Incident Report On Pt Who Voiced Suicidal Ideation

[treeye]

We never got briefed with what to do when a clinic patient voiced suicidal ideation and a plan. The patient told me that he has a plan but he would like to get help and agreed to go to ED. I perceived that he has no immediate danger of hurting himself so we called RRT and had the pt was escorted to ED with no incident, however we received incident report that the pt was left alone before RRT arrived. Just wondering how big of a deal it is to have left the pt alone. Of course we did not do this intentionally. 

[heron, ASN, RN]

It's a big deal. On the inpatient units I've worked, SI with or without a plan required immediate 1:1 suicide watch. Once we have assumed responsibility for a patient, we are responsible for ensuring their safety while they are under our care.

[Nurse Alexa, MSN, RN]

Safety watches are something separate - a constant observation for suicidal ideation and plan is serious.

The patient's observation should not be taken seriously after something happens. but needs to be taken seriously from the get go. This is considered a fall out and would be investigated if JACHO was aware

[treeye]

thanks! anyone knows the following question? if a patient says he has no immediate plan of self harm but had thought about plans at times and the patient is calm cooperative and is asking to get help, do we need to call security or rapid response or the patient can be escorted to ED by a staff member.

[heron, ASN, RN]

treeye said:

thanks! anyone knows the following question? if a patient says he has no immediate plan of self harm but had thought about plans at times and the patient is calm cooperative and is asking to get help, do we need to call security or rapid response or the patient can be escorted to ED by a staff member.

Good question. How much is overkill? Your medical director and facility risk manager need to consult EMS and come up with a policy/procedure. In the absence of a concrete procedure, I vote for overkill.

ETA: what I neglected to point out is that the determination of lethality - fancy term for will he actually do it - is done by a psych practitioner, not nursing, admin or medical practitioners with no psych training. Hence - my choice to go full tilt boogie on suicide precautions until an assessment is done. It's about the patient's safety and my license.

[JKL33]

treeye said:

Just wondering how big of a deal it is to have left the pt alone. Of course we did not do this intentionally. 

It's important to follow the facility's procedures when serious issues like this arise. If a situation arises where you are not sure then it's best to quickly look up the policy if it is accessible or else call your supervisor for further direction.

Is it a big deal to have left a patient who is not in any immediate danger alone briefly? Yes, if that is not what your policy says.

Other than that, this issue isn't as cut and dried/written in stone as some think. For example, this general issue is (or may be) handled quite differently in primary care. There isn't a law that says someone who has passive SI and no plan but who would like to receive further care and evaluation needs to be attended constantly (that I've ever heard of). There are innumerable  patients with these struggles and general PCPs assess and address this issue regularly. In the community and even in many EDs these patients are assessed by the PCP, the ED provider on duty and/or by social workers/care managers who may or may not have any significant specific training outside of what their bachelor curriculum provided.

Therefore the best way to proceed is according to facility procedure. Your facility/health system has a policy/procedure to minimize risk of harm to the patient and minimize risk of liability to the facility, and it is important to follow it.

[Wuzzie]

heron said:

ETA: what I neglected to point out is that the determination of lethality - fancy term for will he actually do it - is done by a psych practitioner, not nursing, admin or medical practitioners with no psych training. 

One would think this is how it works but our psych practitioners have outsourced this to the clinic staff with zero training because they don't want to be bothered with coming to our clinic which is IN the hospital. This whole NSPG is a hot mess. We have to screen for depression and SI but have no workable plan for when a patient pops positive. Our ED waits are 12-18 hours, we can't discharge the patient to the community crisis center because they are in a medical facility with psych services (including inpatient), mental health providers are scheduling at least 3 months out if not more, insurance barely covers anything and we can't just send them home without an assessment. Not only that but the screening is terrible and must be done every. single. visit. My patients have cancer. We sometimes see them multiple times in a week. You can bet your sweet bippy they are depressed at times. Who wouldn't be? They do not at all appreciate the constant screening. One asked me "do you WANT me to be suicidal"? So we continue with these inane questions with no reasonable ability to help if someone answers "yes" and worse know in our hearts that the "help" we have is inadequate at best.