Reducing Patient Risk for Suicidal Behaviors with a Safety Bundle of Best Practices with Non-Psychiatric Patients

Practice Problem: Suicide is a public health condition that affects people globally. The increased suicidal behaviors of patients in a medical-surgical unit demanded an effective screening protocol to identify high-risk patients. PICOT: In patients 18 years and older on a medical-surgical unit, does the implementation of the Columbia Suicide Severity Rating Scale (C-SSRS) tool and application of a Safety Bundle of Best Practices (SBBP) increase early identification of suicide risk with decreased patient selfharm behaviors, compared to the current standard practice of no assessment tool or safety bundle of best practices within 12 weeks? Evidence: Ten studies served as evidence that assessment of early suicidal-risk behaviors decreased patient self-harm. The evidence supported the implementation of the C-SSRS tool and application of the Safety Bundle of Best Practices for the project intervention. Intervention: The intervention consisted of three phases (pre-intervention, intervention, and post-intervention): a) patients were screened with the Columbia-Suicide Severity Rating Scale (C-SSRS); b) suicidal patients were managed with Collaborative Assessment and Management of Suicidality (CAMS); and c) a Safety Plan Intervention (SPI) was employed to manage suicidal behaviors. Outcome: At the start of the assessment period, pre-intervention data yielded a C-SSRS risk score mean of 0.81; following the eight-week implementation period, post-intervention data yielded a C-SSRS risk score mean of 0.75. There was a marginally significant difference between the means at preand post-intervention, showing a lower suicidal risk at postintervention, p = 0 .07, t-test result (31) = 1.87. REDUCING PATIENT RISK FOR SUICIDAL BEHAVIOR 4 Conclusion: The decrease in patient self-harm behaviors with the implementation of the C-SSRS tool and application of SBBP was not statistically significant (SBBP). However, the decrease did indicate a clinically meaningful improvement in suicidal behavior outcomes after implementation of the intervention. REDUCING PATIENT RISK FOR SUICIDAL BEHAVIOR 5 Reducing Patient Risk for Suicidal Behaviors with a Safety Protocol of Best Practices with Non-Psychiatric Patients The Coronavirus Disease (COVID-19) pandemic has illuminated the increased need for mental health services and suicide screening, especially in individuals who are immunocompromised, at higher risk for COVID-19 complications, or who are financially struggling. Suicide abruptly ends the lives of individuals while leaving friends, family, and colleagues to struggle with their grief and understanding of the situation (King et al., 2017). According to the Center for Disease Control and Prevention [CDC] (2018) over 42,000 individuals have committed suicide in the United States. The disease affects all ages and is the tenth leading cause of deaths in the U.S. (CDC, 2018). Increasing suicide rates illuminate the need to optimize screening strategies to identify high-risk patients. Furthermore, it is recommended that multifactorial suicide-risk screening tools consider the specific needs of the individual person (King et al., 2017). Such recommendations include implementing suicide-risk screening in many healthcare settings, including primary care, medical specialties, and emergency departments (King et al., 2017). The purpose of this Doctor of Nursing Practice (DNP) project was to create a protocol for screening medical-surgical patients for suicide risk. The C-SSRS tool determined the suicide risk of the patient at admission to the unit; then SBBP was implemented based upon the risk assessment. The nursing staff documented in the Electronic Medical Record (EMR) when a patient was identified at risk and which SBBP interventions were implemented to maintain patient safety. Significance of the Practice Problem The practice problem addressed was that the facility has had a number of suicide attempts on non-psychiatric units and was cited by The Det Norske Veritas Accreditation for not having a REDUCING PATIENT RISK FOR SUICIDAL BEHAVIOR 6 protocol in place. Therefore, a need was identified for an evidence-based practice change to implement a protocol for nursing staff to screen medical-surgical patients for suicidal risk. Suicide is described as the intentional taking of one’s own life, a critical health problem that can have lifelong effects on family members and the community. Suicide is a global public health problem (Arensman et al., 2020). The effect of suicide is very disabling on loved ones and can cause long-term pain, depression, and decreased quality of life (Aquila et al., 2020). Suicide is not referred to as a mental illness but can be a symptom of several psychiatric disorders including schizophrenia, bipolar disorder, depression, and substance use disorder (Sadock & Sadock, 2014). In 2018, suicides and suicide attempts cost the nation almost $70 billion per year in medical and work-loss costs alone (CDC, 2020). Globally, suicides are the second leading cause of untimely death in people aged 15 to 29 and the third leading cause of premature death in individuals 15–44 years. The global rate is estimated to be 1.4%, ranging from 0.5% in Africa to 1.9% in Southeast Asia (Bachmann, 2018). There has been a 6.7% increase in the total number of suicide deaths in the last 27 years, amounting to almost 817,000 deaths in 2016 (Naghavi, 2019). According to the World Health Organization (2020), almost 800,000 people die from suicide every year; the global annual mortality rate from suicide has been estimated to be 10.7 per 100,000 individuals. Nationally, suicide is the 10th leading cause of death in the United States for all ages and can be caused by multiple factors, mental health disorders being the most common (CDC, 2018). Suicide is a huge cost to the economy of many countries including the United States. In the United States, the suicide rate increased by 35% from 1999 to 2018, which is the equivalent of going from 10.5 per 100,000 to 14.2, an increase on average of about 1% per year from 1999 to REDUCING PATIENT RISK FOR SUICIDAL BEHAVIOR 7 2006 and of 2% per year from 2006 through 2018 (CDC, 2020). There continues to be a steady rise of suicide rates despite national goals to decrease the rate in the United States (CDC, 2020). Locally, suicide is rated as the 11th leading cause of death in Texas and the third leading cause of death among individuals ages 15 to 24 with almost 30 hospitalizations for suicide attempts (Texas Facts, n.d). In Texas, the estimated medical costs of hospitalizations for suicide attempts average $8,849 per individual or over $95.6 million annually (Texas Facts, n.d). In 2014, the financial implications of suicide in Texas was reported to be $4.264 million in lifetime medical and work-loss costs (University of Texas, 2017). Risk factors for suicide include all traumas and stresses that can alter the psychological wellbeing of an individual: mental illness, financial issues, family conflicts, chronic health conditions, war, sexual violence, grief, and bullying (Bachmann, 2018; Vasconcelos Neto et al., 2020). The ongoing pandemic has also generated more risk factors due to forced isolation, decreased social contacts, increased hospitalization, deaths of loved ones, the inability to visit in the hospital to say goodbye, and the inability to have funeral ceremonies (Aquilla et al., 2020). Suicide is a known critical public health problem that can be prevented if warning signs are recognized and intervention is done promptly. Safety planning, an emerging evidence-based practice that is effective at reducing suicidal behaviors, is a top consideration which includes developing support and coping skills that individuals can rely on when thinking of suicide (Little, et al., 2018). The increased suicide rates locally, nationally, and globally show the need to consider optimizing screening methods to identify patients that are at high risk for suicide.


Conclusion:
The decrease in patient self-harm behaviors with the implementation of the C-SSRS tool and application of SBBP was not statistically significant (SBBP). However, the decrease did indicate a clinically meaningful improvement in suicidal behavior outcomes after implementation of the intervention.

Non-Psychiatric Patients
The Coronavirus Disease  pandemic has illuminated the increased need for mental health services and suicide screening, especially in individuals who are immunocompromised, at higher risk for COVID-19 complications, or who are financially struggling. Suicide abruptly ends the lives of individuals while leaving friends, family, and colleagues to struggle with their grief and understanding of the situation (King et al., 2017). Increasing suicide rates illuminate the need to optimize screening strategies to identify high-risk patients. Furthermore, it is recommended that multifactorial suicide-risk screening tools consider the specific needs of the individual person (King et al., 2017). Such recommendations include implementing suicide-risk screening in many healthcare settings, including primary care, medical specialties, and emergency departments (King et al., 2017). The purpose of this Doctor of Nursing Practice (DNP) project was to create a protocol for screening medical-surgical patients for suicide risk. The C-SSRS tool determined the suicide risk of the patient at admission to the unit; then SBBP was implemented based upon the risk assessment. The nursing staff documented in the Electronic Medical Record (EMR) when a patient was identified at risk and which SBBP interventions were implemented to maintain patient safety.

Significance of the Practice Problem
The practice problem addressed was that the facility has had a number of suicide attempts on non-psychiatric units and was cited by The Det Norske Veritas Accreditation for not having a Rating Scale (C-SSRS) tool and application of a Safety Bundle of Best Practices, C-Compared to current standard practice (of no assessment tool and Safety Bundle of Best Practices), O-Outcome: increased early identification of suicide risk with decreased patient self-harming behaviors, T-Twelve weeks.
PICOT Question: In patients 18 years and older on a medical-surgical unit, does the implementation of the Columbia Suicide Severity Rating Scale (C-SSRS) tool and application of a Safety Bundle of Best Practices (SBBP) increase early identification of suicide risk with decreased patient self-harm behaviors, compared to the current standard practice of no assessment tool or safety bundle of best practices within 12 weeks.

Evidence-based Practice Framework and Change Theory
The evidence-based change framework that was used for this project is the Iowa model of evidence-based practice. This model centers on the healthcare system as a whole to implement and guide practice decisions based on the best available research and evidence (Christenbery, 2017). A theoretical framework was used in providing a structure and design of reference for the project. Eric Havelock's model of planned change supports this scholarly project. Havelock formulated the planned change that expanded on Lewin's theory (Havelock, 1973). He proposed his change model on building a relationship, diagnosing the problem, gathering resources, choosing the solution, gaining acceptance, and maintaining the change (Havelock, 1973).
Havelock emphasized that the initial step when planning a change is to establish a relationship with the system in need of change (Havelock, 1973).
The second step of change is diagnosing the problem. He described this stage as a period when the reason for change needs to be established (Havelock, 1973). Havelock described the third process as the period of acquiring resources for the change project once it has been decided upon (Havelock, 1973). The fourth stage occurs when a pathway of change is selected from available options and then implemented (Havelock, 1973). The fifth stage is establishing and accepting change. After the implementation of the change, it must be established and accepted by the organization since resistance to change may occur at this time (Havelock, 1973). The last stage is making sure that the change is successfully maintained (Havelock, 1973).

Evidence Search Strategy
The search strategy included an electronic search of digital databases of different scientific literatures related to the PICOT questions within the last five years. Databases that were used included the following: CINAHL (n=540), ProQuest (n=150), PubMed (n=500), Medline (n=380), EBSCOhost (n=520), and Google Scholar (n=800). The initial search yielded 2,520 articles, most of which were not relevant to the project. After duplicates were excluded, 575 articles relevant to the project topic were retrieved. Filters were applied, and 190 studies conducted in English were selected, excluding 385 articles. Among the 190 relevant articles retrieved, 58 were full-text articles screened for eligibility; 43 were excluded, leaving 15 articles.
The keywords used for the article search were safety, suicide, suicide screening, suicide prevention, suicide risk, deliberate self-harm and suicidal behaviors. A PRISMA diagram from the original template by Moher et al., (2009) was used to summarize the result (see Figure 1).
Upon review of the articles, five were meta-analyses which were evaluated, using the Johns Hopkins evidence level, to be level I [grades A and B] (Hopkins Medicine, n. d.). Four of the articles were longitudinal, cohort studies, which were level 4 (grade C). One was an observational study assessed to be evidence level 6 (grade D).

Evidence Search Results and Evaluation
The search yielded 2,520 articles. Articles were limited to the five-year period 2015-2020, After a thorough search through several databases, critical appraisals were made to judge the clinical and statistical importance of the chosen articles. Several of the articles showed expert opinion.
Databases search included: CINAHL (N=540), ProQuest (n=150), PubMed (n=500), Medline (n=380), EBSCO host (N=450), and Google Scholar (n=500). Duplicates were excluded, and 575 relevant articles were retrieved. Filters were used, 190 studies conducted in English within the last five years applicable to the project were chosen, 385 articles were ruled out. Filters included full texts, quantitative studies, and date range. Among the 190 relevant articles retrieved, screening was done, 58 full-text articles were eligible; 43 were excluded and this left 15 articles. The 15 articles were then organized and summarized for PICOT question.
The Johns Hopkins Nursing Evidence-Based Practice hierarchy method was used to determine the level of each article in analyzing the literature. Evidence hierarchy helps in locating and ranking evidence sources according to the strength of the evidence (Petrisor & Bhandari, 2011). A seven-level hierarchy is shown in Appendix J. The evidence table (Appendix A) represents the different evidence levels for the selected articles. The PRISMA ( Figure 1) is a format modified from the original template by Moher et al. (2009). Articles reviewed included eight systematic reviews, evaluated by applying the Johns Hopkins level 1 and were graded as As and Bs (Hopkins Medicine, n.d). The other nine articles reviewed were randomized and nonrandomized control studies of levels 1 and ll with grades of As and Bs. There were also observational studies which were evidence level lll and grade quality Bs in Appendix B

Themes from the Evidence
This section will offer the similarities and differences noted in evidence related to suicide, suicide screening, suicide attempt, suicidal behaviors, suicide prevention, and components of PICOT questions. Boudreaux et al. (2016) and Schmutte et al. (2020) found that those attempting suicide or who had suicidal ideation were more likely to receive a diagnosis of a mental disorder in emergency departments and to recieve follow-up mental care than were those who merely self-harmed in ways short of suicide. They further noted that the identification of risk was the first necessary step for preventing suicide. McCabe et al. (2018) emphasized that brief psychological interventions appear to be effective in reducing suicide and suicide attempts. Katz et al. (2020) conducted a study to assess the association between self-reports of suicidal ideation and suicidal behavior using the C-SSRS. The study was done on Veterans Administration patients receiving mental health services. The rate of suicide attempts reported on the C-SSRS were higher than those documented in Veterans Health Administration (VHA) records through either SPAN or ICD-10 (Katz et al., 2020). The authors recommended the use of C-SSRS screening to help detect patients at early risk for suicidal behavior (Katz et al., 2020).
Recommendation was made to always use clinical judgement when assessing patients and interpreting responses. The findings supported the predictive validity of C-SSRS and proved that it can be used to identify mental health patients who are at risk but have never been diagnosed.
The CAMS is an evidence-based clinical intervention that has significantly emerged over many years of clinical research (Jobes, 2012). CAMS is a unique therapeutic scheme that combines assessment and treatment planning between a patient experiencing suicidal thoughts and a clinician. Ellis et al. (2015) also explained that CAMS has been shown to be a therapeutic approach in decreasing suicidal ideation and death. Stanley and Brown (2012) developed a set of safety plan interventions (SPI) that consisted of a written, prioritized list of coping strategies and sources of support that patients can use to prevent a suicidal crisis. The basic components of the SPI included the following: recognizing warning signs of an impending suicidal crisis; employing internal coping strategies; utilizing social contacts and social settings as a means of distraction from suicidal thoughts; utilizing family members or friends to help resolve the crisis; contacting mental health professionals or agencies; and restricting access to lethal means.
According to Little, Neufeld and Cole (2018), suicidal thoughts and attempts can be decreased and lives may be saved if health care providers add safety measures into patient care, which will include screening to identify at-risk patients for suicide in all health care settings.

Practice Recommendations
Suicide is a serious public health concern with over 800,000 deaths annually; the rates have increased nationwide with the increase in pandemic cases, making suicide prevention a global public health priority (McCabeet al., 2018). In response to the question that guided this project, the literature supported the use of early intervention through screening patients at all health care settings for suicide symptoms. McCabe et al. (2018) reported that one in four people who complete suicide have had an encounter with a health care practictioner within twelve months of their death. This suggested that early engagement and therapeutic intervention focusing on theories of suicidal behavior as well as ongoing follow up contacts might help identify and decrease the rate of suicide (McCabe et al., 2018).
There are practice recommendations guided by national guidelines developed by the U.S. (2019) Based on the empirical literature and evidence noted, the following practice recommendations were implemented: educational intervention for patients to discuss the treatment, condition, and methods that was utilized to protect them. The nurse should provide both verbal and written information regarding crisis hotlines such as the National Alliance on Mental Illness and should assess the patient for making healthcare decisions. The second recommendation was for the facility to provide educational intervention for the nurses using the C-SSRS instrument, interactive role-play, and teach-back methods. The third was to provide safety planning (remove cords, move patients closer to nurses' station, discuss plans with family or support system, and call the physician while activating the behavior team). The fourth was that once the patient is discharged from the hospital to close the loop within 48 hours by calling, texting, or emailing the patient (The National Action Alliance for Suicide Prevention, 2018).

Department of Veteran Affairs
All the articles presented supported patient safety through the early identification of suicidal behaviors in all settings. The ten articles used for this section were levels I and II with grade As and Bs based on the John Hopkins evidence level and grade quality along with the mental health organizations [Hopkins Medicine, n.d.] (see Appendix A). Research supported that suicidal ideations and suicide attempts can be decreased if healthcare providers screen patients and identify suicidal behaviors during the initial encounter (Bolster et al., 2019). This recommendation, derived from the various sources of literature and mental health institutions, led to the selection of the interventions for the PICOT question based on substantial information to support its efficacy when using the safety bundles that included screening patients with C-SSRS tool and using CAMS and SPI on patients that screen positive for suicidal behaviors.
The evidence-based practice change was the creation of a protocol for the use of the C-SSRS tool upon admission of patients to any medical-surgical unit and implementing CAMS and Safety Plan Interventions when patients are identified at risk. Sustainability consisted of an annual staff meeting and the development of medical-surgical department policies to include the protocol created for the DNP project to decrease suicidal risk for patients.

Project Setting
This evidence-based practice change project was conducted at a not-for-profit, west-Texas hospital that serves Midland County and its surrounding region. It is the only hospital in Midland, Texas, and delivers care to pediatric, adult, and geriatric patients with medical or surgical needs. The hospital serves a diverse population that includes all of the cities that surround Midland, including urban, suburban and rural areas. The mission of the organization is to create an environment that supports the healing process and that improves the health and wellbeing of the community (Midland Health, 2020). The vision of the hospital is for Midland to be the healthiest community in Texas (Midland Health, 2020). The culture embraces a caring partnership, community outreach, and a care-delivery model of patient-and family-centered care.
The organization meets the needs of a dynamic community, the organizational structure includes a president, vice president, and the board of directors who oversee the health board, executive team, and senior leadership (Midland Health, 2020).
A combination of best practices as found in the literature and a desire to decrease suicidal ideation and deaths established the organization's desire to implement the use of C-SSRS and the application of SBBP on non-psychiatric patients (R. Powers, personal communication, May 13, 2020). The evidence-based practice change was the creation of a protocol for the use of the C-SSRS tool upon admission of patients to the medical-surgical unit, on every shift, and before discharge. The protocol also included implementing CAMS and Safety Plan Interventions when patients are identified at risk. Sustainability will consist of an annual staff meeting as well as the development of medical-surgical department policies to include the protocol created for the DNP project to decrease patient suicidal risk. There was strong evidence that the use of screening tools and the application of safety bundles results in detecting suicide ideation and decreasing suicide attempts (Appendix A). Organizational support was confirmed by personal communication with the Director of Patient Services (R. Powers, personal communication, May 13, 2020).
The stakeholders are the president, vice president, clinical director, education director, executive team, information technology, medical directors, nurses, preceptor, and this DNP student. The SWOT analysis can be used to plan the development of an organization and can also be used for a goal that requires strategic planning (Good, 2020). The strength of an organization includes internal factors such as financial resources, human resources, facilities, equipment, processes, and systems (Good, 2020). Weaknessess were factors that prevent the organization from achieving the stated goals. Opportunities were positive factors that influence the growth of the organization such as climate, market trends, environment, and funding (Good, 2020). Threats were issues that could hinder the development of the organization.
The strength of the organization included dedicated staff, teamwork, quality transparency, experienced providers, support from the leadership team, and improved medical technology. Weaknesses were a lack of screening protocols for patients at risk for suicide on the non-psychiatric unit and a lack of provider training regarding a standardized procedure for screening suicidal patients. Despite its excellent performance, the organization had opportunities for more growth such as educational advancement and the motivation of key stakeholders to implement the evidence-based project.
The organization was faced with the threat of costs, time constraints, and the resistance to change by the staff. However, research showed that interprofessional collaboration can allow professionals from different fields to collaborate and provide high-quality care with the goal of decreasing cost, decreasing medical errors, and improving health (Hinrichs et al., 2020).
Promoting collaboration among several healthcare providers is effective in managing comorbidities and in improving lives. Interprofessional collaboration is an important aspect of care delivery needed to accomplish excellent patient and system-level outcomes (Akuamoah-Boatenget al., 2019). The DNP student facilitated terprofessional collaboration to positively impact the outcomes of the project. A SWOT analysis is provided in (Appendix I).

Project Overview
This evidence-based change project was to deliver care in connection with the hospital's mission and vision statement. The goal is to offer healthcare that is representative of the diversified community it serves. The mission for this project was to implement the use of the C-SSRS tool and apply a SBBP on non-psychiatric patients to identify suicidal ideations and decrease suicide death. The vision for the project was to promote the lives of patients by working with the interprofessional team to provide patient-centered and high-quality safety measures for suicide prevention. Safety bundles included the use of CAMS and Safety Plan Interventions.

Short-Term Objectives
The hospital's short-term goal was to create a facility protocol of early identification of patient risk for suicide on the medical-surgical unit with the use of an evidence-based reliable and valid tool such as the C-SSRS and the implementation of a SBBP once a patient is deemed "at risk." The second goal was to prevent patient from any self-harm related to suicide attempts.
The screening occurred during the second month of project implementation. Additional short-term goals included 100% nursing adherence in performing the screening utilizing the correct instrument and documentation. All nursing staff (registered nurses) completed the educational training within the first two weeks of implementing the project. The performance rates of conducting the suicide screening were measured by the numerator, which defines the desired action. The staff needed time to adjust to implementing a new task in their area. For this evidence-based practice change project, the overall short-term objectives were to increase the nursing staff's knowledge and implementation of suicide screening in non-psychiatric patients.

Long-Term Objectives
The long-term objective was to ensure the use of the screening tool by the nurses and the application of SBBP in identifying at-risk patients for suicidal behaviors during an inpatient stay in order to prevent incomplete and complete suicides. Currently, the hospital has had nine records of discharged patients who committed suicide in the last eighteen months (R. Powers, personal communication, May 13, 2020). The inpatients were tracked by reviewing their medical history and by making a weekly chart audit. Protocols that were implemented included screening all patients using the standardized, evidence-based suicide screening tool on admission; reviewing the patient's medical history on every shift; implementing the safety bundle on any patients that says yes to any question on the C-SSRS tool; and reviewing the screening questionnaires with the patient or patient's family before hospital discharge. For patients with a positive screening, the protocol included notifying the doctor and getting an order for one-on-one monitoring, removing all items that patient could use to harm self, and notifying the charge nurse and the behavioral team.
The behavioral team intervened by using CAMS and SPI as discussed in (Appendix F).
Consistent screening promoted early suicide detection rates as the result of the project. The longterm goal included ensuring compliance with on-going annual training for the staff.

Risks and Unintended Consequences
For the participants that were screened positive for risk for suicide, the safety bundle was implemented and the behavioral team activated for a mental health professional to assess and create a plan of care for such patients. A few risks and unwanted consequences of the project included unwilling participants, non-buy-in from staff and nursing administration, resistance to change by the providers, increased time to implement the project because of unforeseen circumstances, and costs of educating staff. Additionally, risks involved were lack of reporting or documenting suicidal risk by the nurse and the subsequent lack of SBBP. The project manager and the charge nurses reviewed the C-SSRS assessment for follow-through of the protocol to promote patient safety. The Havelock's Theory of Change was used to create the change process.

Project Plan (Method)
The evidenced-based model that guided the development and implementation of the project is Havelock's theory of change (1973). The rationale for using this model was to help to thoroughly obtain and understand information for carrying out the evidence-based project and to improve patient outcomes. Havelock's Theory of Change builds on Lewin's change theory, which stated that there are two paths in examining stages of an intervention. The first path was to see things from the viewpoint of the individuals being changed, and the second path was to know the position of the person creating the change (Havelock, 1973). For many nurses, change was hard because most people prefer traditional methods (Kodama & Fukahori, 2017). They prefer to continue using a method that has worked versus trying something new. The project manager was a change agent with four roles: catalyst, solution giver, process helper, and resource linker. This model summarizes three approaches for one to accept a change. The first was problem-solving, the second was social interaction, and the third was research development directed by five assumptions. The assumptions were the rationale for the change, planning, division of labor, passive consumer, and initial development costs (Havelock, 1973). Havelock's model utilizing change-agent roles, strategies, and assumptions has shown how an empowered staff could improve the quality of patient care by using the C-SSRS tool for medical-surgical unit patients. Havelock's model also offered a six-step sequence for staff adopting a new change intervention. The six steps included establishing a client relationship, establishing the need for change, securing the necessary resources, selecting the appropriate method, accepting and adapting the chosen strategy, and directing the individual in self-renewal (ability to change).
The project manager already established a relationship with the client system (as a nurse leader for the hospital). Interacting with the staff and nurse managers has allowed the project manager to develop positive relationships. The project manager enlisted viewpoints from the night and day shift nurses to help develop the project. The second phase is diagnosing the opportunity for change (Havelock, 1973). The project manager collaborated with the nurse manager, nurse liaison, and other disciplines for the input of ideas by brainstorming. The project manager considered the staff issues (strengths and weaknesses) related to patient care. In collaboration with the various individuals, the project manager was able to select the most appropriate strategy to implement suicide screening on the medical-surgical unit.
The resources used for the project were the nursing manager, nursing liason, patient safety manager, charge nurse, clinical manager, and nurse educator. The accepting and adapting phase use the chosen method of pre-intervention, intervention, and post-intervention as well as the suicidal screening tool as the method of implementation. The last stage involved the project manager guiding the staff into self-renewal ability to change (Havelock, 1973). The implementation of this project and sustainability led to staff empowerment and assimilation of change (Havelock, 1973). The project manager reassessed the project's effectiveness within two months of exceuting the project. During this time, the collaboration team assisted with orienting new nurses including students, new hires, and registry nurses.
The step-by-step method of how the project was implemented is as follows: a. Hold initial meetings with interprofessional team members (preceptor, nurse manager, charge nurse, and administrators to gain support and approval for the DNP evidence-  i. Begin staff screening of all patients age 18 and up with C-SSRS tool for suicide risk upon admission to the medical-surgical unit. j. Screening will continue to be performed by nurses on every shift; any patient that answers "yes" to any of the questions on the screening form will go through the intervention process, which is implementation of the Safety Bundle of Best Practices (CAMS and SPI). Behavioral team will be activated.
k. Remind all nurses that the Safety Bundle of Best Practices must be followed for each patient, the same way, every shift, and at discharge, collect data after seven days, two weeks, one month, and two months after implementation of intervention, perform data analysis and evaluation, and disseminate project results.
Patients identified at risk received the Safety Plan Intervention, part of the SBBP included obtaining order from provider to place patient on one-to-one monitoring and notifying behavioral team for mental health professional to assess the patient. The nursing staff checked patient environment and removed items such as cords, clothing, knives, metal, belts, shoelaces or anything that the patient could use to harm themselves. Additionally, the nursing staff initially met with patient and obtained permission to sit and talk, followed by encouraging patient to describe their psychological pain, stress, agitation, hopelessness, self-hate, and suicide risk. It is essential that nursing staff establish and document a plan to facilitate patient coping skills with current crisis. Nurses documented on paper and in the EMR if patients were assessed to be suicidal and if the SBBP was initiated.
A copy of paperwork was given to patient for the agreed upon Safety Plan. The additional Safety Plan Interventions included distraction, placing patient close to the nurse's station, and helping patient to explore resources for coping skills. The C-SSRS tool was in paper form. The nurses administered this form once every shift, at the end of which the forms were collected and submited to the charge nurses. The charge nurses gathered the forms and kept them in a locker in the nurse manager's office. Only the nurse manager and the charge nurses had access to the keys of the locker. The project manager collected the paper forms of the assessment for data analysis.

Interprofessional Collaboration
Interprofessional collaboration is often defined within healthcare as an active and ongoing cooperation between professionals from diverse backgrounds with distinctive professional cultures working together to provide services for the benefit of all healthcare users (Morgan et al., 2015). In a healthcare organization, interprofessional collaboration allows different providers from diverse professional backgrounds to work closely together with patients, families, and communities with the main goal of providing quality care (Schot et al., 2020). The interprofessional collaboration for this project occurred face-to-face with the hospital manager, director, administration, and DNP preceptor bi-weekly at the conference hall of the organization.

Budget
The budget proposal was agreed upon by the team and finalized by the end of the fourth week. Table 4 shows the breakdown of the proposed budget.

Data Collection
Data collection and assessment began at one-week, one-month and two-month intervals to evaluate whether implemented changes have led to improved outcomes. A retrospective chart audit was conducted prior to the implementation of the intervention. A minimum of 30 charts were audited prior to intervention, and a minimum of 30 patients were in the sample for which intervention will be implemented. A form as shown in (Appendix G) was used to collect information for the chart audits and another form as shown in (Appendix D) for data collection after the implementation of the protocol to analyze results. The project manager used deidentifying methods to adhere to confidentiality procedures. The paper survey did not contain the participant's name, birthdate, or employee number. The de-identified code consisted of the first two letters of the participant's middle name with the last four digits of their cell phone number.
There was no identifying data on any information obtained from the participants.
Data collection began with retrospective chart audits of the current-practice process of suicide risk assessment which consisted of asking the patient if they had suicidal ideation at admission as well as measures taken to protect the patient from harm, including monitoring through the use of a telemonitor (the telesitters are staff that continuously watch the patient's activities at the camera monitoring station). Data collected for the evidence-based practice change included the use of the CSSRS tool and the start of the SBBP when at-risk patients were identified. A data collection sheet tracked the patient by admission date, their responses to suicidal ideation, whether a monitor camera was used, and if the SBBP checklist was initiated.

Project Timeline
There was collaboration meetings among the chair, the DNP preceptor, and the project manager weekly or bi-weekly according to the development of the project. Interprofessional collaboration meetings occurred bi-weekly throughout the implementation of the project.
Throughout the first weeks, several other meetings took place: the stakeholder's meeting, the budget proposal meeting, the Evidence-Based Practice Project Review Council (EPRC) submission meeting, and the meeting between the Nursing Chair and the DNP preceptor.
Submission to the Nursing Research Review Board and Institutional Review Board (IRB) was completed by the third week for the approval of the project.

Barriers and Facilitators
Anticipated facilitators for these collaborations included brainstorming, administrative support, and supervised guidance by the DNP preceptor and chair. Barriers to the implementation of the project were assessed that could have been a delay in implementation due to the ongoing pandemic, lack of funds, or the nurses' resistance to change. The education and training for the nurses and staff took place between the third and the seventh weeks. A schedule of the evidence-based practice change is shown in (Appendix C). The expected benefits included administrative support, interprofessional collaboration and improved patient outcomes. Barriers included lack of funds to coordinate training of staff and resistance to change by the providers.

Project Results
The evidence-based project was evaluated by the outcome measures as described in the PICOT question. This section includes the data collection, data analysis, data storage, and data sources' integrity. Other segments comprised the integrity of the process, evaluation design, project setting and environment, comparison data, and how the intervention impacted the current use of suicidal screening. The last sections consist of HIPPA, recruitment process, participants, selection of participants, and how the project manager handled the missing data. The categories of measures discussed include outcome, process, balancing, finances, and sustainability.
The purpose of this evidence-based change project was to implement the use of the C-SSRS tool (Appendix D) in identifying patients at risk for suicide upon admission to the medical-surgical unit and to initiate the SBBP when risk was identified, comparing the outcome to that of the current practice of simply asking patients if they have suicide ideation and documenting "Yes" or "No." The nurses screened all patients age 18 and older using the C-SSRS tool upon admission to the medical-surgical unit, at every shift, and at discharge. If "yes" was answered to any of the C-SSRS questions, an intervention process occurred utilizing the SBBP in (Appendix F) that comprised the CAMS and the SPI in managing suicidal behaviors.
Suicidal patients were assessed by the nursing staff, then received orders from the doctor to put the patient on one-on-one monitoring, activating the behavioral team. The behavioral team included the psychiatrist, medical doctor, registered nurses, charge nurse, and therapists. Any items such as cords, clothing, knives, metal, belts, shoelaces, or anything that patients could use to harm themselves were removed (Columbia University Department of Psychiatry, 2018).
Compliance with the education and training was monitored by the facility's Director of Safety.

Recruitment and Selection of Participants
Recruitment and the selection of the participants began once the project manager received IRB approval from the university. All participants were informed that the project was voluntary.
Informed consent by the participants was provided with a signature. The evidence-based project was conducted in a non-psychiatric (medical-surgical unit). A total of 32 patients participated in the evidence-based practice project. The inclusion criteria were any admitted adult patient ages 18 and above who stayed during the specified time. The exclusion criteria included individuals younger than 18 years and those diagnosed with mental illness or disability.
A chart audit of 32 patients was done dated back to two months prior with the form shown in (Appendix G); this was compared with the post-data after the implementation of the practice-change project. The rationale for collecting the pre-and post-intervention data was to determine whether the intervention made any impact on outcomes of the evidence-based project.
A purposive sampling was used because it was easy and convenient for the facility (Elil & Negida, 2017). The sample size was met for the evidence-based project (n=32). Other participants in the project were the Director of Patient Care, Director of Safety, and 15 full-time medical-surgical nurses who worked on the floor 7am-7pm and 7pm-7am.

Data Collection
The project was implemented after obtaining permission from the University of St.
Augustine for Health Sciences (USAHS) Evidence-Based Practice Review Council and the facility. Patients were given details about the project, and their consents were obtained before they participated in the project. Clinicians and nurses were given a questionnaire to assess their knowledge of and experience using the C-SSRS tool with education and training to use the tool.
The patient questionnaires were collected on every shift by the charge nurses that placed them inside a sealed envelope and securely transported them to the unit manager's office where they were placed in a locked file cabinet. The C-SSRS and the SBBP for each patient were deidentified using codes with numbers. Electronic data was kept on a Microsoft Excel 2016 spreadsheet and accessed using an encrypted computer password accessible only to project manager. Confidentiality measures were utilized per the university's IRB, hospital guidelines, and the Belmont Report. The questionnaires and any other data collected associated with the evidence-based project will be destroyed in three years per USAHS's protocol.

Instrumentation and Permission to Use C-SSRS
The C-SSRS is a questionnaire that was developed by Columbia University to assess for suicide; the protocol is evidence-supported and backed by the National Institute of Mental Health

Protection of Human Rights
The DNP project proposal was submitted to and implementation approved by the EPRC review committee. Strict adherence was followed by using the Belmont Report to ensure the participants' protection and privacy. The C-SSRS and the SBBP for each patient were deidentified using codes consisting of the first two initials of the participant's middle name and the last four digits of the cell phone number (X: ST7736) and were kept in a locked file cabinet.
Patient information was protected according to HIPPA guidelines. There were no conflicts of interest encountered or reported during the implementation of the project.

Validity
The validity of the C-SSRS tool has been determined by high sensitivity and specificity for suicidal behavior in comparison with other behavior scales and independent suicide evaluation boards (Posner et al., 2011). The validation of the tool was confirmed in three multisite studies conducted by Posner et al. (2011): a treatment study of adolescent suicide attempters (n=124), a medication efficacy trial with depressed adolescents (n=312); and a study of adults presenting to an emergency department for psychiatric reasons (n=237). The C-SSRS tool shows good convergent and divergent validity with other multi-informant suicidal ideation and behavior scales (Posner et al., 2011).

Reliability
Reliability has been reported in many studies (Madan et al., 2016;Mundt et al., 2013;Na et al., 2018;Viguera et al., 2015;Youngstrom et al., 2015). The internal consistency of the tool is high with a Cronbach's alpha of 0.937 and 0.946 (Posner et al., 2011). Other studies such as confirm that the C-SSRS is a valid measure for suicide risk assessment.

Data Analysis
The questionnaire was given to the patient upon admission into the medical-surgical unit, every shift, and at discharge. A demographic survey was obtained from the EMR which includes the gender, age, ethnicity, employment, and level of education presented as ungrouped frequency distribution (Sylvia & Terhaar, 2018). Descriptive statistics were used to analyze and document the selected population and the sample size (Leedy & Ormrod, 2011). Categorical responses were used to analyze the mean, mode, and median (Sylvia & Terhaar, 2018). A paired sample ttest was conducted to compare the C-SSRS data before and after the eight-week implementation period. The higher the C-SSRS risk score, the more likely a person is at risk of engaging in suicidal behavior. At the start of the assessment period, pre-intervention data yielded a C-SSRS risk score mean of .81; following the eight-week implementation period post-intervention data yielded a C-SSRS risk score mean of 0.75 (see Table 2). There was a marginally significant difference between the means at pre-and post-intervention, indicatining lower suicidal risk at post-intervention, t (31) = 1.87, p = 0.07). These findings are documented in Table 3.

Paired Sample t-test
A paired sample t-test was used to analyze the participant's risk for suicidal behavior upon admission and discharge from the hospital; this comprised the use of the C-SSRS tool by the admitting nurse and the discharge nurse on the unit. Statistical significance was defined as a p-value of less than 0.05. The results of the answered questionnaires were compiled and saved using Microsoft Excel Spreadsheet (2016). Pearson's r was used to determine the strength and direction of the relationship between the variables.

Data Storage and Integrity
The data was collected and analyzed by the project manager. Patient information was protected by strictly using de-identifying information. The hospital HIPPA policies were strictly adhered to in preventing loss of patient identifiers and maintaining confidentiality procedures.
The hard copies of any C-SSRS assessments, the patient's SBBP plan, and data collection documents were kept in a locked file cabinet in the nurse manager's office to ensure privacy. The documents will be destroyed at the required time per USAHS's protocol.

Handling of Missing Data
Missing data is described as the information that is not stored in a variable of interest; this can threaten the validity of the project and reduce statistical power (Kang, 2013). The project manager handled missing data by narrowing down data collection to those who participated in the project. Two charge nurses (one day and one night shift) assisted with the data collection to prevent missing data (Kang, 2013). To ensure the evidence-based project's validity, the nurse manager and the project manager conducted a chart audit of the electronic medical records four weeks prior-and post-implementation. Any participant who had over 50% of the preintervention/post-intervention test information was not used in the project.

Data Security
Data was safely stored in a locked cabinet in the office of the Director of Patient Care and only the project manager had access to the keys. Necessary information will be destroyed after use according to the University's protocol. The project manager's laptop is company-issued and maintained in a locked office accessible only to the project manager. The documents will be destroyed at the required time per USAHS's protocol. Data will be erased from the laptop using ERASER software and hard copies will be placed in a Shred-It container at Staples.

Process and Outcomes Measures
The outcomes evaluated are decreased suicidal ideation and suicidal behaviors in nonpsychiatric patients as these outcomes are important in addressing the practice problem. A preintervention chart review of 32 patients in a medical-surgical unit was made dating back to two months before implementing the project for comparison data. Screening was conducted on patients by administering the C-SSRS questionnaire upon admission into the medical-surgical unit and telemetry unit. The C-SSRS tool was administered on every shift and at discharge. Data was collected and analyzed, and the approaches that were used to determine the success of the project and whether the outcomes were related to the interventions were the selection of quality measures and utilization of appropriate statistical analysis to compare baseline data to data collected after implementation of interventions (Sylvia & Terhaar, 2018).
Training and education were provided to the nurses on how to use the screening tool; this included how to implement the safety bundle on patients identified at risk for suicidal behaviors.
The project manager created a compliance checklist as shown in (Appendix E) that identified the non-compliant nurses. The Director of Patient Care frequently reminded the nurses to use the tool with the safety bundle effectively. Education on the use of the C-SSRS and the safety bundle was done weekly and bi-weekly for the first four weeks of the intervention on both shifts.
Process measures included nurses' and clinicians' compliance with using the C-SSRS as a first-line screening tool upon patient arrival into the non-psychiatric unit; nurses' and providers' compliance with education and training on the use of C-SSRS tool; clinicians' and nurses' compliance with timely administration of C-SSRS upon patient arrival to the unit; nurses' and clinicians' compliance with the use of safety bundles (Appendix G). Balancing measures included ensuring that suicidal ideations were identified and that suicidal behaviors do not increase throughout patients' stay in the non-psychiatric unit. Financial measures included the cost of providing training, education, and overtime cost due to training. The sustainability measures include on-going education and training of nurses and clinicians, compliance with the use of the screening tool in identifying at-risk patients, and early assessment of suicidal behavior.

Outcome Measures
The CSSRS Tool helped to identify patients at risk for suicide, telemonitoring assisted with decreasing the risk of patient self-harm, and the Safety Bundle of Best Practices initiated for at-risk patients decreased the risk for patients at risk for self-harm.

Benchmarks
The three benchmarks met were 100 % of CSSRS screening for the patient at risk for suicidal ideation by the nursing staff, 100% of appropriate patients placed on telemonitoring by the nursing staff, and 100% nursing staff initiation of Safety Bundle of Best Practices with documentation of which safety practice was implemented for the patient.

Impact
Suicide is a public health issue that affects people locally, nationally, and globally. The impact of suicide causes a great deal of pain, depression, impairment, and poor quality of life in loved ones left behind (Aquila et al., 2020). Suicide can be a serious symptom of several mental illnesses including depression, bipolar disorder, schizophrenia, and substance abuse. Adequate screening is important to detect suicidal ideations and to prevent suicidal behaviors (Sadock & Sadock, 2014). This project's primary outcome showed that the implementation of C-SSRS and the SBBP on the non-psychiatric unit decreased suicidal behaviors and deaths.
The clinical findings suggested that there was a marginal difference between suicide risk among medical-surgical patients following the eight-week period of implementation of the C-SSRS, such that suicide risk only appeared to decrease. However, since pre-intervention data revealed that the mean score for suicide risk collected eight weeks prior to implementation was higher than the mean eight weeks after the implementation, it can be inferred that suicide risk decreased over time. It shows promise for a clinical significant implication for a practice change.
Plans are underway to include the C-SSRS tool in the electronic health record of the facility site.

Limitations of the Project
During the planning and the implementation phase, some limitations were encountered. (Simon & Goes, 2011). One of the limitations encountered was the small sample size, which was limited to the medical-surgical unit. The sample size was 32 (n =32), with females, n = 15; males, n = 17, resulting in a lack of sufficient power, a condition known as "underpowered." It was noted that the small sample size did not validate the outcome of the project. A larger sample would have allowed more evaluation of the data, improved the data accuracy, preventing potential errors and limiting bias (Leedy & Ormrod, 2011).

Limitations define the restrictions or constraints beyond an individual's control
Another limitation was not having sufficient time to carry out the implementation; eight weeks was a short time frame and the changes brought about by the COVID-19 pandemic. Many nurses had left to care for their loved ones with Covid-19, the limited nurses were rotating to other departments, the facility had to rely on travel nurses who focused more on ensuring patient safety and reducing deaths. The shortage of staff and limited leadership support made it difficult for some of the nurses to participate in the project.
The use of the C-SSRS tool in (Appendix D) and the SBBP in identifying patients at risk for suicide upon admission to the medical-surgical unit is very important in decreasing suicidal ideations and behaviors (Ellis et al., 2015). The project has altered practice and addressed the practice problem of not having a protocol in place for nursing staff to screen medical-surgical patients for suicidal risk. Nurses and clinicians are now aware of the importance of adequately screening patients for suicidal behaviors at every shift. The future implications of the project include the continuous use of the C-SSRS and the SBBP by the nursing staff on the medicalsurgical unit to decrease suicidal behavior.
There needs to be continuous education and training of clinicians and nurses to maintain the sustainability of the intervention over time. Incorporating the screening tool in the EMR of the facility for daily monitoring of patients on the non-psychiatric unit in identifying suicidal behavior will ensure an ongoing evaluation of effectiveness.

Plans for Dissemination
The development of a dissemination plan is an essential component of an evidence-based process (Edwards, 2015). A 40-minute PowerPoint presentation of the project findings was given for the stakeholders, allowing feedback from everyone; members that couldn't attend were encouraged to watch the presentation through Zoom. The project findings will also be disseminated through a PowerPoint presentation at the Summer, 2021, Texas Association of Psychiatric Nurse Practitioner conference in Dallas,Texas, and at the American Psychiatric

Nurses Association West Texas region. The Journal of American Psychiatric Nurses
Association, which is a peer-reviewed journal and the largest resource for psychiatric-mental health and preventive nursing, has been selected for publication.

Conclusion
The Center for Disease Control and Prevention, (2018) has emphasized the increased suicide rates within the last decade. The need for suicidal screening has intensified with the COVID-19 pandemic and its financial and emotional obstacles. This project has illuminated the need to improve screening approaches in identifying high-risk individuals. Utilizing a multipurpose suicide-risk screening instrument allows a healthcare provider to better identify such persons (King et al., 2017). This project helped identify opportunities for improving and implementing policies that can be used for high-risk suicidal medical-surgical patients. Early detection is an essential part of the prevention strategy, and many individuals who commit suicide visit a healthcare provider months before their demise (NIMH, 2020). Practitioners must seize opportunities to identify individuals at risk and to connect them with the best available mental health resources.    Having compared all the interventions in the study, it is evident that brief psychological interventions appears to be effective in reducing suicide and suicide attempts.

Health Literate Care Model
Although the evidence base is small, brief psychological interventions appear to be effective in reducing suicide and suicide attempts.
It was discovered that two trials that measured suicidal ideation found no impact. Two studies showed fewer suicide attempts, one showed fewer suicides and one found an effect on depression. Usefulness: The interventions could potentially be adopted for inpatient and other outpatient settings. Early engagement and therapeutic intervention based on psychological theories of suicidal behavior, sustained in follow-up contacts, may be particularly beneficial.  screening program was designed and developed in a large safety-net health care system.
than 40% in the emergency department (ED), and slightly less than 5% in the hospital inpatient units. In the ED, 6.3% of the screens were positive, as were 1.6% in the inpatient units, and 2.1% in the outpatient clinics. The odds of a positive suicide screening in the ED was 4.29 times higher than the inpatient units and 3.13 times higher than the outpatient clinics. The cases showed some of the difficulties that have been part of the debate concerning a classification system for suicidal behaviors.
81% of patients reported that they believed all medical/surgical A total of 387 C-SSRS interviews had been conducted and 36 cases had been discussed and tracked by study group. Out of the 113 interviews conducted at baseline, an attempt (actual, aborted, or interrupted) or preparatory behavior was reported in 105 (92.9%) interviews. Self-report of suicidal intent can be highly complicated by ambivalence of intent, and circumstances of the evaluation.
It was concluded that patients should be asked directly about suicide. Mental health should also be an Research has repeatedly suggested that ED patients have significant undetected suicide risk. This the first study to address the key question of whether detection feasibly can be increased by implementing universal suicide risk screening protocols in the ED.
None clearly stated patients in a hospital should be screened for suicide risk; 9.5% disagreed, andanother 9.5% reported they don't know.
The first outcome, documentation of intentional self-harm ideation or behavior screening, was defined broadly as any documentation of past or current intentional self-harm ideation or behavior appearing in the record as either present or absent. The second outcome, intentional self-harm risk detection, was defined as past or current intentional self-harm ideation or behavior integral component in the delivery of medical care for patients.Also, every provider should be educated on the importance of intervening, protecting, and keeping patients safe in a hospital setting.
Across the three phases (N1⁄4236,791 ED visit records), documented screenings rose from 26% (Phase 1) to 84% (Phase 3). Detection rose from 2.9% to 5.7%. The majority of detected intentional self-harm was confirmed as recent suicidal ideation or behavior by patient interview.
Usefulness: If these findings remain true when scaled, the public health impact could be tremendous, because identification of risk is The papers included in this review were peerreviewed and published in English.
Articles that did not focus on the screening or assessment of suicide risk were discarded.
It is a qualitative review of literatures.
Sleep disturbances in general are both a risk factor and potential warning sign for suicide. Not all patients presenting with suicide risk will have a history of psychiatric illness.
Using evidence-based risk screening tools, such as the Columbia suicide severity rating scale (C-SSRS), is recommended despite insufficient evidence to date on the outcomes of suicide risk screening. It is recommended that sleep clinicians be aware of idiosyncratic instances of emergent suicide risk that could result as part of standard care and monitor patient access to hypnotic medications during highrisk periods due to increased risk for inducing parasomnia and self-injurious behavior.
For sleep clinic professionals who do not have the time to comprehensively assess and manage suicide risk, Universal suicide risk screening in the ED was feasible and led to a nearly twofold increase in risk detection. If these findings remain true when scaled, the public health impact could be tremendous, because identification of risk is the first and necessary step for preventing suicide.

Collaborative Assessment and Management of Suicidality (CAMS)
Staff will initially meet with patient Obtain permission to sit and talk Encouraging patient to describe their psychological pain, stress.
Encouraging patient to describe their agitation, hopelessness, self-hate, and suicide risk.
Developing plan to ensure coping skills with current crisis Asking patient for their problem drivers.
Documentation will be done on a paper form.
Copy of paperwork will be given to patient.

Interventions include using distraction
Placing patient close to the nurses' station

Removing lethal means
Helping patient to explore resources for coping skills Follow-up every two hours until patient is discharged home Follow-up with resources and patient in 48 hours of discharge.

Brochure for Nurses
Using the Columbia-Suicide Severity Rating