Assessing and managing suicide risk

2. LEARNING OBJECTIVE:
• 1. To know the importance of suicide prevention as part of the recognized organizational
practices and CBAHI ER Standard
• 2. To effectively assess patients and recognize who are at risk for suicide
• 3. to learn proper documentation of identified patients
• 4. to ensure patient safety upon triaging until management of patients at risk for suicide

3. AS AN ROP AND CBAHI REQUIREMENT
• has been identified internationally, as a fundamental safety issue among health care
organizations. A lack of information on documentation of suicide risk has been identified as a
common issue in reviews of cases where persons have died by suicide
• A standard requirement for addressing the immediate and ongoing safety needs of persons
identified as being at risk, and appropriately documenting risks and interventions in the
person’s health record
• ROP #30 Suicide Prevention under Patient Safety Area( Risk Assessment)
• CBAHI ER Standard 9.2.3 There is a policy and procedure on management of Suicidal Patient

4. DEFINITION:
• Attempted suicide: a suicidal act with non-fatal outcome
• Self-harm: is behavior damaging to one-self but not necessarily with the intention of resulting
in death. acts of self-harm, regardless of the extent of physical injury or the apparent reasons
for the act.
• Suicide: is a suicidal act with a fatal outcome.
• Risk factors: factors such as biological, physiological, social and cultural agents that are
associated with suicide/suicide ideation and increase their probability
• Suicidal ideation: thoughts about attempting or completing suicide.
(Definition taken from the policy : MC –PSY-P/01)

5. IDENTIFIED PATIENTS AT RISK IN ED
Dec 17
4.76%
Jan 18
4.32%
Feb 18
1.28%
Mar 18
1.58%
Apr 18
1.17% Percentage of patients identified
Dec-17 18-Jan 18-Feb 18-Mar 18-Apr
From a total of 12674 adult patients seen in emergency department, 344 were at risk for suicide.

6. START
TRIAGE
the patient by the nurse
HAS one or more:
1. Depression (New/Known)
2. Past Psychiatric History
3. Patient/Family Concern
4. Self Harm Behavior/Thoughts of Self
Harm
ED Physician to do Columbia Suicide Risk
Assessment Tool
YES
Continue with DEM
Management Process,
manage other psychiatric
disorders not associated with
suicidality
NO
Level
Categorize Patient
as Cat. 1
HIGH
Categorize Patient
as Cat 2/3
Accordingly
MODERATE
Discharge with
Appointment in
Psychiatric Clinic
MILD
Direct to
Psychiatry
Assessment
Room/Single
Waiting area to be
seen according to
his category
ED Physician Assessment
REFER to Psychiatrist Psych Management
END
FLOWCHART for ED
Suicide Risk Assessment

7. MANAGEMENT & RISK ASSESSMENT FOR IDENTIFICATIONS OF PATIENTS
AT RISK FOR SUICIDE
MC –PSY-P/01
1. To provide guidance for KSUMC in responding to client observation, allegation and
disclosures indicating self-harm and/or suicide
2. To ensure safety and prevent injury to patients with suicidal/self-harm
behavior/thoughts.

8. POLICY:
• 1. DEM triage nurse should screen and identify all clients at risk for suicide using the 4
yes/no
• 2. Dem triage physicians will assess patients for suicide by using the columbia-suicide
severity rating scale
• 3. The columbia-suicide severity rating scale should be completed for all admitted patients
in psychiatry wards by the admitting psychiatrist.
• 4. Each patient at risk for suicide should be assessed upon admission and reassessed every
24 hours, or as needs change.
• 5. The team addresses the immediate safety needs of patients who are identified as being at
risk of suicide.
• 6. Ensure patient safety during treatment and monitoring.

9. PROCEDURE
• If one or more questions answered with “yes”, the c-ssrs should be used.
• Known depression/new depression
• Past psychiatric history
• Patient/family concern
• Self-harm behavior/thoughts of self-harm
Dem triage physician/psychiatrist in clinic will use the c-ssrs) in esihi (adhoc-suicide folder)
Level of risk:
Mild = score<5
Moderate = score 5 – 7
High = score > 7

10. MANAGEMENT ACCORDING TO SCORE:
MILD MODERATE HIGH
DEM physician should manage
patient as category 4-5
DEM physician should manage
patient as category 2 -3
Immediately seen my DEM
physician manage patient as
category 1
DISCHARGE with urgent
appointment in psychiatric clinic
REFER to Psychiatrist on call Place patient in single room and
REFER to Psychiatrist on call
Psychiatrist on call to manage
the patient, and ensure safety
during treatment and montioring
Psychiatrist must place an order
for level of observations
Psychiatrist on call to manage
the patient, and ensure safety
during treatment and montioring
Psychiatrist must place an order
for level of observations

11. SAFETY NEEDS OF PATIENTS WHO ARE IDENTIFIED AS BEING AT RISK
FOR SUICIDE INCLUDE:
• “Routine Search Patient and Environment”
• Place patient in single room
• Remove all sharp items from patient access
• Educate the family not to bring any glass items
• Use plastic spoons and bone out meats for meals
• Removal of chest bra for female patients
• Prevent all types of strings in dressings of the patient
• All shampoos, soap and razors are kept in a locked cabinet under strict supervision
• Regular and random checking of patient’s bedside cabinet in all shifts.

12. All patients placed on suicidal precautions will be assigned an acuity level based upon the severity of
the suicidal thoughts, plan or behaviour/Columbia-Suicide Severity Rating Scale
SUICIDE LEVELS OF OBSERVATION:
Responsibility Procedure
Nurse 30M OBSERVATION
Least restrictive toward the patient, involves continuous monitoring every 30 minutes and
documentation on the Nursing Observation Record
Assess and document the level of suicidal thoughts every shift to warrant the patient
remaining on such observation or allowing the physician to discontinue the precautions
based upon this assessment

13. Nurse 15M OBSERVATION
Moderately restrictive toward the patient, involves continuous
monitoring every 15 minutes on the Nursing Observation Record
Nursing personnel must be within eyesight of the patient at all times
except for toileting and showering where the staff be within hearing range
Assess and document the level of suicidal thoughts every shift to
warrant the patient remaining on such observation or allowing the
physician to discontinue the precautions based upon this assessment

14. NURSE LINE OF SIGHT OBSERVATION
very restrictive toward the patient, involves continuous monitoring at all time
Staff must be within visual contact at all tomes with the exception of toileting and
showering during which times staff shall be outside a door left ajar
Staff may observe more than one patient on line of sight observation only while those
patients remain in an area for scheduled activity, if one or more patient go to separate
areas, the staff must transfer responsibility for line of sight to other staff so that there is
continuous observation of patients on line of sight.
Nurse must maintain a continuous log which indicates the patient’s location every 15
minutes and documents the patient’s thought and behaviour throughout each shift.
Patient on this level are considered high risk and documentation must reflect the need
for re-categorized to another level

15. Nurse 1-to-1 observation at all times
most restrictive, involves continuous monitoring and physical proximity to the
patient at all times.
Staff must be within arm’s reaching at all times including toileting and showering.
Nurse must maintain a continuous log which indicates the patient’s location every
15 minutes and documents the patient’s thought and behaviour throughout each
shift.
Patient on this level are considered high risk and documentation must reflect the
need for re-categorized to another level

16. TREATMENT STRATEGIES:
• Psychiatrist should establish and maintain a therapeutic alliance:
attempt to build trust, establish mutual respect and develop a therapeutic relationship with the patient
• The team should attend to the patient’s safety, call security in need
• Determine a treatment setting
• Develop a plan of treatment that integrates a range of biological and psychosocial therapies may increase the
likelihood of a successful outcome.
• Coordinate care and collaborate with other clinicians
• Promote adherence to the treatment plan
• Provide education to the patient and family
• Reassess safety and suicide risk
• Monitor psychiatric status and response to treatment
• Obtain consultation
• Attending nurse to log all patients at risk for suicide in the “Registry”

18. • The most evidence-supported tool of its kind, is a simple series of questions that anyone can use anywhere
in the world to prevent suicide.
• Efficient. Use of the scale redirects resources to where they’re needed most. It reduces unnecessary
referrals and interventions by more accurately identifying who needs help — and it makes it easier to
correctly identify the level of support a person needs, such as patient safety monitoring procedures,
counseling, or emergency room care.
• Effective. Real-world experience and data show the scale has helped prevent suicide.
• Evidence-supported. An unprecedented amount of research has validated the relevance and effectiveness
of the questions used in the C-SSRS to assess suicide risk, making it the most evidence-based tool of its
kind.
• Universal. The C-SSRS is suitable for all ages and special populations in different settings

19. TRIAGE:

25. REFERENCES:
• Http://www.Who.Int/mental_health/suicide-prevention/en/
• http://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3893686/
•