Ligature and/or Suicide Risk Reduction - Monitoring High Risk Patients Requiring Transmission-based Precautions
Does a patient who is at high risk for suicide, who also requires transmission-based precautions, require the 1:1 observer to be in the room?
Any examples are for illustrative purposes only.
Suicide Prevention Portal
FAQ Ligatures and/or Suicide Risk Reduction – Video Monitoring of Patients at High Risk for Suicide
Based on both the infection control and safety monitoring requirements for the patient, the organization may either implement 1:1 observation outside the room where the 1:1 observer must be able to maintain full continuous view of the patient and can immediately intervene or have the 1:1 observer inside the room.
In the context of transmission-based precaution, if observation occurs outside of the room, the 1:1 observer must be able to maintain full continuous view of the patient, with the door closed, and be able to intervene without delay when necessary. This means that the observer would have to maintain the appropriate (clean) PPE to ensure entry into the room without delay if necessary. If this is not possible, the 1:1 observer would have to remain in the room, with the door closed, donning the appropriate PPE with full continuous view of the patient and within a distance to be able to immediately intervene if necessary.
The Joint Commission does not prescribe a specific distance from which the observer must be to the patient. This is determined by the organization. The observer must always have full continuous view of the patient and be able to intervene without delay if necessary.
The Joint Commission requires organizations to follow the current CDC guidelines for Transmission-based Precautions which are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. When deciding which observation strategy to deploy, the organization must consider the following:
- Implement interventions based on the following principles:
In the context of transmission-based precaution, if observation occurs outside of the room, the 1:1 observer must be able to maintain full continuous view of the patient, with the door closed, and be able to intervene without delay when necessary. This means that the observer would have to maintain the appropriate (clean) PPE to ensure entry into the room without delay if necessary. If this is not possible, the 1:1 observer would have to remain in the room, with the door closed, donning the appropriate PPE with full continuous view of the patient and within a distance to be able to immediately intervene if necessary.
The Joint Commission does not prescribe a specific distance from which the observer must be to the patient. This is determined by the organization. The observer must always have full continuous view of the patient and be able to intervene without delay if necessary.
The Joint Commission requires organizations to follow the current CDC guidelines for Transmission-based Precautions which are to be used in addition to Standard Precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. When deciding which observation strategy to deploy, the organization must consider the following:
- Implement interventions based on the following principles:
- Route(s) of transmission of the known or suspected infectious agent
- Risk factors for transmission in the infected patient (e.g., patient's willingness to observe precautions to prevent transmission to other patients)
- Risk factors for adverse outcomes resulting from an HAI in other patients in the area or room being considered for patient-placement
- Availability of single-patient rooms
- Patient options for room-sharing (e.g., cohorting patients with the same infection)
- Use personal protective equipment (PPE) appropriately
- The observer must have received training on and demonstrate an understanding of how to properly don, doff, dispose of, and maintain PPE.
- Ensure proper selection and use of personal protective equipment (PPE) based on the nature of the patient interaction and potential for exposure to blood, body fluids and/or infectious material and/or the organization's policy/process/procedure.
- Gloves, gowns, protective eyewear, mask, face shield N95 respirator that are appropriate to the suspected or confirmed infectious agent should be selected and can be worn individually or in combination.
Suicide Prevention Portal
FAQ Ligatures and/or Suicide Risk Reduction – Video Monitoring of Patients at High Risk for Suicide
Manual:
Behavioral Health
Chapter:
Infection Prevention and Control IC
New or updated requirements last added: July 25, 2023.
New or updated requirements may be based on revisions to current accreditation requirements, regulatory changes, and/or an updated interpretation in response to industry changes. Substantive changes to accreditation requirements are also published in the Perspective Newsletter that is available to all Joint Commission accredited organizations.
Last reviewed by Standards Interpretation: July 25, 2023
Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: July 25, 2023
This Standards FAQ was first published on this date.
This page was last updated on July 09, 2024
with update notes of: Reflects new or updated requirements
Types of changes and an explanation of change type:
Editorial changes only: Format changes only. No changes to content. |
Review only, FAQ is current: Periodic review completed, no changes to content. |
Reflects new or updated requirements: Changes represent new or revised requirements.
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