Consider the psychiatric patient intent on suicide. Can he strangle himself by hooking a cord to the door between his inpatient room and bathroom or hang himself from a pipe accessible via a drop ceiling? Can she jump to her death or suffocate herself with the trash can’s plastic liner?
In recent years, experts – notably The Joint Commission, federal Department of Veterans Affairs (VA) and the Facility Guidelines Institute– have developed recommendations or requirements designed to minimize the risk of suicide in the physical environment of behavioral health settings. The Joint Commission recently issued updated guidelines for complying with its existing standards. The federal Centers for Medicare & Medicaid Services expect to issue their own guidelines in mid-2018.
“Think of safety in a behavioral health unit as being on a scale,” says David Sine, DrBE, CSP, ARM, CPHRM, co-editor of the Facility Guidelines Institute’s “Design Guide for the Built Environment of Behavioral Health Facilities.” “At the far end is a prison in a concrete box. That doesn’t come close to being a therapeutic or healing environment. On the other end, we have something that looks like your home. It is full of items that a determined patient can use to harm himself. Where on that scale do we want to be? Fifteen years ago there were few specialty items to help designers and clinicians. Now there are catalogues filled with items to make behavioral health units homelike but as safe as possible.”
Guidelines for other facilities, including emergency departments and general acute inpatient units, follow similar principles to reduce patient suicide, adjusted for differences in how and where care is delivered.
Inpatient suicide data is lacking
It is difficult to find precise data on the number of inpatient suicides nationally. The Joint Commission has received sentinel event reports of approximately 85 suicides per year over the past five years. The VA, in an April 2017 brief report in the journal “Psychiatric Services,” cites a 2003 American Psychiatric Association overall U.S. estimate of about 1,500 inpatient suicides annually. It reports that its own VA inpatient suicide rate of 0.74 per 100,000 mental health admissions is down from 4.2 suicides per 100,000 admissions in the years prior to implementation of its Mental Health Environment of Care Checklist in 2007.
“That’s three or four veterans every year not dying in our facilities,” says Peter Mills, PhD, director of the VA National Center for Patient Safety Field Office in Vermont. “There are also lots of great staff. It’s not just improving the physical environment, but this has made a difference.
“The main thing people can do is eliminate anything you can hang something on. Any protrusion. Anything on the ceiling that you could attach a lanyard or a sheet or a piece of clothing,” Mills adds. “The anchor point doesn’t have to support the weight of a human being. You can lean into it with only 10 pounds of weight. Fifty percent of hangings use anchor points that are below the head.”