Patient Safety Tip
of the Week
December 12, 2017
Joint Commission on
Suicide Prevention
We’ve done many columns on the issue of suicide in hospitals
(see the full list at the end of today’s column). A recent issue of Joint
Commission Online (TJC
2017) had a perspective on safeguards
to prevent suicide in a variety of healthcare settings. It summarized
recommendations from 3 expert panels that reviewed interventions to prevent
suicide in several different healthcare settings, with a heavy focus on making
the environment safe.
You’ll see that the recommendations 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.
Particular attention was paid to potential ligature-related risks. They present in an appendix some statistics about use of ligature points for suicide attempts on corridor doors, drop ceilings, and toilet seats. Recommendations are made for inpatient psychiatric units, general acute inpatient settings, and emergency departments.
Recommendations for
Inpatient Psychiatric Units
Inpatient psychiatric units, in both psychiatric hospitals and general/acute care settings, must be ligature-resistant in the following areas:
- Patient rooms
- Patient bathrooms
- Corridors
- Common patient care areas
In inpatient psychiatric units, in both psychiatric hospitals and general/acute care settings, the doors between patient rooms and hallways must contain ligature-resistant hardware which includes, but may not be limited to, hinges, handles, and locking mechanisms.
But the recommendations note that nursing stations with an
unobstructed view (so that a patient attempt at self-harm at the nursing
station would be easily seen and interrupted) do not need to be ligature-resistant
and will not be cited for ligature risks. Areas behind
self-closing/self-locking doors would also be considered exempt.
In inpatient psychiatric units, in both psychiatric hospitals and general/acute
care settings, the transition zone between patient rooms and patient bathrooms must be ligature-free or
ligature-resistant. They note that this may be accomplished with mechanical or
behavioral solutions. Mechanical solutions include removing the bathroom door,
placing an alarm on the door to prevent inappropriate use, and using a special
door designed to prevent using the top to support a ligature (for example, an
angled upper edge or breakaway magnetic hinges). A
behavioral solution would be denying access to the bathroom unless staff is
present; this still requires having the profile of the door be
ligature-resistant in the closed arrangement. Our August 29, 2017 Patient Safety Tip of the Week “Suicide
in the Bathroom” discussed
these issues in detail. The Joint Commission document does note that in
some states modifications or removal of doors are not allowed due to privacy
concerns.
The panel discussed whether standard toilet seats (with a
hinged seat and lid) posed significant ligature/suicide risk but concluded that
traditional toilet seats are as safe as toilets without movable seats and
covers, offer patients more comfort, and are less stigmatizing.
Corridor doors remain problematic. Several panelists reported that they were aware of cases in which a patient slipped a ligature between the corridor door and the door frame and/or hinges and committed suicide. And there are several mechanical devices available to decrease the risk of the top of a door being used to fix a ligature (eg. laser beams, pressure-sensing plates, and monitoring cameras) but the efficacy of such devices is unproven. So the panel does not recommend mandatory installation of such devices. Rather, they recommend organizations should note such doors on their environmental risk assessments and describe their mitigation strategies, such as appropriate rounding and monitoring by staff, requiring that doors be left open during certain hours, and so on.
In inpatient psychiatric units, in both psychiatric hospitals and general/acute
care settings, patient rooms and bathrooms must have a solid ceiling and that a
drop ceiling is not an acceptable
alternative because patients might climb up to the drop ceiling, remove a
panel, and gain access to ligature risk points in the space above the drop
ceiling. They do allow drop ceilings in hallways and common patient care areas as long as all aspects of the hallway are fully visible to
staff and there are no objects that patients could easily use to climb up to
the drop ceiling. But for areas that are not fully visible to staff or where
patients could easily move objects to access the area above the drop ceiling
there should be a risk assessment and an appropriate mitigation plan.
Mitigation strategies might include gluing the tiles in place, using tile
retention clips, installing motion sensors above the ceiling to sense
tampering, or using another comparable harm-resistive arrangement.
Importantly, the document recognizes that some patients in psychiatric units
may have medical needs that
necessitates use of beds or equipment that may present ligature risks. In such
cases, the medical needs and the patients’ risk for suicide should be carefully
assessed and balanced. In such cases, there must be appropriate mitigation
plans and safety precautions in place.
Recommendations for General Acute
Inpatient Settings
Joint Commission recognizes that, because of the medical needs of patients on med/surg units, it is impossible to make their environment truly ligature-resistant. Therefore. the general medical/surgical inpatient setting does not need to meet the same standards as an inpatient psychiatric unit to be a ligature-resistant environment. Instead, while it is still incumbent to remove all objects that pose a risk for self-harm without adversely affecting the ability to deliver medical care, Joint Commission focuses on human/behavioral solutions to prevent suicides on these units. These would include mitigating strategies such as:
- one-to-one (1:1) monitoring
- careful assessment of objects brought into the room by visitors
- protocols for transporting patients to other parts of the hospital (such as radiology).
Organizations should have policies, procedures, training, and monitoring systems in place to ensure these are done reliably. That would include training staff and testing them 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 conducting risk assessments for objects that could pose a risk for self-harm and identifying those objects that should be routinely removed from the immediate vicinity of patients with suicidal ideation. And plans for monitoring visitors would be required.
Monitoring bathroom use and protocols for having qualified staff accompany patients on intrahospital transport would also be necessary. We are a bit troubled that the recommendations did not specifically address one area we always focus on: the bathrooms in the radiology suite (or other hospital area to which psychiatric patients might occasionally be transported). Virtually every time we visit a hospital we find a bathroom in such areas that has multiple potential ligature points and which can be locked from the inside. While it may not be feasible to make those bathrooms ligature-free, the staff accompanying the potentially suicidal patient must have ready access to the keys in the event the patient locked him/herself in the bathroom.
Recommendations for
Emergency Departments
Like the med/surg units, emergency departments do not need to meet the same standards as an inpatient psychiatric unit to be a ligature-resistant environment.
But Joint Commission recommends two main strategies to keep patients with serious suicide ideation safe in emergency departments:
- Place the patient in a “safe room” that is ligature-resistant or that can be made ligature-resistant by having a system that allows fixed equipment that could serve as a ligature point to be excluded from the patient care area (for example, a locking cabinet)
- Keep the suicidal patient in the main area of the emergency department, initiate continuous 1:1 monitoring, and remove all objects that pose a risk for self-harm that can be easily removed without adversely affecting the ability to deliver medical care.
Once again, organizations should have policies, procedures, training, and monitoring systems in place to ensure these are done reliably. A defined policy for “demonstrably reliable monitoring” could include 1:1 continuous monitoring, observations allowing for 360-degree viewing, or continuously monitored video) but monitoring must be linked to the provision of immediate intervention by qualified staff member when needed.
Other interventions should include:
- Screen all patients presenting with psychiatric disorders for suicidal ideation
- Assess the risk of a suicide attempt among patients with suicidal ideation (“secondary screening”).
- Conduct a risk assessment for objects that pose a risk for self-harm and identify those objects that should be routinely removed from the immediate vicinity of patients with suicidal ideation who are cared for in the main area of the emergency department.
- Have a protocol for removing all movable items that could be used for self-harm from within reach of a patient with suicidal ideation.
- Have protocols for monitoring patients with suicidal ideation, including the use of the bathroom.
- Have protocols to ensure that visitors do not bring objects that the patient could use for self-harm.
- Have a protocol to have qualified staff accompany a patient with serious suicidal ideation from one area of the hospital to another.
Staff must be trained and tested for competency on how they
would address a situation with a patient with serious suicidal ideation.
Update: See our January 29, 2019 Patient Safety Tip of the Week “National Patient Safety Goal for Suicide Prevention” for the elements of performance (EP’s) for National Patient Safety Goal NPSG.15.01.01: Reduce the risk for suicide.
Some of our prior columns on preventing hospital suicides:
- January 6, 2009 Patient Safety Tip of the Week “Preventing Inpatient Suicides”
- February 9, 2010 Patient Safety Tip of the Week “More on Preventing Inpatient Suicides”
- March 16, 2010 Patient Safety Tip of the Week “A
Patient Safety Scavenger Hunt”
- December 2010 What’s New in the Patient Safety World column “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”
- September 27, 2011 Patient Safety Tip of the Week “The Canadian Suicide Risk Assessment Guide”
- December 2011 What’s New in the Patient Safety World column “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”
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
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
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