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Patient is suicidal? Inform all others
If ED nurses believe a patient poses a risk of harm to themselves or others, a patient safety checklist is used for "closed-loop" communication with security, says Alexandra Penzias, RN, MEd, MSN, CEN, clinical nurse educator in the department of emergency medicine at Tufts Medical Center in Boston, MA. "This ensures that all members of the ED team are aware of the patient's status and plan of care," she explains.
The checklist tells everyone on the ED team whether the patients may wear their own clothing, if they must be escorted when they leave their room or go to the bathroom, and whether the patient may move around in the room, says Penzias. [The checklist used by ED nurses is included.]
Patients are re-evaluated throughout their stay for changes in risk level, says Penzias. "If the nurse believes the patient is at heightened risk or is in possession of new contraband, the patient may be subject to an additional search," she adds. To alert others in the ED of potentially suicidal patients:
Use "visual alerts."
Saint Louis University Hospital's ED nurses place at-risk patients in disposable blue scrub suits. "This serves as a visual alert in case a patient who is a threat to themselves or others tries to elope," says Helen Sandkuhl, RN, MSN, CEN, TNS, FAEN, director of nursing, emergency and trauma services at Saint Louis (MO) University Hospital. "Once the patient is disrobed, the patient's clothing and personal belongings are placed in a secure location outside of the patient's room."
Minimize opportunities for elopement.
Patients may be angry, fearful, or agitated, notes Sandkuhl. "If your seclusion room is already in use, place the patient in an area that is away from exits, allows for easy observation, and an area with decreased stimulation," she says. "An example would be not to place the patient next to the resuscitation room."
Give at-risk patients 1:1 observation.
"The ED practices as a team, so maximize your resources," says Sandkuhl. "Make everyone aware that elopement could be possible while the patient is in the department." (See related story, below, on assessment of potentially suicidal patients.)
For more information on potentially suicidal ED patients, contact:
Vague complaints? Get more details
Do rapid screening
If your ED patient presents with generalized weakness, is disheveled, unable to make eye contact, has difficulty articulating the history of present illness, or has a history that is discordant with his or her presentation, more detailed questions regarding the patient's psychosocial well-being may be necessary, according to Alexandra Penzias, RN, MEd, MSN, CEN, clinical nurse educator in the department of emergency medicine at Tufts Medical Center in Boston, MA.
"Many patients with undiagnosed mental-health issues will present to the ED with vague physical complaints," notes Penzias. "It is only once the triage nurse has an opportunity to interact with the patient that we can identify some of the signs and/or symptoms of a mood-, thought-, or substance-related disorder."
For this reason, all ED patients are screened at triage for potential suicidality, says Penzias. "Patients deemed at risk are placed under immediate observation by a patient-care safety aide or an ED nurse," she explains.
If the patient is at risk, ED nurses facilitate rapid placement and removal of clothing and belongings, says Penzias. "We explain that all patients must be placed in a gown for medical evaluation, and facilitate a superficial physical search and search of their belongings for actual or potential weapons or other contraband," she says.
Searches are performed by an ED nurse and a member of the security staff, and belongings are catalogued and stored away from the patient until the patient is no longer considered at risk, says Penzias.
Screen all patients
Gregory Torok, RN, an ED nurse at Hennepin County Medical Center, says that all patients older than 18 years old admitted from the ED are screened for suicide risk. "We do not screen intoxicated patients to prevent the risk of false positives," he adds. "Critical patients are not screened due to their medical condition."
Helen Sandkuhl, RN, MSN, CEN, TNS, FAEN, director of nursing, emergency and trauma services at Saint Louis (MO) University Hospital, says ED nurses complete a brief screening tool for early and accurate identification of patients at risk. "This early identification results in improved treatment and patient outcomes," she says.
Recently, Sandkuhl cared for an intoxicated student who didn't initially reveal that he had also ingested an unknown amount of acetaminophen. "Alcohol acts as a depressant and may sometimes make a suicidal patient act out his ideations," she warns.