We’ve done many columns on the issue of suicide in hospitals (see the full list at the end of today’s column). A recent issue of Joint Commission Online (TJC 2017) had a perspective on safeguards to prevent suicide in a variety of healthcare settings. It summarized recommendations from 3 expert panels that reviewed interventions to prevent suicide in several different healthcare settings, with a heavy focus on making the environment safe.
You’ll see that the recommendations rely heavily on many of the points from the VA’s Mental Health Environment of Care Checklist, which we’ve discussed in so many columns (most recently in our August 29, 2017 Patient Safety Tip of the Week “”). In our February 14, 2017 Patient Safety Tip of the Week “” we mentioned 2 publications (Watts 2016, Mills 2016) showing sustained results from implementation of the Mental Health Environment of Care Checklist (MHEOCC). The checklist and program became mandated at all VA hospitals in 2007. Inpatient suicide rates in VA hospitals dropped from 4.2 per 100,000 admissions to 0.74 per 100,000 admissions from 2000 to 2015. The reduction in suicides coincided with introduction of the MHEOCC and has been sustained since implementation in 2007. The authors stress that the physical changes brought about by the MHEOCC likely have a bigger impact on inpatient suicide reduction than the numerous other interventions used.
Particular attention was paid to potential ligature-related risks. They present in an appendix some statistics about use of ligature points for suicide attempts on corridor doors, drop ceilings, and toilet seats. Recommendations are made for inpatient psychiatric units, general acute inpatient settings, and emergency departments.
Recommendations for Inpatient Psychiatric Units
Inpatient psychiatric units, in both psychiatric hospitals and general/acute care settings, must be ligature-resistant in the following areas:
In inpatient psychiatric units, in both psychiatric hospitals and general/acute care settings, the doors between patient rooms and hallways must contain ligature-resistant hardware which includes, but may not be limited to, hinges, handles, and locking mechanisms.
But the recommendations note that nursing stations with an
unobstructed view (so that a patient attempt at self-harm at the nursing
station would be easily seen and interrupted) do not need to be ligature-resistant
and will not be cited for ligature risks. Areas behind
self-closing/self-locking doors would also be considered exempt.
In inpatient psychiatric units, 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. They note that this may be accomplished with mechanical or behavioral solutions. Mechanical solutions include removing the bathroom door, placing an alarm on the door to prevent inappropriate use, and using a special door designed to prevent using the top to support a ligature (for example, an angled upper edge or breakaway magnetic hinges). A behavioral solution would be denying access to the bathroom unless staff is present; this still requires having the profile of the door be ligature-resistant in the closed arrangement. Our August 29, 2017 Patient Safety Tip of the Week “” discussed these issues in detail. The Joint Commission document does note that in some states modifications or removal of doors are not allowed due to privacy concerns.
The panel discussed whether standard toilet seats (with a
hinged seat and lid) posed significant ligature/suicide risk but concluded that
traditional toilet seats are as safe as toilets without movable seats and
covers, offer patients more comfort, and are less stigmatizing.
Corridor doors remain problematic. Several panelists reported that they were aware of cases in which a patient slipped a ligature between the corridor door and the door frame and/or hinges and committed suicide. And there are several mechanical devices available to decrease the risk of the top of a door being used to fix a ligature (eg. laser beams, pressure-sensing plates, and monitoring cameras) but the efficacy of such devices is unproven. So the panel does not recommend mandatory installation of such devices. Rather, they recommend organizations should note such doors on their environmental risk assessments and describe their mitigation strategies, such as appropriate rounding and monitoring by staff, requiring that doors be left open during certain hours, and so on.
In inpatient psychiatric units, in both psychiatric hospitals and general/acute care settings, patient rooms and bathrooms must have a solid ceiling and that a drop ceiling is not an acceptable alternative because patients might climb up to the drop ceiling, remove a panel, and gain access to ligature risk points in the space above the drop ceiling. They do allow drop ceilings in hallways and common patient care areas as long as all aspects of the hallway are fully visible to staff and there are no objects that patients could easily use to climb up to the drop ceiling. But for areas that are not fully visible to staff or where patients could easily move objects to access the area above the drop ceiling there should be a risk assessment and an appropriate mitigation plan. Mitigation strategies might include gluing the tiles in place, using tile retention clips, installing motion sensors above the ceiling to sense tampering, or using another comparable harm-resistive arrangement.
Importantly, the document recognizes that some patients in psychiatric units may have medical needs that necessitates use of beds or equipment that may present ligature risks. In such cases, the medical needs and the patients’ risk for suicide should be carefully assessed and balanced. In such cases, there must be appropriate mitigation plans and safety precautions in place.
Recommendations for General Acute Inpatient Settings
Joint Commission recognizes that, because of the medical needs of patients on med/surg units, it is impossible to make their environment truly ligature-resistant. Therefore. the general medical/surgical inpatient setting does not need to meet the same standards as an inpatient psychiatric unit to be a ligature-resistant environment. Instead, while it is still incumbent to remove all objects that pose a risk for self-harm without adversely affecting the ability to deliver medical care, Joint Commission focuses on human/behavioral solutions to prevent suicides on these units. These would include mitigating strategies such as:
Organizations should have policies, procedures, training, and monitoring systems in place to ensure these are done reliably. That would include training staff and testing them for competency on how they would address the situation of a patient with serious suicidal ideation and 1:1 monitoring of patients with serious suicidal ideation.
It would also include conducting risk assessments for objects that could pose a risk for self-harm and identifying those objects that should be routinely removed from the immediate vicinity of patients with suicidal ideation. And plans for monitoring visitors would be required.
Monitoring bathroom use and protocols for having qualified staff accompany patients on intrahospital transport would also be necessary. We are a bit troubled that the recommendations did not specifically address one area we always focus on: the bathrooms in the radiology suite (or other hospital area to which psychiatric patients might occasionally be transported). Virtually every time we visit a hospital we find a bathroom in such areas that has multiple potential ligature points and which can be locked from the inside. While it may not be feasible to make those bathrooms ligature-free, the staff accompanying the potentially suicidal patient must have ready access to the keys in the event the patient locked him/herself in the bathroom.
Recommendations for Emergency Departments
Like the med/surg units, emergency departments do not need to meet the same standards as an inpatient psychiatric unit to be a ligature-resistant environment.
But Joint Commission recommends two main strategies to keep patients with serious suicide ideation safe in emergency departments:
Once again, organizations should have policies, procedures, training, and monitoring systems in place to ensure these are done reliably. A defined policy for “demonstrably reliable monitoring” could include 1:1 continuous monitoring, observations allowing for 360-degree viewing, or continuously monitored video) but monitoring must be linked to the provision of immediate intervention by qualified staff member when needed.
Other interventions should include:
Staff must be trained and tested for competency on how they
would address a situation with a patient with serious suicidal ideation.
Suicide should be a “never event” for patients in the hospital and every hospital, not just those with inpatient psychiatric units, must be prepared to do everything possible to prevent such events. We encourage you to read our other columns on this issue.
Update: See our January 29, 2019 Patient Safety Tip of the Week “National Patient Safety Goal for Suicide Prevention” for the elements of performance (EP’s) for National Patient Safety Goal NPSG.15.01.01: Reduce the risk for suicide.
Some of our prior columns on preventing hospital suicides:
TJC (The Joint Commission). November 2017 Perspectives Preview: Special Report: Suicide Prevention in Health Care Settings. Recommendations Regarding Environmental Hazards for Providers and Surveyors. Joint Commission Online 2017; October 25, 2017
Mental Health Environment of Care Checklist (VA)
Watts BV, Shiner B, Young-Xu Y, Mills PD. Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services 2016; Published Online Ahead of Print: November 15, 2016
Mills PD. Use of the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA. TIPS (Topics in Patient Safety) 2016; 16(3): 3-4 July/August/September 2016