I repeatedly hear that psychiatric hospitals don't need to provide more than a few “secure” rooms near the nurse station to resist suicide because all of their patients are not suicidal. This is very likely a true statement. There are many reasons for inpatient psychiatric admissions and being a threat to one's self or others is not the only diagnosis. However, at any point in time there may be a number of these patients on a given unit.
This sets up two questions for the unit:
- Which patients are going to be assigned to these rooms?
- What do we do if we happen to have more patients that are deemed to be actively suicidal at the same time than secured rooms on the unit?
Let’s explore these in more detail.
Suicide assessments are a very familiar element in most psychiatric hospital settings. I am not a clinician and am not qualified to discuss the pros and cons of the various tools available for this purpose. However, looking at the trends in inpatient suicides, I have to conclude that whatever we are using is not very effective.
Recently released Sentinel Event information from The Joint Commission indicated that their voluntarily submitted data shows that suicides almost doubled (67 to 131) between 2010 and 2011 in all health care settings, not just inpatient psychiatric units.
Granted, these data may reflect that a lot more hospitals chose to report their suicides last year and their criteria includes suicides that occur in the first 72 hours after discharge. The Root Cause Analysis data presented in this same report indicates that, while many suicides have multiple contributing factors, that Assessment was a contributing factor in 82% (484 of 598) of the suicides and that Physical Environment was a contributing factor in 49% (291 of 598) cases.
As I have stated in previous blogs on this website, studies by The American Hospital Association have indicated that two-thirds of inpatient suicides were by patients that were not on 15 minute checks and that the numbers they report have increased in recent years. Also, studies conducted in 2001 and 2006 that were published by the American Psychiatric Association and the Academy of Psychiatric Law concluded that hospitals and architects should proceed as if there is no reliable means to determine a patient’s true intentions.
The dilemma becomes more difficult when our currently available assessment tools tell us that we have more patients at high risk for suicide than we have “secured” rooms available. This creates a truly difficult situation for staff in that they will have to decide which patients to assign to less secured rooms. This means that they may have to move a patient that has been identified as being actively suicidal out of a secured room into a less safe environment. This is placing staff in a very difficult position and may create a condition where the patient and the hospital have a high degree of risk.
In my opinion, the term “Evidence Based Design” is being misused and overused by some people these days. I do not contend that the information contained above is “Evidence” and I cannot find any truly scientifically based studies that address this subject. In the absence of such evidence, I suggest that it is in the patients’ and hospitals’ best interest to design all patient rooms and patient toilet rooms to limit the hazards for potential suicide attempts to the extent possible. When done sensitively, this can retain much of the “familiar and comfortable” appearance that is very desirable on these units.
Providing as safe an environment for all patients does cost a little more, but that is a one-time cost and the benefits gained in staff efficiency are an ongoing savings for the hospital and result in better treatment for the patients.