Caring For Adult Patients With Suicide Risk
Caring for Adult Patientswith Suicide RiskA Consensus Guidefor EmergencyDepartmentsSPRCSuicide Prevention Resource Center
Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments (the full and quick guide versions)is based upon the best information available at the time of publication. It is designed to provide information and assist decisionmaking and act as a guideline only. It is not intended to define a standard of care and should not be construed as one. Neithershould it be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriatelyoccur when providers take into account the needs of individual patients, available resources, and limitations unique to aninstitution or type of practice. Every health care professional making use of these guidelines is responsible for evaluating theappropriateness of applying them in the setting of any particular clinical situation.Consensus Panel MembersMichael Allen, MDCara AnnaGary Behrman, PhD, LCSWJon Berlin, MDLanny Berman, PhDEdward Bernstein, MD, FACEPEmmy Betz, MD, MPHEdwin Boudreaux, PhDEdward Boyer, MD, PhDPeter Brown, MAGreg Brown, PhDMarilyn Bruguier Zimmerman, MSWStuart Buttlaire, PhD, MBAJoel Carr, PhD, LCSW, LPCJennifer Chaffin, MDCindy Claassen, PhDM. Justin Coffey, MDMaureen Cooper, MSN, RNGlenn Currier, MD, MPHSusan De Luca, PhDJohn Draper, PhDKen Duckworth, MDAvrim Fishkind, MDAmy Goldstein, PhDPeter Gutierrez, PhDJill Harkavy-Friedman, PhDCharles R. Harman, MSMatt Havens, MSW, LCSWLisa Horowitz, PhD, MPHDarcy Jaffe, MN, ARNP, NE-BC,PMHCNS-BCBarbara Kaminer, LCSWShelby Kneer, MSW, LCSWDavid Knesper, MDRandolph Knight, MD, FACEPGail Lenehan, EdD, MSN, RN, FAEN,FAANDeQuincy Lezine, PhDMary Nan Mallory, MDAnne Manton, PhD, APRN, FAEN, FAANRichard McKeon, PhD, MPHVan Miller, PhD 2015 Education Development Center, Inc. All rights reserved.James Mitchiner, MD, MPHGillian Murphy, PhDMarlene Nadler-Moodie, MSN, APRN,PMHCNS-BCMeera Narasimhan, MDStephen O’Connor, PhDMary Ellen Palowitch, RN, MHASeth Powsner, MDLaura Raymond, BSN, RN, CENBrett Schneider, MD, LTC, MCSusan Self, MSW, LCSW, CCWMorton Silverman, MDChris Souders, MDBarbara Stanley, PhDLauren Whiteside, MD, MSRichard Wild, MD, JD, MBA, FACEPMichael Wilson, MD, PhD, FAAEMMatthew Wintersteen, PhDDoug Zatzick, MDScott Zeller, MDLeslie Zun, MD, MBA, FAAEM
Contents1. About the Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 Introduction1.2 Key Components of Caring for Adult Patients with Suicide Risk in EDs122. Decision Support Tool. . . . . . . . . . . . . . . . . . . . . . . . . . . 32.1 About the Decision Support Tool2.2 Using the Decision Support Tool2.3 Comprehensive Suicide Risk Assessment3573. ED-Based Brief Suicide Prevention Interventions. . . 83.13.23.33.43.53.6Brief Patient EducationSafety PlanningLethal Means CounselingRapid ReferralCaring ContactsCrisis Center Information910121314154. Discharge Planning Checklist. . . . . . . . . . . . . . . 165. Providing Patient-Centered Care. . . . . . . . . . 186. Support for the Emergency Department. 216.16.26.36.46.5Documenting the ED VisitWorking with Crisis CentersUsing Telepsychiatry with Suicidal PatientsSuicide Risk Associated with Intoxication and Substance Use DisordersReducing Liability Concerns2122232323Appendices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Appendix A: Quick GuideAppendix B: Guide Resources and URLsAppendix C: Primary Screening and Suicide Risk AssessmentAppendix D: Sharing Patient Health InformationAppendix E: Sample Letter to Outpatient Mental Health ProvidersAppendix F: Community Resource List TemplateAppendix G: Caring Contacts Sample MaterialsAppendix H: Key Elements of a Patient Care PlanAppendix I: Examining Your Views about ts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
“[I]t is important to recognize that suicidal experiences exist on a continuum. Somepeople have seriously considered suicide, some have made plans that were not carriedout, and some have attempted suicide. Of the millions of people who have livedthrough a suicidal crisis, the vast majority recover.”—The Way Forward: Pathways to Hope, Recovery, andWellness with Insights from Lived Experience
1About the Guide1.1 IntroductionCaring for Adult Patients with Suicide Risk: A Consensus Guide forEmergency Departments (the ED Guide) is designed to assist emergencydepartment (ED) providers with decisions about the care and discharge ofpatients with suicide risk. Our main goal in developing and disseminatingthis guide is to improve patient outcomes after discharge.Studies indicate that the risk of a suicide attempt or death is highest within the first 30days after discharge from an ED or inpatient psychiatric unit. Yet for many reasons, up to70 percent of patients who leave the ED after a suicide attempt never attend their firstoutpatient appointment (Knesper, 2010).ED providers are in a unique position to improve outcomes and facilitate a safer dischargefor patients with suicide risk by providing them with brief interventions, onsite mental healthconsultations when appropriate, and linkages to sources of follow-up care. Research suggeststhat ED-based interventions could reduce annual deaths from suicide by 20 percent (NationalAction Alliance for Suicide Prevention: Research Prioritization Task Force, 2014).WHAT’S INSIDE:»» Key components of caring for adultpatients with suicide risk in EDs»» Decision Support Tool Section 2»» ED-based interventions Section 3»» Discharge planning checklist Section 4»» Patient-centered care guidelines Section 5»» Information on related topics, suchas documentation, working withcrisis centers, and intoxication andsubstance use disorders»»The ED Guide provides information about decision support, briefinterventions, and discharge planning with adult patients who have beenidentified as having some risk of suicide. It can also help answer thefollowing questions:»»»»»»Can this patient be discharged or is further evaluation needed?How can I intervene while this patient is in the ED?What will make this patient safer after leaving the ED?A Quick Guide version of this document is in Appendix A. We recommendproviders read the complete version before using the Quick Guide.A comprehensive set of external resources, referenced in this guide, canbe accessed by clicking on the blue text or viewing the list of resources inAppendix B.The ED Guide was written for health care professionals (e.g., physicians,nurses, mental health specialists, and other practitioners) who provideTools and resources to supportclinical care in EDs, although some topics may be appropriate for ED andimplementation of the ED Guidehospital administrators. The authors recognize that clinical roles vary acrossEDs, therefore institutions can adapt the recommendations given here totheir own organizational structures. In this guide, all relevant health careprofessionals are referred to as “provider.” All clinical information provided in this guide ismeant to complement, not replace, provider judgment.Caring for Patients with Suicide Risk 1
About the Guide1The ED Guide was developed with extensive input from a consensus panel of experts fromemergency medicine and suicide prevention organizations, including people who livedthrough suicidal experiences (i.e., “lived experience.”). Recommendations in the ED Guidewere developed using an iterative process that included both reviews of the literature andexpert panel consensus. For more on how the ED Guide was developed, see the companionpaper, Technical Report: Developing Caring for Adult Patients at Risk of Suicide: A ConsensusGuide for Emergency Departments.1.2 Key Components of Caring for Adult Patients withSuicide Risk in EDsFigure 1 illustrates one process for the care and discharge of adult patients with suicide riskfrom EDs. This process emphasizes the actions and decisions that are most relevant for thedischarge of patients in lower-risk categories. The items shaded blue are consensus-based toolsand resources provided in this guide. Broader topics, such as the utility of universal screeningor appropriate medical screening of mental health patients in EDs, are available from otherauthoritative sources and may be consulted by EDs developing suicide care protocols.Figure 1. Process for Care and Discharge of Patients with Suicide Risk for EDsProvide patient-centered careAdultpatientwithsuicidalideation orsuspectedsuicide riskAssesspatientcapacityto ontinue with medicalassessment; Treat orobserve as appropriateSuicideattemptas reasonfor visitUse DecisionSupport Toolfor secondaryscreening(Section 2)Score 0ProvideED-BasedBrief SuicidePreventionInterventions(Section 3)UseDischargePlanningChecklist(Section 4)DischargeandreferOutpatientCareScore 1 Use SAFE-T(Section 2.3)Consultmental healthspecialistfor furtherevaluation &suicide riskassessmentMake levelof caredeterminationInpatientCareAdmitIdentification of individuals at risk may occur as a result of (1) patient disclosure; (2) reports by family, friends, or other collaterals;(3) individual indicators such as depression, substance use or debilitating illness; or (4) primary screening.2See Appendix C for information on primary screening.3Consult your ED’s policies to determine how medical clearance applies to this diagram.1Caring for Patients with Suicide Risk 2
2Decision Support Tool2.1 About the Decision Support ToolWhat is the Decision Support Tool?The Decision Support Tool is a secondary screening instrument developed by expertconsensus to help ED providers make decisions about the care and discharge of adultpatients with suicide risk. It indicates whether a patient’s health and safety needs maybe met in the outpatient environment following a brief ED-based intervention or whetherevaluation from a mental health specialist may be needed first. The Decision Support Toolis designed for use with adult patients who have been identified as having suicide risk (i.e.,suicidal ideation or suspected suicide risk) and who have the capacity to make health caredecisions. Identification of these patients may occur as a result of (1) patient disclosure; (2)reports by family, friends, police, or other collaterals; (3) individual patient presentations,such as depression, substance use, or debilitating illness; or (4) primary screening. TheDecision Support Tool does not replace a provider’s best judgment or experience.Who should use the Decision Support Tool?Clinical staffing roles vary in EDs, and the Decision Support Tool may be used by EDphysicians, nurses, and mental health specialists.How does the Decision Support Tool differ from primary screeningand suicide risk assessment tools?The Decision Support Tool is a secondary screening tool that helps providers with practicaldecisions, such as “Can I make a disposition decision without consulting a mental healthspecialist?” and “Is it appropriate to discharge this patient after providing a brief ED-basedintervention?”In the ED, primary screening tools are used to detect possible suicide risk in every ED patient(universal screening) or in patients belonging to groups shown to be at a higher-thanaverage risk of suicide (selective screening), such as patients with depression. Primaryscreening does not uncover the nature of suicide risk that may be present.The Decision SupportTool is a secondaryscreening tool thathelps providers withpractical decisionssuch as, “Can I makeA comprehensive suicide risk assessment is used to collect detailed information about apatient’s suicide risk (e.g., risk and protective factors), to detect the possibility of imminentrisk, and to inform treatment decisions.Table 1 describes the relationships among these different tools. For more information onSuicide Risk Assessment see Appendix C.a disposition decisionwithout consultinga mental healthspecialist?”Caring for Patients with Suicide Risk 3
2Decision Support ToolTable 1. Using Primary, Secondary, and Risk Assessment Tools in the EDTYPE OF TOOLUSED WITHTELLS YOULOCATION INTHE ED GUIDEPrimary ScreeningTool (universal orselective)Every ED patient orpatients with known riskfactorsWhether suicide riskis present or absentAppendix CSecondary ScreeningTool (DecisionSupport Tool)Patients with some suiciderisk as identified throughuniversal screening,patient disclosure, or otherindicatorsWhether dischargefollowing ED-basedinterventions maybe appropriate orfurther assessmentby a mental healthspecialist is neededto make a dispositiondeterminationSection 2.2ComprehensiveSuicide RiskAssessmentPatients with suicide riskwho score positive ( 1) onthe Decision Support ToolInformation abouta patient’s risk andprotective factors,immediate danger,and treatment needsAppendix CNote: If resources permit, asuicide risk assessment maybe used with any patientwith suicide risk.How does the Decision Support Tool inform inpatient admissiondecisions?The Decision Support Tool indicates which patients with suicide risk may need a mentalhealth evaluation (which should include a suicide risk assessment) during the ED visit.Informed decisions about admission combine the results of a comprehensive suicide riskassessment, the provider’s clinical judgment, input from the patient and his or her socialsupports, input from the team of professionals caring for the patient, and the institution’spolicies and procedures for suicide evaluation and management.Primary screening, secondary screening, and suiciderisk assessment are distinct but related practicesdesigned to help providers understand the nature oftheir patients’ suicide risk.Caring for Patients with Suicide Risk 4
2Decision Support Tool2.2 Using the Decision Support ToolThe Decision Support Tool is a six-item, yes/no response tool (Figure 2). The first item, withno number, is unscored and is designed to confirm that suicide risk exists and to transitioninto the topic of suicide. Items numbered 1 through 6 are scored. Step-by-step instructionsfollow the tool.Decision Support ToolTransition question: Confirm Suicidal IdeationHave you had recent thoughts of killing yourself?Is there other evidence of suicidal thoughts, such as reports from family or friends?YNot part of scoring.Thoughts of carrying out a plan1Recently, have you been thinking about how you might killyourself?YNYNYNYNYNYNIf yes, consider the immediate safety needs of thepatient.2Suicide intent3Past suicide attemptDo you have any intention of killing yourself?Have you ever tried to kill yourself?Significant mental health condition4Have you had treatment for mental health problems? Doyou have a mental health issue that affects your ability to dothings in life?Substance use disorder5Have you had four or more (female) or five or more (male)drinks on one occasion in the past month or have you useddrugs or medication for non-medical reasons in the pastmonth? Has drinking or drug use been a problem for you?Irritability/agitation/aggression6Recently, have you been feeling very anxious or agitated?Have you been having conflicts or getting into fights? Is theredirect evidence of irritability, agitation, or aggression?STEP 1: Inform the patient.Tell your patient that you will be asking a few questions to help you consider next steps.STEP 2: Review the patient’s suicidal ideation.If this is your first interaction with the patient, begin by confirming that he or she hassuicidal ideation. Ask the patient directly1 or state your understanding of the nature of his orher suicide risk. This will facilitate a smooth transition to item number 1 (plan).1 If the patient says that he or she does not have suicidal ideation and there is no evidence to suggest that he or she may be atrisk, this tool is not needed. Review the reasons why he or she was identified as having suicide risk.Caring for Patients with Suicide Risk 5
2Decision Support ToolSTEP 3: Ask questions for items 1 through 6.The tool includes example questions to ask. Use an open, nonjudgmental style to overcomesocial response bias and encourage honest answers.Use availabledata (e.g., patientobservation,medical records)STEP 4: Review other available information.Use available data (e.g., patient observation, medical records) and consult with availablecollaterals (e.g., friends, family members, and outpatient providers) to corroborate thepatient’s report. Let the patient know you would like to contact his or her collaterals, andthat the visit may be delayed while you are awaiting corroborating information.and consult withavailable collaterals(e.g., friends, familymembers, andoutpatient providers)to corroborate thepatient’s report.Can ED providers share patient health information with others?Yes. For patients with concerning risk factors who minimize or deny suicide risk, itmay be life-saving to contact collaterals for corroborating information. First requestthe patient’s permission to contact friends, family, or outpatient treatment providers.If the patient declines to consent after reasonable attempts have been made to obtainpermission, there are circumstances in which collaterals may be contacted without thepatient’s permission. HIPAA permits such contacts when the clinician, in good faith,believes that the patient may be a danger to self or others.»» For more information see Appendix D: Sharing Patient Health InformationSTEP 5: Check the score.A “yes” response is equal to 1. Total the number of “yes” responses on items 1–6.2Score 0. If the response to every item (1–6) is “no,” discharge may be appropriatefollowing the provision of one or more ED-based brief suicide preventioninterventions.3 These are described in Section 3, ED-Based Brief Suicide PreventionInterventions.Score 1. If the responses to the transition question (i.e., suicidal ideation) andany item 1–6 are “yes,” consider consulting a mental health specialist4 during theED visit for further evaluation, including a comprehensive suicide risk assessment.Consider the immediate safety needs of the patient as you determine next steps. If theevaluation points to discharge as the recommended disposition, provide the ED-basedbrief suicide prevention interventions listed in Section 3.STEP 6: Tell the patient what happens next.Explain next steps. For example:Score 0. Say that you are considering discharging him or her to an outpatient care setting andwould first like to provide a brief intervention. Describe the intervention you plan to use. Ask forthe patient’s feedback on this plan and discuss any reservations he or she may have about it.Score 1. Say that you would like him or her to see a specialist for further evaluation aspart of the ED visit. Explain that the specialist may repeat some of the questions that you’ve2 Suicidal ideation is an unscored item and should not be included in the scoring.3 In settings where a mental health specialist is readily available, consider referring all patients with any suicidal ideation orsuspected suicide risk to the mental health specialist for further evaluation, including suicide risk assessment.4 The availability of mental health specialists varies in EDs. Some hospitals use
Adult patient with suicidal ideation or suspected suicide risk . 1,2,3. Assess patient capacity to make healthcare decisions. Use Decision Support Tool for secondary screening (Section 2) Use SAFE-T (Section 2.3) Consult mental health specialist for further evaluation & suicide risk assessmen
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