If you are a mental health provider, you absolutely must read “Constant Observation of Suicidal Patients: The Intervention We Love to Hate,” by Mark J. Russ, MD (Journal of Psychiatric Practice, 2016;22;382–388). This study is a must-read for psychiatric and general hospital risk managers, staff, and attending psychiatrists – because it provides valuable information that can help you protect your patients from serious harm or death.
Constant observation (CO) is defined by Dr. Russ as maintaining uninterrupted, physically close visual surveillance of a patient. He says it has been a mainstay of the inpatient care of the acutely suicidal patient. But sadly, in many hospitals, rehabilitation centers and other residential facilities, patients at acute risk for suicide are not put under CO. This is a dangerous decision.
Though CO is the standard of care for these patients, some argue against its effectiveness. One argument against it is a lack of evidence to support its use. This is a tired excuse. Another is that CO is too expensive and time-consuming, as it requires a staff member to be with one patient at all times. This excuse, at its core, puts profits over patient safety.
Even with a clinician, nurse or other health-care professional allegedly near the patient, there have been a few reported deaths by suicide that have occurred while the patient was under CO. None however, explain how the attempt was made.
Attorney Skip Simpson has a case in which a patient was able to tie a sheet to a vent and hang herself while she was allegedly being constantly watched. The reason for this death was an unsafe environment of care, poor staff training and supervision, and lack of leadership in the hospital. These are all common root causes of suicide listed by the Joint Commission.
It costs money to have a safe place to keep suicidal patients, train and supervise staff and have solid leadership. It always comes back to money—money that bean counters don’t want to spend to protect patients. Skip Simpson will not give hospitals and incompetent leaders a pass, nor will juries.
Most, if not all of the cases of suicide by patients supposedly under CO involved clinicians and staff who did not uphold the strictest level of constant observation. Any time there is a shift change or other circumstance in which a patient is left unobserved, even briefly, there is the risk of a suicide attempt.
Patients deserve the highest level of care
Given the state of our knowledge for the past 20 years, at least, an argument against the effectiveness of CO cannot be made, according to Dr. Russ. Skip Simpson agrees. The axiom asserting that “the absence of evidence is not evidence of absence” applies in this circumstance. There may be weak reasons not to recommend CO as a strategy to mitigate suicide risk in the hospital, but lack of effectiveness cannot be one. The very fact that it would be unethical to test the question with a randomized controlled trial—where some patients are properly protected and others are not—speaks to the validity of its effectiveness.
Many experts agree that CO, like most other procedures, is most effective when all medical professionals are adhering to all safety protocols. The risk of suicide can be prevented by ensuring that all staff are properly trained and follow the proper care procedures. This process also relies heavily on communication between health professionals.
Another method of care for patients who are at risk of suicide is routine 15-minute checks, or Q15. However, this has proven to be ineffective and is dangerous. With this method of observation, patients at high risk of suicide are left alone for 15 minutes at a time. This puts highly vulnerable patients at even greater risk of a successful suicide attempt. Hundreds of patients die by suicide every year while being watched every 15 minutes.
In this respect, the healthcare field is lagging behind virtually every other field. For instance, the reason most new bridges are now safe – ironically – is that so many collapsed in the early days. Whenever a bridge collapsed anywhere, bridge engineers flocked to the site to learn why. Once they found out, they made sure no one ever allowed that problem to arise again. They followed the “stop-it-next-time” rule. In contrast, hospitals do a root cause analysis of their suicides and bury the results. The public, other hospitals, researchers, the CDC, and even the hospital’s own staff don’t know why the suicide on a Q15 occurred.
Predicting a person’s exact moment of suicide is difficult; this is a reason at-risk patients are hospitalized. Every 15-minute watch for acutely suicidal patients must be eliminated. Medical professionals must be properly trained in using appropriate safety protocols, including CO. Overall, there needs to be improvement in the quality of care to help reduce the risk of suicide. This is easy—it means that the priority in healthcare must be the patient, not the pocketbooks of healthcare executives.
If you have lost a loved one to suicide while they were in an inpatient program, hospital or residential facility, contact Skip Simpson today. He has the unique expertise to help you get through this difficult time.