Definitions
This is the evidenced-based tool Emory uses to screen all patients for suicide risk
What is the Columbia Suicide Severity Rating Scale (C-SSRS)
These are ONLY applied and manipulated by Public Safety Officers (unless an emergency situation has arisen)
What are Violent or RIPP restraints
A nurse performs the Columbia suicide severity rating scale a what points throughout
What is upon arrival to the ED (or L&D triage), admission to the hospital, if patient displays behaviors or expresses thoughts/feelings of suicide, and every shift if suicide risk is identified.
This is where you can find the documentation for violence, safety screen, and event documentation
What is the admission navigator
This is a form used to initiate the involuntary transportation related to patients with mental health needs to an Emergency Receiving Facility
What is a 1013
This type of a licensed medical professional can make a written order for violent restraints
What is a physician.
A PA/NP cannot write written orders for restraints; however, can perform a face to face assessment and obtain a Verbal Order from the provider for restraint usage. In a emergent situation r/t to behavior a RN can verbally order violent restraints.
True or False: When using the Columbia Suicide Severity Rating Scale (C-SSRS) it is permitted to reword the six questions provided for screening
False
Please do not reword the screening tool. It is a validated risk assessment screening tool written specifically for patients. You may be surprised how honest this patient population is.
A family member of your patient walks in to the patients room and aggressively demands to speak to the provider immediately or they will put the patient in a wheelchair and take them out of here. What do you do?
Escalate to charge nurse.
These are used for behavioral changes primarily related to a patient’s medical/surgical condition and the behavior results in interference with necessary treatment. Examples include pulling at lines, tubes or dressings, dementia, delirium, and behaviors such as agitation, restlessness, confusion, disorientation, and unaware of physical limitations
Non-Violent Medical Restraints
In an emergency, any qualified RN may initiate the use of restraint/seclusion; however, the patient must be seen face-to-face by a physician, PA or NP and a physician's order written within this time frame after applying any form of restraint
What is One Hour.
This is true even if the patient no longer requires violent restraints within the hour. Also true for physical restraint for medication use
This interprofessional participant conducts belongings searches when concern is present for harmful objects
Who is Public Safety.
An order must be entered by the provider (MD or APP).
A patient has thrown his turkey sandwich at you, where do you document this incident?
These are used when behavior of which is consistent with an emotional or behavioral disorder and/or the patient is at risk for injury to self and/or others. Examples include attempted suicide, physical assault, or violent behavior, etc
What are Violent or RIPP Restraints
A sitter is required for all patients in violent restraints and must stay within this many feet of the patient at all times and chart on the patient activity how often
What is 15 ft and 15 minutes
True or False: Visitors can be limited for patients with suicide risk order set
True - visitors are a part of the order set and can be identified based on patient presentation
An elopement risk patient is exhibiting increasingly erratic behavior verging on agitation and violence. They have been deemed unable to make medical decision-making capacity and is making attempts to leave the hospital. What do you do as the nurse?
Call emergency operator (404-686-1777 or 6-1777) for Security Alert. Escalate to charge RN and work to safely de-escalate. Make attempts to not let the patient leave.
This is a specific designation by the GA department of Behavioral Health and Developmental Disabilities (DBHDD) given to facilities that accept involuntary admissions for initial assessment of psychological care needs
BONUS if you can name the ERFs in GA
What is an Emergency Receiving Facility
Georgia Regional, Grady, WellStar Kennestone are the three ERFs in the state of GA
The nurse assesses and offers the patient these things every two hours
Respiratory effort, circulation, skin integrity, LOC, readiness to release, ROM, fluids/food offered, and voiding needs addressed. IF the patient is on tube feeds must address this in the documentation as feeding opportunity. We will talk more about documentation after our game :)
High-Risk Suicide Patients or those patients who are deemed unable to lack medical decision-making capacity are placed under these precautions and wear these colored paper scrubs.
What are elopement precautions, maroon paper scrub top, and blue paper scrub pants
Ordered from central supply. There is also an elopement sign for the door
You are using the C-SSRS tool to screen a patient. The patient answers “no” to question 1, but “yes” to questions 2-5 and endorses taking 30 Elavil tablets because he “wanted to end his misery”. Per the CSSRS he has scored a HIGH RISK. As his nurse, what are your next steps?
SBAR to provider. Initiate the Suicide Risk Order Set and place the patient on 1:1 observation. Remove Hazards from room and search belongings. Request a psychiatric and social consult. Policy Manager is your FRIEND