Q132] While you are on rounds in psychiatry wards, a 50 yr old depressed female patient tells you that she wants to be discharged soon. She says sometimes she feels like stabbing herself with a dinner knife provided along with her food. Your most important next step:
A] Discharge the patient according to her request
B] Replace the knifes and forks with plastic utensils
C] Arrange one-on one supervision
D] Arrange a nurse to visit her every 30 minutes
Archer USMLE Step 3 Blog 
c
c
ccc
Dr.Red please answer ,why ans is c and not d
C. Not B coz pt can still stab herself to death with a plastic knife (seen it myself), although they should be replaced anyway. Not D coz pt can die 100 times within 30min, well before a nurse checks on her.
Beautiful question to brush up current (2009-2013) trends and protocols for monitoring suicidal patients. Nowadays there is justifiably very high emphasis on the protocol for in-patient monitoring of suicidal patients. Despite all protocols one third of all observed suicidal inpatients commit suicide in the hospital, and despite heavy costs of continous monitoring, hospitals and doctors get sued & deal with legal settlements and charges on grounds of negligence and medical incompetence. Because of this hospitals are taking this more and more seriously. There is a lot of information on this subject, I’ll try to summarize.
There are two main protocols for patient monitoring, continous and intermittent. Continous observation includes a spectrum of activities , more than simply assigning a staff to a patient & it has levels ranging from 1:4 to 1:1 assignment; one on one (1:1) is the closest/ most strict observation and it means one trained staff must remain in close proximity of the patient at all times with no physical barriers. This is used for all patients with suicide ideations in hospitals until the attending psychiatrist eases the observation order.
15 minute observation (Q15) and 30 minute observation (Q30) are intermittent forms of observation, I repeat, they are intermittent forms of observation. Studies have strongly recommended not to use these forms of monitoring in suicidal patients.
Protocols Now for some protocol models;
Johns Hopkins Psychiatry has one level of intermittent observation and three levels on continous observation. Only a psychiatrist can lower the level of observation but any staff can raise the level of observation. FEMA analysis team is on board for proactive intervention in place of root cause analysis.
John Dempsey Hospital protocol utilizes 1:1 for all patients with impulsive high risk behavior including active suicide ideations. Continous monitoring that is less restrictive than 1:1 monitoring for example 1:2, 1:3, 1:4 is used in patients with high fall risk, delirium, impaired judgement, intrusive thoughts, low risk of elopement, wandering patients, interference with medical treatment like pulling IV line or tubes or drains.
References:
Grant JE, “Falling the 15-minute Suicide Watch: Guidelines to Monitor Inpatients” Current Psychiatry 2007; 6(6):41-43.
Jayaram G, “The Utility and Effectiveness of 15-minutes Checks in Inpatient Setting” Psychiatry (Edgmont) 2010; 7(8):46-49.
Janofsky J, “Reducing Inpatient Suicide Risk: Using Human Factor Analysis to Improve Observation Practices” J Am Acad Psychiatry Law 2009; 37(1):15-24.
“Protocol for 1:1 Observation/Constant Observation: Monitoring of Acute Medical/Surgical and/or Behavioral Health Patients” Clinical Protocol John Dempsey Hospital University of Connecticut Health Center, Department of Nursing, Clinical Manual/Nurses Practise Manual 2013, p1-5.
Gliatto MF, Rai AK, “Evaluation and Treatment of Patients with Suicide Ideations” Am Fam Physician 1999; 59(6):1500-1506.
MY ANSWER: In the index patient, there are suicide ideations; discharging the patient home(option a) replacing the knifes and forks (option b) or arranging a nurse to visit every 30 minutes (option d) are not options as effective as one on one supervision (option c). One on one supervision is a whole protocol of activity for a trained staff to stay by the bed side at all times; it includes removing knifes, a whole lot more. Direct one on one supervision is the best next step. I think the right answer is C.
(Please review the 1:1 continuous observation protocol for John Dempsey Hospital, from their Nursing Practice Manual 2013, in the reference. It is very comprehensive. Also, John Hopkins attending Psychiatrist Janofsky has a marvelous account of their practice and recommendation for monitoring patients with suicide ideations. You can find more about this article in my references).