The COVID pandemic and the resulting economic recession have negatively affected many people’s mental health and exacerbated already growing needs for mental health services. Referrals have more than doubled and it can take months to find a provider, with some providers being forced to limit care. Emergency rooms are receiving more psychiatric patients than ever, and the average visit is lasting much longer, keeping the emergency department full. Across-the-board staffing shortages compound the high demand for care, leaving an already struggling workforce incredibly overwhelmed, and patients and communities unserved. Healthcare settings serve large numbers of diverse individuals in our communities and can lead to the identification of individuals at risk for suicide.1 From 2010-2017 there were up to 64 hospital inpatient suicides per year in the United States recorded in The Joint Commission’s Sentinel Event (SE) Database. 70% were from hangings and approximately half occurred in the bathroom. That is only reported events, other credible reviews indicate much higher rates of up to 1500 hospital suicides per year. 2 The resulting strain on a healthcare system in crisis has created new barriers for caregivers, health systems, and people suffering from mental illness and substance use disorders.
Virtual Patient Monitoring Guidelines and Recommendations for Behavioral Health
Digital health, using information and communication technology to enhance the efficiency of healthcare delivery and personalization, can greatly improve care and outcomes. Video patient monitoring can be an appropriate intervention for monitoring patients at risk for self-harm, substance abuse, or suicide along with a comprehensive patient safety program with internal policies and procedures defined specifically for this and that adhere to regulatory guidelines.
Many hospitals screen all patients for suicidal ideation – self-reported thoughts of engaging in suicide-related behavior – due to the risk of missing a diagnosis. These patients may show signs of hallucinations, psychosis, agitation, confusion, impulsiveness, restlessness, disorientation, or delirium, or they may be inclined to try and remove medical devices such as I.V. lines and catheters. Hospitals must then define action plans based on that risk. For example, a patient determined to be at high risk may warrant a screening by a licensed psychiatrist, provided 1:1 continuous visual observation, designated to psychiatric units (locked units, held to ligature-resistant standards), and have objects that can be used for self-harm removed from their room, etc.
These TJC guidelines for hospitals are at National Patient Safety Goal 15.01.01, effective July 1, 2020, for suicide prevention.3
- Environmental risk assessment and minimization.
- Screen all patients for suicidal ideation who are being evaluated or treated for behavioral health conditions as their primary reason for care.
- Use a validated screening tool to conduct a suicide assessment of patients for suicidal ideation.
- Document patients’ overall level of risk for suicide and the plan to mitigate the risk.
- Follow written policies and procedures for training, reassessment, and patient monitoring.
- Follow written policies and procedures for counseling and follow-up care at discharge.
- Monitor implementation and effectiveness of policies and procedures.
CMS guidelines indicate patients with non-high-risk suicidal ideation can be monitored by video, if appropriate, as determined by the facility. For high-risk patients, video monitoring should only be used when it is unsafe for a staff member to be in the room: it should be 360-degree viewing, continuous, 1:1, and linked to the provision of immediate intervention by a qualified staff member when required. Video monitoring can also be a complement to 1:1 monitoring and ligature-resistant standards. It is important to reassess patients who are at risk for suicide, despite the monitoring method that is chosen.
Since The Joint Commission’s (TJC) special recommendations on Suicide Prevention in Healthcare Settings4 came out in 2017, we have seen video patient monitoring use increase for suicidal ideation. Under clear policies for example you may have a patient in the ED waiting on a psych eval for suicidal ideation. You may not have an immediate sitter provision but require continuous monitoring – or perhaps it’s not safe for staff to be in the room. The facility could initiate a policy for video patient monitoring to be a strategy when immediate observation is needed, and a sitter is not available.
Patient Video Monitoring Best Practices for Suicide Prevention
These best practices were created keeping in mind the current regulatory guidelines, evidence-based literature, and best practices shared by hospitals currently using video patient monitoring for suicide prevention:
- Clear policies and procedures to identify which patients qualify for video patient monitoring
- 2-way audio and an immediate escalation process for communication are indicated
- Group monitored patients by acuity
- Prep room with ligature-resistant equipment that does not prevent medical care and educate patient monitoring technician of all potential objects involved in room prep (ex-no gloves, no trash bags, safety meal trays, etc.)
- Process for patient monitoring technician to notify floor staff when the patient needs to go to the bathroom and initiate 2-way audio with the patient asking them to wait on the nurse
- Track and measure intervention/alarm response time
- Nursing staff educate patients on the use of video patient monitoring technology
- Consider trained PCAs/PCTs for a patient monitoring technician role
- Monitoring must be continuous and allow for 360-degree viewing
Patient Safety Monitoring Key Points
- Can be an appropriate intervention for suicide ideation patients in a non-psychiatric unit based on the patient’s identified risk level as defined by the facility policy.
- Can be used for high-risk patients when it is unsafe for a staff member to be physically located in the patient room.
- Must be continuous, allowing for 360-degree viewing, and immediate intervention must be available.
Some CareView customers are beginning to use video patient monitoring for patients admitted under the Baker Act, that are deemed non-suicidal and stable, to reduce physical sitter utilization and others are expanding camera use into the ED for high elopement risk patients. Remote video patient monitoring can even be beneficial in preemptively identifying anticipated behavioral event escalation, like sundowning, before it happens. The Safety Technician becomes a key member of the care team, enabling an extra set of eyes and visibility on every patient.
Find out how the CareView Patient Safety System can play a vital role in developing a culture of patient safety, schedule a demo today!
- King, C. A., Horwitz, A., Czyz, E., & Lindsay, R. (2017). Suicide Risk Screening in Healthcare Settings: Identifying Males and Females at Risk. Journal of Clinical Psychology in Medical Settings, 24(1), 8–20. https://doi.org/10.1007/s10880-017-9486-y
- Williams, S. C., Schmaltz, S. P., Castro, G. M., & Baker, D. W. (2018). Incidence and Method of Suicide in Hospitals in the United States. Joint Commission Journal on Quality and Patient Safety, 44(11), 643–650. https://doi.org/10.1016/j.jcjq.2018.08.002
- Suicide Prevention R3 Report. (2019, November 20). Retrieved June 26, 2020, from r3_18_suicide_prevention_hap_bhc_cah_11_4_19_final1.pdf (jointcommission.org)
- Special Report: Suicide Prevention in Health Care Settings. (2017, November). The Joint Commission Perspectives, 37, 1-16. Retrieved from https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/suicide-prevention/november_perspectives_suicide_risk_reduction.pdf?db=web&hash=236585A71D0B5B2D0DAB5DBBB8BA8EE6
- Ligatures and/or Suicide Risk Reduction – Video Monitoring of Patients at High Risk for Suicide. (2020, March 19). Retrieved from https://www.jointcommission.org/en/standards/standard-faqs/hospital-and-hospital-clinics/national-patient-safety-goals-npsg/000002227/#:~:text=Can%20video%20monitoring%2Felectronic%2Dsitters,at%20high%20risk%20for%20suicide%3F&text=The%20use%20of%20%E2%80%9Celectronic%2Dsitters,the%20discretion%20of%20the%20organization.
- DRAFT-QSO-19-12-Hospitals (Rep.). (2019, April 19). Retrieved June 23, 2020, from Centers for Medicare and Medicaid Services website: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO-19-12-Hospitals.pdf
- DNV GL Healthcare. (2019, January 21). Accreditation Requirements, Interpretive Guidelines and Surveyor Guidance Revision 18-2. Retrieved from https://brandcentral.dnvgl.com/original/gallery/10651/files/original/0d9513b108d847808df973607dd5b32e.pdf
- Kroll, D. S., Stanghellini, E., DesRoches, S. L., Lydon, C., Webster, A., O’Reilly, M., Hurwitz, S., Aylward, P. M., Cartright, J. A., McGrath, E. J., Delaporta, L., Meyer, A. T., Kristan, M. S., Falaro, L. J., Murphy, C., Karno, J., Pallin, D. J., Schaffer, A., Shah, S. B., Lakatos, B. E., … Mulloy, D. F. (2020). Virtual Monitoring of Suicide Risk in the General Hospital and Emergency Department. General Hospital Psychiatry, 63, 33–38. https://doi.org/10.1016/j.genhosppsych.2019.01.002