[Insert
Hospital
Logo]
I.
[Insert Name of Manual]
Title:
SUICIDE RISK ASSESSMENT
No.
Page:
Origination Date:
05-01-11
Effective Date:
Retires Policy Dated:
Previous Versions Dated:
Governing Board
Approval Date:
Medical Staff
Approval Date:
CO-2.027
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SCOPE:
This policy applies to [insert name of Hospital] (“Hospital”).
II.
PURPOSE:
The purpose of this policy is to describe the process for assessing for risk and developing a plan
of care for patients thirteen years of age or older with suicidal ideation.
Risk factors for suicide include but are not limited to:
III.
IV.
A.
Psychosocial Factors: history of suicide attempt, history of deliberate self harm,
comorbid alcohol and other substance disorders, current or past psychiatric
disorders particularly mood disorders, schizophrenia, anxiety, and personality
disorders, history of trauma or physical or sexual abuse, major physical illness,
chronic pain, family history of suicide, history of violent or aggressive behavior.
B.
Environmental Factors: triggering event leading to humiliation, despair, loss (job,
financial, relational, social), easy access to firearms or other lethal means.
DEFINITIONS:
A.
“Suicidal patient” is one who has recently made an attempt in the last 12 months
or has expressed the desire/compulsion to attempt to end his or her own life or is
intending to end his or her own life in the near future.
B.
“Risk Factors” are psychological or environmental factors as described in
Section II., above.
POLICY:
The approach to the care of the suicidal patient is multidisciplinary. At a minimum, all patients
aged thirteen years or older entering the Emergency Department for care or admitted to the
Hospital who present with a behavioral health related complaint or shows signs/symptoms of
being a self harm risk will be screened using the following three screening questions:
1.
Have you been feeling depressed in the last couple of weeks?
2.
Are you feeling hopeless to the extent that you would want to end your life?
3.
Have you attempted suicide or had a plan to attempt within the last 12 months?
[Insert
Hospital
Logo]
[Insert Name of Manual]
Title:
SUICIDE RISK ASSESSMENT
No.
Page:
Origination Date:
05-01-11
Effective Date:
Retires Policy Dated:
Previous Versions Dated:
Governing Board
Approval Date:
Medical Staff
Approval Date:
CO-2.027
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A “yes” answer to any of the three questions puts the patient at risk of suicide and will require
further assessment by a physician or other qualified mental health personnel (QMP) as
recognized in the Hospital Medical Staff Bylaws/Rules, Regulations and Policies to determine
the patient’s level of risk. The assessment completed by the physician or other qualified mental
health provider will determine the interventions and monitoring necessary to maintain patient
safety. Until the patient receives his or her in-depth assessment, performed by the physician or
other qualified mental health provider, the nursing staff will use the Environment Patient Safety
Checklist to ensure that the patient has been provided a safe environment (see Attachment A).
The nursing staff will place the patient on [insert hospital-specific precautions here] and use
the Behavior/Close Observation Flowsheet to document observation following the Hospital
protocol (see Attachment B).
V.
PROCEDURE:
A.
Emergency Department
1.
At a minimum, a Registered Nurse will complete a suicide risk screen on
all patients 13 years of age or older who present with a behavioral health
related primary complaint or who exhibit signs/symptoms of self harm
during the triage process in the Emergency Department.
2.
If patients that are 13 years of age or older who present with a behavioral
health related complaint or show signs/symptoms of being a self harm risk
respond yes to any of the three screening questions, a full Suicide Risk
Assessment will be completed. Physicians and QMP recognized in the
Hospital Medical Staff Bylaws/Rules, Regulations and Policies to do these
assessments may utilize the tool provided in Attachment C. The result of
the assessment will determine the level of risk and corresponding
monitoring and interventions required to maintain patient safety.
3.
If the patient cannot be assessed upon arrival due to the patient’s medical
status, i.e., the patient is unconscious, intubated, intoxicated or mentally
unable to respond, the assessment will be postponed until the patient can
be assessed. This assessment should be performed as soon as the patient’s
condition permits. Any concerning or contributing history or
circumstances that might indicate an increased risk of suicide shall be
communicated to all Hospital personnel involved in the care of the patient.
[Insert
Hospital
Logo]
[Insert Name of Manual]
Title:
SUICIDE RISK ASSESSMENT
4.
B.
No.
Page:
Origination Date:
05-01-11
Effective Date:
Retires Policy Dated:
Previous Versions Dated:
Governing Board
Approval Date:
Medical Staff
Approval Date:
CO-2.027
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Emergency Department Documentation
a.
The suicide risk screen will be integrated into the documentation
process.
b.
If indicated, the suicide assessment will be completed within
MEDHOST or similar emergency documentation system where
applicable.
c.
The nursing staff must complete the Environment Patient Safety
Checklist for a patient at risk of suicide at the beginning of every
shift (see Attachment A). The nursing staff will place the patient at
risk for suicide on [insert hospital-specific precautions here].
d.
A Behavior/Close Observation Flowsheet (see Attachment B) is
required for at-risk patients and the frequency of documentation
will be dictated by the level of risk and Hospital protocol.
Inpatient Procedure
1.
At a minimum, all patients admitted to the Hospital 13 years of age or
older with a behavioral health related chief compliant or shows
signs/symptoms of self harm risk will be screened for suicide risk using
the suicide risk screening questions; this screen is integrated into the initial
patient assessment.
2.
For patients who are 13 years of age or older and who present with a
behavioral health complaint or show signs/symptoms of being a self harm
risk and who respond yes to any of the three screening questions, the full
suicide risk assessment will be completed by a physician or QMP as
defined in the Hospital Medical Staff Bylaws/Rules, Regulations and
Policies. The physician or QMP may utilize the tool in Attachment C to
complete the assessment. The result of the assessment will determine the
level of risk along with corresponding monitoring and interventions
required to maintain patient safety. The nursing staff will use the
Environment Patient Safety Checklist and Behavior/Close Observation
Flowsheet with the patient on [insert hospital-specific precautions here]
until the assessment is complete (see Attachments A and B).
[Insert
Hospital
Logo]
[Insert Name of Manual]
Title:
SUICIDE RISK ASSESSMENT
3.
No.
Page:
Origination Date:
05-01-11
Effective Date:
Retires Policy Dated:
Previous Versions Dated:
Governing Board
Approval Date:
Medical Staff
Approval Date:
CO-2.027
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When a patient is determined to be at risk for suicide through screening,
regardless of the level of risk, the patient’s safety is maintained by the
following:
a.
The patient’s environment is secured using the Environment
Patient Safety Checklist at a minimum of every shift (see
Attachment A).
b.
A patient with suicidal risk will be admitted to the appropriate
level of care based on his or her medical needs.
c.
The rationale and plan for establishing safety is explained to the
patient.
d.
In the event that a gun or other deadly weapon is discovered during
the search of a patient, Hospital Security will be called
immediately to assist and secure the weapon (see Security Policy
2.43 Firearms/Dangerous Weapons).
4.
The nursing staff notifies the patient's physician of the need for suicide
precautions as soon as possible following implementation.
5.
A patient who is suspected of self-harm but is unconscious, comatose or
unresponsive due to his or her medical condition requires frequent
assessments by the RN for change in level of consciousness. As soon as
the patient regains consciousness, the patient will be screened for suicidal
risk and, if appropriate, assessed for level of risk and appropriate level of
suicide precaution.
6.
Implement close observation process using the form in Attachment B for
level of risk.
7.
Notify the physician and receive consult for appropriate assessment by
psychiatrist or QMP as approved by the Hospital’s Medical Staff Bylaws/
Rules, Regulations and Policies.
8.
Once initiated, only a psychiatrist or mental health provider as approved
by the Hospital’s Medical Staff Bylaws/Rules, Regulations and Policies
may discontinue or reduce suicide precautions. If a psychiatrist or mental
health provider is unavailable, changes to a patient’s risk level and
[Insert
Hospital
Logo]
[Insert Name of Manual]
Title:
SUICIDE RISK ASSESSMENT
No.
Page:
Origination Date:
05-01-11
Effective Date:
Retires Policy Dated:
Previous Versions Dated:
Governing Board
Approval Date:
Medical Staff
Approval Date:
CO-2.027
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interventions may only be made through a consensus between the patient’s
nurse, physician, and social worker (if available).
9.
Recommended interventions based on level of risk as assessed in the
medical screening exam by a psychiatrist or QMP as approved by the
Hospital’s Medical Staff Bylaws/Rules, Regulations and Policies:
a.
Not at Risk: No intervention necessary.
b.
Low Risk:
c.
(1)
Notify physician
(2)
Conduct hourly safety checks
(3)
Search all patient belongings and remove those items which
are deemed hazardous to the patient
(4)
Place patient close to nurse’s station
(5)
Place sign on door requiring visitors to check-in with nurse
(6)
Search any bags brought by visitors and remove any
hazardous items. Contact Hospital Security
(7)
Update Plan of Care
(8)
Patient is accompanied by staff 1:1 for any off unit
activities
Moderate Risk: Implement all of the interventions for low risk
patients, as well as:
(1)
Remove personal belongings that pose a safety issue (shoe
laces, belts, etc.)
(2)
Observe every 15 minutes
(3)
Complete family/visitor education
[Insert
Hospital
Logo]
[Insert Name of Manual]
Title:
SUICIDE RISK ASSESSMENT
d.
10.
No.
Page:
Origination Date:
05-01-11
Effective Date:
Retires Policy Dated:
Previous Versions Dated:
Governing Board
Approval Date:
Medical Staff
Approval Date:
CO-2.027
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(4)
Place patient in a room where continuous, direct line of
sight visual observation and monitoring is maintained at all
times by trained staff
(5)
No curtains are to be drawn unless staff is in the room with
the patient
(6)
RN will stay with patient during medication administration
to ensure patient has taken all medications and is not
stockpiling medications for future use
(7)
Refer to Social Service
(8)
Patients on suicide precautions may be cohorted to
facilitate patient monitoring
High Risk: Implement all of the interventions for low and
moderate risk patients as well as:
(1)
Place patient in a room where 1:1 monitoring at the
patient’s bedside is maintained at all times by trained staff
(2)
The patient is restricted to the unit
(3)
For any medically necessary transport to other departments
(i.e., radiology, surgery) the patient will have 1 staff
member accompany at all times
(4)
Visitors may be supervised until the RN has determined the
benefit to the patient or therapeutic nature of the visit
Inpatient Documentation:
a.
Admitted patients will have the suicide screen documented as part
of the initial assessment/screening form.
b.
The nursing staff will use the Environment Patient Safety
Checklist (Attachment A) to document securing the patient’s
environment and complete each shift.
[Insert
Hospital
Logo]
C.
[Insert Name of Manual]
Title:
SUICIDE RISK ASSESSMENT
No.
Page:
Origination Date:
05-01-11
Effective Date:
Retires Policy Dated:
Previous Versions Dated:
Governing Board
Approval Date:
Medical Staff
Approval Date:
CO-2.027
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c.
The nursing staff will document the patient’s behavior and activity
on the Behavior/Close Observation Flowsheet (Attachment B).
d.
Admitted patients at risk for suicide may have an assessment
performed and documented on the Suicide Assessment Form
(Attachment C).
e.
Clinical status of the patient will be documented along with
changes in physical or emotional condition on the Behavior/Close
Observation Flowsheet (Attachment B).
Auditing and Monitoring
The Clinical Quality Department shall audit adherence to this policy in its
Comprehensive Clinical Audits.
D.
Responsible Person
The Nursing Department Directors are responsible for ensuring that all
individuals adhere to the requirements of this policy, that these procedures are
implemented and followed at the Hospital and that instances of non-compliance
with this policy are reported to the Chief Nursing Officer. The Risk Manager is
responsible for ensuring that all individuals adhere to the requirements of this
policy reported to the
E.
Enforcement
All employees whose responsibilities are affected by this policy are expected to
be familiar with the basic procedures and responsibilities created by this policy.
Failure to comply with this policy will be subject to appropriate performance
management pursuant to all applicable policies and procedures, including the
Medical Staff Bylaws/Rules and Regulations.
VI.
REFERENCES:
- Jacobs D, Screening for Mental Health, A Resource Guide for Implementing the Joint
Commission 2007 Patient Safety Goals on Suicide
- Suicide Risk: A Guide for ED Evaluation and Triage Substance Abuse and Mental Health
Services Administration (SAMHSA), U.S. Department of Health and Human Services,
September 2010
[Insert
Hospital
Logo]
[Insert Name of Manual]
Title:
SUICIDE RISK ASSESSMENT
No.
Page:
Origination Date:
05-01-11
Effective Date:
Retires Policy Dated:
Previous Versions Dated:
Governing Board
Approval Date:
Medical Staff
Approval Date:
CO-2.027
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- Joint Commission Alert: Suicides – a Risk in the ER, Hospital November 2010
- Brookwood Medical Center (2011), Birmingham, Alabama
- Security Policy 2.43 Firearms/Dangerous Weapons
- Nock, M., Borges, G., Bromet, E., & Alonso, J. (2008). Cross-national prevalence and risk
factors for suicidal ideation, plans and attempts. The British Journal of Psychiatry, 192, 98-105.
- Borges, G., Angst, J., Nock, M., Ruscio, A., Walters, E., & Kessler, R. A risk index for 12month suicide attempts in the National Comorbidity Survey Replication (NCS-R).
- Crawford, M., & Kumar, P. (2007). Intervention following deliberate self-harm: Enough
evidence to act? Evidence-Based Mental Health, 10, 37-39.
- Cooper, J., Kapur, N., Webb, R., Lawlor, M., Guthrie, E., Mackway-Jones, K., & Appleby, L.
(2005). Suicide after deliberate self harm: A 4 year cohort study. American Journal of
Psychiatry, 162, 297-303.
- Trepal, H., & Wester, K. (2007). Self-injurious behaviors, diagnoses, and treatment methods:
What mental health professionals are reporting. Journal of Mental Health Counseling, 29(4),
363-376.
- Robertson Blackmore, E. (2008). Psychosocial and clinical correlates of suicidal acts: Results
from a national population survey. BJ Psych.
- INTERQUAL Level of Care Criteria (2011) Behavioral health Psychiatry (Adults 17-65)
VII.
ATTACHMENTS:
- Attachment A: Environment Patient Safety Checklist
- Attachment B: Behavior/Close Observation Flowsheet
- Attachment C: Suicide Assessment
Attachment A
CO-2.027 – Suicide Risk Assessment Policy
Page 1 of 1
Environment Patient Safety Checklist
Attachment B
CO-2.027 Suicide Risk Assessment Policy
Page 1 of 1
Behavior/Close Observation Flowsheet
Attachment C
CO-2.027 Suicide Risk Assessment
Page 1 of 2
Suicide Assessment
Attachment C
CO-2.027 Suicide Risk Assessment
Page 2 of 2
Suicide Assessment
Suicide Risk Assessment
Released November 30, 2012
Policy Summary
Suicide Risk Assessment is a revised model policy designed to assist hospitals in identifying, then
developing and implementing plans of care for, those patients who could be at risk for suicide or self
harm. Key edits include:
 Clarifying the patient population to be screened is the group of patients aged
13 and older presenting with a behavioral-health related complaint or showing
signs or symptoms of being at risk for self harm; and
 Having each hospital establish its own risk-based monitoring protocols.
A redline version of the policy is available on Policy Central with this link.
Click
here
to
watch a video
summary of the
policy
Responsible Persons


The Hospital’s Chief Nursing Officer is directly responsible for implementing the Policy.
The Hospital A-team will support the CNO with policy compliance.
Hospital Action
Home Office staff are working on medical record documentation and education processes to support
the revised policy, including a .edu program that will be customizable by each hospital. The go-live
date for these processes is anticipated for February, 2013.
Each hospital must develop its own monitoring protocols and add these to the policy where indicated.
The hospital’s Regional Senior Director of Patient Care must approve the monitoring protocols. Each
hospital’s policy need to be in place by the go-live date, with all hospital-specific training completed.
Whenever possible, adoption of the model Suicide Risk Assessment in its entirety is preferred;
however, we recognize that hospitals may have existing policies that address this subject. If this is the
case, compare the policy and its procedures and modify your existing policies to include all model
components.
Jeff Klenklen, Senior Director of Patient Safety & Clinical Risk Management, in the Clinical Operations
Department, must clear any additions or modifications to the model components. His telephone number
is 469-893-6897 and his email address is jeffrey.klenklen@tenethealth.com.
As a key component of your patient safety program, the policy requires Medical Staff and Governing
Board approval. The Hospital Compliance Committee does not need to review the policy.
Training
No additional training on the policy is required at this time. As the processes supporting this policy are
finalized, Home Office staff will issue invitations for conference calls to discuss the processes.
Auditing and Monitoring
Clinical Quality will audit compliance with the policy as part of the Comprehensive Clinical Audits.
Questions?
Contact
Jeff Klenklen
Phone
469-893-6987
Email
Jeffrey.Klenklen@tenethealth.com
Thank you for your attention to this important policy.
Published: November 30, 2012
Published: November 30, 2012