January 2021 marks eighteen months since changes were initiated with more focus on NPSG 15.01.01, Reducing the risk of suicide. The changes in focus were in response to devastating statistics showing a trend of increasing rates of suicide. According to the Centers for Disease Control and Prevention (CDC) WISQARS Leading Causes of Death Reports, in 2018:
• Suicide was the tenth leading cause of death overall in the United States, claiming the lives of over 48,000 people.
• Suicide was the second leading cause of death among individuals between the ages of 10 and 34, and the fourth leading cause of death among individuals between the ages of 35 and 54.
• There were more than two and a half times as many suicides (48,344) in the United States as there were homicides (18,830).1
Suicides had been on the rise since 2005, which is the highest rate since WWII. Something had to be done. In October, the Centers for Disease Control and Prevention posted new suicide death rate data showing that the suicide rate dropped to 13.9 in 2020 from 14.2 in 2019.2 Perhaps, this downturn could be attributed to the increase in attention to suicide risk. However, with the advent of the COVID-19 pandemic, a downturn in the economy, job losses and social isolation, it is not clear how suicide rates will change.
Clearly the stress level of the nation has gone up with just about every aspect of our lives changed due to the pandemic. A recent Gallup poll has found that Americans’ latest assessment of their mental health is worse than it has been at any point in the last two decades. Seventy-six percent of U.S. adults rate their mental health positively, representing a nine-point decline from 2019.3 Reports from the field indicate that Emergency Department staff are seeing patients with greater acuity for suicide risk possibly due to delaying treatment for fear of exposure or social isolation. The potential risk for patient suicide is present now more than ever for healthcare organizations. It is important the organizations are continuously focused on meeting the elements of performance for NPSG 15.01.01 to ensure the safety of their at-risk patients.
Assessing Environmental Risks for Suicide
The healthcare environment is fraught with potential dangers for at risk patients who are intent on self-harm. Psychiatric hospitals and psychiatric units in general hospitals must perform a comprehensive review of the environment to identify risks and minimize them by removal or other mitigating strategy. This review should be kept current to ensure that new changes in the environment are quickly identified and addressed with the goal of being ligature resistant, meaning ligature-free. For example, when Facilities conducts any work on the unit infrastructure, is a risk assessment conducted during and after work to ensure risks are mitigated? Is there a process in place to know when work is being conducted that would prompt the application of an environmental risk assessment?
For non-psychiatric units, such as Emergency Departments and Med-Surg Units, the requirement for environmental risks is different. There is no requirement to be ligature resistant unless you have designated areas as such. It is expected that you would evaluate environmental risks and employ appropriate mitigation strategies. What is your process to identify environmental risks and mitigate them where at-risk patients are located? Some organizations utilize an environmental risk form that guides their healthcare team in identifying and addressing potential risks specific to patient care settings. These are often combined with guidance for 1:1 attendants to provide observation as a safety measure when risks cannot be mitigated. It is important to ensure that your team is trained and competent to complete the environmental assessment as well as fulfill the role as an attendant given the responsibility in caring for these at-risk patients.
Patient Screening and Assessment for Suicide Risk
Identifying patients who are at risk and assessing the severity of their ideation is critical to ensure that potential patient harm can be avoided. Although the requirement is that patients who are being seen for behavioral health related issues must be screened for suicide risk, some organizations choose to screen all patients regardless of chief complaint. Regardless of approach, being consistent with policy is imperative. Organizations can choose from a variety of tools to perform both screening and the follow-on assessment (if required). It is important to ensure that age-specific tools are addressed in organizational policy and that staff are trained and competent to use them. The Joint Commission requires that evidenced based assessment tools are used for ages 12 and above.
Documentation of the patient’s risk for suicide in the medical record must be completed. Furthermore, the plan of care should reflect mitigating actions to address the patient’s risk as well as the plan for counseling and follow-on care upon discharge. Organizations must ensure that documentation includes the patient’s progress toward goals and their plan of care reflects any change in their mental health status.
Policy and Monitoring Program Effectiveness
It is important to ensure organizations have robust Suicide Prevention Policies and Procedures based on their patient population. At a minimum, these should address training/competency of staff who care for at-risk patients, guidelines for reassessment and monitoring patients who are at-risk for suicide.
Additionally, active monitoring that reviews implementation and effectiveness of your Suicide Prevention program including compliance with screening and assessment and management of these patients is required. Identified gaps should be addressed including follow up monitoring for effectiveness of interventions.
Resources for Suicide Prevention:
Here is a selection of Suicide Prevention resources that can assist you with guidance on how to reinforce your program.
• Courtemanche & Associates Quality Academy, Preventing Suicide
• American Association of Suicidology
• American Foundation for Suicide Prevention
• National Center for Injury Prevention and Disease Control
• National Strategy for Suicide Prevention
• The Jason Foundation
• The Jed Foundation
• The Link Counseling Center
• National Organization for People of Color Against Suicide
• Organization for Attempters and Survivors of Suicide in Interfaith Services
• Suicide Awareness Voices of Education
• Suicide Prevention Action Network USA
• Suicide Prevention Resource Center
Although suicide prevention has received increased focus by regulatory agencies, it is still a national healthcare crisis. The COVID-19 pandemic has shifted the attention of healthcare resources, but the risk to our patients remains. It is essential that facility leaders ensure that they maintain focus especially with the increased levels of stress that the pandemic has created.
1National Center for Health Statistics. Public-use data files: Mortality multiple cause files.
2018. Available from: https://www.cdc.gov/nchs/data_access/vitalstatsonline.htm#Mortality_
2Ahmad FB, Bastian B. Quarterly provisional estimates for selected indicators of mortality, 2019-Quarter 1, 2020. National Center for Health Statistics. National Vital Statistics System, Vital Statistics Rapid Release Program. 2020.
3Brenan, Megan. Americans’ Mental Health Ratings Sink to New Low. 2020. Retrieved from https://news.gallup.com/poll/327311/americans-mental-health-ratings-sink-new-low.aspx .