UNITED STATES HOSPITALS, PROGRAMS AND GUIDANCE
To mitigate the risk of self-harm and suicide attempts in inpatient settings, organizations and hospitals in the United States have provided regulations and programs that offers insight into methods to prevent these sentinel events from occurring. Prevention in clinical and community settings for those at risk is a major priority among many private, medical, and other stakeholders, including the federal government (Claassen et al., 2014). Understanding previously implemented practices and programs illuminates best practices for reducing suicide risk.
Recognizing the importance of suicide and self-harm prevention in hospital settings, The Joint Commission established suicide prevention as a National Patient Safety Goal in 2007 (Williams et al., 2018). Revised in recent years, the National Patient Safety Goal for Suicide includes ensuring psychiatric areas of hospitals are ligature resistant, all other areas of the hospital are screened for possible hazards and extra precautions are followed when a high-risk patient is admitted (The Joint Commission, 2020). Validated suicide assessment tools should be used to screen all patients admitted with a mental health condition (The Joint Commission, 2020). Once the level of risk for a patient is determined, the hospital should create an individualized plan to help reduce the suicide risk and document all activities and progress (The Joint Commission, 2020). While not mentioned by itself, self-harm prevention in hospital settings is addressed as a means to reduce suicide risk (The Joint Commission, 2020).
One prevention technique that has been utilized is constant observation of the patient by hospital staff. However, methodological constraints do not allow for proper research to understand the benefits and risks of this method (Russ, 2016). Thus, the use of constant observation has had conflicting literature because there are concerns from ethical and effectiveness perspectives. Constant observation of certain patients – such as those most at risk for suicide or self-harm – may be effective (Russ, 2016); however, other techniques should also be considered.
Staff training is an important aspect of suicide prevention in inpatient settings, yet as of 2017, only ten States required suicide prevention trainings in hospitals, while training was simply encouraged in others. Additionally, these trainings were mostly required for nurses and direct-care staff, not other members of the hospital team (Graves, Mackelprang, Van Natta, & Holliday, 2018). The gatekeeper training approach had successful short- and long-term success to improve self-efficacy and help-giving behaviors in clinical and non-clinical individuals who completed the Question, Persuade, and Refer Program (Litteken & Sale, 2018). The Suicidal Intervention Response Inventory can be utilized to assess effectiveness of intervention and ensure individuals are prepared to respond to suicidal patients (Neimeyer & Maclnnes, 1981; Neimeyer & Pfeiffer, 1994).
A few studies found that emergency departments in hospitals around the United States have a significant role in preventing suicide and self-harm. Emergency departments may be important in diagnosing suicide risk through expanded screenings and increased provider knowledge (Betz et al., 2016). Also, they may have a critical role in preventing future suicide attempts after treatment for a self-harm episode that does not receive in-hospital care (Olfson, Marcus, & Bridge, 2012). The Safety-Planning Intervention consists of providing patients with tools and strategies to help cope should suicide ideation become overbearing. This intervention can be utilized for patients in the emergency department or for inpatient stays (Stanley & Brown, 2012). The Safety-Planning Intervention can be standardized for each hospital, yet personalized to help mitigate suicide risk as doctors understand more about warning signs, external support, and coping strategies the patient has used in the past or has available at present (Stanley & Brown, 2012).
The Department of Veterans Affairs is a part of as necessary after the United States government tasked with caring for military veterans through various programs and a vast health care system. Veterans Affairs identified the need to improve access to care after non-fatal self-harm (Haney et al., 2012). Researchers developed the Mental Health Environment of Care Checklist to help mitigate and reduce risk among inpatients. The checklist was developed after researchers identified the objects most associated with risk in patient rooms to help prepare staff for prevention, as well as areas where self-harm or suicide most commonly occurs (Mills et al., 2010). Many serious and moderately hazardous items identified and were found in bathrooms, bedrooms, and hallway, including artwork, silverware, drawers, plastic in trash cans, cleaning products, and more (Mills et al., 2010). Since the checklist was developed, additional research has shown how common hospital room items could be used for self-harm and suicide attempts (Mills, King, Watts, & Hemphill, 2013).
Multidisciplinary approaches for suicide prevention have also been addressed in the United States. The Therapeutic risk management of a suicidal patient integrates behavioral health and clinical approaches when treating suicidal patients (Grant & Lusk, 2015; Wortzel, Matarazzo, & Homaifar, 2013). This approach is patient-centered and recognizes the importance of therapeutic assessment and treatment for suicide (Wortzel et al., 2013). Rather than a straightforward clinical assessment, structured suicide risk and severity psychological measures should be addressed in a clinician assessment as well to determine suicide risk (Wortzel et al., 2013). Once severity is understood, a safety plan should be developed by the hospital staff to appropriately address suicide prevention techniques best suited for each patient (Wortzel et al., 2013) and that addresses multiple areas of health: biological, psychological, social, and cultural (Grant & Lusk, 2015). Thus, it is important for care teams to include a psychiatrist or other behavioral health specialist in decision-making for suicidal patients (Grant & Lusk, 2015).