Presented by David Sine, CSP, ARM, CPHRM

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SAFETY AND THE BUILT ENVIRONMENT Helping
Behavioral Healthcare Organizations Stay Up to
the Minute"

• Presented by David Sine, CSP, ARM, CPHRM
• for

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Suicide Prevention

• Suicide still ranks as the 11th most frequent
  cause of death (third most frequent in young
  people) in the United States.
• Suicide of a care recipient while in a staffed,
  round-the-clock care setting has been the 1 most
  frequently reported type of sentinel event in
  most years since the inception of the Joint
  Commissions Sentinel Event Policy in 1996.
•  -continued-

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Suicide Prevention (continued)

• In 75 of the cases, the method of suicide was a
  hanging in a bathroom, bedroom, or closet (mostly
  in a bathroom)
• The environment of care (such as the presence of
  non-breakaway bars, rods, or safety rails) and
  the lack of testing of breakaway hardware are
  major contributing factors
• (But, testing for what? Define breakaway.)

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 Implementation Expectations for JC Patient
Safety Goal on Suicide Requirement

• Joint Commission, Sentinel Event Alert, September
  1998

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Implementation Expectations

• Identifying and removing or replacing
  non-breakaway hardware
• Mostly done Were now left with the more
  difficult task of identifying and managing the
  non-obvious points of attachment edges of
  picture frames, corners of desks, edges of doors,
  edges of furniture, toilets.

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Implementation Expectations

• Weight testing all breakaway hardware
• But to what standard? If the literature cannot
  agree on a number (since the width of the
  ligature used as well as the weight and
  anatomical features of the patient are variables
  that may influence the safety factor), how can
  hospitals be held to such a standard? Relatively
  little pressure is necessary is required.no
  definition for breakaway.

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Implementation Expectations

• Make sure that items that can harm patients in
  the facility are addressed (for example, install
  appropriate shower heads, shower bars, and closet
  bars that do not easily suggest such a use)
• Again, these are the most easily identified
  precautions. How do we prevent the attachment of
  a shirt, or pajama bottom, or robe to a chair
  that has been set upon a desk top? Or, tied to a
  toilet seat? The tough choices are now left to
  be resolved.
• -continued-

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• One study showed that collectively hooks, bed
  parts, and shower fittings represented 64 of the
  points of attachment for psychiatric suicides by
  hanging.
• Belts, sheets, towels, and shoelaces were used
  in 70 of the suicides in the above study.
• 50 of hanging suicides employ attachment points
  that are below head level (a slumping suicide).
  No safety zone at floor level for points of
  attachment its possible to loop up and over an
  object.
• SOURCE Gunnell, David, Bennewith, Olive,
  Hawton, Keith, et al. The epidemiology and
  prevention of suicide by hanging a systematic
  review. International Journal of Epidemiology,
  34 433-442. 2005
•  

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Implementation Expectations

• The risk assessment includes identification of
  specific factors and features that may increase
  or decrease risk for suicide.
• If applied to the EOC, who is doing the risk
  assessment at your facility? What are their
  qualifications? Are they truly experts? Would a
  set of fresh eyes be a good idea?
• Has your patient population shifted in the past
  five years? Has your BH EOC kept up with the
  change?

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Implementation Expectations

• The patients immediate safety needs and most
  appropriate setting for treatment are addressed.
• Our other dilemma is if the EOC is appropriate
  for patients who are not suicidal. What are the
  ethics of treating each and every patient as if
  they were known to be suicidal? The real
  issueknowing when we have gone too far.
• SOURCE Sine, David M. The Architecture of
  Madness and the Good of Paternalism, Psychiatric
  Services, 59(9), 2008

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Move Toward Single Bedrooms

• Is this a loss of an added safety factor in
  behavioral health?

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It would seem so

• 1. Is there, given your experience, ever a
  therapeutic benefit to a two-bed patient bedroom
  and, therefore, the option for a two-bed room
  retained in the Guidelines?
•  
• 2. Is there, given your experience, ever a
  patient safety benefit to a two-bed patient
  bedroom and, therefore, the option for a two-bed
  room retained in the Guidelines?
•  
• 3. Are you aware of any suicide attempt,
  elopement, or other act of patient self-harm that
  was prevented or mitigated because of the
  presence of a roommate in a semi-private patient
  bedroom?

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Survey Results

• 100 of survey respondents indicated that, based
  on their experience, there were therapeutic
  benefits to a two-bed patient room.
• They further indicated that, based on their
  experience
• there were patient safety benefits to a two-bed
  patient room.
• they were aware of the prevention or mitigation
  of suicide attempts, elopements, or other act of
  self-harm because the patients were in a two-bed
  room.

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Contact

• David Sine, CSP, ARM, CPHRM
• Email dsine_at_austin.rr.com