How to design your units to keep alert for ligature and suicide risks
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February 1, 2019
There’s been a lot of talk lately about ligature and suicide prevention in hospitals, especially as The Joint Commission and other accreditation agencies have passed sweeping (and often confusing) standards to help crack down on patients harming themselves or taking their own lives.
The issue goes back to February 2016, when The Joint Commission, in acknowledgment of Centers for Disease Control and Prevention (CDC) statistics showing suicide as the 10th leading cause of death, issued Sentinel Alert #56: Detecting and Treating Suicide Ideation in All Settings as a call to action.
The CDC reports that the suicide rate has increased more than 25% nationwide from 1999 to 2016.
According to the agency, suicide now claims more than 40,000 U.S. lives a year. Furthermore, the CDC found that 54% of those who died by suicide in that period had not been diagnosed with a mental health condition. The most recent data published by the National Violent Death Reporting System reveals that, in 2015, 83 suicides occurred in medical facilities.
The statistics bear out that suicide is a serious problem, which suggests hospitals must do a better job not only of identifying and monitoring patients at risk, but of removing the means to accomplish suicide in the physical environment.
Effective March 1, 2016, The Joint Commission ordered its surveyors to place more emphasis on the prevention of suicides in hospitals and pay close attention to the assessment of potential ligature (i.e., hanging) injuries, suicide, and self-harm monitoring, especially in psychiatric hospitals and inpatient psychiatric patient areas in general hospitals.
The added emphasis comes at a time of national concern about hospital suicides and highlights the “Zero Suicide” campaign, an effort by several national outreach groups trying to eliminate suicide in U.S. healthcare facilities, according to Joint Commission literature.
On July 20, 2018, CMS issued further information regarding its expectations for ensuring that behavioral health patients are provided a safe and appropriate environment.
“The memorandum does not indicate when we can expect the finalized interpretive guidance, but things do seem to be moving at a pretty good clip, so I’m thinking (maybe, just maybe), we’ll see that information before the end of the year,” said Steven MacArthur, senior consultant and safety expert for The Greeley Company in Danvers, Massachusetts, in his weekly blog, Mac’s Safety Space.
What does this mean if you are confused about how to stay compliant and reduce the risk of suicides at your facility? Well, for one, you need to do something. While there may not yet be conclusive guidelines from CMS about what exactly you need to show surveyors, the issue is being discussed in life safety circles, and you need to stay aware of those conversations. Surveyors will be keeping an eye out to see what your facility does to reduce risks, too, and that’s nothing new.
“I do think that the compliance path appears to be fairly reasonable and straightforward from an implementation standpoint,” wrote MacArthur. “That said, until the interpretive guidance is finalized by CMS, there will likely continue to be some surveyor interpretation in the mix, particularly on the part of those accreditation and regulatory organizations other than Joint Commission (DNV, CIHQ, HFAP, state agencies, etc.). Which means it will be incumbent upon pretty much all hospitals to know where they stand relative to TJC recommendations, particularly as a function of how the strategies and facilities modifications they’ve made meet the intent of the recommendations.”
In other words, get started now on fixing whatever you know is wrong with your facility, because those issues have probably been there for a while. If you’ve been doing your due diligence, you know where your ligature risks lie. Don’t let a surveyor find them for you.
“The vast majority of these inpatient suicides have resulted from hanging, most commonly in a bathroom or bedroom and often using a door or its handle or hinge; a head, handle, bar or door in the shower; a ceiling or sink pipe; or another type of fixture as the ligature fixation point,” writes Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, deputy executive director of the American Society for Health Care Engineering (ASHE), in Health Facilities Management magazine.
ASHE has published a three-step ligature guideline that it hopes will help healthcare facilities cut down on risks.
“Logic dictates that eliminating these and other ligature risks from the environment of a patient with suicidal ideation is necessary. Standards and requirements by accrediting organizations mandate as much,” Beebe writes.
Surprisingly, Beebe concedes that most hospitals should not plan to make major facility renovations to protect against ligature threats.
“The truth is, many health care organizations are misinterpreting the requirements for reducing ligature risk,” he writes. “Others mistakenly believe that new ligature-resistance rules have been put into effect, which is not accurate. And plenty suffer from the misconception that eliminating ligature points is the only effective solution. In reality, decreasing ligature risks isn’t practical in many hospitals. Additionally, it’s not the best or sole option. The key to more successfully preventing suicides is for health care organizations to change their way of thinking about this issue.”
That’s an eye-opening revelation if you’ve been working on fixing issues that could lead to ligature risks. For instance, conventional wisdom would say that if your hospital has many ligature risks, such as grab bars, sink drain pipes, or door hinges, you should work to get rid of them. For many hospitals, though, that is simply not possible from a budgetary and logistical standpoint. Beebe says your solution could be much easier: Post guards that can keep a close watch on your at-risk patients.
“Put another way, if a person in the hospital can watch one assigned at-risk patient unceasingly, the only hazards that need to be removed are anything that could quickly be used to inflict harm,” he says. “That means taking away items like glass flower vases, pens, and sharp eating utensils. It doesn’t require major changes to the physical environment or installing over-the-door sensors. There’s no pragmatic reason to take these steps, because an assigned sitter watching closely could easily intercede before a patient could achieve suicide.”
That’s your first step and first priority, he says: continuous one-to-one observation of at-risk patients. Constant visual monitoring—especially 360-degree viewings by a paid sitter in the room assigned to one patient—provides little room for error.
“Removal of objects that can inflict harm is also important, but there’s no substitute for human eyeballs and the ability to immediately intervene when suicidal thoughts change to a suicidal attempt,” writes Beebe.
If you’re looking to make some changes to your facility to cut down on suicide risk, there is no shortage of advice. The Joint Commission recommends the Behavioral Health Design Guide (formerly known as the Design Guide for the Built Environment of Behavioral Health Facilities) , published by the Facility Guidelines Institute, and there are design guidelines published by the International Association for Healthcare Security and Safety (IAHSS) that include plenty of information about preventing patient suicides and harm.
In the meantime, assess your facility and take measures with your staff to help cut down on the risk. Experts say you should consider the following:
Decrease patient waits. Many safety experts say that long waits are major precursors to violence and anxiety, especially among behavioral health patients, forensics patients, or any people prone to harming themselves or others. Anything you can do to cut waiting and boarding times will help decrease the risk of violence or suicidal behaviors.
Make the environment friendly. Many hospitals are creating behavioral health units—and general patient treatment areas—that boast high ceilings, open areas, and large windows that allow more natural light to come in.
What you do will depend on your space and budget, but picture behavioral health units with “wander space”: a group area where patients can hang out and walk off energy as opposed to sitting around. Some hospital waiting rooms are being designed to include items such as comfy furniture, fireplaces, showers, and video game areas, creating a less-threatening environment for those who may be subjected to longer stays.
Design through the eyes of a suicidal patient. In 2013, Minnesota hospitals began redesigning patient rooms when it was found that facilities there were seeing some of the highest national rates of suicides since the 1990s. As a result, facilities began floor-to-ceiling reviews of room designs, eliminating any features that patients could use to harm themselves.
In psychiatric units, hospitals concentrate on patient bathrooms, which is where many suicide attempts take place. Breakaway shower heads are now the norm, and there are no doorknobs.
Think about flexibility. If you have behavioral health patients who need special rooms—and all your rooms are filled with equipment that they could harm themselves with—those patients will have to wait until you can accommodate them, and that can lead to other problems. Why not redesign your rooms so that they can accommodate anyone?
To cut down on hazards, some facilities have begun designing “multimodal rooms” that can be transformed depending on the needs of the patient being treated. Need a safe room for a behavioral health patient? Regular rooms are designed with medical equipment, oxygen tanks, IV poles, and other potentially harmful items behind a sliding “garage door” that can be pulled down and secured.
Lower surfaces. Although it can be pricey and difficult for older hospitals to renovate current spaces, newer construction is focusing on design elements that provide fewer opportunities for patients to harm themselves. "You want to design it in such a way that it makes it difficult to jump off higher areas,” says Thomas A. Smith, CHPA, CPP, president of Healthcare Security Consultants, Inc., in Chapel Hill, North Carolina. Smith has served on a construction and renovation task force for IAHSS, which focuses on recommendations ranging from avoiding high parking decks to eliminating rooftop play areas.
Search everyone. Especially in a busy emergency room environment, it can be difficult to assess who will be a violence or a suicide risk, so many hospitals have developed procedures for screening patients as they are admitted. Clothes are removed; sharps, belts, and jewelry are inventoried; and purses and other belongings are placed somewhere safe.
Use checklists. Many physicians and hospitals swear by checklists to minimize mistakes in the surgical suite. Now, some hospitals are adapting checklists to other areas, such as the behavioral care unit.
St. Cloud (Minnesota) Hospital uses a checklist that gives staff a list of things to do when preparing a room for a new patient arrival. Tasks on the checklist include things like moving extra garbage cans into the bathroom, removing excess furniture and cords, taking down decorative crucifixes, and folding a room’s computer up into a wall when it’s not being used.
Ligature risk prevention recommendations
Some of The Joint Commission’s recommendations for removing ligature risks from inpatient psychiatric units in both psychiatric hospitals and general/acute care settings include the following:
- Patient rooms, patient bathrooms, certain corridors, and common patient care areas must be ligature-resistant. Note the use of the term “resistant” instead of “free.” This reflects the idea that it’s almost impossible to remove all ligature risks from the environment. The term “resistant” was clarified to mean that the environment must be free from points that a cord, rope, bedsheet, or other material can be looped or tied around to cause self-harm or loss of life.
- Doors between patient rooms and hallways must contain ligature-resistant hardware that includes—but may not be limited to—hinges, handles, and locking mechanisms. In many facilities, this is already a common practice.
- In an interesting recommendation, The Joint Commission says that in both psychiatric hospitals and general/acute care settings, healthcare organizations should not be required to have risk-mitigation devices installed to decrease the chance that the top of a corridor door will be used as a ligature attachment point. The accreditor noted that there are devices on the market to stop this risk, including lasers, pressure plates, and cameras. However, the recommendation appears to take into account the limitations of these devices, including the possibility of false alarms that could distract staff and provide an opportunity for a patient to attempt suicide. Hospitals instead will be required during surveys to note such doors on their environmental risk assessments and describe their mitigation strategies, such as appropriate staff rounding and monitoring.
- In both psychiatric hospitals and general/acute care settings, the transition zone between patient rooms and patient bathrooms must be ligature-free or ligature-resistant. This can be done through mechanical means, such as removing the door, using alarms, or using doors with angled top edges. Many hospitals use behavioral means such as denying access to the bathroom unless staff is present, but this still requires a ligature-resistant door.
- In both psychiatric hospitals and general/acute care settings, patient rooms and bathrooms must have a solid ceiling, rather than a drop ceiling.
- Drop ceilings may be used in hallways and common patient care areas if all parts of the hallway are fully visible to staff. Also, the hallways must be clear of any objects that patients could use to climb up to the drop ceiling, remove a panel, and find something to attach to a ligature risk object. Note that some facilities already have drop ceilings that may not be fully visible—such as where a corridor takes a 90-degree turn. In such cases, the facility will be required to note these problem areas on a risk assessment and have an appropriate mitigation plan using items such as retention clips or motion sensors.
- Medical needs and the patient’s risk for suicide should be carefully assessed and balanced to determine the optimal type of bed for each patient. For patients who require medical beds with ligature points, there must be appropriate mitigation plans and safety precautions in place.
- Standard toilet seats with a hinged seat and lid are not a significant risk for suicide attempts or self-harm and will not be cited. A panel of experts found that traditional toilet seats are as safe as toilets without movable seats and covers, such as the ones used in prisons.