Behavioral Health in Acute Care

Caring for patients in an acute care setting presents a number of challenges when the patient is at risk for suicide. It is vital for nurses and other staff members to be able to identify and provide proper care for these patients in order to prevent suicide attempts – as well as to protect all patients and hospital staff members from potential harm.

“In order to address these challenges, nurses and the behavioral health team at Our Lady of the Lake Regional Medical Center collaborated to develop educational tools and processes,” says Denise Dugas, Executive Director of Mental and Behavioral Health at Our Lady of the Lake.

The first step in the process is to clearly define suicidal (and homicidal) patients so that acute care nurses will be able to identify these patients. To that end, all patients are assessed using the Columbia risk assessment criteria. If the patient scores high enough on this assessment, the nurse doing the assessment should immediately place the patient on a one-to-one high-risk observation to keep the patient safe. The nurse must then contact the attending physician, who will then decide if the commitment of the patient is needed.

When a patient is placed on a one-to-one, the observer should be of the same sex as the patient. If the patient must leave the room for medical consultation or any type of testing, the observer must remain with the patient at all times. Should a procedure such as an MRI or CAT scan be needed, the observer must remain within eye contact of the patient.

In addition, if a patient is admitted under an order of protective custody (OPC), a PEC or CEC (or sometimes a judicial commitment) the patient must be immediately placed on a one-to-one observation.

During the one-to-one high-risk observation, a CPI-trained observer will manually record the patient’s location, activity, behavior, etc. every 15 minutes. This documentation is done on a green sheet. This is important because the team that developed this process made it a point to use the color green as a theme when dealing with at-risk patients. In addition, the patient is dressed in green scrubs as well as a green armband and green non-skid socks. A laminated green rose is also placed on the door of each room of at-risk patients. By educating the entire hospital staff about this “green theme,” it allows everyone in the facility to be aware when they are dealing with a potentially suicidal patient.

It’s also vitally important that all potentially hazardous items and contraband be removed from the room during one-to-one observation. This includes anything that can cause safety or ligature risks such as belts, ties, ropes, plastic bags, purses, make-up cases, cell phones, or any electronic devices. These items should be placed in a ligature risk box, given to security for storage, or sent home with the patient’s family members.

In addition, all plastic garbage bags must be removed and replaced with paper bags – and any glass items must be removed from the room or sent home with the patient’s family.

Any non-essential furniture should also be removed, including over-bed tables, guest chairs, and recliners. These items should be tagged with the room number and stored until the patient is discharged.

Any extra linen should also be removed from the room. The bedding and sheets, spreads, pillowcases and gowns should be checked for any hidden objects at the start of each shift. It’s also important to ensure that no medication is ever left in the patient’s room.

Another important part of the process is to do a ligature risk assessment and develop a mitigation plan. For example, IV tubing can be used as a ligature – as can electrical cords on medical equipment. All such items must be identified and watched closely by the observer.

In addition, any non-essential medical equipment must be removed, including tubes, hoses, suction, IV poles, pumps, etc.

Once a one-to-one observation is deemed necessary, it’s important to educate the patient and their family members as to why this level of precaution is being taken. Let them know how the process will work, all the steps that are being taken, and why (it’s for everyone’s protection).

Visitors for a patient under observation must check-in at the nurses’ station (and their names must be recorded). Only two visitors at a time should be allowed in the patient’s room. Visitors may not bring in any outside items, including food, drinks, purses, cell phones, or electronic devices. Overnight visitation is not permitted.

Observers must be present during all visits. In addition, visitation may be restricted (and phone calls may be restricted as well). In these cases, staff must document exactly why the restrictions are needed (this is actually a legal requirement in Louisiana).

When meals are provided to patients under observation, the meal must be delivered by the nursing staff. All utensils must be disposable – and the nurse must account for all utensils when removing the tray after the meal. It’s actually a good idea to serve finger foods when possible to avoid using any utensils at all.

Staff education is also very important when it comes to caring for patients at risk for suicide. It’s recommended that all behavioral health and emergency department personnel be CPI certified. Requiring staff to undergo de-escalation education via HealthStream is also important – and security personnel should have CPI green cards. In addition, all observers should be CPI trained – and all staff members should undergo annual training or refreshers.

Another important part of the plan is to institute a post-event process (an event is defined as a situation with a patient that causes a verbal or physical altercation). Following an event, the staff should meet to identify the cause (which may be due to the people, process, or policy involved). This will allow the team to implement changes to prevent such events – and also lets staff members share their feelings and thoughts.

It’s also a good idea to hold post-event leadership huddles to identify the causes and develop solutions that may help to prevent events from occurring.

“We make it a point to identify the causes and work on solutions within 24 hours of an event,” says Dina Dent, Vice President of Nursing at Our Lady of the Lake. “Anytime we have an event we look at it as an opportunity to improve the entire process.”

By learning how to identify patients who are at risk for suicide – and developing a process of caring for these patients – your facility will be helping to keep all patients and staff members safe in these potentially dangerous situations.