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Patient Safety Tip of the Week 

February 9, 2010 

More on Preventing

Inpatient Suicides

In the year that has gone by since our January 6, 2009 Patient Safety Tip of the Week “Preventing Inpatient Suicides” there have been several very informative articles pertaining to inpatient suicides. Keep in mind that suicides may occur in general hospitals as well as psychiatric hospitals so you need to be cognizant of the risks regardless of what type of facility you have.

An excellent review of inpatient suicides (Tishler 2009) emphasized that individual risk assessment is critical and that one of the biggest mistakes made is that decisions about managing suicide risk are often made based upon staffing levels rather than the individual patient’s risk assessment. In fact, Tishler et al caution against relying too heavily on risk factors or predictors taken from previous studies because those often don’t provide a good assessment of current risk. Rather they make the case for determining the presence of warning signs or immediate “red flags”. They make the distinction between chronic and acute risk factors, the latter tending to be more predictive of suicide and including symptoms such as severe anxiety, agitation, and severe anhedonia.

A study from Taiwan (Cheng et al 2009) compared psychiatric inpatients to “nonpsychiatric” inpatients who attempted or completed suicide in general hospitals and found some very important differences. Patients who attempted or committed suicide in general hospitals were older, more likely male, had more chronic physical conditions, and were more likely to attempt suicide in the first week of admission and use more violent means than those patients who were admitted to psychiatric units. They were also more likely to attempt suicide at night or while absent without leave and less likely to have communicated suicidal intent. Delirium and substance abuse were also more common in nonpsychiatric patients who committed suicide. Tishler et al (Tishler 2009) also noted that patients with delirium or dementia that is associated with agitation or impulsivity are at increased risk for suicide. Like the Cheng study, Tishler et al also noted that patients who attempt or commit suicide on general hospital units are more likely to be male and older, have agitation or delirium, have pain or other physical distress related to their medical or surgical condition, and often have factors such as poor family relationships, divorce, unemployment, bereavement, or a poor prognosis for longevity.

And when we are talking about “nonpsychiatric” patients above, we are not talking about the overdose patient who is temporarily admitted to an ICU until medically stable enough to be transferred to an inpatient psychiatry unit. Those patients usually get sufficient attention to suicide risk and close observation. Rather, we are talking about patients admitted to a med/surg unit with primarily a medical problem who go on to attempt or commit suicide, usually to everyone’s surprise. We don’t do a very good job of assessing suicide risk in the medical/surgical patient nor have we really come across any good tools for assessing that risk. Note that in some cases we may even enable it. We’ve talked before about the value of moving the delirious patient to a room that has more natural daylight. Well, some of these rooms also have windows from which someone can jump! So the choice of rooms needs to consider whether the windows can be opened from the inside or whether there are protective screens. Also keep in mind that patients on med/surg floors are more likely to have access to things like plastic trash can liners and cleaning materials (see below) that can also be used for suicide attempts. And whereas we may do a good job of removing suicide hazards from the environment on a psychiatric inpatient unit, the patient on the med/surg unit has access to sharps, tubing, loopable items and more easy egress for elopement (Bostwick et al 2009).

And one other good caveat: when we put a patient on 1:1 observation, whether for suicidal risk or because of delirium, we also need to remember it is not practical for any one individual to remain continuously vigilant for long periods of time nor should they be engaged in other activities. Tishler et al (Tishler 2009) recommend changing the observation person every two hours to avoid burnout.

Elopement/absconding is an issue that appears in many articles on inpatient suicide. That is these are inpatients who abscond/elope from the unit (either psychiatric unit or med/surg unit) and then commit suicide. A large study done in the UK (Hunt et al 2010) notes that such patients tend to be young, unemployed, and homeless with high rates of schizophrenia, previous violence, and substance abuse. They were also more likely to be involuntarily admitted to psychiatric units and likely to be noncompliant with treatment.

One of the more comprehensive studies on suicide focused on avoidable deaths (University of Manchester 2006). They confirmed that absconding from inpatient wards was a significant risk factor, particularly in the first 7 days. They note that wards can reduce absconding by:

• understanding the factors that trigger it, such as a disturbed ward environment or an incident affecting the patient

• making greater use of technology, such as CCTV or swipe cards, to observe and control ward entry and exit

The time immediately following discharge from an acute inpatient service is also a vulnerable period. 22% of the suicides in the Manchester study occurred between discharge and first followup appointment in community. They recommend regular assessment of risk during the period of discharge planning (or temporary leave) include:

• addressing stressors that will be encountered on leave and on discharge
• the patient having ways of contacting services if a crisis occurs during leave or after discharge
• early follow-up on discharge, including telephone calls immediately after discharge for high risk patients and face-to-face contact within a week of discharge
• support arrangements for people who discharge themselves from wards

The Manchester study was quite informative. Despite a substantial number of deaths, in only 28% of in-patient suicides did clinicians retrospectively view these deaths as preventable yet all such deaths should be regarded as potentially preventable. 22% of the in-patient deaths occurred in people who were (or were supposed to be) under observation, with 3% said to be under one-to-one observation. Two conclusions are clear from this. Firstly, intermittent observation regimens provide long gaps in observation and they are unsuitable for the care of high risk patients unless additional measures are taken, such as the observation of ward exits. Secondly, close observation must be strictly carried out. There should be no gaps in one-to-one observation and if a patient is to be observed every ten minutes, this time gap must be carefully adhered to. They also stressed that clinical staff need be diligent in removing non-collapsible curtain rails and eliminate other ligature (loopable) points, or at least make them inaccessible, with particular attention to hooks and handles on windows and doors. They also stressed risk factors for suicide, noting that those patients with dual diagnoses were especially at risk and that there are different antecedents of suicide in older patients.

Some lessons from our previous column “Preventing Inpatient Suicides” are also worth repeating. While suicide risk assessments are usually done on admission (though sometimes incomplete due to the patient’s inability or unwillingness to participate), the Joint Commission Sentinel Event Alert on suicides noted that reassessments are not well done.

We noted cases where patients have attempted suicide after locking themselves in the bathroom of the radiology suite (or other area in the hospital aside from the behavioral health units). We recommended use of a “Ticket to Ride” type communication tool for such hospital transports including special warnings and considerations for potentially suicidal patients so that all staff at the “receiving” end understand their responsibilities.

Also, the “sitters” commonly utilized to monitor the potentially suicidal patient on the non-psychiatric unit are often not specifically trained in assessment of the environment or management of the suicidal patient.

And standardized order sets for various behavioral health conditions, whether paper-based or computer-based, are now being developed and implemented in a more widespread manner. With use of computer order entry and clinical decision support tools, alerts and reminders (eg. to do a suicide reassessment) might be used to improve care.

There are also some good tools available that can help reduce the likelihood of patients committing suicide as inpatients. In our January 6, 2009 Patient Safety Tip of the Week “Preventing Inpatient Suicides” we noted that the VA has developed a mental health environment-of-care checklist that is available by e-mail request. Actually that checklist is now available online on the VA Patient safety website and there is a new article on use of that checklist in this month’s Joint Commission Journal on Quality and Patient Safety (Mills 2010). They implemented the checklist at 113 VA facilities and identified over 7000 potential hazards. A real value of the checklist is that it not only itemizes hazards but it is actually weighted by potential severity of the risk of each hazard (on a scale of 1 to 5). The commonest hazards they identified were anchor points that could be used for hanging. The second most common hazards were materials that could be used as a weapon against staff or other patients. Third most common were security issues that raised the risk for elopement. They also looked at the location of hazards and noted that bathrooms and bedrooms were a frequent site for hazards. Those two rooms obviously are potentially at greater risk for suicide because of patient isolation. Their discussion of the elopement risk is also quite good. They note certain areas (eg. physical therapy rooms, art rooms, group rooms, utility rooms, etc.) where it is important to identify that patients will not be left unsupervised and they discuss safeguards such as self-closing and locking doors. Though they discuss the use of video camera monitoring, they point out that it is unreasonable to expect staff to reliably monitor video screens for long periods of time. They also point out that, though they found materials for suffocation or poisoning less often, the high potential for lethality of those materials merits special attention. This would include items like plastic liners in trash cans and cleaning products. Those are especially important to look for on units other than psychiatric units. Overall, this is a very good checklist for conducting environmental rounds with a purpose of reducing potential risk for suicides.

The National Patient Safety Agency (NPSA) in the UK also has a toolkit on preventing suicide for mental health services. This includes the toolkit itself, a ward manager checklist and an audit tool. These tools address not only the environmental risks similar to the VA tool but also look at your systems for evaluation of patient suicide risk assessment, layout of your unit, observation policies, treatment plans, post-discharge plans and follow-ups, medication and compliance issues, and staff training and retraining. And don’t forget that you need to educate and train any agency staff that may be working temporarily on your units. And teaching family members or significant others what signs of symptoms to watch for is also very important. Very comprehensive tools.

Suicide on one of your inpatient services, whether psychiatric or med/surg, is a devastating event for families, your other patients, your staff, your community, and your reputation. You need to get a better understanding of your vulnerabilities and take action to mitigate the risks of potentially avoidable events.

References:

Tishler CL, Reiss NS. Inpatient suicide: preventing a common sentinel event. General Hospital Psychiatry 2009; 31: 103-109

http://www.ncbi.nlm.nih.gov/pubmed/19269529?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=11

Cheng I-C, Hu F-C, Tseng M-C M. Inpatient suicide in a general hospital
General Hospital Psychiatry 2009; 31: 110-115

http://www.ncbi.nlm.nih.gov/pubmed/19269530?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=3

Bostwick JM, Lineberry TW. Editorial on “Inpatient suicide: preventing a common sentinel event”. General Hospital Psychiatry 2009; 31: 101-102

http://www.ncbi.nlm.nih.gov/pubmed/19269528?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=5

Hunt IM, Windfuhr K, Swinson N, et al. and the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Suicide amongst psychiatric in-patients who abscond from the ward: a national clinical survey. BMC Psychiatry 2010; 10: 14

http://www.biomedcentral.com/content/pdf/1471-244x-10-14.pdf

University of Manchester. Five Year Report of the National Confidential Inquiry Into Suicide and Homicide By People With Mental Illness. Avoidable Deaths. December 2006

http://www.medicine.manchester.ac.uk/psychiatry/research/suicide/prevention/nci/reports/avoidabledeathsfullreport.pdf

Mental Health Environment of Care Checklist

http://www.patientsafety.gov/SafetyTopics/MHEOCC.xls

Mills PD, Watts BV, Miller S, Kemp J, Knox K. DeRosier JM, Bagian JP.

A Checklist to Identify Inpatient Suicide Hazards in Veterans Affairs Hospitals
Joint Commission Journal on Quality and Patient Safety. Volume 36, Number 2, February 2010 pp. 87-93(7)
http://www.ingentaconnect.com/content/jcaho/jcjqs/2010/00000036/00000002/art00006

NPSA (UK). Preventing suicide: a toolkit for mental health services

http://www.nrls.npsa.nhs.uk/resources/?entryid45=65297

toolkit itself

http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=65293&type=full&servicetype=Attachment

audit tool

http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=65295&type=full&servicetype=Attachment

ward manager checklist

http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=65296&type=full&servicetype=Attachment

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What's New in the Patient Safety World?

February 2010

·Joint Commission Sentinel Event Alert on Maternal Deaths

·Rapid Response Teams Still Not Cutting It

·NEJM Infection Control Articles

·Preoperative Testing for Non-Cardiac Surgery

Joint Commission Sentinel Event Alert on Maternal Deaths

The Joint Commission has issued a new sentinel event alert “Preventing Maternal Death”, pointing out that maternal mortality rates may be increasing. Previous studies have shown that hemorrhage, complications of hypertension, pulmonary embolism, amniotic fluid embolism, infection, and pre-existing conditions are the major causes of maternal mortality. Black women, older women, and women who lack prenatal care are at greater risk of dying during pregnancy. The rise in the prevalence of obesity and its complications may be making coexisting medical conditions more important in leading to morbidity and mortality. They also note that significant morbidity is 50 times more common than mortality.

They cite studies putting the percentage of preventable maternal deaths at between 28 and 50%. Prior studies of preventable maternal deaths have identified issues such as inadequate attention to blood pressure management, inadequate management of pre-eclampsia, inadequate attention to vital signs after C-section, hemorrhage after C-section, and pulmonary embolism.

Some hospital systems have begun universal use of pneumatic compression stockings for all women undergoing C-section. Joint Commission makes this one of their recommendations and also suggests that low-molecular weight heparin prophylaxis be considered women at high risk for VTE in the post-partum period.

This sentinel event alert also discusses the importance of recognition of clinical deterioration in patients, an issue we have discussed in detail in our December 29, 2009 Patient Safety Tip of the Week “Recognizing Deteriorating Patients”. In addition to establishing triggers that should lead to immediate attention to maternal status, they recommend having staff run drills on how to respond to various types of clinical deterioration.

The December 2009 issue of the Pennsylvania Patient Safety Advisory has a great series of articles pertaining to patient safety in obstetrics. They provide a listing of all the maternal complications reported to the PPSRS over a 5-year period plus an excellent review of medication errors in labor and delivery with recommendations for reducing maternal and fetal harm.

References:

The Joint Commission. Sentinel Event Alert. Issue 44, January 26, 2010

Preventing Maternal Death

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_44.htm

Pennsylvania Patient Safety Authority. Pennsylvania Patient Safety Advisory. December 2009

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/dec16_6(suppl1)/Pages/home.aspx

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Rapid Response Teams Still Not Cutting It

A new systematic review and meta-analysis (Chan et al 2010) of studies on rapid response teams (RRT’s) again concludes that the evidence fails to support a significant impact of RRT’s on mortality. For adults there was some evidence of a reduction in non-ICU cardiopulmonary arrests (a more modest reduction was seen when only high quality studies were included). However, the meta-analysis showed no overall effect on hospital mortality. In pediatric populations, there was a lower hospital mortality rate seen after implementation of RRT’s. The authors attribute the apparent better outcomes in pediatric populations to the fact that respiratory problems are more frequently the cause of arrest in children and that children overall have far fewer co-morbidities.

The accompanying editorial (Edelson 2010) echoes a point we have made in several of our articles on RRT’s: the weak link is in the recognition of deterioration. Dr. Edelson notes that 2 parameters which have been shown to be predictive of mortality (respiratory rate and mental status) are notoriously poorly monitored. Dr. Edelson also points out that many or our alert systems are based on absolute levels of a vital sign and may miss trends. We actually gave some examples of that in our December 29, 2009 Patient Safety Tip of the Week “Recognizing Deteriorating Patients”.

The need for better systems to identify signs suggestive of deterioration, without creating too many false alarms, is obvious. Along these lines, a new article in Anesthesiology (Taenzer et al 2010) discusses preliminary outcomes for a new system of monitoring post-op orthopedic patients with continuous pulse oximetry at Dartmouth. They developed a system in which data from continuous pulse oximetry was analyzed by computer and tied to a system of notifying the patient’s nurse by pager. Key concepts were setting thresholds that met a balance between high sensitivity and numbers of false alarms. They also incorporated a delay into the notification system to further minimize the number of false alarms that nurses would have to respond to. The ultimate triggers used were an oxygen saturation of less than 80% and a heart rate below 50 or greater than 140. Their preliminary results show a reduction in rescue events and fewer transfers to the ICU. There were also fewer deaths, though the numbers were too small to be considered significant. This is an exciting concept and suggests that noninvasive monitoring tied to computer algorithms might someday operate in the background to help identify patients in need of early intervention.

All this negative evidence does not negate the logic of having a culture of safety that helps recognize early patients that are in need of “rescue”. But it does raise many questions about committing many resources to develop RRT’s without better evidence-based validation of the RRT concept. The idea remains a sound one but the most appropriate targets, the triggers, the makeup of teams, the mode of response, the logistics, and the best outcome measures all need to be validated before hospitals rush willy-nilly into developing RRT’s.

Our other columns on rapid response teams and recognition of clinical deterioration:

• August 2007 What’s New in the Patient Safety World column “Responding to Patients with Clinical Deterioration”
• Novermber 27, 2007 Patient Safety Tip of the Week “More on Rapid Response Teams”
• December 2008 What’s New in the Patient Safety World “Rapid Response Teams Don’t Live Up to Expectations”.
• April 2009 What’s New in the Patient Safety World “Early Emergency Team Calls Reduce Serious Adverse Events”
• December 29, 2009 Patient Safety Tip of the Week “Recognizing Deteriorating Patients”.

References:

Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid Response Teams: A Systematic Review and Meta-analysis. Arch Intern Med. 2010; 170(1): 18-26

http://archinte.ama-assn.org/cgi/content/abstract/170/1/18

Edelson DP. A Weak Link in the Rapid Response System.
Arch Intern Med. 2010; 170(1): 12-13

http://archinte.ama-assn.org/cgi/content/extract/170/1/12

Taenzer AH, Pyke JB, McGrath SP, Blike GT. Impact of Pulse Oximetry Surveillance on Rescue Events and Intensive Care Unit Transfers: A Before-and-After Concurrence Study. Anesthesiology 2010; 112(2): 282-287

http://journals.lww.com/anesthesiology/Fulltext/2010/02000/Impact_of_Pulse_Oximetry_Surveillance_on_Rescue.10.aspx

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NEJM Infection Control Articles

The January 7, 2010 issue of the New England Journal of Medicine had two extremely important articles on infection prevention. The first was a randomized controlled trial of chlorhexidine-alcohol vs. povidone-iodine for surgical site antisepsis (Darouich et al 2010). This study showed that the chlorhexidine-alcohol group had significantly lower incidences of superficial incisional infections and deep incisional infections. But there was no difference in the rate of organ-space infections.

The lack of a good head-to-head study of these two antiseptics has been problematic in the past. In our efforts to reduce the risk of surgical fires, the debate about which antiseptic to use has been an unsolved one. Clearly the risk of fire is significantly higher with alcohol-based products. And since it had previously appeared that there was no substantial difference between the two products in antisepsis efficacy, there had been a trend toward using more povidone-iodine. However, the new study clearly shows superiority for the chlorhexidine-alcohol solution. So the real caveat now will be to ensure adequate drying time when using chlorhexidine-alcohol to reduce the risk for surgical fires.

The second paper (Bode et al 2010) looked at a strategy of rapid identification of nasal carriers of Staph aureus (using a PCR assay) followed by nasal decontamination with mupirocin nasal ointment and chlorhexidine soap in an effort to reduce surgical site infections. This was a randomized controlled multicenter trial. The nasal decontamination group had significantly fewer surgical site Staph aureus infections and the effect was most pronounced for deep surgical site infections.

References:

Darouich RO, Wall MJ, Itani MF et al. Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis. NEJM 2010; 362:18-26

http://content.nejm.org/cgi/content/abstract/362/1/18

Bode LGM, Kluytmans JAJW, Wertheim HFL et al. Preventing Surgical-Site Infections in Nasal Carriers of Staphylococcus aureus. NEJM 2010; 362:9-17

http://content.nejm.org/cgi/content/abstract/362/1/9

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Preoperative Testing for Non-Cardiac Surgery

What do you think about “medical clearance”? You know, that’s where a surgeon sends you a patient before surgery so you can give your blessing that the surgery is safe for that patient and the patient can likely tolerate the surgery. To be honest, most primary care physicians know very little about the mechanics and stresses involved in surgery and anesthesia. So the pre-op “medical clearance” evaluation often consists of reflexly ordering a bunch of tests that clearly add to the cost of medical care but often add little to patient safety or quality outcomes. The American College of Cardiology and American Heart Association have issued Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery but these are often not followed.

Two recent papers help put those guidelines in context and suggest we need more restraint in pre-op cardiac testing. Writing in the Annals of Internal Medicine in November 2009, Chopra et al suggest it is time to throttle back on testing. The suggest that perioperative tests and treatments improve cardiac outcomes only when targeted to clearly defined patient subsets and that clinical trials have shown no additional benefit of cardiac testing in patients at low to moderate risk for perioperative cardiovascular events.

Furthermore, perioperative coronary revascularization can cause harm and does not improve clinical outcomes, even in high-risk patients. Though the role of perioperative beta blockers is still evolving, perioperative β-blockers at doses titrated to heart rate and blood pressure can reduce risk in high-risk patients. They suggest that implementing the American College of Cardiology/American Heart Association perioperative guidelines can improve clinical outcomes and reduce perioperative costs.

The second paper (Wijeysundera et al 2010) was a retrospective cohort study done in Canada. They found that noninvasive stress testing before major non-cardiac surgery was associated with improved one-year survival and shorter mean hospital length of stay. However, when patients were stratified by cardiac risk, the mortality benefit was primarily in those with high risk (Revised Cardiac Risk Index 3-6 points) and to a much lesser degree in those at intermediate risk (RCRI 1-2 points). Furthermore, such testing in those at low risk actually caused harm.

Basically, both papers support the current ACA/AHA guidelines. Not everyone needs pre-op cardiac testing and you can actually harm some patients by doing it. Keep in mind that there are other things you could be doing as part of that “medical clearance”. You could be doing simple tests to identify patients at risk for post-op delirium and suggesting strategies to minimize that possibility.

References:

Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al; ACC/AHA Task Force Members.ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007; 116: e418-e500 http://circ.ahajournals.org/cgi/content/full/116/17/e418

Chopra V, Flanders SA, Froelich JB, Lau WC, Eagle KA. Perioperative Practice: Time to Throttle Back. Annals of Internal Medicine 2009. Published online before print November 30, 2009

http://www.annals.org/content/early/2009/11/19/0003-4819-152-1-201001050-00184.full?aimhp

Duminda N Wijeysundera, W Scott Beattie, Peter C Austin, Janet E Hux, Andreas Laupacis

Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study

BMJ  2010;340:b5526 (Published )

http://www.bmj.com/cgi/content/abstract/340/jan28_3/b5526

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