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Patient suicide prevention project

Coming changes address suicide in our patient population

By Dana Hawkes, MSN, RN, NE-BC, director, adult health services

Over the last two years, there have been suicides or suicide attempts in our patient population either while in care or within 72 hours of discharge from the hospital. This prompted a review of our practice, which identified opportunities for improvement.

A go-live date for Oct. 1, 2018 has been set and will include the following Epic changes used by the nursing staff for ordering Suicide Precautions and providing instructions at discharge.

Current State

Future State – Oct. 1, 2018

  • No severity of risk assessed/identified
  • ED patients with psychiatric disorders to be screened. Inpatients to be screened if new statements/threats made
  • RN to complete primary screening assessment to determine level of risk: low/none, moderate or severe
  • Secondary screening to be completed by MHE or MD/Psych Consult
  • Variation in safety measures (i.e. 1:1, q15 minute checks, small group assignments)
  • Use of staff resource regardless of risk level
  • Patient presents with post-suicide attempt or makes attempts for self-harm = continuous visualization
  • Severe risk = continuous visualization 
  • Moderate risk = post-hospitalization resource information provided
  • Provider orders suicide precautions
  • RN initiates Suicide Precautions
  • Provider required to order MHE/psych consult for secondary assessment
  • Inconsistent post-hospitalization resource information
  • After visit summary instructions auto-populate Crisis Hotline and other community resource information

The Columbia-Suicide Severity Rating Scale, adapted by Parkland, is the evidence-based tool that has been selected for our risk assessment use. To reference this tool search “Columbia” in Epic flowsheets. Each patient, 18 years and older, with a psychiatric disorder in the emergency department will be screened. Any patient in the inpatient setting who makes suicidal statements or threats will be screened. The tool comprises these six questions – with level of risk determined by points scored.

In the last two weeks:

  1. Have you wished you were dead or wished you would go to sleep and not wake up?
  2. Have you actually had thought of killing yourself? (if no, skips to #6)
  3. Have you been thinking about how you would kill yourself?
  4. Have you had these thoughts and had some intention of acting on them?
  5. Have you started to work out or worked out the details of how to kill yourself?
  6. Have you ever done anything, started to do anything, or prepared anything to end your life?

The following table lays out the clinical response for suicide risk identification levels.

Risk Identification Level

Clinical Response

No Risk Identified

(0 Points)

No psychiatric response required

Suicide screening complete


Moderate Risk Identified

(1-3 points)

No indication for Suicide Precautions

A.  In ED – Consult to mental health evaluator order to be placed and notify licensed independent practitioner

B.  In Inpatient – Notify LIP and request consult to psychiatry for assessment and safety planning

C.  Crisis hotline information automatically prints on AVS (Polk, Marion, Youth and Family #’s)


Severe Risk Identified

(4 + points)B.

A.  Initiate Suicide Precautions and place order

          1.  Initiate continuous observation or ligature                           resistant environment (S Room).

          2.  Patient environment check

          3.  Search of patient belongings

          4.  Monitoring of visitors

B.  In ED - Consult to MHE order to be placed and notify LIP

C.  In Inpatient - Notify LIP and request consult to psychiatry for assessment and safety planning

D.  Crisis hotline information automatically prints on AVS (Polk, Marion, youth and Family #’s)

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