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Running head: DETECTING AND TREATING SUICIDE IDEATION

Detecting and Treating Suicide Ideation


Kathy Le
California State University, Stanislaus

Detecting and Treating Suicide Ideation


Sentinel events are situations when the patient results in death, permanent harm, or severe

temporary harm and interventions were required to save the patients life (The Joint Commission,

2016a). These events call for immediate investigation and response, hence the term sentinel

(The Joint Commission, 2016a). Nurses should prevent sentient events from occurring and know

how to respond when one does occur. This paper addresses Sentinel Event Alert 56: Detecting

and treating suicide ideation in all settings from The Joint Commission (2016b). The suicide

prevention program proposed in this paper aims to increase the usage of suicide assessments and

outlines the program plan with a case study, root cause analysis, literature review, and corrective

action plan.
Sentinel Events
Sentinel events cover a wide spectrum of serious adverse events. Examples of sentinel

events include elopement, rape, assault, suicide of any patient receiving care, homicide, wrong
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site surgery, unintended retention of a foreign object after surgery, etc. (The Joint Commission,

2016c). These examples involve the nursing staff because their patients, their jobs, and nursing

license could be jeopardized. The patient could die, be permanently harmed, or severely harmed

temporary. The Joint Commission reviews sentinel events that involve an unanticipated death

and loss of a function not related to the patients underlying condition (The Joint Commission,

2016c). The examples mentioned above are reviewable cases. Hospitals are not required to

report to The Joint Commission but are highly encouraged to (The Joint Commission, 2016c).

The Joint Commission may also be reported to by family members or employees involved in the

sentinel event (The Joint Commission, 2016c). Once The Joint Commission has been contacted,

the hospital is expected to prepare a root cause analysis (RCA) and an action plan within 45 days

of the sentinel event (The Joint Commission, 2016c). The Joint Commission will determine

whether or not the RCA and action plan are acceptable, thorough, and credible (The Joint

Commission, 2016c). Then when the RCA and action plan are approved, The Joint Commission

will schedule an appropriate follow up activity due in four months (The Joint Commission,

2016c). The Joint Commission will also collect and analyze the data to add to their database

(The Joint Commission, 2016c). The database will increase knowledge about sentinel events,

contributing factors, and prevention strategies (The Joint Commission, 2016c). These are the

steps the Joint Commission will act upon when a sentinel event occurs.
Case Study

J.B. is a college senior struggling with major stress and loneliness. As the fall season

approaches, he finds himself feeling more emotional than normal. All his friends graduated the

semester prior, so he has no one there to support him. He turns to painkillers and alcohol to

cope. At 1440, 23 year-old male J.B presents to the emergencies room (ER) for acetaminophen
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(Tylenol) toxicity and acute liver failure (ALF). Acetaminophen toxicity and ALF are the

primary diagnoses. ALF may lead to irreversible brain damage and multi-organ failure

(National Center for Biotechnology Information (NCBI), 2009). Healthcare professionals are

rushing to treat him with oxygen therapy, intravenous (IV) fluid, and N-acetylcysteine (NAC).

However, as J.B. recovers, the primary diagnosis will shift to a diagnosis of major depression.

This shift goes unnoticed. He is discharged from the ER and is relieved to be heading back to his

apartment. His liver recovered from the acetaminophen overdose and he swears to never do that

again. However, the hospital visit set him behind on all his classes. He was unable to catch up

on the lectures, so he failed all his midterms. He feels worthless and still has no one to turn to

for support. He spends the whole night crying in desperation about how he needs to get rid of his

emotional pain. At 0115, J.B. is readmits himself to the hospital because he overdosed on

acetaminophen again. The ER employees start treating the acetaminophen toxicity and ALF

again. However, he swallows more acetaminophen pills from his personal bottle, goes into

multi-organ failure, and successfully commits suicide in the ER.

Root Cause Analysis


RCA is a tool used to examine any adverse incidents (Patient Safety Network & Agency

for Healthcare Research and Quality (PSNET&AHRQ), 2016). The purpose of RCA is to

identify underlying problems that increase the likelihood of error while avoidingfocusing on

mistakes by individuals (PSNET&AHRQ, 2016). Refer to Appendix A for the Fishbone

diagram. The suicide prevention program used a Fishbone diagram method to visually represent

the RCA process. The Fishbone diagram is also used to brainstorm the contributing factors

leading to the sentinel event.


The effect in the Fishbone diagram is that the patient commits suicide during readmission

into the ER. The contributing factors leading to the effect are failure to assess for suicide risk,
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absence of a suicide risk assessment policy in the ER, and also a hectic ER environment. Failure

to assess for suicide risk in a suicidal patient increases the rate at which those patients reattempt.

The suicidal patient will not have their mental health diagnosis identified, assessed, or treated.

Absence of a suicide risk assessment policy in the ER leads to the ER doctors and nurses not

assessing for suicide risk. The ER doctors and nurses are unlikely to practice a new assessment

if it is not outlined in a policy. The hectic ER environment causes the employees to overlook

mental health issues in their patients. The ER doctors, nurses, medical technicians, and nursing

assistive personnels (NAPs) are already rushed to do their required tasks, so its doubtful that

they would acknowledge the mental health issues in the patient if the hospital policy doesnt

require them to. These are all the significant contributing factors addressed in the Fishbone

diagram that lead up to the sentinel event.


Literature Review
In the following articles, evidence based research was reviewed to see what we know

about responses to the prevention of suicide in United States (US) hospital settings. Data

regarding the medical methods are used to assess and treat suicide ideation was summarized.

Studies show that acetaminophen overdoses are a major concern in the ER. Preventive methods

include reoccurring suicide precaution plans, the Brief Symptom Rating Scale (BSRS-5), and the

Attempted Suicide Short Intervention Program (ASSIP). The implementation of these evidence

based preventative methods could be used to detect suicidal patients in hospital settings.
Incidence
Budnitz, Lovegrove, and Crosby (2011) conducted a study to measure the frequency and

risks of unrelated substance abuse acetaminophen overdoses in the ER. Results showed that

most acetaminophen overdoses are self-directed acts of violence acts by 15-24 year olds

(Budnitz et al., 2011). The purpose of a 2011 study by Manthripragada, Zhou, Budnitz,

Lovegrove, and Willy was to review the number of US ER acetaminophen overdoses by


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intention, age, gender, and database reliability. The results revealed that there was an age-

adjusted rate of 13.9 acetaminophen overdose-related hospitalizations per 100,000 US

population, with the highest rate (15.7) occurring from 2005 to 2006. Between 1991 and 2006,

there was no decrease noted in hospitalizations for intentional or unintentional overdoses

(Manthripragada et al., 2011 p.819). This data is useful in determining age incidence in suicide

from acetaminophen overdose. The overall age incidence for suicide is 13-24 year olds.
Assessment
A study conducted by Adams (2013), suggests reducing suicide by developing a suicide

precaution assessment plan. The study reviewed literature on suicide prevention and the general

hospitals. The results revealed that assessment questions and policies are the most beneficial in

preventing suicide. The literature helped initiate a suicide precaution plan for physicians and

nurses. The final suicide precaution plan consists of a set suicidal assessment order for the

physicians and an automated suicidal assessment task set for nurses (Adams, 2013). Gray and

Dihigo (2015) state that assessments are more detailed and determine the level of suicide risk.

Assessment is utilized for the doctors and nurses to decide on the best treatment plan for the

individual (Gray & Dihigo, 2015). Assessment is useful for the hospital setting for determining a

detailed level of suicide risk in the patients.


Tools
Further research shows that a five-item symptom checklist can be used to screen suicide

ideation (Wu et al., 2016). The purpose is to detect likelihood of suicide with the Brief Symptom

Rating Scale (BSRS-5) screening tool. This tool is used for psychiatric morbidity and suicide

ideation screening within the general public. The participants were given the BSRS-5, which

include questions such as Do you have any suicide ideation? These questions are rated on a

one to five scale, the higher the score meaning the poorer the participants mental health. The
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results suggest that the screening is effective in detecting suicidal ideation for both the

psychiatric patients and community residents (Wu et al., 2016).


Research implemented a 24-month follow-up randomized controlled study of the

attempted suicide short intervention program (ASSIP), assessed the effectiveness of ASSIP

reducing suicidal ideation (Gysin-Maillart, Schwab, Soravia, Megert, & Michel, 2016, p.1). The

ASSIP is used in addition to usual the clinical treatment for reducing suicide. Usual clinical

treatment is dependent on the clinicians orders for a specific patient. Study protocol initiated

three therapy sessions followed by regular contact through personalized letters over 24 months

(Gysin-Maillart et al., 2016, p.1). The patients were also asked to complete questionnaires about

the study every six months in order to evaluate the intervention. The results showed that ASSIP

reduced repeated suicide attempts by 80%. ASSIP is also a low-cost and easy to use intervention

(Gysin-Maillart et al., 2016). Gray and Dihigo (2015) also state that suicide risk screening tools

are brief and easy to perform. They are normally used for lower risked individuals (Gray &

Dihigo, 2015). These tools are effective in screening for suicide when used in conjunction with

the ongoing risk assessments.


Research shows that suicide from acetaminophen overdose is still a major concern in the

ER. There are many studies covering various suicide precaution plans. The most effective

precaution plan includes suicide assessments from both the physician and the nurse. Recent

studies introduce tools such as the BSRS-5 and the ASSIP. Data suggests that these suicide

assessments and new tools are effective in detecting suicide ideation and reducing attempts.
Corrective Action Plan
A corrective action plan is a step by step plan of action that is developed to achieve

targeted outcomes for resolution of identified errors (Centers for Medicare and Medicaid

Services (CMS), 2013). The corrective action plan includes cost-effective actions, an

implementation plan, measureable goals, and elimination of inadequate practices. The


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stakeholders involved in this plan are physicians, nurses, ER staff, hospital administrators,

psychiatrists, psychologists, suicide attempted survivors, and families. These stakeholders are

invested in the development, implementation, and evaluation of the corrective action plan. Nine

employees will comprise the suicide prevention team. The ER nurse manager and the program

leader will recruit the team members. The board will be made up of an ER nurse manager, a

program leader, a mental health counselor, mental health nurses, and champions.
Problem Statement, Goal and Objectives
In 2011, the number of ER visits in the U.S. due to suicide attempts were 836,000, and in

2014 suicide is listed number 10 on the cause of death rank (Centers for Disease Control and

Prevention (CDC), 2016a). These numbers of suicides need to be reduced. The goal is to

increase usage of suicide assessments in the ER by 99% in one year. The first objective is to

increase the awareness of suicide and their risk factors to the ER nurses by 95%. This will be

achieved by identifying the ER staff that needs to be trained, developing a curriculum, training of

the champions, evaluation of the champions, and monitoring the impact. The second objective is

to increase awareness and training of suicide prevention strategies and policy to the ER nurses by

95%. This will be completed by identifying the ER staff that need to be trained, developing

suicide assessment guidelines and policies, training of champions, evaluating the training, and

monitoring the impact. The third objective is reducing the stigma of suicidal patients among the

ER nurses by 95%. This will be accomplished by identifying the ER staff that need the training,

develop a stigma reduction curriculum, training of champions, evaluation of trainers, and

monitoring the impact by using surveys.


Logic Model
The logic model is a tool that plans and defines how a program will work (National

Network of Libraries of Medicine (NNLM), n.d.). The logic model provides a framework for the

planning, implementation, and evaluation of the suicide prevention program. The logic model is
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presented in Appendix B. The overall goal is to increase the usage of suicide assessments in the

ER by 99% in one year. The approach involves mental health experts, which are mental health

nurses and a mental health counselor, to conduct a training of champions. The champions are

hospital employees who will teach the information to their fellow staff members. The trained

champions will then take charge of the in-services at the hospital. Education topics will include

suicide, suicide risk factors, suicide prevention strategies, and the stigma affecting suicidal

patients. The first in-service will teach suicide and suicide risk factors. The second in-service

will teach about suicide prevention strategies and policy. The third in-service will teach about

reducing the stigma affecting suicidal patients. The in-services will span over three months and

there is one mandatory class each week. Appropriate informational pamphlets will be distributed

to each employee after the in-services. Evaluation and reevaluation of the program will be done

in the seventh to ninth months. The evaluation is to assess whether or not the in-services

increased the awareness of suicide and their risk factors, increased knowledge of suicide

prevention strategies and policy, and reduced the stigma of suicidal patients.
Change Strategy
The suicide prevention program will utilize the Lewins Change Model. The Lewins

Change Model describes the basic stages of the change process, which includes the stages of

unfreezing, change, and refreezing (Lewin, 1951). The unfreezing stage is the actions used to

increase readiness for change. The change stage is the actions that need to be done in order for

the change to happen. The refreezing stage is the stage in which the change becomes the new

norm (Lewin, 1951). The suicide prevention program will unfreeze by initiating suicide

awareness. It will start change by teaching and training the ER staff about how to assess for

suicide risk factors, how to use suicide prevention strategies, and how to implement the suicide
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prevention policy. It will refreeze by educating about reducing the stigma and practicing the

policy.
Implementation Plan
The implementation plan is a detailed accounting of how the suicide prevention program

plans to present this project. The work plan is outlined in Appendix C. The timeframe of the

suicide prevention plan is from January 2017 to January 2018. Initially, the program will meet

with key stakeholders, identify champions, and form the task group. Then the task force will

identify the proposal, present the proposal, budget for approval, and request funding. The task

force will meet monthly for updates and evaluations. The champion training will last three

months and the champions will have classes twice a week with the mental health experts. Then

the champion training will be reevaluated within two months. The in-services of suicide

awareness and risk factors, suicide prevention strategies and policy, and suicide stigma will span

over a three-month period. The in-services will be evaluated during the training months, in the

beginning and end of each month. By the last month, the task force will meet with key

stakeholders to disseminate findings.


Budget
The budget request (Appendix D) details the direct salaries and wages, direct staff costs,

consultant costs, equipment, supplies, and other costs. A proposed annual budget total of

$30,363.28 will be required to implement the corrective action plan. This will include salaries

for the nurse managers, mental health counselor, mental health nurses, and champions. A total of

$9,038.40 will be needed for total direct staff costs. These costs include the hourly rate for the

champions to conduct the training, the champion training evaluation hours, and all the in-service

hours for the champions and ER nurses. An additional $3,764.88 will be allocated for consultant

costs, and this is used when the program needs exerts to advise in reevaluations. Additionally,

$1,700.00 will be requested for equipment of laptops, a projector, and simulation lab. The
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supplies will total to about $260.00 for teaching packets, pre and post surveys, and pamphlets.

Both the equipment and the supplies will be necessary when conducting the in-services. The

other costs for contracts, recruiting, and travel will be $15,600.00.


Evaluation and Dissemination Plan
The goal of the suicide prevention program is to increase the usage of suicide

assessments in the ER by 99% in one year. The evaluation plan will include evaluation of the

champion training, in-services, and the effectiveness of the overall program. The champion

training evaluation will take place within two months. By the second month, the champions will

be evaluated for how effective their teaching is. The champions will teach to the evaluators as

they would to the ER employees. The evaluators will then assess whether or not the champions

are ready to teach the in-services. If the champions are not ready, then the evaluators will re-

evaluate the training. The in-service training will be evaluated with pre and post-tests. The pre

and post-test will determine whether or not the in-services were effective. By the end of the

year, the program will be evaluated via compilation of data collected throughout the program.

During this time, the goal of increasing the use of suicide assessments in the ER will be

determined as either effective or ineffective. If the program is ineffective, then the program

administrators, managers, and task force will re-evaluate the curriculum and training. However,

the program was proven to be effective. The program reached its goal with a 99% increase in the

usage of suicide assessments in the ER within one year. The pre-test for the first in-service was

50%, the pre-test for the second in-service was 25%, and the pre-test for the third in-service was

20%. All the post-tests were met with 95% within one year. The findings and results will be de-

identified before dissemination. Dissemination of these findings will be shared with the hospital,

key stakeholders, and other hospitals with the same management. It will be disseminated

through posters and handouts throughout all the hospitals nursing offices, employee locker
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rooms, and break rooms. This will allow the employees to readily access the findings throughout

the hospital.
The CAP was effective in reaching the goals and objectives of the suicide prevention

plan. It was also adequate in outlining what those goals and objectives were. The logic model

and the Lewins Change Model framed the suicide prevention plan to success. The

implementation plan was efficient in keeping the program on time with their detailed accounting.

The budget proposal and evaluation plan also keeps the plan on track, but with finance and

measuring effectiveness.
In 2014, suicide was the listed number 10 on the cause of death ranking (CDC, 2016a).

Suicide in the ER is a sentinel event that should never be overlooked. The suicide prevention

team concluded that the absence of a suicide assessment and policy were the main causes leading

up to J.B.s suicide. Suicide assessments are key in reducing the incidence of suicide. The

suicide prevention team implemented three in-service courses to increase the usage of suicide

assessments by 99%. The ER staffs knowledge of suicide, risk factors, suicide prevention

strategies, policy, and stigma also reached the programs objectives. The suicide prevention plan

was effective and will be shared with the hospital, key stakeholders, and other hospitals with the

same management.

References
Adams, N. (2013). Developing a suicide precaution procedure. MEDSURG Nursing, 22(6), 383-

386
Budnitz, D., Lovegrove, M., & Crosby, A. (2011). Emergency department visits for overdoses of

acetaminophen-containing products. American Journal of Preventive Medicine, 40(6),

585592. http://dx.doi.org.libproxy.csustan.edu/10.1016/j.amepre.2011.02.026
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Centers for Disease Control and Prevention (CDC). (2016a). Suicide and self-inflicted injury.

Retrieved October 22, 2016 from: http://www.cdc.gov/nchs/fastats/suicide.htm


Centers for Disease Control and Prevention (CDC). (2016b). Suicide: Risk and protective

factors. Retrieved October 22, 2016 from:

http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html
Centers for Medicare and Medicaid Services (CMS). (2013). Corrective action plan (CAP)

process. Retrieved October 22, 2016 from: https://www.cms.gov/Research-Statistics-

Data-and-Systems/Monitoring-

Programs/PERM/Downloads/2013correctiveActionPowerpoint.pdf
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Gysin-Maillart, A., Schwab, S., Soravia, L., Megert, M., & Michel, K. (2016). A novel brief

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Patient Safety Network & Agency for Healthcare Research and Quality (PSNET&AHRQ).

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https://psnet.ahrq.gov/primers/primer/10/root-cause-analysis
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https://www.jointcommission.org/sea_issue_56/
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