more reliably than leaving the identification up to a by themselves. Provide immediate access to clinician’s personal judgment or by asking about care through an emergency department, suicidal thoughts using vague or softened inpatient psychiatric unit, respite center, or Patient For example, a study using the language. 33 crisis resources. Check these patients and those -9) Health Questionnaire (PHQ found that their visitors for items that could be used t o who expressed thoughts of death or self -harm make a suicide attempt or harm others . Keep were 10 times more likely to attempt suicide than 26,31 these patients away from anchor points for Some those who did not report those thoughts. hanging and material that can be used for PHQ - practices use a shorter version called the 41 34 Some specific lethal means that self -injury. which asks two questions about depression , 2 are easily available in general hospitals and and some add an additional question symptoms, that have been used in suicides include: bell about suicidal thoughts and feelings. If a patient cords, bandages, sheets, restraint belts, answers “yes” to any of these questions, the PHQ - 35 plastic bags, elastic tubing and oxygen Other brief screening tools 9 is administered. 42,43 tubing. - ED Emergency Medicine Network’s include the 36 make For patients at lower risk of suicide, • SAFE Patient Safety Screener for emergency personal and direct referrals and linkages to Suicide Behaviors and the departments 37 outpatient behavioral health and other Questionnaire- . Revised (SBQ -R) hin one week of -up care wit providers for follow 8 3. Review screening questionnaires before the rather than leaving it up to initial assessment, patient leaves the appointment or is the patient to make the appointment. discharged. To determine the proper immediate For all patients with suicide ideation: • course of treatment, c onduct or refer for and his or her family Give every patient o secondary screening and assessment patients members the number to the National Useful determined to be at risk for suicide. 273 - 800- Suicide Prevention Lifeline, 1- Suicide secondary screeners include t he TALK (8255), as well as to local crisis and 44 Prevention Resources Center’s Decision Support peer support contacts. 38 and the Emergency Medicine Network’s 45 Tool by o Conduct safety planning 39 ED -SAFE Patient Safety Secondary Screener for collaboratively identifying possible coping 20 emergency departments. The T SAFE- Pocket strategies with the patient and by and Suicide Severity Rating Columbia- the Card 12,44 providing resources for reducing risks. 40 can be used for in- -SSRS) depth Scale (C de contract” suici a “no- A safety plan is not screening and assessment . (or “contract for safety”), which is not recommended by experts in the field of For patients who screen positive for suicide 44 Review and reiterate suicide prevention. ideation and deny or minimize suicide risk or the patient’s safety plan at every decline treatment, obtain corroborating information interaction until the patient is no longer at by requesting the patient’s permission to contact 38 risk for suicide. friends, family, or outpatient treatment providers. If o Restrict access to lethal means. Assess the patient declines consent, HIPAA permits a whether the patient has access to hout the clinician to make these contacts wit firearms or other lethal means, such as patient’s permission when the clinician believes prescription medications and chemicals, 38 the patient may be a danger to self or others. and discuss ways of removing or locking up firearms and other weapons during TAKING IMMEDIATE ACTION AND SAFETY . Restricting access is crisis periods PLANNING impor tant because many suicides occur with little planning during a short -term

4 56 Issue Sentinel Event Alert Page 4 strategy. crisis, and both intent and means is See an overview of these and other 46 The Harvard evidence- , which emphasize based interventions required to attempt suicide. T.H. Chan School of Public Health’s patient engagement, collaborative assessment provides helpful ter website Means Mat and treatment planning, problem -focused 46 advice on means restriction. clinical intervention to target suicidal “drivers,” skills training, shared service 12 BEHAVIORAL HEALTH TREATMENT AND proactive and personal and responsibility, DISCHARGE ransitions and clinician involvement in care t Behavioral health clinicians manage the patient’s -up care, such as: follow evidence- , based treatments and discharge plans • Engaging the patient and family coordinate care transitions and follow - as well as members/significant others in collaborative are with the patient’s other providers. up c discharge planning to promote effective 5. Establish a collaborative, ongoing, and coping strategies. systematic assessment and treatment process Discussing the treatment and discharge plan • with the patient involving the patient’s other with the patient and sharing the plan with other providers, family and friends as appropriate. providers having responsibility for the patient’s – changing namic Suicide risk, by nature, is very dy -being. well according to personal events, a person’s level of • Determining how often patients will be called desperation, and available interventional and seen. 47 Treatment of individuals at risk for resources. Establishing real -time telephone or live • suicide requires a collaborative approach that -risk patients who don't stay in contact with at the desire to find acknowledges the ambivalence – touch or show up for an appointment, rather a solution to their pain versus the innate desire to than having staff or resources just leave 48 A valuable live – that these patients often feel. reminder messages or emails. support to traditional risk assessment is to use a • Directly addressing patients’ thoughts about – drawn from prevention risk formulation model 62 suicide at every interaction. 50 49 and violence assessment research – that can Using motivational enhancement to increase • help providers to understand a patient’s current the likelihood of engagement in further thoughts, plans, access to lethal means, and 44 treatment. acute risk factors. This understanding can be used to develop personalized care and both short - and CATION AND DOCUMENTATION EDU long- term safety plans for patients struggling with These recommendations are relevant to all care thoughts of suicide. providers and settings. for at- risk patients, To improve outcomes 6. 7. Educate all staff in patient care settings ns that develop treatment and discharge pla about how to identify and respond to patients 12 Traditionally, directly target suicidality. . Develop a process for how with suicide ideation behavioral health clinicians often have treated the ely respond to a patient with staff can sensitiv underlying depression or other mental health suicidal thoughts and feelings in a way that is disorders in patients but have not directly appropriate to their role and professional addressed suicide risk. Providing direct treatment 63 Education for staff should cover training. of suicide risk using evidence- based interventions environmental risk factors; finding help in Hospitalization is often necessary for a is vital. emergencies; and policies for screening, patient’s immediate safety, but hospitalization sment, referral, treatment, safety and asses used solely as a containment strategy may be The Clinical support of patients at risk for suicide. 51-53 and ineffective or counterproductive Workforce Preparedness Task Force of the considered by the patient as a disincentive or National Action Alliance for Suicide Prevention 54 penalty for expressing suicidal thoughts. Suicide Prevention and the Clinical developed “ based clinical appr oaches that help to Evidence- 64 Workforce: Guidelines for Training “ Caring for .” 1) reduce suicidal thoughts and behaviors include: Adult Patients with Suicide Risk : A Consensus Cognitive Therapy for Suicide Prevention (CBT - 38 Guide ,” The Joint for Emergency Departments 55 -56 2) the Collaborative Assessment and SP), Commission’s Standards BoosterPak™ Suicide 19,57 and 3) Management of Suicide (CAMS), Risk for National Patient Safety Goal 15.01.01, the 58 In addition, Dialectical Behavior Therapy (DBT). DoD Clinical Practice QPR Institute and the VA/ 59-61 has a growing body of Caring Contacts Guideline Assessment and Management of for evidence as a post -discharge suicide prevention

5 Sentinel Event Alert 56 Issue Page 5 14 (2013) also are good Caring Patients at Risk for Suicide age 21 of docum entation checklist, see P resources. for Adult Patients with Suicide Risk: A Consensus 38 Guide for Emergency Departments . 8. Document decisions regarding the care and isk. referral of patients with suicide r Related Joint Commission requirements Thoroughly document every step in the decision- The advice provided in this alert applies making process and all communication with the universally to all patients in all settings. In addition, patient, his or her family members and significant since the risk of suicide increases after discharge others, and other caregivers . Document why the from emergency departments and inpatient patient is at risk for suicide and the care provided settings, it’s important for health care to patients with suicide risk in as much detail as organizations to incorporate appropriate transition possible, including the content of the safety plan -up actions in accordance with Provision and follow and the patient’s reaction to and use of it; of Care, Treatment, and Services accreditation discussions and approaches to means reduction; requirement The organization has a – 04.01.01 PC. -up activities taken for missed and any follow process that addresses the patient’s need for appointments, includi ng texts, postcards, and calls continuing care, treatment, and services after from crisis centers. Be generous in discharge or transfer . documentation, as it becomes the main method of communication among providers. For a equirement s r Joint Commission related to detecting and treating patients with suicide ideation -based surgery Behavioral health Ambulatory Home care Nursing care center Hospital Office Care, Treatment, and Services  CTS.02.01.01 Environment of Care  EC.02.01.01  EC.02.06.01 National Patient Safety Goal   NPSG.15.01.01, EPs 1, 2, 3 Performance Improvement  PI.01.01.01 Provision of Care, Treatment, and Services  PC.01.01.01 EP 24  PC.01.02.01  PC.01.02.13      PC.04.01.01 See the content of these standards on The Joint Commission website, posted with this . alert , from the Suicide and Quick Guide for Clinicians Resources Prevention Resource Center , from the Suicide Prevention Zero Suicide Toolkit Resource Center and the National Action Alliance , from the Harvard T.H. Means Matter website de Prevention for Suici Chan School of Public Health , from the Emergency -SAFE Materials ED Mental Health Environment of Care Checklist – Medicine Network inpatient mental health units for For reviewing , from the VA National environmental hazards – A Caring for Adult Patients with Suicide Risk Center for Patient Safety. Consensus Guide for Emergency Departments,

6 Issue Sentinel Event Alert 56 6 Page Veterans Affairs, Department of Defense, June 2013 – Suicide prevention courses and QPR Institute (accessed Jan. 10, 2016). training for professionals, institutions, and the 15. Mental Health America. Suicide . (Accessed May 18, public, on site or through a sel f-study program. 2015). American Foundation for Suicide Prevention. Key 16. T Pocket Card for C SAFE- linicians – Five -step . (Accessed May 31, 2015). research findings evaluation and triage for suicide assessment 17. Krysinska K, et al: Suicide behavior after a traumatic April -June a Nursing, Journal of Traum event. Suicide Prevention and the Clinical Workforce: 2009;16(2):103- 110. , from the Clinical Guidelines for Training 18. U.S. Preventive Services Task Force. Screening for Workforce Preparedness Task Force of the suicide risk in adolescents, adults, and older adults in National Action Alliance for Suicide Prevention primary care: recommendation statement. American Family -190I. 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7 56 Issue Sentinel Event Alert Page 7 Assessment and Follow -up Evaluation (ED -SAFE): method , February 2004;43(2):183- 190. Adolescent Psychiatry Will I be committed to a mental hospital if and design considerations. Contemporary Clinical Trials, 54. Freedenthal S. I tell a therapist about my Speaking of s? suicidal thought 24. September 2013;36(1):14- Suicide website (accessed July 28, 2015). . Developed by 9 (PHQ Patient Health Questionnaire- 33. -9) Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke 55. Brown GK, et al. Cognitive therapy for the prevention of and colleagues (accessed Aug. 17, 2015). suicide attempts: a randomized controlled trial. Journal of the Kroenke K, et al. 2: The Patient Health Questionnaire- 34. 570. 2005;294(5):563- American Medical Association, Medical Care . Item Depression Screener Validity of a Two- Stanley B, et al. 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Compliance & Value- November Based Care, Commission on patient safety issues and, with other 2. 2014;1- sources, advises on topics and content for Sentinel Event 48. Zero Suicide in Health and Behavioral Health Care. Alert . Members : James P. Bagian, MD, PE (chair); Frank . (Accessed May 31, 2015). de Risk Interventions for Suici (vice chair); Jane H. Barnsteiner, RN, Federico, BS, RPh 49. Pisani AR, et al. Assessing and managing suicide risk: ames B. Battles, PhD; William H. Beeson, MD; PhD, FAAN; J Core competencies for behavioral health professionals. Bona E. Benjamin, BS, Pharm; Patrick J. Brennan, MD ; University of Rochester, Copyright 2015. Todd Bridges, RPh; Michael Cohen, RPh, M S, ScD; Cindy 50. Douglas KS and Skeem JL. Violence risk assessment: -Sh Michael El Marilyn CPHQ; Dougherty, RN, BS, ammaa; Getting specific about being dynamic. Psychology, Public Flack; Steven S. Fountain, MD; Tejal Gandhi, M D, MPH, , September 2005;11(3):347- 383. Policy, and Law CPPS; Martin J. Hatlie, Esq; Robin R. Hemphill, MD, MP H; 51. Paris J. Chronic suicidality among patients with Jennifer Jackson, BSN, JD; Paul Kelley, CBET; Heidi B. borderline personality disorder. Psychiatric Services, June King, MS, FACHE, BCC, CMC, CPPS; Ellen Makar, MSN, 2002;(53)6:738- 742. ; Jane McCaffrey, MHSA, BC, CCM, CPHIMS, CENP RN- 52. Muralidharan S and Fenton M. Containment strategies N, MBA, MHS DFASHRM; Mark W. Milner, R ; Grena Porto, for people with serious mental illness. Cochrane Database of RN, MS, ARM, CPHRM; Matthew Scanlon, MD; Ronni P. Systematic Reviews, July 19, 2006. Solomon, JD; Dana Swenson, PE, MBA 53. Huey SJ, et al: Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies. Journal of the Am erican Academy of Child and

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