Identifying patients at risk for suicide has been a requirement of the National Patient Safety Goals since 2007. Since that time, inpatient suicide remains the second most frequently reported sentinel event to The Joint Commission, after wrong-site surgery.
Those patients who arrive at the hospital with a primary diagnosis of an emotional or behavioral disorder must be assessed for their suicide risk, and it's important to document well that the assessment occurs, said Sharon Chaput, RN, C, CSHA, director of standards and quality management at the Brattleboro (VT) Retreat, during a recent HCPro audio conference.
"We all know documentation is critical for risk management and legality issues, but it's also a communication vehicle, and we want to ensure that all members of the treatment team have a very clear picture of the patient's risk level," said Chaput.
Chaput and Tasha Farrar, MD, medical director of outpatient services at the Brattleboro Retreat, spoke on the program titled "Suicide Risk Assessment: Comply With The Joint Commission's National Patient Safety Goal and Keep Your Patients Safe."
The components of a suicide risk assessment, as recommended by the American Psychiatric Association, include looking at whether the patient has any psychiatric illness, family history of suicide or personal history of attempted suicide, individual strengths and vulnerabilities, as well as looking at the patient's psychosocial situation.
Documentation
Times to document a suicide risk assessment include:
- At the first psychiatric assessment or admission
- With the occurrence of any suicidal behavior, ideation, or statements
- Whenever there is a noteworthy clinical change
In addition, for those working in an inpatient psychiatric setting, documentation is important prior to increasing privileges, issuing passes, and discharge, said Chaput. Also, documenting whether firearms are present in the home is of the utmost importance.
"It's extremely important if they're present to always remember to document the instructions given to family or guardians, such as 'Removal of guns from the home,' " said Chaput. "If the patient or client states that they do not have firearms or access to firearms, please be sure to also document that you were informed during the assessment that there were no firearms available to the patient after discharge."
To help staff members remember what to document in a suicide risk assessment, Chaput recommends using the acronym SLAP, which stands for:
- Suicidality: Does a patient have active or passive suicidal ideation?
- Lethality: How lethal/serious is the suicide plan?
- Availability: Is the patient's plan for suicide available to him or her?
- Plan: What is the plan of action for the patient's team of caregivers?
Suicide risk scales
Suicide risk scales can be great tools for caregivers who do not specifically have a behavioral health background to assess a patient's suicide risk. These tools work well for patients who are admitted through the ED.
Chaput recommended using the well-known SADPERSONS scale, an acronym originally developed by William Patterson and published in the journal Psychosomatics, which assigns a point for each positive response for certain risk factors.
Suicide contracts
Although suicide contracts are commonly used, they have not been proven to reduce suicide, said Chaput, and cannot be considered a legal document. However, if there is a positive therapeutic relationship, contracts can be helpful.
"Suicide contracts can be a very useful tool to help you determine risk and also to counsel the patient, but they do not necessarily protect you or your organization from citation or reduce liability issues," said Farrar. A suicide contract is really a method for gathering information as well as a way of measuring the patient's risk of committing suicide.
Farrar gave the example of a patient expressing depressed and suicidal thoughts. Farrar would ask that patient about her thoughts and also whether she could commit to seeking care when she has strong thoughts about hurting herself before acting on them.
"Now what I just asked her to do is, in a roundabout way, a suicide contract," said Farrar. "But it is primarily an information-gathering tool. She may say, 'Yes, Dr. Farrar, I do have these thoughts, but I don't think I'm going to act on them. They build up slowly, but I do know that if they came back, I would call you or an emergency hotline or go to an emergency room.' She has, by definition, just contracted for safety."
To read more about evaluating a patient's risk for suicide, please see the April issue of Briefings on Patient Safety, a product of Patient Safety Monitor.
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Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing hcomak@hcpro.com.