The Joint Commission added the National Patient Safety Goal: Identifying Individuals at Risk for Suicide (NPSG 15. 01. 01) in 2007. This goal was directed at psychiatric and general hospitals with patients whose primary complaint is an emotional or behavior disorder, including substance abuse (according to DSM).
This goal is directed at both types of hospitals for important reasons; (1) general hospitals do not have an environment that is conducive to the protection of individuals who are suicidal, and (2) psychiatric hospitals are constructed to protect individuals who are suicidal but have a high concentration of suicidal individuals and are not always staffed appropriately. This goal has an intent that basic issues related to suicide and mental status assessment are included in patient care and should be applied with the use of an electronic health record.
(Anderson, Ridge, Latimer, 2007). It was the Joint Commission’s opinion that identification of individuals at risk for suicide while under the care of or following discharge from a health care organization is an important step in protecting these at-risk individuals (The Joint Commission, 2010). This requirement is applicable in general hospitals or any facility providing hospital services, or practice setting, including the emergency room department but still only applies to patients whose chief compliant is emotional, behavioral, or substance abuse.
A patient entering the emergency room with an injury whose secondary complaint is depression or a patient receiving an appendectomy with a history of major depressive disorder, safety goal 15 is not directly applicable and these numbers do not need to be reported to the Joint Commission (Adamski, 2007). Psychiatric hospitals are required to conduct a more detailed screening and assessment as appropriate for every admission. This was chosen as a national goal because suicide is a major, preventable public health problem.
According to the Centers for Disease Control, in 2007 suicide was the tenth leading cause of death (third most in young people) in the U. S. , accounting for 34,598 deaths. The overall rate was 11. 3 suicide deaths per 100,000 people. An estimated 11 attempted suicides occur per every suicide death. Suicide was the third leading cause of death for young people ages 15 to 24. Of every 100,000 young people in each age group, the following number died by suicide: Children ages 10 to 14 — 0. 9 per 100,000 Adolescents ages 15 to 19 — 6. 9 per 100,000 Young adults ages 20 to 24 — 12. 7 per 100,000.
Older Americans are also disproportionately likely to die by suicide. Of every 100,000 people ages 65 and older, 14. 3 died by suicide in 2007. (CDC, 2010) Suicide is the result of an untreated mental illnesses, severe mental illnesses usually where the patient is noncompliant, substance abuse, and physical or sexual abuse. These diagnoses make suicide the taboo of our society and suicide attempts are frowned upon and ignored in families instead of this being a time of healing, increased communication, education and awareness of symptoms the opposite occurs escalating the problem.
This disgrace of a suicide attempt is a time of silence instead of a time of rapport with friends and family members. Research has shown that adults and women who die by suicide are likely to have seen a primary care provider in the year before death; improving primary-care providers’ ability to identify and treat risk factors that may help prevent suicide among these groups (Luoma, Pearson, ; Martin, 2002). According to the National Institute of Mental Health 50% of all suicide victims visit a doctor the month before their death (Anderson 2007).
In the general hospital setting, hospitals have been required, long before safety goal 15, identifying individuals at risk was a national safety goal, to monitor suicidal patients. General hospitals have done this differently, some gave patients a low risk, medium risk, or high risk, and others had only a low or high risk. High risk means constant one to one observation, and medium risk may be checks every 5-10 minutes and low may mean every 15 minutes. (Anderson, 2007). Constant one to one observations means that someone must be with the patient twenty-four hours a day.
This means an extra staff person that could be doing something else is now doing solely on observation duty, a sitter. Hospitals have always had this financial burden, safety goal 15 is a small increase in financial burden on general hospitals because for the most part this has been effective. The Joint Commission reported in cases studied in 1998 that of 65 reviewed inpatient suicides most of the suicides occurred in psychiatric hospitals (34) followed by general hospitals (27) and residential care facilities (4).
Of those cases in general hospitals, 14 occurred in psychiatric units, 12 in medical/surgical units, and one in the emergency room. However, in 75% of the cases, the method of suicide was a hanging in a bathroom, bedroom or closet, 20% resulted from jumping from a window or roof. (Sentinel Event Alert, 1998). Realistically, this goal requires general hospitals to comply with a three-pronged approach. The assessment process for suicide must be streamlined and diligent. Definitions on how a patient is observed, or the role of the “sitter” must be clear, e. g. is simply in the room, within arms length at all times, etc.
This policy should be clear and written, and lastly the staff must be educated on the policy (Hagen ; Quillen, 2010). The actual cost of compliance, as I have described above in a general hospital is minimal. In a psychiatric hospital compliance with Safety Goal 15 is less of a financial burden, as it is always their intent and within the scope of their operations to prevent a suicide. Psychiatric and general hospitals are required to, “Conduct a risk assessment that identifies specific characteriscts of the individual served and environmental features that may increase or decrease the risk for suicide” (Joint Commission, 2010).
Many psychiatric hospitals have extended their services in the last few decades to drug and alcohol rehabilitation and these admissions and their environments will now require a complete suicide risk assessment, if it has not been done so before. Safety goal 15A puts emphasis on care during and following discharge from a healthcare organization to be an important first step in protecting and planning care for at-risk individuals, especially in emergency medicine where young patients are treated quickly and not for overnight stays (Adamski, 2007). Elements for Performance for NPSG 15.
01. 01 as described by the Joint Commission in July 2010, M 3 reads, “When an individual at risk for suicide leaves the care of the organization, provide suicide prevention information (such as a crisis hotline) to the individual and his or her family” (Joint Commission, 2010). In general hospitals and psychiatric hospitals assessment of the patient at risk for suicide will be done by the treating physician and the nurse. Collaboration will be done with other treating physicians and other support personnel should also be trained to understand verbal cues from the patient.
Patients that are being treated for non-emotional, behavioral or substance abuse problems but indicate during the course of their treatment suicidal ideation or signs of depression should be administered standard suicidal assessment questions before they are discharged and treated appropriately. This is especially true for young patients (ages 10-24) who have suicide as third leading cause of death. These patients are often seen in the emergency department and quickly discharged. (Adamski, 2007)
As the CNL in an emergency department (ED) I will ask to take a leadership role in this process and handle the responsibility of evaluating the current risk assessment and evaluation of the specific factors used to determine the risk of suicide. The Joint Commission currently does not give guidance for the assessment process, therefore I see it as a process that should be monitored and evolve with the needs of the patients. I will also evaluate the demographics that my hospital predominately treats, and identify our highest risk groups and determine if we have features in our assessment to capture this group (Hagen ; Quillen 2010).
I will evaluate current procedures and develop a step-by-step process to be used with all at-risk patients, which I will collaborate with others to define. I think it is important when building an infrastructure that will be a part of a practice within your organization to make it work it must be made from those utilize it. I will collaborate with triage nurses, “sitters,” certified nurse assistants, charge nurses, and the legal department (Hagen, 2010). I will require annual training to review the agencies policies and procedures on this training as part of a continuing education program that I will have approved by the Joint Commission.
My role will always be a colleague to all nurses who are not sure if a suicide watch is necessary for a patient and would like my participation in the assessment as well. A measurement of suicide occurrences onsite at a general hospital may not be reflective of the benefits of our organization’s change in practices, although they will continue to be monitored and reported to the Joint Commission. It is not possible to measure the number of doctors and nurses who may possibly intervene with a depressed patient, and encourage the patient and family to make connections with referrals outside the hospital for depression.
These conversations may thwart the efforts of unknown numbers of attempted suicides and possible suicides. Knowing the staggering statistics of young people dying from suicide, as well as older adults, and the general community at large, it is a health care workers obligation to confront suicidal ideation seriously. I believe this will continue to be a patient safety issue in the next decade. Depression currently effects 10% to 20% of the population (Kee, Hayes, McCuistion, 2009).
The changing family dynamics, changes in the economy, healthcare, and technology has made it easier to work harder but see less of your family and spend time on vacation. It is unlikely that Americans will see less stress anytime soon, and depression rates are not expected to fall. References 1. The Joint Commission (2010). Accreditation Program: Behavioral Health Care National Patient Safety Goals (Pre-publication version, Effective July 1, 2010). Retrieved from: http://www. jointcommission. org/NR/rdonlyres/4D0F9019-E4E7-49FD-8191-700688637BB3/0/July2010NPSGs_Scoring_BHC. pdf 2.
Anderson, S. C. , Ridge, R. , Latimer G. E. (2007) Assessing Suicide Risk and Defining Precautions: Evaluating Join Commission Expectations and Implementation Examples Siemens Medical Solutions USA, Inc. website:
http://www. medical. siemens. com/siemens/en_US/gg_hs_FBAs/files/IT_Solutions_And_Consulting/Assessing_Suicide_Risk_Defining. pdf 3.
National Institute of Mental Health, Suicide in the U. S. : Statistics and Prevention. (2010). (NIH Publication 06-4594) Retrieved from: http://www. nimh. nih. gov/health/publications/suicide-in-the-us-statistics-and-prevention/index. shtml 4.
Pat Adamski. (2007). Recognizing the issues behind patient suicide. Nursing Management, 38(5), 10. Retrieved November 10, 2010, from ProQuest Medical Library. (Document ID: 1272466821). 5. Kee, J. L, Hayes, E. R. , McCuistion, Linda E. (2009) Antidepressants and Mood Stabilizers. Pharmacology A Nursing Process Approach. (p. 409) Saunders Elsevier, St. Louis, MO. 6. Hagen, L. ; Quillen, J. (2010). NPSG#15A: Crafting a Suicide Risk Assessment Policy. Strategies for Nurse Managers. com. Retrived from: http://www. strategiesfornursemanagers. com/ce_detail/202080. cfm 7. The Joint Commission.
Inpatient Suicides: Recommendations for Prevention The Sentinel Event Alert. (Issue 7) November 6, 1998. Retrieved from: http://www. jointcommission. org/SentinelEvents/SentinelEventAlert/sea_7. htm 8. Centers for Disease Control, Injury Prevention and Control: Data and Statistics. (2010) 10 Leading Causes of Death 2007. 10 Leading Causes of Non-fatal injury. Retrieved from: http://www. cdc. gov/injury/wisqars/index. html 9. Luoma JB, Pearson JL, Martin CE. Contact with mental health and primary care prior to suicide: a review of the evidence. American Journal of Psychiatry, 2002; 159: 909-16.