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Impact of over-the-door alarms: Root cause analysis review of suicide attempts and deaths on veterans health administration mental health units

January 2021
The Center For Health Design

Why does this study matter?
In order to reduce inpatient suicide, ligature resistance has been a focus of CMS and accrediting organizations for the past several years, but questions remain as to how far we go and where the real risks lie. We know from data that most suicides happen in mental health units, and hanging has been reported as the most common method. It usually involves doors and their related hardware – like hinges and handles. This study was prompted by an adverse event after a hospitalized Veteran committed suicide in 2019. Following an investigation, it was established that the bedroom doors from the corridor hadn’t been identified by the facility as a hazard or area of vulnerability.

How was the study done?
The researchers, based in the VA National Center for Patient Safety, conducted a retrospective review and analysis of system-wide data. In this case, data for the previous 11.5 years was coded for 389 events. Using the root cause analysis of suicide attempts and deaths, the dataset included the event type and method; other details associated specifically with hanging events such as the anchor points, ligatures used; and, importantly, the presence of an O-T-D alarm.

So what do we learn from the study?
Nearly half (46%) of the suicides or attempts involved hanging, consistent with other data about the prevalence of hanging. In this study, this included 6 deaths. That’s 3.3%. The next most frequent method of suicide was strangulation with nearly a quarter (23.7%) of the recorded events, and the third most frequent, at 19.6%, was cutting - hanging was twice the number of the next method.
Of the hanging events, nearly three quarters (71.0%) used doors as the anchor point. This accounted for 4 of the 6 door-related deaths. According to the chart in the paper, the next most cited anchor point was the shower, but this was less than 7% of the time. Think about this in context 71% to 7% between the first and second most common anchor points.

Of those events where the patient was using a door, 44 of the attempts, more than a third (34.6%), involved an OTD alarm, and none of those events included a death, suggesting the alarm helped prevent 44 deaths. Of the 6 deaths, 4 of which used the corridor doors to the bedroom, none happened on units with the door alarms. Even knowing the alarm was there was a deterrent.Importantly, from a built environment perspective, a lack of visibility was also cited as a root cause for hanging attempts.

Can we say the results are definitive?
This is a retrospective study, so we’re relying on what data that was recorded, along with how it was recorded. We don’t know what changed over the decade plus of the reported data or what other factors may have influenced reporting. And we also go back to an important premise in research. Correlation does not prove causation, so we can’t “prove” that OTD alarms prevented death by hanging on corridor doors.

But, it does pass the sniff test, and two attempts didn’t happen because the patients knew the alarm might alert staff, this also suggests there is a benefit to the alarms.

What’s the takeaway?
Doors are documented as a common anchor point for hanging and this study supports that again. This takeaway is pretty simple: In mental health units where the risk of patients committing suicide is high, OTD alarms may help save lives, but it’s not the alarm alone. There is rarely a single cause of an adverse event, and in this analysis, more than 150 root causes were identified, many of which act together to create a safety issue. Sight lines, rounding, ongoing maintenance, and even ligature resistant bedding needs to be considered.

However, as part of a system, the OTD acts as another layer of defense in preventing use of a common anchor point, the door. And on a final note, even though we all hear about alarm fatigue in ICUs and med-surg units, this is a different type of setting that is not plagued by the same number of alarms and alerts.Based on data, the VA has now made this a standard. This is really evidence-based design.

Mills, P. D., C. Soncrant, J. Bender, and W. Gunnar. “Impact of Over-the-Door Alarms: Root Cause Analysis Review of Suicide Attempts and Deaths on Veterans Health Administration Mental Health Units.” General Hospital Psychiatry 64 (2020): 41–45. https://doi.org/10.1016/j.genhosppsych.2020.01.005.



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