Protecting At-Risk Patients from Self-Harm in the ED

By Jonathan Springston, Editor, Relias Media

Investigators at an ED in a large, urban institution created a safety precautions protocol that cut the number of self-harm episodes among at-risk patients.

The researchers identified patients who underwent a psychiatric evaluation between August 2017 and July 2018 and were identified as at high risk of causing harm to self or others. This can be a difficult and volatile population to treat; longer waits in an ED for an inpatient bed or for further evaluation can exacerbate underlying psychiatric issues. The group identified 4,408 unique at-risk patients, with 6,220 separate ED visits.

After identifying these patients, the authors analyzed self-harm episodes that happened in the ED between August 2017 and July 2018 and what caused those events. The group created a protocol built around five improvements: safe bathrooms, number and training of patient observers, management of personal belongings, clothing search or removal policies and training, and additional protocols for high-risk patients.

Investigators implemented their protocol in August 2018, and then spent 12 months observing and collecting data. After one year, the authors noted these precautions and improvements led to lower rates of self-harm (albeit not statistically significant).

“The increase in at-risk ED patients with psychiatric illness with longer lengths of stay creates a critical need for comprehensive safety policies. These comprehensive policies are best developed by a multidisciplinary team, with input from a variety of role groups,” the authors concluded. “Further research is indicated with larger, multisite samples to assess for statistical significance of these interventions and to identify which specific interventions have the greatest impact on safety.”

Despite the limitations, the authors of an accompanying editorial praised this work for its team-based methodology and adherence to published organizational best practice guidelines.

“Safety protocol development should be thought of not only as creating guidelines to prevent patients from having access to the means to inflict self-harm but also as an opportunity to improve patients’ conditions, resulting in a lower likelihood of frustration and anger leading to agitation and aggression,” the editorialists wrote. “These safety-boosting interventions include concepts such as enhancing patient engagement, providing a more healing and comforting environment, using de-escalation and calming techniques to increase cooperation while avoiding coercion, and beginning targeted treatment as soon as possible.”

A series of articles published in the December 2020 issue of ED Legal Letter explains the poor clinical outcomes connected to boarding critically ill patients in the ED, how long wait times in the ED can lead to patient safety events, and how boarding is not just an ED problem. The January issue of ED Legal Letter includes a report about how multiple departments at one facility worked together to solve problems that cause patient backlogs and long wait times.

For more on this and related subjects, be sure to read future issues of ED Management.