Join/Renew

ACEP ID:

  • Topics Arrow
  • Practice Arrow
  • Education Arrow
  • Advocacy Arrow
  • About ACEP Arrow

iCar2e

Left Arrow Right Arrow Down Arrow Up Arrow Left Arrow Right Arrow Down Arrow Up Arrow
 

A tool for managing suicidal patients in the ED

Section Icon Identify suicide risk
Presentations indicating possible suicide risk
Does the patient report or exhibit any of the following:
Suicidal ideation or attempt
Overdose (especially medication overdose, but also consider in illicit drug overdose)
Single car motor vehicle crash
Hanging injury
Burns
Evidence of cutting or other self-harm
Depression, especially when combined with recent bereavement, breakup, job loss, humiliating event
Psychotic symptoms such as delusions, hallucinations (especially command)
Changes in behavior, sleep, or substance use
Other clues
Does the patient report or exhibit any of the following:
Poor engagement with provider (verbal or non-verbal cues like poor eye contact or hesitance to answer questions)
Poor hygiene, flat affect
Report of gathering lethal means (eg, buying a firearm, stockpiling medications)
Family or friends report concerns or discrepant history
Concerns from other/recent providers
Screen for suicide risk
Perform initial screen using the PSS-3 Primary Screener (including Tip Sheet)
Perform secondary screening using the ED-Safe Secondary Screener (ESS-6) (including Tip Sheet))
More Information:
Section IconCommunicate
Tips for communicating with the patient
Assume some patients may be hesitant to discuss mental health or suicide risk (but may feel relief by being asked)
Create safe space and enhanced rapport
Aim to have discussions in private, comfortable space – offer blankets, food, or other comforts as appropriate
Explain you/ED are here for patients with health problems and mental health is one type of health problem, common among many
Explain your view that sometimes when mental health deteriorates under life stressors, people can feel overwhelmed or such intense desperation that they think about taking their life
Set the tone with explanations such as, that you understand and want to help
Ask open-ended questions, “what’s that been like for you?” or “can you tell me what your triggers for feeling overwhelmed/suicidal tend to be?”
Section IconAssess for life threats, ensure safety
Ensure patient safety while preserving patient dignity
Environment
Is the environment free of potential means such as sharps, cords, tubes, glass etc.?
If no: Create a safe environment
Constant observation
Ensure 1:1 observation when necessary
Follow local institutional policies
Consider for agitation, impulsivity, or high risk
Possessions
Search and remove weapons, pill bottles, ligatures, and other lethal means
Medical workup for ingestion or injuries
Use diagnostic testing as indicated by history and exam
Consider new medications which may be associated with suicidality
Section IconRisk assessment
Using the following risk and protective factors to assess patient’s current risk
Current mental state and history
Are any of the following present?
  • Psychiatric illness, history or current symptoms - remember to ask about any uncharacteristic behaviors and changes in mood, anxiety, sleep
  • Use of alcohol or other substances
  • Physical health conditions (eg, chronic illness or pain)
Previous attempts
How many previous attempts were made?
What were the consequences of these attempts? (ie, was the patient hospitalized?)
What were the circumstances of previous attempts and are they present now?
Access to lethal means
Access to firearms at home, including current storage status
Prescription and other medications, drugs, and substances in home
Other method specified by patient (including gathering means)
Other life stressors
Loss of job
Financial stress
Death of loved one
Divorce
Shame, rejection, humiliation
Substance abuse
Chronic illness
Legal problems
Recent bullying, harassment, or intimidation
Homelessness
Recent life transitions including moves, discharges, work
Protective factors
Check for presence of each of the following:
  • Support from family, friends, or others
  • Mental health care established and patient engaged
  • Reasons for living (ask patient)
  • Connection to community and support systems
  • Cultural or spiritual beliefs (including belief that connecting and leaning on others or seeking support are signs of strength)
Section IconReduce the risk
Is discharge possible? Yes / No
Screening instruments such as the Columbia Suicide Severity Rating Scale (CSSRS) may be helpful guides for clinicians to remember essential parts of a mental health interview. However, the use of risk assessment scale scores alone to decide either admission or discharge is not recommended, as this practice is not well studied and may result in harm. When deciding who can be discharged, it is reasonable to take into account traditional risk factors (see above), protective factors (see above), and other factors that may help identify patients at elevated suicide risk (see “Identify” above). Clinicians should attempt to manage known risk by reducing this in the ED (see “Reduce the risk” above). Mental health professionals may be helpful in performing this assessment on patients in whom these risk factors are not immediately obvious.
Good discharge planning may allow outpatient management of several conditions thought to be particularly associated with suicide risk, including substance use disorders, underlying psychiatric conditions such as mood and anxiety, and access to lethal means. Management of these conditions is thought to reduce short-term risk and potentially allow for safe discharge. In particular, substance use disorders and underlying psychiatric conditions have been closely associated with suicidal behavior.
If discharging to home/community
Counsel to reduce access to firearms and other lethal means (ideally move the means out of home, otherwise lock at home without access to key or PIN)
Establish safety plan
Patient Safety Plan Template (PDF) (Printable)
ED-SAFE Safety Plan (PDF) (Printable)
Communicate safety plan and lethal means plan with family or friend when possible
Provide medication as indicated
If risk is high or no resources available for discharge:
Admit to inpatient care patients who are likely to attempt suicide, who do not engage with the discharge process, who do not cooperate with safety planning, or in whom outpatient management is not feasible
Section Icon Extend care beyond the ED visit
If discharged from ED
Patients who are being discharged should have a discharge planning process which addresses high-risk conditions such as substance use disorders or underlying psychiatric conditions (see “Reduce the risk”)
Connect with available community health resources such as behavioral health and primary care provider, ideally with set appointment soon after discharge
Follow up after discharge (phone calls, postcards)
Note: There is a body of evidence that communication in various forms after discharge reduce patients' risk of suicide
  Back To Top

Downloadable Materials

Guides

Suicide Prevention Resource Center (SPRC)

Caring for Adult Patients with Suicide Risk: A Consensus Guide for Emergency Departments

Web Page Full Guide (PDF) Quick Guide for Clinicians (PDF)

Recommended Standard Care

National Action Alliance for Suicide Prevention

Recommended Standard of Care for People with Suicide Risk: Making Heath Care Suicide Safe

Safety Planning

Patient Safety Plan Template (Printable PDF)

 

ED-SAFE Safety Plan (PDF)

Screening

Patient Health Questionnaire PHQ-9 (PDF)

 

Patient Health Questionnaire PHQ-2 (PDF)
+ suggest adding suicide item #9 “In past 2 wks have you thought about ending your life or that you’d be better off dead?”

 

ED-SAFE Patient Safety Screener (PDF)

 

Suicide Behaviors Questionnaire-Revised SBQ-R (PDF)

Compliance & Education

Compliance

The Joint Commission (Compliance with NPSG 15.01.01)

Suicide Prevention Portal

Online Courses

Suicide Prevention Resource Center (SPRC)
Preventing Suicide in Emergency Department Patients

Selected Literature

Wilson MP, Moutier CM, Wolf L, et al. Emergency department recommendations for suicide prevention in adults: The ICAR2E mnemonic and a systematic review of the literature. Am J Emerg Med. 2020;571-581. Learn More

Pisani AR, Murrie DC, Silverman MM. Reformulating suicide risk formulation: from prediction to prevention. Acad Psychiatry. 2016;40:623-629. Learn More

Acknowledgments

ICAR2E: Identifying Suicide Risk

Developed by members of the American College of Emergency Physicians

Contributors:
Michael Wilson, MD, PhD Marian E. Betz, MD, MPH Christine Moutier, MD Kimberly Nordstrom, MD, JD Lisa Wolf, PhD, RN

 

ACEP Staff
Loren Rives, MNA Travis Schulz, MLS

 

Publisher’s Notice

The American College of Emergency Physicians (ACEP) and the Emergency Medicine Foundation (EMF) make every effort to ensure that contributors to its resources are knowledgeable subject matter experts. Readers are nevertheless advised that the statements and opinions expressed in this resource are provided as the contributors’ recommendations at the time of publication and should not be construed as official College policy. ACEP and EMF recognize the complexity of emergency medicine and make no representation that this resource serves as an authoritative resource for the prevention, diagnosis, treatment, or intervention for any medical condition, nor should it be the basis for the definition of or standard of care that should be practiced by all health care providers at any particular time or place. If drugs are mentioned, they generally are referred to by generic names; brand names might be added for easier recognition. Device manufacturer information, if provided, is listed according to style conventions of the American Medical Association. This resource is provided “as is’ without warranty of any kind, either express or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. To the fullest extent permitted by law, and without limitation, ACEP and EMF expressly disclaim all liability for errors or omissions contained within this publication, and for damages of any kind or nature, arising out of use, reference to, reliance on, or performance of such information.

© Copyright 2018, American College of Emergency Physicians and the Emergency Medicine Foundation. All rights reserved. Except as permitted under the US Copyright Act of 1976, no part of this resource may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including storage and retrieval systems, without permission in writing from the publisher. Produced in the USA.

Requests for permission should be sent here.

[ Feedback → ]