Joint Commission Issues Sentinel Event Alert 56 – Detecting and Treating Suicide Ideation in All Settings
The Joint Commission has issued a NEW Sentinel Event Alert that addresses detecting and treating suicide ideation in all settings. According to TJC, the suicide rate in the United States is the 10th leading cause of death. With this new Sentinel Event Alert, TJC seeks to assist inpatient and outpatient health care organizations better identify and treat individuals with suicide ideation. This alert replaces two previous TJC Sentinel Event Alerts on this topic (Issues 46 and 7).
Data from TJC’s Sentinel Event Database shows:
- Between 2010 and 2014, 1,089 suicides occurred in patients who received care, treatment, and services in staffed, 24-hour care settings or within 72 hours of discharge, including from a hospital’s emergency department.
- Root cause analysis reveals shortcomings in assessment, and most often in psychiatric assessment.
- 4 percent (165) of Joint Commission accredited behavioral health organizations and 5.14 percent (65) of Joint Commission-accredited hospitals (for which the requirement was applicable) were rated non-compliant in 2014 with National Patient Safety Goal 15.01.01 Element of Performance 1 – Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.
In the Alert, TJC identifies who is at risk for suicide. Please see the Sentinel Event Alert for that list of characteristics. Noteworthy is the reality that there is no “typical” suicide victim. Individuals with none of the described characteristics also attempt suicide. Clinician judgment is a crucial component of suicide risk prevention. Considering only individuals who fit certain characteristics is unwise; health care provider should better detect suicide ideation in all patients.
TJC recommends that all health care organizations develop “clinical environment readiness” through identifying, developing and integrating comprehensive behavioral health, primary care and community resources. TJC has eight specific recommendations broken down into four categories:
Detecting Suicide Ideation in Non-acute or Acute Care Settings:
- Primary, emergency and behavioral health clinicians should review each patient’s personal and family medical history for suicide risk factors.
- Use a standardized, evidence-based screening tool to screen all patients for suicide ideation.
- Consider using a waiting room questionnaire that specifically asks about thoughts of suicide. Suggested screening tools include the Patient Health Questionnaire (PHQ-9), Emergency Medicine Network’s EDSAFE Patient Safety Screener or the Suicide Behaviors Questionnaire-Revised (SBQ-R).
- Review screening questionnaires before the patient leaves the appointment or is discharged; conduct secondary screening if appropriate. Secondary screening tools include: Suicide Prevention Resources Center’s Decision Support Tool, Emergency Medicine Network’s ED-SAFE Patient Safety Secondary Screener, SAFE-T20 Pocket Card and the Columbia-Suicide Severity Rating Scale (C-SSRS).
- For patients who screen positive for suicide ideation and deny or minimize suicide risk or decline treatment, clinicians should obtain corroborating information by requesting the patient’s permission to contact friends, family, or outpatient treatment providers. If the patient declines consent, HIPAA permits a clinician to make these contacts without the patient’s permission when the clinician believes the patient may be a danger to self or others.
Taking Immediate Action and Safety Planning:
- Assessment results should dictate the level of safety measure needed.
- Patients in acute suicidal crisis should be kept in in a safe health care environment under one-to-one observation.
- Patients at lower risk of suicide should be provided with personal and direct referrals and linkages to outpatient behavioral health and other providers for follow-up care within one week of initial assessment. It should not be left up to the patient to make the appointment.
- All patients with suicide ideation should:
- Be given the telephone number to a suicide prevention hotline
- Be engaged in safety planning that includes coping strategies and resources for reducing risk
- Have restricted access lethal means such as firearms, prescription medications and chemicals
Behavioral Health Treatment and Discharge:
- Establish a treatment process that is collaborative, ongoing, and systematic. Utilizing a risk formulation model can help providers to understand a patient’s current thoughts, plans, access to lethal means, and acute risk factors.
- Develop treatment and discharge plans that directly target suicidality. Evidence demonstrates that patient engagement, collaborative assessment and treatment planning, problem-focused clinical intervention to target suicidal “drivers,” skills training, shared service responsibility and proactive and personal clinician involvement in care transitions and follow-up care are effective for suicide prevention. Specific strategies include:
- Engaging the patient and family members/significant others in the discharge process and in identifying effective coping strategies.
- Discussing the treatment and discharge plan with the patient and sharing the plan with other providers having responsibility for the patient’s well-being.
- Determining how often patients will be called and seen.
- Establishing real-time telephone or live contact with at-risk patients who don’t stay in touch or show up for an appointment, rather than having staff or resources just leave reminder messages or emails.
- Directly addressing patients’ thoughts about suicide at every interaction.
- Using motivational enhancement to increase the likelihood of engagement in further treatment.
Education and Documentation:
- Educate all staff in patient care settings about how to identify and respond to patients with suicide ideation. Develop and implement organizational processes for responding to a patient with suicidal thoughts. Education for staff should include:
- Environmental risk factors
- Identifying help in emergencies
- Policies for screening, assessment, referral, treatment, safety and support of patients at risk for suicide.
- Documentation should reflect the assessment, care and referral of individuals with suicide risk. Documentation should include why the patient is considered at risk for suicide, care treatment and services provided, content of the safety plan and the patient’s reaction to and use of it; discussions and approaches to means reduction; and any follow-up activities taken for missed appointments, including texts, postcards, and calls from crisis centers.
Included with today’s notice are several policies related to the detection and prevention of suicide ideation.
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