2.

hours

Continuing Education

By Alexis M. Schmid, MS, RN, CPNP-PC/AC, CPEN, Amy W. Truog, BSN, RN, CPEN, and Frances J. Damian, MS, RN, NEA-BC

Care of the

Suicidal Pediatric Patient in the ED: A Case Study

Careful screening, assessment, and intervention can help patients and families weather the crisis.
the hall to the exam room; his mother walked beside me, tears streaming down her face. As part of the ini tial triage examination, I asked what had brought them to the ED that day. J.J.s mother began to tell me. (This is a real case; identifying details have been changed to protect the patients anonymity.) J.J., a boy of elementaryschool age, had recently started a new school year, and new situations could be especially difficult for him. He had been diagnosed at five years of age with Aspergers syndrome, a develop mental disorder on the autism spectrum. Although peo ple with Aspergers syndrome have normal intelligence and verbal skills, they usually have problems with com munication, including difficulty understanding nonver bal cues such as inflection and body language.1 Other characteristics include an obsessive interest in a partic ular topic; repetitive routines; eccentricities in speech and language; a tendency toward literal interpretation; socially and emotionally inappropriate behavior; dif ficulty with social interactions; and sensitivity to sensory information such as light, texture, and sound.2 J.J. had been having problems making friends and getting along with other children in his class. Because he was different, classmates teased him. He responded with angry words, and the situation had worsened in the weeks before the ED visit. When one of his class mates reportedly said to J.J., Im going to kill you be cause youre weird, J.J. took this threat literally and
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Overview: The suicide rate among children and adolescents has increased worldwide over the past few decades, and many who at tempt suicide are first seen at EDs. At Childrens Hospital Boston (CHB), an algorithmthe Risk of Suicidality Clinical Practice Algorithmhas been developed to ensure evidencebased care sup ported by best practice guidelines. The authors of this article provide an overview of pediatric suicide and suicide attempts; describe screen ing, assessment, and interventions used at CHB; and discuss the nursing implications. An illustrative case study is also provided. K eywOrds: algorithm, Aspergers syndrome, attempted suicide, bullying, emergency, emergency department, patient safety, pediat rics, pediatric suicide, suicide, suicide screening, triage J.J.s sTORY he charge nurse had asked me (AMS) to meet a patient in the reception area and walk him back to an examination room. J.J. was sit ting in a chair with his knees drawn up to his chest. He stared at his shoes with their untied laces, avoiding eye contact. His mother and grandfather sat on either side of him. I introduced myself to J.J. and his family and asked them all to follow me. J.J. reluc tantly unfolded himself and shuffled behind me down

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began refusing to go to school. His mother had to coax him and bargain and plead with him daily to get him to go. School staff responded by searching the classmates backpack in J.J.s presence to show him that the boy didnt have a weapon. The two boys were separated while in class by assigning them to seats far ther apart and to different study groups. J.J. was also seen by a guidance counselor. Despite these interven tions and his parents reassurances, J.J. became increas ingly depressed and fearful. On the morning of the ED visit, as the family members were starting their day, J.J. had gone into the kitchen, found a butcher knife, and held it to his throat. His mother walked in and saw him. Although J.J. willingly surrendered the knife to her, she said she was rattled to the core. I listened to the story and then reviewed J.J.s medi cal history, including allergies, vaccinations, and pos sible exposures to communicable diseases. In keeping with triage examination protocol, I also needed to take his vital signs and perform a headtotoe assessment. I explained every step of the assessment to J.J. as I went along. He let me measure his height and weight with out complaint. But as soon as I put my stethoscope to his chest, he said that he could feel his heart beating faster and that he thought it meant he was going to die. To reassure him, his mother and I modeled the exam ination for him. After about 15 minutes, he was calmer, and I was able to continue. Throughout the examina tion, I let his affect and behavior guide my actions; if his anxiety rose, I waited until he felt ready for me to perform the next task. In this way I was able to ob tain heart and respiratory rates, take temperature and blood pressure readings, and perform a complete re spiratory and cardiac assessment. At this point, because J.J. had tried to hurt himself earlier, I called for a pa tient safety watchthe presence of a onetoone care companion who would stay with J.J. to ensure his safety. Also in keeping with protocol, a urine toxicology screening and a 12lead electrocardiogram (ECG) were completed. The urine toxicology screening reveals whether any substances that might cause aberrant or abnormal behaviors have been ingested. A baseline ECG is important because many psychopharmaco logic agents can affect the conduction system of the heart. To minimize J.J.s anxiety during these tests, I continued to explain calmly what I was doing and was careful not to make any sudden movements. His mother and grandfather remained nearby, speaking to him quietly and helping to distract him as I applied the ECG leads. Two hours later, the tests were finished; the results were reviewed, and J.J. was medically cleared and eligible to be seen by the consulting psychiatric social worker. But as the wait to see the psychiatric social worker extended into the late morning, J.J. became increas ingly anxious and upset. He tried to run out of the
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The ED Behavioral Health Cabinet at Childrens Hospital Boston

Copies of hospital policies and procedures: Medically necessary restraint Behavioral restraint Chemical restraint Seclusion Suicide risk screening, assessment, and precautions Family education sheets and items: Medically necessary and behavioral restraint Suicide precautions Copies of Section 12a The patients confiscated belongings and receipt forms Resource phone numbers Restraint resources: Restraint log Documentation forms (including debriefing forms) Documentation help sheets (these explain how to fill out forms) Stockinettes (for use as restraints) Deescalation tools: Small bounce or stress balls Pinwheels Paper, pencils, pens, crayons Portable video game player, DVD player, video games, movies
a Section 12 is shorthand for a portion of the Massachusetts law that authorizes temporary involuntary hospitalization or trans port to or from a psychiatric facility.

examination room, but the care companion, who was positioned near the doorway, stopped him. At that point, he started kicking the wall, and I called for secu rity. The attending ED physician asked to have physical restraints on standby, but we knew this was a measure of last resort. So before security personnel arrived, I asked J.J.s mother to help me find ways to calm him. I also alerted the charge nurse that J.J. would need onetoone nursing care for a period of time. BACKGROUND AND EVIDENCE Definition. Although definitions vary, most experts agree that a suicide attempt is associated with some po tentially selfinjurious behavior and intent; the attempt may or may not result in injuries, and the lethality of the intention is irrelevant to the definition.3 ED visits for pediatric mental health concerns (including attempted suicide) usually occur when a childs behavior cannot
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be managed at home or when adult caregivers cannot safely care for the child.4 Background. The suicide rate among children and adolescents has increased worldwide over the past few decades.5 Using World Health Organization (WHO) data, one source writes that among fiveto14year olds, the mean annual suicide rates per 100,000 are 0.5 for girls and 0.9 for boys; among 15to24year olds, these rates rise to 12 for girls and 14.2 for boys.6 Many patients are evaluated at the ED after suicidal ideation or a suicide attempt; in a survey of California EDs, visits by suicidal patients of any age accounted for nearly 2% of all ED visits.7 A 2010 study of more than 1,500 children and adolescents ages 11 to 20 who were seen in an urban primary care system found that 14% reported having suicidal thoughts within the previous month,8 a finding also supported by data from the 2009 Youth Risk Behavior Survey conducted by the Centers for Disease Control and Prevention.9 The American Academy of Pediatrics (AAP) recom mends that pediatricians screen for suicidality in rou tine historytaking throughout adolescence, preferably at both acute care and routine care visits.10 At the ED,

Laboratory Tests and Studies for Medical Clearance at Childrens Hospital Boston
Always done: Electrocardiogram Urine toxicology screening Urine human choriogonadotropin level (in girls of reproductive age) Sometimes done: Chemistry panel Serum toxicology screening Thyroid function tests Complete blood count Bedside glucose level Serum alcohol level Computed tomographic head scan Streptococcal culture Carboxyhemoglobin level Liver function tests Rarely done: Syphilis serology Serum ammonia Chest Xray Electroencephalogram Arterial blood gas analysis Lumbar puncture Serum osmolarity Vitamin B12 level Folate levels
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a thorough assessment for suicidality is vital because this might be a childs only contact with health care professionals. Indeed, one risk factor for suicidality is a familys use of the ED for primary care, according to one literature review; this further highlights the im portance of screening because 50% of adolescents who attempt suicide come to general medical attention in the month before their attempt.4 The AAP reports that causes of the increased youth suicide rate include greater accessibility to lethal tools, stiffer academic competi tion, greater pressures of modern life, and increased vi olence in the media.11 Reducing both the suicide rate overall and suicide attempts by adolescents in particular were two of the goals of Healthy People 2010 (objectives 181 and 182) from the U.S. Department of Health and Hu man Services, and theyre again named as goals of the current Healthy People 2020 (objectives MHMD1 and MHMD2).12 The Joint Commission has also named the identification of patients at risk for suicide as a National Patient Safety Goal (goal 15), although it applies only to patients in psychiatric hospitals and those being treated in general hospitals for emotional or behavioral disorders.13 As goal 15 states, the hospital identifies safety risks inherent in its patient population through such actions as conducting a risk assessment (screening), addressing the patients immediate safety needs, and providing suicide prevention information at the time of discharge to the patient and family. These directives underscore the importance of screening pa tients during the triage process in the ED. Risk factors for suicidality are many and varied; al though none is absolute, the presence of one or more should raise red flags for clinicians. The ethnicity and sex of children and adolescents who demonstrate self harm are frequently studied variables. In the United States, among people ages 10 and older, Native Ameri can males have the highest suicide rate and nonHispanic black females have the lowest rate.14 According to the American Academy of Child and Adolescent Psychi atry (AACAP), more girls than boys attempt suicide, but more boys complete the act.15 Psychosocial risk factors include the presence of a psychiatric condition, a history of prior suicide at tempts, a history of physical or sexual abuse, and a lack of mental health treatment.4, 10 The AACAP has repor ted that in more than 90% of adolescent suicides, there was a preexisting psychiatric disorder at the time of death.15 Specifically, mood disorders and, in those 16 years old or older, substance abuse place children and adolescents at higher risk for suicide. In girls, panic at tacks are a risk factor; in boys, aggressiveness is a risk factor.15 Poor coping has been identified as predictive of a suicide attempt in adolescents of both sexes.16 For Americans in general, firearms are the most common method used to commit suicide, and the pres ence of a firearm in the home has been identified as an
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Triage Phase
All patients with psychiatric signs and symptoms, known or suspected s uicidality, or both If patient is in or needs restraints: See order sheet and ED psychiatry flow sheet Walk patient back to treatment area

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Yes Is the patient a walk-in?

No No

Do you expect a referral call from the CHB psychiatry on-call clinician?

Initiate call to the CHB psychiatry on-call clinician

Yes

Triage history and assessment begin nursing flow sheet for mental health patients

Take expected referral call

If referral to ED, take referral call

Figure 1. Risk of Suicidality Clinical Practice Algorithm, Childrens Hospital Boston

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No Triage status as clinically indicated

Is patient suicidal?

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Yes

Begin acute care phase (on reverse)

Disclaimer: This clinical practice guideline algorithm is designed to provide clinicians with an analytical framework for the evaluation and treatment of a particular diagnosis or condition. It is not intended to establish a protocol for all patients with a particular condition, nor is it intended to replace a clinicians clinical judgment.
1997 Childrens Hospital Boston. Adapted with permission.

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Acute Care Phase

Yes Continue nursing history and assessment with personal and property safety checks Does patient need immediate medical treatment? No

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Place patient on ED suicide observation Page ED psychiatric clinician Medical and psychiatric evaluation Yes Admit patient for medical or psychiatric care (or both)? No eview home safety plan, outpaR tient treatment plan, and follow-up instructions with family Discharge patient to home

Perform personal and property safety check

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Begin medical treatment (see order sheet) and ED suicide observation

Psychiatric placement

Psychiatric clinician reviews case disposition and treatment plan with ED nursing and medical staff

Disposition: Review treatment plan with family ax or call in ED nursing and medical report to appropriate F contact at patients destination (psychiatric unit; medical surgical unit, with nursing suicide coverage; or an outside institution)

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environmental risk factor for child and adolescent sui cide.4 Other social and environmental risk factors in clude being homeless or living in a corrections facility or a group home, poor parentchild communication, social isolation, and difficulties at school.10, 15 Bullying can also be a risk factor. A Finnish study found that boys who were both bullies and victims of bullying were more likely to exhibit suicidal behavior than were boys who were solely victims; however, this finding was nonsignificant after the researchers con trolled for conduct and depression.17 But girls who were victims of bullying were more likely to exhibit suicidal behavior than girls who were bullies or had never been victims, and the significance held even after conduct and depression were controlled for. A survey of 34 parents of children with Aspergers syndrome found that nearly twothirds of the children had been bul lied, victimized, and shunned by peers and siblings; sev eral were reportedly suicidal.18 Children who are gay, lesbian, bisexual, or transgender are also at higher risk for both bullying19, 20 and for suicide, because of multi ple risk factors, including substance abuse, depression, sexual victimization, family conflict, and isolation at school.10, 15, 21 One study in the United Kingdom found that adolescents who were both bullies and victims dem onstrated higher levels of selfharm (such as by cutting, burning, bruising, overdosing, or otherwise hurting one self on purpose) than did those who were not.22 ED TRIAGE AND sUICIDAL PATIENTs Many hospital EDs use the fivelevel triage classifica tion system called the Emergency Severity Index (ESI) Triage Algorithm (for the most recent version, visit http://1.usa.gov/pqejvo). This algorithm takes into ac count not only the acuity of the patient but also the number of resources that will be required during the ED evaluation.23 Using this algorithm, nurses assess patients, score the results, and determine the acuity level. A level 1 patient requires immediate lifesaving in tervention (several conditions and interventions are specified). A level 2 patient has danger zone vital signs as noted and needs emergent treatment because she or he is in a highrisk situation; is confused, lethar gic, or disoriented; or is in severe pain or distress. Pa tients not meeting the criteria for level 1 or 2 are then triaged according to the resources needed. Level 3 pa tients require more than one resource; level 4 patients require one resource; and level 5 patients require none. Resources, many of which are clearly specified, include laboratory testing, Xray studies, and iv hydration. Other actions or procedures, such as simple wound care, that arent counted as resources (and are listed as nonresources) are also specified. Because suicidal patients are at high risk for loss of life if their safety isnt immediately established, theyre classified as highacuity (level 2) cases. Moreover, such patients are likely to require several resources or one
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toone care if they have changes in mental status or ex hibit outofcontrol behavior. During an ED triage assessment at Childrens Hospi tal Boston (CHB), a patients airway, breathing, and cir culation are first assessed and an ESI Triage Algorithm score is assigned. After a brief physical assessment, all patients whose chief complaint is related to a mental health issue are then screened by a nurse to identify those at immediate risk for selfharm. The validated screening tool used at CHB for this purpose is com posed of four questions24: Are you here because you tried to hurt yourself? In the past week, have you been having thoughts about killing yourself? Have you ever tried to hurt yourself in the past other than this time? Has something very stressful happened to you in the past few weeks? The questions can be answered either by the patient or, if the patient is unwilling or unable to answer, by an accompanying caregiver. If the patient answers yes to one or more of these questions (a positive result for suicidality), she or he is categorized as ESI level 2. At this point the nurse explains the hospitals policy on chemical or physical restraints, which are used as a last resort: theyll be used only if the patient is determined

Resources for Families

American Academy of Child and Adolescent Psychiatry www.aacap.org National Institute of Mental Health www.nimh.nih.gov Stop Bullying www.stopbullying.gov Substance Abuse and Mental Health Services Administration www.samhsa.gov Suicide Prevention Resource Center www.sprc.org Surgeon Generals Call to Action to Prevent Suicide www.surgeongeneral.gov/library/calltoaction/ default.htm For information related to a specific diagnosis, or for more help in finding local support groups, talk with your childs pediatrician, mental health provider, and school personnel.
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Figure 2. Childrens Hospital Boston ED examination room, shown with the safety door open. Photo courtesy of Childrens Hospital Boston.
to be an imminent danger to herself or himself, family members, or staff. (The Centers for Medicare and Med icaid Services defines chemical restraints as any drug used for discipline or convenience and not required to treat medical symptoms.25) The nurse also asks the patient or the accompanying caregiver whether any restraints have been needed in the past, then asks whether there have been any recent changes in the pa tients mood or behavior. At CHB, a clinical practice algorithm for patients at risk for suicide has been developed to ensure evidence based care supported by best practice guidelines. This algorithm, the Risk of Suicidality Clinical Practice Al gorithm (see Figure 1), is based on Joint Commission requirements for any patient seeking psychiatric ser vices. Its use can be initiated on the basis of a positive response to one or more of the four screening ques tions, a school nurse or other nonCHB clinicians obser vation, a parents observation, or the ED triage nurses observation. It has two parts, or phases: a triage phase and an acute care phase. All patients presenting with a psychiatric chief complaint, such as depression, anxiety, or suspected sui cidality, are evaluated using the triage phase of the al gorithm. As this phase progresses, the patient is screened specifically for suicidality. Patients determined to be sui cidal or at risk for selfharm are further evaluated using the acute care phase of the algorithm and are escorted as soon as possible to an examination room to continue their care. At that point, while maintaining the patients dignity and privacy (by closing the door, for example), the nurse searches the patient and her or his belongings for any items that could be used to harm her or himself
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or others. This is necessary to ensure both patient and staff safety. Next, the nurse assesses the patient from across the room, considering general appearance, mood, affect, interactions with caregivers, speech, cog nitive state, insight and judgment, and impulse control before beginning a full physical assessment. During the full assessment, the patients medications are also reconciled. Confiscated items are documented using a receipt form, with one copy given to the family and an other placed with the items. The items are then locked in the EDs behavioral health cabinet (see The ED Behavioral Health Cabinet at Childrens Hospital Bos ton) for safekeeping. This cabinet also contains video game and DVD players, games and DVDs for all age groups, art supplies, and ageappropriate sensory toys (such as balls) for children and adolescents. (If there isnt room in your facility for a behavioral health cab inet, a drawer containing ageappropriate activities or toys could be established.) Also at this time, a onetoone patient safety watch is initiated and carried out by a care companion, secu rity officer, or nursing assistant. Documentation of one toone patient observation, as well as of the patients mental status and affect, is completed hourly. As part of the medical evaluation and to rule out organic etiologies of changes in mental status and be havior, various laboratory tests and studies are per formed (see Laboratory Tests and Studies for Medical Clearance at Childrens Hospital Boston). The two studies most commonly done in the ED at CHB are the urine toxicology screening and the ECG, although other studies may be necessary for medical clearance. Organic causes of aggressive or violent behavior are generally reversible, and by correctly diagnosing and treating the underlying issue, interventions such as chemical or physical restraint can be avoided.4 And as Baren and colleagues noted, a failure to diagnose and treat an underlying medical condition (such as hypo glycemia or an intracranial bleed) can have disastrous results.4 They also stated that although there is no consensus on what constitutes appropriate medical clearance in children, a comprehensive history and physical examination remain the cornerstone of med ical clearance. Nursing implications. Throughout a patients ED visit, nurses use various strategies to promote success ful interactions with the patient and her or his family members, while at all times maintaining their privacy and an atmosphere of respect. Such strategies include active listening and close observation of behavior, at tending to nonverbal body language that could indicate what the patient is feeling. Other strategies include us ing openended questions, conveying a nonjudgmental attitude, clarifying information, and providing sup port. Cultural competency and an ability to act as pa tient and family advocate throughout the visit are also vital.
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With a patient whos exhibiting increasingly aggres sive behaviors, the nurses primary concern is always the safety of the patient and staff. In order to ensure pa tient and staff safety, the nurse must first consider the physical environment. Also, before restraints are used, nurses must also exhaust all other treatments and op tions that are available for ensuring patient and staff safety. At CHB, the ED examination rooms are fitted with special inner safety doors that block a patients access to monitoring equipment, wires, and other po tentially dangerous supplies. When the safety door is closed, the patients environment contains only four walls and a gurney or stretcher (see Figures 2 and 3). Indeed, Brock and colleagues recently studied the use of a similar secure room [with] security guard system to determine its effectiveness in the management of vio lent, aggressive, or suicidal patients26; the researchers concluded that this intervention can be safely used in treating many patients admitted to rural hospitals in a mental health crisis. J.J., REVIsITED While waiting to see the psychiatric social worker, J.J. had become increasingly upset and started kicking the wall of the examination room. I had called security and, to ensure J.J.s safety in the interim, the team de cided to lower the rooms safety door. (J.J.s care team included ED resident and attending physicians, an ED nurse, a care companion, a psychiatric social worker, a clinical assistant, the ED child life specialist, and the ED pharmacist. Any licensed member of the team can make the decision to lower the door.) As an added pre caution, I stepped outside the room and removed my trauma shears from my pocket and my ID badge on its lanyard from around my neck and left these items at my work station. I reentered the room and stood quietly. Keeping my path to the door unobstructed, I invited J.J. to talk. I asked why he was kicking the wall, but he remained si lent. I turned to his mother for help, asking her, What helps to calm or soothe J.J. when he gets upset at home? She told me that at such times, she often held her son in a basket hold, encircling him with her arms and legsessentially a physical restraint. Since restraint of any type is always a last resort, I asked about other calming strategies. As we talked, J.J. continued to kick the wall and then began punching a pillow on the bed. I removed all potentially dangerous items, such as the trash barrel and a loose chair, from the room. The se curity staff arrived. After safety was established, I used several deescala tion and aggressionmanagement techniques: I stayed approximately three to four feet away from J.J., and I consciously kept my body language neutral and relaxed. I also recalled the acronym HALTTS, which stands for hungry, angry, lonely, tired, thirsty, and scared. (Used in addiction counseling and in the care of psychiatric
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patients, the acronym works as a kind of checklist to guide intervention; when a person is feeling one or more of these sensations or emotions, she or he can become frustrated, upset, or aggressive.) I used the HALTTS ac ronym to guide me in addressing J.J.s possible needs. For instance, I offered him a granola bar and some chicken nuggets; if he was hungry, the food might as suage his hunger and distract him from kicking. I explained the next steps in J.J.s care to him in an effort to prepare him for what would happen next. I explained what would occur during the psychiatric evaluation. I also told him that if he was unable to calm himself, we might have to use restraints; and that if he would stop kicking the wall, he could have a prize (such as the use of art supplies or a handheld video game player). I gave him time to ask questions, but he was minimally responsive, giving oneword answers to my questions. The EDs consulting psychiatric social worker came to help encourage J.J. to express his feel ings and to help brainstorm other ways to calm him. J.J.s mother offered suggestions that had worked in the past. She said that at home, he loved to sit and bounce on a large yoga ball, and that the rocking, bounc ing motion soothed him. I called the inpatient psychi atric unit and the occupational health department to locate such a ball. While we waited for it to arrive, I con tacted the EDs child life specialist to ask about other developmentally appropriate distractions. I also dim med the lights and redirected hallway traffic to help decrease environmental stimulation. The child life spe cialist gave me a soft, squishy ball that J.J. could squeeze or throw, as well as a pinwheel for him to blow on to

Figure 3. Childrens Hospital Boston ED examination

room, shown with the safety door closed. Photo courtesy of Childrens Hospital Boston.
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promote deep, slow breathing. When the yoga ball arrived, J.J. started to bounce on it. His mother said that classical music also helped to calm him, and the child life specialist located a CD player and some ap propriate music. We set up the player just outside the room for safety reasons and played the music. (DVD or VHS players with ageappropriate movies can pro vide similar, calming distraction, as can some hand held, ageappropriate video games.) We had promised J.J. a prize if he stopped kicking; when he stopped, we gave him the handheld video game player. After two hours of bouncing calmly on the ball and playing video games, he decided that he wanted to watch a movie, and he moved to the bed. But he soon started to become restless and uncomfortable. He told his mother he felt itchy and scratchy. I obtained soft, starchfree sheets and changed the bed, and J.J. was again able to relax.

Every childs case disposition is different and must take into account the childs home and school environments, the acuity of the suicidal ideation or attempt, and the reliability of the childs caregivers.
The resident physician and I had discussed the use of psychopharmacologic agents to calm him; but we decided that the risks outweighed the potential ben efits. However, if J.J.s distress and aggressive behavior had continued to escalate, that would have been our next intervention. The team did contact the ED phar macist for help in determining the best medication and dosage for him, had chemical restraint become neces sary, in order to minimize the risk of complications or interactions with medications he was already taking. I spoke with J.J. about his fears; among other things, he was afraid that the numerous security guards in the hallway were going to take him to jail. To help him feel less threatened while continuing to ensure his safety, I dismissed all but one security officer. After J.J. had a sustained period (about 30 minutes) of calm be havior, the team clinicians participated in a debriefing to discuss successful and unsuccessful interventions. Other inhouse resources were identified. A plan of ac tion, to be used if J.J.s distress and aggressive behavior were to escalate again, was developed and kept in his chart for quick access. It incorporated the measures that had been successfully used to calm J.J. and identified appropriate adjuncts (such as medications and distrac tion measures) that have worked for him in the past. After interviewing J.J. and consulting with his mother, the ED physician and nurses on J.J.s care
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team, together with the ED psychiatric social worker, determined that J.J. could safely be discharged with close monitoring at home and intensive outpatient treatment after school. Every childs case disposition is different and must take into account many factors, including the childs home and school environments, the acuity of the suicidal ideation or attempt, and the reliability of the childs caregivers. In J.J.s case, the hos pitals consulting ED psychiatric social worker con tacted his primary care physician, his school counselor, and prospective outpatient treatment providers prior to discharge to discuss J.J.s ED visit and the plan of care. J.J. remained calm and cooperative up to and dur ing his discharge. At that time, I provided patient and family education, including an individualized home safety planin this case, among other measures, the plan called for keeping knives out of J.J.s reachand detailed written and verbal followup instructions for outpatient care. FAMILY EDUCATION Many pediatric psychiatric patients are discharged and then managed from home, with followup instructions for their outpatient care, outpatient psychiatric sup port, and a home safety plan. Family and patient educa tion, always vital, helps to ensure the safety of young patients at risk for selfharm. At CHB, home safety education is an important component. Research has shown that when, as part of a home safety plan, edu cation of parents and other home caregivers includes the importance of locking up or disposing of firearms, alcohol, and prescription and overthecounter med ications in the household, they heed this advice.27 Parents and other adult caregivers also receive de tailed instructions regarding increased supervision of the child. The nurse encourages them to check in with the child at least once daily, asking about suicidal thoughts and mood; this helps with early identification of declin ing status and facilitates timely intervention. The nurse also makes sure that the patient understands the ratio nale behind increased supervision. Patients are asked to identify supportive adults at home and at school. Parents are then instructed to make sure that these adults are aware of the childs recent sui cidal crisis and that the child has easy access to these adults. The nurse also helps parents to identify their childs coping skills and explains how such skills can be useful in addressing rising distress or aggression. Cop ing skills for schoolaged children commonly include reading, drawing, and playing outside. Both patients and parents are also asked to identify a resource person at school, someone with whom CHBs psychiatric pro viders can make contact if the need arises. This is es pecially important in cases like J.J.s, in which bullying at school was a precipitating factor. Before discharge, the health care team identifies and contacts outpatient providers; these might include an
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intensive outpatient treatment program, psychologists, social workers, nurses, physicians, and psychiatrists. An outpatient treatment plan is then drawn up and re viewed with patients and families. An outpatient re source guidea list of providers in the home area and within the familys insurance networkand a discharge sheet with specific followup instructions are provided. The instructions might include scheduled appoint ments with outpatient providers, instructions for call ing the familys primary care provider, a meeting with school personnel, or a combination of these. Reasons to return to the ED or to use other crisis re sources are also reviewed with the patient and family. Theyre instructed to seek emergency medical care if the patient has significant changes in mood, behavior, or functionality, such as a reduced ability to perform ac tivities of daily living. Families are also given contact information for both the hospitals psychiatric resident on call and a local crisisresponse resource (such as county mental health services or a community crisis hot line). (For more, see Resources for Families.) Caring for suicidal pediatric patients in the ED can be a challenge; both the child and the parents or adult caregivers often exhibit acute distress and anxiety at pre sentation, and thorough evaluation and appropriate case disposition take time. Through careful screening, assessment, and individualized interventions, nurses can help patients and their families to weather the im mediate crisis; through education, they can provide in valuable guidance for the future, should the patients safety again be threatened. For 39 additional continuing nursing educa tion articles on pediatric topics, go to www. nursingcenter.com/ce.
Alexis M. Schmid is an acute care pediatric NP in the medical surgical ICU and a per diem staff nurse in the ED, Amy W. Truog is a staff nurse III in the ED, and Frances J. Damian is the EDs director of nursing and patient services, all at Childrens Hospital Boston. Contact author: Alexis M. Schmid, alexis. schmid@childrens.harvard.edu. The authors have disclosed no potential conflicts of interest, financial or otherwise.

REFERENCES
1. Eunice Kennedy Shriver National Institute of Child Health and Human Development. Asperger syndrome. National Institutes of Health. 2007. http://www.nichd.nih.gov/health/ topics/asperger_syndrome.cfm. 2. National Institute of Neurological Disorders and Stroke. NINDS Asperger syndrome information page. 2011. http:// www.ninds.nih.gov/disorders/asperger/asperger.htm. 3. OCarroll PW, et al. Beyond the Tower of Babel: a nomen clature for suicidology. Suicide Life Threat Behav 1996; 26(3):23752. 4. Baren JM, et al. Childrens mental health emergenciespart 2: emergency department evaluation and treatment of children with mental health disorders. Pediatr Emerg Care 2008; 24(7):48598. 5. Pompili M, et al. Childhood suicide: a major issue in pediat ric health care. Issues Compr Pediatr Nurs 2005;28(1):638.
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