Inpatient Suicide: Identifying Vulnerability in the Hospital Setting

Of the 35,000 or more suicides per year in the United States, about 1800 (6%) are inpatient suicides.¹ It is estimated that a psychiatric nurse will experience a completed suicide every 2½ years on average.²

While approximately 1 of 4 outpatient suicides will result in a claim, about 1 of 2 inpatient suicides will result in a claim. Courts and juries generally perceive inpatient units as having a greater degree of control over the patient and, thus, a greater responsibility to prevent suicides. Inpatient suicide is the most common sentinel event reported to the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) over a 10-year period (1995 to 2005). According to JCAHO, the greatest clinical root cause of inpatient suicide is a failure in clinical assessment. Risk was not adequately assessed in about 60% of suicides, or else the risk level was not accorded appropriate precautions.³

In psychiatric hospitals, the most frequent method of suicide is hanging, and 75% of inpatient suicides occur in the patient’s bathroom, bedroom, or closet. The patient’s bathroom is the one area where a patient can be assured of some privacy for a certain amount of time.^4(p64) However, “It only takes 4 or 5 minutes of adequate pressure on the carotid arteries in a person’s neck to produce death by oxygen deprivation to the brain. Thus . . . 15-minute suicide watches tend to allow a patient sufficient time to commit suicide, especially if the patient has a private bathroom with a lockable door. Almost any article of clothing and any protruding object can be utilized for self-asphyxiation.”^5(p663)

Common areas for concern on psychiatric inpatient units are ligature attachment points that pose a hanging risk from a sitting or kneeling position. It is well known that the greatest risk areas are where patients are provided privacy or are otherwise unobservable by staff. For example, support bars (“grab bars”) in showers and bathrooms are potentially dangerous. Plumbing fixtures also provide hanging risks. All of these can be eliminated by building safety features, such as a stainless steel box, around plumbing fixtures and by adding “plates” to grab bars that permit functionality but minimize hanging risk. A third level includes twist risks. These would most frequently utilize lower fixed items, such as sink drains, bed frames, and hard mounted doorstops.⁶

A problem that commonly arises in sentinel event reports, peer reviews, and malpractice litigation involves “inadequate monitoring and protection of new patients with moderate or high suicide risk, or with unknown risk. Unknown or unpredictable risk must be assumed to be ‘high’ until clarified by a qualified clinician.”⁷ The failure to conduct an adequate suicide risk assessment, when necessary, deprives the psychiatrist and hospital staff of the ability to use reasonable professional judgment in determining the proper safety precautions required for the patient.

The use of 15-minute checks should be avoided in seriously suicidal patients or those with uncertain risk levels.^7,8 To be clear, the use of 15-minute checks is not here being discouraged. Rather, caution is being advised in their use because inpatients can and do commit suicide while on 15-minute checks. In a study of 76 patients who committed suicide while in the hospital or immediately after discharge, 78% denied suicidal ideation when last asked, and 51% were on 15-minute checks or 1:1 observation.⁹

Inpatient suicides are viewed as the most avoidable and preventable because they occur in close proximity to staff. Early in the admission is a clear high-risk period, but risk declines more slowly for patients with schizophrenia. Other risk factors include absence of support and presence of family conflict. Findings of a systematic review of inpatient suicides included¹⁰:
•Inpatient suicide rates correlate strongly with the admission rate
•78% had at least 1 previous admission
•20% to 62% of suicides occurred on intermittent observation
•2% to 9% of suicides occurred on constant observation (staff informally cease observation to undertake other activities)
•Inpatients who commit suicide are not a homogeneous group
•Immediate post discharge is a high-risk period because of the increased stress it poses
•Reduced staff supervision increases risk, especially at nights, during hand-offs, and in unsupervised areas

It is important for the inpatient psychiatrist to understand the perspective of the newly admitted patient. Many patients will find the experience depersonalizing, threatening, and socially alienating and may perceive it as a personal failure. Therefore, they may be predisposed to “self-concealment.”¹¹ The two highest-risk times are the first week after admission¹² and shortly after discharge.^13,14 Likely causes of increased suicide risk at discharge include the problems of incomplete recovery, return of insight leading to depression, reexposure to life stressors, and easier access to suicidal means.¹⁵

In busy inpatient units, suicides have occurred when there is a break down of the therapeutic alliance, which may be a result of malignant staff attitudes. Staff may lose objectivity and begin to view patients as manipulative, provocative, unreasonable, overdependent, or feigning.¹⁶ The deterioration in the therapeutic alliance “between patient, staff, and others due to negative perceptions of behavior (where the patient had been perceived as provocative, unreasonable, or overdependent) has also been identified as a potential risk factor.”¹⁷ Thus, suicide risk may increase “when the therapeutic alliance breaks down, a phenomenon described . . . as ‘malignant alienation,’ commonly found in patients with recurrent relapses and resistance to treatment, and perceived by staff a manipulative, provocative, unreasonable, overdependent, and feigning disability.”¹¹

It is important to keep in mind that even patients who respond honestly may misunderstand their own symptoms, condition, and level of risk.⁷ They may not be capable of predicting their future condition, impulses, and behaviors, particularly in the midst of (1) a psychiatric illness severe enough to warrant inpatient admission, and (2) a life crisis that typically precedes some admissions.

“Generic” group therapy may do little, and paradoxically may increase risk by introducing psychological conflicts and issues prematurely. Thus, inpatient group therapies should be chosen thoughtfully and monitored carefully. I have seen malpractice cases in which the patient began to decompensate in group therapy. The therapist documented the symptoms and signs of clinical worsening, but the attending psychiatrist missed this important documented information.

Prevention of inpatient suicide
Approaches that have been recommended to prevent inpatient suicides include morbidity and mortality conferences, root cause analyses, and Failure Mode and Effect Analysis (FMEA). FMEA is a prospective analysis of an entire system and process of suicide risk assessment and management that assesses where high-risk problems might occur, with the goal of reducing or eliminating failure points.

Table. Inpatient suicide prevention recommendations^7,11,18,19*
•More stringent assessment of risk
•More stringent monitoring of patients’ risk
•Better monitoring of behavioral signs and symptoms
•Improve staff communication of signs and risk
•Wait for significant, stable, reliable change before relaxing precautions
•Improve suboptimal staff-patient relationships
•Gather collateral information
•Do not rely solely on patient self-report of no suicidal ideation
•Do not rely on “no suicide” contracts
•Ensure a safe physical environment that is devoid of means to commit suicide, access to hidden areas; units should be periodically checked to ensure suicide-proof architecture
•Avoid overconfidence in or overreliance on 15-minute checks
•Avoid premature discharge
•Smooth, tight transition to outpatient care
•Base suicide precautions on an adequate risk assessment and clinical rationale
•Document risk assessment and clinical rationale
•Form a suicide prevention committee
•Utilize Failure Mode and Effect Analysis

[*Note: Click here for the Tipsheet on this topic]

References:

1. Jabbarpour YM, Jayaram G. Suicide risk: navigating the failure modes. Focus. 2011;9:186-193. http://www.ap.psychiatryonline.org/article.aspx?articleid=114953. Accessed May 22, 2012.
2. Nijman H, Bowers L, Oud N, Jansen G. Psychiatric nurses’ experiences with inpatient aggression. Aggressive Behav. 2005;31:217-227.
3. Burgess B, Pirkis J, Morton J, Croke E. Lessons from a comprehensive clinical audit of users of psychiatric services who committed suicide. Psychiatr Serv. 2000;51:1555-1560.
4.Suicide Prevention: Toolkit for Implementing National Patient Safety Goal 15A. Oak Brook, IL: Joint Commission Resources; 2007.
5. Maris RW, Berman AL, Maltsberger JT. Summary and conclusions: what have we learned about suicide assessment and prediction? In: Maris RW, Berman AL, Maltsberger JT, Yufit RI, eds. Assessment and Prediction of Suicide. New York: Guilford Press; 1992.
6. Yeager K, Saveanu R, Roberts A, et al. Measured response to identified suicide risk and violence: what you need to know about psychiatric patient safety. Brief Treatment Crisis Intervention. 2005;5:121-141.
7. Reid WH. Preventing suicide. J Psychiatr Pract. 2010;16:120-124.
8. Jayaram G, Sporney H, Perticone P. The utility and effectiveness of 15-minute checks in inpatient settings. Psychiatry (Edgmont). 2010;7:46-49.
9. Busch KA, Fawcett J, Jacobs DG. Clinical correlates of inpatient suicide. J Clin Psychiatry. 2003;64:14-19.
10. Bowers L, Banda T, Nijman H. Suicide inside: a systematic review of inpatient suicides. J Nerv Ment Dis. 2010;198:315-328.
11. de Leo D, Sveticic J. Suicides in psychiatric in-patients: what are we doing wrong? Epidemiol Psichiatr Soc. 2010;19:8-15.
12. Qin P, Nordentoft M. Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry. 2005;62:427-432.
13. Deisenhammer EA, Huber M, Kemmler G, et al. Psychiatric hospitalizations during the last 12 months before suicide. Gen Hosp Psychiatry. 2007;29:63-65.
14. Hunt IM, Kapur N, Webb R, et al. Suicide in current psychiatric in-patients: a case-control study The National Confidential Inquiry into Suicide and Homicide. Psychol Med. 2007;37:831-837.
15. Appelby L. Prevention of suicide in psychiatric patients. In: Hawton K, van Heeringen K, eds. The International Handbook of Suicide and Attempted Suicide. West Sussex, England: John Wiley & Sons; 2000:617-630.
16. Huband N, Tantam D. Attitudes to self-injury within a group of mental health staff. Br J Med Psychol. 2000;73(pt 4):495-504.
17. Cassells C, Paterson B, Dowding D, Morrison R. Long- and short-term risk factors in the prediction of inpatient suicide: review of the literature. Crisis. 2005;26:53-63.
18. American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors [published correction appears in Am J Psychiatry. 2004;161:776]. Am J Psychiatry. 2003;160(11 suppl):1-60.
19. [Physicians, along with nursing staff, must also be aware of areas and elements of the environment that represent opportunities for an individual’s intent to commit suicide.] The Physician’s Promise: Protecting Patients From Harm. 2nd ed. Joint Commission Resources, Suicide Reduction Measures. 2006;75:chap 5.