Suicide Risk Screening, Assessment and Precautions (Non Psychiatric Care Units) Policy No.: NSI SFT_05

Transcription

1 Suicide Risk Screening, Assessment and Precautions (Non Psychiatric Care Units) Policy No.: NSI SFT_05 ACKNOWLEDGEMENT: By opening and reviewing the following attachment: acknowledges that I have reviewed and assume responsibility for maintaining ongoing educational and practical unit competency.

2 The hospital identifies patients at risk for suicide by conducting a suicide risk screening for all patients admitted to the Emergency Department and inpatient care units. A suicide risk assessment is completed for those patients meeting criteria with suicide precautions implemented when indicated. Patients will be transferred to Behavioral Medicine as soon as possible after medical clearance is obtained. DEFINITIONS: Suicidal: A person is considered to be suicidal when they intend to purposely end their life and/or has threatened self harm, to take their life, has made a selfdestructive gesture, or has been described by the physician as suicidal. Screening: Process of identifying those patients requiring a Suicide Risk Assessment. Suicide Risk Assessment: Assessment consisting of a series of questions and observations to determine if patient is suicidal.

3 Suicide Risk Screening: 1. Nursing screens all patients for risk of suicide on admission to the hospital by reviewing the primary diagnosis or primary complaint for admission. This is documented as part of the admission assessment to the area/in the electronic medical record. 2. Primary diagnoses or primary complaints triggering the need to complete the Suicide Risk Assessment are: a. Depression b. Substance abuse c. Mood disorders (e.g. bipolar, unipolar, or mania) d. Violent or disruptive disorders e. Postpartum depression Version 7 Posted 7/7/2016 f. Physical, sexual or domestic abuse/violence g. Eating disorders 3. If any one of a g the above is identified, a Suicide Risk Assessment is completed by nursing.

4 Suicide Risk Assessment: 1. The risk assessment includes identification of specific factors and features that may increase the risk for suicide. (See Modified SAD PERSONS scale) under suicide screen in electronic medical record. 2. Patients found to be at Risk according to the assessment tool will be placed on suicide precautions and admitting physician will be notified immediately for orders. A Psychiatry consult is recommended. The patient will be considered at risk for suicide until physician indicates patient is no longer at risk. 3. The patient and family/significant other, if appropriate, will be interviewed and included in the plan of care when indicated. 4. Patient s assessed at risk, will have their immediate safety needs and most appropriate setting for treatment addressed. (See Suicide Precautions listed below)

5 Suicide Precautions: 1. The patient will be transferred to Behavioral Medicine as soon as possible after medical clearance obtained. 2. While in the acute care or post acute care setting, the patient will be under constant supervision. Either a sitter or camera may be utilized for monitoring of the patient. A sitter will be a trained direct caregiver, at the minimum a CNA. Document method of observation and name of sitter (if utilized).. 3. Direct observation of the patient is maintained at all times, including, during bathing and toileting. 4. The sitter must remain with the patient until they are relieved by available health care personnel only for breaks and meals. 5. Belongings and the room will be searched for potentially dangerous items, clothes and suitcases. All clothing is to be removed; hospital gown and pajama bottoms are provided as needed or requested by the patient. Hospital footies are removed so nothing can be hidden in their socks, under clothing etc Note: Nursing should attempt to obtain the patient s permission for the search. However if the patient protests, the search will still be conducted with the patient in the room and another staff member present. Security should participate in search, as needed. Document findings.

6 Note: All belongings and items removed from patient are to be inventoried and secured by nursing staff until deemed appropriate for return to patient 6. Remove all sharp objects from room, such as razors, knives, scissors, and needles. 7. Remove matches, cigarettes, lighters, etc 8. Remove all cords such as telephone cords, belts, pajama strings, nurse call cords, shoestrings, and pantyhose. 9. Remove potentially dangerous supplies and equipment from the room when not in use (i.e. IV poles) 10. Check food trays upon receiving and completion to assure all utensils are returned with the tray. Plastic silverware should be used on trays. 11. Place a sign on patient s door for visitors and hospital personnel to report to the Nurse s station. Any visitation MUST be approved by the patient and physician and/or nurse, if appropriate. Document presence of visitors. 12. Plastic garbage bags to be removed. 13. Notify House Manager and Security of patient on medical unit on Suicide Precautions.

7 14. Suicide Precautions may only be discontinued based upon the physician s reassessment of the patient s suicidal risk and documentation of the absence of risk for self injury. 15. The least restrictive, but most effective means of patient supervision available must be utilized, which includes the need to transfer to Behavioral Medicine Services as soon as possible. 16. Clinical reassessment by physician of the risk must be documented every 24 hours in the progress notes. 17. A patient who is unconscious, comatose or unresponsive due to medical condition does not require direct observation since they are incapable of selfharm. However, any unresponsive patient must be assessed by the RN for level of consciousness and intent and ability for self harm at a minimum of every shift and as needed. The patient will be placed under direct observation if it is assessed that the patient is capable of self harm until the medical team has established that the patient is not at risk for self harm and direct observation is no longer necessary.

8 Documentation Requirements: 1. Suicide Risk Screening and Modified SAD PERSONS assessment 2. Patient s constant supervision and person(s) supervising 3. Room Search and removal of potentially dangerous items 4. Presence of visitors 5. Physician clinical reassessment of suicidal risk and documentation of absence of risk for self injury, for discontinuation of suicide precautions. 6. Provision of National Suicide Prevention Hotline number upon discharge.

9 Patient/Significant Other Teaching 1. It is essential that staff explain reasons for constant supervision to Patient and family/support system, with emphasis upon our commitment to patient safety. 2. Instruct patient and family of signs, symptoms and treatment options of depression/suicide risk. 3. Obtain Social Service referral for participation in discharge planning if patient is being discharged from acute or post acute care. 4. Upon discharge, instruct patient to call the National Suicide Prevention Hotline ( TALK (8255)). Document provision of phone number.

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