Addressing Suicide Risk
in Emergency
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Section 3: Addressing Suicide Risk in ED Patients
Suicide: A Serious Public Health Concern in Arizona
According Arizona Department of Health Services (ADHS) Vital Statistics, suicide has been one of the top ten causes of death in Arizona every year for over a decade. The median charge for a self-inflicted injury-related hospitalization was $14,614 and hospital charges for self-inflicted injury-related hospitalizations in 2009 alone totaled over $116.8 million.
Misconceptions about Suicidality
Although patients presenting with issues of suicidality or deliberate self harm (DSH) come to emergency departments every day, some EDs may feel underprepared to fully address the immediate needs of these individuals. Many misconceptions persist about suicidal individuals that may undermine effective patient care. Below are some common misconceptions:
Misconception: Asking about suicide would plant the idea in my patient's head.
Reality: Asking how your patient feels doesn’t create suicidal thoughts any more than asking how your patient’s chest feels would cause angina.
Misconception: There are talkers and there are doers.
Reality: Most people who die by suicide have communicated some intent. Any person who talks about suicide provides an opportunity for health professionals to intervene before suicidal behaviors occur.
Misconception: Anyone who tries to kill him/herself must be crazy.
Reality: Most suicidal people are not psychotic or insane. They may be upset, grief- stricken, depressed or despairing, but extreme distress and emotional pain are always signs of mental illness and are not signs of psychosis.
Misconception: If somebody wants to die by suicide, there is nothing you can do about it. Reality: Most suicidal ideas are associated with the presence of underlying treatable disorders. Providing a safe environment for treatment of the underlying cause can save lives. The acute risk for suicide is often time-limited. If you can help the person survive the immediate crisis and the strong intent to die by suicide, then you will have gone a long way towards promoting a positive outcome.
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Misconception: He/she really wouldn't kill themselves since ______. ….she has young children at home
….he signed a No Harm Contract
….he knows how dearly his family loves him
Reality: The intent to die can override any rational thinking. In the presence of suicidal ideation or intent, the physician should not be dissuaded from thinking that the patient is capable of acting on these thoughts and feelings. No Harm or No suicide contracts have been shown to be essentially worthless from a clinical and management perspective. The anecdotal reports of their usefulness can all be explained by the strength of the alliance with the care provider that results from such a collaborative exchange, not from the specifics of the contract itself.
Misconception: People who die by suicide are people who were unwilling to seek help.
Reality: Studies of suicide victims have shown that more than half had sought medical help within six months before their deaths.
Misconception: Multiple and apparently manipulative self-injurious behaviors mean that the patient is just trying to get attention and are not really suicidal.
Reality: Suicide “gestures” require thoughtful assessment and treatment. Multiple prior suicide attempts increase the likelihood of eventually dying by suicide. The task is to empathically and non-judgmentally engage the patient in understanding the behavior and finding safer and healthier ways of asking for help.20,21
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Guidelines for Addressing the Needs of Suicidal Patients in EDs
Below are some guidelines22 that can help the ED respond appropriately to patient presenting with issues of suicidality:1. Restrict the means of a suicide attempt in the ED. The patient presenting with issues of suicidality should not be left alone. The patient should be checked for weapons, pills, and other threats to safety. Suicide means such as unguarded window, electric cords, etc., should be removed from the patient’s access.
2. The patient should be medically cleared. Patients presenting with suicide issues who arrive at the ED with physical injuries or other immediate health needs (e.g., drug overdose) should have these issues addressed before a risk assessment is performed. A physical exam may help rule out underlying medical explanations for mental health symptoms. A patient who cannot reach medical stability at the ED should be referred for inpatient admission to medical services with psychiatric consult or transferred to an inpatient psychiatry unit.
3. Once medically cleared a preliminary suicide risk assessment should be conducted to determine immediate risk. This determination may involve the following:
Intention
Plan
Previous attempts
Available means
4. The patient who is identified as at immediate or high risk for suicide should receive a mental health consultation and/or admission to an inpatient psychiatric unit on involuntary hold. The patient at low or ambiguous risk according to a preliminary assessment should receive a more comprehensive assessment before being released. 5. If mental health staff are not available to assess, trained ED personnel can assess using
the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) included in this toolkit. Screening tools alone should not be relied upon in making an assessment; the “whole picture” should be taken into account. A patient who is determined to be at immediate or high risk should receive a mental health consultation and/or admission to an inpatient psychiatric unit on involuntary hold.
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6. A patient presenting with suicide issues should be screened for risky or problematic substance use. Substance abuse is a risk factor for suicide. If substance abuse issues are identified, they can be addressed in the ED, often with a brief intervention (See earlier sections of this guide.)
7. A patient who is medically cleared and is determined to be at less than high or immediate risk for suicide can be released under certain circumstances:
A supervising adult has been identified who will maintain close monitoring until scheduled outpatient follow up appointment
A supervising adult has been identified and informed how to respond should the patient’s condition deteriorate (e.g., return to ED)
A supervising adult has been instructed how to reduce means in the home of the patient (e.g., securing of firearms, removal of lethal medications, etc.) (See Brief Intervention below)
Did you know…? In Arizona, firearms and poisoning are the
most frequently used mechanisms for death
by suicide
A referral for urgent outpatient follow-up
should be arranged for every patient
presenting with suicidality who is released
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Low/ ambiguous risk
Decision Tree for Addressing the Needs of Suicidal Patients in the ED
Assessment tools should support the decision but the “whole picture” needs to be taken into account in determining level of risk
Suicidal patients should be assessed for risky substance use Moderate risk
Low risk
Restrict the means of a suicide attempt in the ED
Medically clear the patient
Preliminary assessment to determine immediate risk
Mental health consultation and/or admission to an inpatient psychiatric unit;
take suicide precautions
More comprehensive assessment such as the SAFE-T
Can be released in accordance with careful guidelines with social
supports established A supervising adult should be
instructed how to reduce suicide means in the home of the patient
Consider admission
If released: develop crisis plan; referral for urgent outpatient follow up with a mental health professional; symptom reduction; give
emergency/crisis numbers
Immediate/ High risk
Immediate/ High risk
Referral for urgent outpatient follow up with a mental health professional; symptom
reduction; give emergency/crisis numbers
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Assessing Patients for Suicidality
Which patients should be assessed?
At a minimum, patients who present to the ED with a suicide attempt or suicidal ideations should be assessed for current level of risk. Patients presenting with drug overdose may also be considered for assessment, even if the overdose in not recognized as a suicide attempt. Evidence has suggested that a fairly high percentage of people who die by suicide had a visit with a healthcare provider in the previous year,23 indicating that it also could be lifesaving to screen a broader patient population for suicide risk.
When should patients be assessed?
Once medically cleared, a preliminary suicide risk assessment to determine immediate risk should be conducted with all patients who present in the ED having attempted suicide or with suicidal ideations. This preliminary assessment may contain elements such as intention, plan, previous attempts, and available means, and should identify individuals at current high risk for suicide attempt, who should receive a mental health consultation and/or admission to an inpatient psychiatric unit on involuntary hold. The patient at low or ambiguous risk according to a preliminary assessment should receive a more comprehensive assessment to support the findings from the preliminary screening and to provide further services as indicated.
Who should deliver assessments?
It is important to remember that suicide risk assessment tools are not diagnostic tools, which should be delivered by mental health professionals. Assessment tools are designed to be delivered by ED personnel, including physicians, nurses, social workers, and mental health staff.
Is your patient suicidal?
1 in 10 suicides are by people seen in an ED
within 2 months of dying, yet many patients
are never assessed for suicide risk.
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Will assessing for suicide be sufficient?
Some suicide assessment tools may require screening for other issues that increase the risk for suicide, such as substance abuse and depression. Screening tools for substance abuse are described early in this toolkit. A common screening tool for assessing depression is the Beck Depression Inventory (BDI). Details regarding the BDI can be found in the following publication: Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J (June 1961). "An inventory for measuring depression." Arch. Gen. Psychiatry 4: 561–71.
Can assessment tools adequately assess suicide risk?
Screening tools are not considered sufficient alone to assess suicide risk. Many suicide risk assessment tools, including the one included in this toolkit, do not have a scoring system because they are intended to help the assessor identify relevant risk factors while leaving the assessment of actual risk to the assessor. Each patient should be evaluated on a case-by-case basis taking the “whole picture” into account.
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Description of Assessment Tools for Suicidality
What assessment tool for suicidality can be delivered in EDs?
Many tools to assess suicidality have been developed, typically for screening general populations. A tool that can be used to help assess suicide risk in ED patients is the Suicide Assessment Five-step Evaluation and Triage (SAFE-T). This tool has been endorsed by the American College of Emergency Physicians (ACEP), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Suicide Prevention Resource Center (SPRC). Further details, including the tool itself, are provided in the following section of this toolkit.
Screening Tools Patient Population Notes
Adults Adolescents
SAFE-T (2009 version) X X
Evidence-based
Assessment of adolescents includes consultation with parent or guardian
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Suicide Assessment Five-Step Evaluation and Triage (SAFE-T)
The Suicide Assessment Five-step Evaluation and Triage (SAFE-T)24 was conceived of by Douglas Jacobs, a doctor of psychiatry at Harvard Medical School, and developed in collaboration with the Suicide Prevention Resource Center (SPRC). It is based on the American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors and designed for use with adults and adolescents. Implementing this tool with adolescents assumes the inclusion of parents or guardians, consulting them in Step 3 (Suicide Inquiry) and providing them with a role in the treatment plan in Step 5 (Documentation).
The SAFE-T tool is comprised of the following steps: 1. Identify risk factors
2. Identify protective factors
3. Conduct a “suicide inquiry” (current suicidal thoughts, plan, behavior and intent)
4. Determine risk level and need for intervention (based on Steps 1-3). Reassess and re- determine risk level and appropriate intervention level as the patient or environmental circumstances change
5. Document risk level, rationale, treatment plan, means restriction instruction, and follow-up plan. Documentation should continue throughout each reassessment
Interpreting the SAFE-T
Determining risk level and appropriate level of intervention using the SAFE-T tool is based on Steps 1-3 (identifying risk factors, identifying protective factors, and conducting a suicide inquiry):
Risk/Protective Factors Suicidality Patient’s Risk Level
Suggested Intervention Psychiatric disorder with
severe symptoms, or acute precipitating event; protective factors not relevant
Potentially lethal suicide attempt or persistent ideation with strong intent of suicide rehearsal
High Risk Admission generally indicated unless a significant change reduces risk. Take suicide precautions
Multiple risk factors; few protective factors
Suicidal ideation with plan but no intent or behavior
Moderate Risk Admission may not be necessary depending on risk factors. Develop crisis plan. Give emergency/crisis numbers
Modifiable risk factors; strong protective factors
Thoughts of death; no plan intent, or
behavior
Low Risk Outpatient referral. Symptom reduction. Give
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Suicide Assessment Tool for Use in the ED
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Brief Intervention for Patients Presenting with Attempted Suicide
Means Restriction Training as an Intervention
A brief, evidence-based intervention that can be easily and quickly delivered in the ED without follow-up is a strategy addressing the elimination of means of suicide from the patient’s environment (“means restriction”). This semi-structured intervention is delivered not to the patient but to the parent of the patient, a caregiver, or a support system member. It consists of 1) educating the parent or caregiver to recognize the importance of restricting access to firearms, alcohol and prescription and over the counter drugs; and 2) providing practical advice in disposing of or locking up firearms and locking up other substances. Such interventions have been implemented in Idaho, Illinois, and other states and have been implemented with the families of teens and adults.25
The effectiveness of means restriction interventions is based on findings that suicidal crisis are often short-lived and that suicide attempts are often impulsive acts that can be mitigated by the difficulty of obtaining means. Ninety percent of suicide attempters who do not succeed never die by suicide; up to 65% never try again.26
The primary focus of means restriction interventions with ED clients is firearms because this is the most common and also most lethal means of suicide; however, restriction of other means such as prescription and over the counter drugs, sharp objects, means of strangulation, etc. are also relevant.
Intervention guidelines are presented in the following section. Additional guidance in firearm means restriction can be found at the Arizona Firearm Injury Prevention Coalition (AFIPC) website http://www.afipc.org.
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Means Restriction Brief Intervention: Speaking with the Patient’s Family and
Loved Ones about Firearms and Prescription Medications
(If the patient is an adult, follow your agency’s protocols regarding gaining the patient’s permission to contact family/loved ones)
Explain that you’re concerned that their loved one is at risk for suicide
Ask if there are prescription medications in
the house Ask if there are
firearms at home and explain why
you’re asking
The presence of a gun increases the chance that a suicide attempt will be fatal
Ask the men too; when clinicians speak with a parent, it is often the mother. Women don’t always know when their
male partner has a firearm in the home. If yes, please review next page Ask about all firearms; if there’s one
gun, there’s usually more than one.
Advise that the safest options in not having firearms at home until
the situation improves
Sympathize with gun owners who find the option of living without a firearm at home,
even temporarily, very difficult. Don’t minimize that this is a tough sacrifice.
Storing firearms at a trusted friend or relatives home until the situation improves may be an acceptable option. Not
everyone can legally hold onto a firearm however.
Locking the firearm up is also an option if the family won’t remove the guns but it’s not the safest option. Lock all firearms, unloaded, in a safe, designated for firearms
or in a tamper-proof, locked storage place. Lock the ammunition separately
Document in your notes that you’ve reviewed this information with the family
Local law enforcement may be able to store the guns or dispose of them.
Families should contact their police or sheriff’s department
to find out if a storage or disposal program is available.
You’re all on the same team trying to keep the patient safe. Be firm that the safest option is keeping guns out
of a suicidal person’s home.
Hiding unlocked guns is not advisable. Remember, kids know
their parents’ hiding places.
Advise the family not to keep ammunition at home until the situation improves. Be
sure the keys or combination are not accessible to the person at risk.
Don’t limit your conversation to lethal means. Lethal means counseling is only part of a comprehensive approach to activating the patient’s support system Assess each relevant household
(e.g. for teenagers in joint custody ask about both parent’s homes)
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Means Restriction Brief Intervention: Speaking with the Patient’s Family and
Loved Ones about Firearms and Prescription Medications, continued
Adapted From “Means Matter: Suicide, Guns and Public Health.” Available at http://www.hsph.harvard.edu /means-matter/, 2010.27
Ask if there are prescription medications in the house and
explain why you’re asking.
Assess each relevant household (e.g. for teenagers in a joint custody situation, ask about
both parents’ homes).
Advise clients and families to remove lethal doses from the
home
Limit prescriptions of lethal medication to suicidal patients to a
non-lethal quantity.
Call the Poison Control Hotline if you need help determining a non-lethal
quantity. 1-800-222-1222
The presence of lethal medication increases the chance that a suicide