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Joint Commission outlines new suicide risk expectations in aftermath of controversy

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December 1, 2017

Review your policies and procedures for treating suicidal patients in general acute inpatient and emergency care areas following newly finalized recommendations from The Joint Commission (TJC).

The recommendations come from the meetings of three multidisciplinary panels of experts that included representatives from CMS and healthcare organizations nationwide.

The panels were convened earlier this year to discuss how hospitals should make their facilities safer for patients at risk of self-harm, as suicides and suicide attempts at hospitals continue to be among the top Sentinel Events year to year.

“Over the last year there have been several specific situations where surveyors for The Joint Commission and/or state agencies have disagreed on what constitutes a ligature risk and what mitigation strategies are acceptable,” states TJC in what it calls a special report to be published in the November Perspectives magazine.

“There needs to be consensus on these issues so that healthcare organizations will know what changes they need to make to keep patients safe and so surveyors can reliably assess organizations’ compliance with standards,” says the TJC statement.

Report based on experts’ input

The expectations outlined in the report mirror those announced by Carrie Mayer, who oversees strategic and operational excellence activities for TJC’s Accreditation and Certification Operations, during a presentation on upcoming changes through the commission’s Project Refresh. Mayer spoke at TJC’s annual Executive Briefings conference in Chicago earlier this month.

Most of the recommendations focus on expectations for mitigating ligature risk within the physical environment of patient care areas in psychiatric hospitals and behavioral health units in general or acute care settings.

The panels of experts include professionals from across many healthcare settings and fields of expertise, including representatives from Veterans Affairs and psychiatric hospitals and several major health systems throughout the nation, said Mayer.

Based on input from those experts, Mayer said that TJC surveyors would not have the same expectations for general medical or surgical areas, and emergency rooms will not be required to have a safe room.

Expectations for general areas set

However, TJC surveyors will cite ligature risk in general acute-care settings “if the organization cannot demonstrate all of the following are routinely and rigorously done,” said Mayer:

  • Hospitals must be conducting risk assessment for self-harm.
  • If a patient is identified as at risk of self-harm, any items that can be used for self-harm must be removed from the immediate vicinity.
  • Hospitals must train staff and test for competency on how a staff member would address a situation with a patient who is actively suicidal or threatening self-harm.
  • Staff must monitor the bathroom in the case of a suicidal patient.
  • Patients and visitors to the patient must be monitored.
  • And in what Mayer described as a “very important component,” there must be a protocol in place “to have qualified staff accompany an actively suicidal patient from one area of the hospital to another.” Mayer explained that should include staying with the patient during any medical tests or procedures.

The recommendations published online October 25 also reiterated that patients with serious suicidal ideation must be under 1-to-1 monitoring.

“Organizations should have policies, procedures, training, and monitoring systems in place to ensure these are done reliably,” states TJC of its expectations in general care areas.

Safe room not required in ER

For emergency departments, surveyors would have similar expectations. And while a safe room was not required, there is the additional expectation that if you have an actively suicidal patient in the emergency department, Mayer said “that patient must be placed on what we’re terming ‘demonstrably reliable monitoring.’”

In the TJC recommendations, that is defined as including 1-to-1 continuous monitoring, “observations allowing for 360-degree viewing, continuously monitored video.” In addition, “the monitoring must be linked to the provision of immediate intervention by a qualified staff member when called for.”

Note that the recommendations also state: “The organization has a defined policy that includes this detail.”
Earlier this month, TJC also posted an update to its frequently asked question (FAQ) on ligature risk that added, among other things, the Facility Guidelines Institute’s Design Guide for the Built Environment of Behavioral Health Facilities as a recommended resource.

While the suicide risk recommendations will be in the November Perspectives, it may not be the last word on what TJC expects. The recommendations from a third panel of experts convened on October 11 have yet to be finalized. (See related story on p. x for more on TJC’s stance on suicide risks from toilet seats.)
 
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