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

National Patient Safety Goals (NPSGs)

• Establishment

  • National Patient Safety Goals were established by The Joint Commission in 2002.

  • The driving factor was a concerted effort to promote safety, health, and wellness for individuals across the nation.

  • Much of the healthcare workers’ practice is centered around these regulatory guidelines.

  • The list of NPSGs is updated annually based on reported data regarding safety concerns.

2021 National Patient Safety Goals

• Improve the accuracy of patient identification.

• Improve the effectiveness of communication among caregivers.

• Improve 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

  • Focuses heavily on risk reduction for patient suicide, a long-standing issue in both inpatient and community settings.

• Screening Requirements

  • The Joint Commission requires screening for suicidal ideation using a validated tool (Columbia Suicide Severity Scale) at age 12 and above.

• Assessment Areas

  • The assessment directly queries the following:

  • Suicidal ideation: thoughts of self-harm.

  • Plan and intent: existence of a specific plan and intent to commit suicide.

  • Self-harm behaviors: any past behaviors towards self-harm.

  • Risk factors: identify factors that could increase risk.

  • Protective factors: identify what might mitigate risk.

  • Documentation on the patient’s overall level of risk and the plan to mitigate this risk is essential.

Risk Factors for Suicide

• Marital Status

  • Single individuals (never married) are twice as likely to attempt suicide compared to married individuals.

  • Divorced and widowed individuals show a significant increase in risk.

• Gender

  • More women attempt suicide, but men tend to be more successful with a ratio of 70% male to 30% female.

• Age

  • The risk of suicide increases with age, peaking among individuals aged 45-64 and those older than 85.

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

• Religion

  • Higher risk among individuals who identify as non-religious.

• Socioeconomic Status

  • Greater risk associated with individuals in very high or very low social classes compared to middle class.

• Ethnicity

  • Caucasian individuals show a higher risk compared to Native Americans, African Americans, or Hispanic cultures.

Additional Risk Factors

• Psychiatric History

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

• Severe Insomnia

  • Increased risk even without a depression diagnosis.

• Substance Abuse

  • Risk increased with alcohol, barbiturates, stimulants, or their combination.

• Prolonged Health Issues

  • Chronic pain or disability significantly increases risk.

• Sexual Orientation

  • Gay men and lesbian women exhibit an increased risk.

• Family History

  • An individual’s risk increases if there is a family history of suicide, especially from a same-gender parent.

• Previous Attempts

  • Approximately 50% of individuals who die from suicide have made previous attempts.

Assessment for Suicide Risk

• Importance of Assessment

  • Assessment is crucial in suicide prevention.

• Screening

  • Suicide risk screening is required for every patient admitted, utilizing the Columbia Suicide Severity Rating Scale (C-SSRS).

  • The C-SSRS screening should be documented every shift and with any change in caregiver.

  • It includes a series of questions related to self-harm, with high scorers indicating whether suicide risk is an imminent threat.

Columbia Suicide Severity Rating Scale (C-SSRS)

• Key Questions

  1. Wish to be dead:

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

     • Indicates thoughts about wishing to be dead or not alive anymore.

  2. Non-specific active suicidal thoughts:

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

     • Indicates general thoughts of wanting to end one’s life without specifics.

  3. Active suicidal ideation with any methods (not plan) without intent to act:

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

     • Includes thoughts of how to carry out self-harm without a detailed plan.

  4. Active suicidal ideation with some intent to act, without a specific plan:

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

     • Explores intent to act on suicidal thoughts.

  5. Active suicidal ideation with specific plan and intent:

     • 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?"

     • Controls for specific planning and intent.

  6. Suicidal behavior:

     • Question: "Have you ever done anything, started to do anything, or prepared to do anything to end your life?"

     • Captures any preparatory actions or thoughts regarding self-harm.

• Scoring

  • The resulting scores determine mild, moderate, or severe suicide risk.

• Source Reference

  • Posner K., Brent D., Lucas C., Gould M., et al. (2008). Columbia-suicide severity rating scale (C-SSRS). Screener with triage for primary health settings. Available from CSSRS Resource .

Results of Suicide Risk Assessment

• Suicide Precautions

  • Resulting actions taken depend on screening tool answers:

  • If mental illness is the primary diagnosis, clients are admitted to the psychiatric unit.

  • If medical, they are admitted to inpatient with 1:1 sitter.

  • Regular documentation of every 15-minute checks is mandated.

  • Hazardous tools or equipment must be removed from the environment.

  • Utilization of specialized clothing and eating utensils designed to minimize risk.

  • Clients cannot be left alone, including during bathroom usage.

Standard Suicide Precautions on Mental Health Units

• Security

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

• Environmental Safety

  • Every potentially harmful object is removed from the area.

• Monitoring

  • Frequent interaction ensured through checks every 15 minutes.

• Contracts

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

• Medication Verification

  • Confirmation of medication swallowing occurs at each med pass.

• Team Communication

  • Daily interdisciplinary communication occurs with nurses, psychiatrists, and social workers.

Severe or Imminent Risk Management

• Direct Observation

  • For severe risks, 1:1 direct observation is initiated.

• Seclusion

  • Seclusion can be prescribed, requiring constant supervision.

• Restraint Use

  • Physical or chemical restraints may be necessary depending on severity.

• Documentation

  • Concise and detailed documentation is required throughout.

Standard Precautions in Medical Settings

• Sitter Requirement

  • Clients must not be left unattended; a sitter is required.

• Safety Measures

  • Harmful objects (e.g., sharps, cords) are removed.

  • Paper eating utensils are employed.

  • Clothing without straps, ties, or belts is prescribed.

  • Patients can be placed on psychiatric 72-hour hold (weekends excluded).

Strategies & Institutional Resources

• Community and Crisis Resources

  • Resources provided at discharge for both clients and their support persons.

  • May include:

  • Individual therapy.

  • Case management.

  • Support groups.

  • Medications and adjunctive therapies.

NPSG: Improve Staff Communication

• Critical Results Reporting

  • Ensures important information is communicated timely to the appropriate healthcare personnel.

  • Critical results necessitate immediate action to prevent client harm.

  • The individual reporting must provide their name when reading back results from lab/tech.

  • Thorough documentation in EMR is required (including time, result, and action taken).

Reporting Process: Diagnostic/Lab to RN

• Procedure

  • A tech places a call to receiving RN upon obtaining a critical result.

  • Two client identifiers (name and date of birth) are given and read back.

  • RN documents the result and should read the result back to the tech for confirmation.

  • Results, time, interventions, and notifications of healthcare providers must be documented in EPIC.

  • A fail-safe system exists if the healthcare provider is unavailable.

Reporting Process: RN to Provider

• Direct Communication Required

  • The RN must communicate directly to the provider without leaving messages or voicemails.

• Time Sensitivity

  • Critical results need to be communicated within 15 minutes of receiving notification.

  • If no response in 15 minutes, a second call is required.

  • If still no response within 30 minutes, a fail-safe plan must be activated, which may involve a higher authority.

Early Recognition of Client Condition Changes

• Utilized Tools

  • Various tools have been initiated to alert RNs of changes in patient condition.

  • TriHealth utilizes EWS (Early Warning Score) based on client’s vitals for clinical judgment.

  • Clients and families should engage in the SPEAK-UP campaign advocating for timely care.

  • Reporting information from caregiver to caregiver should follow the SBAR format (Situation, Background, Assessment, Recommendation).

  • The Rapid Response Teams have been established to address urgent patient needs.

Rapid Response

• Purpose

  • Designed for quick intervention before conditions escalate to a Code Blue situation.

  • It allows for early intervention and assessments by clinicians skilled in critical care.

  • Rapid responses can be initiated at two levels of urgency.

  • Encourage calling a Rapid response whenever warranted; not limited to RNs—anyone can initiate.

  • Delayed activation of a Rapid response can frequently result in a Code Blue situation.

Client Conditions for a Rapid Response

• Mental Status Changes

  • Acute changes in mental status or seizures.

• Restlessness/Agitation

  • Acute onset observed.

• Respiratory Status

  • Acute changes or respiratory compromise, including:

  • Stridor or pink-tinged sputum.

  • Respiratory rate below 12 or above 30.

  • Increased oxygen requirements with declining O2 saturation.

• Cardiovascular Status

  • Acute changes in cardiovascular status or syncopal episodes.

• Vital Signs

  • Heart rate below 40 or above 130; blood pressure below 90 or above 200.

• Temperature

  • Acute temperature changes below 95 or above 103.

• Signs of Bleeding

  • Any significant signs of bleeding warrant a Rapid response.

The Intuition of Nursing

• Trust Your Instincts

  • Always heed your intuition; if something feels wrong, it likely is.

  • When in doubt, consult your charge nurse or activate a Level One Rapid response.

Early Warning Score (EWS)

• Purpose

  • Based on vital signs to allow for clinical judgment.

  • Interventions are determined by the score and the overall clinical presentation of the client.

Summary: Suicide

• Key Points

  • Understand the risk factors associated with suicide.

  • Recognize demographics of high-risk individuals.

  • Differentiate between mental illness and medical conditions.

  • Familiarize with institutional strategies and community resources available.

Summary: Critical Results Reporting

• Key Points

  • Understand institutional processes for reporting critical results.

  • Know client identifiers required.

  • Be aware of fail-safe plans and documentation needed.

Summary: Rapid Response Process

• Key Points

  • Familiarize with institutional processes for activating a rapid response.

  • Understand guidelines and the importance of nursing intuition in recognizing when to call for help.

  • Know how scoring impacts interventions.