Safety Precautions:

Suicide, Danger to Self, and Danger to Others in Non-Behavioral

Health Settings for Adults, Children, and Adolescents

Behavioral Health Clinical Education Team

7/17/2019
Objectives

Learners will:
1. Identify behaviors, mental status, or
conditions that may indicate a risk of
imminent suicide.
2. Demonstrate screening for emotional and/or
behavioral disorders, or altered mental
status using the Columbia Suicide Severity
Rating Scale (C-SSRS) Screening Tool in Non-
Behavioral Health (BeH Health) areas.
3. Implement Procedure/Protocol/Interventions
based on C-SSRS screening risk.
Purpose

To promote patient safety through screening

and early identification of patients at risk for
self-harm or suicide.
To provide guidelines based on screening and
intervention for patients who are at risk for
self-harm or suicide.
To maintain a safe environment for the patient
and others.
Definitions

Adolescent: Individuals 13 years – 17 years old, (13 to 18 in

Nebraska)

Against Medical Advice (AMA): A discharge from the hospital at

the patient’s request contrary to the advice of the attending
physician.

Behavioral Health Consult: Patient assessment by any licensed

independent practitioners whose scope of practice includes the
ability to assess suicide/homicide risk, initiate commitment
procedures for involuntary psychiatric hospitalization, or
otherwise facilitate prompt access to mental health services.

Child: Individuals under the age of eighteen (18) years (nineteen

[19] in Nebraska).
 Definitions

Columbia- Suicide Severity Rating Scale (C- SSRS) - (Screen Version): The
screening tool approved by the BH Behavioral health CCG for use in the
non-behavioral setting for use in the non-behavioral setting.

Close observation: An intermediate observation level in which personnel

round frequently on a specified patient, having visual observation and
confirming a patient’s safety at intervals not exceeding 15 minutes. It is
strongly recommended that patient rounding be completed at random
intervals and may be shorter than 15 minutes based on physician or
other allied health provider order or nursing assessment but is never to
exceed 15 minutes. A staff member performing close observation may
monitor more than one patient as dictated by clinical need and as
appropriate.

Continuous Direct Observer: Role assigned for suicidal patients not in a

Behavioral Health setting performed by validated Banner Health
personnel.
Definitions

Continuous Direct Observation: Maintaining visual observation of the patient

at all times. Staff members must initiate demonstrably reliable monitoring
that is linked to immediate intervention by a qualified staff member when
called for.

Danger to Others (DTO): A patient’s behavior that can be expected to result in

intentional or unintentional harm to others.

Danger to Self (DTS): A patient’s behavior that can be expected to result in

intentional or unintentional self-harm. This can include:
Self-harm Suicide
Suicide Attempt/Act Suicidal Ideation
Suicide Intent

Prohibited items: Any item that poses a threat to the safety of the patient,
other patients, visitors, or staff and items thought to be detrimental to the
therapeutic environment.
Definitions

Safety Precautions for Suicide/DTS: Based on the patient response to

the C-SSRS – Screen Version initiate the Response Protocol.

Screening: Screening is a clinical process completed by qualified staff

using the approved Banner Screening tool to detect signs of risk for
Danger to Self. Screening results may require further assessment by a
physician, allied health provider, or behavioral health consultant.

Suicide Risk Assessment: The clinical data set forming the basis for
suicide prevention practices and interventions. Suicide risk
assessment includes risk of ideation (thoughts), intent (intention to
act on thoughts), plan (specific method), and access to means (is the
method plausible).

Transponding Devices - Security system includes a small radio

transmitter with a tamper mechanism that is enabled as soon as the
tag is applied to the patient with the tamper-proof band.
 Answer is directly across from term
– Randomize answers for the
learner
Columbia- Suicide Severity Rating Scale
Safety Precautions for DTS
Continuous Direct Observation
Behavioral Health Consult
Danger to Self (DTS)
Screening
Screening tool Banner approved for use in the non-
behavioral setting.
Initiated based on the patient response to the C-
SSRS – Screen Version initiate the Response
Protocol.
Maintaining visual observation of the patient at all
times.
Patient assessment by psychiatrists; psychologists,
another mental health professional, provider, or
Licensed Independent Practitioners
A patient’s behavior that can be expected to result in
intentional or unintentional self-harm.
Completed by qualified staff using the approved Banner
Screening tool to detect the most characteristic sign or
signs of risk for self-harm
Role assigned for DTS patients not in a Behavioral Health
setting performed by validated Banner Health personnel.
Demand for discharge from the hospital before the
completion of treatment/against advice of physician.

Continuous Direct Observer

Against Medical Advice

Drag the word on the left over to the correct

definition on the right. Submit

Clear
Suicide Deaths in the Hospital

Suicide is one of the most frequently reported events

in hospitals resulting in patient death.

Since 1995, 827 reports of inpatient death due to

suicide
14% occurred in med-surg, ICU, oncology,
telemetry
8% occurred in the emergency department

Patients who kill themselves in general hospital

inpatient units MAY NOT have a psychiatric history
and may be “unknown to be at risk” for suicide
Suicide Deaths in the Hospital

General hospital departments (ED/Inpatient)

provide easy access to items that can be
used to attempt suicide.
Common environmental risk factors include:
Potential anchor points for hanging
Material that can be used for self-injury
Problems maintaining a secure
environment
Risk Reduction

According to hospital regulations, organizations

are required to identify patients at risk of
suicide and then intervene to prevent suicide.
This is achieved by:
1. Screening all patients for risk behaviors,

mental status characteristics, or conditions

that contribute to risk for suicide
2. Intervening with those at risk to reduce

the risk of suicide in the inpatient and

emergency department settings.
Screening: What are risk factors?

Clinical staff should watch for behaviors, mental

status, or conditions that may indicate a risk of
imminent suicide:
Acute signs of depression, anxiety, agitation,
delirium, dementia, or other altered mental
states
Medical or psychological disorders/problems
that significantly impact judgment, including
intoxication with alcohol or drugs
Chronic pain or other debilitating problems,
including chronic illness and terminal cancer.
Screening: When to do it?

All patients in a non-behavioral health inpatient or

outpatient setting must be screened (excludes
Home Care, Hospice, B-UMG, and BMG).

Screen all patients:

On arrival
When there is a change in behaviors, mental
status, or conditions that may increase risk for
suicide (restraints, code gray, new terminal
diagnosis)
Anytime risk factors are identified
Screening: C-SSRS

Columba - Suicide Severity Rating Scale (C-

SSRS):
Is an evidence-based model identifying
suicide risk
Provides a standardized tool to screen for
factors predictive of suicide risk
Columbia- Suicide Severity Rating Scale (C-SSRS)
 Risk Levels from C-SSRS
No Risk
Patients who answer NO to all questions

Low Risk
Patients who answer YES to questions 1 or 2
Patients who answer YES to question 6, but it was at least 1 year prior to
the screening

Moderate Risk
Patients who answer YES to questions 2 and 3, but no to questions 4
and 5
Patients who answer YES to question 6, but it was at least 3-12 months
prior to the screening

High Risk
Patients who answer YES to question1, 2, and 3 and questions 4 or 5
Patients who answer YES to question 6 and it was within the last 3 months
Scenario: Joe

66yr old male

NIDDM
Presented to ER with
Ulcerated Heel
Increased alcohol
consumption over past
few months
Recent death of spouse
Primary provider has
prescribed
antidepressant with
sporadic use
Dismissive to treatment
planning
 Need buttons on yes or no spots next to questions 1
Low Risk Screening and 2. Staff need to select yes or no on 6. 1=N,
2=N, 6=N
Nurse: Joe, I have some questions to ask
you that might feel uncomfortable. We
need to ask them to make sure that we
meet all of your needs and to help keep
you safe.
Joe: Okay, that’s fine.
Nurse: Joe, have there been times in the
last month where you wish you were dead
or wished that you could go to sleep and
not wake up?
Joe: No, I have never had thoughts like
that.
Nurse: Okay, do you ever have thoughts of
actually killing yourself?
Joe: No, I would never do that.
Nurse: Joe have you ever done anything,
started to do anything, or prepared to do
anything to end your life?
Joe: No, I miss my wife but I am glad to be
Ye No alive.
s
No Risk Screening: Actions
 Need buttons on yes or no spots next to questions 1
Low Risk Screening and 2. Staff need to select yes or no on 6. 1=Y,
2=N, 6=N
Nurse: Joe, I have some questions to ask
you that might feel uncomfortable. We
need to ask them to make sure that we
meet all of your needs and to help keep
you safe.
Joe: Okay, that’s fine.
Nurse: Joe, have there been times in the
last month where you wish you were dead
or wished that you could go to sleep and
not wake up?
Joe: Well, sometimes I just wish I could
just go and see my wife again.
Nurse: Okay, do you ever have thoughts of
actually killing yourself?
Joe: No, I would never do that.
Nurse: Joe have you ever done anything,
started to do anything, or prepared to do
anything to end your life?
Joe: No, I miss my wife but I am glad to be
Ye No alive.
s
Low Risk Screening: Actions
 Need buttons on yes or no spots next to questions
Moderate Risk Screening select yes or no on 6. 1=Y, 2=Y, 3=Y, 4=N, 5=N, 6=
year
Nurse: Joe, have there been times in the last month
where you wish you were dead or wished that you could
go to sleep and not wake up?
Joe: Well, sometimes I just wish I could just go and see my
wife again.
Nurse: Okay, in the last month, have you ever had
thoughts of actually killing yourself?
Joe: Sometimes, when I miss her a lot I do.
Nurse: Joe, when you have these thoughts, do you ever
think about how you could do it?
Joe: Well, I thought about just taking a lot of sleeping
pills.
Nurse: Do you think you would do this, or do you have any
intention of acting on these thoughts?
Joe: No, it’s hard and I miss her but I couldn’t do that to
my kids.
Nurse: Joe, have you ever stated working on the details of
how to kill yourself? Do you intend on carrying out this
plan?
Joe: No, it’s just a thought I have sometimes.
Nurse: Joe have you ever done anything, started to do
anything, or prepared to do anything to end your life?
Ye No Joe: Once, when I was in high school I started to speed so
s I could crash my car, but I stopped at the last minute.
Moderate Risk Screening: Actions
 Need buttons on yes or no spots next to questions
High Risk Screening select yes or no on 6. 1=Y, 2=Y, 3=Y, 4=N, 5=Y, 6=

Nurse: Joe, have there been times in the last month where you
wish you were dead or wished that you could go to sleep and
not wake up?
Joe: Well, sometimes I just wish I could just go and see my
wife again.
Nurse: Okay, in the last month, have you ever had thoughts of
actually killing yourself?
Joe: Sometimes, when I miss her a lot I do.
Nurse: Joe, when you have these thoughts, do you ever think
about how you could do it?
Joe: Well, I thought about just taking a lot of some of my old
meds.
Nurse: Do you think you would do this, or do you have any
intention of acting on these thoughts?
Joe: No, it’s hard and I miss her but I couldn’t do that to my
kids.
Nurse: Joe, have you ever stated working on the details of how
to kill yourself? Do you intend on carrying out this plan?
Joe: Right after she died, I saved up a bunch of my old meds. A
couple times I have pulled them out.
Nurse: Joe have you ever done anything, started to do
anything, or prepared to do anything to end your life?
Joe: Like I said, a few times I have pulled out the meds I
Ye No saved.
Nurse: When was the last time you did this?
s Joe: I did it a couple weeks ago, but I put them back.
High Risk Screening: Actions
Discharge Education and Crisis Supports
 Review of Actions and Interventions

Patient Observation/ Environmental

Monitoring Safety
Patient visitors

Prohibited Items
Documentation
Care Planning for the Suicidal Patient
References

Safety Precautions: Suicide; Danger to Self;

Non- Behavioral Health settings for
Adults/Child/Adolescents (# 706)
A follow-up report on preventing suicide:
Focus on medical/surgical units and the
emergency department. Retrieved from
http://www.jointcommission.org/assets/1/18/S
EA_46.pdf