Renewed Focus: New Guidance Released for Anti-Ligature Compliance

Identifying risks, remediation strategies in behavioral health facilities

Suicide is the 10^th leading cause of death in the U.S. Although the majority of suicides occur outside the hospital environment, the industry has renewed its focus on designing facilities to avoid ligature risks. The Joint Commission and Centers for Medicare and Medicaid Services recently formalized new standards to help facility operators and surveyors assess organizational compliance and prevent suicide in healthcare settings. Until recently, those standards were not well-defined, and it was up to individual surveyors to determine what poses a ligature risk. This led to confusion from facility operators as to how to mitigate these risks. In fact, some facilities have been forced to close due to the cost and nature of the renovations required to meet today’s standards. The following is intended to help facilities avoid meeting a similar fate by clarifying the new rules, detailing some common violations and providing a course of action to remedy ligature risks.

First, let’s define a few key terms. The Joint Commission defines ligature-resistant as “without points where a cord rope, bedsheet or other fabric/material can be looped or tied to create a sustainable point of attachment that may result in self-harm or loss of life.” The group points out they intentionally do not use the term ligature-free with respect to elements in the physical environment as they do not think it is possible to remove all potential ligature risk points. Now that we understand that distinction, let’s take a closer look at the standard in specific care environments.

The new standards better define the rules related to inpatient psychiatric units and spaces that typically are not under supervision of staff, such as the patient rooms and toilets. They address the following common violations:

• Patient rooms, patient bathroom, corridors and common patient areas must be ligature-resistant, with some exceptions noted below.
• Doors between patient rooms and hallways must contain ligature-resistant hardware. Typical violations are locks, levers and hinges with non-ligature-resistant hardware. To remedy violations, these doors would need to be modified to have appropriate hardware and, depending on how the door is prepped, it may require replacement.
• In general, areas with an unobstructed view from a team station and areas behind self-closing and locking doors do not need to be ligature-resistant and should not be cited. The facility needs to perform risk assessments to determine the level of ligature resistance required within the given space.
• Hospitals are often cited for cross-corridor doors and exposed closer arms. If these doors are not under direct supervision, a facility may be required to replace these with floor type closers.
• Drop ceilings can be used in hallways and common patient care spaces provided these areas are fully visible to staff and furniture is arranged so the ceiling plenum is not easily accessible. We have used monolithic ceilings or metal-type ceilings secured to the grid in areas where this may be an issue. Most facilities avoid ceilings with hold-down clips as these pose issues when maintenance is performed above the ceiling.

The new requirements do not stop with inpatient psychiatric units; they also apply to general acute inpatient units that host patients with serious suicidal ideation. Organizations must be able to demonstrate the following is rigorously and routinely done in those spaces:

• Staff is trained on how to address a patient with serious suicidal ideation and tested for competency
• 1:1 observation of patients with suicidal ideation must be performed
• Risk assessments for objects that will cause self-harm must be performed, and access to those objects should be routinely removed from patient
• Any items a patient can use for self-harm must be removed
• Visitors must be monitored
• The patient’s bathroom use must be monitored
• Protocols to have staff accompany individual patients with suicidal ideation from one area to another must be implemented

A few changes to the standards could also help new facilities save money.  Top-of-door alarm sensors on corridor doors will not be required and hinged toilet seats can remain in use. Neither will be cited for ligature risks because there is a lack of data supporting the suggestion that these conditions pose a threat.

As of July 1, seven new and revised elements of performance are now applicable to all Joint Commission-accredited hospitals and behavioral health facilities. These new requirements are designed to improve the quality and safety of care for those being treated for behavioral health conditions and those identified as a high risk for suicide. Accredited hospitals are now required to:

• Conduct an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide and take necessary action to minimize the risk.
• Screen individuals being treated or evaluated for behavioral health conditions as their primary reason for care to determine suicide risk using a validated tool. In a behavioral health organization, this would be all individuals served. (Note: The National Patient Safety Goal does not require universal screening in non-behavioral healthcare settings.)
• Develop a plan to mitigate suicide based on an individual’s overall level of risk.
• Follow written policies and procedures for counseling and follow-up care for individuals identified as at risk for suicide.

These new, more specific and instructional guidelines are a meaningful step forward as healthcare designers, planners and caregivers lay the groundwork for the next generation of behavioral health facilities. And, while this article provides a starting point for addressing major ligature risks, it’s also an opportunity to scrutinize the smallest details to make sure they are up to date with best-practice standards.