Lessons Learned

The Disturbing Increase in Hospital Suicides

According to the Centers for Disease Control and Prevention, suicide was the 10th leading cause of death in the U.S. in 2014. Between 2004 and 2014, the suicide death rate increased 21%, from 11.1 to 13.4 deaths per 100,000 resident population. Among adults aged 45–64, suicide death rates increased 27% between 2004 and 2014. Paramedics and law enforcement are typical first responders to suicide attempt or completed suicide cases, and hospital emergency departments receive patients for further care.

CHPSO recently convened members at a safe table meeting on the topic of suicidal ideations, suicide attempts, and completed suicides in hospitals. Lessons learned from this meeting were shared (see resources below). Patients with behavioral health conditions are typically seen by general acute care hospital emergency departments before they are transferred or admitted to a behavioral health hospital. Challenges general hospitals face include availability of sitters, communicating patient charts during shift-changes, and identifying facilities for transfer.

CHPSO Event Reports on Suicide

A review of event reports in the CHPSO database using the term “suicide” yielded a return of 1,570 events. A breakdown of events by age, gender, and location of where suicidal ideations, suicide attempts or completed suicides were made, is listed below:

Events by Gender

Of the 1,570 suicide-related events in the CHPSO database, 62% involved males and 38% involved females.

Events by Age


Of the 1,570 suicide-related events, 91% of involved adults aged 18-64. A number of extraordinarily vulnerable populations – children, adolescents, older, mature, and aged adults – are on the rise.

Events by Location

Approximately 32% of cases occurred in the inpatient general acute care area.Over 23% occurred in the ED, 6% in a special care area (ICU, CCU), 5% in an “other” area, and 0.4% in the labor and delivery department. Nearly 33% of events were not mapped in the CHPSO database to a location.

 

    Among the 1,570 suicide-related events in the CHPSO database, 45 resulted in death. Of these 45,

    • 39 occurred at home, 21 of which occurred post-discharge (within 1 hour – 6 days, if mentioned)
    • 6 occurred in the hospital

    Of the suicides that occurred outside of the hospital, 7 were gunshot wounds, 3 were prescription overdoses, 3 jumped from buildings, and 2 by car. The remaining reports did not identify the suicide methods. One report mentioned the patient had post-partum depression.

    Suicides that occurred in the hospital involved sharp devices for self-inflicted wounds and hanging by using bed sheets. Not all events specified the suicide method.

    In a sample of 50 event reports related to suicide, the following patient and hospital details were gathered:

    PATIENT DETAILS MENTIONED NUMBER OF EVENTS
    Discharged AMA 8
    Elopement 4
    Violent with nurse or physician 3
    Smoked in hospital 2
    Drank alcohol in hospital 1
    Used medications (e.g. antihistamines, opioids) 3
    Restraints used on patient 1
    Devices used to attempt suicide (bed sheets, plastic wrapping, IV tubing, scissors, pens, cafeteria utensils) 16

    Patients who left AMA signed discharge paperwork and were aware of their options. In one case, a physician followed-up with a patient and convinced the patient to go to a rehabilitation facility, which the patient did. Patients who eloped ran out of the ED or the patient room while a nurse or sitter stepped away. There were cases where the patients’ belongings were not thoroughly checked or reviewed at all, and patients brought alcohol, cigarettes, and medications in gum or mint tins, hidden pockets within their clothing, or from visitors. 

    Patients who attempted suicide in a general hospital setting used items that were easily in reach, such as IV tubing, plastic wrapping from medical devices/products or food, or items from pockets of medical staff. There were a few cases of self-inflicted harm due to breaking a light bulb from the bathroom or hallway.

    Details mentioned about the hospital environment and resources in the sample of 50 events are below:

    HOSPITAL DETAILS MENTIONED NUMBER OF EVENTS
    Sitter available 5
    Sitter unavailable 4
    Physician deviated from standard of care 3
    Waiting for placement 2
    Transport communication breakdown 2
    Code Gray called 3
    Law enforcement engaged 7

    Event details varied across each report, some with minimal information and others with lengthier descriptions. There were disagreements of who was required to serve as a sitter for the patient (e.g. law enforcement, security, nurse). A few cases also mentioned physicians not following or understanding the hospital’s protocol on caring for patients with suicidal ideations.

    Prevention and Resources

    In preventing suicide, it is important for medical staff and hospitals to establish a relationship with their local police department. When law enforcement bring patients to a hospital, they can share important information with hospital staff including:

    • Whether the patient communicated suicidal ideations
    • Whether the patient made a suicide attempt
    • Whether the patient died by suicide

    Hospital staff across all departments can prepare by reviewing their policies. It is important to understand hospital protocols on caring for suicidal patients. Hospitals can also engage their transporters on working with suicidal patients. Conducting an environmental scan of the patient’s room and surroundings for items that would be used in suicide may help reduce an attempt. The Veterans Affairs Hospitals developed the Mental Health Environment of Care Checklist (MHEOCC) as an environmental review of inpatient mental health units. General hospitals may benefit from reviewing some of the suggested precautions (e.g. flush mounted light fixtures where the bulb is not exposed, institutional sprinklers that cannot be used as an anchor for hanging, fitted bed sheets without elastic, etc.).

    The California Hospital Association offers a number of resources to members of which they can take advantage:

    Hospitals can also connect with the National Alliance on Mental Illness (NAMI) for local collaborative opportunities.

    Patients with suicidal ideations and suicidal attempts in both psychiatric and general hospitals have different needs. While suicides in psychiatric units are anticipated, patients with suicidal ideations may not necessarily have the same predictability. Hospitals can work interdepartmentally on suicide prevention efforts and within their community. This collaboration is a stepping stone to improve the quality of treatment for this vulnerable population.

    References

    CDC. Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. https://www.cdc.gov/nchs/data/hus/hus15.pdf#019

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