Patients often present to the ED with behavioral health concerns, but psychiatric experts recognize the environment is hardly optimal for easing anxiety or calming a troubled mind. Further, patients with psychiatric concerns often wait in the ED for extended periods before they are connected with appropriate care, a time that can be fraught with danger for individuals at risk for self-harm.

Recognizing the safety challenges at issue, a multidisciplinary team at Massachusetts General Hospital (MGH) in Boston developed and implemented a protocol aimed at protecting such patients.

Early findings from a before-and-after study suggest the range of safety precautions included within the protocol are on target. Specifically, in the 12 months before the protocol was implemented, investigators reported there were 13 episodes of attempted self-harm among 4,408 emergency patients found to be at risk. In six cases, actual self-harm occurred.

In the 12 months following implementation, there were six cases of attempted self-harm in a group of 4,523 at-risk emergency patients, with one case that resulted in actual self-harm.1 Investigators noted the precautions focus on creating safe bathrooms, increasing the number and training of observers who can monitor patients deemed at risk for self-harm, managing access to belongings and clothing, and the implementation of added measures for patients found to be at high risk.

Considering the positive results, the ED at MGH is continuing to adhere to the protocol. Investigators would like to see other EDs implement and monitor the effects of similar interventions.

The lead author of this research says when developing an approach to protect at-risk patients, it is critical to include representation from all groups that play a role in patient care and safety in the ED.

“In our institution, these groups include emergency medicine, emergency psychiatry nursing, police and security, and administration, representing both overall ED administration and administrative coordinators,” explains Abigail L. Donovan, MD, associate director of the acute psychiatry service at MGH. “We also found consultation with the hospital office of the counsel invaluable.” By taking a multidisciplinary approach, ideas for inclusion could be honed and improved before implementation. For example, Donovan notes some early discussions focused on searching patient belongings.

“Given the volume of patients at risk for self-harm presenting to our ED, searching the belongings of each patient would have required many hours of police and security time each day, and would have ultimately necessitated hiring additional police and security officers,” she observes. “Furthermore, the police and security officers felt that searching belongings was not a foolproof safety measure.”

Researchers decided to secure patient belongings away from patients. “The ED administrative coordinators were critical in devising this new workflow, which includes labeling belongings, storing them in a secure area, and logging their location,” Donovan notes.

Another idea that benefitted from multidisciplinary review concerned how to manage personal cellphones. “Initial discussions were focused on removing cellphones entirely and storing them with patient belongings,” Donovan recalls. “However, emergency psychiatry representatives felt that phones were an important way to connect with psychosocial supports, including family and friends.”

Overall, emergency psychiatry believed cellphones help patients endure their ED stay and lower the risk of agitation and aggression.

“Administrative coordinators also felt that if patients did not have access to their phones, there would be a large volume of calls into the ED ... from family members looking to speak with patients, [creating] significant challenges with managing the volume of these calls and providing patients with access to ED phones,” Donovan says.

Security representatives were concerned contraband could be hidden in cellphone cases. In the end, the multidisciplinary team allowed patients to access their phones as long as the cases were removed.

Protocol creators continue meeting as needed to review procedures and consider revisions. “These meetings are typically triggered by an identified safety concern,” Donovan notes. “For example, [this could involve] a protocol lapse or an identified near-miss event or a change in regulations.”

In the case of a safety concern, the group will meet, conduct a root cause analysis, and discuss potential interventions to prevent future challenges. A change in regulations will prompt a review of the new requirements and a brainstorming process on how best to meet them. From there, the group will develop and implement a plan.

One example involves how the group responded to a new requirement by The Joint Commission (TJC) to complete suicide screening with a validated tool on every patient who presents to the ED with a behavioral health chief complaint. Donovan notes the approach used in this case illustrates the critical role emergency medicine clinicians play in the safety protocol.

In the MGH ED, nurses complete the Ask Suicide-Screening Questions and the Columbia-Suicide Severity Rating Scale at triage, Donovan shares. Before TJC issued its requirement, emergency medicine physicians would determine risk of self-harm as part of the initial triage.

“They would conduct a brief safety evaluation, which included a discussion of the presenting problem with a focus on safety concerns including suicidality and homicidality, a review of the pertinent clinical history, and focused mental status and physical exams,” Donovan recalls.

As part of the process change, emergency clinicians participated in training, designed by colleagues in emergency psychiatry and psychiatric clinical nurse specialists, to better understand how to perform these evaluations and administer the screening tools.

“As roles change, additional training is completed to keep all clinicians updated,” Donovan says.

Donovan emphasizes that safety reporting is a critical part of the protocol, not only for monitoring performance but also for continuous quality improvement.

“Even prior to the development of this protocol, we actively promoted safety reporting among all ED employees,” she explains. “The safety reporting system has been streamlined to improve ease of use, [and] reporters receive feedback about their report, which reinforces their engagement in the system.”

In an earlier quality improvement initiative, staff were required to complete one safety report so they would become familiar with the system. “The safety reporting system is [now] well-embedded within our workplace culture and day-to-day operations,” Donovan reports.

To successfully implement a safety protocol of this nature, Donovan says leaders must be committed to making financial and time investments. “These investments are ultimately justified by the lower rates of self-harm within vulnerable populations and by improvements in staff perception of safety,” Donovan says.

Donovan also notes a safety protocol must be customized to fit the needs of individual institutions. “Areas of vulnerability for at-risk patients may be institution-specific,” she explains. “Identifying these individual vulnerabilities can be accomplished through completing a root cause analysis of self-harm events.”

The development and implementation process may be long and challenging, so it is critical to keep goals in mind. “We were driven by the overarching goal of providing safe, humane care,” Donovan explains.

At each step, developers asked themselves what they would want the care to look like for their family. “We felt that if we designed a protocol that we could feel good about for our loved ones’ care, then we were on the right track,” Donovan adds.


  1. Donovan AL, Aaronson EL, Black L, et al. Keeping patients at risk for self-harm safe in the emergency department: A protocolized approach. Jt Comm J Qual Patient Saf 2021;47:23-30.