1. 1 Homicide, Suicide and Elopement (HSE) Precautions Karmanos Policy CLN 219

2. 2 Objective To identify and provide a safe environment for patients at risk for homicide, suicide or elopement.

3. 3 Screening All patients are screened for the potential for self-harm, and/or thoughts of hurting others on admission. Assessment information is documented on the Adult Assessment History form. Refer to the Adult Assessment History form and observation of behavioral cues for identification of high risk patients.

4. 4 When to Consider the Potential for Self Harm Consider the potential for self-harm or violence toward others when the patient: –Verbalizes intent or desire to hurt self/others –Demonstrates aggressive behavior

5. 5 Risk Factors For Suicide Ideation or Behavior Suicidal ideation/behavior often occurs in patients admitted to the general hospital who manifest depressive symptoms.

6. 6 Risk Factors 1.The presence of psychiatric illness. Strong predictors include depression or psychosis and/or recent treatment for a psychiatric disorder, even though florid symptoms may not be present. 2.The presence of a suicide plan with the intention and means to carry out the plan. 3.The presence and/or history of a suicide attempt. The degree of lethality and intention is most significant. The lethality should be assessed both in real terms as well as the patient’s understanding of what was sufficient to be lethal. 4.Patients who have attempted suicide are at a greater risk for future attempts and/or successful suicide. 5.Expressions of a wish to die. 6.The presence of a family history of suicide.

7. 7 Cancer Diagnosis Related Risk Factors Advanced stage of disease Exhaustion or fatigue Loss of control Physical impairments –Loss of mobility –Incontinence –Inability to eat or swallow Poor prognosis Uncontrolled pain

8. 8 Complicating Factors 1.The presence of a recent loss (including death of a loved one, divorce, separation, loss of a job, status, finances). 2.The presence of mental illness associated with pain and/or disability. 3.The presence of alcohol/drug abuse. 4.The lack of adequate social supports (e.g., living alone, no family). 5.The sex/age of the patient. In the general hospital patient population, two groups appear to be particularly at risk: Patients older than 70 years with chronic medical illness. Patients aged between 20-30 years with concurrent psychiatric illness and/or substance abuse. 6.Giving away cherished possessions.

9. 9 Warning Signs that a Suicide Attempt may be Imminent Irritability Increased anxiety Agitation Impulsivity Decreased emotional reactivity c/o unrelenting pain Refusing visitors Crying spells Refusing medications Decreased interest in treatment or prognosis Feelings of worthlessness Refusing to eat

10. 10 What to do When a Patient Shows Signs of HSE Initiate HSE Precautions: –Place patient under continuous visual observation. –Obtain Physician order for HSE precautions within 8 hours of initiation. –Obtain an order for STAT Psychiatry consult. –Alert Security when HSE precautions are ordered/discontinued. –Consult Social Work.

11. 11 Continuous Visual Observation Visual observation of the patient must be initiated immediately for patients at risk for self- harm or violence toward others. Notify supervisor for assistance with re- assigning a Patient Support Associate (PSA) or Oncology Care Associate (OCA) to sit with the patient.

12. 12 Additionally Patients on HSE precautions are not permitted to leave the hospital prior to completion of treatment, Against Medical Advice (AMA). –Notify the attending physician of the patient’s request or attempt. If/when patient is medically stable and HSE precautions must continue, patient will be transferred to an appropriate psychiatric facility. –If not medically stable, patient must remain hospitalized until medically stable for transfer. Psychiatry is responsible for discontinuation of HSE precautions.

13. 13 Interventions The patient is to be assessed by Psychiatry and interventions may include: –Environmental restrictions –Patient Safety Associate (Sitter) –Use of physical restraints (in an emergent situation (CLN 012) –Or combination of the above

14. 14 Attempt to Maintain Patient’s Privacy & Security Conduct search of area and personal search upon initiation of the HSE precautions (notify Security if assistance is required) (patient/family/staff safety overrides patients’ right to privacy) –Educate patient/family/visitors of potentially harmful gifts/articles/personal items –Remove hazardous articles, send home with family or keep in patients’ property –Remove all potentially harmful medical care equipment and supplies after use –Notify Nutritional Services to prohibit glass, metal utensils, cans and metal trays

15. 15 In the Event of Patient Elopement Immediately notify Security RN notifies the physician, nurse manager/designee RN documents in medical record the efforts to locate the patient Clinical Manager/Director/Administrative Supervisor notifies the Administrator On-Call If unable to notify the family by telephone, the Clinical Manager/Director/Administrative Supervisor will send a telegram to the individual listed at “Notify in Case of Emergency” in the medical record to contact the hospital immediately and notify Risk Management.

16. 16 Required Documentation Every 12 hours in the Progress Note An objective description of the patient's behavior or verbalizations The type(s) of HSE interventions in use and if a Patient Safety Associate is present, include their name, title, and time services provided. The reason for initiation or discontinuance of HSE Precautions. Note: If the patient is restrained, the above documentation may be incorporated in the documentation required for the use of restraints on the Restraint Flow Record.

17. 17 Summary We hope this Computer Based Learning course has been both informative and helpful. Feel free to review this course until you are confident about your knowledge of the material presented. Click the Take Test button on the when you are ready to complete the requirements for this course. Click on the My Records button to return to your CBL Courses to Complete list. Click the Exit button on the left to close the Student Interface. References: Karmanos Policy CLN 219