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.
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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