At the Bedside

  • Immediate safety
  • Place patient in a safe room; remove weapons, cords, sharps, belts, personal meds.
  • Continuous observation/1:1 sitter if active suicidal ideation, intoxication, agitation, psychosis, or unreliable history.
  • Search belongings per institutional policy.
  • Do not allow elopement if imminent risk; use emergency hold/involuntary commitment process when criteria met.
  • Initial assessment
  • Ask directly:
  • “Are you thinking about killing yourself?”
  • “Do you have a plan?”
  • “Do you have access to the means?”
  • “Have you tried before?”
  • “What stopped you today?”
  • Assess:
  • Suicidal ideation, intent, plan, lethality, access to firearms/meds.
  • Prior attempts, psychiatric disease, substance use, recent loss, chronic pain, terminal illness, legal/financial crisis.
  • Protective factors: family, religion, future plans, therapeutic alliance.
  • Homicidal ideation, psychosis, command hallucinations.
  • Use structured tools as adjuncts, not replacements:
  • C-SSRS, SAFE-T, ED-SAFE style assessment.
  • Medical evaluation
  • Vital signs, glucose if altered mental status.
  • Focused exam for trauma, toxidromes, self-harm wounds, intoxication, withdrawal, delirium.
  • Labs are not mandatory for all psychiatric patients; order based on history/exam and receiving facility requirements.
  • Common targeted tests:
  • Acetaminophen and salicylate levels if overdose possible.
  • Ethanol level if intoxicated.
  • Pregnancy test when relevant.
  • ECG for overdose, chest pain, syncope, antipsychotic/TCA exposure.
  • CMP/CBC/TSH/UDS only if clinically indicated or needed for placement.
  • Intoxicated patients require reassessment when clinically sober enough to participate.
  • Risk stratification
  • High risk: active SI with intent/plan, firearm access, recent attempt, psychosis, severe agitation, command hallucinations, intoxication plus SI, poor support, inability to safety plan → psychiatric admission or involuntary hold.
  • Moderate risk: SI without clear intent but significant risk factors → psychiatric consultation; likely observation/admission depending supports.
  • Low risk: passive death wishes only, no plan/intent, no prior attempts, strong support, stable housing, outpatient follow-up, collaborative safety plan → possible discharge.
  • Management
  • Treat medical emergencies first: overdose, lacerations, fractures, intoxication/withdrawal, delirium.
  • De-escalate verbally before medications/restraints.
  • Use restraints only when patient is an imminent danger and less restrictive measures fail; reassess frequently.
  • Create a safety plan for discharge:
  • Warning signs.
  • Internal coping strategies.
  • People/places for distraction.
  • Family/friends to ask for help.
  • Crisis resources.
  • Lethal-means restriction.
  • Lethal means counseling
  • Firearms should be removed from home or locked unloaded with ammo separate; ideally held by trusted person/law enforcement per local rules.
  • Limit medication quantities; lock meds; remove stockpiles.
  • Arrange rapid follow-up, ideally within 24–72 hours.
  • Provide crisis resources: 988 Suicide & Crisis Lifeline in the U.S.
  • Disposition decision points
  • Admit/hold if imminent risk, inability to contract collaboratively for safety, psychosis, severe intoxication, lack of capacity, unreliable support, or persistent intent.
  • Discharge only if clinically sober, medically cleared, risk is acceptably low, lethal means addressed, safety plan completed, and follow-up arranged.
A Classic Presentation
A 42-year-old man presents after texting his sister goodbye and drinking alcohol with access to a handgun at home. He reports worsening depression, job loss, and a prior overdose attempt. Exam shows intoxication but no trauma; glucose is normal, ECG is reassuring, acetaminophen/salicylate levels are negative. He is placed on 1:1 observation, belongings removed, firearm access is addressed with family, and he is held for psychiatric evaluation after sobriety because of high-risk features: stated intent, lethal means, prior attempt, intoxication, and acute stressor.

Study Directive

  • Practice a 2-minute suicide assessment script from memory: ideation, plan, intent, means, prior attempts, psychosis, substances, supports.
  • Review your hospital’s involuntary hold criteria and documentation requirements.
  • Complete one mock safety plan including firearm and medication restriction.
  • Know which “medical clearance” tests are clinically indicated versus routine placement requirements.
  • Read one ED agitation pathway and memorize first-line medication doses used at your institution.

Recent Literature