Sharp Drop in Inpatient Suicides With VA Checklist

Nancy A. Melville

December 06, 2016

Implementation of a set of standards that address the physical environment in Veterans Affairs (VA) hospitals has been linked to a significant and sustained drop in inpatient suicides.

"Use of the MHEOCC [Mental Health Environment of Care Checklist] was associated not only with an initial reduction in the number of suicides on inpatient mental health units but also with a sustained reduction over more than seven years," the authors report.

"In looking at the more lasting effects, we expected that there would be some loss of the improvement – maybe not back to where it was before, but some fading from the original effect ― but that wasn't the case. If anything, it looks like the effect has continued to improve over time," coauthor Vince Watts, MD, MPH, director of the VA Patient Safety Fellowship and assistant professor of psychiatry at the Geisel School of Medicine at Dartmouth College, in Hanover, New Hampshire, told Medscape Medical News.

The study was published online November 15 in Psychiatric Services.

Durable Approach

Introduced at more than 150 VA hospitals in 2007, the checklist addresses architectural and physical environmental hazards identified as increasing the risk for inpatient suicide, particularly hooks or anchor points for hanging, non-shatterproof glass, and materials that could be used for suffocation or poisoning.

To determine the efficacy of the checklist in preventing suicides, the authors evaluated data from all VA hospitals between 2000 and 2015.

Results showed there were 24 completed inpatient suicides at VA hospitals prior to implementation, for a rate of 4.2 per 100,000 admissions, compared to five suicides in the 7 years after implementation, or 0.74 per 100,000 admissions.

The expectation of some diminishment of the improvement was based in part on an analysis showing little evidence of sustained effects from mental health interventions in general.

The sustained benefit seen with the MHEOCC may be attributed to the fact that its primary focus is on physical and environmental changes, as opposed to a reliance on staff training, which tends to result in inconsistency and a lack of adherence, according to a previous analysis of root causes of inpatient suicide from the VA National Center for Patient Safety.

"[The research] suggests that interventions and improvements based on staff education and training are unlikely to be sustained, whereas changes that are related to physical changes are more likely to have a sustained effect," the authors write.

"This assertion, if valid, would have broad implications for future interventions to improve mental health; it suggests that interventions that are not entirely based on staff training and education are preferable."

Prevented or Delayed?

Dr Watts noted that the average length of stay in VA mental health centers declined from approximately 11 days to about 7 days during the study period, similar to trends seen outside of the VA system. However, the rates of suicide also improved substantially when calculated per admission and per days in the hospital.

Although the intervention calls for measures to remove a variety of hazards, including materials that could be used for suffocation or poisoning, the key focus is on prevention of hanging, he said.

"In looking at the data on patients committing suicide while they were hospitalized, one finding that surprised us was that virtually all of the deaths were from patients hanging themselves, mostly in the psychiatric unit.

"So one of the most important ingredients in the checklist has been that relentless search to remove both the anchor points and the lanyards that people could use to hang themselves from, like a hook or a bar in a closet or shower, as well as the items such as long cords or even belts," said Dr Watts.

Among the study's limitations is its inability to determine whether suicide was truly prevented or was just delayed until after discharge. With that concern in mind, ongoing efforts are focusing on extending some of the checklist measures into the home, Dr Watts said.

"An important concern is that we are simply delaying a patient who is intent on harming themselves, and it's known that the period after a patient is discharged is an extremely high-risk time," he said.

"So we're currently working on a series of interventions, some based on the checklist and some based on other research outside of the VA, such as working with families to remove things from the home, such as firearms and excess supplies of medications."

Not the Only Tool in the Box

Commenting on the findings for Medscape Medical News, Isaac Sakinofsky, MD, professor emeritus of psychiatry, the Dalla Lana School of Public Health, the University of Toronto, and head of the High Risk Consultation Clinic, Center for Addiction and Mental Health, said the findings are an important validation of the benefits of the MHEOCC approach.

"The conclusions drawn by the authors have been considerably reinforced by the fact that veteran hospital suicides continue to be significantly less over the longer period. So the finding is, in effect, validating," he said.

In an analysis of inpatient suicide risk published in 2013, Dr Sakinofsky and colleagues described key elements in preventing risk. These included optimizing patient visibility and providing appropriate patient supervision.

He agreed that various factors can undermine the efficacy of staff training in preventing suicide over time and that the MHEOCC approach can buy precious time.

"The beneficial effects [of staff training] do not seem to be sustained over the longer term because, putatively, the quality and intensity of the training may not be maintained, nor may the enthusiasm," Dr Sakinofsky said.

"There may be staff changes that overwhelm the beneficial effects of training.... [But] the MHEOCC physically prevents the patient from taking their life and gains time for treatment to work, whether with medication, psychological therapies, or managements that can be applied with staff training."

Dr Sakinofsky underscored the fact that ultimately, a mix of components is the best approach to suicide prevention.

"[The MHEOCC] should never be thought of as the only preventive intervention for hospital suicide," he noted. "It should be used synergistically with excellent and humane clinical care."

The authors and Dr Sakinofsky have disclosed no relevant financial relationships.

Psychiatr Serv. Published online November 15, 2016. Abstract

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