1:1 Observation for Suicidal Patients: Does Your Policy Place Staff at Risk?

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Protecting patients who are prone to self-harm is an issue that is paramount in healthcare today, especially in extremely busy Emergency Departments. Much research and investigation has gone into the best way to protect individuals who are expressing intent on self-harm, but, are some of these policy inclusions encroaching on the safety of the healthcare provider?  This question arises at a time when several healthcare facilities make policy regarding the 1:1 direct observation of suicidal patients by using language such as the 1:1 observation provider will remain “within an arm’s length” of the patient at all times. This level of observation (Level IV) was developed as one of four levels of observation by Reynolds et al.¹ Dr. Isaac Sakinofsky described this method of observation as a “best practice” and thus has been incorporated by many healthcare facilities as policy for 1:1 observation.² What these facilities fail to do is recognize that Sakinofsky is referring to inpatient facilities rather than outpatient facilities such as Emergency Departments. Not only can this approach place staff in harm’s way, it is also “labor intensive, stressful to nurses, and burdensome to nursing budgets,”² not to mention the potential for violence it places on the healthcare sitter, who must remain in close proximity at all times, even as they are using the restroom. It places both healthcare giver and patient in very uncomfortable situations who, if determined to cause themselves harm, will more than likely not be impeded by someone intent on stopping them.

The Occupational Safety and Health Administration (OSHA) requires employers to maintain a safe working environment for their staff. The Joint Commission requires healthcare organizations to comply with local, state, and federal laws, rules, and regulations per LD.04.01.01 EP 2³ to maintain a safe environment for everyone coming into the facility. TJC also recommends the healthcare organization should consider conducting a risk assessment, per EC.02.01.01 EP 1³, specific to workplace violence risks within the organization. Under EC.01.01.01, EP 4³, the organization is responsible for the security of everyone who enters the hospital. As a result, the surveyors will ask hospital representatives about the process to accomplish this goal. As we construct policy to keep patients with suicidal ideations free from self-harm, we must also measure it against other regulations and standards to protect staff and others. Continuous Direct Observation or “one on one observation of the patient and their immediate surroundings but with a distance buffer to avoid unanticipated injury from a violent patient” is Level III of the four levels of observation created by Reynolds et al.¹ This level will serve to protect the patient expressing self-harm from doing so and reduce the probability of causing harm to staff. In the Emergency Department, this level should be considered “best practice,” as it is the best approach at accomplishing both goals.

1. Reynolds T, O’Shaughnessy M, Walker L, et al, Safe and Supportive Observation in Practice: A Practical Governance Project. Mental Health Practice, 2005; 8(8): 13-16

2. Sakinofsky I, Preventing Suicide Among Inpatients, Canadian Journal of Psychiatry, Vol. 59, No. 3, March 2014.

3. The Joint Commission, Standards Related Information, Joint Commission requirements relevant to physical and verbal violence against health care workers. Questions and Answers on Accreditation Standards & Workplace Violence

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