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Use checklist to reduce self-harm risks in the ER by ensuring no items are overlooked


July 1, 2018

There’s a case where a World War II POW committed suicide by hitting himself in the head with an empty metal canteen after days without water. While that happened in the hold of a Japanese prison boat, not a hospital, it highlights how resourceful a suicidal person can be when it comes to finding ways to self-harm. Earbud cords, compact mirrors, trash bags, bed frames, IV tubing, socks, and much more can be used to attempt suicide in a hospital setting.

With the renewed focus on ligature and self-harm, facilities need to undergo a complete reassessment of the physical environment where patients with behavioral or mental health problems are cared for.

That goes especially for emergency departments. Annually, 460,000 emergency department visits occur following cases of self-harm, and those patients are six times more likely to make another suicide attempt in the future. To prevent patients from further harming themselves, staff should start each shift by reviewing emergency department rooms designated for treatment of behavioral health patients to remove any items patients could use in a suicide attempt.

You may want to use a checklist to ensure no items are overlooked. In rooms that can’t be completely cleared of ligatures or other instruments for self-harm, facilities should have trained one-on-one observers available to keep patients safe.

“As healthcare organizations and accrediting bodies intensify efforts to make the healthcare environment safer, it is critical to use available data and expert opinion to have clear guidelines on what constitutes serious environmental hazards that must be corrected and what mitigation strategies are acceptable in those situations when all potential hazards cannot be removed,” wrote The Joint Commission in a special report on suicide prevention.

Boarded patients a concern
When evaluating physical risks in emergency departments, remember that behavioral health patients awaiting transfer to a psychiatric unit or facility may be in the ER for hours, if not days, says Ernest E. Allen, a former Joint Commission life safety surveyor and current patient safety account executive with The Doctors Company in Columbus, Ohio. The company is a medical malpractice insurer.

Minimizing self-harm opportunities in the physical environment is not only a patient safety issue, but also vital to the hospital’s bottom line, says Allen, who presented an HCPro webinar last November on evaluating the environment of care for suicide risk.

That’s because patient suicides can not only result in investigations by CMS and your accrediting organization, but also a visit from your local or state department of health and possible fines. Lawsuits from family members can draw unwanted media attention.

Incidents of self-harm by patients also create poor morale among staff, notes Allen. He recommends you consider designating a room or rooms in your ER area to specifically house psychiatric patients if necessary.

Design features can help
Those rooms should have many of the features CMS and The Joint Commission now expect in behavioral health units or facilities: rooms without drop-down ceilings, ligature-resistant plumbing features and door handles, no clothes hooks or hooks that break away, and only paper trash can liners.

If you are renovating or designing new exam rooms, consider installing a roll-down door in the room behind which dangerous items can be easily and quickly locked away, says Allen.

For rooms that cannot be modified, The Joint Commission will allow one-on-one observation, says Allen. Sometimes items considered dangerous, such as intravenous poles and tubing, a sharps container, portable equipment with tubing or electrical cords, or other supplies, may be necessary.

“If the patient also has medical issues, sometimes some of those items are needed,” he says, “but a sitter should be with the patient.”

Train your sitter
While the task sounds simple, it’s essential that your observer is trained and understands hospital policies. Just last year, CMS put one hospital under immediate jeopardy (IJ) after learning that a one-on-one observer left her post to take a break after deciding the patient was asleep.

Another hospital faced IJ, which threatens a hospital’s ability to bill Medicare, after a patient was brought into a hospital by law enforcement, who warned staff that the patient was suicidal. As the patient awaited triage, family members called to tell the hospital of specific problems with this patient, but the nursing assistant who took the call refused to take the information, citing erroneously that HIPAA privacy regulations prevented it.

In the 20 or so minutes before the patient was seen—also a violation of hospital policy, which stated that ER patients were to be triaged within 15 minutes of arrival—the patient used a belt to hang himself. The belt was not taken from the patient because hospital staff was unsure if it was legal to do so. That also was apparently in violation of hospital policy, which said the belt should’ve been taken away.
Extensive education and retraining of staff was required before the IJ rulings were removed from both hospitals, according to CMS inspection reports found on HospitalInspections.org, maintained by the Association of Health Care Journalists.

Safe environment checklist for suicidal patients
The following checklist is used at the beginning of every shift when reviewing exam rooms for at-risk patients at a hospital in Georgia. The checklist is part of an effort to revamp the hospital’s policies and procedures around minimizing suicide risk, says Susie Jester, MSN, RN, director of clinical practice.

Reviewed by Allen, the checklist should mainly be used in non-psychiatric areas, such as emergency rooms, since many of the items, such as sharps containers, would not be found on a psychiatric unit. In the event that not all items can be removed, Allen recommends having a one-on-one patient observer also be available.

To be completed at the beginning of every shift:
Remove all detachable/removable hanging risk items, if possible and unless medically necessary, including:

  • Suction tubing
  • Electric cords/telephone cords/bed cords (if detachable)
  • Oxygen tubing/flowmeter (unless required for continuous use)
  • Excess IV tubing
  • Cords attached to mounted equipment not in use
  • Remove IV poles and other portable equipment not in use, such as oxygen cylinders
  • Remove plastic trash bags
  • Remove glass, plastic, or metal objects that can be broken and used for harm, such as lab specimen tubes
  • Remove gloves, tourniquets
  • Remove hand sanitizer
  • Remove any unsecured items not in use
  • Lock supply cabinets/carts in the room
  • Remove extra linen (sheets, towels, pillowcases)
  • Sharps container no more than half-full
  • Remove any items that would be dangerous if ingested
  • In addition, when patient is in the room:
  • Door remains open (unless care is being provided)
  • If curtain in room cannot be removed, it is to remain pulled back
  • Patient should be in paper scrubs (not wearing any personal items except wedding band)
  • No personal belongings, including, but not limited to:

             - Ribbons

             - Pins

             - Socks

             - Scarves

             - Jewelry

             - Nail polish/remover

             - Toiletry items

             - Earbuds

             - Compacts with mirrors

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