Patient Safety Tip
of the Week
January
29, 2019
National Patient Safety Goal for Suicide Prevention
In our December 12, 2017 Patient Safety Tip
of the Week “Joint Commission on Suicide Prevention” we
highlighted The Joint Commission’s recommendations on suicide prevention (TJC 2017).
Those have now been
incorporated into a new National Patient Safety Goal NPSG.15.01.01: Reduce
the risk for suicide (Lyons 2018). Effective July 1,
2019, there will be seven new and revised elements of performance (EPs) supporting
this NPSG (TJC 2018). These are
listed below for both the behavioral health care (BHC) and hospital (HAP)
accreditation programs. There are also some elements important for
non-psychiatric units in general hospitals.
NPSG.15.01.01.EP1: Environmental
Risk Assessment
BHC: The organization conducts an
environmental risk assessment that identifies features in the physical environment
that could be used to attempt suicide; the organization takes necessary action
to minimize the risk(s) (for example, removal of anchor points, door hinges,
and hooks that can be used for hanging).
HAP: For psychiatric hospitals and
psychiatric units in general hospitals: The hospital conducts an environmental
risk assessment that identifies features in the physical environment that could
be used to attempt suicide; the hospital takes necessary action to minimize the
risk(s) (for example, removal of anchor points, door hinges, and hooks that can
be used for hanging).
As we noted in our December 12, 2017 Patient
Safety Tip of the Week “Joint Commission on Suicide Prevention”, non-psychiatric
units in general hospitals are not expected to be ligature-resistant. But that
does not mean they are exempt from taking steps to reduce the risk of patient
suicide. They are expected to implement procedures to mitigate the risk of
suicide for patients at high risk for suicide, such as one-to-one monitoring,
removing objects that pose a risk for self-harm if they can be removed without
adversely affecting the patient’s medical care, assessing objects brought into
a room by visitors, and using safe transportation procedures when moving patients
to other parts of the hospital. (See also below for our own comments on areas,
such as your radiology suite bathrooms, where you probably should make sure
they are ligature-resistant). The Joint Commission elements do stress that each
organization needs to assess how it will identify objects that could be used
for self-harm and use this information in staff training.
We refer you back to our December 12, 2017 Patient
Safety Tip of the Week “Joint Commission on Suicide Prevention”
for details of The Joint Commission’s recommendations on the environmental risk
assessment (TJC 2017), most of which rely
heavily on many of the points from the VA’s Mental Health Environment of Care Checklist, which we’ve discussed in so many columns
(most recently in our August 29, 2017 Patient
Safety Tip of the Week “Suicide in the Bathroom”).
In our February 14, 2017 Patient Safety
Tip of the Week “Yet More Jumps from Hospital Windows” we
mentioned 2 publications (Watts 2016, Mills 2016) showing sustained results from implementation of the Mental Health
Environment of Care Checklist (MHEOCC). The checklist and program became
mandated at all VA hospitals in 2007. Inpatient suicide rates in VA hospitals
dropped from 4.2 per 100,000 admissions to 0.74 per 100,000 admissions from
2000 to 2015. The reduction in suicides coincided with introduction of the
MHEOCC and has been sustained since implementation in 2007. The authors stress
that the physical changes brought about by the MHEOCC likely have a bigger
impact on inpatient suicide reduction than the numerous other interventions
used.
Again, see our comments below regarding
special issues for non-psychiatric units in general hospitals.
NPSG.15.01.01.EP 2: Use of a validated screening tool to assess
patients at risk
BHC: Screen all individuals served for
suicidal ideation using a validated screening tool.
HAP: Screen all patients for suicidal
ideation who are being evaluated or treated for behavioral health conditions as
their primary reason for care using a validated screening tool.
TJC provides examples
of validated screening tools: the ED Safe Secondary Screener, the PHQ-9, the Patient Safety Screener, the TASR Adolescent Screener, and the ASQ Suicide Risk Screening Tool. The Columbia-Suicide
Severity Rating Scale can
be used for both screening and more in-depth assessment of patients who screen
positive for suicidal ideation using another tool. There is more information on
the use of the Columbia-Suicide Severity Rating Scale in the NPSG.15.01.01 Suicide Prevention Resources
document. (We also
discussed it in our December 2011 What’s New in the Patient Safety World column
“Columbia Suicide Severity Rating Scale”).
TJC also provides a
link to an article “Development and Implementation of a Universal Suicide Risk
Screening Program in a Safety-Net Hospital System” (Roaten 2018).
NPSG.15.01.01.EP 3: Evidence-based process for conducting suicide
risk assessments of patients screened positive for suicidal ideation
BHC: Use an evidence-based process to conduct
a suicide risk assessment of individuals served who have screened positive for
suicidal ideation. The assessment directly asks about suicidal ideation, plan,
intent, suicidal or self-harm behaviors, risk factors, and protective factors.
Note: EPs 2 and 3 can be satisfied through the use of
a single process or instrument that simultaneously screens individuals served
for suicidal ideation and assesses the severity of suicidal ideation.
HAP: Use an evidence-based process to conduct
a suicide risk assessment of patients who have screened positive for suicidal
ideation. The assessment directly asks about suicidal ideation, plan, intent,
suicidal or self-harm behaviors, risk factors, and protective factors.
Note: EPs 2 and 3 can be satisfied through the use of a single process or instrument that
simultaneously screens patients for suicidal ideation and assesses the severity
of suicidal ideation.
Here they again
note that the Columbia-Suicide Severity Rating Scale can be used for both screening and more
in-depth assessment of patients who screen positive for suicidal ideation using
another tool. Another tool is SAMHSA’s SAFE-T
Pocket Card: Suicide Assessment Five-Step Evaluation and
Triage for Clinicians, which is now also available for download as an app on
your mobile devices.
NPSG.15.01.01.EP 4: Documentation of patients’ risk and the
plan to mitigate
BHC: Document individuals' overall level of
risk for suicide and the plan to mitigate the risk for suicide.
HAP: Document patients’ overall level of risk
for suicide and the plan to mitigate the risk for suicide.
Here they stress the importance that all
clinicians who might come in contact with a patient at
risk for suicide be aware of the level of risk and the mitigation plans to
reduce that risk. Such information should be explicitly documented in the
patient’s record.
NPSG.15.01.01.EP 5: Written policies and procedures addressing
care of at-risk patients, and evidence they are followed
HAP:
Follow written policies and procedures addressing the care of patients
identified as at risk for suicide. At a minimum, these should include the
following:
· Training and competence assessment of staff
who care for patients at risk for suicide
· Guidelines for reassessment
· Monitoring patients who are at high risk for
suicide
Those
written policies and procedures should include specifics about training and competence
assessment of staff.
NPSG.15.01.01.EP 6: Policies and procedures for counseling and
follow-up care for at-risk patients at discharge
BHC: Follow written policies and procedures
for counseling and follow-up care at discharge for individuals served
identified as at risk for suicide.
HAP: Follow written policies and procedures
for counseling and follow-up care at discharge for patients identified as at
risk for suicide.
A patient’s risk for suicide is high after
discharge from the psychiatric inpatient or emergency department settings.
Developing a safety plan with the patient and providing the number of crisis
call centers can decrease suicidal behavior after the patient leaves the care
of the organization. We would also stress the importance of scheduling the
patient’s first followup visit and checking to see
that the patient is compliant with such visit.
NPSG.15.01.01.EP 7: Monitoring of implementation and
effectiveness, with action taken as needed to improve compliance
BHC: Monitor implementation and effectiveness
of policies and procedures for screening, assessment, and management of
individuals served at risk for suicide and take action
as needed to improve compliance.
HAP: Monitor implementation and effectiveness
of policies and procedures for screening, assessment, and management of
patients at risk for suicide and take action as needed
to improve compliance.
Your quality improvement program should
monitor how often screening was done, the level of severity of risk assessed, how
often specific items in the mitigation plan (eg. 1:1
monitoring) were followed, discharge arrangements made, and that all staff have
had both initial training and reorientation as specified in your written
policies.
There are a few points of our own we would like
to stress about issues outside of behavioral health units. If you are a general
hospital that has a behavioral health unit, there undoubtedly will be patients
at risk for suicide in areas other than your behavioral health unit. One
particularly important area is your radiology suite. In our August 25, 2015
Patient Safety Tip of the Week “Checklist
for Intrahospital Transport” we
stressed that suicide risk should be considered when patients are
transported to Radiology (or other sites) whether the patient is on a behavioral
health unit or medical unit (see our prior columns January 6, 2009 “Preventing
Inpatient Suicides”, February 9, 2010 “More
on Preventing Inpatient Suicides” and December 2010 “Joint
Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”). We’ve
inspected bathrooms in radiology departments in several hospitals and uniformly
found that not only do those bathrooms have numerous “loopable”
items that could be used for hanging but also that they can be locked from the
inside and there is typically no one readily available with a key to get in. In
fact, that is one of the items we added to our patient safety scavenger hunt
list (see our March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt”). Bathrooms and other rooms in the
radiology department also have many other tools and implements that could be
used for suicide. So observation protocols for
potentially suicidal patients on such units should ensure that doors are not
locked (or, if they can be locked, that the “observer” has keys to access the
bathroom). Having observers of the same gender as the patient also is recommended.
The other vulnerable area for patients at high
risk for suicide is any of your acute care units in which you house psychiatric
patients while their acute medical problems need attention. We’ve now done
several columns on patients attempting or committing suicide by jumping from
hospital windows. You should become familiar with the patient profile we’ve
described for such patients (see, for example, our July 10, 2018 Patient Safety
Tip of the Week “Another Jump from a Hospital Window”).
For those of you
who frequently have such patients on your acute medical or surgical units, we
suggest you actually consider
making one or two rooms safer to be used for such patients. You could change
the windows in such rooms to the type of windows used in behavioral health units.
You could also minimize the number of “loopable”
items in such rooms though, being realistic since you’ll more often be using these
rooms for patients not at risk for suicide, some potentially loopable items will be needed in the rooms.
But there is much more than the physical
environment that needs attention. In many, if not most, suicide incidents on
med/surg units or ICU’s the staff have been inadequately trained to deal with
behavioral health patients. Often, hospitals designate “sitters” to observe
such at-risk patients but fail to ensure those “sitters” have adequate training
for that task. The need training and testing for competency on how they
would address the situation of a patient with serious suicidal ideation and 1:1
monitoring of patients with serious suicidal ideation. It would also include
de-escalation techniques, conducting risk assessments for objects that could pose
a risk for self-harm, identifying those objects that should be routinely
removed from the immediate vicinity of patients with suicidal ideation, and
plans for monitoring visitors (including what items visitors are
allowed to bring with them). We also recommend you become familiar with
the issue of bed positioning and furniture positioning we’ve discussed in our
columns on jumps from windows.
Some of our prior columns on preventing
hospital suicides:
- January 6, 2009 “Preventing Inpatient Suicides”
- February 9, 2010 “More on Preventing Inpatient Suicides”
- March 16, 2010 “A
Patient Safety Scavenger Hunt”
- December 2010 “Joint Commission Sentinel Event Alert
on Suicide Risk Outside Psych Units”
- September 27, 2011 “The Canadian Suicide Risk Assessment
Guide”
- December 2011 “Columbia Suicide Severity Rating Scale”
- July 2012 “VA
Checklist Reduces Suicide Risk”
- August 2013 “Suicide
Attempts on Med/Surg Units”
- August 25, 2015 “Checklist
for Intrahospital Transport”
- October 6, 2015 “Suicide
and Other Violent Inpatient Deaths”
- March 2016 “TJC Sentinel Event Alert on Preventing
Suicide”
- April 12, 2016 “Falls from Hospital Windows”
- February 14, 2017 “Yet More Jumps from Hospital Windows”
- August 29, 2017 “Suicide in the Bathroom”
- December 12, 2017 “Joint Commission on Suicide Prevention”
- July 10, 2018 “Another Jump from a Hospital Window”
- September 18, 2018
“More on Hospital Suicides”
References:
TJC (The Joint
Commission). November 2017 Perspectives Preview: Special Report: Suicide
Prevention in Health Care Settings. Recommendations
Regarding Environmental Hazards for Providers and Surveyors. Joint Commission
Online 2017; October 25, 2017
Lyons M. Joint
Commission announces new National Patient Safety Goal to prevent suicide and
improve at-risk patient care. Revisions effective July 1, 2019, for accredited
hospitals and behavioral health programs. The Joint Commission 2018; December
5, 2018
TJC (The Joint
Commission). R3 Report. National Patient Safety Goal for suicide
prevention. The Joint Commission 2018; Issue 18: Nov. 27, 2018
https://www.jointcommission.org/assets/1/18/R3_18_Suicide_prevention_HAP_BHC_1_2_18_Rev2_FINAL.pdf
Mental Health
Environment of Care Checklist (VA)
http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
Watts BV, Shiner B,
Young-Xu Y, Mills PD. Sustained Effectiveness of the Mental Health Environment
of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services 2016; Published
Online Ahead of Print: November 15, 2016
http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600080
Mills PD. Use of
the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient
Suicide in VHA. TIPS (Topics in Patient Safety) 2016; 16(3): 3-4 July/August/September 2016
http://www.patientsafety.va.gov/professionals/publications/newsletter.asp
Suicide Prevention
Resource Center, The Patient Safety Screener (PSS-3): A Brief Tool to Detect
Suicide Risk in Acute Care Settings.
http://www.sprc.org/micro-learnings/patientsafetyscreener
PHQ-9, (Patient Health
Care Questionnaire – 9).
https://www.phqscreeners.com/sites/g/files/g10049256/f/201412/PHQ-9_English.pdf
TASR Adolescent
Screener, The Tool for Assessment of Suicide Risk for Adolescents (TASR-A): How
to use the TASR – A.
http://teenmentalhealth.org/wp-content/uploads/2015/12/TASR-A_Package.pdf
ASQ Suicide Risk Screening Tool.
https://www.nimh.nih.gov/labs-at-nimh/asq-toolkit-materials/index.shtml
Columbia-Suicide
Severity Rating Scale
TJC (The Joint
Commission). NPSG.15.01.01 Suicide Prevention Resources document. November 15,
2018
https://www.jointcommission.org/npsg_150101_suicide_prevention_resources/
Roaten K, Johnson
C, Genzel R, et al. Development and Implementation of a Universal Suicide Risk
Screening Program in a Safety-Net Hospital System. Joint Commission Journal of Quality
and Patient Safety, 2018; 44(1): 4-11
https://www.sciencedirect.com/science/article/abs/pii/S1553725017303343?via%3Dihub
SAMHSA (Substance Abuse and Mental Health
Services Administration). SAFE-T Pocket Card: Suicide Assessment Five-Step
Evaluation and Triage for Clinicians.
Print “PDF
version”
http://www.patientsafetysolutions.com/