A 2023 Hospital National Patient Safety Goal is to reduce the risk of suicide (The Joint Commission, 2022). Suicide is a tragedy that affects the entire world and all levels of society. It does not discriminate against race, religion, sexuality, wealth, or education. In the hospital many patients are overlooked because they do not present as a psychiatric patient. There are several interventions that we can do to reach this goal. Health Care Providers (HCP) must do a better job screening and identifying patients that are at risk for suicide. We also need to improve our interpersonal relationship skills to build trusting relationships with patients and make suicide a comfortable topic of discussion. We can ensure a plan is in place for timely outpatient care before discharge.
Screening tools for suicide can easily identify patients at risk and can be done on admission and discharge. Two suicide assessment tools that are used are the Risk Rescue Rating Scale (RRRS) and Brief Symptom Rating Scale (BSRS-5). The RRRS looks at the severity of the risk of a suicide attempt compared to the likelihood of being rescued (Berardelli et al., 2022). The data from this assessment could be used to examine the need for a longer hospital stay or interventions that could be used inpatient and after a patient is discharged, such as removing firearms from home or removing from medications after an overdose attempt (OD). The RRRS has two categories: risk and rescue. Each category is further broken down into five subcategories. Each of the subcategories are rated from one to five. One represents minimal risk of suicide or low likelihood of being rescued and a five means the greater risk of suicide or greater likelihood of rescue. (Berardelli et al., 2022) The risk categories are method used, toxicity, reversibility, treatment required and impaired consciousness. Rescue also has five factors: delay until discovery, the person initiating the rescue, probability of discovery, location, and accessibility to rescue. (Berardelli et al., 2022)
The BSRS-5 questionnaire is an assessment tool that is used to identify patients at risk for psychological distress and suicidal ideations. BSRS-5 has patients rate their symptoms of insomnia, depression, anxiety, hostility, and feelings of inferiority in the past week. It has the patients rate each category item on a scale from 0-4. A score greater than 6 confirms psychological distress. The last item on the scale asks for a yes or no answer about suicidal ideation in the past week. The data from a case study in Taiwan found that in the subgroup of people that endorse suicidal ideations in the past week, depression was the most common symptom followed by hostility, anxiety, inferiority, and feelings of inferiority (Jia‐In et al., 2021).
After a patient is screened, the HCPs can start minimizing and examining risk factors. Risk factors for suicide could be items in the milieu, patient belongings, patient gender and comorbidities. To combat environmental risk factors, rounds should be done by HCPs in staggered intervals. Rounds give the HCPs an opportunity to assess patient areas and things on the unit that could increase the risk of suicide. Equipment can be used as a weapon to self-harm, such as a metal leg from laundry cart could be sharpened and used to cut or stab self. Fixated objects in patient areas are ligature risks. Common ligature risk items are doorknobs, cabinets, fixed objects, mirrors, and sheets. A study in the United Kingdom found 50% of hanging suicides are by low suspension hanging (Gunnell et al., 2005). Low suspension hangings are ligature points below head level. This method of hanging has a success rate of 70% (Gunnell et al., 2005). Monitoring patient belongings is also key for safety. It is common for patients to try to sneak in contraband upon admission or at visitation. Contraband that could be used to self-harm or attempt suicide such as, anything glass, belts, bras, bathrobe cords, compact mirrors, disposable utensils, knitting needles, nail clippers, pens, pencils, shoelaces, razors, and suspenders to name a few. These items should not be allowed around patients that pose a risk to themselves.
There are risk factors associated with gender. Research suggests that females have greater incidence of suicidal ideation and suicide attempts (Berardelli et al., 2022) This is attributed to methods used. Women are more likely to complete suicide by OD. Men are more likely to be successful at suicide due to choosing more violent methods of suicides but, OD by females is thought to be under reported because not all drug deaths are reported as suicide. (Berardelli et al., 2022) Woman are also more likely to have common risk factors such as depression, a greater prevalence of anxiety disorders, childhood sexual trauma and previous suicide attempt or suicidal ideations (Berardelli et al., 2022). Men are more likely to have higher incidence of alcoholism or substance abuse and are more likely to complete suicide by hanging, firearms or jumping in front of moving objects.
Physical comorbidities are not a risk factor that the average person would link to suicide. Studies suggest that comorbidities such as cancer, epilepsy, COPD, chronic pain, and stroke coupled with depression have higher rates of suicide after discharge from a general hospital (Jia‐In et al., 2021). Patients recently discharged from a general hospital are three times more likely to commit suicide than the general public and the rates are higher than patients discharged from psychiatric hospitals (Jia‐In et al., 2021). A theory for this is that the inpatient setting is a protective factor that relieves psychological distress. Early screening is necessary to identify at risk patients to set up outpatient treatment. It is recommended that patients at risk of suicide be followed up by the provider within one week, at one month, and then at three months. Seventy percent of patients that completed suicide after discharge from a general hospital had suffered from depression or substance abuse, but only 1 in 44 was ever referred to outpatient mental health (Jia‐In et al., 2021).
Traditionally, the focus of safety for patients at risk for suicide has been minimizing adverse events but not improving systems that are already in place. Relisilent Healthcare (RHC) focus is to improve everyday clinical practices of HCP (Berg, Rørtveit, Walby & Aase, 2022). RHC considers the patient’s perspective to improve treatment to reduce the risk of suicide. The outcome was patients reported the more they felt cared for and understood, it led to trust between HCP and the patients (Shaimaa Mosad & Soltis-Jarrett, 2020). Patients reported that a trusting relationship and being validated by HCP is essential for reducing the risk of suicide (Berg, Rørtveit, Walby & Aase, 2022). RHC focuses on nonverbal cues, protection through dignity and personalized approaches to alleviate emotional pressure.
Nonverbal communication focuses on changes in body language and affect. This can look like isolating in their room, withdrawing from normal peer to peer interactions, a sudden disinterest in therapy, and changes in facial expressions. Sudden changes in nonverbal communication need to be closely monitored to protect at risk patients.
Protection through dignity aims to increase a patient's feeling of physical protection. An example of this is patient rounds. Patient rounding is a standard practice in psychiatric hospitals. It is done in staggered intervals of 5, 10, and 30 minutes, depending on hospital policy. It was found that when HCP interacted with patients during this time it made patients feel safe and cared for. The results were patients reporting a reduction in suicidal ideations when staff took the time to interact with them. A lack of support made from HCP made patients feel alienated and objectified and increased the risk of suicidal ideation (Berg et al., 2022).
Approaches to alleviate emotional pressure focus is individualized treatment plans to meet specific needs. It also looks at relieving underlying stressors such finances, reducing psychotic symptoms or access to medications (Berg et al., 2022).
Suicide is a grave issue that is unpredictable, but it is preventable. Screening patients for psychological distress and suicidal ideation is an easy intervention to implement throughout the entire hospital system. Once identified, HCP can minimize risk factors, prevent unnecessary environmental risk, and improve therapeutic relationship with patients. By providing a safe trusting environment and ensuring appropriate outpatient resources for patients, HCP can reduce the risk of suicide in 2023.
References
Gunnell, D., Bennewith, O., Hawton, K., Simkin, S., & Kapur, N. (2005). The Epidemiology and Prevention of suicide by hanging: A systematic review. International Journal of Epidemiology, 34(2), 433–442. https://doi.org/10.1093/ije/dyh398
National Patient Safety Goals - Joint Commission. (n.d.). Retrieved November 13, 2022, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient- safety-goals/2022/simple_2022-hap-npsg-goals-101921.pdf
Shaimaa Mosad, M. E., & Soltis-Jarrett, V. (2020). Suicide prevention education for psychiatric inpatient nurses in egypt. Journal of Psychosocial Nursing & Mental Health Services, 58(5), 32-38. https://doi.org/10.3928/02793695-20200305-02
Berardelli, I., Rogante, E., Sarubbi, S., Erbuto, D., Cifrodelli, M., Concolato, C., Pasquini, M., Lester, D., Innamorati, M., & Pompili, M. (2022). Is lethality different between males and females? clinical and gender differences in inpatient suicide attempters. International Journal of Environmental Research and Public Health, 19(20), 13309. https://doi.org/10.3390/ijerph192013309
Jia‐In Lee, Burdick, K. E., Chih‐Hung Ko, Tai‐Ling Liu, Lin, Y. C., & Ming‐Been Lee. (2021). Prevalence and factors associated with suicide ideation and psychiatric morbidity among inpatients of a general hospital: A consecutive three‐year study. The Kaohsiung Journal of Medical Sciences, 37(5), 427-433. https://doi- org.coloradotech.idm.oclc.org/10.1002/kjm2.12336
Berg, S. H., Rørtveit, K., Walby, F. A., & Aase, K. (2022). Shared understanding of resilient practices in the context of inpatient suicide prevention: a narrative synthesis. BMC Health Services Research, 22(1), 1–13. https://doi-org.coloradotech.idm.oclc.org/10.1186/s12913-022-08282-x