How to Create a Safety Protocol for Emergency Department Psychiatric Patients

• In the year before the safety protocol was put in place at Massachusetts General Hospital in Boston, there were 13 episodes of attempted self-harm by 4,408 at-risk psychiatric patients, with six of those episodes resulting in actual self-harm
• In the year after the safety protocol was put in place at the hospital, there were six episodes of attempted self-harm by 4,523 at-risk psychiatric patients, with one of those episodes resulting in actual self-harm

Although the safety protocol did not result in a statistically significant reduction in the number of attempted self-harm events and number of actual self-harm events, the safety protocol had a clinically significant impact, the journal article’s co-authors wrote.

“With a very small number of events, it is challenging to demonstrate statistically significant changes; however, these reductions do have substantial clinical significance. With thousands of at-risk patients receiving ED care each year, the impact of improving their safety is substantial. These patients are among the most vulnerable in our healthcare system, and preventing even one episode of self-harm is a critical patient care goal,” they wrote.

How the safety protocol works

Earlier research has shown that hanging is the most common form of attempted suicide in hospitals, and EDs have several lanyards such as sheets and call cords as well as anchor points such as bars and IV poles. In addition, emergency room patients or visitors may have dangerous items such as prescription drugs and sharp objects.

To reduce the danger of self-harm in EDs among patients with psychiatric illness, a multidisciplinary task force at Massachusetts General Hospital crafted four primary elements in the safety protocol.

1. Safe bathrooms: Several episodes of self-harm had been attempted in bathrooms, so the safety protocol called for the creation of “safe bathrooms.” Characteristics of safe bathrooms included shatterproof fixtures and mirrors, paper wastebasket liners, and minimal lanyard risks.

2. Patient observers: After conducting research, the task force concluded that one observer with adequate visibility could monitor as many as three patients. The task force also recommended hiring dedicated ED patient observers rather than using observers who were hospitalwide.

Patient observers received a significant level of training that featured a mandatory three-week orientation and annual retraining. The patient observers learned about safety issues such as suicide risk, possession of dangerous items, and risk of harm to others.

The task force also created a check list tool for patient observers. The check list included safety concerns such as elopement risk and observation goals such as constant vigilance, safe bathroom usage, and making sure there were no dangerous objects in the environment.

3. Personal belongings: The task force determined patient belongings should be removed and stored securely. Possession of cell phones was only allowed if the case was removed to ensure dangerous items could not be hidden inside. Patient requests to keep personal belongings were allowed on an individual basis under review by nursing staff.

4. Clothing search or removal: Patients at risk for self-harm were encouraged to change into safe clothing.

Forcible disrobing of a patient was determined to be appropriate in cases of extreme risk and was based on an individual risk assessment conducted by the ED physician with the option of consultation with psychiatry staff. Forcible disrobing is inherently risky, the journal article’s co-authors wrote. “Forcibly changing a patient is considered a physical restraint, and, practically, to change an unwilling patient, physical restraint is often used. Therefore, patients who are forcibly disrobed must meet restraint criteria, specifically that there is risk to the immediate physical safety of the patient or others.”

The lead author of the journal article, Abigail Donovan, MD, an associate psychiatrist at Massachusetts General Hospital and assistant professor of psychiatry at Harvard Medical School in Boston, told HealthLeaders that forcible disrobing is a complex issue.

“The risk of self-harm compared to the risk of forcible changing is based upon an individual assessment at the time of presentation. That assessment must include an understanding of current suicidality, a thorough history of prior suicide attempts, a current mental status exam, and a review of additional risk factors, including substance use, current intoxication, impulsivity, prior behavior in healthcare settings, and an understanding of the individual’s trauma history. To forcibly change an individual, the risk of imminent self-harm must outweigh the risks of forcible changing, which can be substantial,” she said.

Safety protocol tips

A multidisciplinary team acting on solid research should be involved in the creation of a safety protocol for ED patients with psychiatric illness, Donovan said. “The varied perspectives of members from different disciplines are critical for developing a comprehensive and thoughtful initiative. We also advise using a root cause analysis of self-harm events to identify high-risk areas specific to the individual hospital or care setting as the starting point for a safety protocol.”

It is extremely challenging to balance the creation of a safe space with maintaining a therapeutic and humane environment that also maintains the dignity of patients, she said. “At each step, we tried to ask ourselves, ‘What would I want care to look like for my mother? For my child? For myself?’ We felt that if we designed a protocol that we could feel good about for our loved ones’ care, then we were on the right track.”