by Diana Scott, MHA, RN, CPHQ
Associate Vice President, Accreditation Services

In the United States, suicides rank 10th in the nation as the leading cause of death. Of the nearly 45,000 suicides that occur each year, approximately 50 to 65 occur in hospitals. Although this is a low number, facilities must be diligent in their efforts to provide a safe environment for at-risk patients.

The ability to provide care to this high-risk patient population is greatly challenged by multiple factors. In hospitals without behavioral health services, patients may be held in emergency departments for a few hours or several days while awaiting placement in the most appropriate care setting. Suicide-risk patients also may have medical needs that require care in a regular medical unit until a physical condition is resolved. These care delivery areas are not designed to be ligature resistant and may not have adequately trained staff for this patient population.

Additional scrutiny of patient-safety risk has come from the U.S. House Committee on Energy and Commerce. The Committee is requiring the Centers for Medicare & Medicaid Services (CMS), state agencies and accrediting organizations to take a closer look at how the medical community is keeping patients safe in these temporary care locations and eliminating ligature risks in inpatient behavioral health units.

In response, CMS has raised the bar on demonstrating compliance, expecting all safety risks be identified in every care setting with strategies to permanently correct ligature risks or implement temporary mitigation strategies, depending on the type of setting where care is being provided. Failing to meet regulatory compliance can ultimately result in a loss of an organization’s Medicare certification and reimbursement.

Identifying the ligature risks

Hospitals are required to provide a safe physical environment wherever a suicide-risk patient is being cared for. The physical space is expected to be ligature resistant in patient rooms, patient bathrooms, common patient care areas and corridors that are not continuously monitored.

Medicare-certified facilities are tasked with evaluating ligature risks in any location. The most common ligature risks involve:

  • Doors
  • Handles and hooks
  • Windows
  • Belts
  • Sheets and towels

Additional safety risks involve equipment and supplies that are needed for behavioral health patients who have a medical condition. These items are not only a risk to patients using them but provide access to a means of self-harm by other patients in the unit.

Protecting patients from self-harm

Ensuring that any room at your health care facility is free of items that a patient could use to commit suicide is a huge undertaking, but well worth the effort, especially if it saves someone’s life. Here are some steps you can take in preventing a patient from using something as a ligature while in your care:

  • Evaluate all patient care areas and rooms for ligature points, i.e. anything that a material could be wrapped around. Even ligature points that are low to the ground can result in a successful suicide. Include an evaluation of each patient room unless the rooms are structurally and clinically set up exactly the same with the same equipment or other medical devices.
  • Develop an immediate mitigation strategy and a plan for permanent correction for inpatient behavioral health units with identified ligature points. Consider renovating patient bathrooms, ceilings and doors to lower the risk of inpatient suicide. Because this may be a costly endeavor depending on the size of your units, start planning to factor that cost in your capital budget immediately.
  • Select or develop an evidenced-based suicide-risk screening tool and ensure all staff are familiar with the criteria for when to do a suicide-risk screen.
  • Create policies related to suicide-risk patients that include:
    • A timeline for conducting a thorough suicide-risk assessment for all patient care areas
    • A list of mitigation risk strategy options to resolve identified issues
    • The definition of one-to-one continuous monitoring and staff qualifications to perform this type of monitoring
    • A process for screening and managing visitors to eliminate patient access to self-harm or harm to others items inadvertently or intentionally brought by visitors
  • Establish a plan for ongoing staff education on:
    • Recognition of ligature and other safety risks to suicide-risk patients, other patients and staff, including potential weapons and barricading
    • Recognition of escalating behavior
    • De-escalation techniques
    • Roles and responsibilities for one-to-one continuous monitoring

Education should be provided to any employee providing direct or indirect care or services to suicide-risk patients.

The challenges in becoming regulatory compliant and improving safety for patients at high risk for suicide are immense, but the reward of saving an individual who has lost all hope is even greater. Preserving life is our mission as health care providers and making sure your facility is free of ligature points or ligature resistant is the right step in preventing suicides in medical and behavioral health units.

About the author. An accomplished nurse and consultant, Diana Scott leads accreditation advisory services for Vizient. In this role, she provides direction and support for member organizations’ compliance with The Joint Commission (TJC) standards and CMS Conditions of Participation (CoPs). Her areas of focus include compliance assessments, education programs on TJC standards and CMS CoPs, onsite coaching during surveys, and post-survey activities, including adverse decision response. Scott has participated in more than 250 TJC accreditation surveys over the past 19 years.

Published: November 15, 2018