The goal of National Patient Safety Goal 15.01.01 is for health care professionals to identify individuals at risk for suicide (The Joint Commission, 2012). “Suicide of an individual served while in a staffed, round-the-clock care setting is a frequently reported type of sentinel event. Identification of individuals at risk for suicide while under the care of or following discharge from a health care organization is an important step in protecting these at-risk individuals” (The Joint Commission, 2012). This presentation will focus on the emergency department “ED” where most patients enter a hospital. In one study in Ireland it was determined that for 45% of all deliberate self-harm patients the emergency department was their only treatment setting (Doyle, Keogh, & Morrissey, 2007). The scope and severity is broad because for patients exhibiting suicidal behavior the Emergency Department “ED” is often their first point of health care access and they could be discharged from the ED without being admitted to the hospital so the ED staff may be the only healthcare providers the patient sees
Emergency Department visits for attempted suicide and self-inflicted injury has increased over the past two decades. According to statistics “the average annual number for these ED visits more than doubled from 244,000 in 1993–1996 to 538,000 in 2005–2008” (Sarah,Ashley,Edwin,Ivan, & Carlos, 2012). Another problem is that if the patient does not received adequate follow-up care, they are at a higher risk for attempting suicide again. Up to 25% of suicide attempters seen in the ED end up making another suicide attempt (Larkin & Beautrais, 2010). “Most reattempts after an index visit for suicide attempt occur within 3 months; hence, interventions must be initiated promptly after ED discharge and sustained for several months if they are to have meaningful impact on suicide reattempt rates” (Larkin & Beautrais, 2010). (Image from http://www.suicide.org/international-suicide-statistics.html).
In order to meet NPSG 15.01.01 the nurse must: Conduct a risk assessment to identify specific characteristics that increase or decrease the risk for suicide; address the immediate safety needs of the patient; determine the appropriate treatment; and provide the patient with prevention information to them and their family. “The requirement under this safety goal is that a suicide risk assessment will be done in the receiving ED and appropriate precautions will be taken. There are several cases in The Joint Commission’s sentinel event database of suicides in emergency departments while the patients were awaiting transfer” (The Joint Commission, 2008).
The IOM has six aims: Safe, Effective, Patient/Family-centered, Timely, Efficient and Equal Care(Crossing the Quality Chasm, 2001). Each of the studies and interventions meet different IOM Aims. SAFE VET meets IOM Aims because it is safe, timely and equal. SAFE VET promotes a safe environment, provides services to those who will benefit, can be initiated in a timely manner and does not discriminate. Providing mental health nursing education falls under the IOM Aims for family-centered care as it ensures that patient values guide all clinical decisions. Universal screening and the wraparound safety system falls under the IOM Aims for safe, effective, family-centered, timely, and efficient care. This system avoids injuries to patients, is based on doing the right thing for the right person, provides care that is responsive to patient needs, is timely and avoids waste. Finally, the postcards and follow-up phone calls are effective, timely, efficient and equal. The postcards have been proven effective, can be sent timely, are efficient and do not discriminate. The follow-up phone calls take safety into consideration, can be done within one month of discharge which is timely, are efficient and do not discriminate.
The SAFE VET project is an innovative project by the Department of Veterans Affairs designed to prevent suicides by veterans. This project involved four areas for health care workers in the emergency department to address: Means restriction;Teaching brief problem-solving and coping skills (including distraction);Enhancing social support and identifying emergency contacts; andMotivational enhancement for further treatment. SAFE VET is “An innovative project (SAFE VET) designed to help suicidal veterans in emergency departments in the Department of Veterans Affairs (VA) (that) has been successfully implemented in 5 intervention sites” (Knox, et. al, 2012). Processes to measure the outcome of SAFE VET include collecting statistics on suicide rates after implementation of SAFE VET. This project meets the IOM Aims as it is safe, provides timely follow-up and does not discriminate (i.e. it is equal).
In the study “Caring for patients with suicidal behaviour: an exploratory study”, nurses at a large hospital emergency department in Ireland filled out questionnaires to determine the challenges they faced when dealing with suicidal patients. In the ED psychiatric liaison services were only available from 9am – 5pm while presentations of self-harm took place around midnight. Emergency nurses ended up having to care for patients without any psychiatric help and felt unprepared to deal with suicidal patients. The study found that nurses did not care for the patient’s psychological well-being because they did not believe displaying “empathy” and “understanding” was part of their role. Nurses felt they lacked the necessary skills to care for suicidal patients including as they did not have the skills to communicate with “uncooperative”, manipulative” or “distressed” patients. They also reported insufficient resources such as not enough psychiatric beds. The study determined that ED nurses need specialized education in mental health nursing in order to care for this population (Doyle, Keogh & Morrissey, 2007). This study falls under the IOM Aim for family-centered care as it ensures that patient values guide all clinical decisions.
In order to meet goal 2, hospitals must implement a universal screening program. “Waiting until the patient is seen for treatment is too late, because the patient may commit suicide while in the waiting room” (Healthcare Risk Management, 2011). Hospitals should implement a “wraparound safety system” for any patients identified as a suicide risk so that the patient is never left alone. “The triage person makes sure that another nurse is in the room before leaving. From that point on, the patient is never left alone until discharge or it is determined that” (Healthcare Risk Management, 2011). Education should be provided to the family about what can be brought into the patient’s room so that the patient is not given items they could harm themself with. One final policy is that certain patients are coded as risk for suicide based on certain characteristics. “The Sanford Health ED now has a policy of considering every patient who comes in with a drug overdose to be high risk for suicide, whether the overdose was thought to be intentional or accidental” (Healthcare Risk Management, 2011). This program falls under the IOM Aims for safe, effective, family-centered, timely, and efficient care.
A study in France set out to determine “the effects over one year of contacting patients by telephone one month or three months after being discharged from an emergency department for deliberate self poisoning compared with usual treatment” (Vaiva & Meyer, 2007). From 13 emergency departments, 605 people who had attempted suicide were studied. In the study, psychiatrists who had not previously met the participants telephoned them to find out if they were doing the recommended treatment regime they were given. They also asked them if they had attempted to commit suicide again since they had presented to the ED. The study showed that “contacting people by telephone one month after attempted suicide may help reduce the proportion of people who reattempt suicide” (Vaiva & Meyer, 2007). In conclusion, according to the study, contacting patients by telephone one month after attempted suicide may reduce the number of patients who reattempt suicide. In order to meet the third goal of NPSG 15.01.01 patients at risk for suicide should be referred for telephone follow-up after discharge from the ED. This intervention meets the IOM Aims as it is effective, timely, efficient and equal.
In order to meet safety goal 3, patients who present to the ED with attempted suicide should receive follow-up care that includes postcards. A study in Australia in which patients who had attempted suicide were sent postcards at 1, 2, 3, 4, 6, 8, 10, and 12 months showed a decreased rate of repeated hospitalization due to attempted suicide. “This study of hospital-treated self-poisoning showed that a low-cost postcard intervention was effective in reducing the number of events per individual by a relative reduction of more than 50%. The postcard intervention continued to be effective in reducing repeat episodes of hospital-treated self-poisoning for 1 year after the intervention ceased” (Carter, Clover, Whyte, Dawson & D'Este, 2007). The benefits of postcards are that they are easy to send and are also low-cost. The following powerpoint shows a sample of one of the postcards that was sent. This intervention meets IOM Aims as it is effective, timely, efficient and equal. The postcards have been proven effective, can be sent timely, are efficient and do not discriminate.
Above is a sample postcard that was sent to patients who had presented to the ED with attempted suicide. The study showed that these postcards were not only successfully but also quick and low-cost (Carter, Clover, Whyte, Dawson& D'Este, 2007).
In order to meet National Patient Safety Goal 15.01.01 ED nurses must identify patients at risk for suicide, provide for the safety needs of those patients, and have a method of prevention. Studies show that to meet these goals hospitals can put programs into place such as SAFE VET, universal screening and wraparound safety systems, provide telephone follow-up to suicide risk patients, and introduce mental health training to nurses. Nurses should pay particular attention to certain populations at risk such as the elderly and those who have previously attempted suicide. (Image from http://www.wellsphere.com/healthcare-industry-policy-article/joint-commission-2009-national-patient-safety-standards-reality-compared-with-expectations/540411).
Quality presentation: Suicide in the emergency department
National Patient Safety Goal 15.01.01 Identify individuals at risk for suicide. Julie-ann Forrester Nursing Quality
Summary of National Patient Safety Goal “NPSG” 15.01.01 and Scope and Severity• NPSG Goal 15.01.01 is for health care professionals to identify individuals at risk for suicide.• This presentation will focus on the Emergency Department “ED”.• This is where most patients enter a hospital.• The ED staff may be the only healthcare providers patients see if they are discharged.
Scope and Severity Continued• The number of ED visits for attempted suicide has more than doubled in the last decade.• Up to 25% of suicide attempters seen in the ED end up making another suicide attempt.• Interventions must be initiated promptly after the ED because most suicide reattempts happen within 3 months of discharge.
Quality Improvement Initiatives for NPSG 15.01.01In order to meet NPSG 15.01.01 the nurse must:Goal 1) Conduct a risk for suicide assessment.Goal 2) Address the immediate safety needs of the individual.Goal 3) Provide suicide prevention information at discharge.
Initiatives to meet NPSG 15.01.01• The SAFE VET program to meet all three goals.• Specialized education in mental health nursing to meet goal 1.• Universal screening program and wraparound safety system to meet goals 1 and 2.• Telephone follow-up/postcards to patients to meet goal 3.
How the Initiatives meet IOM Aims• To meet the IOM’s six aims these initiatives provide: • Safe Care: Prevent patient’s at risk for suicide from injuring themselves. • Effective Care: Provide services to patients identified as a suicide risk and focus interventions on these patients. • Patient/Family-centered Care: Provide respectful and responsive care and involve the family by informing them of objects they should not bring to the hospital • Timely Care: Prevent harmful delays by identifying those at risk for suicide. Also follow-up phone calls are provided within one month of discharge. • Efficient Care: Postcards can be sent quickly without creating waste. • Equal Care: Unbiased care that does not discriminate. http://hospitals4health.files.wordpress.com/2011/09/frame-work-succes-graphic4.gif?w=1024&h=326
Initiative 1: Suicide Prevention in Veterans in the Emergency Department: SAFE VET• A project at the Department of Veterans Affairs has been successful in preventing suicide.• This project involved: • Identifying those who are moderate to high suicide risk • Providing them with impatient mental health services • Referring them to intensive outpatient follow-up care• 93% of Veterans studied agreed to use the SAFE VET intervention.
Initiative 2: “Caring for patients with suicidal behaviour: an exploratory study”• Study in Ireland at a large hospital ED department• The study determined that because of lack of psychiatric services, ED staff lacked skills on how to communicate with suicidal patients.• This can hinder the ability of the nurses to do a thorough risk assessment.• The study results show that nurses need specialized education in mental health nursing.
Initiative 3: Universal Screening Program and Wraparound Safety System• In order to address the immediate safety goals of the patient (goal 2) hospitals should implement a universal screening.• This program should include a wraparound safety system in which the patient is never left alone• It should also include education to the family about items that the patient could use to harm themselves.• Finally, certain patients should be labeled high suicide risk.
Initiative 4: Effect of Telephone Contact on Further Suicide Attempts• According to the study “People who have attempted suicide are at high risk of further attempts or completing suicide within a year.” (Vaiva & Meyer, 2007).• People who attempted suicide were contacted by telephone one month and three months after discharge from the ED.• Telephone contact enabled the detection of people at high risk for future suicide attempts.• Patients at risk for suicide who are seen in the ED should be referred for telephone follow-up (meeting the third goal of NPSG 15).
Initiative 5: Postcards from the Edge• In order to meet goal 3, patients who present to the ED with attempted suicide should receive follow-up care that includes postcards.• A study in which postcards were sent to patients at 1, 2, 3, 4, 6, 8, 10 and 12 months showed a decreased rate of repeated hospitalization.• Postcards are easy to send and low-cost.
Initiative 5: Postcards from the Edge: Postcard Example
Conclusion• In order to meet National Patient Safety Goal 15.01.01 ED nurses should: • Utilize the SAFE VET program as a guide; • Undergo mental health training; • Provide universal screening; • Use a wraparound safety system so the patient is never left alone; and • Refer patients to telephone follow-up or send postcards to patients.
References• Carter, G., Clover, K., Whyte, I., Dawson, A., & DEste, C. (2007). Postcards from the EDge project: randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning. BMJ: British Medical Journal (International Edition), 331(7520), 805-807. doi:10.1136/bmj.38579.455266.E0• Crossing the quality chasm : a new health system for the 21st century / Committee on Quality Health Care in America, Institute of Medicine. (2001). Washington, D.C. : National Academy Press, c2001.• Doyle, L., Keogh, B., & Morrissey, J. (2007). Caring for patients with suicidal behaviour: an exploratory study. British Journal Of Nursing (Mark Allen Publishing), 16(19), 1218-1222.• The Joint Commission. (2012). 2012 hospital national patient safety goals. Retrieved from http://www.jointcommission.org/assets/1/6/2012_NPSG_HAP.pdf.
References Continued• The Joint Commission. (2012). National patient safety goals effective January 1, 2012. Retrieved from http://www.jointcommission.org/assets/1/6/NPSG_Chapter_Jan2012_BHC.pdf.• The Joint Commission. (2008). Suicide Risk Reduction - NPSG - Goal 15 - 15.01.01. Retrieved from http://www.jointcommission.org/mobile/standards_information/jcfaqdetails.aspx?Stan dardsFAQId=166&StandardsFAQChapterId=77.• Knox, K. L., Stanley, B., Currier, ,. W., Brenner, L., Ghahramanlou-Holloway, M., & Brown, G. (2012). An Emergency Department-Based Brief Intervention for Veterans at Risk for Suicide (SAFE VET). American Journal Of Public Health,102(S1), S33- S37. doi:10.2105/AJPH.2011.300501• Larkin, G., & Beautrais, A. L. (2010). Emergency departments are underutilized sites for suicide prevention. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 31(1), 1-6. doi:10.1027/0227-5910/a000001
References Continued• Pompili, M., Innamorati, M., Serafini, G., Forte, A., Cittadini, A., Mancinelli, I., & ... Tatarelli, R. (2011). Suicide Attempters in the Emergency Department Before Hospitalization in a Psychiatric Ward. Perspectives In Psychiatric Care,47(1), 23-34. doi:10.1111/j.1744-6163.2010.00263.x• Sarah A., T., Ashley F., S., Edwin D., B., Ivan, M., & Carlos A. Camargo, J. r. (n.d). Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993–2008. General Hospital Psychiatry, doi:10.1016/j.genhosppsych.2012.03.020• Suicides in the hospital: the liability risk nobody wants to talk about: most prevention focused on psych care, but ED also is high risk for suicides. (2011). Healthcare Risk Management, 33(3), 25-28.• Vaiva, G. G., Ducrocq, F. F., & Meyer, P. P. (2007). Psychiatric telephone contact following emergency department discharge reduces suicide re-attempts in people originally admitted for attempted suicide. Evidence Based Mental Health,10(1), 19