UNIVERSAL HEALTH SERVICES

1
UNIVERSAL HEALTH SERVICES

• KATHY KORDELSKI
• CORPORATE BEHAVIORAL HEALTH RISK MANAGER

2
SUICIDE PREVENTION

• Best Practices Established by Patient Safety
  Councils
• Source materials include UHS protocols and JCAHO
  literature

3
ASSESSMENT

• Include direct questions regarding precipitating
  factors
• Depression, hopelessness
• Suicide ideation, plans
• Past self harm, suicide attempts and/or aborted
  attempts
• Agitation, panic, anxiety, sleep
  difficulties/sleeplessness
• Recent bereavement
• Access to weapons

4
ASSESSMENT

• Stressors
• Conflicts in interpersonal relationships/support
  systems
• Absence of responsibility for children
• Job loss/financial stress
• Patient stressors are identified from the
  patients perspective, not the staffs and are
  taken seriously

5
ASSESSMENT

• Identify medical/high risk factors
• Imminent risks co-morbid panic symptoms, severe
  anxious depression, medical conditions CNS
  diseases, head injuries, chronic pain, AIDS
• Alcohol or other substance abuse or any increase
  in use
• Past hospitalizations for psychiatric disorders
  cycling episodes (bipolar)

6
ASSESSMENT

• Assessments and re-assessments are conducted at
  critical stages of treatment
• Admission
• Change in privilege level
• Change in mental status
• After a concern or reported change in patient
  condition by a family member
• Prior to discharge

7
TREATMENT

• Focus is on things that can be changed
• Patients psychological condition symptoms
• Agitation
• Anxiety
• Sleeplessness

8
THERAPEUTIC MILIEU

• Staff interactions and attitudes can deeply
  affect a patients decision regarding suicide
• Staffs actions are focused on increasing patient
  self esteem/decreasing potential for suicide

9
CONTRACTS FOR SAFETY

• Use of these contracts are to be avoided
• Patients may view them as a failure of empathy by
  the caregiver
• No evidence that they prevent suicide, determine
  lethality or mitigate liability
• Ask patient and/or family to identify specific
  interventions that were effective in previous
  attempts

10
Items Used in Suicide Attempts

• Draw strings from clothing
• Shoe laces
• Belts
• Shower curtains
• Bed sheets
• Towels
• Ace bandages
• Torn cloth from a mattress
• Pantyhose
• Bathrobe sash
• Braided belt made from a patient gown

11
Methods

• Hanging from a showerhead/shower rod
• Item tied to sink pipes and fell/push forward
• Item looped over a door frame
• Bathtub

12
PATIENT MONITORING

• Staff complete rounds per physician order and
  vary the times
• Staff visually check the patient observes
  patient breathing ( if patient is sleeping)
• Staff obtains verbal response (if patient is in
  the shower/bathroom)
• Staff reports when patient isolates self in
  bedroom or other areas of the unit during
  programming time
• Shower times are scheduled to allow adequate
  monitoring

13
PATIENT MONITORING

• Hand-off patients from staff to staff between
  unstructured activities
• Staff hand-off directly to the next assigned
  staff each patient is known to the person taking
  over the checks
• Same sex staff assigned to provide 11
• Enforcement of patient observation levels

14
ENVIRONMENT

• Design patient care areas to eliminate
  environmental elements that could facilitate
  suicide attempts
• Provide patients with alternatives to belts and
  shoelaces
• Installing and frequently testing breakaway
  shower rods and fixtures
• Lock bathroom doors ( unless contraindicated by
  State Law) and other non-supervised areas when
  not in immediate use

15
ENVIRONMENT

• Assigning at risk patients to rooms with a
  roommate and/or close to the nurses station
• Replacement of items that could support hanging
• Bedroom doors locked and opened only during
  specific times (unless contraindicated by State
  Law)

16
PATIENT/FAMILY EDUCATION

• Patient orientation provide alternatives for
  self harm behavior
• Provide educational handouts/packets
• How to handle a Bad Day
• How to call your physician
• How to Ask for Help
• How to Recognize Relapse
• What to do if you miss a medication dose

17
Discharge Planning/Aftercare

• Address issues motivating patients to commit
  suicide
• Pre-discharge suicide risk assessment completed
  on day of discharge
• Distribute ER Help card with resource phone
  numbers wallet sized and laminated

18
Discharge Planning/Aftercare

• Discharge criteria screens for and prevents
  patients at risk for suicide from being
  discharged prematurely
• Get family commitment to remove potential weapons
• To assist in medication compliance
• To be available and provide support and safety
  measures
• Discharges on Friday and Saturday are minimized
  if there is no available support for the at-risk
  patient

19
Discharge Planning/Aftercare

• Discharge with 2-week supply of medications with
  1 refill vs. one 30 day prescription to reduce
  chances of overdose
• Second opinion obtained prior to discharge when
  there is doubt about the patients risk
• No show appointments are immediately followed up
  with a phone call to patient and/or family to
  determine the reason
• Policy defines process for staff response to
  patient calls received after discharge regarding
  relapse and/or suicidal thoughts and actions.
  Staff appropriately initiate suicide prevention
  intervention.

20
Prevention of Sexual Misconduct

• Best Practices Established by Patient Safety
  Councils

21
Sexual Misconduct Prevention

• Staff Education
• Assessment/Identification
• Staffing/Patient Monitoring
• Programming
• Environment

22
Staff Education

• Annual In-service and competencies
• Staff education in completing patient rounds
• Education completed by Medical Director
• Enhanced new hire orientation on supervision of
  patients
• Develop age-specific posters regarding sexual
  boundaries, behaviors
• Develop group materials for patient education on
  sexual boundaries, behaviors, responsibility

23
Staff Education

• Review of previous treatment documentation and
  assessment data
• Addressing high-risk behaviors in treatment
  planning
• Early intervention in pt/pt relationships
• Appropriate response to incidents
• Reporting requirements for incidents
• Monitoring procedures
• Considering risk factors when making room
  assignments

24
Assessments/Identification

• SAO questions moved to more predominant place on
  the Intake Call Sheet to cue staff to ask about
  SAO with the same thoughtfulness as suicide
• Nursing assessment revised to include data
  collection on sexual abuse/behavior history
• Educate Physicians/Admissions staff on
  identification of risk factors upon admission
• Ensure procedures are developed to obtain
  previous discharge summaries to review past
  history
• Revise hospital forms to ensure prompt
  identification of SAO risk factors

25
Staffing/Patient Monitoring

• Enforce wake-up times, lights out times and night
  security/bed checks
• Video camera surveillance in hallways and common
  areas
• Install motion detectors to alert staff of
  patients movements at night
• Charge Nurse, House Supervisor complete random
  checks of rounds sheets
• Zone Supervision Procedures implemented
• Adolescents placed on q 15 minute checks from
  bedtime through change of shift

26
Staffing/Patient Monitoring

• Assign patients to bathroom/bedroom activities
  one at a time prevent two or more patients in
  bathroom/bedroom at a time
• Station staff in hallways all shifts
• Staff assignment process redesigned to specify
  supervision requirements crisis intervention
• Develop and implement a protocol for Sexual
  Acting out Precautions and Patient Observation

27
Programming

• Modify visiting hours to occur during family
  sessions only comply with state guidelines
• Eliminate family visitation from weekends
  replaced with family service sessions scheduled
  during weekdays comply with state guidelines
• Eliminate in-room quiet time for youth
• Implement structured groups during change of
  shift both day and evening
• Frequent review of treatment program schedules to
  ensure structure and accountability
• Implement Neighborhood Watch program

28
Environment

• Segregate male and female smoke breaks
• Install mirrors in hallways
• Single sex utilization of hallway showers
• Locked bathrooms at all times
• Alarms on patient bedroom doors
• Creation of male and female hallways
• Bedrooms doors locked on youth and opened during
  specified times