Policy Name: Suicidal Ideation Patient Safety Policy (Includes Patient Care Attendant

Policy Name: Suicidal Ideation Patient Safety Policy (includes Patient Care Attendant Guidelines)

Effective Date: 02/25/16

Review History: 03/01/2007,07/20/2012, 02/25/2016

Policy Primary:

Status: Published

Final Approval:

Glossary: Term: Definition:

Definitions:

Level: Interdependent - asterisked [*] items require an order from a health care practitioner licensed to prescribe medical therapy.

Personnel: RNs or Licensed independent providers (MD/NP/PA) will identify patients at risk for serious self-harm due to suicidal ideation. The unit nursing staff, NCAs or agency patient attendant will provide constant observation (continuous visual contact) of patient until assessed by provider. If a safety risk is identified, the provider will document the need for additional safety precautions.

Competencies/Skills:

Required Resources:

Policy Statement: Purpose: To provide a safe environment of care for patients assessed at risk for serious self-harm due to suicidal ideation.

Content:

A. Admission: 1. Prior to admission: 1.a. Remove all sharp objects 1.b. Remove unnecessary monitor cables, unnecessary cords, shoe laces, and equipment 1.c. Remove the telephone 1.d. Check call bell is shortened so as not useful to cause harm, but able to be used to call for assistance 1.e. Remove bottles/containers of solutions 1.f. Limit linen in room 1.g. Use paper trash can liners or limit plastic trash can liners to one/trash can

Intellectual Property of Duke Health. All Rights Reserved. Page 1 of 8 1.h. Place a sign on the door stating visitors must report to the nurse’s station prior to entering room. 1.i. Visitors are not permitted to take anything into room; this includes what may be in their pockets which could be used to cause harm. The physician may order "No Visitors" if appropriate and necessary for patient safety 1.j. Patient belongings are searched upon arrival for potential self-harm items or contraband 2. On admission to room RN responsibilities: a.a. Explain to the patient & family that the patient is on suicide precautions for their safety a.b. Immediately place patient on constant 1:1 observation a.b.i. Patient will remain 1:1 until a psychiatrist determines it is unnecessary a.b.ii. The patient care attendant should be the same gender as the patient whenever possible a.b.iii. Family members are not permitted to provide 1:1 observation a.b.iv. Complete the "Suicidal Patient Safety Flowsheet" with the staff assigned to perform the role a.c. Assist patient into hospital gown a.d. Search all belongings, including pockets in clothing and purse/bags: a.i.i. This is to be done by two Duke Hospital employees in the patient’s presence a.i.ii. Items which can be used for self-harm include but are not limited to:  Belts  Shoelaces  Cell phones/phones  Magazines (staples)  Ties  Necklaces  Medications brought by the patient (OTC and prescription)  Other dangerous items- i.e. glass, scissors, knives, razors, nail files, belts, electrical appliances/cords, lighters, scalpels, cleaning chemicals, ink pens worn around the neck, shoe laces, alcohol foam, compact with mirror, phone cord or any items which could be used to harm patient/ staff a.i.iii. Contraband will be turned over the DUH Security:  Guns  Knives  Illicit drugs  Any device which can lead to significant bodily harm a.i.iv. Explain to the patient that we are doing this for their safety and according to policy a.i.v. If the patient’s physical person is searched, a staff member of the same gender as the patient must assist in carrying out the search a.e. Document all patient belongings, remove them from the room and secure them or return to a family member to be taken from the hospital (this includes cell phones). a.f. Enter/confirm diet order includes comment: a.i.i. Order "Totally Disposable Isolation Tray" for meals. B. Assessment: 1. Patients must be assessed by RN on admission, each shift and with any reported change in behavior: 1.a. This assessment will include: 1.a.i. The last time the patient had thoughts about hurting him/herself 1.a.ii. The way the patient thought about doing this 1.a.iii. How the patient was able to stop him/herself from doing this 1.a.iv. If psychotic, ask if the voices tell the patient to harm him/herself and if other people may be trying to harm to the patient 2. *If patient is found to be at risk for serious self-harm due to suicidal ideation upon assessment by RN, immediately place patient on Suicide Precautions and notify physician and get an order for Suicide Precautions. C. Interventions: 1. *Suicide Precautions will be initiated upon suspicion of serious self-harm due to suicidal ideation or determination by provider 2. Patient on Suicide Precautions must have continuous visual contactby a competent personnel or assigned patient attendant. 3. Suicide Precautions will remain in effect until a provider evaluates the patient and deemed them no longer at risk. *A providers’ order must be obtained to discontinue suicide precautions. 4. Charge nurse will: 4.a. Notify IOP/OA that a patient will be on Suicide Precautions when notified by bed control or ED. 24-hour patient attendant coverage will be arranged through IOP/OA or unit’s nursing staff will be utilized until coverage is assigned. IOP/OA must be notified when suicide precautions are no longer in effect. 4.b. Plan a room assignment that would facilitate observation by unit staff as well as the patient care attendant. 4.c. Meet with patient attendant upon arrival to unit. Arrange break times, sign time cards, and verify the next staff person has arrived, and periodically check to validate constant surveillance of patient. 4.d. Verify that patient attendant knows patient is on Suicide Precautions and reviews the Suicidal Patient Safety Flowsheet. 4.e. Notify Duke Police at 684-2444 or 911; DRH Security at 470-4262 for any patient behavior escalation, such as disputes or disturbances. 5. Patient’s Care Nurse will: a.a. Verify practitioner’s order for Suicide Precautions. a.b. Assess patient for risk of serious self-harm due to suicidal ideation each shift. a.c. Inform patient of suicide precautions, including items prohibited in the patient’s room, and explain patient’s plan of care for that shift. a.d. *Patient is restricted to room unless determined by psychiatrist that ambulation is beneficial and safe. a.e. Collaborate with patient attendant to address patient’s safety care needs for the shift. Review and sign Suicidal Patient Safety Flowsheet.

Intellectual Property of Duke Health. All Rights Reserved. Page 3 of 8 a.f. Search patient’s room and belongings on admission and at the beginning of each shift to remove potentially harmful items. Contents of patient’s belongings will be documented in the patient’s chart. Another Duke employee must serve as a witness during the search. RN-RN handoff should include care nurse of off-going shift and on-coming shift: a.f.i. Every search or seizure will be documented. Documentation will include:  Scope of search  Reason for search  Procedures in search  Description of any property seized  Account of disposition of seized property a.g. Potentially harmful items include: glass, scissors, knives, razors, nail files, belts, electrical appliances or cords- including telephone cords, lighters, scalpels, cleaning chemicals, ink pens worn around the neck, shoe laces, medications (either prescription or over the counter), alcohol foam, consider any item which could be used to cause harm to patient or staff. Any items identified as contraband will be handled according to the Suicidal Patient Safety Procedure for Contraband Search Policy (LINK). a.h. All visitors will check with care/charge nurse prior to entering the room. A sign will be placed on the patient’s door instructing the visitors to check at the front desk. For any packages brought by visitors to patient, permission will be requested to search these packages for potentially harmful items. If harmful items are noted, they will be removed and given to the visitor to take home when they leave. If permission is not provided, the packages will not be allowed into the patient’s room. a.i. Care nurse will observe patient taking all medications. Collaborate with Pharmacist to obtain liquid medications when possible. Check patient’s mouth to verify that medication was swallowed. Do not leave medications at patient’s bedside or with the patient attendant. a.j. Obtain "Totally Disposable Isolation Tray" for all meals. Verify this order is in CPOE. a.k. Document patient behavior and verbal content every shift and with any change in behavior. a.l. If patient needs to be restrained, institute restraints per hospital policy. LINK 6. Patient attendant will: a.a. Report to charge nurse at the beginning of the shift to get instructions and begin continuous visual contact. a.b. Patient attendant and care/charge nurse will review and sign the Suicidal Patient Safety Flowsheet. a.c. Documentation hourly patient observation on Suicidal Patient Safety Flowsheet. a.d. Get two 15-minute breaks and one 30-minute lunch break prearranged with the charge nurse. Communicate with the care/charge nurse at such times to provide continuous visual contact. a.e. Keep patient within continuous visual contactatall times. Patient’s room and bathroom doors should be kept open; the privacy curtain will be closed in lieu of the room door being closed. Accompany patient to all tests and procedures off the unit. Notify care/charge nurse before leaving the unit with patient. a.f. Facilitate visitors to check with care/charge nurse prior to visiting with patient. Patient attendants will remain in the room with all visitors. Patient attendant may step out of room, remaining outside of the room, when providers are examining the patient. a.g. Notify nurse of changes in patient behavior immediately. Behavior that requires immediate attention such as a change in level of alertness, pulling at IV lines, tubes, restraints, verbal threats, yelling, or refusal to comply with requests must be reported to patient’s care nurse. a.h. Request assistance if harm to the patient or patient attendant is imminent. a.i. Remain alert at all times. Do not read or watch TV. The TV may be on only if the patient requests it. 7. Hand-off process: a.a. If patient is admitted through the Emergency Department with suicide precautions in place, a patient attendant or other competent a.b. personnel must accompany patient to the unit from the ED a.c. No patient will be admitted from the ED without being accompanied by at least a patient attendant or licensed personnel. a.d. Patient belongs which are determined to have potential for self-harm, will not be handed back to patient until Suicidal Precautions are discontinued or items are sent home with family. Final disposition of patient items will be documented and included in verbal hand-off to receiving unit. a.e. Confirmation and status of IOP request for patient attendant will be included in verbal hand-off.

Patient Attendant Guidelines:

1. Remember safety first! Patients require continuous visual observation.Patients should be watched for signs of possible or actual intentional or unintentional harm to self, unpredictable behaviors that place the patient at risk of injury, and rapid changes in the patient’s ability to think clearly. 2. Check in with charge nurse upon arrival to the unit. Review the guidelines for working with patients on Suicide Precautions. Pre-arrange break times at the beginning of the shift with the charge nurse and communicate with charge nurse to assure continuous coverage for the patient. Report to charge nurse at end of your shift when the next patient care attendant arrives. 3. Introduce yourself to patient and explain how long you will be with them. Identify how you will meet their patient care needs. 4. Get report from the patient’s nurse about what care the patient will require during your shift. 5. Complete all patient care as listed in Nursing Care Assistant I skills list to include: a. Vital signs (to include blood pressure, temperature, respirations, and pulse) and complete intake and output. b. Personal care: bathing, mouth, skin, hair care and linen change. c. Assist with ambulation, turn and position every 2 hours, range of motion. d. Assist with meals. e. Observe standard precautions, contact, and respiratory isolation. f. Offer bedpan, urinal, and collect test specimens as requested. 6. Never leave the patient alone in the room. Patient must be in eyesight at all times. Do not allow the patient to go off the unit, except for ordered and prearranged tests that have been cleared by the care nurse. Patients on suicide precautions are not allowed to go off the unit to smoke. 7. Families cannot observe the patient, only a hospital employee. Do not leave the patient alone with a family member or visitor.

Intellectual Property of Duke Health. All Rights Reserved. Page 5 of 8 8. If a patient must leave the unit for a test or procedure, you must accompany them. Notify the care nurse before leaving the unit with the patient. You must remain in the room if the patient has visitors. 9. Wait for scheduled breaks and relief person. Do not leave the patient unattended at the end of your shift. You MUST wait to leave until the next patient care attendant arrives and the charge nurse has approved your departure. 10. Doors to patient’s room and bathroom must remain open at all times. Use curtain to ensure patient’s privacy. 11. Always remain between the patient and the door. Sitting on the opposite side of the room from the door puts you at risk of harm if the patient becomes violent, and could permit the patient to elope from the room. 12. Notify charge nurse and patient’s nurse immediately if patient attempts to leave the unit without permission. 13. Use the call light when needed. If necessary and urgent, yell for assistance. 14. Remain alert at all times. Notify the nurse if you become sleepy. You are not allowed to sleep in the room. 15. Check meal tray before and after the patient eats for presence of utensils. All trays should be a Totally Disposable Isolation Tray, which contains only paper and plastic dinnerware. Make sure all dinnerware is returned to the tray and discarded and notify care nurse if items are missing. 16. Do not discuss the patient with anyone except the patient’s caregivers. Send visitors to the care nurse for information. 17. Promote a safe and caring environment. Remain calm at all times. 18. Give care nurse feedback on patient response to nursing interventions. 19. Maintain patient confidentiality. 20. Tell the patient what you are going to do before you do it. 21. Avoid giving advice to the patient. Do not argue with the patient. Tell the patient to discuss problems or feelings with the doctor or nurse. 22. Do not become a "pal" with the patient, try to "cheer up" the patient, burden the patient with tales of your personal life, or have the patient become your friend. Do not share personal information with the patient. Let the patient know you are uncomfortable if questioning becomes too personal. 23. Focus your activities on the patient. Do not use headphones. Use the patient’s room phone or your personal cell phone only to call for resources. Check with the nurse to find out what activities you could do with the patient, such as watching TV, drawing or writing, playing cards or games, etc. 24. Do not wear hair down, dangling earrings, neckties, ink pens around the neck, or other objects, which could be used to injure the patient or staff. 25. Ensure that housekeepers do not leave chemicals, cleaners, spray cans, or other potentially harmful items in room. 26. Ensure no items such as tourniquets, syringes, and/or needles are left in room. 27. Refer visitors to nurse if they bring belongings, packages, etc. 28. Remember that you are a valuable member of our team and together we will work together to ensure the safety of the patient!

REFERENCES

Citations: Bumgarned, S., & Haygood, V. (2009). Suicide prevention outside the psychiatry department: a bundled approach. Patient Safety & Quality Health; 6:5, 34-40.

Armes, A. (2007). The Joint Commission: 2008 National Patient Safety Goals, 15A. Oakbrook Terrace, Il; Joint Commission Resources.

NSW Health, (2004). Suicide risk assessment and management protocols: general hospital ward. Retrieved on October 10, 2011 at http://www.health.nsw.gov.au

The Joint Commission, (2010, November 17). A follow-up report on preventing suicide: focus on medical/surgical units and the emergency department. 46. Retrieved on October 17, 2011 at http://www.jointcommission.org/assets/1/18/SEA_46.pdf

North Carolina: 122C-263.2. Mental health crisis management: reasonable safety and containment measures.

An acute care hospital licensed under Chapter 131E, a department thereof, or other site of first examination that that uses reasonable safety or containment measures and precautions to manage the population of patients being held under appropriate supervision pending involuntary commitment placement and that does not otherwise operate as a licensable mental health facility shall not be deemed to be acting as a 24-hour facility; operating a psychiatric, substance abuse, or special care unit; offering psychiatric or substance abuse services; or acting as a licensed or unlicensed mental health facility. Actions considered to be reasonable safety or containment measures and precautions shall include the following: (i) altering rooms or removing items to prevent injury; (ii) placing patients in a consolidated location of the hospital; (iii) improvements to security and protection of staff; and (iv) any other reasonable measures that do not violate applicable law.

Reasonable safety or containment measures and precautions shall not be considered a violation of rules regulating acute care hospitals or mental health facilities. Placing patients in a consolidated location of the hospital pursuant to this subsection shall not constitute a special care unit. Nothing in this subsection relieves an acute care hospital or other site of first examination from complying with all other applicable laws or rules. (2012-128, s. 1.)

LINK: http://www.ncleg.net/EnactedLegislation/Statues/PDF/BySection/Chapter_122C/GS_122C- 263.2.pdf

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