Screening
What is our screening tool called?
C-SSRS
What does "Low Risk" mean?
Minimal risk for committing suicide in the hospital setting
What does Moderate-High Risk mean?
Moderate to high risk for attempting or committing suicide while in our care
What is a ligature risk?
Points where a cord, rope, bedsheet, or other fabric/material can be looped or tied to create a sustainable point of attachment that may result in self-harm or loss of life.
Basically, Something that can be used to hang oneself. Name some ligature risks in your area
What is 1:1 monitoring?
1 qualified staff member to 1 moderate-high risk patient - goal to prevent patient/other harm
The observer has eyes on the patient AT ALL times, including during bathroom use and while in ancillary departments, and can intervene immediately should the patient attempt to self-harm.
When and on whom should the C-SSRS be performed?
On arrival, daily, when observed mental status changes.
All patients 12 and older
What is required for Low Risk patients?
-Frequent Observations every hour with documentation.
-Using nursing judgement, environmental risk assessment if needed
What safety precautions are required for Moderate-High Risk precautions?
-1:1 Monitoring
-Disrobing and removal of belongings unless otherwise ordered by provider.
-Removal of ligature risks inside room.
-Safety Precautions sign posted on the door.
-Dietary notification for safety utensils
What do we do with patient belongings when they are removed?
Inventory, secure in bin, lock, document, store in designated area (which is not inside the patient's room)
Where should the 1:1 observer be located?
Inside the room near the door if safe, or outside the room near the door as long as the patient is in direct line of sight and can immediately respond to the patient should the patient attempt to self-harm
What does the C-SSRS determine?
The patient's risk level for attempting or committing suicide
What is required for Low Risk patients at discharge?
If a patient that is initially a high risk screens low risk after 2 days on the C-SSRS, what steps should you take?
-Notify provider if necessary
-Do NOT remove 1:1 unless ordered by provider AFTER a comprehensive risk assessment is performed BY the provider.
What precautions should be taken with visitors?
Inform them personal belongings are not allowed and to leave items at home or in their vehicle.
How often should 1:1 monitoring be documented?
-Every 15 minutes on the frequent observation intervention or paper form.
Who can do the initial C-SSRS?
-RNs
-LPNs can do subsequent screenings
What is required to discontinue Low Risk precautions?
A provider's order
What is required for moderate-high risk patient prior to discharge?
-List of community mental health resources
-Suicide prevention instructions
-Education on limiting access to lethal means (remove firearms/lock in safe, dispose of unused meds, lock up toxic meds)
-FU should be made by nurse during business hours, within 7 days. If after business hours, illicit help of family member to do this
When should an environmental risk assessment be performed?
-On arrival
-At least every 12 hours
-When visitors leave or the patient returns from another location
-When changing observers
When can the nurse go from 1:1 monitoring to frequent observations, or remove monitoring all together?
Only after a provider's order with specific instructions to do so.
Caution should be taken and the patient's status highly considered.
How should the questions be asked?
As they are stated in the intervention for the best accuracy
For suicidal patients in general, how do we mitigate suicide risk?
-Removal of potentially harmful items
-Because SWMC does not have a LIGATURE RESISTANT environment, we do 1:1 observations for moderate-high risk patients.
What do you do if your high risk patient jumps out of bed and heads to the door to leave?
-Yell for help, call code speed, 911.
-Do not stand in front of the patient because you will likely be hit.
-Follow to ensure their and others safety. Wait for PD to bring them back.
What are potential environmental risks?
-EVS/Plant Op/Lab carts nearby
-Things in pockets (pens, scissors)
-Items inside drawers and cabinets
Aside from monitoring the patient, what other things can the 1:1 observer do?
-Stay focused
-Take/ask for regular (short) breaks every 1-2 hours if able
-Give report to oncoming observers