Status of the Suicidal Patient – What’s the Right Question?

Confusion could cloud status of psych patients.

Tens of thousands of patients present to emergency departments each year expressing suicidal ideation. These patients are often viewed as having low acuity, yet they require emergent attention. 

According to the Centers for Disease Control and Prevention (CDC), approximately 45,000 Americans die each year by suicide, making it the 10^th-leading cause of death in the United States overall and the second-leading cause among Americans ages 10-44. And suicide risk increases in patients with physical illnesses, such as cancer, COPD, diabetes, and heart disease. The acute management of suicidal ideation includes medical stabilization, reduction of any immediate risk, management of underlying factors and psychiatric disorders, treatment planning, monitoring, and follow-up. 

Suicides can occur within healthcare organizations, including emergency departments and general medical/surgical units, so such patients should be placed in specialized rooms free of objects that pose a risk for self-harm while receiving constant “one-to-one” monitoring. Given the significant risk of mortality associated with this patient population and the extraordinary utilization of resources required to provide the appropriate care, I wonder why there is so much controversy related to patient status selection. To be fair, the two-midnight rule is often more complicated than it sounds. But the simple fact that a psychiatric patient is involved should not raise any additional concerns when it comes to patient status. 

Consider this example: a 63-year-old male with a history of COPD, hypertension, and diabetes presents with suicidal ideation. The emergency department physician does not feel that the patient is safe to be discharged, and so has requested transfer to an inpatient psychiatric facility, but the local facility does not have a bed available. The hospitalist is asked to admit the patient to the hospital until a bed becomes available. 

In this case, the patient is at high risk for suicide and will require monitoring and supportive treatment of his acute condition in a hospital. By contrast, consider instead a patient who presents with weakness and fatigue, is found to have acute leukemia and requires transfer to a tertiary care center for induction chemotherapy. Why would this patient be any more deserving of “inpatient care” (with monitoring and supportive treatment) than the suicidal patient in the first example? The answer is that he isn’t.

The decision to admit any patient to inpatient status or place the patient in outpatient status with observation services should be made based on the anticipated length of stay in the facility. Specific to psychiatric cases, if the patient is expected to be transferred prior to the second midnight, he or she should be placed in outpatient status with observation services. 

If the patient will require treatment that spans two midnights, the patient is appropriate for inpatient status. While the patient is awaiting transfer to an inpatient psychiatric unit, he or she should receive a thorough psychiatric assessment conducted by a psychiatrist who can explain the patient’s disease process to the patient and initiate appropriate medication treatment; this could be performed by a telepsychiatrist or by an in-person psychiatrist. 

For those patients who are initially placed in outpatient status with observation services, expecting to be transferred to an inpatient psychiatric unit the next day, but then require a second midnight in the hospital, the decision to make them inpatients should be based on the need and provision of ongoing psychiatric care by nursing, social work, case management, and physician staff. Patients who are not receiving ongoing psychiatric care should remain outpatients.

We need to stop distinguishing between psychiatric patients and other patients when determining patient status; while there are meaningful differences among all patients, as it relates to the specific care they need, the principles that guide patient status decisions are universal.