Version 5.0
The Johns Hopkins Hospital
Nursing Practice and Organization Manual Vol II: Clinical
Clinical Protocols and Procedures
Policy Number
GEN386
Effective Date
12/10/2015
Approval Date
09/15/2015
Subject
Page
Suicide Risk Screen and Precautions, Management of patients on
non-psychiatric units...
Supercedes
1 of 5
01/23/2014
Keywords: certified patient observer, CPO, suicidal, suicide, suicide risk
Table of Contents
Page Number
I.
OBJECTIVES
II.
INDICATIONS FOR USE
III.
DEFINITIONS
IV.
RESPONSIBILITY
V.
PROCEDURE
VI.
REPORTABLE CONDITIONS
VII. DOCUMENTATION
VIII. SUPPORTIVE INFORMATION
IX.
SIGNATURE
Appendix A: Certified Patient Observer (CPO) Responsibilities for One-to-One Accompaniment for
Patients on Suicide Precations
Appendix B: Crisis Hotline Information
Appendix C: Outpatient Procedure for Suicidal Patients in Non-Psychiatry Areas
Appendix D: Suicidal Ideation Screening Tool
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I. OBJECTIVES
A patient on a non-psychiatric service who is determined to be at risk for suicide will be protected from self-harm.
II. INDICATIONS FOR USE
A.
B.
C.
This protocol is implemented when:
1. A patient has a positive screen for suicide and is currently having suicidal thoughts as assessed in the Emergency
Department and upon hospitalization. Refer to Appendix D for suicidal ideation screening tool.
2. The nurse observes any of the criteria listed in Section V.A. during the course of assessment.
3. An authorized prescriber writes an order for suicide precautions.
Refer to Appendix C for procedures in outpatient clinics.
Situations in which this protocol does not apply:
1. Suicidal patients on psychiatry service
2. Adult and Pediatric Emergency Department psychiatry suite.
III. DEFINITIONS
Suicidal Ideation
Thoughts of self-harm or death
Suicidal Behaviors /
Self Injurious
Behaviors
Intentional behaviors demonstrated that jeopardize life or safety
Version 5.0
The Johns Hopkins Hospital
Nursing Practice and Organization Manual Vol II: Clinical
Clinical Protocols and Procedures
Policy Number
GEN386
Effective Date
12/10/2015
Approval Date
09/15/2015
Subject
Page
Suicide Risk Screen and Precautions, Management of patients on
non-psychiatric units...
Supercedes
2 of 5
01/23/2014
Certified Patient
Observer(CPO)
A healthcare team member who carries identification from the Maryland Board of Nursing and
provides constant observation to ensure patient safety.
Roles other than a Nurse who may serve as a CPO are:
•
Certified Nursing Assistant (CNA)
•
Clinical Nurse Extern (CNE)
•
Clinical Technician (Clin T)
NOTE: This may include agency personnel.
Refer to ACT212 Certified Patient Observer (CPO)/Patient Companion, Utilization Protocol for
additional information.
One to One
Accompaniment
Is indicated for individual observation (one staff member observing only one patient). A staff
member within close proximety of one patient on observation at all times with no barriers between
the patient and staff member
Petition for Emergency A legal and valid document ordered by the court, peace officer, physician, psychologist, clinical
Evaluation
social worker, licensed clinical professional counselor, or a health officer or designee of a health
officer who has examined the individual.
IV. RESPONSIBILITY
A.
B.
C.
Registered Nurse (RN)
1. Assesses suicide in the Emergency Department or risk upon hospitalization. Refer to Appendix D for suicidal
ideation screening tool.
2. Initiates suicide precautions if:
a. the patient has a positive screen for suicide and is currently having suicidal thoughts.
b. the nurse observes any of the criteria listed in section V.A. during the course of assessment.
c. the authorized prescriber writes an order for suicide precautions
3. Notifies the authorized prescriber of initiation of suicide precautions
4. Is accountable for the patient who is under observation by a PSA who is not a RN.
5. Shall direct the care given by the PSA including review of Appendix A.
6. Shall assign other licensed or trained nursing staff to provide breaks for the CPO.
In the absence of an RN, staff (e.g., outpatient clinic area, Licensed Practical Nurse, Certified Medical Assistant, Clinical
Technicians) will immediately report patient concerns related to suicidal statements/behaviors to the provider.
1. Initiate patient observation and refer to Appendix C for further instruction.
Certified Patient Observer (CPO)
1. See Appendix A for specific CPO responsibilities.
2. When assigned to a patient on suicide precautions, shall be relieved of all other duties and one-to-one patient:CPO
ratio shall be maintained.
3. All personnel used for one-to-one accompaniment, including contracted personnel, shall be thoroughly familiar with
this protocol.
Version 5.0
The Johns Hopkins Hospital
Nursing Practice and Organization Manual Vol II: Clinical
Clinical Protocols and Procedures
Policy Number
GEN386
Effective Date
12/10/2015
Approval Date
09/15/2015
Subject
Page
Suicide Risk Screen and Precautions, Management of patients on
non-psychiatric units...
Supercedes
3 of 5
01/23/2014
V. PROCEDURE
A.
B.
C.
D.
E.
F.
INITIAL ASSESSMENT - When the patient is determined to be at risk for suicide, the RN will assess for:
1. Suicidal ideation (e.g., patient expressed thoughts/pre-occupation about death or suicide, ability to articulate a
definitive plan) or report from significant other that patient has expressed suicidal thoughts or made suicidal gestures
2. Evidence of self-inflicted injuries
3. Demonstration of behavior that jeopardizes patient’s life
Be aware of risk factors for suicide, including but not limited to:
1. schizophrenia,
2. depression,
3. bipolar disorder,
4. substance abuse (including alcohol),
5. prior suicide attempts,
6. age greater than 65 (older caucasian male),
7. recent loss, family history of suicide, history of abuse, newly diagnosed or worsening health,
8. impulsivity, feelings of hopelessness, agitation
If a patient has been determined to be at risk for suicide, RN will initiate suicide precautions and will notify the authorized
prescriber to obtain an order to initiate suicide precautions.
1. Authorized prescriber should consider Psychiatry consultation
RN will assess the environment for potentially hazardous items
1. All patients’ belongings shall be checked in the presence of both the RN and the patient.
2. Hazardous items shall be removed (e.g., neckties, belts, shoe strings, sharp items, medical equipment or supplies,
etc. that could be hazardous). See Appendix A for more detail.
ONGOING ASSESSMENT
1. RN will assess patient for the following every 8 hours and document this assessment in the electronic medical
record:
a. Signs or verbalization of suicidal ideation
b. Signs of self injurious behavior
c. Stated intent and means to carry out an expressed plan
IMPLEMENTATION
1. Immediately assign a CPO to provide one-to-one accompaniment of the patient. The patient shall not be left
unattended at any time. A trained staff member, LPN, Clinical Technician, Medical Assistant, RN, Nurse
Practitioner, Physician Assistant, or Physican) is required to be placed with the patient until a PSA arrives. If a
trained staff member is unavailable, refer to ACT212 Certified Patient Observer (CPO) or Patient Companion,
Utilization Protocol Appendix G.
a. RN shall review Appendix A (CPO Responsibilities) with the designated CPO.
b. Family member/significant others are not permitted to assume responsibility for one-to-one accompaniment.
c. PSA shall be relieved of all other duties.
2. Make certain that potentially hazardous items have been removed from the patient’s person, belongings, and the
room (including, but not limited to, medical equipment and supplies).
3. All patient visitors shall report to the nurses’ station before seeing the patient.
4. RN and authorized prescriber will employ crisis management strategies in the event of a serious suicide threat or
other crisis situation. This includes, but is not limited to:
a. Listen intently and respectfully.
b. If the physician is not present, notify him or her immediately.
Version 5.0
The Johns Hopkins Hospital
Nursing Practice and Organization Manual Vol II: Clinical
Clinical Protocols and Procedures
Policy Number
GEN386
Effective Date
12/10/2015
Approval Date
09/15/2015
Subject
Page
Suicide Risk Screen and Precautions, Management of patients on
non-psychiatric units...
Supercedes
4 of 5
01/23/2014
c.
d.
5.
6.
7.
Express concern and clarify.
Ask direct question. Try to find out if the person has a specific plan and what method of suicide is being
considered.
e. Do not promise confidentiality.
f.
Acknowledge the person’s feelings.
g. Implement measures that will maintain safety.
Do not allow a patient on suicide precautions to leave the unit unless there is a written order by an authorized
prescriber.
At discharge, RN will provide patient and significant other with Crisis Hotline information. See Appendix B.
Consider contacting Psychiatry resources and/or JHH Facilities for special assistance on environmental safety
assessments.
VI. REPORTABLE CONDITIONS
A.
RN will report the following to the authorized prescriber:
1. Expression of suicidal ideation by patient or report by significant other.
2. Evidence of self-inflicted injuries.
3. Intent to carry out an expressed plan.
4. Overt suicide gesture.
VII. DOCUMENTATION
A.
The following shall be documented in the electronic medical record when one-to-one accompaniment is initiated, during
one-to-one accompaniment, and when one-to-one accompaniment is discontinued:
1. Patient’s described plan, described means (and if available to patient), described ability and intent to act on these
thoughts while in the hospital and if patient can come to staff if they want to hurt themselves while in the hospital.
2. Presence of reportable conditions and subsequent notification of the authorized prescriber.
3. Nursing interventions (e.g., removing hazardous items, providing verbal support).
VIII. SUPPORTIVE INFORMATION
References:
1.
2.
3.
4.
5.
6.
Bostwick, J. & Rackley, S. (2007). Completed Suicide in Medical/Surgical Patients: Who is at Risk? Current Psychiatry
Reports, 9: 242-246.
Healthcare Risk Management (2007). Wide-Scale Suicide Assessment Needed to Avoid Tragedy and Significant
Liability. Volume 29 (1), 1-4.
Joint Commission Sentinel Event Alert link –– Inpatient Suicides, November 6, 1998, A follow-up report on prevening
suicide: Focus on medical/surgical units and the emergency department, November 27, 2010
Joint Commission Standards Booster Pak for Suicide Risk (NPSG.15.01.01)
Lieberman, D., Resnik, H., Perkins, V.(2013) Suicide and Life-Threatening Behavior. 43 (3), pp. 235-346.
Miret, M., Nuevo, R., Avuso-Mateos, J. (2009) Documentation of Suicide Risk Assessments in Clinical Records.
Psychiatric Services. July; 60 (7): 994
See Also
•
The JHH Nursing Practice and Organization Manual, Vol I: ACT212 Patient Safety Attendant (PSA) or Patient
Companion, Utilization Protocol
Version 5.0
The Johns Hopkins Hospital
Nursing Practice and Organization Manual Vol II: Clinical
Clinical Protocols and Procedures
Policy Number
GEN386
Effective Date
12/10/2015
Approval Date
09/15/2015
Subject
Page
Suicide Risk Screen and Precautions, Management of patients on
non-psychiatric units...
Supercedes
Sponsor:
•
Central Nursing SOC
Developer:
•
Psychiatric Nursing
IX. SIGNATURE
Electronic Signature(s)
Deborah Baker
Vice President of Nursing and Patient Care Services, The
Johns Hopkins Hospital
Date
10/08/2015
5 of 5
01/23/2014