Suicide risk reduction strategy implementation at Mercy Health emergency department

Introduction: Description of Organization and Risk Emergency departments can play a major role in reducing the risk and occurrence of suicide by taking steps to create a safety plan for the patient (Stanley et al., 2018). This risk management project looks at the role that a risk manager can play in helping to protect against suicide by implementing the steps to create a safety plan with individuals who come into the emergency room when vulnerable to suicide ideation. The organization selected for this project is Mercy Health. This paper will describe the mission, vision, and values of Mercy Health; describe the risk that is being addressed, why it is a safety issue, who it impacts and who is vulnerable. It will discuss the strategies available for addressing this issue and its viability. Finally, it will provide a set of recommendations, which will link to the mission, vision, and values of the organization. The strategy will be discussed in terms of how to implement it, who the stakeholders are, what education is required, what resources are needed; what the timelines for planning, taking action and evaluation are; how to measure outcomes, how data will be collected and analyzed, and how data will be used to complete the quality improvement feedback loop. The paper will conclude with a summary of the role of the risk manager in addressing this issue for Mercy Health.

Risk Management Project: Suicide Protection in the ED

Mission, Vision, and Values The mission of Mercy Health is “Exceptional health care services with a passion for making lives better” (Mercy Health, 2019). The organization’s vision is to have quality through “Excellence in patient care,” service through “Exceptional patient and customer service,” cost-effective care and a workplace environment where people want to work (Mercy Health, 2019). The company’s values include:

Healing in the broadest sense Patients come first Treat each other like family Always seek excellence (Mercy Health, 2019). One of the key features of its vision is to “demonstrate excellence in patient care using evidence-based medicine, best practices and industry benchmarks to ensure continuous improvement” (Mercy Health, 2019). It is this particular emphasis on evidence-based practice that will be linked to the recommended strategy later on in this paper.
Risk Being Addressed Safety Issue The risk of suicide for patients who come into the emergency room is high: as Olfson, Marcus and Bridge (2013) point out, “each year in the United States, roughly two-thirds of a million patients present to emergency departments for the treatment of deliberate self-harm” (p. 1442). These patients are, moreover, at an elevated and very high risk of suicide (Cooper et al., 2005). To prevent these patients from succumbing to suicide ideation, Mercy Health should take steps to implement a risk reduction strategy for those who present to the emergency room for self-harm or suicidal ideation.
This risk issue was selected because of the lack of policy in place at Mercy Hospital for this particular issue. As the research shows, patients who present at the emergency room for self-harm need to receive extra care and attention because of the fact that they are at higher risk for suicide than other patients. Mercy Health needs a policy in place to address this risk and reduce it. Impact This risk reduction response is not to any existing regulation but rather to the safety issue that the research has exposed for this particular population. If Mercy Health does not address the risk by developing and implementing a strategy, it will be failing in its mission and not upholding its vision for itself and its patients. It will also fail to be at the leading edge of the health care industry when it comes to this particular risk. Left unaddressed, Mercy Health’s reputation could begin to falter. To prevent stakeholders from losing trust in Mercy Health’s ability to be a leader in providing top-level quality care in the industry and to prevent emergency room patients from suicide, it is necessary to address the risk that these patients pose.

Vulnerable Mercy Health is no more or less vulnerable to this particular risk than any other health care organization in the industry. However, if it does not do something to address the risk, it will become more vulnerable over time, as the evidence of a helpful strategy has been provided by researchers in recent years and Mercy Health prides itself on implementing EBP. Currently, only approximately half of all patients on Medicaid receive a mental health diagnosis before being discharged when reporting to the emergency room for self-harm (Olfson et al., 2013). This statistic essentially puts half of all health care facilities in a risky situation with regard to failing to help this population. If health care facilities are not provided these patients with the mental health assistance they require, they will be failing in their aim to provide quality care to every patient who presents to them. Mercy Health is in the same situation.

Strategies There are numerous tools available for physicians to assess patients and predict the likelihood of future suicidal behavior. There is the Columbia Suicide Severity Rating Scale (C-SSRS), the Patient Safety Plan Template, and the Safety Plan Treatment Manual to Reduce Suicide Risk. The overall aim that researchers say should be sought is to improve access to mental health assessments for these patients in the emergency department (Olfson et al., 2013). Three strategies for improving that access are:

training emergency department staff to provide mental health evaluations and give acute management of patients at risk for self-harm (Appleby et al., 2000) providing access for these patients to mental health specialists (Callaghan, Eales, Coates & Bowers, 2003) integrating the services of mental health professionals in the emergency department (Browne et al., 2011).

Viability Each of these strategies is viable, as Olfson et al. (2013) point out. Training emergency department staff to provide mental health assessments and give acute care for self-harm is not beyond the capacity and ability of emergency department staff to handle. Tools to assist in that process have already been developed, as stated above. Likewise, as Callaghan et al. (2003) point out, offering a liaison service to mental health specialists would also be feasible and well within the mandate of emergency room staff to provide. Or there is the option of simply integrating mental health services into the emergency department’s own services, though the practicality of this step would hinge upon budgetary issues and constraints (Browne et al., 2011).

Recommendations Recommendations for the governing body of Mercy Health are to focus on the training staff at the ED and giving them the tools to provide a brief mental health assessment for self-harm patients who present to the ED. The reason for this is that, as Stanley et al. (2018) point out, emergency department staff can be trained to provide a quick suicide prevention intervention to patients presenting to the emergency room for suicide-related issues. Doing so can both reduce the risk of suicide and improve the quality of care that these patients receive in the emergency department (Stanley et al., 2018). Thus, the recommendations for Mercy Health are that the hospital’s emergency department provides training to staff on how to conduct a suicide prevention intervention for patients presenting to the ED for self-harm concerns. The intervention that the hospital staff should provide is the Safety Planning Intervention, which Stanley et al., (2018) tested and found to be significantly helpful in reducing the risk of suicide and enhancing the quality of care provided these patients. Once trained in how to provide the Safety Planning Intervention, staff should implement it for every patient who presents in the ED for suicide-related problems.

Link to Mission, Vision, and Values Since the mission of Mercy Health is to provide “Exceptional health care services with a passion for making lives better” (Mercy Health, 2019), it stands to reason that Mercy Health should implement this simple strategy for assisting patients who present to the emergency room for self-harm related issues. The staff can be trained to provide the patient with the Safety Planning Intervention, the purpose of which is to help patients “who are experiencing suicidal ideation with a specific set of concrete strategies to use in order to decrease the risk of suicidal behavior” (Safety Planning Intervention, 2019). Stanley et al. developed the intervention and tested it on 1,200 patients at five different VA hospitals across the U.S. (Stanley et al., 2018). One of the strengths of the Intervention is its brevity: it does not require a great deal of time to conduct and the patient senses the helpfulness of it immediately. Thus, the Intervention links up with Mercy Health’s core vision and value statements as well, which focus on implementing EBP and putting patients first.

Implementation of the Strategies The strategy of using the Safety Planning Intervention can be implemented easily in approximately 30 minutes. It is a collaborative exercise between the patient and the care provider. The first step is to work with the patient to identify the warning signs that a suicidal crisis is about to strike. The second step is to work with the patient to identify the patient’s own coping strategies. The third step is to contact others to assist in distracting from the suicidal thoughts. The fourth step is to contact the support network (family or friends) who can help to bring the crisis to a resolution. The fifth step is to contact mental health services. The final step is to remove or reduce the means available for accomplishing suicide. This is the essence of the Safety Planning Intervention (Stanley et al., 2018). With a little basic training, every care provider in the ED could provide this intervention. The intervention can be paired with follow-up phone contact post-discharge within 72 hours of discharge. During the phone contact, the care provider encourages the patient to make an appointment with a long-term mental health services provider. Phone contact continues until the patient has been for two appointments with a mental health services provider such as a therapist or counselor. At the point, the intervention is concluded (Stanley et al., 2018).

Stakeholders Care providers in the ED are the primary stakeholders who would need to be trained on the EBP of the Safety Planning Intervention of Stanley et al. (2018). Since they are the ones giving the care in the emergency department, they are on the front lines and thus the ones who need to be educated on how the Intervention works, what their role is, and how to follow the Intervention up with the necessary follow-up phone calls that provide the additional support needed for these patients. The patients themselves are the secondary stakeholders as they are on the receiving end of the Intervention and are somewhat more passive in the process, though not entirely as the Intervention is a collaborative process and depends upon their input for effective implementation as well. The mental health services providers are the tertiary stakeholders as they will play a part in providing long-term care for the patient if and when they are contacted and the necessary appointments are made. It would be helpful for them to know that the Safety Planning Intervention has been applied and this should be recorded in the patient’s medical record and shared with the mental health provider upon request. Family and friends of the patient are also stakeholders as they will be part of the patient’s support network and will be “on-call” so to speak whenever the patient is facing a suicidal crisis and needs support. The primary focus on implementing this strategy is, however, the care providers of the emergency department at Mercy Health.

Education Required by Stakeholders The care providers in the emergency department at Mercy Health would require basic training in how to conduct the Safety Planning Intervention for persons who present to the ED with suicide-related issues. Training can be conducted in a simple manner, according to the developers of the intervention. The training steps are:

reading the safety plan manual by Stanley & Brown (2008), reviewing the brief instructions (Stanley & Brown, 2008) and the safety planning form; attending training in which the intervention, its rationale, and evidence base are described; and conducting role-plays to practice implementing the intervention (Safety Planning Intervention, 2019).

Resources Needed The resources needed for this training are the safety plan manual, which can be obtained from http://www.suicidesafetyplan.com/Training.html. A training room and practice intervention session will be required in which trainees get to role play implementing and receiving the intervention. This is a form of simulation that gives the care providers extra assistance in learning how to conduct the intervention. The trainer, presumably the head nurse or instructor nurse at the ED, will require the rationale and evidence base provided by Stanley et al. (2018) to assist with the instruction phase of the training.

Timelines for Planning, Action, and Evaluation Planning the training should not take long at all. Putting in the request for the Safety Plan Form will at http://www.suicidesafetyplan.com/Training.html will take a matter of moments and the necessary materials can be shipped quickly once the order is put in. Nurses will have to schedule training and it is reasonable, given the size of the ED staff, that training could be concluded over the span of 3 weeks. The necessary reading materials could be delivered ahead of time so that trainees are read-up on the intervention before attending the initial first session. Scheduling and planning the training session, which can be a one-time, hour-long class should not take any more than a week. Providing the training should take at most three weeks to get all nurses into the class. Initial evaluation can be conducted at the end of each training session, so this step would be lumped in with the training preparation. Post-intervention evaluation should continue for two years to determine whether there has been a drop-off rate in emergency calls for self-harm from previously admitted patients at the ED.