2017 Suicide Education UpdateTelesitter

Suicide Risk Assessment Collaborative Task Force

October 2017

Objectives1. Participants will understand the importance of

suicide screening and their role in notifying theclinical staff of potential risks .

2. Participants will learn and understand theInterventions associated with Low, Medium, HighRisk Levels and Negative Screens.

3. Participants will learn and understand the roompreparations necessary for Low, Medium and HighRisk levels.

CalvertHealth Medical Center recognizes theescalating number of suicides and individualsexperiencing suicidal ideation. The hospital hasupdated the Columbia Suicide Severity Risk Scale(C-SSR) to standardize the process foridentifying the level of risk.

Suicide Definitions

Suicide: is defined as death caused by self-directed injuriousbehavior with intent to die as a result of the behavior.

Suicide Attempt: is a non-fatal, self-directed, potentiallyinjurious behavior with intent to die as a result of the behavior. Asuicide attempt might not result in injury.

Suicide ideation: refers to thinking about, considering, orplanning suicide.

www.nimh.nih.gov

Did You KnowAccording to the Centers for Disease Control and Prevention (CDC) in 2015

Suicide was the tenth leading cause of death overall in the United States,claiming the lives of more than 44,000 people.

Suicide was the third leading cause of death among individuals between theages of 10 and 14, and the second leading cause of death among individualsbetween the ages of 15 and 34.

There were more than twice as many suicides (44,193) in the United States asthere were homicides (17,793).

Did You KnowSuicide Ideation and Attempts Are Unbelievably Common…

IN YOUR AVERAGE HIGH SCHOOLERS

• 8% attempted in the past year!

• 17% seriously considered it

Within any typical classroom,it is likely that three students(one boy and two girls) haveattempted suicide in the past

year.

Did You Know

Each Year over 1,500 patientscommit suicide in a hospital setting,over 25% occur on units other thanBehavioral Health.

Did You Know

22% of those who die by suicide are veterans. (VA SuicideData Report, 2012)

20 Veterans commit suicide every day.

MYTHS of Suicide

Myth: People who talk about suicide do notcomplete suicide.

Fact: Many people who commit suicide havegiven warnings of their intention.Always take any comment about

suicide seriously

Myth: Suicidal people are fully intent on dying.

Fact: Most suicidal people are undecided(ambivalent) about living or dying.

MYTHS of Suicide

Myth: Suicides happen without warning.

Fact: Most suicidal people give manyclues and warning signs regardingtheir suicidal thoughts.

Myth: Improvement after a suicidal crisis ordepressive episode means that the risk isover.

Fact: Most suicides occur within 3 months of“improvement”, when the person hasmore energy and motivation to carryout a suicide plan.

Why Is It Important to YOU?

For every suicide death, 25 additional attempts are made.

50% of people complete suicide in the first attempt; 30%will have a repeat attempt.

45% of people who die by suicide saw their HealthcareProvider within a month of their death.

Why Is It Important to YOU?

EVERY 40 SECONDS WORLDWIDE ANDEVERY 13 MINUTES IN THE UNITED STATES

A PERSON DIES BY SUICIDE.

(REPORTED BY THE COLUMBIA LIGHTHOUSE PROJECT)

Definition of Columbia-Suicide Severity Rating Scale(C-SSRS)

• The Columbia-Suicide Severity Rating Scale (C-SSRS)supports suicide risk assessment through a series ofsimple, plain-language questions that anyone can ask.

• The answers help users identify whether someone is atrisk for suicide, assess the severity and immediacy of thatrisk, and gauge the level of support that the person needs.

Columbia-Suicide Severity

Rating Scale (C-SSRS) Risk Levels

CalvertHealth Medical Center has moved to using the C-SSRS todetermine a level of risk . Our C-SSRS is the same, however; eachquestion carries a risk level, noted at the end of each question. Thequestions generate an automatic risk level result of High, Medium, LowRisk or Negative Screening which also imports a bundle of interventionsto the nursing worklist. Telesitter services (continuous visual monitoring)will be used for Medium and High Risk patients. For High Risk patientstelesitter services are to be used until a 1:1 patient observer arrives.

Changes at CalvertHealthOverall changes for everyone include:

Updated Columbia-Suicide Severity Rating Screening(C-SSR)

Developed risk categories for C-SSR screening

Updated policy to incorporate CVM (Continuous VisualMonitoring System)

Telesitter (continuous visual monitoring)

Continous visual monitoring is an intervention to beutilized with suicidal patients to promote patientsafety

High Risk and Medium Risk

Patients

Cannot be left unattended. Everything STOPS. Clinical staff are responsible for

confirming that the patient is on CVM or has a PatientObserver.

Family members CANNOT be a Patient Observer.

High and Medium Risk patients; SAFETY trumps all.

HIGH RISK

Must have EPS

Consult/EVAL

Patient is NOT TO BE LEFT UNOBSERVED until Continuous Visual Monitoring

(CVM) active or Patient Observer present

ALL Clothing, jewelry if considered a ligature risk, including any hair accessories and

secured

Room Prep

All electronic devices removed

Initiate CVM until Patient Observer arrives

Patient Observer the room

Patient placed in Psych Scrubs or Gown without strings

CSSR every 12 hours (shift assessment)

Hourly Rounding

Revised diet order for safety diet

Alert Security upon admission

Restrict visitors until Behavioral Health Professional evaluation and based upon their

recommendations (Nursing Units post sign on door)

Initiate urgent consult for EPS in ED or SW/EPS on nursing units for CSSR Assessment

Patient must be escorted to the bathroom w/ door cracked or staff member in the

bathroom

Call Get Well and turn off Internet connection (where applicable)

Telesitter Duties

You have an important role.

Patients at risk for suicide need differentinterventions than confused patients

HIGH RISK

Must have EPS

Consult/EVAL

Patient is NOT TO BE LEFT UNOBSERVED until Continuous Visual Monitoring

(CVM) active or Patient Observer present

ALL Clothing, jewelry if considered a ligature risk, including any hair accessories and

secured

Room Prep

All electronic devices removed

Initiate CVM until Patient Observer arrives

Patient Observer the room

Patient placed in Psych Scrubs or Gown without strings

CSSR every 12 hours (shift assessment)

Hourly Rounding

Revised diet order for safety diet

Alert Security upon admission

Restrict visitors until Behavioral Health Professional evaluation and based upon their

recommendations (Nursing Units post sign on door)

Initiate urgent consult for EPS in ED or SW/EPS on nursing units for CSSR Assessment

Patient must be escorted to the bathroom w/ door cracked or staff member in the

bathroom

Call Get Well and turn off Internet connection (where applicable)

Important info for Telesitters• Patients at risk for suicide are usually ambulatory and will walk around the

room. They should not be redirected as walking and pacing is expected• Bathrooms are an especially dangerous place with many ligature risks. If a

patient at risk appears to be walking towards the bathroom and redirectionis not successful, activate STAT alarm

• Hands should be visible on top of the covers. If a patient’s hands are underthe covers, redirect them to keep their hands in view. If redirection isunsuccessful, contact clinical staff or activate STAT alarm

• Patients at risk for suicide can be less “busy” than confused patients andrequire less redirection. Don’t become complacent as their safety requiresconstant vigilance.

• Be alert for changes in behavior – patients who were restless suddenlybecome calm, or patients who were calm suddenly begin pacing. Alertclinical staff regarding changes in behavior

• Unlike medical patients who are often experiencing physical pain, patientsat risk for suicide are experiencing emotional pain

Things to pay attention for – all patients at risk for suicidereceive the following interventions

Room Prep – the room is cleared of all equipment, supplies anddevices that might pose a threat

Clothing and belongings are removed and secured

No electronic devices

Patient is placed in paper scrubs or safety gowns (without ties)

If you notice deviations in any of the above, alert clinical staffimmediately

ED ROOM Preparedness Checklist

The ED will be implementing an EDRoom Preparedness checklist. In

rooms other than 14/15 all items willbe removed and placed in the

designated bins in each section.

Nursing Unit ROOM Preparedness Checklist

There must be a consistent methodfor preparing the rooms for patient

with a Low, Medium or High Risklevel. The Nursing units will use theNursing Units Room Preparedness

checklist for patient’s rooms.

Updated Guidelines for Mental Health Patients

Chairs can become weapons or used by the patient to assist inhangings. In the Emergency Department, patients areunpredictable therefore, chairs cannot be in a room of a mentalhealth patient. Chairs should be removed if not in use. If apatient has a visitor a chair may be utilized during visitation. Donot leave any chairs in the room.

Clothing / Belongings Removed & Secured

ALL CLOTHING, JEWERLY (if considered a ligature risk) AND HAIRACCESSORIES MUST BE REMOVED.

• No Bra

• No underwear

• No socks (hospital issued socks only)

• High Risk and Medium Risk patients will be placed in PsychSCRUBS or safety gowns (without strings)

• Females on their menstrual cycle will be permitted to keeptheir underwear.

• No jewelry if considered a ligature risk

• No electronic devices

Patients May Use Any Means to HarmThemselves!

Ligature Points – anything which could be used to attach acord, rope or other material for the purpose of hanging orstrangulation.

Examples of objects used - Long sturdy necklaces,belt, shoe laces, sheets and leggings

Look at every object apatient has or you give andthink…..

Can they HARMthemselves with it????

Hair Accessories Must Be Removed

Every effort should be madeto check all MEN and

WOMEN who have their hairpulled up; to ensure there isnothing hidden in the hair.Please be respectful andmindful of all ethical and

religious beliefs.

I’m Hungry!!!

Patient is not to have own food or Drink

No outside food brought in

Nourishments will be provided by the hospitaldepending on the patients RISK LEVEL

Safety Tray – Items that will not allow self harm

(NO – Metal Cans, Silverware ect…)

Pt will receive finger foods in a Styrofoam box withnapkin, straw and Styrofoam cup!

Patient Observer Badge Buddies

Suicide Risk Restricted ItemsPlastic Bags ShoesCell Phones Shoe lacesElectronics BeltsCords Hair tiesPaper clips HatsPens ScarfsPencils Head wrapsSunglasses StringsFood/drink (outside) Anything sharpPlastic wrap covering

Patient Observers SBAR TOOLS: Situation

Why observation needed and where; inroom or within arm’s reach

B: BackgroundCurrent and past 24 hour behavior

A: AssessmentOrientation of patient; what care itemscan the patient do for themselves; anysafety concerns

R: RecommendationsNotify RN of any concerns or care needs;no outside belongings or food/drinkallowed

Resources

National Institutes of Health, National Institute of Mental Health. 2017. Suicide. Retrieved from

https://www.nimh.nih.gov/health/statistics/suicide/index.shtml

The Columbia Lighthouse Project. C-SSRS. 2017. Retrieved from http://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/