In Section 2 of this course, we discuss the management and assessment of high-risk situations in mental health. It highlights the management of situations from traditional concepts, as well as from patient safety or quality improvement perspectives, and we will go over aspects of suicide, violence and aggression, elopement, diagnostic errors in psychiatry, falls, as well as working and collaborating with patients and families. Our first part is the management of suicidality, thinking about it from traditional, as well as patient safety or quality improvement perspectives. Suicide is a high-risk, but relatively low-frequency event that most psychiatrists encounter at some point in their practices, but are unable to predict. We have to ask, what are the traditional means to prevent suicide, and how can the patient safety or quality improvement approach help? Inpatient suicide itself is a problem. Some 5-6% of all suicides are occurring in hospitals. A sentinel event regarding psychiatry is a suicide that occurs within 72 hours of discharge from the hospital. Traditional management of suicidality includes an assessment of risk, placement and status being aligned to the patient's risks. It includes vigilance by staff, including checks of possessions of the patient, constant observation, one-to-one, day-room intervention, redundancy of efforts, gathering support from family and staff and friends, and assessment of dangers in the environment, particularly weapons or sharps. Robert Simon had put forth a five-step plan for management of suicide, including risk assessment, risk formulation, safety management and treatment plan, plans for what to do during crises, and ongoing reassessment of suicide risk. And these have ongoing practices that are consistent with the National Patient Safety Goal, which is to reduce and to find those who are at risk for suicide. That includes conducting risk assessments, addressing the individual's immediate needs, and to think about the discharge plan for patients who are leaving the hospital. The assessment of suicide risk always begins with the patient and with a comprehensive psychiatric evaluation, including the particular disposition and constitutional dimensions of the patient, past suicide for the patient, as well as in the patient's family, depth of depression that's affecting the patient, and various other aspects of the patient's current status. It may also include triggers that may affect the patient, and levels of observation are obviously going to be tailored to the patient at that time. But clinicians are not always able to predict suicide with accuracy. The assessment of risk is a reliable task that clinicians have engaged in, and this may include the extent of suicidality, static and dynamic risk factors, as well as risk reduction factors that can be applied. Outcomes may depend on the good assessment of individual risk factors, as well as protective factors. If the patient can be served or treated in a less restrictive facility, it's important to assess the patient's capacity to be there and to act on their own, whether in a crisis or to implement a treatment plan that has been put together for them. This slide includes various static and dynamic risk factors for suicide and suicide risk reduction factors. A risk formulation is based on the suicide risk assessment, where the psychiatrist formulates the information into a coherent, clinically-based assessment that includes estimation of risk. Although suicide assessment measures may be used as an adjunct to the clinical interview, in this traditional method, no formal suicide risk assessment measure used alone currently has predictive value for suicide in individual patients. The artful and skilled formulation by the clinician is the key. Key elements of suicide risk formulation have been discussed in various resources. When thinking about current management of suicide risk, it's important to think about the suicide safety management and treatment plan. The suicide risk assessment and formulation will drive the treatment plan. Determination of the level of care and decisions about the use of one-to-one or other precautions will be based on an estimation of risk, and treatment plans should address the mitigation of all the dynamic risk factors and strengthening those risk reduction factors. Biologic therapies and psychosocial treatments, including CBT, have been shown to decrease suicide risk. In terms of making crisis plans for outpatients, a crisis plan can be a safety net and a valuable part of recovery, especially for those who may develop a crisis once discharged. This is one part of an ongoing process to care for patients as they are discharged from the hospital. And this slide includes elements of a crisis plan. Reassessment of suicide risk should also be ongoing. It should occur at the time of high-risk transitions for the patient. Identification of high-risk transitions should be individualized based on the patient's clinical situation and life history. The most common locations for suicide are bathrooms, followed by the individual's room on the inpatient unit. Inpatient suicide has been assessed both through the root cause analysis process as well as the FMEA process. The literature on these examinations has shown that they can create positive effects, and so patient safety quality improvement methods can be used to protect patients from suicide. Is it good enough to say no SI? That's not good enough. And lacking good documentation about suicide risk frequently is present before a suicide has occurred. So mental health can do better, but how? The patient safety quality improvement culture can help by thinking retrospectively and prospectively about what can be done differently. For example, and this is one of the central contributions of the patient safety culture to patient safety in psychiatry, the environment of care can be used to prevent suicide from occurring. An approach to suicide prevention through the patient safety lens gives us some new ideas about how to prevent suicide, particularly on inpatient units. For example, root cause analyses conducted through 1998 found that sources of risk for suicide on inpatient units included the environment of care, the presence of non-breakaway bars, rods, or safety rails, or the lack of testing of breakaway hardware and inadequate security. Also it's important to consider, as those findings occurred, patient assessment methods such as incomplete suicide risk assessments at intake, absent or incomplete reassessments, and incomplete examinations of the individuals, or staff-related factors such as insufficient orientation or training, incomplete competency review or credentialing, and inadequate staffing levels were also involved. Incomplete or infrequent patient observations, information-related factors such as incomplete communication among caregivers and information being unavailable when needed, and care planning deficiencies such as assignment of the patient to an inappropriate unit or location. These are various environmental or process problems that have been found over time, and they continue to be in the attention of hospital leadership around the country. These activities, fixing these problems, are akin to other patient safety-related processes and improvements that have been done in other parts of healthcare. When looking at Joint Commission root cause analyses of inpatient suicides through 2005, this slide shows that patient assessment is one, but poor communication, poor training, poor environmental safety and security are other significant components that can lead to improvements and reduction of inpatient suicides. The Joint Commission Sentinel Event Database through 2010 included other information, such as the fact that suicides can occur beyond the inpatient psychiatric unit, including general medical units, surgical units, the emergency room, and only very few occurred in other psychiatric settings. Watts and others used root cause analyses to improve patient safety in terms of the reduction of inpatient suicide. They used prior root cause analysis findings and created a checklist that can be used throughout their system, and when applied, this checklist of environmental hazards led to a statistically significant reduction in inpatient suicides. Here was the use of a checklist, a basic method, that led to improvement in quality. One can also use, as we discussed before, FMEA, failure modes effects analysis, to prevent suicide. One can utilize common suicide allegations used in claims or lawsuits, such as inappropriate hospitalization, obtaining supervision and consultation, inappropriate mental status examinations, to look at what features of the patient's experience were most subject to concern and a part of claims that came about. Other findings were that treaters failed to diagnose, that the treaters failed to provide adequate pharmacotherapy. When one does FMEA, one can look at these outcomes and think prospectively about what needs to be addressed in patient care at this time. These are practices that can be effected through FMEA. Any quality improvement method or method for reviewing adverse events can be applied not just to professional staff, but to others involved in the care of patients as well. A study by Janowski and others used FMEA to look at the handoffs and the reliability of information conveyance between those who provide care as one-to-one sitters or for constant observation. As noted before, the environment of care is an important part of suicide prevention. This is a component that is frequently reviewed, as well as improving risk assessment, communication, and other processes on inpatient units. Improvement of prevention of suicide may also come from information that comes from root cause analyses, whether it's changes to suicide risk assessments or reassessment procedures, changing staffing models, changing training, updating policies. These are all examples of changes that can come as a result of root cause analyses of inpatient suicides. This also may apply to changing the processes or the policies for removing contraband, transfers, or how to design visiting time. System-wide alterations also can have effects on reducing inpatient suicide, such as the creation of common processes for checking all patients, regardless of their being psychiatric patients, and also the provision of patient-centered care. Patient-centered care engages the person at risk in care planning and in decision-making rather than focusing on the disease, and this too may help to identify patients who might be suicidal. And then there are system-based quality improvements. A system should tailor intervention strategies that take into account age or cultural factors, and there should be an offering to patients to have the opportunity to be visited by family members or others who can provide peer support and who can alert staff to problems. Peer support also can be provided by a certified peer support specialist or someone who has had similar problems that the patient has had, particularly when talking about general medical conditions. One should engage the person at risk and the family in the care plan, and the plan should include care after discharge. Again, at the system level, improvements can be made in terms of handoff procedures or procedures in handing off patients between units. And mandating the use of evidence-based practices has been shown to improve suicide prevention.

suicidality

risk assessment

patient safety

quality improvement

inpatient suicides