Suicide/Homicide Precautions Protocol

Outcome
To reduce the risk of harm to self and/or others for the patient in crisis or severe depression.

Supportive Data
Interventions for safety are of primary importance for patients whose behavior may be destructive to themselves or others. The goal is to provide protection for the patient in the least restrictive environment that allows for necessary level of observation and/or physiologic monitoring. Interventions range from regular and periodic observation to 1:1 contact observation in an observation or secluded area.

The level of precautions level needed may be ordered by attending physician, resident physician, or initiated by nursing staff. Should the nursing staff initiate any level of observation, rationale for this decision is recorded in the medical record and the patient's physician notified as soon as possible. If the physician concurs, an order must be written. Orders for "suicide precaution" must specify which level of observation is intended. Level of observation can be reduced only by physician order.

Observation must be provided by RN, or by LPN or PCT under the direct supervision of an RN. Use of family members and/or significant others as observers is determined by attending physician and nursing staff (case-by-case basis) only after careful assessment of these individuals; the physician must document approval of family/SO in medical record.

The need for suicide precautions must be re-evaluated every 24 hours by the physician and nursing staff; discontinuations or change in level can be made by the attending physician or consulting psychiatrist; current clinical state and reason for continuing, modifying or discontinuing precautions must be documented by physician.

Psychiatric consultation should be requested on all patients requiring suicide precautions.

Assessment

1. Assess for presence of destructive, suicidal, or homicidal behavior, thoughts, verbalizations and/or intent at least every 8 hours or as condition changes.
2. Assess for need to assign a "Precaution" level to provide unobstructive surveillance at least every 8 hours or as condition changes.
3. Assess risk for suicide using "Suicide Clues & Behavior Rating Scale" of patient on Suicide CareMap.
4. Monitor need to move patient to a more controlled environment to decrease stimuli which may be influencing moods, behavior or emotions.
5. Mental Health Unit (MHU): Assess for need to assign Elopement precautions using elopement criteria on Admission Database.

Levels of Observation

6. Assign one of the following "Precaution" levels for the protection of the patient

a.  Watch Closely - observe every 30 minutes for patient safety; initiate frequent verbal contact (indications: expressed vague suicidal ideation without a plan; no demonstrated self-destructive behavior; may have chronic suicidal thoughts; exhibits poor impulse control).

b.   PSR (possible suicide risk) - observe every 15 minutes (indications: patients admitted for medical stabilization following suicide attempt; active suicide ideation with or without suicidal plan).

c.  SSR (serious suicide risk) - observation with 1:1 contact at all times (indications: verbalizes clear intent to harm self, has concrete/specific plan; exhibits disorganized and/or psychotic behavior; also indicated for medically stabilized patient following suicide attempt)

d.  Mental Health Unit only: Elopement (patient at risk of leaving unit) - observe every 30 minutes. Patient placed in locked observation area on the Mental Health Unit.

Consult with Physician

7. Obtain physician order for appropriate "Precaution" level as soon as possible.
8. Contact physician regarding obtaining behavioral health consult when suicidal statements, self-destructive behavior, or threatening comments about others occurs. Consult should be completed within 24 hours.
9. Consult with Mental Health Unit staff/CCM for assistance with Precaution level determination and/or identifying specific, helpful interventions (supportive statement; statements to avoid).

Report To Physician

10. Report to physician/other care team members the effectiveness of interventions (behavior/mood changes, any increase or decrease in suicidal ideation, verbalization of positive self/future planning) and discuss need to increase or decrease the level of the precaution at least once daily.

Interventions

11. Communicate initiation of Suicide Precautions and level of observation to care team members.
12. Initiate Suicide Attempt CareMap if actual suicide attempt has been made.
13. Provide for patient safety by removing potentially harmful objects or contraband from patient and environment (e.g., sharp objects, glass items, belts, straps, ties, drugs, hair dryer, curling iron, purse, cosmetics in glass containers). Itemize items removed and give to family as soon as possible; call Security to dispose of contraband.
14. Allow only cordless razors.
15. Search any object or package brought to patient by visitors.
16. Consider serving meals on paper plates, using only paper/plastic containers, plastic forks and spoons; have USR order "isolation tray" (necessary for SSR).
17. Observe patient when he/she using shower; observe SSR patient using bathroom or shower.
18. Do not allow patient to leave unit for any reason without staff escort. If patient becomes resistant or belligerent, call Security and/or Supervisor for assistance. (Consult with Supervisor regarding involuntary admission to Mental Health Unit)
19. Refrain from criticizing actions or minimizing patient's feelings. Avoid offering solutions; avoid statements like "I know how you feel".
20. Facilitate discussion of factors or events which precipitated the suicidal thoughts/destructive behavior; respond with active listening; demonstrate concern.
21. Offer to contact Pastoral Care for spiritual guidance.
22. Inform patient/family of availability of Behavioral Health Services.

Teaching

23. Explain "Precaution" level, associated restrictions, and rationale to patient and family.
24. Inform family/visitors that potentially harmful items (glass, scissors, etc) are not to be given to the patient.
25. Explain to patient/family that suicidal thoughts are a normal symptom of depression.
26. Encourage support of patient by family/friends.
27. Instruct family about possible warning signs or pleas for help patient may use. Notify Mental Health Unit regarding availability of educational materials.
28. Encourage patient to watch "Mending the Mind" and "Rhythms" videos available from Mental Health Unit.

Documentation

29. Assessment findings.
30. Suicide precautions maintained; level of precautions and observation intervals; effectiveness of interventions.
31. Physician notification.
32. Items removed from patient or environment.
33. Patient/family teaching and response.

REFERENCES:
Hogarty, S. & Rodaitis, C. (1987). A suicide precaution policy for the general hospital.  Journal of Nursing Administration. 17 (10)

Lego, S. (1996). Psychiatric Nursing: A Comprehensive Reference. Philadelphia:  Lippincott.

Tucker, S., et al. (1995). Patient Care Standards: Collaborative Practice Planning Guides. St. Louis: Mosby.

APPROVAL:
Procedure/Protocol Committee, 10/95

Revised: 12/98

DISTRIBUTION:
Generic Process Standards Manual - All Patient Care Units.