Suicidal Ideation and Patient Safety

Suicidal Ideation & Patient Safety

Each patient who enters your organization should expect to receive care in a safe environment. But the statistics around suicides in hospitals indicate there is a lot of room for improvement when it comes to keeping patients with suicidal ideation safe. Like a puzzle, many pieces must come together to form a complete approach to providing a safe and effective care environment. Here we discuss the different influencing factors, from the physical environment, to screening and monitoring.

Identifying requirements that are location dependent

Inpatient psychiatric units, in both psychiatric hospitals and general/acute care settings, must be ligature-resistant in the following areas:

  • Patient rooms (including having a solid ceiling)
  • The transition zone between patient rooms and patient bathrooms
  • Patient bathrooms (including having a solid ceiling)
  • Doors between patient rooms and hallways must contain ligature-resistant hardware (hinges, handles, locking mechanisms)
  • Corridors (drop ceilings can be in these areas as long as all aspects of the hallway are fully visible to staff and there are no objects that patients could use to climb up to have access to the drop ceiling)
  • Common patient care areas

Emergency departments, with dedicated psychiatric beds or units, when within a locked area in which the patients may not move freely in and out of the unit/rooms, are also expected to achieve a ligature resistant environment.

The Emergency Department has two main strategies to keep patients who present with suicidal ideation safe:

  • Place the patient in a room that is ligature resistant.
  • Initiate 1:1 monitoring with continuous visual observation and remove all objects from the patient’s room that pose a risk unless that are needed to provide direct patient care.

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; however, all objects that pose a risk that can be removed should be, unless they are needed to provide direct patient care, and mitigation strategies must be put into place and documented, including 1:1 monitoring.

In all areas, video monitoring cannot be used as a substitution for 1:1 monitoring. The use of video monitoring is not acceptable because staff would not be immediately available to intervene. For high risk patients, video monitoring should only be used in place of 1:1 monitoring when it is unsafe for a staff member to be physically located in the patient’s room.

Identifying patients at risk for intentional harm to themselves or to others

Early identification of patients is a key suicide prevention strategy. Screening identifies individuals that require further mental health/suicide safety assessment. Organizations should choose an evidence-based tool to screen patients that are at risk of harming themselves or others. Hospitals are expected to implement a patient screening and risk assessment strategy that is appropriate to the patient population (e.g. pediatric population versus adult population). Organizations are cautioned not use evidence-based screening tools designed for depression to screen patients for suicidal ideation. Organizations should never alter the evidence-based tool that they choose.

Additionally, patients who screen positive for suicide ideation must receive an in-depth assessment to determine overall suicide risk. There are several tools available and some tools, such as the Columbia Suicide Severity Rating Scale (C-SSRS), can be used in both the screening and assessment processes. In addition to documenting the results of the suicide risk screen and assessment, the electronic health record should include the level of risk assessment.

Identifying environmental safety risks, and developing strategies to mitigate those risks

When changes in the environment occur (or at least annually), conduct an environmental risk assessment in all areas designated for the treatment of psychiatric patients. Environmental risk assessments must be appropriate to each unit and should consider the possibility that the unit may sometimes care for patients at risk for threat of harm to self or others. These areas include but are not limited to Emergency Departments, ICUs, Medical Units, and Behavioral Health Units. A multi-disciplinary group should participate in developing the environmental risk assessment to ensure that both the physical environment, clinical implications, and mitigation strategies are fully explored.

Examples of environmental risk assessment tool content includes prompts for staff to assess items such as the following:

  • Handrails, door knobs, door hinges, hooks, exposed plumbing/pipes, soap and paper towel dispensers on walls, power cords on medical equipment or call bell cords, mirrors, fire alarm strobes and horns, air vent covers, cameras, exposed sprinkler heads, and light fixtures or projections from ceilings, etc.
  • Patient beds
  • Solid versus drop ceilings
  • Windows that can be opened or broken
  • Unattended items such as utility or environmental service carts that contain hazardous items such as cleaning agents
  • Unsafe items brought in by visitors

This risk assessment should not only identify all potential ligature points but should also provide strategies to mitigate the risk. Mitigation strategies should include:

  • Removal of equipment that is not needed for direct patient care
  • Securing personal belongings
  • 1:1 monitoring with continuous visual observation if the environment is not ligature-resistant (including toileting)
  • Removing sharp objects (i.e. utensils)
  • Securing utility or environmental service carts
  • Having a process to ensure that visitors do not bring in unsafe items

The results of the environmental risk assessment should be reported to leadership and the appropriate oversight committee. This should be incorporated into the hospital’s overall Quality Assessment/Performance Improvement (QAPI) program.

Resources to consider:

Providing guidance and training for staff

Organizations should have policies, procedures, training, and monitoring systems in place to ensure that care is provided safely. The policy and procedures should outline important steps on the care of a patient with suicidal ideation including screening and assessment guidelines, when to place the patient on 1:1 monitoring, identifying items that could be used as a ligature point, removal of items that are not being used in direct patient care, monitoring patients including the use of the bathroom, accompanying patients to other areas of the organization, and documentation requirements. This policy should include the ability of the assigned staff member to immediately intervene when patient safety may be at risk.

Staff should be routinely trained on providing care to the patient that aligns with policy and procedure. This includes anyone who might provide 1:1 monitoring such as security, sitters, patient care attendants, etc.

During regulatory or accreditation surveys, expect surveyors to ask staff who provide 1:1 monitoring about the training they have received regarding reducing suicide risks and to request evidence of competency assessment forms when the employee files are reviewed.

TiER1 Healthcare can help!

To discuss how TiER1 Healthcare can help your team form a complete approach to providing a safe and effective care environment, call (800) 241-0142 or email for a consultation.

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