A multidisciplinary team from Einstein Medical Center Montgomery comprised of members from Quality, Safety, Facilities, Environmental Services, and Nursing earned a PA Patient Safety Authority award in the Focus on the Patient category. The team convened to take a close look at how care is given to suicidal patients with a special emphasis on ligature risks inherent to the hospital environment. Based on the findings, the team developed a proactive approach which led to increased safety for a high-risk population.
The project was recognized by the PA Patient Safety Authority for its commitment to patient safety, initiative, and patient impact and as a program that can be replicated by other hospitals.
The eight-person team recognized that the suicidal population is a relatively small but extremely high-risk subset of the overall population. Since Einstein Medical Center Montgomery is not a psychiatric facility, the staff may not be as acutely tuned into the physical risks built into the everyday environment. Therefore, the first course of action for the team was to look at their environment with fresh eyes.
Members of the team walked through the patient care areas and noted every item that could potentially be used as a ligature or anchor point. The team was surprised by the number of everyday items that could become dangerous to someone who wants to cause self-harm. When caring for a patient that is known to be at risk of suicide, in addition to the hospital’s standard process of maintaining one-to-one close observation, the team adopted a policy of removing ligature risk items from the suicidal patient’s environment unless there was a medical necessity to have the item in the room.
Staff was educated on this policy, but the team felt more awareness was warranted. They wanted staff to have the same eye-opening experience they had when walking through the patient care areas while looking through the lens of a suicidal patient.
To recreate this experience, the team set up an activity station outside the cafeteria. Staff members were asked to look at pictures of average patient care rooms and bathrooms and identify the ligature risks. This was a very powerful activity and generated thought-provoking conversations. Staff from all departments participated.
In addition to the focus on the safety of the physical environment, the multidisciplinary team identified improvement opportunities in several other steps of the process of caring for suicidal patients. As a result, the way staff handle personal items has changed in order to ensure that all items are carefully inventoried and secured by Protective Services in a timely fashion to keep the patient, staff and visitors safe. To increase safety at mealtime, the team worked with Dietary Services and began serving finger foods on disposable trays. The project was a very effective way to reeducate staff on the safety considerations for performing one-on-one observation of a suicidal patient.
The PA Patient Safety Authority received 156 nominations from hospitals and health care organizations throughout Pennsylvania and nine hospitals were recognized with awards in a variety of categories.
Team members include:
Kristy Burkart, BSN, RN, HNB-BC, Quality Coordinator (Team Leader).
Aurora Capone Soll, MSN, RN, Clinical Nurse Manager
Thomas Cleary, BSN, RN, Clinical Nurse Manager
Mark Menapace, BSN, RN, CEN, Emergency Department
John A. Barella, CHFM, Director of Facilities & Security
Kim Tissue, MHA, BSN, RN, Director Performance Measurement & Quality Improvement
Jimmy Hawkins, Director of Environmental Services & Patient Transport