Immediate safety
- Place in safe room (ligature-free, no sharps, no cords); remove belongings
- 1:1 sitter at all times — line of sight, never leave alone
- Search patient & belongings for weapons / pills / sharps
- Hospital gown only; lock up clothing & personal effects
Risk stratification (C-SSRS quick screen)
- Wish to die? · Active thoughts? · Method? · Intent? · Plan?
- Past attempt within 3 months → high acute risk
- Access to lethal means (firearms, large pill supply) → high risk
- Document plan/means/timeline, protective factors, supports
Medical clearance
- Vitals, glucose, focused exam (rule out trauma, intoxication, AMS)
- Targeted labs only if indicated (acetaminophen + salicylate + EtOH after OD)
- Pregnancy test in females of reproductive age
- ECG before QT-prolonging meds
Acute agitation / refusing care
- Verbal de-escalation first; offer PO meds (lorazepam 1–2 mg, olanzapine 5–10 mg ODT)
- If unsafe: midazolam 5 mg IM ± haloperidol 5 mg IM (B52 alternative)
- Place on involuntary hold per state statute if refusing & high acute risk
Disposition
- Psychiatry consult / crisis team for all moderate-high risk
- Inpatient psych admission for high acute risk, plan + means, recent attempt
- Safety plan + lethal-means counseling + 24-h follow-up if discharged
- National suicide line: 988