Reducing Suicide Risks – Recommendations

In the November edition of Perspectives, the Joint Commission unveiled it’s conclusions on reducing suicide risks in inpatient hospital settings.

These conclusions are not as simple as they were a year ago. But, they are greatly improved and much clearer than two months ago. For example, the Joint Commission utilizes a term called ligature resistant, instead of ligature free. That’s because nothing is foolproof and patients who are intent on self harm are unfortunately very innovative at times.

Reducing Suicide Risks

TJC defines the term ligature resistant to mean: “without points to loop or tie a cord, rope, bed sheet, or fabric/material creating a point of attachment that may result in self harm or loss of life.” So, as you are evaluating your inpatient space, take this step. Carry a thin cord or cloth with you to test the safety of your fixtures and in particular your doors. In fact, hospitals often purchase new doors in belief that they are safer. However, using this cord technique helped us identify doors and hinges that still permit an easy tie or pinch point.

The other noticeable change in the expectations eliminates the terms “dedicated” and “non-dedicated” spaces since they were not universally used.

Inpatient Psychiatric Units

The first recommendation to reducing suicide risks targets inpatient psychiatric units in both psychiatric hospitals and general medical hospitals. They require that the following areas are ligature resistant:

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

Here’s what the asterisk after corridors and common patient care areas mean. Bedrooms and bathrooms require solid ceilings. A drop or suspended ceiling is “permitted” in corridors and group rooms. But, only in the following situations:

• When they are fully visible
• If there are no objects that a patient could easily use to climb on to gain access to the ceiling tile

In addition, TJC now states that “nursing stations with an unobstructed view” (so that you can see and interrupt a patient attempt at self harm from the nursing station) and areas behind self closing/self locking doors do not need to be ligature resistant. And, they will not be cited for ligature risks.

So this means two important things. First, if your risk assessment identifies a ligature risk right in front of the nursing station. But, you can easily see the risk and protect the patient, you don’t need to eliminate the risk. If you have been using our risk assessment tool, this is the “detectability” factor on the spreadsheet.

The second important conclusion here is that a group room can have ligature hazards. But only if the patients are never left unsupervised in the group room. Our advice, develop a trained, competent staff with a solid documented mitigation plan. And, ensure the concept is in policy and practiced every single day. The Joint Commission will make future recommendations on acceptable mitigation plans for areas that are not ligature resistant. Stay tuned for this.

Recommendation #2

Recommendation 2 states: “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 not limited to hinges, handles and locking mechanisms.” Here is where walking around with your own cord comes in handy. You can easily test the safety of hinges, door handles and locks by trying to affix your cord to the potential hazard. This is also where finding safer alternatives may require some research. We recommend two sources for identifying safer alternatives:

• The FGI Design Guide for the Built Environment. You can download the 2017 edition free from the FGI website. The authors of this document were on the Joint Commission’s ligature task force. Download the guide here.
• The New York State Office of Mental Health. They are an operator of and regulator for psychiatric hospitals in NYS and have nice purchasing guide identifying ligature resistant fixtures and hardware. Download their free 2017 edition.

Recommendation #3

Recommendation 3 is somewhat of a refinement on recommendation 2. It states the top of the top of the corridor door does not need to have a risk mitigation device installed that would identify a cord or pressure placed on the top of the door. However, they do require that hospitals identify the corridor door on their risk assessment and describe the mitigation strategies used such as regular rounding or leaving doors open.

Recommendation #4 – Difference Between Corridor Doors & Bathroom Doors

This recommendation highlights an important difference between corridor doors and bathroom doors in a bedroom. Here the door must be ligature “free.” This one is complicated and potentially expensive. Solid wood doors require hinges that do not create any tie or pinch points. For example, this might include a continuous piano hinge or a pin hinge. Unfortunately we have seen too many pin hinge bathroom doors that have a gap at the top allowing a cord to create a tie or pinch point.

In addition, TJC says that a solid bathroom door must include a sensor device at the top to alarm for weight placed on the sensor. Furthermore, watch out for angle cut wooden doors. These usually just move the pinch point a foot lower, but still represent a significant ligature risk. TJC is recommending removal of the door entirely, or replacement of the door with a light weight partial door connected to the frame with magnets.

One last option. They suggest denying patient access to the bathroom by locking it unless staff are present to ensure safe use. TJC also advises checking your state regulations before eliminating the bathroom doors. Some states do not permit their removal.

Recommendation 5 – Solid Ceilings

Recommendation 5 mandates solid ceilings for bedrooms and bathrooms in psychiatric units or hospitals. Even if when using tile clips, you can’t employ a drop or suspended ceiling.

Recommendation 6 – Drop Ceilings In Hallways

The recommendation elaborates on the permissibility of a drop ceiling in the hallway. It states that the hallway must be visible to staff. Plus, there can be no object in the hall that would enable the patient to easily climb up to the ceiling to attempt removal of a tile. If your hallway makes a right angle turn, TJC requires you to note this in your risk assessment and put an appropriate mitigation strategy in place. In addition, TJC suggests to clip or glue the tiles in place, install tamper sensors or use another “harm resistive strategy.” Furthermore TJC states the acceptability of the mitigation strategy depends on the physical capabilities of the patient population. This recommendation is less clear and objective than the others. Hopefully they will provide additional advice on:

• Camera monitoring
• Mirror monitoring
• Stationing employees

In the hall at the right angle turn to seen in both directions.

Recommendation 7 – Beds In Inpatient Psychiatric Unit

Recommendation 7 addresses the beds used in the inpatient psychiatric unit. It says that if providing medical care requires beds with potential ligature risks, then it requires an appropriate mitigation plan and safety precautions. But they don’t define any details. This recommendation does not contain the clarity of others. Specifically, what is an appropriate mitigation plan? For example, on an acute medical floor, the subsequent recommendations make clear that it requires 1:1 supervision.

Recommendation 8 – Toilet Seats

Recommendation 8 eliminates concerns about toilet seats. Both TJC and CMS voiced concerns about this issue at the start of this enhanced examination of suicide hazards last spring. TJC makes it clear it won’t cite toilet seats and toilet seat lids. In addition, noting on the risk assessment is now unnecessary.

Recommendations 9 and 10 – Acute Inpatient Setting

Recommendations 9 and 10 address the management of psychiatric patients treated on acute medical floors. Recommendation 9 basically says it is understandable that the physical environment won’t be ligature resistant. Recommendation 10 then addresses the minimum requirements to safely serve patients with severe suicidal ideation. This will require documented mitigation strategies including:

• Removing all non essential medical equipment that can be removed
• Implement 1:1 monitoring
• Assess items that visitors bring in with them
• Have a supervision protocol in place to safeguard the patient remains if they leave the unit for a diagnostic procedure. For example, have policies and procedures in place for training and monitoring to ensure reliability

Recommendations 11, 12 and 13 – The Emergency Department

These recommendations address the emergency department. Recommendation 11 states that the ED does not have to meet the same rigorous physical environment standards that inpatient psychiatric units must meet. Then recommendation 12 basically says you could create a safe room, make the room safer by removing non-essential medical equipment in conjunction with 1:1 or continuous observation, or keep the patient in the “main area” of the hospital. They do permit continuous 360 degree patient video monitoring. However, the person monitoring the video must continuously observe. In addition, their location must allow them to immediately intervene if needed. Thus, remote tele-monitoring would not be permitted.

Furthermore, we do not recommend video monitoring. It’s because we have never seen it work successfully for psychiatric patients. The staff tasked with observation are too easily distracted or bored. Plus, they are often called upon to fulfill other duties like answering the phone or patient call lights.

The recommendations also state that in the ED, you should screen all patients presenting with psychiatric disorders for suicidal ideation. Those that screen positive must undergo a secondary screen. A risk assessment needs to identify which items to remove from patients with suicide ideation. Plus, you must have a protocol for monitoring patients and keeping them safe when:

• In the bathroom
• Moving from the ED to another area of the hospital
• Visitors are present

Finally you are required to train staff and document competencies.

What’s Next

In conclusion, these recommendations are good news. It starts to lend some degree of clarity to organizations anticipating a survey. But, additional questions will arise. Hopefully future FAQ’s on reducing suicide risks will explain those details.