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Suicide Assessment and Prevention (2.4.1)

Suicide Assessment and Prevention (2.4.1) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Behavioral Health

2.4.1


UW HEALTH CLINICAL POLICY 1
Policy Title: Suicide Assessment and Prevention
Policy Number: 2.4.1
Category: UW Health
Type: Inpatient
Effective Date: October 26, 2015

I. PURPOSE

To establish procedures for assessment and to provide protective interventions for the potentially suicidal
patient.

II. POLICY ELEMENTS

Suicidal thoughts and/or attempts are a common event, and may result in signif icant morbidity and
mortality. Suicide risk may be missed more frequently w hen patients are not directly screened for current
risk factors. All patients, age 10 and older, w ill be screened as part of the admission Health Assessment
(see Nursing Patient Care policies 13.14, 14.10). Any patient w ho has a positive screen and/or makes
suicidal statements or demonstrates behavior that is indicative of suicidal potential w ill be promptly
assessed. The initial assessment is the responsibility of the primary physician team.
If additional assistance or expertise is required for further assessment or interventions, the follow ing services
may be consulted:
ξ For assessment of suicide risk and recommended precautions/interventions:
o For inpatients, outpatients and the ED, the Department of Psychiatry's consultation service
is available at any time. The ON CALL Psychiatry resident may be called for consultation
on pager 0079.
o For patients at The American Center (TAC) or other locations (inpatient or ED), on-site
clinical staff should f irst assess the patient. On-site staff may include physicians and/or
clinical social w orkers. Staff should then contact the psychiatry faculty on-call for that
location (Contact through the paging operator, 262-2122). Consultation may be telephone
or video only based on location and availability.
ξ For assistance w ith nursing-related patient management:
o For inpatients and the ED at the University Hospital (600 Highland Avenue)/AFCH,
nursing consultants are available (Psychiatric Clinical Nurse Specialist and Inpatient
Psychiatry Clinical Nurse Manager) to assist nursing staff w ith patient management
betw een 8:30 a.m. and 5 p.m. Monday through Friday on pager 6339 or 7401. This
assistance may be telephone only based on availability of nursing staff.
o At other times, call inpatient psychiatry nursing staff at 263-7525 for assistance w ith
patient management until an assessment can be made by the consult service. This
assistance may be telephone only based on availability of nursing staff.

III. PROCEDURE

A. Identif ication and Initial Protection of Patients at Risk.
i. All patients, 10 years of age and older, on admission are screened for risk of suicide as part of the
admission nursing assessment.
ii. If a patient has a “yes” statement to any of the screening questions or if the patient’s w ords or
behaviors imply risk of suicide, the treating physician (resident and/or attending) should be notif ied
as soon as possible to determine if any further interventions or assessments are necessary.
iii. If the attending physician is not initially notif ied, s/he must be consulted as soon as possible, but no
later than w ithin 24 hours.
iv. If the treating physician determines that further assessment is needed, Psychiatric Consultation
may be requested:
a. For patients at the University Hospital/AFCH (inpatient or ED), the Department of
Psychiatry consult service is available at any time. The ON CALL Psychiatry resident may
be called for consultation on pager 0079.
b. For outpatients (at University Hospital/AFCH or other clinic locations), the ON CALL
Psychiatry resident may be called for telephone consultation on pager 0079, or Psychiatry
faculty may be reached through the paging operator or access center.



UW HEALTH CLINICAL POLICY 5
Policy Title: Suicide Assessment and Prevention
Policy Number: 2.4.1

c. For patients at TAC or other locations (inpatient or ED), on-site clinical staff should f irst
assess the patient. On-site staff may include physicians and/or clinical social w orkers.
After assessment, the clinical staff should contact the psychiatry faculty on-call for that
location. (Contact through the paging operator, 262-2122). Consultation may be telephone
or video only based on location and availability.
B. Evaluation and Ordering of Protective Measures for Patients at Risk.
i. Psychiatric Inpatients:
a. An inpatient on the Psychiatry Unit w ho is considered a signif icant suicide risk by the RN
or Physician is immediately placed on "Level I, II or III Suicide Precaution” by the
Psychiatry physician. (See III.C.) Rationale for suicide precautions w ill be documented in
the medical record.
ii. Other Inpatients: Suicide precautions outside of Inpatient Psychiatry (Other inpatient units; For ED
see III.B.iii.).
a. The treating physician should complete the initial assessment, and as appropriate, place
orders for suicide precautions from the list below , and may contact the psychiatry consult
service for a full suicide risk assessment and recommendations.
b. All positive statements to screening questions, or other suicidal statements or attempts,
should be taken seriously. For patients w ho screen positive on a nursing assessment or
routine questions, level of risk can begin to be assessed by a brief interview gathering
more detail about suicidal thoughts and actions. Example questions may include:
1. How recent w ere thoughts about suicide?
2. Did you have a plan for how you w ould attempt suicide?
3. Did you make any preparations?
4. Did you act on those thoughts?
5. Are you having thoughts of harming yourself or ending your life now ?
c. If assistance w ith suicide risk assessment and recommendations is needed, the treating
physician(s) may contact the Psychiatry consult service (as described in III.A.iv).
d. Suicide precautions may include any or all of the follow ing:
1. Patient may be placed in a hospital gow n.
2. All sharps, medications, belts, and shoelaces – as w ell as any other potentially
self-injurious items – may be removed from the patient. Careful inspection of both
patient and belongings is necessary. Be aw are of availability of items patient may
use for hanging (including robe ties, gow n ties, phone cords and call buttons). If
permission is granted to the patient to use sharps, this is only under supervision
of a member of the health care team.
3. A designated staff person (e.g. - Personal Safety Attendant or “sitter”) may
remain w ithin arm’s length of patient at all times. This may include accompanying
the patient into the bathroom. Bathrooms are extremely risky for suicidal patients
because often the method of choice in a hospital is hanging. Patients may also
be accompanied and at arm’s length w hen of f unit for diagnostic tests.
4. Those patients w ho have a personal safety attendant for suicidality are not safe
to leave the hospital. Notify Security and primary MD if patient attempts to leave
the hospital. Security is to hold patient until Attending Physician assigned to
patient determines disposition. The Attending may consult w ith other services
(e.g. Psychiatry, Legal, Risk Management, etc.) to assist w ith this determination.
5. Patient safety may require the use of disposable trays and plastic eating utensils.
6. A suicide and safety assessment may be performed by a nurse as needed. This
suicide and safety assessment w ill be documented in the progress notes.
7. Patient is assigned a room close to the nurse’s station, if available.
e. Changes of the suicide precautions should be the result of a team decision. The
precautions can at any time be made more protective/restrictive; how ever, precautions
can only be made less restrictive after consultation w ith the attending physician or
Psychiatry Consult Service. Reasons for reduced precautions should be clearly
documented in the medical record. The Clinical Nurse Specialist Psychiatric Liaison
service can provide assistance w ith implementation of suicide precautions by unit staff.
f. If an adult patient is judged to still have substantial suicide risk after their non-psychiatric
medical condition(s) have stabilized, s/he should be assessed for possible transfer to the
inpatient psychiatry unit.



UW HEALTH CLINICAL POLICY 5
Policy Title: Suicide Assessment and Prevention
Policy Number: 2.4.1

1. For patients admitted at the University Hospital/AFCH, the Psychiatry consult
service should evaluate the patient for possible transfer to inpatient psychiatry.
2. For patients admitted at TAC or other facilities, the treating physician should
contact inpatient psychiatry (B6/5) for possible transfer.
3. If the patient is appropriate for transfer, and agreeable to inpatient psychiatric
care, he may sign himself in voluntarily.
4. If the patient is appropriate for transfer, but refuses admission, an emergency
detention (Chapter 51) should be pursued. Police (UW Police (University
Hospital/AFCH) or Madison Police (TAC)) and Journey Mental Health (for Dane
County residents) must be involved w ith this process. The psychiatry consult
service w ill assist w ith coordination. (Refer also to UW Health clinical policy
1.2.1-Emergency Detention-State Mental Health Act)
iii. Patients in the Emergency Department (ED).
a. The Emergency Department physician interview s the patient and determines the adaptive
plan for suicide precautions. If a psychiatric consultation is needed, the ED physician w ill
contact the Psychiatry Consult service. The Psychiatry Consult service (as described in
III.A.iv) can assist w ith suicide assessment, precautions and determination of disposition
plan.
b. Suicidal patients in the ED are immediately searched for harmful/dangerous items and
placed in a safe room.
c. For patients being admitted, the admission plan must include recommendations regarding
suicide precautions:
1. Suicide Precaution Level for inpatient psychiatry.
2. Specif ic suicide precautions (as identif ied in III.B.ii.b; e.g. – 1:1 observation
(“sitter”)) if admitted to other inpatient areas.
d. If admission is unnecessary but immediate assistance is required to discharge patient into
the community, Crisis Intervention of Journey Mental Health may be helpful (608-280-
2600), 24 hours/day. (Note: This applies to Dane County residents only.) Department of
Psychiatry Consult service can be contacted (as described in III.A.iv) to assist w ith this or
other plans, as appropriate.
e. If a minor, w ho has made a suicidal gesture or attempt, although not considered serious
enough to w arrant hospitalization, is seen in the ED, the ED physician or pediatric resident
should contact the family. S/he should attempt to schedule follow up evaluation in the
Child Psychiatric Outpatient Clinic or Ambulatory Pediatric Service. Patients less than 18
years of age w ho require an admission to a psychiatric unit are referred to a program
specif ically for this population (often Meriter Hospital). Patients under 18 years of age are
not admitted to the adult psychiatry unit.
C. Suicide Precaution Levels (Inpatient Psychiatry Only).
On admission all patients are assessed for suicidality. If suicidal, patients may be placed on one of the
follow ing three levels. Rationale for suicide precautions w ill be documented in the medical record. Patients
not on a level can also have suicide risk prevention measure in place such as no belts or shoelaces. This is
based on nursing assessment. Any changes of the suicide precautions should be a result of a team
decision. The precautions can at any time be made more protective/restrictive; how ever, precautions can
only be made less restrictive after consultation w ith attending physician.
i. Level I (Most restrictive):
a. Patient is placed in a hospital gow n.
b. All sharps, medications, belts, and shoelaces—as w ell as any other potentially self -
injurious items—are removed from the patient at the time of placement on level I. Careful
inspection of both patient and belongings is necessary. Although telephone cords and bed
cords have been removed/shortened on inpatient psychiatry, be aw are of availability of
other items patient may use for hanging. If permission is granted to the patient to use
sharps, this is only under supervision of a member of the health care team.
c. A designated staff person must remain w ithin arm’s length of patient at all times unless the
patient is in locked seclusion on inpatient psychiatry. This includes accompanying the
patient into the bathroom. Bathrooms are extremely risky for suicidal patients because
often the method of choice in a hospital is hanging.
d. Patients w ill be assessed for suicidality and safety by the nurse tw ice a day (on days and
evenings) and as needed at other times. This assessment w ill be documented in the



UW HEALTH CLINICAL POLICY 5
Policy Title: Suicide Assessment and Prevention
Policy Number: 2.4.1

progress note.
e. The patient w ill be placed on "Unit Restricted Status," that is, s/he may not leave the unit
for any reason, including diagnostic tests. If diagnostic tests are needed, a specif ic order
is obtained for off unit status from the physician.
f. If a patient is in locked seclusion, decision to seclude and monitoring and evaluation are
made according to Hospital Administrative policy 10.27-Restraint and Seclusion.
g. Patient safety requires use of disposable trays.
ii. Level II:
a. Patient may be placed in a hospital gow n.
b. All sharps, medications, belts and shoelaces—as w ell as any other potentially self -
injurious items—are removed from patient at time of admission and stored in a designated
area. Careful inspection of both patient and belongings is necessary. Although telephone
cords and bed cords have been removed/shortened on inpatient psychiatry, be aw are of
availability of other items patient may use for hanging. If permission is granted to the
patient to use sharps, this is only under supervision of a member of the health care team.
c. Patients w ill be assessed for suicidality and safety by a nurse tw ice a day (on days and
evenings) and as needed at other times. This assessment w ill be documented in the
progress notes.
d. Whereabouts of the patient must be know n at all times. A designated staff person must
observe the patient at least every ten minutes. Observations are documented on the
precaution-behavioral section of the daily care f low sheet. Patient w ill be locked out of
room and in public areas except w hen staff are accompanying patient into room.
e. Patient is assigned to a room close to the nurse’s station, if available.
f. Patient is on unit “restrict" status. If assessment of patient by primary treatment team
w arrants, patient may be on staff/student or RA (responsible adult) status.
g. Patient w ill sleep in open seclusion.
h. Patient may require use of disposable trays.
iii. Level III:
a. Patient is placed on level III w hen the physician determines it is safe to have a reduced
level of observation.
b. All sharps and medications are removed from the patient at time of admission and stored
in a designated area. Assessment w ill be made on need to remove any self -injurious items
such as belts and shoelaces.
c. Patients w ill be assessed for suicidality and safety by a nurse tw ice a day (on days and
evenings) and as needed at other times. This assessment w ill be documented in the
progress notes.
d. Patient is on unit “restrict” status. If assessment of patient by primary treatment team
w arrants, patient may be on staff/student or RA (responsible adult) status.
e. Interventions may include draf ting a safety plan, problem solving issues, w ritten or verbal
no self-harm contract, ten minute checks, open seclusion or any other method to keep
patient safe.
f. Changes of the suicide levels should be the result of a team decision. The levels can at
any time be made more protective/restrictive; how ever, levels can only be made less
restrictive after consultation w ith the attending physician.
D. Reassessment
i. On inpatient psychiatry, patients on suicide levels must be reassessed by the attending psychiatrist
every 24 hours to determine continued need for suicide level. This reassessment usually occurs
during treatment rounds.
ii. On other inpatient units (at University Hospital/AFCH or TAC), the attending physician should
reassess and document suicide precautions every 24 hours. Reassessment usually occurs during
treatment rounds.
a. At the University Hospital/AFCH the Psychiatric Consult service (as described in III.A.iv)
w ill reassess and assist w ith precautions upon request of the treating physician.
b. At TAC or other locations, the primary service may contact the covering psychiatry faculty
(as described in III.A.iv.c) w ith questions.
iii. For all patients, the least restrictive precautions deemed to provide adequate safety should be
utilized.




UW HEALTH CLINICAL POLICY 5
Policy Title: Suicide Assessment and Prevention
Policy Number: 2.4.1

IV. COORDINATION

Author(s): Nurse Manager, Inpatient Psychiatry
Senior Management Sponsor: SVP, Patient Care Services and CNO
Review ers: Directors of Inpatient Psychiatry; Director of Hospital Psychiatric Services; Clinical Nurse
Specialist Psychiatric Liaison
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: August 17, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Jeff Grossman, MD
UW Health CEO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REVIEW DETAILS
Version: Revision
Next Revision Due: February 26, 2018
Formerly Know n as: Hospital Administrative policy #10.10