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<p>All EDs are at risk for unwanted outcomes, including patient self-harm. Developing and implementing comprehensive safety precautions is an important clinical and risk management strategy. Protocols should be tailored to the specific ED to address their different physical environments.</p>

Safety Protocols Reduce Risk of Self-Harm for At-Risk Patients

April 5, 2021

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A safety precautions protocol reduced self-harm for at-risk ED patients, according to a recently published paper.1

“Our ED cares for a large volume of patients at increased risk for self-harm,” says Abigail Donovan, MD, the study’s lead author and associate psychiatrist at Massachusetts General Hospital.

Even though staff took basic safety precautions, there were several episodes of self-harm in the ED. “This prompted the formation of a task force to investigate root causes, and to make self-harm a ‘never event’ in the ED,” says Donovan, assistant professor of psychiatry at Harvard.

Donovan and colleagues compared the frequency of self-harm events before and after a protocol was implemented. “The initiation of comprehensive safety precautions correlated with lower, although not statistically significant, rates of self-harm among at-risk patients in the ED,” Donovan reports.

The year before the protocol was implemented, there were 13 episodes of attempted self-harm among 4,408 at-risk patients. Six of those episodes resulted in actual self-harm. The year after the protocol was introduced, the numbers declined to six episodes and one episode, respectively.

Donovan and colleagues also discovered an interesting finding: Half of the self-harm events that happened after the protocol involved some sort of protocol breach. “While our fidelity was overall quite good, the impact of a protocol breach can be significant,” Donovan notes.

The ED’s protocol dictates all patients at increased risk of self-harm must use designated safe bathrooms that are ligature-resistant (i.e., free of anything that could be used for the purpose of strangulation or hanging, such as cords or ropes). In addition, the bathrooms must be observed at all times.

In one case of protocol breach, a patient used a non-safe bathroom, which included a plastic trash can liner. The patient attempted to take out the trash can liner to self-harm, but an observer intervened. “Having multiple mitigation strategies in place was critical to prevent actual self-harm,” Donovan says. “But the protocol breach created an area of vulnerability.”

All EDs are at risk for unwanted outcomes, including patient self-harm. “Developing and implementing comprehensive safety precautions is an important clinical and risk management strategy,” Donovan says.

Protocols should be tailored to the specific ED to address their different physical environments. Some examples:

• Bathrooms may or may not be ligature-resistant. Mass General’s ED designated safe bathrooms that are ligature-resistant. In an ED without ligature-resistant bathrooms, specific guidance for observers regarding particular hazards in those bathrooms would be prudent. “For example, a protocol may dictate that observers receive training on the hazards that sink handles, paper towel [holders], and toilet paper holders pose,” Donovan offers.

The protocol also might require observers to visually check the bathroom after the patient leaves to verify trash bag liners, light bulbs, pull cords, or other hazards were not removed.

• Patient visibility differs depending on the ED’s physical environment. At Mass General, multiple ED patients can wait in a large, open area. That gives a single observer excellent visibility of up to four patients at once. Therefore, the ED’s protocol requires just one observer for up to four patients.

Not all EDs include a large, open area. Instead, staff might place each patient in individual rooms. “In this case, one-to-one observation may be necessary,” Donovan explains.

• EDs may want to create individual policies on whether at-risk patient belongings are searched or stored, depending on available space and resources. “Our ED has sufficient storage space, but no surplus of police and security bandwidth to search belongings,” Donovan says. The ED made the decision to store belongings, rather than require police or security to search them for contraband.

For any ED, safety events (including near-misses) should be monitored continually to allow for protocol updates. A recent example at Mass General involved patients who ask to keep a book or phone on their person — but they might have been hiding a sharp item to attempt self-harm.

“In our ED, we had several episodes of observers stopping patients from using hidden sharps to self-harm,” Donovan reports.

If no one tracked these recurring episodes, it would have seemed to clinicians that each time it was just a one-off. In fact, the near misses happened multiple times. “It needed to be addressed by a safety protocol,” Donovan adds.

The Joint Commission’s National Patient Safety Goal 15.01.01 applies to EDs. It lays out a comprehensive suicide prevention plan.

“This includes understanding the environment patients at risk for suicide may be in, and removing objects that they may use to harm themselves from those spaces, when possible,” says Stacey Paul, MSN, RN, APN/PMHNP-BC, clinical project director of standards and survey methods at The Joint Commission. These specific requirements pertain to EDs:

  • If the environment presents risks that cannot be removed, and a patient at high risk for suicide is in that space, 1:1 monitoring may be necessary.
  • All patients who present to the ED with emotional or behavioral concerns as their primary concern must be screened for suicide risk.
  • For patients who screen positive, an evidence-based process must be used for assessment.
  • Based on the screening and assessment, appropriate safety procedures, protocol, and treatment plan are determined.
  • Staff must give counseling and follow-up instructions when discharging a patient at risk for suicide.
  • All ED providers who care for patients at risk for suicide must be given training.
  • Hospitals must implement a quality improvement process related to their suicide prevention program.

All this is highly likely to be scrutinized during Joint Commission surveys, when surveyors “trace” a patient’s experience throughout the hospital stay. “A surveyor will likely trace a patient who has been determined to be at risk for suicide,” says Emily Wells, MSW, CSW, project director of surveyor management and development for The Joint Commission.

The surveyor will look at everything that happened to the patient, from intake to discharge. In the ED, says Paul, that covers “the screening process and assessment process, determining what components of the environment needed to be removed for that patient to be kept safe, and monitoring procedures.”

REFERENCE

  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.