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Screening, Assessment and Intervention for Suicidal Ideation and/or Attempts – Adult/Pediatric – Emergency Department/Inpatient

Screening, Assessment and Intervention for Suicidal Ideation and/or Attempts – Adult/Pediatric – Emergency Department/Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Psychiatry


1
Screening, Assessment and Intervention
for Suicidal Ideation and/or Attempts –
Adult/Pediatric – Emergency
Department/Inpatient
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................................................... 3
SCOPE .................................................................................................................................................................... 4
METHODOLOGY ..................................................................................................................................................... 5
DEFINITIONS .......................................................................................................................................................... 5
INTRODUCTION ..................................................................................................................................................... 6
RECOMMENDATIONS ............................................................................................................................................ 6
Primary Screening ..................................................................................................................................................... 7
Secondary Screening and Suicide Risk Assessment .................................................................................................. 7
Involvement of Psychiatry ....................................................................................................................................... 10
Management by Non-Psychiatry Clinicians ............................................................................................................. 11
Immediate Interventions .................................................................................................................................... 11
Medical Evaluation/Clearance ............................................................................................................................ 15
Brief Suicide Prevention Interventions ............................................................................................................... 15
Management During Inpatient Admission (Excluding the Psychiatry Unit) ........................................................ 18
Discharge and Follow-up ......................................................................................................................................... 19
UW HEALTH IMPLEMENTATION ........................................................................................................................... 21
APPENDIX A. EVIDENCE GRADING SCHEME(S) ..................................................................................................... 23
EXPECTATIONS FOR THE PATIENT SAFETY ATTENDANT/PERSONAL SAFETY OBSERVER ....................................... 24
PROCEDURAL GUIDELINES FOR THE CARE OF ADULT AND PEDIATRIC SUICIDAL PATIENTS IN THE EMERGENCY
DEPARTMENT (ED) AT UNIVERSITY HOSPITAL (UH) AND THE AMERICAN CENTER (TAC) ...................................... 24
QUICK GUIDE FOR INPATIENT MANAGEMENT OF PEDIATRIC PATIENTS ADMITTED WITH SUICIDE ATTEMPT OR
IDEATION ............................................................................................................................................................. 28
REFERENCES ......................................................................................................................................................... 30
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
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2
Contact for Content:
Name: Steven Garlow, MD- Psychiatry Name: William Taft, MD- Pediatric Psychiatry
Email Address: sgarlow@wisc.edu Email Address: wbtaft@wisc.edu
Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Coordinating Team Members:
Beth Lonergan- Behavioral Health Services Director
Erick Sheftic, MD- Psychiatry Resident
Michael Kim, MD- Pediatric Emergency Medicine
Brian Sharp, MD, FACEP- Emergency Medicine
Kristin Shadman, MD- Pediatric Hospitalist
Dan Sklansky, MD- Pediatric Hospitalist
Andrea Carberry, MD- Pediatric Hospitalist
Nathan Whitman, DNP, RN, PMHCNS-BC- Clinical Nurse Specialist, Psychiatric Liaison
Lynnda Zibell Milsap, MS, RN, PMHCNS-BC, LPC, APNP- Clinical Nurse Specialist, Psychiatric Liaison
Jayne McGrath, MS, RN, CCRN, CEN, CNS-BC- Clinical Nurse Specialist, Emergency Medicine
Mary Jean Erschen-Cooke, RN, MS, BSN, CPEN- Pediatric Emergency Medicine Coordinator
Rachel Edwards, RN- Nurse Manager, B6/5 Psychiatry
Kirsten Koffarnus, RN- Clinical Nurse Specialist, P5 Pediatric General Care
Windy Smith, RN, MSN, CPN- Nurse Manager, P5 Pediatric General Care
Susan Quamme, BSN, RN- Nurse Manager, Pediatric Intensive Care Unit
Jennifer LeNoble- Clinical Psychologist
Lisa McGuffey, PhD- Clinical Psychologist
Josh Vanderloo, PharmD, BCPS- Drug Policy Program
Elizabeth Boyle- Manger of Social Work & Spiritual Care
Kathleen Chambers- Patient Family Connections Director
Nicole Kalscheur- Employee Health Manager
Jan Haedt- Risk Management
Jennifer Grice, PharmD, BCPS- Center for Clinical Knowledge Management (CCKM)
Katherine Le, PharmD- Center for Clinical Knowledge Management (CCKM)
Sue Janty, RN- Director of Behavioral Health Services (UnityPoint Health- Meriter)
Review Individuals/Bodies:
Gene Yang, MD- Psychiatry Resident
Pierre Kory, MD- Pulmonary Medicine
Robert Hoffman, MD- Medicine- Hospitalists
Caitlin Weitzel, NP- Medicine- Hospitalists
Roderick Hafer, PhD- Psychiatry
Michael Peterson, MD, PHD- Director of Hospital Psychiatric Services
Amy Kirsch, MSN, BSW, RN- Director of Psychiatric Services (SwedishAmerican Health System)
Addi Ceja- Behavioral Therapist (SwedishAmerican Health System)
Jennifer Kuroda- Quality Improvement Manager (SwedishAmerican Health System)
Taylor Mathisen, RN, BSN- Nurse Clinician (P5) Pediatric General Medical Surgical Unit
Katie Ayers, RN, BSN- Nurse Clinician (P5) Pediatric General Medical Surgical Unit
Stephanie Peplinski, RN, BSN- Nurse Clinician (P5) Pediatric General Medical Surgical Unit
Shelly VanDenBergh, MS, RN, GCNS-BC- General Medicine (D4/4)
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 04/27/2017)
Release Date: April 2017 | Next Review Date: April 2020
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Executive Summary
Guideline Overview
Caring for patients who have attempted suicide or express statements of suicidal ideation
requires knowledge and skills to manage risk appropriately. The following guideline outlines
recommendations for screening, assessment and intervention/follow-up to support non-
Psychiatric clinicians in the proper management of patients who are suicidal or at risk for
suicide.
Key Practice Recommendations
1. Universal screening for suicidal ideation should be completed in all patients age 10 and
older upon admission to the emergency department (UW Health Moderate quality evidence,
strong recommendation) and/or inpatient settings.1,2 (UW Health Low quality evidence, strong
recommendation) It is recommended to screen all patients using the 4-question version of the
Ask Suicide-Screening Questions (ASQ).3,4 (UW Health Low quality evidence, weak/conditional
recommendation) If the response to any of the questions is positive (“yes”), additional detail
should be obtained via secondary screening and/or a suicide risk assessment.
2. It is recommended that all staff be trained to consistently assess suicidal thoughts and
understand risk factors for suicidal ideation or suicide attempts, as well as underlying
psychiatric diagnoses, in order to approach each patient and family with empathy and in
empowering ways.5-8 (UW Health Moderate quality evidence, strong recommendation) A
comprehensive evaluation, or suicide assessment, is best performed by a mental health
clinician or provider who has completed mental health/behavioral health training. (UW Health
Moderate quality evidence, weak/conditional recommendation)
3. It is important that patients are placed in an environment where physical and structural risk
factors have been removed.1,5,9-11 (UW Health Moderate quality evidence, strong
recommendation) Personal patient property may be restricted at any time if means or threats
of suicide attempt deems necessary. (UW Health Very low quality evidence, strong
recommendation) If staff are concerned that the patient has self-injurious items in their
possession, Security should be called to search the patient’s belongings per UW Health
Policy 2.1.22.
4. Descriptions of the details associated with each level of suicide precaution are outlined
within UW Health Policy 2.4.1. Patients at greatest risk for self-harm (e.g., previous suicide
attempt, presentation from a suicide attempt) should be placed under 1:1 constant
observation and use of a Patient Safety Attendant (PSA) or Personal Safety Observer
(PSO) is recommended.8,10,11 (UW Health Moderate quality evidence, strong recommendation)
5. Routine laboratory evaluations are not recommended in patients with a psychiatric chief
complaint; any diagnostic testing should be dictated by the individual clinical presentation for
medical conditions.12-16 (UW Health Low quality evidence, strong recommendation) Protocolized
ordering of lab testing is not cost-effective and several retrospective evaluations did not find
any patients with pure medical problems who were admitted inadvertently to Psychiatry.12,13
6. All patients with suicidal ideation should receive the contact information for the National
Suicide Prevention Lifeline as well as local crisis and peer support contacts, prior to
discharge from the emergency department or inpatient setting.1,17 (UW Health Very low quality
evidence, strong recommendation)
7. All patients identified as at risk for suicide should have a collaboratively designed safety plan
developed prior to discharge from the emergency department or inpatient admission.1,18,19
(UW Health Low quality of evidence, strong recommendation)
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8. Clinicians should ask the patient and his or her support system about the patient’s access to
lethal means, particularly firearms.1,17,20 (UW Health Very low quality evidence, strong
recommendation) Recommendations should be made to the patient and/or family to remove
all firearms from the home and to lock up all prescription and over-the-counter
medications.17,18,20 (UW Health Low quality evidence, strong recommendation) In addition to
encouraging the patient and/or family to remove lethal means, providers should also warn
about the dangerous disinhibiting effects of alcohol and other drugs.20,21 (UW Health Very low
quality evidence, weak/conditional recommendation)
9. It is recommended that patients be seen for follow-up within 7 days of discharge.11,17,18,20
(UW Health Low quality evidence, strong recommendation)
10. Contacts via telephone encounters, patient letters, postcards, emails, or text messages
should be made by clinical staff or non-medical personnel to all patients following
discharge.11,17,22 (UW Health Moderate quality evidence, weak/conditional recommendation)

Companion Documents
1. Patient Safety Attendant/Personal Safety Observer Expectations When Caring for Patients
at Risk for Suicide
2. Procedural Instructions for Care in the Emergency Department
3. Quick Guide for Inpatient Management of Pediatric Patients
Scope
Disease/Condition(s): Suicidal ideation

Clinical Specialty: Emergency Medicine, Pediatric Emergency Medicine, Hospitalists, Pediatric
Hospitalists, Critical Care, Nursing

Intended Users: Physicians, Advanced Practice Providers, Registered Nurses, Pharmacists,
Patient Safety Attendants, Personal Safety Observers

Objective(s):
ξ To provide evidence-based recommendations for universal suicide screening in all patients
presenting to the emergency department or admitted to the inpatient setting.
ξ To provide recommendations for the management of patients identified as suicidal or
admitted for treatment of self-injurious behavior by non-Psychiatry providers and staff.

Note: This guideline does not contain recommendations for pharmacologic or psychotherapy-
based treatments of suicidal ideation or suicide attempts.

Target Population: Pediatric and adult patients presenting in the emergency department or
admitted to the inpatient setting (on a non-Psychiatry unit).

Interventions and Practices Considered:
ξ Screening and evaluation
ξ Patient education
ξ Safety planning and lethal means counseling
ξ Rapid referral and caring contacts

Major Outcomes Considered:
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ξ Mortality and morbidity
ξ Patient safety
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.

Recognition of Potential Health Care Disparities: Suicide affects patients from all races and
socioeconomic groups. Nationally American Indian/Alaska Native males and sexual minority
youth (i.e. lesbian, gay, bisexual, transgender, and questioning/LGBTQ) have higher rates of
suicide and suicidal ideation, whereas African American females have the lowest rate of
suicide.18 Locally in Illinois and Wisconsin, Non-Hispanic whites have the highest rate of suicide,
but Wisconsin residents of race minority backgrounds experience greater rates of inpatient
hospitalization for self-injury.23 Availability of mental health treatment, age, and economic
climate can also affect suicide risk. For example, in Wisconsin, the highest rates of suicide tend
to be clustered in the northern and western regions of the state.23 Providers caring for patients
at risk for suicide should remain cognizant of the risk factors and protective factors and work to
treat all patients equally.
Definitions
Primary screening: a procedure in which a standardized instrument or protocol is used to
identify individuals who may be at risk for suicide. Primary screening does not uncover the
nature of the suicide risk that may be present.

Secondary screening: a step used by providers to determine whether discharge following brief
suicide prevention interventions may be appropriate or if further assessment by a mental health
clinician is needed to make a disposition determination.

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Suicide assessment: a comprehensive evaluation done by a clinician with mental health
training to confirm suspected suicide risk, estimate the immediate danger to the patient, and
decide on a course of treatment.
Introduction
Suicide is the second leading cause of death for age group 10–24 (17.4% of deaths) and the
10th leading cause of overall U.S. mortality in 2014, 13.4/100,000 people.24,25 The need for a
standardized process involving staff training and a comprehensive and evidence-based
approach to this patient population including assessment, supervision/monitoring, and
consistent room set up can decrease lapses in care decrease risk of suicide.1,5 This clinical
practice guideline works to outline an evidence-based approach for the management of UW
Health patients with a suicide attempt or active suicidal ideation.
Recommendations
Figure 1. Process for Care of Patients at Suicide Risk
Patient Presentation
Universal primary
screening
completed by RN
Positive
result?
No action required.
No
Secondary screening
completed by
primary team
provider (MD or APP)
Yes
Positive
result?
Provide Suicide Prevention Interventions
- Patient Education
- Safety Planning
- Lethal Means Counseling
No
Discharge and Refer for Follow-up
Consider need for
immediate
interventions
Complete suicide risk
assessment
Consider consult to
mental health
clinician
Yes
Primary team to
determine level of care
(with or without input
from consult service)
Admit?*
No
Yes
Demonstration or
verbalization of suicidal
ideation or behavior?
No
Yes
Follow inpatient
management
recommendations
as appropriate
*Admission to a specific unit should be based on requirements for
medical support. UW Health does not provide pediatric psychiatric
services, therefore AFCH admission may be used to temporarily
place the patient in a safe environment until transfer to a local/
regional psychiatric facility is established. Admission criteria for
adult psychiatry is outlined in UWHC Policy 10.22.

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Primary Screening
Universal screening for suicidal ideation should be completed in all patients age 10 and older
upon admission to the emergency department (UW Health Moderate quality evidence, strong
recommendation) and/or inpatient settings.1,2 (UW Health Low quality evidence, strong
recommendation) Patients age younger than 10 years old are unlikely to understand the
irreversibility of death and may not be considered truly suicidal. Primary screening for all
patients should be completed in private, without the presence of a parent/guardian or other
family members, as patients may be more likely to withhold information if others are present.18
Confidentiality may be broken if the patient is determined to pose a risk to themselves or
others.26

Use of a brief screening tool has been demonstrated to identify adult patients at risk for suicide
more reliably than relying only on a clinician’s personal judgement.1 It is recommended to
screen all patients using the 4-question version of the Ask Suicide-Screening Questions
(ASQ).3,4 (UW Health Low quality evidence, weak/conditional recommendation) If the response to any
of the questions is positive (“yes”), additional detail should be obtained via secondary screening
and/or a suicide risk assessment.
Secondary Screening and Suicide Risk Assessment
Secondary Screening: A decision support tool (Figure 2) may be used by providers on the
primary team to help with practical decisions, such as “Can I make a disposition decision
without consulting a mental health specialist?” or to decide whether patients can safely be
discharged from the Emergency Department after providing a brief intervention.17 (UW Health
Very low quality evidence, weak/conditional recommendation) It is important to use available data
(e.g., patient observation, medical records) and consult with available family members, peers or
outpatient providers to corroborate the patient’s report.18




















Figure 2. Decision
Support Tool (adapted
for use at UW Health)17
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If the response to every question is “no”, discharge may be appropriate following provision of
one or more brief suicide prevention interventions. If the response to any of the questions is
positive (“yes”), a consult to a mental health clinician (e.g., Psychiatry, Health Psychology,
Social Work, Case Management) for further evaluation and complete suicide risk assessment
should be considered. (UW Health Very low quality evidence, weak/conditional recommendation)

Suicide Assessment: Suicidal thoughts or comments should never be dismissed as
unimportant.18 Evaluation is recommended in patients who make suicidal statements or
demonstrate behavior that is indicative of suicidal potential (e.g., presentation to the emergency
department for medical care resulting from an attempt). (UW Health Moderate quality evidence,
strong recommendation)

It is recommended that all staff be trained to consistently assess suicidal thoughts and
understand risk factors for suicidal ideation or suicide attempts, as well as underlying psychiatric
diagnoses, in order to approach each patient and family with empathy and in empowering
ways.5-8 (UW Health Moderate quality evidence, strong recommendation) A comprehensive
evaluation, or suicide assessment, is best performed by a mental health clinician or provider
who has completed mental health/behavioral health training. (UW Health Moderate quality
evidence, weak/conditional recommendation) The suicide assessment is used to confirm suspected
suicide risk, estimate the immediate danger to the patient, and to obtain information which will
inform decisions on a course of treatment. This assessment should include7,21,26:
ξ Identification of the main clinical and demographic features known to be associated with
risk of further self-harm and/or suicide;
ξ Identification of the key psychological characteristics associated with suicide risk, in
particular, depression, hopelessness and continuing suicidal intent7;
ξ The nature, frequency, depth, timing and persistence of suicidal ideation. If ideation is
present, clinicians should request more detail about the presence or absence of specific
plans for suicide, including any steps taken to enact plans or prepare for death;
ξ Review of the presence of protective factors;
ξ Evaluation for the presence of a psychiatric disorder and initial survey of patient’s mental
health history;
ξ Development of diagnostic treatment recommendations and a safety plan.

It is important to use available data (e.g., patient observation, medical records) and consult with
available family members, peers or outpatient providers to corroborate the patient’s report.18

Disposition and Determination of Level of Care: It is important for staff to remember that
there is no typical suicide victim, and many patients can exhibit risk factors and not attempt
suicide, while others who attempt or complete suicide may not exhibit any risk factors.
Management decisions should depend on the degree of acute risk (Table 1 and Table 2). Intent
is a key issue in the determination of risk.18

Hospitalization should be considered in patients at high risk for suicide to assure their safety,
manage complex diagnoses, and deliver emotionally intense therapeutic procedures.18,20 (UW
Health Very low quality evidence, strong recommendation) While no evidence exists to show that
inpatient hospitalization is safer than any other care setting, and patients remain at risk for
suicide during their hospitalization, one of the biggest advantages is the ability to diminish
access to lethal means via provision of a safe and controlled physical environment paired with
regular supervision.18,20,21 Adult patients who meet the criteria in UWHC Policy 10.22 may be
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admitted to the Inpatient Psychiatry unit. All other adults and pediatric patients may be admitted
to intensive care or general care, depending on their requirements for medical support (e.g.,
treatment of injuries sustained by an attempt). Note: As UW Health does not provide inpatient
psychiatric services to pediatric patients, admission may be used to temporarily place the
patient in a safe environment until transfer to a psychiatric facility can be established.

Patients determined to be low risk can be considered for discharge. (UW Health Very low quality
evidence, weak/conditional recommendation) Low risk can be defined as patients with a responsive
and supportive family, little likelihood of acting on suicidal impulses (e.g., thought of dying with
no intent or plan), and someone who can take action if there is mood or behavior deterioration
may require only outpatient treatment.18,21

When there is a discrepancy between level of care recommended and that available or agreed-
upon by the family, the mental health clinician consultant should work with the primary team to
navigate available options, including communication with outpatient providers and Journey
Mental Health – Emergency Services Unit (ESU or “Dane County Crisis”, 608-280-2600) as
needed. (UW Health Low quality evidence, weak/conditional recommendation)

Table 1. Factors to Consider in Adolescents1,18,21,27,28
Non-Modifiable
Risk Factors
ξ Family history of suicide or suicide attempts
ξ History of adoption
ξ Male gender
ξ Parental mental health problems
ξ Lesbian, gay, bisexual, or questioning sexual orientation
ξ Transgender identification
ξ Previous suicide attempt
ξ History of physical or sexual abuse
ξ Mental health issues including sleep disturbances, depression, bipolar disorder,
substance intoxication and substance use disorders, psychosis, posttraumatic stress
disorder, panic attacks
ξ History of aggression, impulsivity, severe anger, and pathologic Internet use (> 5
hours/day of video gaming or Internet use, visiting prosuicide websites or participation in
online suicide pacts or forums)
Modifiable
Risk Factors
ξ Nonsuicidal self-injury (e.g., cutting)
ξ Recent stressful life event (e.g., legal or romantic difficulties, argument with a parent)
ξ Bullying victimization or perpetration
ξ Impaired parent-child relationship (i.e., lack of warmth, ineffective communication between
parent-child)
ξ Living outside of the home (homeless, corrections facility or group home)
ξ Difficulties in school
ξ Neither working or attending school
ξ Social isolation
Protective
Factors
ξ Connection between the patient and parents, school and peers
ξ Positive self-image
ξ Effective social problem-solving skills
ξ Good family communication skills
ξ Restrictions on lethal means of suicide
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Table 2. Factors to Consider in Adults1,23,28
Non-Modifiable
Risk Factors
ξ Previous suicide attempt or self-inflicted injury
ξ History of trauma, such child abuse/neglect or domestic violence
ξ Family history of suicide (attempt or completion)
ξ Mental or emotional disorders, particularly depression and bipolar disorder
ξ Family history of psychiatric illness
ξ Serious illness or physical or chronic pain or impairment
ξ Discharge from inpatient psychiatric care (especially within weeks or < 1 year)
ξ Male gender
ξ Widowed, divorced, or single
Modifiable
Risk Factors
ξ Access to lethal means coupled with suicidal thoughts
ξ Social isolation or poor social support
ξ Bereavement or recent loss (e.g., death, economic loss)
ξ Helplessness or hopelessness
ξ Pattern/history of aggressive, impulsive or antisocial behavior
ξ Unemployment
ξ Homelessness
ξ Perpetrator of interpersonal violence within the past month
ξ History of non-compliance with treatment
ξ Alcohol and drug abuse
Protective
Factors
ξ Positive coping and problem-solving skills
ξ Reasons for living (e.g., children in the home, pets)
ξ Moral objections to suicide
ξ Supportive relationship with healthcare providers
ξ Restrictions on lethal mans of suicide
ξ Outpatient care in place; willingness to comply with treatment plan
Involvement of Psychiatry
The Psychiatry Consult service is available to assist at any time with suicide risk assessment,
recommendations for precautions and/or determination of a disposition plan. Circumstances
when a suicide assessment by Psychiatry may be clinically indicated include26(UW Health Low
quality evidence, weak/conditional recommendation):
ξ Emergency department evaluation
ξ Initial identification of suicidal thoughts, suicide attempt and/or risk factors in an inpatient
ξ Before a change in observation status or treatment settings (e.g., discontinuation of one-
to-one observation, discharge from inpatient setting)
ξ Abrupt change in clinical presentation (either precipitous worsening or sudden, dramatic
improvement)

Safety evaluations performed by the Psychiatry consultant should include an account of severity
of symptoms, risk and protective factors in each patient, engagement in mental health
treatment, access to follow-up care, ability of caregivers to provide supervision and means
restriction. (UW Health Low quality evidence, weak/conditional recommendation)
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Management by Non-Psychiatry Clinicians
Immediate Interventions
Safe Environment: It is important that patients are placed in an environment where physical
and structural risk factors have been removed.1,5,9-11 (UW Health Moderate quality evidence, strong
recommendation) Hanging is the most common method utilized in a suicide attempt in the
hospital setting.9,29 Any dangerous or potentially dangerous items should be removed which
could be used as anchor points or materials used for self-harm such as sharps, medications, in
room telephone, bedside table, and/or additional monitoring cords (e.g., call light, blood
pressure cuffs, telemetry, pulse oximetry and oxygen tubing, bandages etc.). Removal of the
hospital bed or bed sheets, with placement of the mattress on the floor may also be considered,
if concerns for patient injury from the bed. It is suggested to assign the patient to a room in close
proximity to the nursing station. The patient’s door should remain open unless medically
necessary or if confidentiality dictates otherwise.

Personal patient property may be restricted at any time if means or threats of suicide attempt
deems necessary. (UW Health Very low quality evidence, strong recommendation) If staff are
concerned that the patient has self-injurious items in their possession, Security should be called
to search the patient’s belongings per UW Health Policy 2.1.22.

Patient Observation: Patients at greatest risk for self-harm (e.g., previous suicide attempt,
presentation from a suicide attempt) should be placed under 1:1 constant observation and use
of a Patient Safety Attendant (PSA) or Personal Safety Observer (PSO) is recommended.8,10,11
(UW Health Moderate quality evidence, strong recommendation) Descriptions of the details
associated with each level of suicide precaution are outlined within UW Health Policy 2.4.1.The
PSA/PSO should receive education and handoff to ensure they are aware of patient specific
triggers and interventions. Constant visualization of the high risk patient should be maintained
even in locations typically associated with privacy, like the bathroom. Bathrooms are considered
to be extremely high risk areas as plumbing, piping or ductwork can be used as anchors for
hanging. A handout of standard expectations should be provided to all PSA/PSO staff.10 At no
time should visitors or family members be considered or used to conduct close observation.

Although several low quality studies have demonstrated significant cost savings with the use of
video monitoring, safe use of remote monitoring in patients at risk for suicide has not been
established.30-32 Therefore, video monitoring of any kind is not recommended in this patient
population. (UW Health Low quality evidence, strong recommendation)

Emergent Behavioral Situations: Agitated patients may require verbal management
techniques or deescalation strategies to calm down. Non-pharmacological approaches should
always be attempted first. (UW Health Low quality evidence, weak/conditional recommendation) It is
important to follow good general de-escalation strategies, such as the following33-35:
1. Have anyone who may be a target for the crisis behavior step out of room.
2. Keep as few staff as possible in the room but enough to provide safety.
3. Do not engage in bargaining or argument
4. Use simple, declarative statements to tell the patient what to do with their body to stay
safe.
5. If there is agitation, consider calling Security right away. Security is unlikely to put hands
on the patient but can be a calming “show of force” whose presence can remind the
patient to be civil.
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6. In the event of patient elopement staff should not attempt to stop patient (i.e.-put self
between patient and exit, be in an enclosed space, etc.) but should call for security and
give details if patient does leave unit (which stairwell they go down, which elevator they
are in). Staff safety must be addressed first.

If verbal management techniques are unsuccessful, pharmacologic restraint can be considered.
(UW Health Moderate quality evidence, weak/conditional recommendation) Most controlled trials of
medications for acute agitation in the emergency department or inpatient psychiatric settings
have been performed in adults.33 The three drug classes most commonly used for treatment of
acute agitation are typical antipsychotics, atypical antipsychotics, and benzodiazepines. When
choosing an agent and dosage, providers should consider the level of sedation desired,
implications for future assessment of patient mental status, length of stay, and potential for
adverse effects. The route of administration and drug selection should also depend on the
patient’s condition (e.g., patient age, co-morbidities and other prescriptions, whether the patient
poses imminent danger to themselves or others, or whether the patient is willing to take oral
medications).35 (UW Health Moderate quality evidence, weak/conditional recommendation) Clinicians
may consider the use of pharmacologic interventions as outlined in Tables 3-4.

There is limited data supporting the use of first-generation and second-generation
antipsychotics in pediatric patients.36 Some studies suggest that second-generation
antipsychotics used with benzodiazepines show comparable efficacy to first-generation
antipsychotics but with improved tolerability.37 As a second-generation antipsychotic,
risperidone has the most evidence supporting its use as an intervention for children with
disruptive behavior disorders and comorbid agitation, especially in children with Autism
Spectrum Disorder or low-average IQ.36 In situations where the cause of agitation is unclear in a
pediatric patient, a stepwise approach may be preferred rather than use of combination therapy
(e.g., benzodiazepine + first-generation antipsychotic).33 (UW Health Low quality evidence,
weak/conditional recommendation) In pediatric patients with mild/moderate acute agitation
secondary to a psychiatric disorder, treatment with a benzodiazepine or antipsychotic
medications can be considered.33,38 (UW Health Low quality evidence, weak/conditional
recommendation) For severe acute agitation, antipsychotic therapy is suggested.33(UW Health Low
quality evidence, weak/conditional recommendation)

In adult patients with undifferentiated acute agitation, combination of a benzodiazepine and a
first-generation typical antipsychotic is recommended.35,39 (UW Health Low quality evidence,
weak/conditional recommendation) Benefits of the use of both medications compared to individual
use include decreased time spent in seclusion or restraint, faster onset of action, fewer
injections, and decreased incidence of extrapyramidal symptoms (EPS).35 Elderly patients tend
to be more susceptible to adverse drug reactions. Particularly in patients age 65 years or older,
it is important to consider dose adjustments to reduce the risk of adverse events or side
effects.35,40 (UW Health Low quality evidence, strong recommendation) In a retrospective chart review
of older patients, low dose haloperidol appeared to be as effective as and safer than higher
doses in the treatment of acute agitation.40

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Table 3. Medications for the Management of Acute Agitation in Pediatric Patients33,34,37
Drug Dose and Route Time Course Side effects Advantages/Comments
Benzodiazepines
Lorazepam
0.05-0.1 mg/kg PO/IM/IV
in children/adolescents

May repeat every
30-60 minutes
Onset
- IV: 5-10 min
- IM: 15 min
- PO: 20-30 min
Duration
- IV: 2 hours
- IM/PO: 6-8 hours
- Sedation
- Respiratory depression
- Hypotension
- Paradoxical disinhibition
- No EPS
- Preferred agent for many
intoxications (e.g. cocaine),
withdrawal (e.g. alcohol)
- Caution in patients with respiratory
compromise
- Contraindicated for intoxication
with other GABAergic drugs (e.g.
barbiturates, benzodiazepines
Midazolam 0.1 mg/kg PO/IM/IV
Onset
- IV: 5-10 min
- IM: 15 min
- PO: 20-30 min
Duration: 3-4 hours
Second-generation, Atypical Antipsychotics
Risperidone
0.025-0.05 mg/kg PO/ODT

Usual dose
- Child 0.25-0.5 mg
- Adolescent: 0.5-1 mg
May repeat every 60
minutes
Onset
PO: 30-60 min
- Prolonged QTc, torsades
de pointes, dysrhythmias
- Hypotension
- Dystonia
- NMS
- Olanzapine: postinjection
delirium and sedation
- May be better tolerated with fewer
EPS than haloperidol
- May have higher risk of dystonia,
especially with higher doses and in
male and/or younger patients
- Olanzapine: consider monitoring
for at least 3 h after IM injection
Olanzapine
0.1 mg/kg PO/ODT/IM

Usual dose
- Child 2.5 mg
- Adolescent: 5-10 mg
Maximum 30 mg daily
May repeat IM every
20-30 minutes, PO/ODT
every 30-45 minutes
Onset
- IM: 10-20 min
- PO: 20-30 min

Duration: 24 hours
Ziprasidone
Usual dose
- 12-16 y: 10 mg
- >16 y: 10-20 mg
Maximum 40 mg daily
May repeat every 2
hours
Onset
- PO: 4-5 hours Duration: 24 hours
First-generation, Typical Antipsychotics
Haloperidol
0.025-0.075 mg/kg IM/PO

Usual dose
- Child: 0.5-2 mg
- Adolescent: 2-5 mg
May repeat IM every
20-30 minutes, PO
every 60 minutes
Onset
- IM: 20-30 min
- PO: 45-60 min

Duration: 4-8 hours
- Prolonged QTc, torsades
de pointes, dysrhythmias
- Hypotension
- Dystonia
- NMS
- Low addiction potential
- High therapeutic index
- Lack of tolerance
Combinations
- Typical antipsychotic + benzodiazepine: Haloperidol + lorazepam or midazolam
- Typical antipsychotic + antihistamine: Haloperidol + diphenhydramine
- Atypical antipsychotic + benzodiazepine: Risperidone + lorazepam or midazolam
- Atypical antipsychotic + antihistamine: Risperidone + diphenydramine


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Table 4. Medications for the Management of Acute Agitation in Adult Patients35,39
Drug Dose and Route Time Course Side effects Advantages/Comments
Benzodiazepines
Lorazepam
Moderate Agitation
Age < 65 yrs.: 1 mg PO
Age > 65 yrs. 0.5 mg PO

Severe Agitation
Age < 65 yrs.: 2 mg IV/IM
Age > 65 yrs.: 1 mg IV/IM
May repeat every
30-60 minutes

Give IM injections if no
IV access
Onset
- IV: 5-10 min
- IM: 15 min
- PO: 20-30 min
Duration
- IV: 2 hours
- IM/PO: 6-8 hours
- Sedation
- Respiratory depression
- Increased risk of falls
- Hypotension
- Increased confusion in
elderly
- Paradoxical disinhibition
- No EPS
- Preferred agent for many
intoxications (e.g. cocaine),
withdrawal (e.g. alcohol)
- Caution in patients with respiratory
compromise
- Contraindicated for intoxication
with other GABAergic drugs (e.g.
barbiturates, benzodiazepines
First-generation, Typical Antipsychotics
Haloperidol
Moderate Agitation
Age < 65 yrs.: 2 mg PO
Age > 65 yrs. 1 mg PO

Severe Agitation
Age < 65 yrs.: 5 mg IV/IM
Age > 65 yrs.: 2.5 mg IV/IM
May repeat IM every
20-30 minutes, PO
every 60 minutes

Give IM injections if no
IV access
Onset
- IM: 20-30 min
- PO: 45-60 min

Duration: 4-8 hours - Prolonged QTc, torsades
de pointes, dysrhythmias
- Hypotension
- Dystonia
- NMS
- Increased mortality in
elderly patients with
dementia-related psychosis.
Give only in circumstances
of imminent danger to self
or others.
- Contraindicated for patients
with Parkinson’s Disease
- Low addiction potential
- High therapeutic index
- Lack of tolerance

Combinations
- Typical antipsychotic + benzodiazepine: Haloperidol + lorazepam or midazolam
- Typical antipsychotic + antihistamine: Haloperidol + diphenhydramine


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Medical Evaluation/Clearance
A complete history and physical exam is recommended in patients presenting with psychiatric
illness.12,15,16 (UW Health Low quality evidence, strong recommendation) Physical exams can identify
cutting or other self-injurious behavior, especially in patients who present for medical care
following a suicide attempt.

Routine laboratory evaluations are not recommended in patients with a psychiatric chief
complaint; any diagnostic testing should be dictated by the individual clinical presentation for
medical conditions.12-16 (UW Health Low quality evidence, strong recommendation) Protocolized
ordering of lab testing is not cost-effective and several retrospective evaluations did not find any
patients with pure medical problems who were admitted inadvertently to Psychiatry.12,13
Diagnostic testing should not be performed until the medical needs are established (e.g., suicide
attempt by poisoning or medication overdose may warrant assessment of risk and consideration
for laboratory testing). Poison Control can be contacted when appropriate to provide
recommendations for evaluation, monitoring, and treatment.
Brief Suicide Prevention Interventions
Care for persons at risk of suicide should be person-centered, where their personal needs,
wishes, values and resources should be the foundation for a continuing care and safety plan.
Where appropriate and practical, families and significant others should be engaged and
empowered as well. It is recommended that brief interventions are provided based on the
individual needs of the clinical scenario, preferably provided as a bundle rather than individually.
(UW Health Low quality evidence, weak/conditional recommendation) When implemented as a group,
the interventions have a greater effect on outcomes than when presented individually.17 The
following interventions may be provided in the emergency department or inpatient settings.

Patient Centered Care: In both adolescent and adult populations, acknowledging and talking
about suicide directly may in fact reduce, rather than increase, suicidal ideation.3,41,42 The term
“suicide gesture” should not be used, because it implies a low risk of suicide that may not be
warranted. Instead, language such as “suicide attempt” is more appropriate.

During communication with a patient, staff should be aware that patients experiencing suicidal
ideation often feel embarrassed, guilty, or fearful of disclosing their thoughts and feelings. Staff
should demonstrate empathy and respect for patient autonomy.10,17,20 (UW Health Moderate quality
evidence, strong recommendation) Staff should use the same techniques to build rapport with a
patient at risk for suicide as any other patient who may be hospitalized for medical care. (UW
Health Low quality evidence, strong recommendation)

Suggested Talking Points for Building Rapport
“Tell me some cool things about you.”
“Tell me about who came to visit you today.”
“What went wrong yesterday that was so bad that death was the answer?”

If patient becomes emotional or begins discussing intense topics…
“It’s really normal to feel that way.”
“Thank you for sharing that with me.”

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In patients placed on suicide precautions, it is recommended that staff discuss the following
expectations (UW Health Very low quality evidence, weak/conditional recommendation):
ξ A staff member (PSA/PSO) will be in the room at all times to help ensure safety. They
will be within arm’s length at all times, even in the bathroom.
ξ The patient’s hands need to be on top of blankets/visible at all times.
ξ In adolescent patients, parents should make the decision on whether or not the patient
may use their phone. If usage becomes aggravating or inappropriate, nursing staff may
intervene and should consider removing the phone if approved by the parent/guardian.
ξ Patients may not leave the unit, unless escorted by staff for a procedure or when being
discharged.
ξ Patient to be placed in a hospital gown, unless cleared by MD/APP to wear personal
clothing.

Patient Education: As patients with suicide risk often do not attend follow-up mental health
appointments after discharge, the emergency department visit or inpatient admission may be
the best or only opportunity to provide the patient and their family with suicide prevention
information. All patients with suicidal ideation should receive the contact information for the
National Suicide Prevention Lifeline as well as local crisis and peer support contacts, prior to
discharge from the emergency department or inpatient setting.1,17 (UW Health Very low quality
evidence, strong recommendation)

Hopelessness is a major risk factor for suicidal thinking and behavior. Therefore, patient
education should focus on restoring positivity, instilling hope of recovery, and reducing stigma
and shame. (UW Health Very low quality evidence, weak/conditional recommendation)

Providers should provide written education materials and use teach-back techniques where
possible to ensure the patient and family understand the information provided.17 (UW Health Very
low quality evidence, weak/conditional recommendation) Educational components which should be
considered include the following17,20:
ξ Patient’s current condition (including impact of any existing psychiatric diagnoses)
ξ Risk factors for suicide risk and protective factors against suicide
ξ Type of treatment and options
ξ Medications and adherence
ξ Substance use
ξ Home care
ξ Lethal means restriction
ξ Follow-up recommendations (placing emphasis on methods for contacting the patient’s
outpatient provider or other medical/community support resources)
ξ Signs of worsening condition (e.g., increased frequency of suicidal thoughts, increased
trouble sleeping) and how to respond (e.g., ask friends or family to help keep you safe,
remove access to lethal means, when to return to the emergency department).
Note: It is preferred that staff in nursing assistant (NA), PSA, or PSO roles not prompt the
patient for information related to the behavioral health admission. Redirection and clarification of
roles/expectations can help if patients begin discussing triggers, intense emotions, become
agitated, etc. For example, a NA/PSA/PSO may state, “My job on the team is to help make you
be comfortable. I know you are going through a lot of uncomfortable things right now, and there
are other people on the team who are going to help you with those, but what are some other
things we can talk about? What kinds of things are you good at?”
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Safety Planning: “No suicide contracts” have not been shown to effectively prevent or reduce
suicides in adolescents or adults.18,43 Instead, all patients identified as at risk for suicide should
have a collaboratively designed safety plan developed prior to discharge from the emergency
department or inpatient admission.1,18,19 (UW Health Low quality of evidence, strong recommendation)

Safety planning is a brief clinical intervention which can be used as a valuable adjunct in
patients who have made a suicide attempt, have suicidal ideation, have psychiatric disorders
that increase suicide risk, or who are otherwise determined to be at high risk for suicide.19
Safety plans are composed of a prioritized list of coping strategies and sources of support that
patients can use during or preceding suicidal crises.19 It is recommended to use the following
forms during this process:
ξ Safety Plan (Form 301307-DT) (Spanish version- 301307S-DT): typically used by staff and
patients familiar with the process.
ξ Staff-Assisted Safety Plan (Form 301869-DT): can be used by staff less familiar with the
collaborative safety planning process, provides more active guidance to patients for
completion.

All patients seen by the consult Psychiatry service should receive safety planning from the
Psychiatry provider. Patients in the emergency department without a Psychiatry consult should
have safety planning completed by Social Work. The primary team physician should be
responsible for safety planning with patients admitted but not seen by Psychiatry.

Lethal Means Counseling: The most common method used to commit suicide in the United
States is with a firearm.44 In Wisconsin, 45% of completed suicides between 2007-2011 were
performed via a firearm, and death by firearm was most common in people age 55 years or
older in Illinois.23,28 Overall, completed suicides via hanging/strangulation is more common in
younger people; however young people in Wisconsin are more likely than young people in
Illinois to use a firearm.23,28 Ingestion of medication (poisoning) is the most common method
used by adolescents to attempt suicide.21

Clinicians should ask the patient and his or her support system about the patient’s access to
lethal means, particularly firearms.1,17,20 (UW Health Very low quality evidence, strong
recommendation) Staff may complete the CALM: Counseling on Access to Lethal Means course
to learn other techniques for counseling patients: http://www.sprc.org/resources-programs/calm-
counseling-access-lethal-means.

Patients and their families should receive education that suicide risk can escalate rapidly, for
example after a fight with a family member, so not having access to lethal means quickly can
help to reduce bad outcomes.17,45 Recommendations should be made to the patient and/or
family to remove all firearms from the home and to lock up all prescription and over-the-counter
medications.17,18,20 (UW Health Low quality evidence, strong recommendation) In addition to
encouraging the patient and/or family to remove lethal means, providers should also warn about
the dangerous disinhibiting effects of alcohol and other drugs.20,21 (UW Health Very low quality
evidence, weak/conditional recommendation)

When clinically possible, providers may consider limiting access to medications that carry risk
for suicide by prescribing limited quantities, supplying the medication in blister packaging,
providing printed warnings about the dangers of overdose, or ensuring that current prescriptions
are actively controlled by a responsible party (e.g., outpatient provider).20,45 Education can also
be provided on the best ways to secure chemical poisons such as agricultural and household
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chemicals, to prevent accidental or intentional ingestion.20 The Poison Control Hotline (1-800-
222-1222) can be used to help determine a non-lethal quantity or suggestions for securing
chemicals appropriately.45

Suggested Talking Points to Assess and Discuss Access to Lethal Means
“One of the important things to talk about is doing what we can to make the home safe. Most
suicide attempts happen rapidly and impulsively, and what we want to do is make it take time for
your to act on any thoughts in a dangerous way, and in that time
hopefully slow down and go for help. The most important things to talk about are guns,
medications, and hanging. With medications, locking them in a safe or padlocked box will slow
your down enough and likely make enough noise that help can
intervene. The best thing to do for guns is to have the guns ‘go on vacation’ until your
is feeling better. Is there somewhere the guns* could go?”

*Note: It is important for providers to know how many and what kinds of guns are present, how
and where ammunition is stored, whether the guns are in a case or safe, and if the guns are
breach locked or merely trigger locked. There is strong evidence that removing guns is very
important for safety, but no evidence that locking guns up is helpful.46 Providers could consider
asking the family to remove ammunition, get a breach lock, and put the gun in a safe, but those
are not evidence-based interventions.
Management During Inpatient Admission (Excluding the Psychiatry Unit)
Safe Environment/Patient Observation: The highest risk period for suicide attempts occurs
within the first week of hospitalization.8,9,20 Interventions previously described, such as
maintaining a safe environment and the use of suicide precautions, should be maintained during
an inpatient admission as deemed appropriate by the primary team.8-10 (UW Health Low quality
evidence, strong recommendation) Descriptions of the details associated with each level of suicide
precaution are outlined within UW Health Policy 2.4.1.

When giving sign-out or hand-off, team members should be frank but non-judgmental about the
reason for admission and need for observation. If there is a concern about visitors and privacy,
they should be asked to step out during handoff. If asked, PSAs/PSOs can tell visitors that they
are there to ensure a safe and speedy recovery. Questions about treatment can be deferred to
the patient: “It’s really his/her place to share what they want about their illness and treatment.”

Patient Ambulation from Room: Elopement is a significant risk in patients at risk for suicide.
Initial orders should be placed to restrict ambulation until patient is assessed by the primary
team. Ambulation privileges or boundaries should be established using input of the primary care
team. (UW Health Low quality evidence, strong recommendation) Following evaluation by the primary
team, pediatric or adult patients on a medical/surgical unit may be allowed to walk around the
unit (with the presence of a PSA/PSO as indicated by the level of suicide precautions).

In pediatric and adolescent patients, Child Life resources may be used to provide customized
distraction kits, as patients may not be allowed to go to the playroom based on a discussion with
the primary team. Adult patients should typically be allowed only to ambulate on the
medical/surgical unit.

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Periodic Assessment for Suicidal Thoughts: Patients that screen positive for suicidal
ideation at admission should have the severity of their thoughts monitored every 8 hours (every
shift). (UW Health Very low quality evidence, weak/conditional recommendation) Patients placed on
suicide precautions should be reassessed every 24 hours to determine continued need of the
precautions. (UW Health Very low quality evidence, weak/conditional recommendation) The following
questions should be used by staff to periodically reassess suicide risk:
1. Do you have suicidal thoughts right now? Yes/No
2. What has changed since admission about those thoughts?
3. How are you coping with those thoughts right now?
4. Is there anything we can do to help you feel safe?

These questions allow for the patient to identify their feelings, assess their resources and
responses to a situation, and reflect an understanding and support from staff.
Discharge and Follow-up
The risk of a suicide attempt or completion is greatest within the first 12 weeks following
discharge from the emergency department or inpatient setting.20 Discharge planning provides
an important opportunity to connect patients at risk for suicide with resources for follow-up and
ongoing medical and/or psychiatric care. Discharge planning should be completed by a multi-
disciplinary team with involvement from the patient and their family.17,20 (UW Health Very low
quality evidence, weak/conditional recommendation)

Literature suggests that beneficial discharge plans include the following components, many of
which may have also been addressed during the emergency department visit or inpatient
admission20,21,47,48:
ξ Reassessment of suicide risk
ξ Education to the patient and support system about the risks of suicide after discharge
and provision of suicide prevention information/education to the patient and family
o Reframing the suicide attempts as a problem requiring action
o Educating families about the importance of outpatient mental health treatment
and restricting access to dangerous attempt methods
o Caution the patient and family about disinhibiting effects of drugs or alcohol
o Check that firearms and lethal medications can be effectively secured or
removed
ξ Reinforcement of the safety plan with validation of available support systems
o Obtaining a commitment from the patient to use a safety plan in future crises
o Strengthening family support by encouraging youth and parents to identify
positive attributes of the youth and family
ξ Coordination of the transition to appropriate care setting with warm hand-offs and
discussion of post-discharge treatment plans for psychiatric conditions and for suicide-
specific therapies as appropriate
o Note: As UW Health does not provide pediatric psychiatric services, Case
Management/Coordinated Care staff should be involved in cases of patients who
require continued inpatient psychiatric care. Case Management/Coordinated
Care staff address discharge components such as coordination of transportation
to outside facilities (e.g., private vehicle or ambulance).

Rapid Referral: It is recommended that patients be seen for follow-up within 7 days of
discharge.11,17,18,20 (UW Health Low quality evidence, strong recommendation) The follow-up
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20



appointment should be scheduled before discharge.21 If this is not possible, a telephone contact
for the patient, a parent, or a caretaker should be obtained and a procedure set up for clinical
staff to initiate contact with the patient, parent, or caretaker, if they have not been contacted
within a reasonable period of time.21

Caring Contacts: The evidence surrounding the efficacy of brief contact interventions to
prevent suicide or self-harm is slightly mixed, however a few randomized control trials in
adolescents and adults support their use to improve connection to outpatient care or reduce risk
of self-harm.22,47,49-52 Suicidal behavior was reduced in a randomized control trial of adult
patients who had recently attempted suicide when in-person therapy sessions were
supplemented by regular, personalized letters for 24 months (i.e., every 3 months in the first
year and every 6 months in the second).50 In a randomized control trial, adolescents at risk for
suicide who received structured telephone contacts for motivating and supporting outpatient
treatment attendance within 48 hours of discharge were associated with improved linkage to
outpatient treatment.47 However, connection to outpatient treatment did not lead to significant
decreases in suicide attempts or improvements on other clinical or functioning outcomes.47

It is suggested that brief contacts provide reinforcement of social support and connectedness
and can improve a patient’s knowledge about suicidal behaviors, available resources, and how
to access help in times of crisis.49 Caring contacts may be especially helpful for patients who
have barriers to outpatient care or are unwilling to access outpatient services or community
resources. Contacts via telephone encounters, patient letters, postcards, or MyChart messages
should be made by clinical staff or non-medical personnel to all patients following
discharge.11,17,22 (UW Health Moderate quality evidence, weak/conditional recommendation) The
frequency of contact should be determined on an individual basis, and increased when the
patient exhibits more risk factors or indicators of suicide risk (e.g., weekly contacts for the first
month in patients at high acute risk).20 (UW Health Moderate quality evidence, weak/conditional
recommendation)

Examples of Caring Contacts17
Dear

It has been a little while since you were at UW Health, and we hope things are going well for you. If you would like to send us a
note we would enjoy hearing from you,

Best wishes, Your Team at UW Health
Dear

It was great to meet you at UW Health. We hope you are doing well. We just wanted to send a quick note to let you know we are
thinking about you and wish you well. If you’d like to reply to us and send us an update, we would be happy to hear from you.

Sincerely, Your Team at UW Health

Please note the following resources are available to you:
Hi ,

I hope you have been doing well since we last spoke. Give me a call if there’s anything I can do for you.


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21



UW Health Implementation
Potential Benefits:
ξ Improved safety for patients and staff by providing consistent training and approach
ξ Consistent care by all health care team members
ξ Patient/Family, Medical staff, and Nursing staff understand expectations for patients
admitted with suicidal ideation or attempt.
ξ Patient and family involvement in developing care plan
ξ Decreased behavioral escalation events
ξ Decreased calls to security team to assist with escalating behaviors
ξ Decreased PSN events surrounding attempted elopement events

Potential Harms:
ξ Potential for escalating behaviors due to adherence by all team members to the guideline.
ξ If guideline is not followed consistently by staff, may lead to frustration for patient and family
which may lead to escalating behaviors.

Qualifying Statements: Providing treatment and care for people who have self-harmed can be
emotionally demanding and requires a high level of communication skills and support. All staff
undertaking this work should have regular clinical supervision in which the emotional impact
upon staff members can be discussed and understood.7

Pertinent UW Health Policies & Procedures
1. UW Health Policy 2.4.1- Suicide Assessment and Prevention
2. UW Health Policy 2.1.22- Patient Belongings and Valuables
3. UW Health Policy 3.5.2- Screening, Assessment and Reassessment of Patients
4. UWHC Policy 8.24- Guidelines for Treating Patients When They Refuse Medical Treatment
5. UWHC Policy 4.20- Death Reports to Coroner
6. UWHC Policy 10.22- Admission & Discharge of Patients To & From the Inpatient Psychiatric Unit
7. UWHC Nursing Policy 14.40- Constant Observation (Adult and Pediatric)
8. UWHC Nursing Policy 8.31A- Safety Considerations for the Admission Procedure on
Inpatient Psychiatry
9. UW ED Policy 10.0- Screening of Emergency Department Patients

Patient Resources
1. Health Facts For You #4449- Suicide
2. Health Facts For You #7418- Suicide- Spanish Version
3. Health Facts For You #5410- After A Suicide Attempt
4. Health Facts For You #7363- Bereavement Next Steps
5. Health Facts For You #7495- Patient Belongings and Valuables
6. Kids Health: About Teen Suicide
7. National Suicide Prevention Line: #1-800-273 TALK (8255) or #1-900799-4TTY (4889)

Guideline Metrics
1. % of patients who screened positive for suicide risk and received a consult to a mental
health clinician (Psychiatry, Health Psychology, Social Work or Case Management).
2. % of patients identified as at risk for suicide discharged with a completed safety plan.
3. % of patients who received a caring contact within 30 days of discharge.

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22



Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.

Best Practice Alerts (BPA)
UWIP B Health Assessment Suicide Screening
UWIP B Suicide Not B6/5
UWIP B Suicide Psych Consult

Clinical Practice Guidelines
Diagnosing and Treating Depression – Adult/Pediatric – Ambulatory

Delegation Protocols
Emergency Department Immediate Orders – Adult/Pediatric [61]

Order Sets
ED – Immediate Orders Delegation Protocol – RN-ED Tech – Adult [4222]
ED – Immediate Orders Delegation Protocol – RN-ED Tech – Pediatric – Patients Less Than 18
Years of Age [4274]
IP – Acute Agitation – Adult – Supplemental [5419]



Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

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Appendix A. Evidence Grading Scheme(s)

Figure 3. GRADE Methodology adapted by UW Health


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.






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24



Expectations for the Patient Safety Attendant (PSA)/Personal Safety
Observer (PSO) Caring for Patients at Risk for Suicide
Why We
Need
Your Help
ξ Your job is to keep the patient safe. It is vital for patient safety that the items below are followed; if
unsure speak with the nurse (RN).
ξ Patients at risk for suicide need continuous supervision.
Do’s
ξ Keep the patient(s) in view at all times. Complete an up close check every 30 minutes.
ξ Stay within arm’s length of the patient at all times (including in the bathroom), unless you are
replaced by another staff member. If the patient is violent, stay at a safe distance (such as by the
door) where you can safely see the patient at all times.
ξ Go with the patient to any medical procedures that must be completed off of the unit or outside the
emergency department.
ξ Promptly report any significant changes in the patient’s behavior or mood to the RN.
ξ The patient must have their hands visible at all times (on top of blankets/out of clothing/etc.).
ξ Remember that this is a difficult and sensitive time not only for the patient, but for the family as well.
ξ If 1:1, sit in your chair at the patient’s bedside. If 2:1, position yourself to see both patients.
ξ Be aware of what family/friends bring into the room (e.g., medications or other items that can be
used for self-harm). Inform the RN immediately if any harmful materials are found.
ξ Communicate with the patient(s) throughout the shift. Start small, attempt to build a therapeutic and
professional relationship with conversations not related to their suicidal thoughts or actions.
ξ (Pediatric patients only) If appropriate, offer a Safe Distraction Kit provided by Child Life.
Don’ts
ξ Do NOT leave the patient(s) with family members or friends.
ξ Do NOT remove restraints (if placed).
ξ Do NOT eat, drink, or sleep.
ξ Do NOT read, use your personal cell phone or the internet, study, or do other non-patient related
activities. The Work Station on Wheels(WOW) can only be accessed for documentation.
ξ Do NOT allow the patient to leave their room (unless orders placed to allow on the unit)
Health
Link &
Hand-offs
ξ Document in Health Link every 30-60 minutes.
ξ Documentation should include the following:
o Vital signs- frequency based on the stability of the patient
o Patient status (e.g., sleeping, agitated)
o Safety measures (e.g., lights on, door open, cables removed, etc.)
o Presence of care providers, family or friends
o Patient’s questions/needs
o Other information the PSA/PSO feels is important in the care of the patient
ξ You can expect to receive a hand-off report at the beginning of the assignment and you will need to
provide a report at the end of your shift.
ξ Follow the SBAR format when providing a hand-off to other staff.
o Situation (demographics, care team, presentation)
o Background (communication barriers, fall risk, isolation, precautions, psychosocial
concerns)
o Assessment (current condition)
o Recommendations (plan, to do list, what to watch for)
ξ Documentation may be as simple as, “SBAR hand off completed to ED Tech Mike.” Mike should then
document, “SBAR hand off received from Tom.”
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25



Should I follow the patient in the bathroom?
ξ Yes, the bathroom is a high risk area. Do NOT leave the patient alone.
ξ The bathroom door should be open at all times, even when the patient is using the bathroom or showering.
ξ If you are uncomfortable watching the patient while in the bathroom, call for additional staff assistance.
What if the patient becomes agitated or angry?
ξ You should never risk your own safety. Tell the RN to call for additional help if needed.
ξ Have any people who are targets for the behavior step out of the room.
ξ Keep as few staff as possible in the room, but keep enough to provide for safety.
ξ Do not engage in bargaining or argument. Remain objective and factual.
ξ Use simple, declarative statements to tell the patient what to do with their body to stay safe.
ξ Consider calling Security right away. They are unlikely to put hands on the patient but can be a calming
“show of force” whose presence can remind the patient to be civil.
What if the patient tries to leave?
ξ You should never risk your own safety. Tell the RN to call for additional help if needed.
ξ Patients are not safe to leave the hospital against medical advice. Notify the following people immediately
with the specific location of where the patient left the unit: Security, RN, CTL/STM, Nurse Manager, and
Medical Team.
ξ DO NOT use force to try and stop them.
ξ DO NOT put yourself in an enclosed space with the patient (e.g., elevator, stairwell)
What if the patient starts talking about deep, emotional issues?
ξ You should never risk your own safety. Tell the RN to call for additional help if needed.
ξ Explain that there are other providers that will help the patient with those issues and thank the patient for
sharing the information with you.
ξ Clarify your role: “My job on the team is to help make you be comfortable. I know you are going through a lot
of uncomfortable things right now, and there are other people on the team who are going to help you with
those.”
ξ Redirect the patient’s focus by asking them what kinds of things they are good at or like to do.

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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

26



Procedural Guidelines for the Care of Adult and Pediatric Suicidal Patients
in the Emergency Department (ED) at University Hospital (UH) and The
American Center (TAC)

Physician Intake/ Triage/ Waiting Room
Patients who present to the ED via self or family member with complaints of suicidal ideation or a
suicide attempt will be triaged when rooms are not immediately available. Upon completion of triage,
the triage nurse will enter a constant supervision order, selecting either 1:1 constant observation or
2:1 continuous visualization. Patients requiring 1:1 constant supervision are at greatest risk for self‐
harm (previous suicide attempt, presenting with suicide attempt). This order will become effective
when the patient is roomed in the ED. The placement of the order will trigger a page to the ED Care
Team Leader (CTL)/ charge nurse alerting him/ her of the need for a sitter once the patient is roomed.
The ED CTL/ charge nurse will send a Jabber message to the Nursing Coordinator, alerting him/ her of
the sitter need.

Belongings will be placed in the locked cabinet in the UH ED waiting room until the patient can be
roomed. Belongings will be placed in a locked cabinet at TAC ED. If the patient refuses to provide his/
her belongings, Security will be contacted to assist with persuading the patient. Security may wand
the patient’s belongings at this time. The patient will not be placed in a gown until roomed.

The triage nurse will alert the Security officer or police officer in the waiting room verbally that the
patient needs to be watched until roomed. The patient should be placed near the Security/ police
officer podium or desk.

Rooming
Once roomed, all patients will be placed in a no‐tie gown. Rooms will be prepared for patient
placement prior to the patient being roomed.

Rooms 10‐12 UH ED or Room 45 TAC ED
*All items will be moved to the head of the bed, locked in the sink closet or removed from the
room.
*The sink door will be closed.
*The call light will be unplugged and placed in the basket at the head of the bed (HOB).
*The garage door will be closed.
*The only item that should be remaining in the room, outside the garage door, is the
stretcher.

Other ED Rooms
*If the patient is 2:1 continuous visualization, the patient should be placed in the one of the
following beds.

‐39 or hallway 39 (UH)
‐34 or 35 or hallway 34 (UH)
‐15 or hallway 15 (UH)
‐43 and 44 or 47 and 48 (TAC ED)

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27



These rooms were paired because they allow one sitter to continuously visualize two patients. If the
patient does not require monitoring, all cords/ cables should be removed prior to the patient being
roomed (e.g., call light, ECG, pulse ox. . .).

Monitoring
If a patient does require physiologic monitoring, the following precautions will be taken.

Room set up
*The door/ curtain will remain open at all times.
*The lights will remain on at all times, but may be dimmed.
*Any unnecessary cords will be removed.

Expectations of Patient Safety Attendants/Personal Safety Observers
Whether the patient is a 1:1 constant observation or a 2:1 continuous visualization, the
PSA/PSO must keep the patient(s) in view at all times. If the PSA/PSO must respond to one
patient, leaving the other unobserved, the PSA/PSO will first call for help. Any staff member
may respond (RN, EDT, EDC, physician. . .) for a short period of time to watch the second
patient. See PSO/PSA handout of expectations.


Disposition
Patients being admitted to UH or American Family Children’s Hospital will have a belongings list
completed and will have their belongings searched and wanded by Security. Patients being transferred
from TAC ED to UH ED or UH inpatient will have their belongings searched and wanded by Security
prior to transfer. Patients being discharged will have their belongings returned to them. Patients being
transferred to another facility will have their belongings turned over to the transporting entity.

For more information, refer to UW Health Policy 2.1.22- Patient Belongings and Valuables



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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org

28



Quick Guide for Inpatient Management of Pediatric Patients Admitted with
Suicide Attempt or Ideation

ADMISSION
Key
Points
Admitting Diagnosis:
Pediatric patients admitted for suicide attempt or suicidal ideation awaiting inpatient psychiatric placement.
Admitting Service/Unit:
1. If patient is 17 years or younger- Pediatric Hospitalist Service (P5 unit).
2. If patient is requiring critical care, admitted to the Pediatric Intensive Care Unit (PICU) under
the Pediatric Critical Care Service.
Safe
environment
and
personal
belongings
ξ 1:1 constant direct observation must be provided at all times when a patient is admitted under
suicide precautions. The Patient Safety Attendant (PSA)/Personal Safety Observer (PSO) may be
any RN or NA (family, relatives, friends MAY NOT substitute as a PSA/PSO).
ξ Attempt to assign patient to a room in close proximity to the nursing station.
ξ Patient’s door shall remain open unless medically necessary or if confidentiality dictates otherwise.
ξ Restrict personal property: place in hospital gown, remove sharps, strangulation risks (e.g., belts,
shoelaces, etc.)
ξ If concerned patient has self-injurious items in their possession, security may be called to search
patient’s belongings.
ξ Remove medical monitoring cords if appropriate (e.g., telephone, blood pressure, pulse oximeter)


PATIENT COMMUNICATION & EMERGENT BEHAVIORAL SITUATIONS
Key Points Avoid trigger words
Therapeutic
Communication
ξ Consistency is the key in caring for patients and their families. Compassionate care with the
firm adherence to the protocol in place is central to a smooth hospitalization.
ξ Start small, attempt to build a therapeutic and professional relationship with conversations.
ξ Remember that this is a difficult and sensitive time not only for the patient but for the family as
well.
ξ Every eight hours asses (and document) the patient’s suicide risk: “ Do you have suicidal
thoughts right now? What has changed since admission about those thoughts? How are you
coping with those thoughts right now? Is there anything we can do to help you feel safe?”
De-escalation
Strategies
ξ Have any people who are targets for the crisis behavior step out of the room.
ξ Keep as few staff as possible in the room, but keep enough to provide for safety.
ξ Do not engage in bargaining or argument. Remain objective.
ξ Use simple, declarative statements to tell the patient what to do with their body to stay safe.
ξ If there is agitation, consider calling Security right away. They are unlikely to put hands on the
patient but can be a calming “show of force” whose presence can remind the patient to be civil.
ξ Patients who have a PSA/PSO for suicidality are not safe to leave the hospital AMA. Notify
Security and CTL/STM, Nurse Manager, and Medical Team if patient attempts to leave
hospital.
ξ DO NOT use force to stop them. Security is to hold patient until the Primary Medical Team
determines disposition. The Attending team may consult with other services (I.E.-Psychiatry,
Legal, Risk Management etc.) to assist with this decision.
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29




PATIENT ACTIVITY AND SUPERVISION
Key
Points
Patients with suicide attempt/ideation need
continuous supervision (e.g., Patient Safety
Attendant PSA) for safety, unless cleared by
Psychiatry.
Family members or friends should NOT be
permitted to substitute for staff providing
constant observation under any circumstances.
Activity
ξ The PSA/PSO should follow the list of expectations.
ξ Patient may not leave the unit unless medically necessary: if they must go off the unit for procedures
they must be accompanied.
ξ Be aware of what family and friends bring into the room (i.e.: medications, items that can be used for
self-harm). PSA/PSO must inform the RN immediately if any harmful materials are discovered.
Bathroom
and
Shower
ξ The bathroom is a high risk area, DO NOT leave the patient alone.
ξ The bathroom door should be open at all times when the patient is using the bathroom or shower and
the PSA/PSO must be within arm’s reach of the patient for their safety. If uncomfortable watching the
patient while in the bathroom, please call additional staff for assistance.

DISCHARGE
Key Points
Patients will be discharged once they are medically stable and a safe discharge plan is in
place (i.e. inpatient psychiatric stay or home with a safety plan as deemed by the
psychiatrist.)
Necessary follow-up appointments should be scheduled prior to discharge.
If Going Home 1. Safety plan MUST be established by mental health clinician or MD on primary team
2. All patients should receive education (including crisis hotline number, local resources)
If Going to
inpatient care
1. Social Worker/Nurse Case Management will contact a referral facility on hospital day 1-2 to
arrange possible transfer
2. Social Worker/Nurse Case Management or Nursing will fax admission H&P and discharge
summary.

HEALTH CARE TEAM & COMMUNICATION
Key Points Multidisciplinary team will include representation from: resident team, attending hospitalist, nursing
staff, and social worker/case manager.
Communication
ξ Daily Family Centered Rounds will occur with the multi-disciplinary team to determine if
patient is medically stable.
ξ Psychiatrist Evaluation will determine patient placement upon discharge.
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30



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Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org