Keeping Patients at Risk for Self-Harm Safe in the Emergency Department: A Protocolized Approach

Background: Increasing numbers of patients with psychiatric illness are boarding in emergency departments (EDs) for longer periods. Many patients are at high risk of harm to self, and maintaining their safety is critical. The objectives of this study are to describe the development and implementation of a comprehensive safety precautions protocol for ED patients at risk for self-harm and to report the observed changes in rates of self-harm. Methods: A multidisciplinary team developed comprehensive safety precautions, including the creation of safe bathrooms, increasing the number and training of observers, protocols to manage access to belongings and for clothing search or removal, and additional interventions for exceptionally high-risk patients. Events of attempted self-harm were measured for 12 months before and after new safety precautions were enacted. Results: In the 12 months prior to the protocol initiation, among 4,408 at-risk patients, there were 13 episodes of attempted self-harm (2.95 per 1,000 at-risk patients), and 6 that resulted in actual self-harm (1.36 per 1,000 at-risk patients). In the 12 months after the protocol was introduced, among the 4,523 at-risk patients, there were 6 episodes of attempted self-harm (1.33 per 1,000 at-risk patients, p = 0.11) and only 1 that resulted in actual self-harm (0.22 per 1,000 at-risk patients, p = 0.07). There were no deaths. Conclusion: Comprehensive safety precautions can be successfully developed and implemented in the ED. These precautions correlated with lower, although not statistically significant, rates of self-harm. Further study of similar interventions with adequately powered samples could be beneficial.