A safety precautions protocol reduces self-harm for at-risk patients in the emergency department

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(OAKBROOK TERRACE, Illinois, January 5, 2020) – Emergency department (ED) boarding of patients with psychiatric illness is a critical issue. These patients are twice as likely as medical patients to require inpatient admission¹ and five times more likely to board (waiting for more than a set number of hours – often 4 hours – for an inpatient bed).²

A new study in the January 2021 issue of The Joint Commission Journal on Quality and Patient Safety, “Keeping Patients at Risk for Self-Harm Safe in the Emergency Department: A Protocolized Approach,” by Abigail L. Donovan, MD, and colleagues at Massachusetts General Hospital, Boston, describes the implementation of a comprehensive safety precautions protocol for ED patients at risk for self-harm.

A multidisciplinary team developed the protocol to include several comprehensive safety precautions, including:

• Creating safe bathrooms
• Increasing the number and training of observers
• Managing access to belongings 
• Managing clothing search or removal
• Implementing additional interventions for exceptionally high-risk patients

The researchers measured events of attempted self-harm for 12 months before and after the new safety precautions were enacted. 

Findings showed in the 12 months prior to the protocol initiation, among 4,408 at-risk patients, there were 13 episodes of attempted self-harm (2.95 per 1,000 at-risk patients) and 6 that resulted in actual self-harm (1.36 per 1,000 at-risk patients). In the 12 months after the protocol was introduced, among 4,523 at-risk patients, there were 6 episodes of attempted self-harm (1.33 per 1,000 at-risk patients) and only 1 that resulted in actual self-harm (0.22 per 1,000 at-risk patients). 

The researchers conclude that comprehensive safety precautions can be successfully developed and implemented in the ED and stress the importance of including multidisciplinary staff in the development of the safety precautions protocol. 

“We commend the use of a multidisciplinary approach to improve ED behavioral health processes and focus on a team-based methodology for patient safety, protocol development and education,” adds an accompanying editorial by Scott Zeller, MD and Seth Thomas, MD. “This recommended collaboration parallels recent best-practice guidelines for behavioral health patients in EDs as crafted by the Institute for Healthcare Improvement and the Emergency Medicine Council.”

The January issue is available free to the public through January 31, 2021. Also featured in the issue: 

• What Safety Events Are Reported for Ambulatory Care? Analysis of Incident Reports from a Patient Safety Organization (University of California, San Francisco) 
• Improving Ambulatory Safety: When Will the Time Come? (editorial)
• Resilience vs. Vulnerability: Psychological Safety and Reporting of Near Misses with Varying Proximity to Harm in Radiation Oncology (University of California, Los Angeles) 
• A Path to Clinical Quality Integration Through a Clinically Integrated Network: The Experience of an Academic Health System and Its Community Affiliates (University of California, San Diego)
• Nurses’ Perceived Causes of Medication Administration Errors: A Qualitative Systematic Review (Villanova University, Pennsylvania)
• Conducting Safety Research Safely: A Policy-Based Approach for Conducting Research with Peer Review Protected Material (Massachusetts General Hospital, Boston)
• Bracing for the Storm: One Health Care System’s Planning for the COVID-19 Surge (University of Washington Medicine, Seattle) 

For more information, visit The Joint Commission Journal on Quality and Patient Safety website.  

¹Agency for Healthcare Research and Quality. HCUP Statistical Brief 92. Mental Health and Substance Abuse-Related Emergency Department Visits Among Adults, 2007. Owens PL, Mutter R, Stocks C. Jul 2010. Accessed Sep 4, 2020. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb92. pdf.

²Nolan JM, et al. Psychiatric boarding incidence, duration, and associated factors in United States emergency departments. J Emerg Nurs. 2015;41:57-64.

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Note for editors  
The article is “Keeping Patients at Risk for Self-Harm Safe in the Emergency Department: A Protocolized Approach” by Abigail L. Donovan, MD; Emily L. Aaronson, MD, MPH; Lauren Black, RN, MS, CEN; Sara A. Fisher, RN, MSN, MEd, PMHCNS-BC; Suzanne A. Bird, MD; Theodore Benzer, MD, PhD; and Elizabeth S. Temin, MD, MPH. The article appears in The Joint Commission Journal on Quality and Patient Safety, volume 47, number 1 (January 2021), published by Elsevier.  

The Joint Commission Journal on Quality and Patient Safety  
The Joint Commission Journal on Quality and Patient Safety (JQPS) is a peer-reviewed journal providing health care professionals with innovative thinking, strategies and practices in improving quality and safety in health care. JQPS is the official journal of The Joint Commission and Joint Commission Resources, Inc. Original case studies, program or project reports, reports of new methodologies or the new application of methodologies, research studies, and commentaries on issues and practices are all considered.