Suicide in hospitals has been a frequent topic in our Patient Safety Tips of the Week. Since our last column on this topic, there have been several published cases with lessons learned plus a timely review of the prevalence of hospital suicides.
There has been some debate over the prevalence of hospital suicides in the past. The Joint Commission, in its Sentinel Event Summary Statistics, has noted hospital suicides have remained relatively stable at an average of about 90 per year (range 84-98) from 2014 to 2017. But, since not all hospitals have reported completely to the Joint Commission, those figures are likely an underestimate.
Now, a recent study (Williams 2018) uses reliable data to provide good current estimates. Those researchers added to the Joint Commission Sentinel Events reports data from 27 states reporting to the National Violent Death Reporting System (NVDRS) for 2014-2015. They found that 73.9% of these suicides occurred during psychiatric treatment. They estimate that between 48.5 and 64.9 hospital inpatient suicides occur per year in the United States. Of these, 31.0 to 51.7 are expected to involve psychiatric inpatients. Many of our prior columns have focused on the 26% that attempt or commit suicide when housed in locations other than behavioral health units.
In the Williams study (Williams 2018), hanging was by far the most common method for suicide in the hospital, accounting for about 70% of cases in both databases when a method was specified. Over 50% of the sentinel event suicides occurred in the bathroom.
Our August 29, 2017 Patient Safety Tip of the Week discussed several cases of inpatient suicides occurring in bathrooms and highlighted many contributing factors, with recommendations to mitigate risks. Two recent published cases also reinforce the need for attention to suicide risks in the bathroom. In one (Glathar 2018) a patient hanged himself from the top hinge of a shower door (the case had other issues, such as staff failing to carry out 15-minute observations). In another case (Mills 2018), a patient who had cut both of her forearms with a kitchen knife in a suicide gesture, had her forearm laceration sutured and bandaged with gauze padding. She was then transferred to the inpatient psychiatric unit. There, she asked to use the bathroom, where she unwrapped the gauze bandage from her wrist, wrapped it around her neck and over the shower bar in the bathroom, and attempted to hang herself. Fortunately, staff heard a noise and responded and were able to cut the gauze before any serious injury occurred. (By the way, while we always recommend removing things like belts and shoelaces from patients on behavioral health units, who would have thought about the gauze bandage as a tool for suicide?).
Weve discussed the VAs Mental Health Environment of Care Checklist (MHEOCC) in many of our columns. That checklist is available online on the VA Patient Safety website, as is an excellent video narrated by Peter Mills, MD. In our February 14, 2017 Patient Safety Tip of the Week 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.
One very pertinent question asked in the MHEOCC is Are doors that are within rooms and that open to other in-room areas such as bath/shower/toilet areas (i.e., not corridor doors) designed to eliminate anchor points?. But keep in mind that almost any type of solid door might be used as an anchor even if it lacks latches, hooks, or other obvious loopable items. One could still conceivably loop bedsheets or clothing over the top of a solid door even if it has a sloped surface. Therefore, the MHEOCC recommends soft break-away doors for bathrooms and showers.
In our August 29, 2017 Patient Safety Tip of the Week we recommended the following:
But its not enough to just ensure that bathrooms on your inpatient behavioral health unit meet the MHEOCC standards. Consider that the potentially suicidal patient on an intrahospital transport, such as a trip to the radiology suite, may lock him/herself in a bathroom in that suite and there are a number of loopable items in those bathrooms. Youll recall that in our March 16, 2010 Patient Safety Tip of the Week A Patient Safety Scavenger Hunt we included the items below as ones to search for in your patient safety scavenger hunt:
And, speaking of intrahospital transports, dont forget to the specific risks for wandering, elopement and/or suicide on your Ticket to Ride checklist for intrahospital transports (see, for example, our August 25, 2015 Patient Safety Tip of the Week Checklist for Intrahospital Transport). 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).
Two recent California Department of Public Health reports also illustrate other risks during transports or transfers from one unit to another. In one (CDPH 2018a), a patient was sent to ED from a psychiatry unit, eloped from the ED, and was hit by a car. In the other (CDPH 2018b), a suicidal patient was being transferred back from the ED to a psychiatric unit, jumped up and ran away and jumped 25-40 feet from a building, suffering skull and spine fractures and numerous other fractures and body trauma. He survived but had a long hospitalization, multiple procedures, and multiple deficits. During the transport, the patient had been accompanied by a nurse assistant who had no training in managing suicidal patients and two security guards who were not authorized to restrain patients. They called local police but it was too late to prevent the jump from the building.
In the Williams study (Williams 2018), when a method of suicide was specified, 6-10% of the suicides involved jumping from heights. Several of our columns have discussed patients who jump from windows and weve noted features that are common to such incidents (see our Patient Safety Tips of the Week for April 12, 2016 , February 14, 2017 , and July 10, 2018 ). These are typically patients who are being housed on general medical or surgical units and there is a a pattern evolving. The typical patient is a young or middle-aged male, but occasionally elderly patients or females have also jumped through or out of windows. The patient is often admitted for an attempted suicide but, again, not always. Typically he/she is confused or hallucinating. Its not just patients with known psychiatric disorders or a history of suicide attempt that are at risk. Patients with brain injuries or delirium are at risk, particularly those who have demonstrated a tendency to wander or have verbalized their intent to get out of here or go home. And the incidents have commonly occurred while patients are already on 1:1 continuous observation and the observer is actually in the room.
In these cases, patients were able to stand up on the bed and launch themselves through the window from the bed. That implies a proximity of the bed to the window. So one key lesson is to position the patients bed in the room at a reasonable distance away from the window so such launches are not possible.
Second, positioning of the observer may be important. The observer is usually positioned in the room on the side away from the window and near the door. We suspect that is intentional and may be a consideration for the safety of the observer plus it would allow the observer to easily yell for help if necessary. But that obviously needs to be rethought.
And some other less obvious equipment needs to be removed: the second bed in a 2-bed room should probably be temporarily moved. That can only hinder someone from attempting to rescue a patient who is trying to jump out of a window.
And since the patient often uses an object in the room to break the window, such as a chair or piece of medical equipment, care must be taken to make sure such objects are not in reach for a patient even for a very brief time. For example, if the observer needs to briefly leave the room perhaps the chair should be removed.
In our October 6, 2015 Patient Safety Tip of the Week Suicide and Other Violent Inpatient Deaths we noted that another potential vulnerability has to do with fire alarms. In one case a patient pulled a fire alarm which automatically unlocked doors on a behavioral health unit, allowing him to escape and jump to his death from a rooftop (Pfeiffer 2010). After we heard about that case we began to include inspection of stairwells and rooftop access points adjacent to behavioral health units in our patient safety walkrounds or environmental walkrounds.
Another recent case did not involve an actual suicide but serves as a reminder of how patients may use fire alarms to facilitate elopement (Fettes 2018). A patient on a behavioral health unit set his mattress and bedding on fire, triggering the facility's fire alarm. The alarm automatically disarmed the facility's fire doors and the patient left the unit. Fortunately, he was later found and returned to the unit. But the case illustrates a problem weve seen before. The behavioral health unit involved did not have a specific policy for "a combined fire and security incident". Youll recall we have recommended that facilities consider combining safety drills to account for such incidents. For example, you could do a fire drill and then immediately do a drill for a missing patient (or an abducted child).
Since several cases mentioned in todays column have also involved the emergency department, it is worth noting a recent study on improving documentation of suicide risk factors in the ED (Reshetukha 2018). The researchers did an educational intervention on suicide for all emergency medicine and psychiatry physicians. This was followed by the placement of a suicide risk assessment prompt within local EDs. Documentation of 34/40 and 33/40 suicide risk factors was significantly improved by emergency medicine and psychiatry physicians, respectively, after the interventions and maintained six months later. Another recent study also emphasized chronic pain as a significant risk factor in 10% of suicides (Petrosky 2018). While a wide variety of causes for chronic pain were noted, the most common were related to back pain, cancer, and arthritis, all common in patients seen in the ED.
Some of our prior columns on preventing hospital suicides:
Some of our past columns on issues related to behavioral health:
See our previous columns on wandering, eloping, and missing patients:
The Joint Commission. Sentinel Event Summary Statistics.
Williams SC, Schmaltz SP, Castro GM, Baker DW. Incidence and Method of Suicide in Hospitals in the United States. Jt Comm J Qual Patient Saf 2018; Published online September 3, 2018
Glathar B. Failed patient checks linked to suicide at Wyoming State Hospital.
Uinta County Herald 2018; September 12, 2018
Mills PD. Web M&M. Suicide Risk in the Hospital. AHRQ PSNet 2018; May 2018
Mental Health Environment of Care Checklist (VA)
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
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
CDPH (California Department of Public Health). Complaint Intake Number: CA00479941; CDPH 2018
CDPH (California Department of Public Health). Complaint Intake Number: CA00462955; ; CDPH 2018
Pfeiffer R. Man survives plunge from roof of hospital. Niagara Gazette 2010; October 17, 2010
Fettes J, Scott E. Patient escapes from Canberra Hospital's mental health unit by starting fire, disarming fire door. ABC (Australia) News 2018; Posted 29 Aug 2018
Reshetukha TR, Alavi N, Prost E, et al. Improving suicide risk assessment in the emergency department through physician education and a suicide risk assessment prompt. General Hospital Psychiatry 2018; 52: 34-40
Petrosky E, Harpaz R, Fowler KA, et al. Chronic Pain Among Suicide Decedents, 2003 to 2014: Findings From the National Violent Death Reporting System. Ann Intern Med 2018; Epub ahead of print 11 September 2018