Quality and Safety: National Patient Safety Goals and Suicide Risk Assessment

NATIONAL PATIENT SAFETY GOALS (NPSGs)

• National patient safety goals were established by The Joint Commission (TJC) in 2002.

  • Aim: To promote safety and health and wellness of individuals across the nation.

  • Significance: Much of healthcare workers’ practices are centered on these regulatory guidelines.

  • Annual Update: The list is updated each year based on data reported about safety concerns.

2021 NATIONAL PATIENT SAFETY GOALS

• Improve the accuracy of patient identification.

• Improve the effectiveness of communication among caregivers.

• Enhance the safety of using medications.

• Reduce patient harm associated with clinical alarm systems.

• Reduce the risk of healthcare-associated infections.

• Identify patient safety risks.

• Reduce mistakes before and during surgery.

NPSG: IDENTIFY PATIENT SAFETY RISKS

• Focus of this goal is on risk reduction for patient suicide.

• Overview: Suicide is a long-standing issue in healthcare—both inpatient and community settings.

• TJC Requirements:

  • Screening for suicidal ideation using a validated tool at age 12 and above; specifically, the Columbia Suicide Severity Scale (C-SSRS).

  • Assessment directly queries:

  • Suicidal ideation

  • Plan

  • Intent

  • Suicidal or self-harm behaviors

  • Risk factors

  • Protective factors

  • Documentation is required on the overall level of risk and a plan to mitigate that risk.

RISK FACTORS

• Marital Status:

  • Single, never married persons are twice as likely to commit suicide as married individuals.

  • Divorced and widowed individuals significantly increase risk.

• Gender:

  • More women attempt suicide, but men are more successful in carrying it out, with a ratio of approximately 70% men to 30% women.

• Age:

  • Suicidal risk increases with age, peaking in individuals aged 45-64 years and those greater than 85 years.

  • For adolescents, suicide is the third-leading cause of death.

• Religion:

  • Non-affiliated individuals exhibit a higher suicide risk compared to those who identify with a religion.

• Socioeconomic Status:

  • Individuals in very high or very low social classes show a higher risk than those in the middle class.

• Ethnicity:

  • Caucasians have a higher suicide rate compared to Native Americans, African Americans, or individuals from Hispanic cultures.

ADDITIONAL RISK FACTORS

• Psychiatric History:

  • Over 90% of individuals who die by suicide have a diagnosable mental disorder.

• Severe Insomnia:

  • Increased suicide risk even in the absence of depression.

• Substance Abuse:

  • Involves alcohol, barbiturates, stimulants, or a combination thereof.

• Prolonged Health Issues:

  • Chronic pain and disabling illnesses can increase risks.

• Sexual Orientation:

  • Gay men and lesbian women show an increased suicide risk.

• Family History:

  • Increased risk, particularly when having a same-gender parent who died by suicide.

• Previous Attempts:

  • Half of the individuals who die by suicide have previously attempted suicide.

ASSESSMENT

• Assessment is key in prevention of suicide.

• Suicide Risk Screening:

  • Every patient admitted must undergo screening and documentation using the Columbia Suicide Severity Rating Scale (C-SSRS).

  • C-SSRS documentation should be completed every shift and with any change in caregiver.

  • A series of questions related to self-harm are asked:

  • Clients scoring high will determine if suicide risk is an imminent threat.

COLUMBIA SUICIDE SEVERITY RATING SCALE (C-SSRS)

• Questions Include (Must Be Bold and Underlined):

  • Wish to be dead:

  • Subject endorses thoughts about a wish to be dead or not alive anymore or wish to fall asleep and not wake up.

    • Example Question: "Have you wished you were dead or wished you could go to sleep and not wake up?"

  • Non-specific active suicidal thoughts:

  • General non-specific thoughts of wanting to end one's life/die by suicide.

    • Example Question: "Have you had any actual thoughts of killing yourself?"

  • If YES to question 2, continue to questions 3, 4, 5, and 6; if NO, go to question 6.

  • Active suicidal ideation with any methods (Not Plan):

  • Subject endorses thoughts of suicide and has considered at least one method without a specific plan.

    • Example Question: "Have you been thinking about how you might do this?"

  • Active suicidal ideation with some intent to act, without specific plan:

  • Active thoughts of killing oneself with some intent to act, but no definite plan.

    • Example Question: "Have you had these thoughts and had some intention of acting on them?"

  • Active suicidal ideation with specific plan and intent:

  • Thoughts of suicide with a detailed plan and intent to carry it out.

    • Example Question: "Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?"

  • Suicidal behavior:

  • Inquiry about any preparations made for ending life.

    • Examples include collecting pills, obtaining a gun, writing a will, etc.

RESULTS OF ASSESSMENT

• Suicide precautions are based on answers from the screening tool.

• If mental illness is the primary diagnosis:

  • Clients are admitted to the psychiatric unit.

• If medical conditions are primary:

  • Clients are admitted to inpatient care with a 1:1 sitter.

• Documentation includes:

  • 15-minute checks performed and recorded.

  • Removal of hazardous equipment or tools.

  • Use of specialized clothing and eating utensils.

  • Clients are not allowed to be left alone, including in the bathroom.

STANDARD SUICIDE PRECAUTIONS IN MENTAL HEALTH

• Clients are admitted to a secure (locked) unit.

• Any potentially harmful objects are removed from the area.

• There is frequent interaction, with checks every 15 minutes.

• A verbal contract of no self-harm is established.

• Confirmation of medication ingestion occurs with each med pass.

• Daily interdisciplinary communication is maintained among nurses, psychiatrists, and social workers.

SEVERE OR IMMINENT RISK MANAGEMENT

• 1:1 direct observation is implemented for high-risk clients.

• Seclusion may be ordered and requires constant surveillance.

• Restraints (physical or chemical) may be necessary depending on severity of risk.

• Emphasis on concise documentation.

STANDARD PRECAUTIONS IN MEDICAL SETTINGS

• Requires a sitter; clients may not be left unattended.

• Removal of harmful objects and equipment:

  • Includes sharps, bed or equipment cords, pull cords in bathrooms, etc.

• Use of paper eating utensils is mandatory.

• Prohibition of clothing with straps, ties, or belts.

• Clients can be placed on a psychiatric 72-hour hold (not including weekends).

STRATEGIES & INSTITUTIONAL RESOURCES

• Community and crisis intervention resources are provided at discharge:

  • Available to both the client and their support persons.

  • These may include:

  • Individual therapy

  • Case management

  • Support groups

  • Medications

  • Adjunctive therapies.

NPSG: IMPROVE STAFF COMMUNICATION

• Critical Results Reporting:

  • Ensures critical results are reported to the right person in a timely manner.

  • Critical results are any result that indicates immediate action is required to prevent client harm or injury.

  • Communication Protocol:

  • Must provide identity verification when reading back results (i.e., name).

  • Documentation in the Electronic Medical Record (EMR) must include the time, result, and any action taken.

  • Healthcare Provider (HCP) must be notified when indicated.

REPORTING PROCESS: DIAGNOSTIC/ LAB TO RN

• Procedure when a critical result occurs:

  • Call made by technician to receiving RN.

  • Two client identifiers (e.g. name and date of birth) are provided and verified.

  • RN documents the result and reads it back to the tech.

  • Results, time, intervention, and HCP notifications are documented in EPIC.

  • Fail-safe protocols are in place if HCPs are unavailable.

REPORTING PROCESS: RN TO PROVIDER

• Must communicate directly with the provider.

  • DO NOT leave messages, voicemails, or texts for critical results.

• Critical results must be communicated within 15 minutes of notification.

• If no response from HCP after 15 minutes, a second call should be placed.

• If no response within 30 minutes, activate the fail-safe plan which may escalate to a higher-level chain of command (hospitalist in charge, intensivist, senior resident, or medical director).

EARLY RECOGNITION OF CLIENT CONDITION CHANGES

• Multiple tools have been established to alert RNs of condition changes.

• TriHealth utilizes the Early Warning Score (EWS) system.

• Clients and families participate in the SPEAK-UP campaign.

• Caregiver communication should adhere to the SBAR method.

• Development of Rapid Response Teams has been initiated.

RAPID RESPONSE

• Purpose: To intervene promptly before a Code Blue situation occurs.

• Provides early intervention and assessment by specialists in critical care.

• Rapid Responses can be classified into two severity levels.

• Call for a Rapid Response if warranted; hesitation may lead to a Code Blue scenario.

• Any individual can initiate a Rapid Response—no requirement for it to be an RN.

CLIENT CONDITIONS INDICATING A RAPID RESPONSE

• Acute mental status changes or seizures.

• Acute restlessness or agitation.

• Changes in respiratory status or respiratory compromise.

• Stridor or frothy, pink-tinged sputum.

• Respiratory rate <12 or >30.

• Increased oxygen needs with declining O2 saturations.

• Changes in cardiovascular status or syncopal episodes.

• Heart Rate <40 or >130; Systolic Blood Pressure <90 or >200.

• Body temperature changes <95 or >103.

• Significant signs of bleeding.

NURSE'S INTUITION

• Instruction: "ANYTIME YOUR GUT TELLS YOU SOMETHING IS WRONG!!!!"

  • Recognize and trust your intuition.

  • When uncertain, consult your charge nurse or activate a Level One Rapid Response.

EARLY WARNING SCORE (EWS)

• Based on client’s vital signs.

• Nurses can employ clinical judgment.

• Interventions depend on the score and the overall clinical picture of the client.

SUMMARY

• Suicide:

  • Risk factors associated with suicide.

  • Demographics of high-risk individuals.

  • Distinction between mental illness versus medical conditions.

  • Institutional strategies and community resources in place.

• Critical Results Reporting:

  • Overview of institutional processes for reporting.

  • Importance of client identifiers.

  • Establishment of a fail-safe plan.

  • Documentation practices.

• Rapid Response Process:

  • Institutional procedures for activation.

  • Guidelines for when to call for a Rapid Response.

  • The significance of nursing intuition.

  • Importance of scoring systems.