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Warning: ED is 'risky' for suicidal people
Patients may not tell you their intent
Minor respiratory complaints were all that a man reported to ED nurses at Hennepin County Medical Center in Minneapolis, but in fact, he was suicidal.
"The patient's nurse asked suicide risk questions, and the patient admitted to being very depressed due to his parent dying years ago," says Gregory Torok, RN. "He informed the nurse that he had means to hurt himself in his backpack that he had with him." The man was medically cleared and transferred to the hospital's acute psychiatric area, says Torok.
In early 2010, ED nurses implemented a suicide risk screening process, which is done after patients are placed in the room, he explains. "Patients may be experiencing suicidal thoughts that they don't want to admit to right away when they come into triage or the hospital," says Torok.
Carrie April, RN, BSN, an ED nurse at St. John's Mercy Medical Center in St. Louis, MO, cared for a patient with back pain who threatened to kill herself if she was not given pain medication. "The nurse was letting the doctor know this when the patient ran to the computer and tried to asphyxiate herself with the cord from the mouse," says April.
A person doesn't have to be a confirmed behavioral health patient to have suicidal ideations, says Helen Sandkuhl, RN, MSN, CEN, TNS, FAEN, director of nursing, emergency & trauma services at Saint Louis (MO) University Hospital. "It is also many times not the one primary ED complaint," Sandkuhl says.
ID at-risk individuals
A November 2010 Sentinel Event Alert from The Joint Commission warns that non-psychiatric patients are committing suicide in non-psychiatric units, including the ED. Of the 827 in-hospital suicides reported since 1995, almost 25% occurred in non-psychiatric settings, including EDs. (See resource box, below, on how to view the alert.)
In non-psychiatric settings, an individual may not be identified upfront as a behavioral health patient, notes Paul M. Schyve, MD, The Joint Commission's senior vice president of healthcare improvement. "One of the risky areas, therefore, becomes the ED," he says.
Rather than recommending that every single ED patient be screened, staff should be looking for "certain behaviors and situations that may indicate there is an increased risk of imminent suicide," Schyve says.
While a patient who appears severely depressed immediately would be associated with a suicide risk, patients who appear anxious, agitated, confused, intoxicated, or those with dementia are also at risk, Schyve says. "You are talking about a whole raft of things that could diminish somebody's judgment," he says.
Another at-risk group are ED patients with chronic pain or illnesses with a poor prognosis, says Schyve. "They may be imminently suicidal," he says. "Obviously if you see a combination of these, such as a patient with chronic pain along with anxiety, that just increases your concern."
If you identify these risk factors, your next step is to screen your patient for depression and suicide risk, Schyve says. He acknowledges that not everyone in the ED is trained to do this type of screening.
"There should be someone who is specially trained that they can call, if they see one of these behaviors, to come and see the patient," Schyve says. "This might be a psychiatric nurse, social worker, or an ED nurse with additional training provided by a psychiatrist in the hospital." (See related stories on assessing the room you place the patient in, below.)
For more information on suicidal ED patients, contact:
No seclusion? Remove these for suicidal patients
Seclusion rooms for suicidal ED patients aren't always available, notes Helen Sandkuhl, RN, MSN, CEN, TNS, FAEN, director of nursing, emergency, & trauma services at Saint Louis (MO) University Hospital.
"Depending on the number of patients present in the ED at any time, EDs may have to improvise," Sandkuhl says.
If you place an at-risk patient in an area other than an approved seclusion room, remove any item that the patient could use to hang themselves, including clothing, shoelaces, belts, sheets, curtains, and blinds, as well as items that can cause suffocation, such as trash liners or shower curtains, she says. "Always check the area for safety before placing the patient in the room," says Sandkuhl.