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Suicide in Hospitals: Ligature Risk Is Becoming Regulatory Focus

By Larry Lacombe

Ranking among the top three sentinel events in The Joint Commission’s (TJC) database, health care leaders are increasingly placing emphasis on the assessment of suicide and self-harm and prompting regulators to focus heavily on ligature risks. With much research identifying suicide attempts as impulsive, reducing environmental risks and opportunities for self-harm is vital for curbing the suicide trend in health care settings.

Although suicide is the tenth leading cause of death in America, many health care providers do not detect signs of suicidal thoughts of individuals, despite a majority of victims receiving health care services within the year prior to death. With that in mind, surveyors are closely inspecting potential hanging or choking points in health care facilities, also known as ligatures. Patients identified as a potential risk to themselves or others are more likely to use any item or ligature point within a room to accomplish harm.

At a time when there is national concern about the number of suicides in hospitals, accreditation organizations are becoming extremely meticulous, meaning health care facilities need to be prepared for any type of scrutiny. For example, some accreditation organization surveyors even considered hanging floss over a door hinge a ligature point. 

Any observable ligature risk, no matter how small, is an immediate Recommendations for Improvement (RFI) when observed in an inpatient psychiatric area and is to be corrected within 45 days or less depending on the severity or the total number of issues identified. With people’s lives at risk, ligature RFIs are never appropriate for time extensions. 

When surveyors walk into a health care facility, they’ll assess:

• Has this facility identified and assessed ligature risks?

• What plans have been developed to eliminate those risks?

• What is their risk assessment process?

• Is staff aware, trained, and well equipped to act on these plans and improvement processes?

In a recent alert, TJC outlined minimum expectations for ligature risk mitigation plans:

• Leadership and staff are aware of current environmental risks.

• A patient’s individual risk for suicide or self-harm is identified, followed by appropriate interventions.

• At-risk behavior is assessed on a recurring basis.

• Staff is properly trained to identify patients’ level of risk and intervene properly.

• Suicide and self-harm mitigation strategies are incorporated into the Quality Assessment/Performance Improvement (QAPI) program.

• Policies and procedures are in place, and staff knows what immediate action to take when a patient is deemed at risk for suicide.

• If equipment poses a risk but is necessary for treatment of psychiatric patients, those risks are considered in the patient’s assessments, and adequate interventions are implemented to minimize those risks.

TJC notes that psychiatric patients may pass through or spend time in non-behavioral health units, such as emergency rooms, so it is imperative ligature risks are addressed in all areas. Any physical risks not required for the treatment of the patient that can be removed, must be removed, per the TJC. Moreover, patients should remain under surveillance if risks remain in the environment.

As health care facilities take steps to counter ligature risks, remember this is much more than a compliance issue. Unfortunately, regulators wouldn’t emphasize ligatures if those risks hadn’t enabled tragedies in health care facilities. Facility managers can help ensure no patient harms him or herself under their watch.

Larry Lacombe is the vice president of program development and facilities compliance at Medxcel Facilities Management, specializing in facilities management, safety, environment of care, emergency management, and compliance. 


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posted on 4/15/2018