According to the Centers for Disease Control and Prevention, suicide was the 10th leading cause of death in the U.S. in 2014. Between 2004 and 2014, the suicide death rate increased 21%, from 11.1 to 13.4 deaths per 100,000 resident population. Among adults aged 45–64, suicide death rates increased 27% between 2004 and 2014. Paramedics and law enforcement are typical first responders to suicide attempt or completed suicide cases, and hospital emergency departments receive patients for further care.
CHPSO recently convened members at a safe table meeting on the topic of suicidal ideations, suicide attempts, and completed suicides in hospitals. Lessons learned from this meeting were shared (see resources below). Patients with behavioral health conditions are typically seen by general acute care hospital emergency departments before they are transferred or admitted to a behavioral health hospital. Challenges general hospitals face include availability of sitters, communicating patient charts during shift-changes, and identifying facilities for transfer.
CHPSO Event Reports on Suicide
A review of event reports in the CHPSO database using the term “suicide” yielded a return of 1,570 events. A breakdown of events by age, gender, and location of where suicidal ideations, suicide attempts or completed suicides were made, is listed below:
Events by Gender
Of the 1,570 suicide-related events in the CHPSO database, 62% involved males and 38% involved females.
Events by Age
Of the 1,570 suicide-related events, 91% of involved adults aged 18-64. A number of extraordinarily vulnerable populations – children, adolescents, older, mature, and aged adults – are on the rise.
Events by Location
Approximately 32% of cases occurred in the inpatient general acute care area.Over 23% occurred in the ED, 6% in a special care area (ICU, CCU), 5% in an “other” area, and 0.4% in the labor and delivery department. Nearly 33% of events were not mapped in the CHPSO database to a location.
Among the 1,570 suicide-related events in the CHPSO database, 45 resulted in death. Of these 45,
39 occurred at home, 21 of which occurred post-discharge (within 1 hour – 6 days, if mentioned)
6 occurred in the hospital
Of the suicides that occurred outside of the hospital, 7 were gunshot wounds, 3 were prescription overdoses, 3 jumped from buildings, and 2 by car. The remaining reports did not identify the suicide methods. One report mentioned the patient had post-partum depression.
Suicides that occurred in the hospital involved sharp devices for self-inflicted wounds and hanging by using bed sheets. Not all events specified the suicide method.
In a sample of 50 event reports related to suicide, the following patient and hospital details were gathered:
PATIENT DETAILS MENTIONED
NUMBER OF EVENTS
Violent with nurse or physician
Smoked in hospital
Drank alcohol in hospital
Used medications (e.g. antihistamines, opioids)
Restraints used on patient
Devices used to attempt suicide (bed sheets, plastic wrapping, IV tubing, scissors, pens, cafeteria utensils)
Patients who left AMA signed discharge paperwork and were aware of their options. In one case, a physician followed-up with a patient and convinced the patient to go to a rehabilitation facility, which the patient did. Patients who eloped ran out of the ED or the patient room while a nurse or sitter stepped away. There were cases where the patients’ belongings were not thoroughly checked or reviewed at all, and patients brought alcohol, cigarettes, and medications in gum or mint tins, hidden pockets within their clothing, or from visitors.
Patients who attempted suicide in a general hospital setting used items that were easily in reach, such as IV tubing, plastic wrapping from medical devices/products or food, or items from pockets of medical staff. There were a few cases of self-inflicted harm due to breaking a light bulb from the bathroom or hallway.
Details mentioned about the hospital environment and resources in the sample of 50 events are below:
HOSPITAL DETAILS MENTIONED
NUMBER OF EVENTS
Physician deviated from standard of care
Waiting for placement
Transport communication breakdown
Code Gray called
Law enforcement engaged
Event details varied across each report, some with minimal information and others with lengthier descriptions. There were disagreements of who was required to serve as a sitter for the patient (e.g. law enforcement, security, nurse). A few cases also mentioned physicians not following or understanding the hospital’s protocol on caring for patients with suicidal ideations.
Prevention and Resources
In preventing suicide, it is important for medical staff and hospitals to establish a relationship with their local police department. When law enforcement bring patients to a hospital, they can share important information with hospital staff including:
Whether the patient communicated suicidal ideations
Whether the patient made a suicide attempt
Whether the patient died by suicide
Hospital staff across all departments can prepare by reviewing their policies. It is important to understand hospital protocols on caring for suicidal patients. Hospitals can also engage their transporters on working with suicidal patients. Conducting an environmental scan of the patient’s room and surroundings for items that would be used in suicide may help reduce an attempt. The Veterans Affairs Hospitals developed the Mental Health Environment of Care Checklist (MHEOCC) as an environmental review of inpatient mental health units. General hospitals may benefit from reviewing some of the suggested precautions (e.g. flush mounted light fixtures where the bulb is not exposed, institutional sprinklers that cannot be used as an anchor for hanging, fitted bed sheets without elastic, etc.).
The California Hospital Association offers a number of resources to members of which they can take advantage:
Save the date! December 4-6 at the Riverside Convention Center
Nominate a colleague for the Šimanek Distinguished Service Award who demonstrates vision and excellence in behavioral health care services. The award is presented at the symposium.
Mental Health Law Handbook, developed by CHA. Consult your quality, risk, or patient safety teams to see if they have a copy before purchasing.
EMTALA Manual, developed by CHA. Consult your quality, risk, or patient safety teams to see if they have a copy before purchasing.
Hospitals can also connect with the National Alliance on Mental Illness (NAMI) for local collaborative opportunities.
Patients with suicidal ideations and suicidal attempts in both psychiatric and general hospitals have different needs. While suicides in psychiatric units are anticipated, patients with suicidal ideations may not necessarily have the same predictability. Hospitals can work interdepartmentally on suicide prevention efforts and within their community. This collaboration is a stepping stone to improve the quality of treatment for this vulnerable population.