A MESSAGE OF GOOD WISHES

Year : 2013  |  Volume : 5  |  Issue : 1  |  Page : 53-55

Prevention of inpatient suicide: Saving Lives : Preventing Avoidable Deaths in Hospital

Shireesh S Shindhe¹, Nagarajaiah², K Reddemma³, BM Suresh⁴, Sateesh Sindhe^5
1 Staff nurse, dept of nursing, NIMHANS, Bangalore-29, India
² Additional professor, dept of nursing, NIMHANS, Bangalore-29, India
³ Associate Professor dept of psychiatry, NIMHANS, Bangalore-29, India
⁴ Senior Professor and HOD dept of nursing, NIMHANS, Bangalore-29, India
⁵ Asst. Professor, dept of CHN, Tulaja Bhavani CON, Bijapur, India

Correspondence Address:

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-1505.261781

Introduction

• Including the assessment of suicide risk regularly throughout hospitalization, including on admission, during changes in a patient’s mental or physical status, after a change in observation level, and before discharge.
• Nurses can incorporate them into a comprehensive menta health assessment to formulate appropriate nursing diagnoses and interventions for hospitalized high-risk patients
• Orientation and in-service education for all staff regarding suicide prevention.^[10]

1. Nurse should take in to account previous history of suicide attempt because it is an established risk factor, particularly if the method used had been intrinsically dangerous and also recent bereavement or separation, social isolation, chronic physical illness and abuse of drug or alcohol will predispose to further suicidal acts.^[8]
2. In some suicidal patient’s mental state appear to be improved prior to suicide. Hence nurses must be aware of an apparent clinical improvement if associated situational problems remain unresolved, these include, broken relationships, financial problem, etc
3. Vigilance regarding development of malignant alienation should be taken care of.^[9]
4. Patients with a history of violence should be assessed for suicidal ideation at regular intervals.^[7]
5. Nurses need to be alert about decreased communication, conversation about death, low frustration tolerance and dissatisfaction with dependency.^[11]
6. Nurse should make note that the cognitive element common to many suicides is probably ambivalence rather than undiluted intent. Many give warnings of their thoughts of killing themselves prior to doing so. The absence, of prior warnings of suicide does not eliminate the potential for suicide, as some patients may prefer not to disclose their intentions. In a few cases, patients experience auditory hallucinations commanding them to kill themselves and not to tell others about it.^{[9],[10],[11]}
7. Continuous eye ball to eye ball observation of patient even when patient is going to bath room and also they have to stay with the client when she/he is meeting the personal hygiene.^[11]
8. Hospitalized patients who are believed to be at high risk for committing suicide are regularly placed on observation protocols. The protocol may require continuous observation (either visual or at arms length, depending on risk), or periodic checks, such as every 15 minutes. Intervals longer than 15 minutes are inadequate, and it is important to realize that much can be done, even in 15 minutes if the patient times the checks carefully. Death by asphyxiation may occur in as little as 5 minutes. Periodic checks should be done in a variable, unpredictable fashion, for example, a 15-minute check could be followed by a 6-minute check, followed by a 10 minute check, and so forth. Randomly varied checks make it more difficult for a hospitalized patient to plan a suicide, and make it more likely that the plan will be discovered.^{[9],[10],[12]}
9. Suicidal patient should be placed in rooms closest to the nursing station, and should have roommate.^[11]
10. An inventory of a patients personnel item including clothing, should always made on admission, and a decision regarding the utility of each item should be made. Additionally, careful clinical assessment of which patients are to share a room will minimize the risk of roommate’s item being used for self harm.^[10],[11]
11. Physical aspects of the unit access to potential points from which a ligature could be attached, electrical wiring, glass from a breakable window or heights from which to jump should all be eliminated^[12]
12. Nurses has to remove all sharp objects and potentially dangerous items from patient possession and they have to place in hospital gown without ties, belts, shoe laces, sharp instruments, stockings etc.^[11]
13. Nurses should keep checks on items that can be used by patient for hanging or strangulation and should avoid such objects or devices in the wards. These items include drapery cords, belts, shoe laces, ties, bathrobe sashes and drawstring pants, torn bath towel, torn bed sheets etc.^{[9],[11],[12]}
14. Nurses have to be alert to the possibility of the patient saving up his/her medications and always should keep the drugs in locked cupboards.^[11]
15. Nurses can use documented checklist of regular safety inspections which may minimize the occurrence of most unfortunate inpatient suicide.^[10]
16. Nurses should avoid over reliance on screening for common risk factors which may lead to decreased vigilance regarding those who do not match the typical profile. Hence only regular, repeated psychiatric evaluations are useful in identifying the most relevant risk factors in individual patients.^[10]
17. Patients in seclusion require very high levels of monitoring by nurses, they have to do regular checks about internal protuberances which may provide access for patient commit suicide.^[11],[12]
18. Nurses and clinician should negotiate a “no-suicide contract” during periods of high risk to determine if the intensity of observation can be reduced. Ongoing assessment of suicide risk is warranted whether or not a patient has agreed to a no suicide contract. There are many variables that can affect patient’s adherence to no suicide contract including the length of time the patient has known to the clinician and nurses, the quality of therapeutic relationship, the presence of varying degree of internal and external stress, and rapidly evolving clinical status. A patient may be able to agree in good faith to refrain from self harm at a specific moment in time, but be unable to adhere to this agreement during the next nursing shift, or some other time in the immediate future.^[6],[8],[10]
19. Monitoring of compliance with medication should be ascertained on regular intervals.^[11]
20. Hanging is the most common method of suicide in hospital and hence the minimization of environmental risk factors begins with elimination of structure that are capable of supporting a hang object such as exposed utility pipes, rods, low end windows n bathrooms and toilets.^[7],[8],[12]
21. A change of case manager a written report should draw the successor’s attention to important specifics in the management of suicidal patient.^[10]
22. Family members of the suicidal patient should be educated about management of suicidal patient and need for continuous monitoring should be ensured.^[11],[12]
23. Encourage and support the client’s expression of anger/emotions. Teach problem solving approach, social skills and self care activities.^[6]
24. If suicide occurs in ward or unit other client to be reassured and taken away from the scene of the attempt as quickly as possible and visit all the patient in ward at regular intervals and see that they appear to be calm.^[9],[11]
25. At some stage after an inpatient suicide it is advisable to hold a postmortem meeting with all staff who has been involved in the patient care. This allows a review of management, event leading up to suicide and various clinical decisions which were made. It enables those who feel guilty about their part in the patient care to express their guilt in a supportive milieu

Conclusion

References

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