Completed suicide in medical/surgical patients: who is at risk?

Inpatient suicide trends and prevention: Insights from a South Korean nationwide study

OBJECTIVE

Inpatient suicide is a significant problem, accounting for the third-highest ratio(17.8 %) of suicides in South Korea in 2017. We aimed to investigate the characteristics of inpatient suicides using national data, evaluate risk factors, and provide recommendations for suicide prevention.

METHODS

This nationwide case-control study utilized national data on all inpatient suicides from police investigations between 2013 and 2017. A total of 4998 individuals were included, comprising 833 inpatient suicides and 4165 controls. Inpatient suicide risk factors were assessed through cross-tabulations and logistic regression analyses.

RESULTS

Among eight hundred thirty-three individuals died by suicide in hospitals; most were male (74.9 %), older than 60 years (61.3 %), married (43.0 %), and unemployed (85.1 %). The primary method of inpatient suicide were jumping from a height (49 %), followed by hanging (39.7 %). Major depressive disorder was the most prevalent psychiatric diagnosis among inpatient suicides. The risk of inpatient suicide was significantly higher in patients with schizophrenia, dementia, and alcohol use disorder.

CONCLUSIONS

Effective management of hospital facilities and environments is essential to prevent inpatient suicides. Nursing hospitals treating patients with dementia require more rigorous psychiatric evaluations and facility safety standards. We recommend implementing crisis interventions and comprehensive psychiatric assessments to prevent inpatient suicide.

Suicide in individuals with no psychiatric disorders: what makes you vulnerable?

Globally, hundreds of thousands of people die by suicide every year. Suicides are usually associated with psychiatric illness. However, considerable evidence suggests that a significant number of individuals who die by suicide do not have diagnosable psychiatric disorders. The goal of this article is to attract attention to an overlooked issue of suicide in persons with no psychiatric disorders and to discuss some aspects of this issue. Research on identification and prevention of suicidal behavior in people with no psychiatric disorders is very limited. The available data indicate that suicides in individuals without psychiatric disorders are related to life stressors, lack of social support, and certain personality traits such as impulsivity. Suicide risk may be increased in military veterans with no psychiatric disorders. Many physical disorders, especially conditions associated with pain increase suicide risk in individuals with no diagnosable psychiatric disorders. Developmental, genetic and physical factors may play a role in the psychobiology of suicide in people with no psychiatric conditions. Promoting resilience may reduce suicide risk in the general population. Clinicians who work with medical or surgical patients need to have sufficient training in suicide prevention. Possibly, shifting some suicide prevention resources from individuals who are regarded as high-risk suicide patients to the general population may reduce suicide rates. Public education and better awareness about suicide may reduce suicide deaths among people with no psychiatric disorders.

Suicide and Suicide Attempts on Hospital Grounds and Clinic Areas

OBJECTIVES

The goal of this study was to describe suicide and suicide attempts that occurred while the patient was on hospital grounds, common spaces, and clinic areas using root cause analysis (RCA) reports of these events in a national health care organization in the United States.

METHOD

This is an observational review of all RCA reports of suicide and suicide attempts on hospital grounds, common spaces, and clinic areas in our system between December 1, 1999, and December 31, 2014. Each RCA report was coded for the location of the event, method of self-harm, if the event resulted in a death by suicide, and root causes.

RESULTS

We found 47 RCA reports of suicide and suicide attempts occurring on hospital grounds, common spaces, or clinic areas. The most common methods were gunshot, overdose, cutting, and jumping, and we have seen an increase in these events since 2011. The primary root causes were breakdowns in communication, the need for improved psychiatric and medical treatment of suicidal patients, and problems with the physical environment.

CONCLUSIONS

Hospital staff should evaluate the environment for suicide hazards, consider prohibiting firearms, assist patients with no appointments, and promote good communication about high-risk patients.

Reducing the risk of patient suicide in Tuscany

Patient suicide is one of the most frequent incidents in healthcare facilities to be reported to the National Observatory of Sentinel Events in Italy. Despite national initiatives, in Tuscany potentially preventable patient suicides still occur in both acute and community care settings. We describe here an aggregated qualitative analysis of 14 patient suicides that took place in public health services between 2017 and 2018. We outline the methodology and results of an improvement action we enacted in the healthcare system that involved reviewing and reinforcing relevant managerial strategies and clinical activities, with the aim of reducing potentially preventable patient suicides.

Keeping Patients at Risk for Self-Harm Safe in the Emergency Department: A Protocolized Approach

BACKGROUND

Increasing numbers of patients with psychiatric illness are boarding in emergency departments (EDs) for longer periods. Many patients are at high risk of harm to self, and maintaining their safety is critical. The objectives of this study are to describe the development and implementation of a comprehensive safety precautions protocol for ED patients at risk for self-harm and to report the observed changes in rates of self-harm.

METHODS

A multidisciplinary team developed comprehensive safety precautions, including the creation of safe bathrooms, increasing the number and training of observers, protocols to manage access to belongings and for clothing search or removal, and additional interventions for exceptionally high-risk patients. Events of attempted self-harm were measured for 12 months before and after new safety precautions were enacted.

RESULTS

In the 12 months prior to the protocol initiation, among 4,408 at-risk patients, there were 13 episodes of attempted self-harm (2.95 per 1,000 at-risk patients), and 6 that resulted in actual self-harm (1.36 per 1,000 at-risk patients). In the 12 months after the protocol was introduced, among the 4,523 at-risk patients, there were 6 episodes of attempted self-harm (1.33 per 1,000 at-risk patients, p = 0.11) and only 1 that resulted in actual self-harm (0.22 per 1,000 at-risk patients, p = 0.07). There were no deaths.

CONCLUSION

Comprehensive safety precautions can be successfully developed and implemented in the ED. These precautions correlated with lower, although not statistically significant, rates of self-harm. Further study of similar interventions with adequately powered samples could be beneficial.

From Pilot to Practice: Implementation of a Suicide Risk Screening Program in Hospitalized Medical Patients

INTRODUCTION

Hospitals have become an important venue for identifying medical patients with occult suicidality. This article describes the implementation of a quality improvement project at the National Institutes of Health Clinical Center (NIHCC) to systematically screen medical/surgical inpatients for suicide risk.

METHODS

Using the Plan-Do-Study-Act method, questions from the Ask Suicide-Screening Questions (ASQ) tool were deployed with medical inpatients aged 10 years and older between April 2018 and April 2019. Goals included the development of a training program, policy and procedure review, electronic medical record integration and data collection, and ongoing management and troubleshooting.

RESULTS

A total of 4,284 patients were screened for suicide risk with a nurse screening compliance rate of 94.3%. Prevalence data on patients aged 10 years and older revealed an overall screen positive rate of 2.3% (97/4,284), with 3.1% of youth aged 10 to 24 years and 2.2% of adults screening positive. Of the 97 patients who screened positive, 96 were non-acute positive screens. Of the full sample, only 1 patient (0.02%) was deemed acute positive, requiring a 1:1 observer and full safety precautions.

CONCLUSION

Universal suicide risk screening was successfully implemented in the NIHCC without incurring a need for additional resources. The intermediate step of a brief suicide safety assessment is a critical part of the workflow, providing guidance for determining appropriate follow-up in a safe and efficient manner that spares limited mental health and hospital resources. Given the increasing suicide rates in the general population, medical venues offer important opportunities for early detection, assessment, and referral.

Characteristics of and management strategies for 54 suicidal inpatients in a general hospital

Objective

The aim of this study was to explore the characteristics of and preventive management strategies for suicidal inpatients in a general hospital.

Methods

A total of 54 suicide victims were drawn from a patient safety adverse event network reporting system during hospitalization in a general hospital from November 2008 to January 2017.

Results

Subjects who committed suicide in the general hospital were women and those who suffered from malignant neoplasms during general hospital treatment. Furthermore, most of the patients who committed suicide used more violent suicide methods. The most common and lethal means was jumping from heights at the windowsill.

Conclusions

It is concluded that management strategies for suicide prevention can be provided from the aspects of patients, medical staff and the hospital environment. It is not only urgent but also feasible to reduce the suicide rate of inpatients and further improve hospital safety management.

Patient Opinions About Screening for Suicide Risk in the Adult Medical Inpatient Unit

As hospital clinicians and administrators consider implementing suicide risk screening on medical inpatient units, patient reactions to screening can provide essential input. This post hoc analysis examined patient opinions about screening for suicide risk in the medical setting. This analysis includes a subsample of a larger quality improvement project designed to screen medically hospitalized patients for suicide risk. Fifty-three adult medical inpatients at a clinical research hospital provided opinions about suicide risk screening. A qualitative analysis of responses to an opinion question about screening was conducted to identify major themes. Forty-three (81%) patients supported screening medical inpatients for suicide risk. Common themes emphasized asking patients directly about suicide, connection between mental/physical health, and the role of screening in suicide prevention. Adult medical inpatients supported screening for suicide risk on medical/surgical inpatient units. Behavioral health clinicians are uniquely poised to champion suicide detection and intervention in the general medical hospital setting. Patient opinions can be utilized to inform thoughtful implementation of universal suicide risk screening in the medical setting.

Suicide medical malpractice: an educational overview

A malpractice lawsuit is in the legal category of an action in tort, which is a demand for compensation for the damages that have occurred. For a physician to be found liable to a patient for malpractice, four essential elements must be proved to sustain an assertion of malpractice: duty, negligence, harm, and causation. The incidence of malpractice litigation in the field of psychiatry is increasing. The most common malpractice claim related to psychiatric practice is the failure to provide reasonable protection to patients from killing themselves. A psychiatrist should be able to evaluate suicide risk on the basis of all available information, including patient responses to direct and indirect questions, known risk factors, information on how the patient behaved under similar circumstances in the past, and collateral information. Reasonable care necessitates that a patient who is either thought of being or established to be suicidal must be the subject of some precautions. A failure either to soundly assess a patient's suicide risk or to employ an appropriate safety plan after the suicide potential becomes foreseeable is likely to make a physician liable if the patient is harmed because of a suicide event. It is imperative for a psychiatric office or facility to have a good documentation. Careful documentation of evaluations and treatment interventions with a description of changes related to the patient's clinical condition indicates clinically and legally appropriate psychiatric care.

The psychology of suicidal behaviour

The causes of suicidal behaviour are not fully understood; however, this behaviour clearly results from the complex interaction of many factors. Although many risk factors have been identified, they mostly do not account for why people try to end their lives. In this Review, we describe key recent developments in theoretical, clinical, and empirical psychological science about the emergence of suicidal thoughts and behaviours, and emphasise the central importance of psychological factors. Personality and individual differences, cognitive factors, social aspects, and negative life events are key contributors to suicidal behaviour. Most people struggling with suicidal thoughts and behaviours do not receive treatment. Some evidence suggests that different forms of cognitive and behavioural therapies can reduce the risk of suicide reattempt, but hardly any evidence about factors that protect against suicide is available. The development of innovative psychological and psychosocial treatments needs urgent attention.

Suicide attempts and completions on medical-surgical and intensive care units

Studies of inpatient suicide attempts and completions on medical-surgical and intensive care units are rare, and there are no large studies in the United States. We reviewed 50 cases, including 45 suicide attempts and 5 completed suicides, that occurred on medical surgical or intensive care units in the Veterans Health Administration between December 1, 1999 and December 31, 2012. The method, location, and the root causes of the events were categorized. The most common methods included cutting with a sharp object, followed by overdose and hanging. Root causes included problems with communication of risk, need for staff education in suicide assessment, and the need for better treatment for depressed and suicidal patients on medical units. Based on these results, we made our recommendations for managing suicidal patients on medical-surgical and intensive care units, including improved education for staff, standardized communication about suicide risk, and clear management protocols for suicidal patients.

Inpatient medical-surgical suicidal behavior: a 12-year case-control study

OBJECTIVE

To describe a medical center's 12-year experience with medically or surgically hospitalized suicide attempters, with the goal of extending the limited literature on this sentinel event.

PATIENTS AND METHODS

Eight Mayo Clinic Rochester patients' self-inflicting injuries serious enough to trigger mandatory reporting while hospitalized on a medical/surgical unit from January 1, 1998 to December 31, 2010 were matched with four same-sex and same-age controls, admitted to the same unit within 2 months. Cases were identified from Sentinel Event Tracking System and Minnesota Adverse Events Statute records. Data were analyzed with conditional logistic regression.

RESULTS

Eight of 777,404 medical/surgical inpatients admitted during 12 years attempted suicide, with significantly more non-Caucasian patients among cases than controls (P=.020). Of 8 attempts, 1 was fatal. More cases than controls had undergone inpatient psychiatric evaluation prior to attempt (P=.020), and elevated risk of attempt was significantly associated with increased number of prior attempts (0.049). Near their attempts, each attempter had an identifiable stressor including inadequately controlled pain in 3, agitation and anxiety in 2 each, and acute delirium, insomnia and psychosocial difficulties in 1 each.

CONCLUSION

First, this study's findings underscore the rarity of reported inpatient medical/surgical suicidal behavior. In this sample, suicide attempters were distinct from nonattempters by the increased likelihood of prior suicide attempts as well as inpatient psychiatric consultations before their attempts. When patients have these characteristics, medical teams should take particular notice and initiate heightened watchfulness for suicidal behavior.

A review of cognitive therapy in acute medical settings. Part I: Therapy model and assessment

Introduction:

Although cognitive therapy (CT) has established outpatient utility, there is no integrative framework for using CT in acute medical settings where most psychosomatic medicine (P-M) clinicians practice. Biopsychosocial complexity challenges P-M clinicians who want to use CT as the a priori psychotherapeutic modality. For example, how should clinicians modify the data gathering and formulation process to support CT in acute settings?

Method:

Narrative review methodology is used to describe the framework for a CT informed interview, formulation, and assessment in acute medical settings. Because this review is aimed largely at P-M trainees and educators, exemplary dialogues model the approach (specific CT strategies for common P-M scenarios appear in the companion article.)

Results:

Structured data gathering needs to be tailored by focusing on cognitive processes informed by the cognitive hypothesis. Agenda setting, Socratic questioning, and adaptations to the mental state examination are necessary. Specific attention is paid to the CT formulation, Folkman's Cognitive Coping Model, self-report measures, data-driven evaluations, and collaboration (e.g., sharing the formulation with the patient.) Integrative CT-psychopharmacological approaches and the importance of empathy are emphasized.

Significance of results:

The value of implementing psychotherapy in parallel with data gathering because of time urgency is advocated, but this is a significant departure from usual outpatient approaches in which psychotherapy follows evaluation. This conceptual approach offers a novel integrative framework for using CT in acute medical settings, but future challenges include demonstrating clinical outcomes and training P-M clinicians so as to demonstrate fidelity.

Assessment of risk for in-hospital suicide and aggression in high-dependency care environments

High-dependency environments are complex both from the standpoint of diversity of patient types and the nature of their functioning. Nurses manage this complexity at many different levels. Being attuned not only to the physical status of the patient but also the emotional/psychological status is paramount in maintaining a safe environment. Staff training and education is paramount in reducing risk. Institutions have a responsibility to provide resources to develop violence prevention programs.

Sentinel events and predictors of suicide among inpatients at psychiatric hospitals

BACKGROUND

The objective of this study was to assess sentinel event analysis and relative factors in different mental healthcare settings. In addition, the occurrence of sentinel events in different hospital settings was compared and potential risk factors contributing to sentinel events identified.

METHODS

A total of 75 consecutive adult subjects were enrolled from 2 psychiatric units, 1 within a general hospital and 1 at a psychiatric hospital in southern Taiwan. A retrospective chart review of the psychiatric inpatients was conducted for patients that met the criteria for a sentinel event between July 2004 and May 2011. A comparison of the hospital settings was made and differences between suicidal and non-suicidal sentinel events studied.

RESULTS

Psychiatric patients that received general hospital psychiatric services (1) appeared to experience a sentinel event soon after admission, (2) the time between the sentinel event occurrence and patient death was shorter, (3) there was a higher probability of potential medical illness than among inpatients treated at a specialized psychiatric hospital, (4) the sentinel event subjects that committed suicide were younger, had a shorter hospital stay, shorter time to occurrence of the sentinel event followed by an unexpected death than the non-suicidal group, and (5) a younger age, higher education level, previous suicide attempt and family psychiatric history were important predictors of suicide among psychiatric inpatients.

CONCLUSIONS

The results of this study suggest that psychiatric inpatients treated at a general hospital require careful examination for potential physical illness and greater efforts to prevent suicide. A younger age, higher education level, history of a previous suicide attempt and family psychiatric history are additional risk factors for suicide among these patients.

Suicidal ideation in medical inpatients: psychosocial and clinical correlates

OBJECTIVE

To identify psychosocial and clinical correlates of suicidal ideation in medical inpatients.

METHOD

In a cross-sectional study, all adults consecutively admitted to the medical wards of a University Hospital had their names recorded and were randomized and evaluated during the first week of admission. Suicidal ideation was assessed using Item 9 of Patient Health Questionnaire-9. The Beck Depression Inventory, the Beck Anxiety Inventory, the WHO Subjective well-being scale, the Charlson Comorbidity Index and other numerical rating scales (pain and self-reported physical illness severity) were used. Patients with less than four confidants were considered with poor social support. The Student's t test, Mann-Whitney U test, chi-square test and stepwise logistic regression analysis were used.

RESULTS

Of the 1092 patients who composed the sample, 7.2% reported having suicidal ideation. After adjusting for psychosocial and clinical confounders, prior suicide attempts (OR: 4.41; 95% CI: 2.12-9.15; P<.001), depressive symptoms (OR: 1.11; 95% CI: 1.06-1.17; P<.001), severe anxiety symptoms (OR: 3.04; 95% CI: 1.47-6.26; P=.003) and poor social support (OR: 2.02; 95% CI:1.03-3.96; P=.04) were independently associated with suicidal ideation.

CONCLUSIONS

Three out of the four correlates of suicidal ideation in medical inpatients are potentially modifiable factors: severe anxiety, depressive symptoms and poor social support. The fourth variable, prior suicide attempts, is not modifiable but should serve as a red flag to suspect and investigate current suicide risk. These findings highlight the importance of suicidal ideation as a proxy for the distress that is incumbent upon physicians to manage if they wish to provide excellent and comprehensive inpatient care.

Factors associated with suicide ideation among medically and surgically hospitalized patients

OBJECTIVE

To identify the factors associated with suicide ideation among medically and surgically hospitalized patients.

METHODS

A consecutive sample of 4328 individuals admitted to a general hospital completed a screening questionnaire comprised of demographic and clinical information, the Mini International Neuropsychiatric Interview item on current suicide ideation, the Hospital Anxiety and Depression Scale subscale for depression and the Alcohol use Disorder Identification Test. A multiple logistic regression produced a discriminate profile of individuals with suicide ideation.

RESULTS

The prevalence rate for current suicide ideation was 4.9% (95% CI: 4.3-5.6). Patients admitted to the Infectious Disease, Oncology and Hematology units presented higher rates of suicide ideation (7.9%, 7.8% and 7.2%, respectively). Suicidal ideation was associated to depression [odds ratio (OR)=8.3], young age (18-35 years old: OR=2.5), alcohol use disorders (OR=2.3), and smoking (OR=1.8).

CONCLUSION

Suicidal ideation was consistently associated with indicators of mental disorders. It is proxy, not for completed suicide, but for a variety of common psychiatric conditions that can and should be dealt with in the medical/surgical setting.

Inpatient suicide: preventing a common sentinel event

OBJECTIVE

Suicide in the hospital is one of the most common types of sentinel events, and hospitals can (and should) take steps to decrease the likelihood of experiencing this type of crisis.

METHOD

MEDLINE, Cochrane Library, National Electronic Library for Mental Health, and PSYCHINFO searches were conducted. In addition, manual and phone queries were used to identify relevant empirical and clinical publications. Reference sections of published articles were also searched.

RESULTS

The current article discusses the rates of suicide in hospitals, related risk factors, methods of suicidal behavior, and factors which contribute to this tragic event. Environmental, patient care, staff training, and hospital policy recommendations for decreasing the number of inpatient suicides are presented.

CONCLUSION

Inpatient suicide is a traumatic event. Although it is a relatively rare occurrence that is often difficult to predict and prevent, continuing to refine our efforts to assist the population at risk is imperative.

Inpatient suicide in a general hospital

OBJECTIVES

This study aimed to compare the characteristics of psychiatric and nonpsychiatric suicidal inpatients in one general hospital and examine the predictors of completed suicide in the patients with suicidal acts during hospitalization.

METHODS

One hundred ten study subjects were identified by the adverse event reports of suicidal acts during hospitalization from 1995 to 2004. Demographic data and clinical information were collected by chart reviews.

RESULTS

Psychiatric inpatients with suicidal acts were mainly younger females with psychiatric diagnoses and previous suicide attempts. Nonpsychiatric suicidal inpatients had less suicide communication, performed suicidal acts more rapidly after admission and used more violent suicidal methods than the psychiatric inpatients did. Suicidal acts performed outside the hospital, use of violent suicidal methods and male gender increased the risk of suicide mortality in our suicidal inpatients.

CONCLUSION

This study suggests that suicide prevention efforts need to be tailored in psychiatric and nonpsychiatric wards according to differing patient risk characteristics in these patient cohorts.

Deep brain stimulation of the subthalamic nucleus for the treatment of Parkinson's disease

High-frequency deep brain stimulation (DBS) of the subthalamic nucleus (STN-HFS) is the preferred surgical treatment for advanced Parkinson's disease. In the 15 years since its introduction into clinical practice, many studies have reported on its benefits, drawbacks, and insufficiencies. Despite limited evidence-based data, STN-HFS has been shown to be surgically safe, and improvements in dopaminergic drug-sensitive symptoms and reductions in subsequent drug dose and dyskinesias are well documented. However, the procedure is associated with adverse effects, mainly neurocognitive, and with side-effects created by spread of stimulation to surrounding structures, depending on the precise location of electrodes. Quality of life improves substantially, inducing sudden global changes in patients' lives, often requiring societal readaptation. STN-HFS is a powerful method that is currently unchallenged in the management of Parkinson's disease, but its long-term effects must be thoroughly assessed. Further improvements, through basic research and methodological innovations, should make it applicable to earlier stages of the disease and increase its availability to patients in developing countries.

Aftermath of suicide in the hospital: institutional response

BACKGROUND

A suicide can be a devastating event in the hospital, and few guidelines exist to aid an institution's response.

METHOD

The authors describe a framework of immediate, short-term and long-term responses in the event of an in-hospital suicide.

CONCLUSION

Implications for administration, communication, assessment, physical environment, and standards of care throughout the hospital are discussed that are relevant to both general-medical and psychiatric settings. Suggestions for the successful management of the aftermath of a suicide, such as the formation of a multidisciplinary leadership team, are included.