Ligature safety for patients at risk for suicide. It’s a topic that continues to receive ongoing clarification. This month’s Perspectives details 17 new FAQ’s further explaining their requirements. You can also find these same FAQ’s on the Joint Commission’s Interpretation website.

Ligature Safety For Patients At Risk For Suicide

We find the first FAQ most enlightening. TJC published the first 13 recommendations in November 2017. They identified areas that must be ligature resistant which included:

• Patient rooms
• Patient bathrooms
• Corridors*
• Common areas*

The asterisk had an associated note. It stated that corridors and common areas could be evaluated differently. For example, a suspended ceiling was acceptable if it was under constant observation. In addition, they referred the reader to further details in recommendation 6.

FAQ  1 – Nursing Stations

There was also a bold printed statement in recommendation 1. It stated that nursing stations with an unobstructed view (so that a patient attempt at self-harm could be easily seen and stopped) and areas behind self-closing and locking doors did not need to be ligature resistant. And would not be cited. In this new FAQ we learn that TJC was referring to ligature hazards inside the nursing station. It does not include potential ligature hazards seen from the hallway or the nursing station.

FAQ 5 – Height Considerations

The 5th FAQ discusses minimum height considerations and what heights are considered a ligature risk. This is an important one to read. Many clients we encounter consider low to the ground ligature hazards as not useable for self-harm. But, this FAQ discusses the “alligator roll.” It is where a patient ties to a very low-level ligature risk. Then, they spin their body applying pressure to the throat, which causes asphyxiation. This FAQ reminds us that we can’t ignore any of these close-to-the-ground ligature hazards.

FAQ’s 9, 10 and 11 – Emergency Department Environment

FAQ’s 9, 10 and 11 are important to the emergency department environment.

FAQ 9 states that emergency departments do not have to be ligature resistant like an inpatient behavioral health unit. But, you must implement alternative safeguards to protect patients at high risk of suicide or self-harm. Unfortunately, this blanket statement is misleading if you created a psychiatric ED with a locked unit inside a larger, general ED. Joint Commission appears to have dropped the use of the terms dedicated and non-dedicated space. But we believe a locked psychiatric ED is in essence, a psychiatric unit.

FAQ 10 – Behavioral Health Safe Room

FAQ 10 then states emergency departments do not have to include a behavioral health safe room. However, we advise if you call something a safe room, it better be completely safe. Better than average is not enough.

If your so called “safe room” still has some ligature risks, you still need supervision for the patients who are high risk for suicide. Plus, the Joint Commission may site you for a behavioral health bedroom or bathroom that is not ligature resistant. Instead, it’s preferable to take these steps:

• Inform TJC that you have a general ED examination room that has the ability to more easily contain common hazards using the garage door mechanism.
• It’s available for use with medical patients as needed
• It is not “designated” behavioral health space.

Further Clarification

FAQ 11 clarifies these details further. Not every psychiatric patient entering the emergency department requires 1:1 supervision. Instead, it is only those with serious (or high) suicide risk – those patients assessed to have a “plan and intent”- that require such monitoring.